Medical Surgical Nursing An Integrated Approach - Compressed

Brief CONTeNTS 37 Caring for Clients with Exocrine Pancreatic
Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 753
Unit 1 Introduction to Medical-Surgical Nursing / 1 38 Managing Clients with A Fecal Diversion . . . . . . . . . . . 764
1 Role of Medical-Surgical Nursing . . . . . . . . . . . . . . . . . . . . . . . . 3
2 Assessing Family Processes and Issues . . . . . . . . . . . . . 17 Unit 10 Nursing Care of Clients with Neurosensory
3 Communicating with Clients with Personal Disorders / 787
and Family Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 39 Assessment of the Neurological System . . . . . . . . . . . 789
40 Caring for Clients with Brain Disorders . . . . . . . . . . . . . 805
Unit 2 Concepts Integral to Medical-Surgical 41 Caring for Clients with Spinal Cord Disorders . . . . . 821
Nursing / 43 42 Caring for Clients with Neurological Disorders. . . . 838
4 Complementary and Alternative Therapies . . . . . . . . . . . 45 43 Managing Clients with Sensory Disorders . . . . . . . . . 857
5 Inflammation and Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 44 Assessing and Caring for Clients with Eye
6 Caring for Clients in Shock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 and Visual Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 864
7 Pain Assessment and Management . . . . . . . . . . . . . . . . . . . 108 45 Assessing and Caring for Clients with Ear,
8 Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 Auditory, and Balance Disorders . . . . . . . . . . . . . . . . . . 884
9 Palliative and End-of-Life Care. . . . . . . . . . . . . . . . . . . . . . . . . 159
Unit 11 Nursing Care of Clients with Musculoskeletal
Unit 3 Nursing Care of Clients with Fluid and Disorders / 911
Electrolyte Needs / 197 46 Assessment of the Musculoskeletal System . . . . . . . 913
10 Assessing and Caringfor Clients with Fluid and 47 Caring for Clients with Musculoskeletal Trauma . . 928
Electrolyte Disturbances . . . . . . . . . . . . . . . . . . . . . . . . . . . 199 48 Caring for Clients with Musculoskeletal
11 Assessing and Caring for Clients with Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 940
Acid–Base Disturbances . . . . . . . . . . . . . . . . . . . . . . . . . . . 221 49 Caring for Clients with Inflammatory Disorders . . . 954
12 IV Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246 50 Caring for Clients with Degenerative Disorders . . . 959
Unit 4 Perioperative Nursing Care / 271 Unit 12 Nursing Care of Clients with Lymph,
13 Caring for Surgical Clients . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272 Immune, or Infectious Disorders / 979
Unit 5 Nursing Care of Clients with Respiratory 51 Assessment of Lymph and Immune Function . . . . . 981
Disorders / 315 52 Caring for Clients with Lymphatic and Plasma
14 Assessment of The Respiratory System . . . . . . . . . . . . 317 Cell Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 994
15 Caring for Clients with Upper Respiratory Tract 53 Caring for Clients with Immunodeficiency
Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 332 and Aids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1004
16 Caring for Clients with Lower Respiratory Tract 54 Caring for Clients with Hypersensitive Immune
Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 346 Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1019
17 Caring for Clients with Acute Respiratory 55 Caring for Clients with Autoimmune
Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375 Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1029
Unit 6 Nursing Care of Clients with Cardiovascular Unit 13 Nursing Care of Clients with Integumentary
and Hematologic Disorders / 393 Disorders / 1047
18 Assessment of the Cardiovascular System . . . . . . . . 395 56 Assessment of the Integumentary System . . . . . . . 1049
19 Caring for Clients with Dysrhythmias . . . . . . . . . . . . . . . 414 57 Caring for Clients with Integumentary
20 Caring for Clients with Inflammatory/Infectious Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1065
Cardiac Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 423 58 Caring for Clients with Burn Injury . . . . . . . . . . . . . . . . 1097
21 Caring for Clients with Occlusive Disorders and Unit 14 Nursing Care of Clients with Reproductive
Heart Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 431 and Sexual Health Disorders / 1113
22 Caring for Clients with Peripheral Vascular 59 Assessment of the Reproductive System . . . . . . . . . 1115
Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 452 60 Caring for Female Clients with Gynecological
23 Caring for Clients with Hypertension . . . . . . . . . . . . . . . 464 Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1130
24 Assessment of the Hematologic System . . . . . . . . . . . 474 61 Infertility and Contraceptive Methods . . . . . . . . . . . . . . 1153
25 Caring for Clients with Hematologic Disorders . . . . 482 62 Caring for Clients with Breast Disorders . . . . . . . . . . 1163
Unit 7 Nursing Care of Clients with Renal and 63 Caring for Male Clients with Reproductive
Urinary Disorders / 513 Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1176
26 Assessment of the Renal System . . . . . . . . . . . . . . . . . . . . 515 64 Assessing and Caring for Clients with Sexually
27 Caring for Clients with Urinary Disorders . . . . . . . . . . 529 Transmitted Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1194
28 Caring for Clients with Renal Disorders . . . . . . . . . . . . 544 Unit 15 Mental Health / 1217
Unit 8 Nursing Care of Clients with Endocrine 65 Assessing and Caring for Clients with Mental
Disorders / 577 Health Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1219
29 Assessment of the Endocrine System . . . . . . . . . . . . . . 579 66 Caring for Clients with Substance Abuse . . . . . . . . 1259
30 Caring for Clients with Endocrine Disorders. . . . . . . 594 67 Caring for Clients with Psychobiological
31 Caring for Clients with Diabetes Mellitus . . . . . . . . . . . 624 Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1283
Unit 9 Nursing Care of Clients with Gastrointestinal Unit 16 Nursing Care of Older Adult Clients / 1313
Disorders / 649 68 Health Care Issues of the Older Adult . . . . . . . . . . . . . 1314
32 Assessment of the Gastrointestinal System . . . . . . . 651 Unit 17 Special Considerations in Medical-Surgical
33 Managing Clients with Nutritional Disorders. . . . . . . 668 Nursing / 1347
34 Caring for Clients with Upper Gastrointestinal 69 Bioterrorism and Mass Casualty Care . . . . . . . . . . . . 1348
Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 690 70 Emergency Nursing Care Principles and
35 Caring for Clients with Lower Gastrointestinal Triage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1362
Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 707 71 Applying Critical Thinking with Multiple
36 Caring for Clients with Hepatobiliary Disorders . . . 731 Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1387
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Medical-Surgical
Nursing
Third Edition
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DeDicatioNS
Gena Duncan:
To my husband, John, who is always there. Thanks.
To Dr. Lois White, who guided me through the first edition of Medical-Surgical
Nursing: An Integrated Approach. I admire your brilliant mind, meticulous style, and
forward stride. Thanks for still being my confidante and friend.
Wendy Baumle:
To my family, friends, and peers ~ you are my inspiration.
To my past, current, and future nursing students ~ continue to light your candles and
strive to be the best nurse possible.
Nursing is a profession full of endless possibilities ~ embrace it.
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Medical-Surgical
Nursing
Third Edition
Lois White, PhD, RN
Former Chairperson and Professor,
Department of Vocational Nurse Education,
Del Mar College, Corpus Christi, Texas
Gena Duncan, MSEd, MSN, RN

Former Associate Professor of Nursing, Ivy Tech
Community College, Fort Wayne, Indiana
Wendy Baumle, MSN, RN, CNE

Northwest State Community College, Archbold, Ohio
Australia • Brazil • Japan • Korea • Mexico • Singapore • Spain • United Kingdom • United States
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Medical-Surgical Nursing: An Integrated © 2013, 2002, 1998 Delmar, Cengage Learning
Approach, Third edition
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coNteNtS
Contributors / xxix Roles of the Medical-Surgical Nurse . . . . . . . . . . . . . . . . 11

Reviewers / xxxi Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Preface / xxxiii Director of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Caregiver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Acknowledgments / xxxviii
Educator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
About the Author / xxxix
Client Advocate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
How to Use This Text / xl Job Opportunities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Professional Affiliations and Certifications . . . . . . . . 13
Standards of Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
UNIT 1 Code of Ethics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Evidence-Based Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Introduction to Medical-Surgical Quality and Safety Education for Nurses. . . . . . . . . . . 14
Nursing / 1 Informatics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Genetics and Genomics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
5-Fluorouracil and Genetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
CHAPTER 1: ROLE OF MEDICAL- Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
SURGICAL NURSING / 3
CHAPTER 2: ASSESSING FAMILY
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Characteristics of the Medical-Surgical Nurse. . . . . 4
PROCESSES AND ISSUES / 17
Prioritization and Organization Skills . . . . . . . . . . . . . . . . . . . . . . 4 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Critical Thinker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Diverse Families across the Life Span . . . . . . . . . . . . . . 18
Innovative Problem Solver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Intergenerational Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Critical Thinking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Nuclear Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Critical Thinking and Problem Solving Require Single-Parent Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Discipline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Gay and Lesbian Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Nursing Guideline to Critical Thinking and Problem Grandparents Raising Grandchildren . . . . . . . . . . . . . . . . . . . . 21
Solving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Stepfamilies and Blended Families. . . . . . . . . . . . . . . . . . . . . . . 21
Critical Thinking and Problem Solving Are Circular . . . . . . 8 Cultural Variations within Families . . . . . . . . . . . . . . . . . . . 21
Critical Thinking and Problem Solving to a Higher Asian American Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Standard . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Hispanic Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Standards Related to Critical Thinking and Problem African American Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Solving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Native American Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Critical Thinking and Problem Solving Require Amish Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Knowledge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Families of Middle Eastern Descent . . . . . . . . . . . . . . . . . . . . . 23
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vi CONTENTS
Family Roles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Psychosocial Growth and Development . . . . . . . . . . . . . . . . . 23 Legal Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Economic Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Historic Foundation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Health Promotion and Wellness . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Ancient Greece . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Spiritual and Personal Growth and Development . . . . . . . 25 The Far East . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Parenting Styles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 India . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Authoritarian . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Shamanistic Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Authoritative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Current Trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Permissive. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Mind/Body Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Characteristics Found in Healthy Families. . . . . . . . . 26 Holism and Nursing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Characteristics of Distressed Families. . . . . . . . . . . . . . 26 Complementary and Alternative Therapies . . . . . . . . 48
Potential Family Crisis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Mind/Body Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Domestic Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Family Member with Mental Illness . . . . . . . . . . . . . . . . . . . . . . 27 Biofeedback . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Familial Genetic Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Spiritual Therapies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Teen Pregnancy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Manipulative and Body-Based Methods . . . . . . . . . . . . . . . . . 51
Unplanned Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Energy Therapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Family Member with Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Family Member with Chronic Illness . . . . . . . . . . . . . . . . . . . . . 28 Biologically Based Therapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Child Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Other Methodologies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Family Member with Substance Abuse . . . . . . . . . . . . . . . . . . 28 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Divorce . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Parental Stressors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 CHAPTER 5: INFLAMMATION
Management of Parental Stressors . . . . . . . . . . . . . . . . . . . . . . 28
AND INFECTION / 64
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
CHAPTER 3: COMMUNICATING Inflammation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
WITH CLIENTS WITH PERSONAL Medical Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
AND FAMILY ISSUES / 30 Infection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Flora . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Pathogenicity and Virulence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Communication When Personal or Family Bacteria. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Issues Are Present . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Viruses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Communicative Traits or Tendencies in Healthy Fungi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Protozoa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Communicative Traits or Tendencies Rickettsia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
in Distressed Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Chain of Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Therapeutic Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Agent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Keys to Effective Listening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Reservoir . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Portal of Exit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Special Communicative Challenges for Nurses . . 33
Modes of Transmission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Areas of Special Challenge for Families . . . . . . . . . . . . 33
Portal of Entry. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Divorced Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Host . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Domestic Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Breaking the Chain of Infection . . . . . . . . . . . . . . . . . . . . . . . 71
Productive Confrontation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Between Agent and Reservoir . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Challenging Communication across Cultures . . . . 34 Between Reservoir and Portal of Exit . . . . . . . . . . . . . . . . . . . . 71
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Between Portal of Exit and Mode
of Transmission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Between Mode of Transmission and Portal
UNIT 2 of Entry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Between Portal of Entry and Host. . . . . . . . . . . . . . . . . . . . . . . . 72
Concepts Integral to Medical- Between Host and Agent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Surgical Nursing / 43 Body Defenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Nonspecific Immune Defense . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Specific Immune Defense. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
CHAPTER 4: COMPLEMENTARY Types and Stages of Infections . . . . . . . . . . . . . . . . . . . . . . . 74
AND ALTERNATIVE THERAPIES / 45 Incubation Stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
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Prodromal Stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Types of Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110

Illness Stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Pain Categorized by Origin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
Convalescent Stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Pain Categorized by Nature. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
Acquired Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Purpose of Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
Hospital-Acquired Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Physiology of Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
Community-Acquired Infections . . . . . . . . . . . . . . . . . . . . . . . . . . 75 Stimulation of Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
Superinfection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 The Gate Control Theory. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Emerging Infectious Diseases. . . . . . . . . . . . . . . . . . . . . . . . . 75 Conduction of Pain Impulses . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 Factors Affecting the Pain Experience . . . . . . . . . . . . 114
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 Age. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
Nursing Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 Previous Pain Experiences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Planning/Outcome Identification . . . . . . . . . . . . . . . . . . . . . . . . . 77 Drug Abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Cultural Norms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Joint Commission Standards . . . . . . . . . . . . . . . . . . . . . . . . 116
Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
Nursing Diagnoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
CHAPTER 6: CARING FOR Planning/Outcome Identification . . . . . . . . . . . . . . . . . . . . . . . 122
Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
CLIENTS IN SHOCK / 80 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
Hypovolemic Shock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 CHAPTER 8: CANCER / 133
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
Cardiogenic Shock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
Pathophysiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Environmental Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Lifestyle Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
Septic Shock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Genetic Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
Viral Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
Detection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Common Diagnostic Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Staging of Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Grading of Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
Neurogenic Shock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
Treatment Modalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 100
Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Radiation Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Chemotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Biotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
Anaphylactic Shock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 Photodynamic Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
Hormone Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
Targeted Cancer Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 Bone Marrow Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
Symptom Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 Bone Marrow Dysfunction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Nutritional Alterations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
CHAPTER 7: PAIN ASSESSMENT Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
AND MANAGEMENT / 108 Fatigue. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Alopecia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Odors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Definitions of Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Dyspnea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
Nature of Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Bowel Dysfunctions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
Common Myths about Pain . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Pathological Fractures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
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Ascites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200

Sexual Alterations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 Homeostasis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
MEDICAL EMERGENCIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 Chemical Organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
HYPERCALCEMIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 Elements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
SPINAL CORD COMPRESSION . . . . . . . . . . . . . . . . . . . . . . . . . . 151 Atoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
SUPERIOR VENA CAVA SYNDROME . . . . . . . . . . . . . . . . . . . 151 Molecules and Compounds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202
CARDIAC TAMPONADE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 Ions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202
PSYCHOSOCIAL ALTERATIONS . . . . . . . . . . . . . . . . . . . . 151 Water . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 Gases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 Substance Movement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 Passive Transport . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 Active Transport . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
Fluid and Electrolyte Balance ....................... 205
CHAPTER 9: PALLIATIVE AND Body Fluids. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
END-OF-LIFE CARE / 159 Exchange between the Extracellular and
Intracellular Fluids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 Regulators of Fluid and Electrolyte Balance . . . . . . . . . . . 206
Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 Disturbances in Electrolyte Balance . . . . . . . . . . . . . . . 207
Loss of Significant Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 Sodium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
Loss of Aspect of Self . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 Potassium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210
Loss of an External Object . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 Calcium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210
Loss of Familiar Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 Magnesium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
Grief . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 Phosphate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
Stages of Grief . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 Chloride . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
Types of Grief . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212
Factors Affecting Loss and Grief. . . . . . . . . . . . . . . . . . . . . . . . 162 Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212
Nursing Care of the Grieving Client . . . . . . . . . . . . . . . . . . . . 165 Nursing Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214
Death. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 Planning/Outcome Identification . . . . . . . . . . . . . . . . . . . . . . . 215
Legal Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166 Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
Ethical Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166 Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
Stages of Dying and Death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220
End-of-Life Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
Palliative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168 CHAPTER 11: ASSESSING AND
Hospice Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168 CARING FOR CLIENTS WITH ACID–
Nursing Care of the Dying Client . . . . . . . . . . . . . . . . . . . . . . . 169 BASE DISTURBANCES / 221
Impending Death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
Care after Death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
Legal Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 Acids, Bases, Salts, and pH . . . . . . . . . . . . . . . . . . . . . . . . . . 222
Care of the Family . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 Acids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
Nurse’s Self-Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 Bases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180 Salts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
pH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
Buffers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
Bicarbonate Buffer System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
UNIT 3 Phosphate Buffer System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
Protein Buffer System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
Acid–Base Balance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Nursing Care of Clients with Fluid Regulators of Acid–Base Balance . . . . . . . . . . . . . . . . . . . . . .
223
224
and Electrolyte Needs / 197 Diagnostic and Laboratory Data . . . . . . . . . . . . . . . . . . . . . . . . 224
Disturbances in Acid–Base Balance . . . . . . . . . . . . . . . . . . . 224
CHAPTER 10: ASSESSING Respiratory Acidosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224
AND CARING FOR CLIENTS Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
WITH FLUID AND ELECTROLYTE Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
DISTURBANCES / 199 Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228
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Respiratory Alkalosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230 UNIT 4

Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232 Perioperative Nursing Care / 271
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233
Metabolic Acidosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234 CHAPTER 13: CARING FOR
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 236 SURGICAL CLIENTS / 272
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238
Preoperative Phase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238
Preoperative Physiological Assessment . . . . . . . . . . . . . . . 274
Metabolic Alkalosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239 Psychosocial Health Assessment . . . . . . . . . . . . . . . . . . . . . . 277
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 241 Surgical Consent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242 Preoperative Teaching . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243 Physical Preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243 Preanesthetic Preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281
Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244 Oral Intake . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245 Preoperative Medication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283
Consent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284
CHAPTER 12: IV THERAPY / 246 Sedation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247 Sedation and Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284
Parenteral Fluids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247 Residual Effects of Sedation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284
IV Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247 Intraoperative Phase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284
Intravenous Filters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247 Physical Description of the Operating Room
Needles and Catheters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247 Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285
Needle-Free System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250 Minimally Invasive Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285
Vascular Access Devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250 Asepsis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287
Preparing an Intravenous Solution . . . . . . . . . . . . . . . . . 252 Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287
Initiating IV Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252 General Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290
Calculating Flow Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253 Fluid Balance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292
Intraoperative Nursing Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293
Locating a Vein. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254
Placing the Needle/Catheter . . . . . . . . . . . . . . . . . . . . . . . . . 254
Postoperative Phase ................................... 293
Postoperative Nursing Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293
Administering IV Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
Continuing Nursing Care in the PACU . . . . . . . . . . . . . . . . . 296
Regulating IV Solution Flow Rate . . . . . . . . . . . . . . . . . . . . . . 255
Later Postoperative Nursing Care . . . . . . . . . . . . . . . . . . . . . . 298
IV Pumps and Volume-Control Devices . . . . . . . . . . . . . . . . 255
Postoperative Pain Management. . . . . . . . . . . . . . . . . . . . 304
Managing IV Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256
Patient-Controlled Analgesia. . . . . . . . . . . . . . . . . . . . . . . . . . . . 305
Hypervolemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256
Regional Analgesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305
Infiltration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
Phlebitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
Ambulatory Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305
Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258
Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306
Intravenous Dressing Change . . . . . . . . . . . . . . . . . . . . . . . . . . 258 Older Adult Clients Having Surgery. . . . . . . . . . . . . . . . 307
Intravenous Drug Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308
Adding Drugs to an Intravenous Fluid Container. . . . . . 258 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308
Adding Drugs to a Volume-Control Administration
Set . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258
Administering Medications by Intermittent Infusion . . . 258 UNIT 5
Intermittent Infusion Devices. . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
Administering IV Push Medications . . . . . . . . . . . . . . . . . . . .
Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
259
259
Nursing Care of Clients with
Blood Transfusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260 Respiratory Disorders / 315
Whole Blood and Blood Products . . . . . . . . . . . . . . . . . . . . . . 260
Initial Assessment and Preparation . . . . . . . . . . . . . . . . . . . . 260 CHAPTER 14: ASSESSMENT OF
Administering Whole Blood or a Blood Component . . 260
Safety Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
THE RESPIRATORY SYSTEM / 317
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318
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Anatomy and Physiology Review . . . . . . . . . . . . . . . . . . . 318 TRACHEA AND LARYNX CONDITIONS . . . . . . . . . . . 343
Thoracic Cavity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318 AIRWAY OBSTRUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343
Conducting Airways . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 319 TRACHEOSTOMY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343
Respiratory Tissues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 319 NEOPLASMS OF THE RESPIRATORY TRACT . . . 344
Accessory Muscles of Respiration . . . . . . . . . . . . . . . . . . . . . 319 LARYNGEAL CANCER. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 344
Respiratory Defense Mechanisms . . . . . . . . . . . . . . . . . . . . . 319 Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 344
Respiration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 344
Neuromuscular Control of Respiration . . . . . . . . . . . . . . . . . 320 Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 344
Gas Exchange . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320 Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 344
Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321
Common Diagnostic Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327 CHAPTER 16: CARING FOR
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331 CLIENTS WITH LOWER RESPIRATORY
CHAPTER 15: CARING FOR TRACT DISORDERS / 346
CLIENTS WITH UPPER RESPIRATORY Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347
PNEUMONIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347
TRACT DISORDERS / 332
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 348
STRUCTURAL/TRAUMATIC DISORDERS Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349
OF THE NOSE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333 Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349
DEVIATED SEPTUM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333 TUBERCULOSIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 350
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 333 Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 353
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333 Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333 Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355
EPISTAXIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334 PLEURISY/PLEURAL EFFUSION . . . . . . . . . . . . . . . . . . . . . . . . 359
INFECTIOUS/INFLAMMATORY DISORDERS NEOPLASMS OF THE RESPIRATORY TRACT . . . 361
OF THE UPPER RESPIRATORY TRACT . . . . . . . . . . . 336 BENIGN NEOPLASMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 361
ALLERGIC RHINITIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 336 LUNG CANCER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 361
ACUTE VIRAL RHINITIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337 Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 362
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 338 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 362
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 338 Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 362
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 338 Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 362
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 338 CHRONIC RESPIRATORY TRACT DISORDERS . 363
INFLUENZA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 338 ASTHMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363
TONSILLITIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 340 CHRONIC OBSTRUCTIVE PULMONARY
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 340 DISEASE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 366
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 340 CHRONIC BRONCHITIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 366
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 340 Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 367
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 340 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367
LARYNGITIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 340 Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367
PHARYNGITIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 340 Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367
OBSTRUCTION OF THE NOSE/PARANASAL EMPHYSEMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369
SINUSES/PHARYNX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342 Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 370
POLYPS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 370
FOREIGN BODIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342 Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 370
SLEEP APNEA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342 Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 370
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BRONCHIECTASIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 372 Anatomy and Physiology Review . . . . . . . . . . . . . . . . . . . 396

Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 372 Structure of the Heart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 396
Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374 Circulation of Blood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 396
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374 Stroke Volume and Cardiac Output . . . . . . . . . . . . . . . . . . . . 396
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374 Coronary Arteries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 396
Conduction System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 397
CHAPTER 17: CARING Arterioles and Arteries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 399
FOR CLIENTS WITH ACUTE Capillaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 400
RESPIRATORY DISORDERS / 375 Venules and Veins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 400
Health History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 400
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 376 Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 400
ACUTE RESPIRATORY TRACT DISORDERS. . . . . 376 Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 400
ATELECTASIS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 376 Common Diagnostic Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . 404
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 413
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 377
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 377 CHAPTER 19: CARING FOR
PULMONARY EMBOLISM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 378 CLIENTS WITH DYSRHYTHMIAS / 414
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 379 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 415
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 379 Cardiac Rhythm/Dysrhythmia . . . . . . . . . . . . . . . . . . . . . . . 415
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 379 Normal Sinus Rhythm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 415
PULMONARY EDEMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 380 Dysrhythmias. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 415
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 380 Atrial Dysrhythmias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 416
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381 Ventricular Dysrhythmias. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 418
Atrioventricular Blocks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 420
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381
ACUTE RESPIRATORY DISTRESS SYNDROME . . . . . . . 382
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 382 Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 421
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383 Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 421
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 422
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383
SEVERE ACUTE RESPIRATORY SYNDROME . . . . . . . . . 384 CHAPTER 20: CARING FOR
ACUTE RESPIRATORY FAILURE. . . . . . . . . . . . . . . . . . . . . . . . . 384
CLIENTS WITH INFLAMMATORY/
CHEST TRAUMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 384 INFECTIOUS CARDIAC
PNEUMOTHORAX/HEMOTHORAX . . . . . . . . . . . . . . . . . . . . . . 384 DISORDERS / 423
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 424
RHEUMATIC HEART DISEASE . . . . . . . . . . . . . . . . . . . . . . . . . . . 424
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 386 INFECTIVE ENDOCARDITIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 424
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 386 Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 424
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 386 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 425
MYOCARDITIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 425
UNIT 6 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 425
PERICARDITIS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 426
Nursing Care of Clients with Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 426
Cardiovascular and Hematologic Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
VALVULAR HEART DISEASE . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
426
427
Disorders / 393 Stenosis and Insufficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . 427
Mitral Valve Prolapse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 427
CHAPTER 18: ASSESSMENT Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 427
OF THE CARDIOVASCULAR Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 429
SYSTEM / 395 Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 429
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 396 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 430
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CHAPTER 21: CARING FOR Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 462

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 463
CLIENTS WITH OCCLUSIVE
DISORDERS AND HEART CHAPTER 23: CARING FOR
FAILURE / 431 CLIENTS WITH HYPERTENSION / 464
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 432 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 465
CORONARY ARTERY DISEASE . . . . . . . . . . . . . . . . . . . . . . . . . . 432 Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 465
Arteriosclerosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 434 Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 466
Angina Pectoris . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 434 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 470
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 437
Acute Coronary Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . 441 CHAPTER 24: ASSESSMENT OF
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 441 THE HEMATOLOGIC SYSTEM / 474
Myocardial Infarction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 441 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 475
Anatomy and Physiology Review . . . . . . . . . . . . . . . . . . . 475
Blood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 475
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 444 Blood Types . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 476
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 444
Rh Factor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 477
HEART FAILURE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 445
Blood Transfusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 477
Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 446 Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 477
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 477
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 449
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 481
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 449
Cor Pulmonale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 450 CHAPTER 25: CARING FOR
Cardiac Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 451 CLIENTS WITH HEMATOLOGIC
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 451
DISORDERS / 482
CHAPTER 22: CARING FOR Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 483
CLIENTS WITH PERIPHERAL RBC DISORDERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 483
VASCULAR DISORDERS / 452 IRON DEFICIENCY ANEMIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 483
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 453 APLASTIC ANEMIA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 483
PERIPHERAL VASCULAR DISORDERS . . . . . . . . . . . . . . . . . 453
Aneurysm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 453 PERNICIOUS ANEMIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 484
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 454 ACQUIRED HEMOLYTIC ANEMIA . . . . . . . . . . . . . . . . . . . . . . . . 485
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 454 SICKLE CELL ANEMIA (INHERITED HEMOLYTIC
Venous Thrombosis/Thrombophlebitis . . . . . . . . . . . 456 ANEMIA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 485
Varicose Veins. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 459 POLYCYTHEMIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 490
Buerger’s Disease (Thromboangiitis Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 491
Obliterans) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 460 Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 491
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 461 WBC DISORDERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 492
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 461 LEUKEMIA .................................................. 492
Raynaud’s Disease/Phenomenon . . . . . . . . . . . . . . . . . . 461 Acute Leukemia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 492
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 462 Chronic Leukemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 493
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Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 493 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 530

Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 494 IMPAIRED URINARY ELIMINATION . . . . . . . . . . . . . . . . . 530
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 494 URINARY RETENTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 530
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 494 URINARY INCONTINENCE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 530
AGRANULOCYTOSIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 496 Stress Incontinence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 530
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 496 Urge Incontinence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 531
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 497 Overflow Incontinence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 531
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 497 Functional Incontinence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 531
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 497 Nocturnal Enuresis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 532
COAGULATION DISORDERS . . . . . . . . . . . . . . . . . . . . . . . . . 497 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 532
DISSEMINATED INTRAVASCULAR INFECTIOUS DISORDERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 532
COAGULATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 497 CYSTITIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 532
HEMOPHILIA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 499 OBSTRUCTIVE DISORDERS . . . . . . . . . . . . . . . . . . . . . . . . . 535
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 499 URINARY CALCULI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 535
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 500 Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 536
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 500 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 538
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 500 Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 538
THROMBOCYTOPENIA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 501 Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 538
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 501 URINARY BLADDER TUMORS . . . . . . . . . . . . . . . . . . . . . . . . . . . 539
PLASMA CELL DISORDER . . . . . . . . . . . . . . . . . . . . . . . . . . . 502 Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 540
MULTIPLE MYELOMA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 502 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 543
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 503 CHAPTER 28: CARING FOR
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 503 CLIENTS WITH RENAL
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 503 DISORDERS / 544
Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 503
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 545
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 504
INFECTIOUS DISORDERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 545
PYELONEPHRITIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 545
UNIT 7 Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 545
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 546
Nursing Care of Clients Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 546
with Renal and Urinary ACUTE GLOMERULONEPHRITIS . . . . . . . . . . . . . . . . . . . . . . . . . 547
Disorders / 513 Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 547
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 548
CHAPTER 26: ASSESSMENT Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 548
OF THE RENAL SYSTEM / 515 CHRONIC GLOMERULONEPHRITIS . . . . . . . . . . . . . . . . . . . . . . 550
Anatomy and Physiology Review . . . . . . . . . . . . . . . . . . . 516 Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 551
Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 519 Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 551
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 519
OBSTRUCTIVE DISORDERS . . . . . . . . . . . . . . . . . . . . . . . . . 552
Common Diagnostic Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . 519 RENAL TUMORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 552
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 528 Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 552
CHAPTER 27: CARING FOR
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 553
CLIENTS WITH URINARY Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 553
DISORDERS / 529 POLYCYSTIC KIDNEY DISEASE . . . . . . . . . . . . . . . . . . . . . . . . . . 555
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RENAL FAILURE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 555 Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 597

ACUTE RENAL FAILURE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 555 Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 597
Prerenal ARF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 555 Syndrome of Inappropriate Antidiuretic
Intrarenal ARF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 555 Hormone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 597
Postrenal ARF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 556 Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 598
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 557 Pituitary Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 599
CHRONIC RENAL FAILURE/END-STAGE Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 599
RENAL DISEASE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 561 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 600
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 564 HYPOPITUITARISM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 601
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 564 Simmonds’ Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 601
DIALYSIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 566 Diabetes Insipidus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 602
Hemodialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 566 Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 602
Peritoneal Dialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 567 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 602
Kidney Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 568 Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 602
Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 569 Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 602
Organ Rejection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 570 THYROID DISORDERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 604
Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 570 HYPERTHYROIDISM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 604
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 570 Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 605
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 607
UNIT 8
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 607
HYPOTHYROIDISM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 609
Nursing Care of Clients with Cretinism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 609
Endocrine Disorders / 577 Myxedema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 609
CHAPTER 29: ASSESSMENT OF
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 612
THE ENDOCRINE SYSTEM / 579 Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 612
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 580 Hashimoto’s Thyroiditis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 613
Anatomy and Physiology Review . . . . . . . . . . . . . . . . . . . 580 THYROID TUMORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 613
Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 583 CANCER OF THE THYROID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 613
Common Diagnostic Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . 585 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 614
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 593 GOITER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 614
PARATHYROID DISORDERS . . . . . . . . . . . . . . . . . . . . . . . . . 614
CHAPTER 30: CARING FOR HYPERPARATHYROIDISM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 614
CLIENTS WITH ENDOCRINE Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 615
DISORDERS / 594
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 615
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 595 Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 615
PITUITARY DISORDERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 595 HYPOPARATHYROIDISM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 616
HYPERPITUITARISM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 595 Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 617
Gigantism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 595 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 617
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 595 ADRENAL DISORDERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 618
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 595 CUSHING’S DISEASE/SYNDROME
Acromegaly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 595 (ADRENAL HYPERFUNCTION) . . . . . . . . . . . . . . . . . . . . . . . 618
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Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 620 Common Diagnostic Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . 660

Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 620 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 667
ADDISON’S DISEASE (ADRENAL
HYPOFUNCTION) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 621 CHAPTER 33: MANAGING
CLIENTS WITH NUTRITIONAL
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 621
DISORDERS / 668
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 621 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 669
PHEOCHROMOCYTOMA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 622 Normal Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 669
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 623 MyPlate Food Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 670
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 623 Enteral Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 673
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 623 Types of Feedings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 673
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 623 Administering Enteral Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . 674
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 623 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 675
NUTRITIONAL AND EATING DISORDERS . . . . . . . . 675
CHAPTER 31: CARING MALNUTRITION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 675
FOR CLIENTS WITH DIABETES Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 681
MELLITUS / 624 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 681
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 681
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 625 Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 681
DIABETES MELLITUS ..................................... 625 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 683
Diagnosis and Classification . . . . . . . . . . . . . . . . . . . . . . . . 625 OBESITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 683
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 626 Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 684
Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 626 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 684
Contributing Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 627 Bulimia Nervosa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 686
Acute Complications of Diabetes . . . . . . . . . . . . . . . . . . . . . . . 635 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 687
Chronic Complications of Diabetes . . . . . . . . . . . . . . . . . . . . 638 Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 687
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 640 ANOREXIA NERVOSA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 689
Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 642 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 689
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 642 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 689
CHAPTER 34: CARING
UNIT 9 FOR CLIENTS WITH UPPER
GASTROINTESTINAL
Nursing Care of Clients with DISORDERS / 690
Gastrointestinal Disorders / 649 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 691
STOMATITIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 691
CHAPTER 32: ASSESSMENT Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 691
OF THE GASTROINTESTINAL Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 691
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 691
SYSTEM / 651 Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 691
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 652 ORAL CANCER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 692
Anatomy and Physiology Review . . . . . . . . . . . . . . . . . . . 652 Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 692
Mouth/Pharynx/Esophagus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 652 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 693
Stomach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 653 Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 693
Small Intestine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 653 Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 693
Large Intestine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 653 ESOPHAGEAL VARICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 694
Accessory Organs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 653 Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 694
Effects of Aging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 655 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 696
Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 655 Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 696
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HIATAL HERNIA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 697 Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 721

Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 697 HERNIAS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 722
GASTROESOPHAGEAL REFLUX DISEASE . . . . . . . . . . . . 697 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 722
GASTRITIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 699 PERITONITIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 723
PEPTIC ULCER DISEASE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 701 HEMORRHOIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 725
GASTRIC CANCER. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 703 CONSTIPATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 727
GASTRIC SURGERIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 704 Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 727
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 704 Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 727
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 705 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 728
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 705 COLORECTAL CANCER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 729
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 706 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 729
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 729
CHAPTER 35: CARING Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 729
FOR CLIENTS WITH LOWER Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 730
GASTROINTESTINAL
DISORDERS / 707 CHAPTER 36: CARING FOR
CLIENTS WITH HEPATOBILIARY
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 708
APPENDICITIS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 708 DISORDERS / 731
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 708 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 732
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 708 HEPATITIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 732
DIVERTICULOSIS AND DIVERTICULITIS . . . . . . . . . . . . . . . 710 Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 734
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 711 LIVER ABSCESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 736
INFLAMMATORY BOWEL DISEASE. . . . . . . . . . . . . . . . . . . . . . 714 CIRRHOSIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 737
IRRITABLE BOWEL SYNDROME . . . . . . . . . . . . . . . . . . . . . . . . . 718 LIVER CANCER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 743
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 718 LIVER FAILURE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 743
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 719 Medical-Surgical Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 744
INTESTINAL OBSTRUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 720 Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 746
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 720 LIVER TRANSPLANT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 747
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CHOLECYSTITIS AND CHOLELITHIASIS . . . . . . . . . . . . . . . 748 UNIT 10

Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 750
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 750 Neurosensory Disorders / 787
Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 751
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 752 CHAPTER 39: ASSESSMENT OF
CHAPTER 37: CARING FOR THE NEUROLOGICAL SYSTEM / 789
CLIENTS WITH EXOCRINE Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 790
PANCREATIC DISORDERS / 753 Anatomy and Physiology Review . . . . . . . . . . . . . . . . . . . 790
Central Nervous System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 791
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 754 Peripheral Nervous System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 791
PANCREATITIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 754 Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 794
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 755 Health History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 794
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 757
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 804
Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 760
CANCER OF THE PANCREAS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 761
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 761 CHAPTER 40: CARING FOR
CLIENTS WITH BRAIN
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 763
DISORDERS / 805
CHAPTER 38: MANAGING Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 806
CLIENTS WITH A FECAL HEADACHE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 806
DIVERSION / 764 Primary Headaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 806
Tension-Type Headaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 806
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 765
Migraine Headaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 806
FECAL DIVERSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 765 Cluster Headaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 807
PROCEDURES USING THE ILEUM . . . . . . . . . . . . . . . . . . . . . . 765
Secondary Headaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 807
Ileostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 765 Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 807
Conventional Ileostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 765 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 808
Continent Ileostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 765 EPILEPSY/SEIZURE DISORDERS . . . . . . . . . . . . . . . . . . . . . . . 808
Ileoanal Reservoir . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 765 Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 808
Surgical Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 766 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 809
PROCEDURES USING THE COLON . . . . . . . . . . . . . . . . . . . . . 766 Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 809
Colostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 766 Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 809
Surgical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 767 PARKINSON’S DISEASE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 811
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 771 ALZHEIMER’S DISEASE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 814
STOMA CARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 773 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 816
PERISTOMAL SKIN CARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 774 Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 816
Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 775 Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 816
OSTOMY APPLIANCES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 775 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 818
IRRIGATION OF AN OSTOMY . . . . . . . . . . . . . . . . . . . . . . . . . . . . 775 HUNTINGTON’S DISEASE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 818
OSTOMY DIET ISSUES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 776 Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 819
DISCHARGE TEACHING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 777 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 819
Home Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 777 ENCEPHALITIS AND MENINGITIS . . . . . . . . . . . . . . . . . . . . . . . 819
Future Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 778 Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 819
Fecal Management System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 778 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 820
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 778 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 820
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CHAPTER 41: CARING FOR Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 853

Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 853
CLIENTS WITH SPINAL CORD GILLES DE LA TOURETTE’S SYNDROME . . . . . . . . . . . . . . 855
DISORDERS / 821 Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 855
HERNIATED INTERVERTEBRAL DISK . . . . . . . . . . . . . . . . . . 822 TRIGEMINAL NEURALGIA (TIC DOULOUREUX) . . . . . . 856
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 823
SPINAL CORD INJURY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 824 CHAPTER 43: MANAGING
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 826 CLIENTS WITH SENSORY
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 827 DISORDERS / 857
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 827
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 827 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 858
AMYOTROPHIC LATERAL SCLEROSIS . . . . . . . . . . . . . . . . . 830 Sensation, Perception, and Cognition . . . . . . . . . . . . . 858
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 830 Anatomy and Physiology Review . . . . . . . . . . . . . . . . . . . 858
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 830 Components of Sensation and Perception . . . . . . . . . . . . 859
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 830 Components of Cognition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 860
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 830 Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 861
MULTIPLE SCLEROSIS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 832 SENSORY, PERCEPTUAL, AND COGNITIVE
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 832 ALTERATIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 861
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 833 SENSORY DEFICIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 861
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 833 SENSORY DEPRIVATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 862
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 833 SENSORY OVERLOAD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 862
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 837 OTHER SENSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 863
TASTE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 863
CHAPTER 42: CARING FOR SMELL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 863
CLIENTS WITH NEUROLOGICAL TOUCH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 863
DISORDERS / 838 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 863
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 839 CHAPTER 44: ASSESSING AND

HEAD INJURY .............................................. 839 CARING FOR CLIENTS WITH EYE AND
Scalp . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 839
VISUAL DISORDERS / 864
Skull . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 839
Brain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 839 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 865
Open Injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 839 Anatomy and Physiology Review . . . . . . . . . . . . . . . . . . . 865
Closed Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 839 The Eye .................................................. 865
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 841 Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 866
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 842 DISORDERS OF THE EYE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 867
CEREBROVASCULAR ACCIDENT/TRANSIENT CATARACTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 869
ISCHEMIC ATTACKS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 843 Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 869
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 847 GLAUCOMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 871
BRAIN TUMOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 849 Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 872
Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 849 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 873
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 851 RETINAL DETACHMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 874
GUILLAIN-BARRé SYNDROME . . . . . . . . . . . . . . . . . . . . . . . . . . 853 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 875
DESIGN SERVICES OF
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INFECTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 876 OTITIS MEDIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 900

Keratitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 876 Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 900
Stye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 876 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 901
Chalazion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 877 Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 901
Conjunctivitis (Pink Eye) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 877 Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 901
REFRACTIVE ERRORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 877 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 901
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 877 OTITIS EXTERNA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 902
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 878 MASTOIDITIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 902
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 878
EYE INJURIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 878
Foreign Bodies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 878 UNIT 11
Chemical Burns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 878
IMPAIRED VISION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 879 Nursing Care of Clients with
AGE-RELATED MACULAR DEGENERATION . . . . . . . . . . . 879
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 879 Musculoskeletal Disorders / 911
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 880 CHAPTER 46: ASSESSMENT
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 880
OF THE MUSCULOSKELETAL
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 883
SYSTEM / 913
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 914
CHAPTER 45: ASSESSING Anatomy and Physiology Review . . . . . . . . . . . . . . . . . . . 914
AND CARING FOR CLIENTS WITH Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 917
EAR, AUDITORY, AND BALANCE Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 917
DISORDERS / 884 Common Diagnostic Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . 921
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 927
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 885
Anatomy and Physiology Review . . . . . . . . . . . . . . . . . . . 885 CHAPTER 47: CARING FOR
The Ear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 885
CLIENTS WITH MUSCULOSKELETAL
Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 886
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 886
TRAUMA / 928
Common Diagnostic Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . 888 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 929
DISORDERS OF THE EAR . . . . . . . . . . . . . . . . . . . . . . . . . . . . 891 MUSCULOSKELETAL TRAUMA . . . . . . . . . . . . . . . . . . . . . 929
IMPAIRED HEARING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 891 STRAIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 929
Types of Hearing Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 891 SPRAIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 929
Behaviors Indicating Hearing Loss . . . . . . . . . . . . . . . . . . . . . 892 DISLOCATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 930
Hearing Aids/Assistive Devices. . . . . . . . . . . . . . . . . . . . . . . . . 892 FRACTURE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 930
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 894 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 935
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 894 Nursing Management ................................... 937
MéNIÈRE’S DISEASE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 895 Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 937
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 895 RHABDOMYOLYSIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 938
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 895 COMPARTMENT SYNDROME . . . . . . . . . . . . . . . . . . . . . . . . . . . . 938
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 895 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 939
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 895 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 939
OTOSCLEROSIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 897
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 897 CHAPTER 48: CARING FOR
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 897 CLIENTS WITH MUSCULOSKELETAL
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 897
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 897
CONDITIONS / 940
ACOUSTIC NEUROMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 899 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 941
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 899 MUSCULOSKELETAL CONDITIONS . . . . . . . . . . . . . . . 941
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 899 AMPUTATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 941
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TEMPOROMANDIBULAR JOINT DISORDER . . . . . . . . . . . 945 TOTAL JOINT ARTHROPLASTY . . . . . . . . . . . . . . . . . . . . . 966
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 945 TOTAL HIP REPLACEMENT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 966
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 946 TOTAL KNEE REPLACEMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . 967
CARPAL TUNNEL SYNDROME . . . . . . . . . . . . . . . . . . . . . . . . . . . 946 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 967
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 947
BENIGN AND MALIGNANT BONE TUMORS . . . . . 947
OSTEOCHONDROMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 948
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 949 UNIT 12
OSTEOSARCOMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 949 Nursing Care of Clients with
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 949 Lymph, Immune, or Infectious
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 950 Disorders / 979
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 950
LYME DISEASE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 952 CHAPTER 51: ASSESSMENT
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 953
OF LYMPH AND IMMUNE
CHAPTER 49: CARING FOR FUNCTION / 981
CLIENTS WITH INFLAMMATORY Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 982
DISORDERS / 954 Anatomy and Physiology Review . . . . . . . . . . . . . . . . . . . 982
Lymphatic System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 982
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 955 Organs of the Immune System . . . . . . . . . . . . . . . . . . . . . . . . . 983
INFLAMMATORY DISORDERS . . . . . . . . . . . . . . . . . . . . . . . 955 Cells of the Immune System . . . . . . . . . . . . . . . . . . . . . . . . . . . . 983
RHEUMATOID ARTHRITIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 955 Types of Immunity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 984
BURSITIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 955 Factors Influencing Immunity . . . . . . . . . . . . . . . . . . . . . . . . . . . 985
OSTEOMYELITIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 956 Assessment of the Lymph System . . . . . . . . . . . . . . . . . 985
Assessment of the Immune System . . . . . . . . . . . . . . . 987
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 957
GOUT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 958
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 993
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 958
CHAPTER 50: CARING FOR CHAPTER 52: CARING

CLIENTS WITH DEGENERATIVE FOR CLIENTS WITH LYMPHATIC
DISORDERS / 959 AND PLASMA CELL
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 960
DISORDERS / 994
DEGENERATIVE DISORDERS . . . . . . . . . . . . . . . . . . . . . . . 960 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 995
OSTEOPOROSIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 960 LYMPH DISORDERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 995
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 960 HODGKIN’S DISEASE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 995
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 961 NON-HODGKIN’S LYMPHOMA . . . . . . . . . . . . . . . . . . . . . . . . . . . 999
OSTEOARTHRITIS (DEGENERATIVE JOINT Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 999
DISEASE) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 962 Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1000
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 962 Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1000
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 963 PLASMA CELL DISORDER . . . . . . . . . . . . . . . . . . . . . . . . . . 1001
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 963 MULTIPLE MYELOMA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1001
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 963 Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . 1002
DUCHENNE’S MUSCULAR DYSTROPHY . . . . . . . . . . . . . . . 963 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1002
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Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1002 Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1017

Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1002 Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1017
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1003 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1017
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1018
CLIENTS WITH IMMUNODEFICIENCY CHAPTER 54: CARING FOR
AND AIDS / 1004 CLIENTS WITH HYPERSENSITIVE
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1005 IMMUNE RESPONSE / 1019
HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1005 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1020
Demographics of AIDS in the United States . . . . . . . . . . 1006 HYPERSENSITIVE IMMUNE RESPONSE . . . . . . . . 1020
Modes of Transmission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1007 ALLERGIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1020
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . 1007 Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . 1021
PULMONARY OPPORTUNISTIC INFECTIONS . . . . . . . . 1008 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1022
Pneumocystis Carinii Pneumonia . . . . . . . . . . . . . . . . . 1008 Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1022
Histoplasmosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1008 Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1022
Tuberculosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1009 ANAPHYLACTIC REACTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1022
Nursing Management .................................. 1009 Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . 1023
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1009 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1023
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1009 Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1023
GASTROINTESTINAL OPPORTUNISTIC Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1023
INFECTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1010 TRANSFUSION REACTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1024
Mycobacterium Avium Complex . . . . . . . . . . . . . . . . . . . 1010 Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . 1025
Cytomegalovirus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1010 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1025
Cryptosporidiosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1010 Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1025
Hepatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1010 Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1025
HIV-Wasting Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1010 TRANSPLANT REJECTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1026
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1011 Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . 1026
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1026
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1011
ORAL OPPORTUNISTIC INFECTIONS . . . . . . . . . . . . . . . . . 1012 Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1026
LATEX ALLERGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1027
Oral and Esophageal Candidiasis . . . . . . . . . . . . . . . . . 1012
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1028
Oral Hairy Leukoplakia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1013
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1013
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1013
CLIENTS WITH AUTOIMMUNE
GYNECOLOGICAL OPPORTUNISTIC DISEASES / 1029
INFECTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1013 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1030
Vaginal Candidiasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1013 AUTOIMMUNE DISORDERS . . . . . . . . . . . . . . . . . . . . . . . . . 1030
Cervical Intraepithelial Neoplasia . . . . . . . . . . . . . . . . . 1014 RHEUMATOID ARTHRITIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1030
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1014 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1031
CENTRAL NERVOUS SYSTEM OPPORTUNISTIC Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1031
INFECTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1014 SYSTEMIC LUPUS ERYTHEMATOSUS . . . . . . . . . . . . . . . . . 1033
AIDS Dementia Complex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1014 Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . 1033
Toxoplasmosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1015 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1034
Cryptococcosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1015 Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1034
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1015 Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1034
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1015 MYASTHENIA GRAVIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1036
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1015 Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . 1036
OPPORTUNISTIC MALIGNANCIES . . . . . . . . . . . . . . . . . . . . . 1016 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1036
Kaposi’s Sarcoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1016 Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1037
Non-Hodgkin’s Lymphoma . . . . . . . . . . . . . . . . . . . . . . . . . . 1016 Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1037
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1016 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1039
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UNIT 13 Eczema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1081

Nursing Management .................................. 1081
Nursing Care of Clients Contact Dermatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1082
with Integumentary Dermatitis Venenata and
Disorders / 1047 Medicamentosa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1082
Exfoliative Dermatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1082
CHAPTER 56: ASSESSMENT Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1082
OF THE INTEGUMENTARY PSORIASIS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1083
SYSTEM / 1049 Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . 1083
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1050
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1084
Anatomy and Physiology Review . . . . . . . . . . . . . . . . . . 1050
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1084
Structures of the Skin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1050
ULCERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1085
Functions of the Skin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1051
VENOUS ULCERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1085
Structure and Function of Hair . . . . . . . . . . . . . . . . . . . . . . . . . 1052
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . 1085
Structure and Function of Nails. . . . . . . . . . . . . . . . . . . . . . . . 1052
Structure and Function of Mucous Membranes . . . . . . 1052
Effects of Aging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1052 Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1086
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1086
Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1053
PRESSURE ULCERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1087
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1053
Physiology of Pressure Ulcers . . . . . . . . . . . . . . . . . . . . . . . . . 1087
Common Diagnostic Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . 1057
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1064
CHAPTER 57: CARING FOR Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1095
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1095
CLIENTS WITH INTEGUMENTARY ALOPECIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1096
DISORDERS / 1065 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1096
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1066
Wounds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1066 CHAPTER 58: CARING
Physiology of Wound Healing . . . . . . . . . . . . . . . . . . . . . . . . . 1066 FOR CLIENTS WITH BURN
Types of Healing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1067
Kinds of Wound Drainage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1067
INJURY / 1097
Factors Affecting Wound Healing . . . . . . . . . . . . . . . . . . . . . . 1068 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1098
Wound Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1069 Burns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1098
Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1069 Major Causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1098
Nursing Diagnoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1070 Severity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1098
Planning/Outcome Identification . . . . . . . . . . . . . . . . . . . . . . 1070 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1100
Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1070 Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . 1101
Cleansing the Wound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1071 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1103
Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1072 Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1104
NEOPLASMS: MALIGNANT . . . . . . . . . . . . . . . . . . . . . . . . . 1072 Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1104
BASAL CELL CARCINOMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1072 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1108
SQUAMOUS CELL CARCINOMA . . . . . . . . . . . . . . . . . . . . . . . . 1072
MALIGNANT MELANOMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1072
CUTANEOUS T-CELL LYMPHOMA . . . . . . . . . . . . . . . . . . . . . . 1073
UNIT 14
Medical-Surgical Managment. . . . . . . . . . . . . . . . . . . . . . . . . . 1073
NEOPLASMS: NONMALIGNANT . . . . . . . . . . . . . . . . . . . 1074
INFECTIOUS DISORDERS OF THE SKIN . . . . . . . . 1074 Reproductive and Sexual Health
Disorders / 1113
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1074
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1074
INFLAMMATORY DISORDERS OF THE SKIN . . . 1081 CHAPTER 59: ASSESSMENT OF
DERMATITIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1081 THE REPRODUCTIVE SYSTEM / 1115
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Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1116 Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1143

Anatomy and Physiology Review . . . . . . . . . . . . . . . . . . 1116 Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1143
External Female Structures . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1116 MENSTRUAL DISORDERS . . . . . . . . . . . . . . . . . . . . . . . . . . . 1145
Internal Female Structures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1116 DYSMENORRHEA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1146
Male Reproductive Structures . . . . . . . . . . . . . . . . . . . . . . . . . 1117 AMENORRHEA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1146
Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1118 OTHER DISORDERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1146
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1118 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1146
Female Reproductive System Assessment . . . . . . . . . . . 1119 Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1146
Male Reproductive System Assessment . . . . . . . . . . . . . . 1120 Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1146
Common Diagnostic Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . 1122 PREMENSTRUAL SYNDROME . . . . . . . . . . . . . . . . . . . . . . . . . . 1147
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1129 Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . 1147
CHAPTER 60: CARING Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1147
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1147
FOR FEMALE CLIENTS WITH MENOPAUSE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1148
GYNECOLOGICAL DISORDERS / 1130 Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . 1148
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1131 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1149
INFLAMMATORY DISORDERS . . . . . . . . . . . . . . . . . . . . . . 1131 Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1149
PELVIC INFLAMMATORY DISEASE . . . . . . . . . . . . . . . . . . . . . 1131 Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1149
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . 1131 STRUCTURAL DISORDERS . . . . . . . . . . . . . . . . . . . . . . . . . 1150
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1132 CYSTOCELE, URETHROCELE, RECTOCELE,
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1132 AND PROLAPSED UTERUS . . . . . . . . . . . . . . . . . . . . . . . . . . 1150
ENDOMETRIOSIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1133 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1151
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . 1133 Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1151
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1135 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1152
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1135
VAGINITIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1135
CHAPTER 61: INFERTILITY AND
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1136 CONTRACEPTIVE METHODS / 1153
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1136 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1154
TOXIC SHOCK SYNDROME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1136 FUNCTIONAL DISORDERS AND CONCERNS . . 1154
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . 1137 INFERTILITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1154
BENIGN NEOPLASMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1138 CONTRACEPTION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1156
FIBROID TUMORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1138 NATURAL METHOD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1159
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . 1138 HORMONAL METHOD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1159
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1138 Oral Contraceptives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1160
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1138 Depo-Provera/Depo-SubQ Provera 104. . . . . . . . . . . 1160
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1138
Implanon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1160
MALIGNANT NEOPLASM . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1139 Mirena . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1160
CERVICAL CANCER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1139
Transdermal Patch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1160
Vaginal Ring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1160
Emergency Contraception Plan B . . . . . . . . . . . . . . . . . 1161
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1140
NONHORMONAL METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1161
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1140
ENDOMETRIAL CANCER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1141 Intrauterine Device . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1161
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . 1142 Barriers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1161
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1142 Spermicides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1161
OVARIAN CANCER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1143 Outercourse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1161
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . 1143 Sterilization Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1162
DESIGN SERVICES OF
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CHAPTER 62: CARING Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1188

Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1188
FOR CLIENTS WITH BREAST
STRUCTURAL DISORDERS . . . . . . . . . . . . . . . . . . . . . . . . . 1189
DISORDERS / 1163 HYDROCELE, SPERMATOCELE, VARICOCELE,
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1164 AND TORSION OF THE SPERMATIC CORD . . . . . . . 1189
BENIGN NEOPLASMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1164 Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . 1190
FIBROCYSTIC BREAST CHANGES . . . . . . . . . . . . . . . . . . . . . 1164 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1190
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1166 FUNCTIONAL DISORDER AND CONCERN . . . . . 1190
Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1166 IMPOTENCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1190
MALIGNANT NEOPLASM . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1167 Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . 1191
BREAST CANCER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1167 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1191
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1171 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1193
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1171
Breast Cancer in Men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1175
CHAPTER 64: ASSESSING
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . 1175 AND CARING FOR CLIENTS
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1175 WITH SEXUALLY TRANSMITTED
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1175 INFECTIONS / 1194
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1175
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1195
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1197
CHAPTER 63: CARING FOR MALE Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1197
CLIENTS WITH REPRODUCTIVE Common Diagnostic Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . 1198
DISORDERS / 1176 SEXUALLY TRANSMITTED INFECTIONS . . . . . . . . 1199
CHLAMYDIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1199
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1177
INFLAMMATORY DISORDERS . . . . . . . . . . . . . . . . . . . . . . 1177 GONORRHEA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1200
EPIDIDYMITIS/ORCHITIS/PROSTATITIS . . . . . . . . . . . . . . . 1177
SYPHILIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1201
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1178 GENITAL HERPES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1202
BENIGN NEOPLASM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1179 CYTOMEGALOVIRUS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1203
BENIGN PROSTATIC HYPERPLASIA . . . . . . . . . . . . . . . . . . . 1179 HUMAN PAPILLOMAVIRUS/GENITAL WARTS . . . . . . . . . 1203
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1181 AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1204
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1181 TRICHOMONIASIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1204
Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1182 HEPATITIS B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1205
MALIGNANT NEOPLASM . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1183 Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . 1205
PROSTATE CANCER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1183 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1205
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . 1183 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1207
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1185
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1185
TESTICULAR CANCER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1186 UNIT 15
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1187 Mental Health / 1217
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1187
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1187
PENILE CANCER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1188 CHAPTER 65: ASSESSING AND
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . 1188 CARING FOR CLIENTS WITH MENTAL
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1188 HEALTH DISORDERS / 1219
DESIGN SERVICES OF
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Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1220 Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1243

Mental Health and Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1220 Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1243
Relationship Development . . . . . . . . . . . . . . . . . . . . . . . . . . 1220 BIPOLAR DISORDER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1244
Trust . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1220 Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . 1244
Rapport . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1221 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1246
Respect. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1221 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1246
Genuineness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1221 Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1247
Empathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1221 Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1247
THE CLIENT EXPERIENCING A CRISIS . . . . . . . . . . 1221 PERSONALITY DISORDERS . . . . . . . . . . . . . . . . . . . . . . . . 1247
ANXIETY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1222 Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . 1249
Mild Anxiety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1222 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1249
Moderate Anxiety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1222 Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1249
Severe Anxiety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1222 Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1249
Panic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1222 THE CLIENT REQUIRING SPECIAL
ANXIETY DISORDERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1222 CONSIDERATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1250
GENERALIZED ANXIETY DISORDER . . . . . . . . . . . . . . . . . . 1222 ATTENTION-DEFICIT/HYPERACTIVITY
PANIC DISORDER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1222 DISORDER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1250
AGORAPHOBIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1222 Predominantly Hyperactive-Impulsive Type . . . . 1250
OBSESSIVE-COMPULSIVE DISORDER . . . . . . . . . . . . . . . 1223 Predominantly Inattentive Type. . . . . . . . . . . . . . . . . . . . . 1250
POST-TRAUMATIC STRESS DISORDER . . . . . . . . . . . . . . . 1223 Combined Type . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1250
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1224 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1252
SOMATOFORM DISORDERS . . . . . . . . . . . . . . . . . . . . . . . . 1226 NEGLECT AND/OR ABUSE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1253
SOMATIZATION DISORDER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1227 Elder Abuse and Neglect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1253
CONVERSION DISORDER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1227 Domestic Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1253
HYPOCHONDRIASIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1227 Rape . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1254
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1227 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1255
DEPRESSION DISORDERS . . . . . . . . . . . . . . . . . . . . . . . . . . 1228 EATING DISORDERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1256
Mild Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1228 Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . 1256
Moderate Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1228 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1257
Severe Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1228 Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1257
MAJOR DEPRESSIVE DISORDER . . . . . . . . . . . . . . . . . . . . . . 1228 Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1257
DYSTHYMIC DISORDER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1229 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1258
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1232 CHAPTER 66: CARING
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1232 FOR CLIENTS WITH SUBSTANCE
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1232
THE CLIENT WHO IS POTENTIALLY VIOLENT . 1234
ABUSE / 1259
Homicidal Intent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1234 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1260
Suicidal Intent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1234 Historical Perspectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1260
Suicidal Ideations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1235 Factors Related to Substance Abuse . . . . . . . . . . . . . 1261
Actively Suicidal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1235 Individual Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1261
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . 1235 Family Patterns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1261
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1237 Lifestyle. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1261
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1237 Environmental Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1262
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1237 Developmental Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1262
THE CLIENT WHO IS PSYCHOTIC . . . . . . . . . . . . . . . . . 1240 Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1262
SCHIZOPHRENIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1240 Diagnostic Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1262
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . 1241 Treatment/Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1263
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1243 Substance Use Patterns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1263
DESIGN SERVICES OF
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CENTRAL NERVOUS SYSTEM Potential for Addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1274

DEPRESSANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1263 Associated Problems/Disorders . . . . . . . . . . . . . . . . . . . . . . . 1274
ALCOHOL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1263 Withdrawal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1274
Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1264 Treatment/Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1274
Signs and Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1264 PHENCYCLIDINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1274
Potential for Addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1264 Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1274
Associated Problems/Disorders . . . . . . . . . . . . . . . . . . . . . . . 1264 Signs and Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1274
Withdrawal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1265 Potential for Addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1274
Treatment/Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1265 Associated Problems/Disorders . . . . . . . . . . . . . . . . . . . . . . . 1274
BENZODIAZEPINES AND OTHER Withdrawal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1275
SEDATIVE-HYPNOTICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1267 Treatment/Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1275
Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1268 OPIOIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1275
Signs and Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1268 Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1275
Potential for Addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1268 Signs and Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1275
MARIJUANA (CANNABIS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1269 Withdrawal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1276
Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1269 Treatment/Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1276
Signs and Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1269 INHALANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1277
Potential for Addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1269 Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1277
Associated Problems/Disorders . . . . . . . . . . . . . . . . . . . . . . . 1269 Signs and Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1277
JWH-018 (K2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1269 Withdrawal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1277
CNS STIMULANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1270 Treatment/Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1277
COCAINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1270 ECSTASY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1277
Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1270 Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1277
Signs and Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1270 Signs and Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1277
Potential for Addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1270 Potential for Addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1277
Associated Problems/Disorders . . . . . . . . . . . . . . . . . . . . . . . 1270 Associated Problems/Disorders . . . . . . . . . . . . . . . . . . . . . . . 1277
Withdrawal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1270 ANABOLIC STEROIDS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1277
Treatment/Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1270 Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1277
AMPHETAMINES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1270 Signs and Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1278
Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1271 Potential for Addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1278
Signs and Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1271 Associated Problems/Disorders . . . . . . . . . . . . . . . . . . . . . . . 1278
Potential for Addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1271 Withdrawal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1278
Associated Problems/Disorders . . . . . . . . . . . . . . . . . . . . . . . 1271 Treatment/Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1278
Withdrawal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1271 Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1278
Treatment/Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1271 Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1278
CAFFEINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1272 Nursing Diagnoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1279
Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1272 Planning/Outcome Identification . . . . . . . . . . . . . . . . . . . . . . 1279
Signs and Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1272 Nursing Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1279
Potential for Addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1272 Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1280
Withdrawal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1272 Codependency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1280
Treatment/Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1272 Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1280
NICOTINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1272 Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1280
Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1272 The Impaired Nurse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1280
Signs and Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1272 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1281
Potential for Addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1273 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1282
Associated Problems/Disorders . . . . . . . . . . . . . . . . . . . . . . . 1273
Withdrawal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1273 CHAPTER 67: CARING FOR
Treatment/Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1273 CLIENTS WITH PSYCHOBIOLOGICAL
METHYLPHENIDATE HYDROCHLORIDE
(RITALIN) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1273
DISORDERS / 1283
HALLUCINOGENS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1273 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1284
LYSERGIC ACID DIETHYLAMIDE . . . . . . . . . . . . . . . . . . . . . . . 1273 Depression in the Client with Chronic
Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1274 Illness and Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1284
Signs and Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1274 Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1284
DESIGN SERVICES OF
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CONTENTS xxvii
Pathophysiology of Stress and Depression . . . . 1284 Reproductive System: Female . . . . . . . . . . . . . . . . . . . . . . . . . 1336

Symptom Onset and Presentation . . . . . . . . . . . . . . . . . . . . 1285 Reproductive System: Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1337
Common Diagnostic Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1285 Integumentary System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1337
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . 1285 Financing Older Adult Care. . . . . . . . . . . . . . . . . . . . . . . . . . 1340
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1289 Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1340
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1289 Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1340
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1289 Omnibus Budget Reconciliation Act . . . . . . . . . . . . . . . . . . . 1341
Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1292 Balanced Budget Act of 1997 . . . . . . . . . . . . . . . . . . . . . . . . . . 1341
Delirium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1292 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1341
Pathophysiology of Delirium in the Medical-Surgical Affordable Care Act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1342
Client . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1292 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1342
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1294
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1294
UNIT 17
Dementia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1296
Pathophysiology of Dementia. . . . . . . . . . . . . . . . . . . . . . . . . . 1296 Special Considerations in
Symptom Onset and Presentation . . . . . . . . . . . . . . . . . . . . 1297 Medical-Surgical Nursing / 1347
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1300 CHAPTER 69: BIOTERRORISM
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1300 AND MASS CASUALTY CARE / 1348
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1302 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1349
Understanding Bioterrorism . . . . . . . . . . . . . . . . . . . . . . . . 1349
Biologic Agents Used in Terrorism . . . . . . . . . . . . . . . . 1349
UNIT 16 Anthrax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1351
Smallpox . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1352
Nursing Care of Older Adult Plague . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1353
Clients / 1313 Botulism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Viral Hemorrhagic Fevers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1354
1354
Tularemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1355
CHAPTER 68: HEALTH CARE Chemical Bioterrorist Agents . . . . . . . . . . . . . . . . . . . . . . . 1355
ISSUES OF THE OLDER ADULT / 1314 Ricin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1355
Sarin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1357
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1315 Nuclear Radiation Bioterrorism Agent. . . . . . . . . . . . . . . . . 1358
Gerontological Nursing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1315 Bioterrorism Preparedness . . . . . . . . . . . . . . . . . . . . . . . . . . 1359
Theories of Aging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1316 Government Agency Involvement . . . . . . . . . . . . . . . . . . . . . 1359
Myths and Realities of Aging . . . . . . . . . . . . . . . . . . . . . . . 1316 Emergency Response Teams . . . . . . . . . . . . . . . . . . . . . . . 1360
Health and Aging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1318 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1361
Activities of Daily Living . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1318 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1361
Exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1320
Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1320
Psychosocial Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . 1320 CHAPTER 70: EMERGENCY
Strengths . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1321 NURSING CARE PRINCIPLES
Health Promotion and Disease Prevention . . . . . . . . . . . 1321 AND TRIAGE / 1362
Physiological Changes Associated
with Aging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1322 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1363
Respiratory System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1322 Emergency/Disaster Preparedness . . . . . . . . . . . . . . . 1363
Cardiovascular System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1325 Approaches to Emergency Care . . . . . . . . . . . . . . . . . . . 1364
Gastrointestinal System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1326 Hospital Triage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1364
Urinary System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1327 Disaster Triage and Mass Casualty Incidents . . . . . . . . 1365
Musculoskeletal System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1329 SHOCK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1366
Neurological System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1330 CARDIOPULMONARY EMERGENCIES . . . . . . . . . . . . . . . . 1366
Sensory Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1332 Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . 1367
Vision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1332 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1368
Hearing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1333 Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1368
Endocrine System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1336 Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1368
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xxviii CONTENTS
NEUROLOGICAL/NEUROSURGICAL MULTIPLE-SYSTEM TRAUMA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 1385

EMERGENCIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1369 Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . 1386
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . 1369 Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1386
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1370 Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1386
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1370 Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1386
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1370 Legal Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1386
ABDOMINAL EMERGENCIES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1371 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1387
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . 1371 Death in the Emergency Department . . . . . . . . . . . . . 1387
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1372
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1372
GENITOURINARY EMERGENCIES . . . . . . . . . . . . . . . . . . . . . 1373 CHAPTER 71: APPLYING CRITICAL
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . 1373 THINKING WITH MULTIPLE
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1374 SYSTEMS / 1387
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1374
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1374 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1389
OCULAR EMERGENCIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1375 SYSTEMS REVIEWED IN DIABETES MELLITUS
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . 1375 MULTISYSTEM CASE STUDY . . . . . . . . . . . . . . . . . . . . . . . . 1389
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1375 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1389–1391
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1375 SYSTEMS REVIEWED IN GASTROINTESTINAL DISORDER
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1375 MULTISYSTEM CASE STUDY . . . . . . . . . . . . . . . . . . . . . . . . . 1391
MUSCULOSKELETAL EMERGENCIES . . . . . . . . . . . . . . . . . 1376 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1391–1392
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . 1376 SYSTEMS REVIEWED IN CIRRHOSIS
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1376 MULTISYSTEM CASE STUDY . . . . . . . . . . . . . . . . . . . . . . . . 1392
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1377 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1392–1393
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1377 SYSTEMS REVIEWED IN HYPERTENSION, HEART
SOFT-TISSUE EMERGENCIES . . . . . . . . . . . . . . . . . . . . . . . . . . 1377 FAILURE, AND CHRONIC RENAL FAILURE
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . 1378 MULTISYSTEM CASE STUDY . . . . . . . . . . . . . . . . . . . . . . . . 1394
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1378 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1394
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1378 SYSTEMS REVIEWED IN PARKINSON’S
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1378 DISEASE CASE STUDY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1395
POISONING AND DRUG OVERDOSES . . . . . . . . . . . . . . . . 1382 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1395
Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . 1382 SYSTEMS REVIEWED IN HEMATOLOGIC
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1382 DISORDER MULTISYSTEM CASE STUDY . . . . . . . . . . 1396
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1382 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1396–1397
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1382 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1397
ENVIRONMENTAL/TEMPERATURE
EMERGENCIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1383
Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1384 Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1405
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1385 Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1409
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1385 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1439
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CONTRIBUTORS
Patti Altman, MSN, RN Marty Downey, PhD, RN, AHN-BC, HTPA

Nursing Faculty Associate Professor
Northwest State Community College Boise State University
Archbold, Ohio Boise, Idaho
Chapter 14: Assessment of the Respiratory System Chapter 4: Complementary and Alternative Therapies
Chapter 15: Caring for Clients with Upper Respiratory
Tract Disorders Janice Eilerman, MSN, RN
Chapter 16: Caring for Clients with Lower Respiratory Assistant Professor of Nursing
Tract Disorders Rhodes State College
Chapter 17: Caring for Clients with Acute Respiratory Lima, Ohio
Disorders Chapter 56: Assessment of the Integumentary System
Chapter 57: Caring for Clients with Integumentary
Diane Behrens, MS, RNCS Disorders
Nurse Consultant Chapter 58: Caring for Clients with Burn Injury
Columbia City, Indiana
Chapter 38: Managing Clients with a Fecal Diversion Lynn M. Franck, MS, RN
Assistant Professor of Nursing
David W. Carroll, DNP, RN, PMHCNS-BC Rhodes State College
Brook Army Medical Center, Department of Behavioral Lima, Ohio
Medicine–Psychiatric Consultation/Liaison Service Chapter 26: Assessment of the Renal System
Adjunct Faculty at University of Texas Health Chapter 27: Caring for Clients with Urinary Disorders
Science Center Chapter 28: Caring for Clients with Renal Disorders
San Antonio, Texas
Chapter 67: Caring for Clients with Psychobiological Carol Greulich, MSN, RN, CNE
Disorders Assistant Professor Nursing
University of Saint Francis
Stephanie Dennison, MSN, RN Fort Wayne, Indiana
Blue Ridge Community College Chapter 39: Assessment of the Neurological System
Flat Rock, North Carolina Chapter 40: Caring for Clients with Brain Disorders
Chapter 33: Managing Clients with Nutritional Chapter 41: Caring for Clients with Spinal Cord
Disorders Disorders
Chapter 42: Caring for Clients with Neurological
Disorders
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xxx CONTribuTOrS
Christine Higbie, MSN, RN Rhoda Owens, MSN, RN

Nursing Faculty Site Manager/Instructor, Department of Nursing
Northwest State Community College Williston State College
Archbold, Ohio Minot, North Dakota
Chapter 14: Assessment of the Respiratory System Chapter 32: Assessment of the Gastrointestinal System
Chapter 15: Caring for Clients with Upper Respiratory Chapter 34: Caring for Clients with Upper
Tract Disorders Gastrointestinal Disorders
Chapter 16: Caring for Clients with Lower Respiratory Chapter 35: Caring for Clients with Lower
Tract Disorders Gastrointestinal Disorders
Chapter 17: Caring for Clients with Acute Respiratory Chapter 36: Caring for Clients with Hepatobiliary
Disorders Disorders
Chapter 37: Caring for Clients with Exocrine
Emily A. Hitchens, EdD, RN Pancreatic Disorders
Professor of Nursing Emerti
School of Health Sciences Linda Romines, MSN, RN
Seattle Pacific University Program Chair, Health Care Support
Seattle, Washington Ivy Tech Community College NE
Chapter 66: Caring for Clients with Substance Abuse Fort Wayne, Indiana
Chapter 2: Assessing Family Processes and Issues
Rebecca Jensen, PhD, RN Chapter 3: Communicating with Clients with Personal
Director of Simulation and Research, Assistant Professor and Family Issues
Indiana University–Purdue University
Fort Wayne, Indiana Carrie A. Stoller, MSN, RN, CNP
Chapter 12: IV Therapy Family Nurse Practitioner
Hospitalist Program
Eric Mason, MSN, RN St. Rita’s Medical Center
Chair, Nursing Division Lima, Ohio
Assistant Professor Chapter 6: Caring for Clients in Shock
Rhodes State College
Lima, Ohio Patricia R. Teasley, MSN, RN, APRN, BC
Chapter 11: Assessing and Caring for Clients Nursing Program Coordinator/Professor
with Acid–Base Disturbances Central Texas College
Killeen, Texas
Susan Mickey, PhD (c), MSN, RN, CNE, ACNS-BC Chapter 69: Bioterrorism and Mass Casualty Care
Penn State University: RN-BS Campus Coordinator
Schuylkill Campus
Schuylkill Haven, Pennsylvania
Chapter 1: Role of Medical-Surgical Nursing
Barbara Overman, MSN, RN

Coordinator, Practical Nursing Program
Rhodes State College
Lima, Ohio
Chapter 29: Assessment of the Endocrine System
Chapter 30: Caring for Clients with Endocrine
Disorders
Chapter 31: Caring for Clients with Diabetes Mellitus
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REVIEWERS
Nicole Adler, MSN, BSN, RN, CFNP Kim D. Cooper, MSN, RN

Mildred Elley Ivy Tech Community College
New York, New York Terre Haute, Indiana
Anne Anderson, MA, BA, RN Carolyn Du, MSN, BSN, RN, NP, CDE
Charter College Pacific College
Canyon Country, California Costa Mesa, California
Margaret P. Bennett, MEd, BSN, RN Laura R. Durbin, BSN, RN, CHPN

Eastern Shore Community College West Kentucky Community and Technical College
Melfa, Virginia Paducah, Kentucky
Lisa W. Blackburn, BSN, RN Penni Ellis, MSN, BSN, RN

Tennessee Technology Center at Elizabethton Mohave Community College
Elizabethton, Tennessee Bullhead City, Arizona
Terri B. Blevins, MSEd, BSN, RN Gwendolyn Gaston, MSN, RN

Tennessee Technology Center at Elizabethton Dallas Nursing Institute
Elizabethton, Tennessee Dallas, Texas
Priscilla S. Burks, MSN, BSN, RN Edith L. Gerdes, MSN, RN, BHCA

Hinds Community College Ivy Tech Community College–Elkhart
Pearl, Mississippi South Bend, Indiana
Dotty Cales, RN Margaret Gingrich, MSN, RN

Northcoast Medical Training Academy Harrisburg Area Community College
Kent, Ohio Harrisburg, Pennsylvania
Sherri Comfort Evelyn Grigsby, MSN, RN

Holmes Community College Bluegrass Community & Technical College–Danville
Goodman, Mississippi Campus
Danville, Kentucky
xxxi
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xxxii rEviEwErS
Janis E. Grimland, BSN, RN Charlotte Prewitt, MSN, RN

Hill College Meridian Technology Center
Clifton, Texas Stillwater, Oklahoma
Brenda J. Holmes, MSN, RN, ARNP Victoria Roehmholdt Koprucki, EdD, MSEd, MS
Savannah Technical College Nursing, CRRN
Savannah, Georgia Trocaire College
Buffalo, New York
Stephanie Holmes-Thomas, MSN, BSN, RN
Dallas Nursing Institute Amy Sherer, MSN/Ed, RN
Dallas, Texas Lincoln College of Technology
Toledo, Ohio
Catherine Hutcheson, BSN, RN
Mineral Area College Patricia Sunderhaus, EdDc, MSN, RN
Park Hills, Missouri Brown Mackie College
Cincinnati, Ohio
Alyson M. Keane, MS, RN
Southern Westchester BOCES Sharon Todd, BSN, ASN, RN
Elmsford, New York Southern Crescent Technical College
Griffin, Georgia
Carleen G. Kendall, RN
Pine Technical College Mary Pat Vetter
Pine City, Minnesota Professional Skills Institute
Toledo, Ohio
Sharron Knarr, RN
Northcoast Medical Training Academy
Kent, Ohio
DESIGN SERVICES OF
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PREFACE
M edical-Surgical Nursing: An Integrated Approach, Third

Edition, is a comprehensive examination of medical-
surgical nursing. Critical thinking skills, real-life client case
traditional single body system chapter presentation, which
can be overwhelming to read all at once. In this new edition,
the concepts are all brought back together in the end-of-unit
studies, and practical clinical activities help integrate nursing wrap-up, which provides summaries of each individual chap-
theory into professional licensed practical nursing (LPN) ter, learning activities, comprehensive references and web
licensed vocational nursing (LVN) practice. Providing thor- resources, and carefully constructed NCELX-style questions
oughly researched, in-depth information on medical condi- to help the student synthesize all of the information covered
tions and best nursing practice, this new edition addresses in the unit. Students have everything they need, tailored to
current health care topics in an easy-to-read, engaging how they want to learn.
format. The authors also wanted to present cutting-edge infor-
The LPN/LVN plays an essential role on the health mation on new equipment, technology, and practice based
care team. An LPN/LVN education lays the ground work to on research, yet emphasize the importance of taking the
competently care for clients or to move on to an advanced time to listen and provide warm, compassionate care to a
nursing education degree while working as a nurse. The learn- client. This text is balanced by presenting the latest informa-
ing opportunities in Medical-Surgical Nursing, Third Edition, tion and linking it with the psychosocial needs of medical-
facilitate critical thinking, which prepares students to solve surgical clients.
nursing problems and make competent, accurate, time-saving Clients are usually not alone when they enter a health
decisions. At the same time as it covers all of the medical- care facility. They are part of a family and community. This
surgical nursing information needed by a student to become a new edition discusses caring for the client in a family context
successful nurse, this text also highlights the many opportuni- and includes chapters on assessing the family structure to pro-
ties that abound in different work settings and equips students vide holistic care for the client. Medical-surgical conditions
to be successful in the ever-changing health care arena. are explored in depth with an emphasis on the older adult
and caring for clients in pain and those experiencing palliative
and end-of-life care. There is an emphasis on community and
CONCEPTUAL APPROACH home health care.
Medical-Surgical Nursing has a respected history of educating
and preparing students to be successful professional LPN/ ORGANIZATION OF THE TEXT
LVN nurses. However, as is true for all textbooks, with time
the information needed thorough revision to reflect new As highlighted earlier, Medical-Surgical Nursing: An Inte-
research and current practice. This became an exciting op- grated Approach, Third Edition, takes an innovative ap-
portunity for the authors to re-envision the text for today’s proach to the organization and presentation of information.
nursing student. Recognizing that students have more to learn Units of related information present smaller, more easily
at the same time that they have more demands on their time, digestible chapters that are wrapped in unit-specific infor-
the authors listened to what students want. This new edi- mation, such as NCLEX-style review questions, references,
tion has an innovative unit wrap-around presentation. Short and resources. Seventeen “wrap-around units” contain 71
chapters are grouped together in units, either by body system total chapters. These smaller chapters each present focused
or related concepts. As students study the overview of these information about a main concept. Driven by student feed-
systems, they can focus on conditions specific to one segment back, this organization facilitates better understanding and
of the body system. Shorter chapters are more easily grasped, a sense of accomplishment in completing reading assign-
and can be fit into several shorter study sessions versus the ments. Today’s student can mark progress in reading and
xxxiii
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xxxiv PrEfaCE
comprehending smaller sections of in-depth content and Unit 7, Nursing Care of Clients with Renal and Uri-
then synthesize all of the unit information by completing the nary Disorders, focuses on assessment and the disease pro-
end-of-unit activities. cesses and medical and nursing management associated with
An exciting new feature at the end of each unit, the The- urinary and renal disorders.
ory to Practice activity, reinforces chapter content in a real-life Unit 8, Nursing Care of Clients with Endocrine Dis-
situation. Students are encouraged to reevaluate their learning orders, addresses the medical and nursing care needed to
experiences through recall of concepts, introspection of clini- provide a comprehensive assessment of the endocrine system,
cal learning opportunities, and application of theory concepts care for clients with endocrine disorders, and care for clients
when interacting with staff or clients. Additionally, students with diabetes mellitus.
are provided with NCLEX-style questions that pull concepts Unit 9, Nursing Care of Clients with Gastrointestinal
from all the unit’s chapters together to challenge critical think- Disorders, features a detailed assessment of the gastrointes-
ing and understanding of the nursing process. tinal system with explanation of disorders affecting the upper
Each body system unit has an introductory chapter with gastrointestinal and lower gastrointestinal systems, hepatobi-
an anatomy and physiology review, recall of assessment tech- liary disorders, and exocrine pancreatic disorders. The nutri-
niques pertinent to the body system, and an explanation of tional needs of clients are explained with a review of the U.S.
diagnostic tests specific to the body system. The rest of the government’s new MyPlate dietary guidelines. The eating dis-
chapters in the unit explain the disorders within the body orders of malnutrition, obesity with bariatric surgery, bulimia
system. These chapters are designed to give an overview of nervosa, and anorexia nervosa are included in this discussion
the disorder and then present the medical and surgical care, of nutrition. Fecal diversions are discussed in depth.
pharmacological care, specific dietary needs, client activity Unit 10, Nursing Care of Clients with Neurosensory
precautions, and the nursing management according to the Disorders, combines discussions of the neurological system
nursing process. The nursing process identifies subjective and and sensory disorders. Brain, spinal cord, and neurological
objective data with health history questions, possible nursing disorders are covered in the neurological section and visual,
diagnoses, outcomes, interventions, rationales, and evalua- auditory, and balance disorders are covered in the sensory
tion. A sample nursing care plan is found in each chapter in section. Also included is a chapter on sensation, perception,
these units. and cognition, and the interrelatedness of the neurological
Unit 1, Introduction to Medical-Surgical Nursing, and sensory systems.
provides students with a solid understanding of the roles Unit 11, Nursing Care of Clients with Musculo-
and characteristics of the medical-surgical nurse, knowledge skeletal Disorders, describes assessment techniques for the
of assessment of family processes and issues, discussion of musculoskeletal system and details trauma care, musculo-
family diversity and culture, and effective communication skeletal conditions, inflammatory disorders, and degenerative
techniques frequently found in healthy functioning families. disorders of this system.
This unit provides stimulating and thought-provoking oppor- Unit 12, Nursing Care of Clients with Lymph, Im-
tunities to learn how to become a knowledgeable, competent, mune, or Infectious Disorders, details assessment of lymph
caring medical-surgical nurse. and immune function, and discusses care of clients with lym-
Unit 2, Concepts Integral to Medical-Surgical Nurs- phatic and plasma cell disorders, immunodeficiency, AIDS,
ing, provides a comprehensive presentation of various top- hypersensitive allergic responses, and autoimmune diseases.
ics integral to medical-surgical nursing. This unit discusses Unit 13, Nursing Care of Clients with Integumen-
complementary and alternative therapies, inflammation and tary Disorders, comprehensively covers assessment and the
infection, shock, pain, cancer, and palliative and end-of-life nursing care of clients with integumentary system disorders
care as applied to a medical-surgical client. including burns.
Unit 3, Nursing Care of Clients with Fluid and Elec- Unit 14, Nursing Care of Clients with Reproductive
trolyte Needs, addresses the homeostatic mechanisms neces- and Sexual Health Disorders, includes assessment and
sary to maintain fluid, electrolyte, and acid–base balance and nursing care for female and male clients with reproductive
discusses the care of clients undergoing IV therapy. Nursing disorders, and a detailed discussion of infertility, contracep-
concepts related to safe IV administration are covered. tive methods, characteristics of conditions and disorders that
Unit 4, Perioperative Nursing Care, takes the student commonly affect the breast, and common sexually transmit-
through the preparation of a client for surgery, the surgical ted infections.
experience, postanesthesia care and postoperative care in the Unit 15, Mental Health, addresses the specific and
clinical setting, and preparing a client for discharge. The em- unique issues of mental illness, substance abuse, and psycho-
phasis is on the postoperative nursing care of a client. biological conditions. The psychobiological chapter shows
Unit 5, Nursing Care of Clients with Respiratory Dis- how physical conditions can also manifest with psychological
orders, provides a comprehensive presentation of concepts symptoms. This chapter emphasizes the need for the com-
integral to respiratory assessment, upper respiratory tract, petent medical-surgical nurse to not only care for the client’s
lower respiratory tract, and acute respiratory disorders. physical problems, but his emotional needs as well.
Unit 6, Nursing Care of Clients with Cardiovascular Unit 16, Nursing Care of Older Adult Clients, explains
and Hematologic Disorders, has joined the cardiovascular assessment and nursing care for the older adult. Physiological
and hematologic body systems. This unit has two assessment changes of aging are presented for each body system.
chapters and a thorough discussion of dysrhythmias, inflam- Unit 17, Special Considerations in Medical-Surgical
matory and infectious cardiac disorders, occlusive disorders Nursing, explains the community, hospital, medical, and
and heart failure, peripheral vascular disorders, hypertension, nursing response in the event of a bioterrorist attack. Biologic,
and hematologic disorders. chemical, and nuclear agents are discussed in detail. A brief
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PrEfaCE xxxv
overview of the nursing care provided to various body systems Case Studies: Each unit has several real-life client sce-
in trauma situations is provided in the emergency chapter. The narios that describe disorders within the unit. These assist the
last chapter is distinct in that it presents several case studies reader in developing the critical thinking skills necessary to
that show how one disorder can affect multiple body systems. provide competent, individualized care to clients.
The students have a unique opportunity to expand their criti- Client Teaching: This feature provides suggestions and
cal thinking skills and explore a holistic approach to client care. specific content for the student to teach the client.
Collaborative Care: The health care system has many
FEATURES experts that work together to provide holistic client care. This
boxed feature shares the multiple departments and roles that
Each chapter includes a variety of learning aids to help the are often involved in providing client care, such as occupa-
reader understand key concepts. Supporting the main nar- tional therapy, physical therapy, speech therapy, radiology,
rative, these thoughtful pedagogical features help the reader and chemotherapy.
synthesize information, apply concepts to nursing practice, Community/Home Health Care: Tips are provided
and critically think to provide the best care for clients. to assist the student in offering community and home health
Learning Objectives are presented at the beginning of care. Teaching tips are provided for the student to use when
each chapter to help the student focus their study and use discharging a client from the acute care setting.
their time efficiently. Concept Care Maps: Each Sample Nursing Care Plan
Key Terms for each chapter identify the terms that are includes a concept care map for a nursing diagnosis. These
important for the student to know or learn for a better under- provide a visual picture of the nursing process.
standing of the subject matter. In addition, these terms are Concept Maps: Concept maps are visual diagrams that
defined in the glossary, and many are also found on the audio link medical and nursing facts about a disorder. These provide
glossary library on www.cengagebrain.com. a visual map so students can recall and relate important facts
Sample Nursing Care Plans are included in appropri- to real-life clinical practice.
ate chapters. These serve as models for students to refer to as Critical Thinking Questions: Critical thinking questions
they create their own care plans. Case studies call for students are scattered throughout the chapters to challenge students’
to draw on their knowledge base and synthesize information thinking and help them apply concepts to client situations.
to develop their own solution to realistic cases. Nursing Di- Cultural Considerations: Characteristics unique to
agnoses, Planning/Outcomes, Interventions, and Rationales are specific cultures are shared so the student can interact in a
presented in a convenient table format for quick reference. culturally sensitive manner and provide appropriate cultural
Theory to Practice: Within the Unit Summary, the nursing care.
Theory to Practice feature provides an opportunity to delve Drug Icons: These icons highlight new or special drugs
deeper into specific topics and apply the theory within the unique to a disorder.
clinical settings. These activities deepen the learning experi- Evidence-Based Practice: Research articles are cited in
ences and improve clinical critical thinking skills. Questions an understandable manner for easy application of evidenced-
and activities are provided to enhance the student’s clinical based practice.
experience. Infection Control: Instructions are given to avoid cross
NCLEX-Style Review Questions: Review questions at contamination and provide a safe, healthy environment of
the end of each unit are developed in the NCLEX format. This care.
assists in preparing the student for the NCLEX-PN exam and Informatics: Presents examples of current nursing sci-
provides an early review for the exam. ence and medical technology that is utilized in health care.
References/Suggested Readings let the student find Life Span Considerations: Each age group or life cycle
the source of the material presented and also provide addi- has specific needs that are unique to that time in life. This
tional information concerning topics covered. feature provides information so the student can relate to each
Resources are listed that provide the names and Internet age group and meet specific needs for their assigned client.
addresses of organizations specializing in a specific area of Memory Tricks: Mnemonics that students learn to re-
health care. call pertinent information.
Mental Health Connections: Encourages the nurse to
assess and be conscious of mental health needs that medical-
Special Features surgical clients may have related to their disease conditions.
In addition to the main pedagogical features, a rich array of Safety: The student is given instructions for providing
thoughtfully crafted feature boxes is included. These spe- safe, competent care.
cial features are used consistently throughout the text to
emphasize key points and provide specific types of detailed
information. NEW TO THE THIRD EDITION
Assessment Questions: These questions can be used as Those familiar with previous editions of Medical-Surgical
a guide when collecting subjective data during a client inter- Nursing: An Integrated Approach will quickly see how thor-
view and when obtaining objective data to assess the physical oughly the new edition has been updated and reorganized.
signs and symptoms pertinent to the client’s diagnosis. These In addition to the exciting new wrap-around unit organiza-
questions encourage the collection of more thorough data. tion, every line of the text has been reviewed and updated to
Best Practice: This feature offers professional tips and reflect the most current nursing information. Nursing and the
technical hints for the nurse to ensure that the best practice health care field are constantly evolving as new technologies,
care is being provided. treatments, drugs, and disorders change our understanding
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xxxvi PrEfaCE
of client care. To address these new concepts and technolo- the neurological systems and sensory organs, the HHIE-S
gies, seven new chapters were added to the third edition of testing tool, and cochlear implants. Many new diagnostic tests
Medical-Surgical Nursing: An Integrated Approach. The new for vision are included, macular degeneration is discussed
chapters are: in detail, and updated content is provided for cataracts and
Chapter 1: Role of Medical-Surgical Nursing glaucoma.
Chapter 2: Assessing Family Processes and Issues Chapter 58, Caring for Clients with Burn Injury, has
Chapter 3: Communicating with Clients with Personal added information that discusses the Lund-Browder clas-
and Family Issues sification system, the BAUX score method, and Parkland’s
Chapter 5: Inflammation and Infection formula. This chapter has been extensively updated to provide
Chapter 6: Caring for Clients in Shock current information about technology in burn care and nutri-
Chapter 67: Caring for Clients with Psychobiological tional support.
Conditions Chapter 65, Assessing and Caring for Clients with Mental
Chapter 69: Bioterrorism and Mass Casualty Care. Health Disorders, has an added discussion of agoraphobia in
Additionally, a special online-only chapter, Genetics, Ge- the anxiety section. Also added are discussions of the four
nomics, and Nursing, provides a brief review of genetics and classifications of medications for the treatment of anxiety,
explains how the Human Genome Project is affecting the binge-eating in eating disorder section, new content about
medical community, pharmacology, and nursing. This chap- communication and language in the schizophrenia section,
ter can be accessed at www.cengagebrain.com. and all new content covering personality disorders and psy-
In addition many chapters have been significantly revised chophysiological (somatoform) disorders.
and updated to reflect current knowledge, research, and prac-
tice. Some of the major revisions include the following:
Chapter 8, Cancer, provides information on updated EXTENSIVE TEACHING/
treatment modalities such as external and internal radiation LEARNING PACKAGE
therapy, biotherapy, photodynamic therapy, hormone ther-
apy; drugs commonly used in chemotherapy; and complica- The complete supplement package for Medical-Surgical Nurs-
tions of cancer treatment. ing: An Integrated Approach, Third Edition, was developed to
Chapter 11, Assessing and Caring for Clients with Acid– achieve two goals:
Base Disturbances, has received a major overhaul with new 1. To assist students in learning the information presented
content added for respiratory acidosis, respiratory alkalosis, in the text.
and metabolic acidosis. 2. To assist instructors in planning and implementing
Chapter 12, IV Therapy, provides current content on their programs for the most efficient use of time and
intravenous administration. resources and the best possible student outcomes.
Chapter 15, Caring for Clients with Upper Respiratory
Tract Disorders, has all new content and headings for the fol-
lowing disorders: deviated septum, allergic rhinitis, acute viral Instructor Resources
rhinitis, influenza, tonsillitis, laryngitis, pharyngitis, polyps,
foreign bodies, and sleep apnea. Instructor Resources to Accompany
In Unit 6, Nursing Care of Clients with Cardiovascular Medical-Surgical Nursing, Third Edition,
and Hematologic Disorders, all cardiovascular and hematologic CD-ROM
disorder sections were updated, and a section on acute coro-
nary syndrome was added. Minimally invasive surgery is also ISBN 13: 978-1-4354-8801-4
covered. The Instructor Resources CD-ROM has four components
Chapter 27, Caring for Clients with Urinary Disorders, to assist the instructor and enhance classroom activities and
includes new content addressing functional incontinence, discussion. Each component has been completely updated to
client teaching for bladder retraining and prevention of UTIs, reflect the comprehensive revisions of the core book, organi-
critical thinking questions, dietary changes for urinary stones, zation, current information, and numerous new features.
cultural considerations for bladder cancer, and client teaching
for the care of urinary diversions. Instructor’s Guide
Unit 9, Nursing Care of Clients with Gastrointestinal Disor- • Instructional Approaches: Ideas and concepts to help
ders, was updated to provide detailed assessment data for a client educators manage different presentation methods. Sug-
with a gastrointestinal disorder; new MyPlate dietary guidelines; gestions for approaching topics with rich discussions and
and added disorders including hiatal hernia, gastric cancer, liver lecture ideas are provided.
abscess, liver cancer, liver failure, liver transplant, and pancre-
atic cancer. All gastrointestinal disorder sections were updated • Student Learning Activities: Ideas for activities such as
with an extensive update to pancreatitis including a concept map classroom discussions, role plays, and individual assignments
that explains the pathophysiology of the disorder. have been designed to encourage student critical thinking as
Unit 10, Nursing Care of Clients with Neurosensory Dis- they engage with the concepts presented in the text.
orders, has added information on intrathecal chemotherapy, • Web Activities: Suggestions are given for student learning
chemotherapy disk-shaped wafers, Stroke Risk Scorecard, diet experiences online, including specific websites and accom-
therapy, positron emission tomography scanning and ablation panying activities.
procedures for Parkinson’s disease, and the sniff test to diag- • Additional Case Studies: Each unit provides an additional
nose Alzheimer’s disease, Parkinson’s disease, and other neu- case study with suggested answers that instructors can use
rodegenerative disorders. It explains the connection between for class discussion, quizzes, or other assignable activities.
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PrEfaCE xxxvii
• Suggested Responses to Chapter Case Studies: Through- CourseMate for Medical-Surgical Nursing,
out the book, students will find carefully crafted case studies
with accompanying critical thinking questions. Suggested Third Edition
answers for these critical thinking questions are included ISBN: 978-1-4354-8798-7
herein to help instructors evaluate student responses. Cengage Learning’s CourseMate brings course concepts to life
• Answers to NCLEX-Style Review Questions: Answers with interactive learning, study, and exam preparation tools
and rationales for all end-of-unit NCLEX-style questions that support the printed textbook. Watch reader comprehen-
are provided to help instructors quickly grade student sion soar as your class works with the printed textbook and the
work and review exams with students to enhance learning textbook-specific website. CourseMate goes beyond the book
opportunities. to deliver what you need! The CourseMate for Medical-Surgical
Nursing, Third Edition includes:
Computerized Test Bank • Interactive e-book with highlighting and note taking
• Following NCLEX style, a rich test bank of over 1,400 abilities.
questions challenges student retention and application of • NCLEX style quizzes for each unit providing additional op-
material in the text. portunities to test student comprehension of content.
• Answers and rationales for each question are provided. • Glossary games such as cross word puzzles and flash cards
• Allows the instructor to mix questions from each of the to challenge comprehension of important medical-surgical
chapters to customize quizzes and tests. terminology and increase comfort with new vocabulary.
• Engagement tracker allows instructors to see how much
Instructor Slides in PowerPoint time students spend in different components of the Course-
• A robust offering of presentation slides created in Power- Mate, which can be used to help remediate students who
Point outlines concepts from the text in order to assist the are struggling.
instructor with lectures. • Animations: Thirty-five multimedia animations of biologic,
• Over 1,400 slides are included. anatomic, and pharmacological processes. These engaging
• Ideas are presented to stimulate discussion and critical animations explain some of the more difficult concepts in
thinking. an easily accessible way.
• Video: Twenty high-quality video clips on topics ranging
Image Library from infection control to the cardiovascular and respiratory
A searchable image library provides more than 300 illustra- systems have been provided. These clips, many of which
tions and photographs that can be incorporated into lectures, were developed by Concept Media, are excellent support
class materials, and electronic presentations. resources for visualizing difficult processes and skills.
Medical-Surgical Nursing, Third Edition,

Student Resources WebTutor Advantage on Blackboard
Premium Website ISBN: 978-1-4354-8800-7
(www.cengagebrain.com) A complete online environment that supplements the course
This robust, password-protected website is designed provided in both Blackboard and WebCT format.
to maximize learning by providing additional resources and Includes unit overviews, competencies, and unit
multimedia tools in support of the concepts covered in Med- summaries.
ical-Surgical Nursing, Third Edition. Follow the directions on Useful classroom management tools include chats and
the printed access card bound into this text to log onto www calendars, as well as instructor resources such as the Exam-
.cengagebrain.com. In the student resources you’ll find the View Computerized Test Bank and instructor slides created
following great resources: in PowerPoint.
Animations: Thirty-five multimedia animations of bio-
• Studyware™ software with glossary games such as Concen- logic, anatomic, and pharmacological processes. These engag-
tration and Hangman, flash cards, and additional NCLEX- ing animations explain some of the more difficult concepts in
style review questions for each unit. You’ll also have access an easily accessible way.
to the Heart and Lung Sounds Review, a unique resource Video: Twenty high-quality video clips on topics ranging
to listen to actual, real-life audio of heart and lung sounds from infection control to the cardiovascular and respiratory
while reviewing the accompanying etiology and ausculta- systems have been provided. These clips, many of which were
tion definition. developed by Concept Media, are excellent support resources
• Bonus chapter on genetics. for visualizing difficult processes and skills.
• Audio Glossary: Link to the Mobile Media site for access to Audio Glossary: Link to the Mobile Media site for access
an alphabetical audio glossary of many of the terms in this to an alphabetical audio glossary of many of the terms in this
book. Download these audio files to your mobile device to book. Download these audio files to your mobile device to
study terms and pronunciations anytime, anywhere. study terms and pronunciations anytime, anywhere.
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ACKNOWLEDGMENTS
W e would like to thank the contributors for the time

and effort they gave to share their knowledge gained
through years of experience in both clinical and academic
to the success of this project. We extend a special thank you
to Steve Helba, executive editor, for his vision for this text.
Brooke Baker, content project manager, was a calm, steady
settings. Thank you for putting your fingerprint on nursing support throughout the production process. Your frequent
education. To the reviewers, thank you for taking time out e-mails will be missed. Jennifer Wheaton, editorial assistant,
of your busy schedules to review the chapters in this text. We was a bright spot in the day when she answered the phone
valued your suggestions and critiques that showed evidence of and then skillfully completed the task requested. Other mem-
your nursing experience and wisdom. bers on the team that we would like to acknowledge for their
We want to sincerely thank the entire team at Delmar diligent work on completing this text include Jack Pendle-
Cengage Learning who have worked to make this textbook ton, senior art director, who made the book look great, and
a reality. Juliet Steiner, senior product manager, receives a Michele McTighe, executive marketing manager, who works
special thank you for her expertise, guidance, and dedication so tirelessly to get the word out about the text.
xxxviii
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ABOUT THE AUTHORS
L ois Elain Wacker White earned a diploma in nursing from

Memorial Hospital School of Nursing, Springfield, Illinois; an
associate degree in science from Del Mar College, Corpus Christi,
program, she was instrumental in starting and obtaining state board
approval of an LPN-RN nursing program. She also assisted with
the development of an associate degree program at Ivy Tech Com-
Texas; a bachelor of science in nursing from Texas A & I Univer- munity College.
sity–Corpus Christi, Corpus Christi, Texas; a master of science in Her master’s research thesis was titled “An Investigation of
education from Corpus Christi State University, Corpus Christi, Learning Styles of Practical and Baccalaureate Students.” The
Texas; and a doctor of philosophy degree in education administra- results of the study were published in the Journal of Nursing Educa-
tion (community college) from the University of Texas, Austin. tion. The textbooks she has coauthored are Foundations of Nursing,
She has taught at Del Mar College, Corpus Christi, Texas, Foundations of Basic Nursing, Foundations of Adult Health Nursing,
in both the associate degree nursing program and the vocational Foundations of Maternal and Pediatric Nursing, two editions of Med-
nursing program. For 14 years, she was also chairperson of the ical-Surgical Nursing: An Integrated Approach, and two editions of
Department of Vocational Nurse Education. Dr. White has taught Transitioning from LPN/VN to RN: Moving Forward in Your Career.
fundamentals of nursing, nutrition, mental health/mental illness, Gena presented the topic Clinical Practicum: Ready or Not, at
medical-surgical nursing, and maternal/newborn nursing. Her pro- the Health Occupations Students of America 2010 Education Sym-
fessional career has also included 15 years of clinical practice. posium. She recently assisted with the development of the nursing
Dr. White has served on the Nursing Education Advisory Com- curriculum for the Delmar Cengage Learning Course 360. She has
mittee (NEAC) of the Board of Nurse Examiners for the State of been an active member of Sigma Theta Tau.
Texas and the Board of Vocational Nurse Examiners, which devel-
W
oped competencies expected of graduates for each level of nursing.
Serving as a National League for Nursing site visitor has given her endy Baumle is currently a nursing instructor at North-
insight into student and program needs that must be met to provide west State Community College, Archbold, Ohio. She has
the best in nursing education. spent 21 years as a clinician, educator, school district health coor-
dinator, and academician. Mrs. Baumle has taught fundamentals
G
of nursing, medical-surgical nursing, pediatrics, obstetrics, phar-
ena Duncan worked as an RN for 36 years as a clinician and macology, psychiatric nursing, anatomy and physiology, ethics,
educator. These experiences have equipped her with a wide nursing theory, transition, and bridge courses in practical nursing,
range of nursing experiences and varied skills to meet the educa- associate nursing, and advanced standing LPN to RN transition
tional needs of today’s students. She has a MSEd from Indiana Uni- nursing degree programs. She has previously taught at Lutheran
versity, Fort Wayne, and an MSN from Indiana Wesleyan University, College, Fort Wayne, Indiana, and James A. Rhodes State College
Marion. During her professional career, Gena served as a staff nurse, in Lima, Ohio. Mrs. Baumle earned her bachelor of science degree
assistant head nurse of a medical-surgical unit, continuing educa- in nursing from The University of Toledo, Toledo, Ohio, and
tion instructor, associate professor in an LPN, LPN-RN, and ADN master of science degree in nursing from The Medical College of
program, and director of an associate degree nursing program. She Ohio, Toledo.
has taught LPN, ADN, BSN, and MSN nursing students. As a faculty Mrs. Baumle is a member of a number of professional organiza-
member she taught foundations of nursing, medical-surgical nurs- tions, including Sigma Theta Tau, the American Nurses Association,
ing, maternal/pediatrics nursing, geriatrics, and community health the National League for Nursing (NLN), and the Ohio Nurses As-
nursing. She served on curriculum committees, a program evalua- sociation. She has obtained her Certified Nurse Educators certifica-
tion committee, National League for Nursing and Commission on tion from the NLN. Mrs. Baumle has co-authored four textbooks:
Collegiate Nursing Education accrediting review committees, and a Foundations of Nursing, Third Edition, Foundations of Basic Nursing,
statewide curriculum committee for Ivy Tech Community College, Third Edition, Foundations of Adult Health Nursing, Third Edition,
Fort Wayne, Indiana. As director of an associate degree nursing and Foundations of Maternal & Pediatric Nursing, Third Edition.
xxxix
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HOW TO USE
THIS BOOK
Introduction to Medical-
UNIT 1
Surgical Nursing
UNIT OPENER
1 Role of Medical-Surgical Nursing / 3
2 Assessing Family Processes and Issues / 17 Each unit opens with a list of chapters and an over-
UNIT X Title
3 Communicating with Clients with Personal
and Family Issues / 30 view of what you will learn. This provides a framework
for understanding all of the chapters of the unit as they
Nursing is constantly changing to meet the challenges of the 21st
century. Today’s nursing student has a tremendous opportunity to be
relate to each other.
a part of these changes in a variety of settings. Medical-surgical nurs-
ing is the foundation of and front line in nursing practice (Academy of
Medical-Surgical Nurses, 2011). This specialty area in nursing is chal-
lenging, on the cutting edge, and evolving with technology. The focus
of this unit provides stimulating, thought-provoking, and exciting op-
portunities to learn how to become a knowledgeable, competent, car-
ing medical-surgical nurse. The unit consists of the following chapters.
Chapter 1, Role of Medical-Surgical Nursing, provides an over-
KEY TERMS KEY TERMS

acupressure curing neurotransmitters
acupuncture energy therapies phytochemicals
Review this list before reading the chapter to familiar- allopathic free radicals psychoneuroimmuno-
alternative therapies healing endocrinology (PNIE)
ize yourself with the new terms and to revisit those antioxidant healing touch shaman
aromatherapy hypnosis shamanism
terms you already know. This will help improve your biofeedback imagery therapeutic massage
understanding of information in the chapter. bodymind
complementary therapies
meditation
neuropeptides
therapeutic touch
touch
LEARNING OBJECTIVES
Upon completion of this chapter, you should be able to:
LEARNING OBJECTIVES
1. Define key terms.
2.
3.
Describe the influences of history on current complementary and alternative modalities.
Discuss the connection between mind and body and how this affects a person’s health.
Read the chapter objectives before reading the chap-
4. Explain the concept of the nurse as an instrument of healing. ter to set the stage for learning. Revisit these when
5. Differentiate the various mind/body, body-movement, energy healing, spiritual, nutritional,
and other modalities that can be used as complementary therapies in client care. preparing for an exam to see which objectives you
6. Evaluate the use of complementary and alternative modalities.
can respond to with “Yes, I can do that.”
CRITICAL THINKING
Assessing Pain CRITICAL THINKING
A 38-year-old client is unable to rate his pain on a Consider these questions as you read the chapter.
0-to-10 scale. What actions should the nurse take
to perform a pain assessment on this client? They are an excellent opportunity to apply your criti-
(Teeter & Kemper, 2008a) cal thinking skills to the concepts presented.
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HOW TO USE THIS BOOK (Continued)
BESTPRACTICE
Use of Complementary/
Alternative Therapy BEST PRACTICE
Nurses wanting to use C/A therapies should:
• Ask the client if he or she is currently using C/A Use these boxes to increase your professional
and, if so, which therapy, the purpose of using
the therapy, and the outcome. competence and confidence and to expand your
• Educate the client about C/A prior to using it.
• Create a supportive environment of healing knowledge base.
conducive to C/A therapy.
• Obtain the necessary training, certification, or
licensure.
• Be aware of the potential risks.
• Provide nonjudgmental supportive counsel. LIFE SPAN CONSIDERATIONS LIFE SPAN CONSIDERATIONS
Elders and Pain
These boxes are included to increase your Older clients often live with pain, believing that
awareness of variations in care based on cli- nothing can be done. Pain often is not reported
by older clients because they fear being labeled
ent age and help you deliver more effective and a “bother” or “complainer.” A competent caring
nurse encourages the client to request pain relief
appropriate care. as needed.
COLLABORATIVECARE
COLLABORATIVE CARE
Respiratory Acidosis These boxes discuss other health care profes-
Collaborative care is important to effectively treat
a client diagnosed with respiratory acidosis. The
sionals who may be involved in the comprehen-
physician and nurse must work closely together to
ensure that the client receives appropriate care. It is
sive care offered to clients. Review these boxes
necessary for the physician and nurse to communicate and ask yourself if you understand how your role
effectively and exchange assessment data so that the
cause of the respiratory acidosis is quickly identified. as a nurse will complement the care provided by
When the cause is clearly diagnosed, the appropriate
treatment and interventions are implemented by the
others on the health care team.
health care team.
INFORMATICS INFORMATICS
This new feature presents examples of current Computer Imaging

for Rhinoplasty
nursing science and medical technology that are Computer imaging is a valuable tool being used
utilized in health care. by physicians to display potential results of
rhinoplasty to a client during consultation and
planning (Mühlbauer & Holm, 2005).
CLIENT TEACHING
CLIENT TEACHING
CLIENT TEACHING
GERD Read these boxes to gain insight into client learn-
• Lose weight as needed.
• Avoid fatty foods, alcohol, nicotine, caffeine,
ing needs related to the specific disorder or
milk products, and spicy foods. condition. You may want to make your own notes
• Take medications as instructed.
• Elevate head of the bed 4 to 6 inches on blocks, listing these teaching guidelines to use when you
eat small meals, and avoid lying down flat for
2 hours after eating.
are working with clients.
• Avoid wearing constrictive clothing.
INFECTION CONTROL
INFECTION CONTROL
When reading the chapter, stop and consider Epistaxis
these features. Ask yourself, “Had I thought of Wear gloves, goggles or a face mask, and a
gown when caring for a client with epistaxis.
that? Do I practice these precautions?” A cough or sneeze can splatter blood.
SAFETY SAFETY
Cold Medications
• Never give aspirin to children. It has been asso-
ciated with Reye’s syndrome (a rare but poten-
Pause while reading to consider these ele-
tially fatal illness). ments and ask yourself, “Do I take steps such as
• Be careful to read all cold medication labels.
Do not give a client two medicines with the these to ensure my own and the client’s safety?
same active ingredient, such as an antihista-
mine, decongestant, or pain reliever. Do I follow these guidelines in every practice
encounter?”
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COMMUNITY/HOME HEALTH CARE COMMUNITY/HOME HEALTH CARE

Tracheostomy Care
Home health care services provide tracheostomy These boxes offer valuable tips for effective pro-
clients with equipment, teaching, routine care,
suctioning, and medication administration to allow
fessional practice when making a home visit to a
clients with special needs to stay in their homes. client.
EVIDENCE-BASED
PRACTICE
African Americans and Hypertension
Source: Artinian, N., Flack, J., Nordstrom, C., Hockman, E.,
Washington, O., Jen, K., & Fathy, M. (2007). Effects of nurse-
managed telemonitoring on blood pressure at 12-month follow-
EVIDENCE-BASED PRACTICE up among urban African Americans. Nursing Research, 56(5),
312–322.
DISCUSSION
Read these overviews of research articles to African Americans develop hypertension at an earlier age and
incorporate evidence-based practice into your because of hypertension have higher rates of illness and death
than Caucasians. A 1-year research study from Wayne State
own nursing approach. University involved 387 African Americans who took their BP
three times a week on a home BP monitor and transmitted
the readings by phone (telemonitoring) to the research center.
The participants were divided into two groups. One group
(n 193) visited a primary care provider, received low-cost
medieations, and a hypertension brochure. The other group
(n 194) received phone calls from nurses who reviewed
their BP readings and provided support and needed informa-
tion to control their hypertension. At the end of the study,
both groups had lowered their BP, but the group that received
the regular phone calls had a reduction of 13 mm Hg systolic
pressure more than those who were referred to a primary care
provider.
IMPLICATIONS FOR PRACTICE
Telemonitoring technology provides a quality-based method
of reviewing clients’ BP. Perhaps clients would have better
quality care and outcomes if nurses provided close review of
telemonitoring BP readings, support, and taught quality life-
style changes. The results of this study may prompt nurses,
especially those working in physicians’ offices, to use telemon-
CULTURAL CONSIDERATIONS CULTURAL CONSIDERATIONS itoring technology, provide quality client support, and teach
hypertensive lifestyle changes.
Amish Families
When an Amish family member becomes ill and is
Improve your sensitivity to cultural and ethnic
hospitalized, it is common for the extended family
to come and stay until the family member is dis-
diversity by reviewing these boxes and incor-
charged. The Amish view illness as a disruption of porating the information into your practice. You
the entire family unit.
Although it may seem that they never leave, may also want to ask yourself what biases or
having close family around is important to the
Amish client’s well-being and will decrease the cli-
preconceptions you have about different cultural
ent’s anxiety. It is important for nurses to consider
that the more at ease the client feels, the faster she
practices, then use the information in these boxes
can start to heal. The nurse should try to incorpo- to modify your approach to clients.
rate the Amish client’s family into some of the care
if possible. For example, an elderly Amish female
client may feel more comfortable having a family
member bathe and dress her and comb her hair.
MEMORY TRICK
MEMORY TRICK CHANS
An easy memory trick to remember the five types
Use the mnemonic devices provided in the new of shock is CHANS.

C Cardiogenic
Memory Trick feature to help you remember the H Hypovolemic
correct steps or proper order of information when A Anaphylactic
working with clients. N Neurogenic

S Septic
MENTAL HEALTH
CONNECTIONS
Anxiety MENTAL HEALTH CONNECTIONS
A client in shock—whether it is hypovolemic, car-
diogenic, septic, neurogenic, or anaphylactic—
will experience a certain level of anxiety. The This box encourages you to assess and be con-
nurse needs to assess clients in shock for anxiety
and provide emotional support and nursing in- scious of mental health needs clients may have
terventions to help lower the client’s anxiety and
alleviate fears and concerns.
related to their disease conditions.
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CASE STUDY CASE STUDIES

Diabetes Mellitus
B.J. is a 68 year old who is obese and has type 2 diabetes. B.J. was admitted for care following diagnosis of
a UTI and uncontrolled diabetes mellitus. The following information is available upon admission: height
Consider the clients presented in these case studies. Draw on the
64 inches, weight 207 pounds, blood pressure 142/84, temperature 100.2° F (37.8°C), pulse 88 beats/
min, respiration 20 breaths/min. Admitting diagnoses include DM type 2, hypertension, peripheral vas- knowledge you have gained and synthesize information to develop
cular disease, impaired gait secondary to peripheral neuropathy, and urinary insufficiency with current
UTI. Current medications include Glucovance 1.25/250 twice daily, Lisinopril 10 mg daily, Furosemide
40 mg daily, Neurontin 200 mg twice daily, Plavix 75 mg daily, Crestor 30 mg daily, Rocephin Gm 1 daily
your own educated responses to the case study questions.
IV, sliding-scale insulin coverage per physician protocol. An IV of normal saline is infusing at 75 mL/hr.
Current diagnostic information includes FBS 252 mg/dL, white blood count 12,000 cells/mL, hemo-
globin 11.5 g/dL, hematocrit 37, BUN 32 mg/dL, creatinine 1.5 mg/dL, sodium 142 mEq/L, potassium
4.7 mEq/L, calcium 5.0 mEq/L, phosphorus 3.7 mg/dL, magnesium 2.25 mEq/L. Urinalysis reveals pH
7.2, specific gravity 1.015, protein 21 mg/dL, glucose positive, ketones negative, bilirubin negative, nitrite
positive, leukocyte esterase positive, RBC 5/hpf, WBC 7/hpf, casts none. Pending labs include liver panel
and lipid panel and urine culture.
Review the spider map (Figure 31-10) and care plan information in this chapter.
Answer the following questions:
1. What symptoms of diabetes would you anticipate the client would report? SAMPLE NURSING CARE PLAN
2. Review each section of the spider map (Figure 31-10) and identify appropriate nursing interventions
for each area of the map.
3. What are your priority nursing tasks?
4. Why is this client at risk for HHNS instead of DKA?
5. What symptoms of HHNS should the nurse observe for?
This feature provides a model for how to create a complete
6. What nursing interventions will help decrease the risk of development of HHNS?
nursing care plan for a specific client. Use this example
Nursing Care of Clients with Endocrine Disorders to test your understanding and application of the content
SAMPLE NURSING CARE PLAN presented. Ask yourself “Would I have come up with the
The Client with Hyperthyroidism same nursing diagnoses? Are these the interventions that I
would have proposed? What other interventions would be
A.J., 33 years old, has returned to her physician’s office to find out results of her tests for hyperthyroidism. She con-
tinues to have multiple concerns: “I have lost 15 pounds in the last month despite eating all the time. I am restless
and can’t sleep. I feel jittery and irritable. My family says my moods change so rapidly they don’t know what to ex-
pect from me. I feel so hot most of the time and sweat a lot.”
During assessment, the client appears flushed and her eyes protrude slightly. Her vital signs are temperature
100.6°F (38.1°C) orally, pulse 120 beats/min, respiration 26 breaths/min, and blood pressure 140/88 mm Hg. These VS
appropriate?”
are slightly elevated from her previous office visit. Test results confirm the presence of hyperthyroidism.
NURSING DIAGNOSIS 1 Imbalanced Nutrition: Less than Body Requirements related to increased metabolism as
evidenced by weight loss despite eating
Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)

Nutritional Status: Food & Fluid Intake Fluid Management
Nutritional Status: Nutrient Intake Nutrition Management
PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE
A.J. will eat a nutritionally balanced Monitor amount of food ingested Provides data to determine if
diet with enough calories to prevent and caloric intake. diet is adequate to prevent weight
weight loss. loss.
Monitor weight daily. Determines weight gains or losses.
Provide a diet high in calories, Maintains or increases weight while
protein, and carbohydrates. preventing muscle mass breakdown.
Advise A.J. to avoid highly sea- Prevents increased peristalsis,
soned or fibrous foods or foods resulting in diarrhea.
causing flatulence.
Provide small frequent meals Provides calories without extremely
spread over waking hours, up to large meals.
six meals per day.
Obtain nutritional consult as Ensures nutritional status.
needed.
EVALUATION
A.J. gained or maintained weight.
NURSING DIAGNOSIS 2 Hyperthermia related to increased metabolic rate as evidenced by reports of feeling
hot, flushing, and elevated temperature

Hydration Fluid Management
Thermoregulation
A.J.’s body temperature will be Assess for elevated temperature, Indicates increased heat production
within normal range. heat intolerance, and diaphoresis. from increased metabolic rate.
UNIT SUMMARY
Provide a well-ventilated room Promotes comfort if heat intolerant.
with temperature control.
Introduction to Medical-Surgical Nursing Suggest wearing cool, loose-fit- Provides comfort and prevents
ting, lightweight clothing. overheating.
Provide frequent bathing and Promotes comfort if diaphoretic.
UNIT SUMMARY changes in linens or clothing.
Provide fluids—up to 3 L/day. Replaces fluid if diaphoretic.
Carefully read the bulleted list to review key con-
• Characteristics of the medical-surgical nurse include orga- • Pharmacogenomics is an exploding field of research that
nization, prioritization, and critical thinking.
• Critical thinking is a systematic process of reasonable re-
evaluates how changes in genetic structure or organization
affect an individual’s response to a certain drug.
cepts discussed. This is an excellent resource
flective thinking that leads to an action or belief.
• Problem solving is taking facts and developing an entire
holistic picture.
• Several diseases are caused by an alteration in an individu-
al’s genetic makeup.
• The nurse’s role with a client who has a genetic disorder
when studying or preparing for exams. It also helps
• The nursing process is used to help guide the nurse in pro-
moting optimal client outcome, and is an ongoing process.
is supporting the client and family, relating accurate facts
about the genetic disorder, and referring the client to reli-
able resources for assistance.
bring the concepts from the different chapters back
• Critical thinking and problem solving can be taken to a
higher level by incorporating clarity, accuracy, precision,
relevance, depth, breadth, logic significance, and fairness.
• Families are diverse and, to be effective, the nurse shows
acceptance to all types of family units. together for comprehension and application.
• Director of care, caregiver, educator, and client advocate • Each family has its own culture.
are roles of the medical-surgical nurse. • Healthy family members love, support, encourage, and
• Standards of practice guidelines have been developed care for one another.
THEORY TO PRACTICE
from the nursing practice acts to direct nursing care. • In distressed families, basic needs are not met and mem-
• A code of ethics provides motivation for establishing, bers have poor communication techniques with ill-defined
maintaining, and elevating professional standards. roles. Family members are not treated with equal respect
• Evidence-based practice is nursing care that uses current or value.
best evidence that is supported by relevant valid research. • A family crisis can mean the destruction of the family
This new feature provides additional learning experi-

• The Quality and Safety Education for Nurses (QSEN) unit or the start of a pattern of using unhealthy defense
project established six competencies to prepare nurses mechanisms.
with the knowledge, skills, and attitudes (KSAs) necessary • The three styles of parenting are authoritarian, authorita-
to improve the quality and safety of health care systems.
• The six QSEN competencies are patient-centered care,
tive, and permissive.
• The individual who can adjust easily to frequent changes ences to improve clinical critical thinking skills. Con-
teamwork and collaboration, evidence-based practice and has a naturally easygoing approach to life will fare bet-
(EPB), quality improvement (QI), safety, and informatics.
• Nursing informatics is used in education, research, admin-
ter when faced with the inherent stress of parenting.
• A healthy functioning family communicates openly, hon-
sidering these questions will help you make the link
estly, kindly, and with candor in a trusting environment.
between learned nursing concepts and application
istration, and nursing practice.
• The Human Genome Project that was completed in 2003 • In some families, patterns of interaction passed from gen-
sequenced the genome, mapped the location of genes on eration to generation set the stage for dysfunction.
all chromosomes, and increased our understanding of the
human genome.
• Effective communication between the nurse and client is
based on a warm and genuine relationship. of effective nursing care.
• Genetics is the study of individual genes and their trans- • Productive confrontation can be an important part of the
mission of traits and single-gene disorders from one gen- communication process between the nurse and client if
eration to the next. this technique is used in a respectful, tactful, and non-
• Genomics is the study of all the genetic material and how threatening manner.
the genes interact with each other and the environment
including cultural and psychosocial factors. NCLEX-STYLE REVIEW QUESTIONS
THEORY TO PRACTICE
1. Consider the roles of the medical-surgical nurse. Interview and observe several medical-
Test your knowledge and understanding by answer-
surgical nurses during your clinical to see if they are actively functioning in all four roles.
Are medical-surgical nurses functioning in any other roles? If so, what are the roles and how ing these review questions with each chapter.
much time are they functioning in those roles? Which role does the nurse view as the most
important role in her job? In postconference, share and discuss as a group the results of the
observations and interviews. Compare and contrast your findings with each other.
These are an excellent way to test your mastery of
2. At the end of the clinical day, practice using SBAR or I-SBAR-R to NCLEX-STYLE
report off to the primary REVIEW QUESTIONS
nurse caring for your client. Organize and prioritize the client data that you need to share the chapter, and they provide a good opportunity
with the nurse.
to become familiar with answering NCLEX-style
1. Which of the following is the priority when organiz- 5. An example of a diverse family unit is the intergen-
3. According to the text, the family can contributeingto the
andgrowth of itsclient
prioritizing members
care? by promot- erational family. This type of family:
ing psychosocial development and growth, providing economic
1. Medication support, promoting health
administration 1. has neither parent available to raise the children
2. Collaboration
3. Client safety
and the grandparents assume responsibility.
2. consists of a married man and woman with questions.
4. Communication children.
2. Which of the following are steps in the nursing pro- 3. has children from one or both parents through
cess that guide nurses when problem solving? remarriage.
(Select all that apply.) 4. has more than two generations living in the same
1. Nursing diagnosis household functioning as a family.
2. Assessment 6. Characteristics of a healthy family include: (Select
3. Planning all that apply.)
4. Therapeutic communication 1. warmth and affection toward each other.
5. Evaluation 2. focusing on psychosocial needs.
6. Properly identifying client 3. silent treatment between members.
3. Creativity, autonomy, application of proactive nurs- 4. flexibility and adaptability to change.
ing expertise, critical thinking, and effective leader- 5. a demonstration of nonequal respect and value.
ship and management skills to ensure quality care 6. financial instability.
are attributes of which medical-surgical nursing 7. When assisting a client and her family through a cri-
role? sis, the nurse can: (Select all that apply.)
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Introduction to Medical-
UNIT 1
Surgical Nursing
1 Role of Medical-Surgical Nursing / 3
2 Assessing Family Processes and Issues / 17

UNIT
3
X Title
Communicating with Clients with Personal
and Family Issues / 30
Nursing is constantly changing to meet the challenges of the 21st

century. Today’s nursing student has a tremendous opportunity to be
a part of these changes in a variety of settings. Medical-surgical nurs-
ing is the foundation of and front line in nursing practice (Academy of
Medical-Surgical Nurses, 2011). This specialty area in nursing is chal-
lenging, on the cutting edge, and evolving with technology. The focus
of this unit provides stimulating, thought-provoking, and exciting op-
portunities to learn how to become a knowledgeable, competent, car-
ing medical-surgical nurse. The unit consists of the following chapters.
Chapter 1, Role of Medical-Surgical Nursing, provides an over-
view of the characteristics of the medical-surgical nurse. Concepts
presented include roles of the medical-surgical nurse, critical thinking,
and problem solving. The learner is provided with detailed discussions
about nursing standards of practice, codes of ethics, evidenced-based
practice, the Quality and Safety Education for Nurses (QSEN) program,
informatics, and genetics.
Each client is an integral part of a family unit. Chapter 2, Assess-
ing Family Processes and Issues, discusses the diversity and culture of
each family. Healthy functioning families and distressed families have
similarities and differences, but the healthy families have valuable cop-
ing skills that help them effectively handle life situations. Parenting is a
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learned skill and a healthy family does not strive for perfection. Parent-
ing styles are learned and often passed from one generation to the next.
However, individuals can choose the style that best fits them and their
children. Nurses serve as valuable guides to direct families to resources
that can meet specific needs.
Chapter 3, Communicating with Clients with Personal and Family
Issues, presents effective communication techniques frequently found
in healthy functioning families and also provides descriptions and ex-
amples of counterproductive communication traits. Nurses are often
faced with challenging situations when working with distressed families,
so several examples are provided of productive confrontation with family
members.
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CHAPTER 1
Role of Medical-Surgical
Nursing
KEY TERMS
accuracy expected outcome pharmacogenomics
assessment fairness planning
breadth genetics precision
certification genomics problem solving
clarity implementation relevance
critical thinking logic significance
depth nursing diagnosis standards of practice
evaluation
LEARNING OBJECTIVES
2. Examine the essential characteristics needed to succeed as a medical-surgical nurse.
3. Discuss the relationship of critical thinking and problem solving to nursing.
4. Differentiate between the nurse’s roles as director of care, caregiver, educator, and client
advocate.
5. Outline the various professional organizations and certifications available to a medical-
surgical nurse.
6. Compare nursing standards of practice and codes of ethics.
7. Explain the role of evidence-based practice in nursing.
8. Discuss the impact the Affordable Care Act has had on informatics in health care.
9. Discuss the genetic and genomics connections to genetic disorders.
10. Discuss the impact of genetics and genomics on nursing practice.
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4 UNIT 1 Introduction to Medical-Surgical Nursing
(© Monkey Business iMages/shutterstock)

Figure 1-1 Medical-surgical nurses at the forefront of
the adult health care industry are problem solvers and critical
thinkers.
(© andresr/shutterstock)
INTRODUCTION
Medical-surgical nurses are on the forefront of the adult
health care industry. This specialty area in nursing requires
the essential characteristics of prioritization and organization,
critical thinking, and innovative problem solving (Figure 1-1).
The roles of the medical-surgical nurse include director of
Figure 1-2 Nurses work together for the benefit of the
client.
care, caregiver, educator, and client advocate. Nurses need to
be knowledgeable regarding evidence-based practice, qual-
ity and safety competencies, informatics, and genetics to be be using Maslow’s hierarchy of needs and asking oneself
able to function in the changing health care delivery system. which client has the greatest need that should be met first.
As health care continues to change, so does the role of the Experienced nurses also have their own unique method
medical-surgical nurse. of organizing their workload for the shift. New nurses should
consult experienced nurses and ask how they organize their
shift workload. Typically, experienced nurses use an organiza-
CHARACTERISTICS OF THE tion sheet or tool. Figure 1-3 displays a useful tool novice and
MEDICAL-SURGICAL NURSE student nurses can use to organize medication administration,
client care, labs and testing, and treatments. Various names
According to the Academy of Medical-Surgical Nurses for this tool include “Med Minder,” “Brain Sheet,” or “Shift
(AMSN) (2011, p. 1), “Medical-surgical nursing has evolved Organizer.” Novice nurses can take this Brain Sheet tool to the
from an entry-level position to an adult health specialty. It is clinical setting and use it to organize their client assignment.
no longer viewed as a stepping-stone, but is the solid rock and Nurses will find it easier to prioritize care if they have an orga-
the backbone of every institution.” Medical-surgical nursing nized plan for handling their workload.
requires the essential characteristics of prioritization and or- Communication skills, both verbal and written, are essen-
ganization, innovative problem solving, and critical thinking. tial for client safety. A standardized communication format
These characteristics assist a nurse in caring for clients with that is used in health care and nursing education to promote
various medical conditions and surgical procedures. client safety is SBAR (situation, background, assessment,
and recommendation). Nurses utilize SBAR to organize and
Prioritization prioritize important client data when calling a health care
provider to obtain orders and/or to update the health care
and Organization Skills provider on a client’s condition. Nurses also use SBAR when
Prioritization of care and organization of workload go hand- giving an end-of-shift report. Utilizing SBAR promotes client
in-hand and often present a challenge to the novice medical- safety and continuity of care.
surgical nurse. Novice nurses can collaborate with experienced Grbach, Vincent, and Struth (2008) proposed reformulat-
nurses on how to prioritize client care (Figure 1-2). When a ing SBAR to become I-SBAR-R (identification of self and client,
new nurse begins his first clinical experience, he often has dif- situation, background, assessment, recommendation, and read-
ficulty deciding and prioritizing which client to care for first. back). They suggested this change because they found several
For example, a nurse is assigned two clients with 0800 medica- important components, such as the nurse identifying herself and
tions. Which client will the nurse give the 0800 medication to the client when calling a health care provider, were missing from
first? Collaborating with an experienced nurse can help guide SBAR. Also added to SBAR is readback, in which the nurse reads
and assist the novice nurse in learning methods for prioritizing back the order that was given by the health care provider for clar-
client care. Such methods could include following the rule of ity before ending the communication. For more information on
CAB (circulation, airway, breathing). Another method would I-SBAR-R visit http://www.qsen.org.
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CHAPTER 1 Role of Medical-Surgical Nursing 5
Room
#/Client Medication
Information Times Labs/Testing Treatments Vitals Misc.
B.D. 127A 0800 Dressing Time BP T P R SpO2 Pain I-1375

-Diabetic 1200 Accucheck Change 0730 136/ 99.3 88 18 99% 4
-Cellulitis 1500 prn 98 O-800
Figure 1-3 Example of a Brain Sheet created by a nursing student to use in the clinical setting. (courtesy of Brenna dunhaM)
At the end of each shift, the nurse should complete a final

MEMORY TRICK checklist to ensure that all of the client’s health care needs
have been met and are communicated to the oncoming nurse.
i-SBAR-R Using a final checklist sheet helps the nurse organize and
To promote client safety and continuity of care, an prioritize the client information. Box 1-1 displays a useful tool
excellent practice is for the nurse to use I-SBAR-R that can serve as a check-and-balance approach for the end
when contacting a health care provider for an or-
of shift.
Health care requires collaboration with multiple mem-
der. Using I-SBAR-R aids in organizing and priori-
bers of the health care team. Communication regarding cur-
tizing important client data. rent client status and the ongoing plan of care is essential.
I 5 Identification of self and client One method of communication is achieved by shift
S 5 Situation
report. Initially, organizing a solid and comprehensive shift
report can be challenging. Box 1-2 provides a tool for outlin-
B 5 Background ing essential elements to be included in a shift-to-shift report.
A 5 Assessment
R 5 Recommendation Critical Thinker
R 5 Readback
The nursing profession requires critical thinking and problem-
solving skills to provide safe nursing practice and quality
(Grbach, Vincent, and Struth, 2008) client care. One must “reprogram” the mind to think as a
nurse so the client achieves the best outcome. As a student
BOX 1-1
End-of-Shift ChECkliSt
Before you leave the unit at the end of the shift, Intravenous Fluids (IV)
make sure that you have completed the following • When will the client’s next IV bag be due? If
checklist. present IV bag will run out in first 2 hours of
1. Check your clients. oncoming shift, it is safe practice to have a
• Is each client comfortable? replacement bag available.
• Pain needs met? • Assess the client’s IV sites and chart the
• Toileting needs met? appearance of the IV site, and the type and
• Nutrition needs met? amount of IV fluid being administered.
• Safety requirements met (call light within 5. Have all of the client’s lab results been received
reach, side rails up as ordered, etc.)? or are the results pending? Do any of the lab
2. Check that the physician’s orders have been in- results need to be reported to the physician?
stituted and signed off. 6. Have all of the client’s radiology and/or cardi-
3. Complete and chart data collection and client care. ology reports been received or are the results
4. Complete specialized flow sheets for your shift. pending? Do the results of the radiology and/or
Vital Signs cardiology reports need to be reported to the
• Have vital signs been charted? physician?
• Have abnormal vital signs been addressed? 7. Have all ordered medications been adminis-
• Does the oncoming shift know when the tered? If a medication has been held or refused,
next set of vital signs is due? has the proper documentation been completed
Intake and Output according to agency policy?
• Has intake and output been calculated, eval- 8. Have issues pertinent to client care been
uated, and recorded? addressed?
• Does there need to be an intervention? 9. Complete report for oncoming shift.
Fluids? Diuretic?
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BOX 1-2
Shift-to-Shift REpoRt GuidElinES
1. Client name, age, and room number • Transfer to lower level care area
2. Attending physician and consulting physicians • Discharge instructions/needs
3. Admitting diagnosis • Follow-up visit schedule
4. Pertinent past medical and surgical history • Lab tests needed postdischarge
5. Pertinent current medical data for the shift 11. Issues that need addressing within the first
(Example: 1630 before dinner, diabetic blood 2 hours of the next shift (Example: Client is
glucose fingerstick result and amount of insulin going to Cardiac Catheter lab at 0800 or OR at
administered per client’s insulin sliding scale) 0845)
6. Day in admission or day postop 12. Issues that your shift has not been able to at-
• Number of day admitted to or within facility tend to (Example: Physician orders still need to
in expected length of stay (e.g. Day 1) be taken off the chart)
7. Review of systems (respiratory, cardiovascular, 13. Current plan for the client (Example: Expected
neurological, urinary, etc.) discharge date)
8. Include changes to plan of care or clinical path- Final Thoughts to Remember
way and teaching needs • Nurses provide 24-hour continuity of care.
9. Diagnostic test results: • Relaying pertinent information will ultimately
• Normal and abnormal values benefit the client.
• Pending lab results for oncoming shift • Addressing the client’s needs in a timely man-
10. Issues that need addressed on physician rounds: ner will benefit the client.
• Coumadin order
• Discharge planning begins at admission.
• Abnormal tests results
• Providing a smooth informed transition from
• Change in condition
• Home medications that need evaluation for shift to shift will benefit the health care team’s
current hospitalization commitment to the client.
• Consults needed: social service, home health
care, physical therapy, etc.
nurse, caring for one or two clients, the importance of critical So, why does it matter if the client is or is not allergic to
thinking may not be fully understood. However, having only morphine? Why not ask the medical doctor for something else
one or two clients allows the student nurse to begin the jour- and move on to the next question?
ney toward developing critical thinking and problem-solving Some nurses write a reaction of nausea as an allergy to
skills. The student nurse needs to understand that critical prevent discomfort for the client. A critically thinking nurse
thinking cannot be memorized but must be learned during recalls that morphine given during a heart attack can decrease
daily care of assigned clients. injury to the heart. So, it is important to determine if the client
has a true allergic reaction to morphine, or is just experiencing
a side effect. If morphine is placed on the client’s records as
Innovative Problem Solver an allergy and at a future date the client comes into the emer-
Problem solving is the process of taking information that gency department having a heart attack, the client may be
has been uncovered and clarified and systematically pro- deprived of a medication that could aid lifesaving measures.
cessing it to find an acceptable resolution to problems. To A nurse may obtain faulty information when questions
problem solve, data must be gathered, organized, analyzed, asked are too broad or focused on the wrong issue or con-
and conclusions drawn. When problem solving, the individual cerns. For example, when assigned a client who has left-sided
continues to ask questions throughout the process. Asking weakness, a student will often explain the client’s data col-
questions clarifies data in an attempt to obtain accurate in- lection findings in relation to nerve damage. Looking at the
formation. For example, if the client states a morphine allergy problem, left-sided weakness does appear to be the subject
on admission to the hospital, the nurse should not take this and nerve damage is involved, but not the cause. The student
at face value and write it as an allergy on the client’s chart. continues to ask questions in order to find the cause of nerve
Instead, the nurse asks, “What happens when you take mor- damage. Usually the nerve damage is traced to a blood clot
phine?” The client may reply, “I vomit.” Vomiting can be a that stopped blood flow in the brain causing tissue death and,
discomfort frequently associated with taking narcotics, so the consequently, nerve damage. Therefore, the plan of care is
nurse should continue to question, “Does anything else hap- based on knowledge that the client had a stroke (a circulatory
pen when you take morphine?” If the client states,“Yes, I break problem) and not focused on the neurological aspects alone.
out in hives,” then that is a true allergic reaction. On the other These data are vital as the nurse may then assist the client to
hand, if the client denies other signs and/or symptoms, there nutritional awareness and the need to exercise and possibly
is no actual allergy. prevent or delay future strokes or a heart attack.
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language or verbalization of those in the room confirm or

CRITICAL THINKING call into question what the client is telling me?” The nurse
Critical thinking is the process of uncovering and clarify- would then take into consideration objective, subjective, and
ing information to make accurate judgments. Critical think- secondary data and make an unbiased judgment based on
ing and problem-solving skills learned during the student fact and allowing for unknown variables. The nursing student
educational experience are the basis of providing safe, quality must move from concrete thinking to a more complex process
client care. Critical thinking involves obtaining and using in- of assessing and collecting data and drawing conclusions.
formation by asking who, what, when, where, and how. Critical
thinking also asks if the information is true, accurate, and if Nursing Diagnosis
variables have a bearing on the data collected. If the process The North American Nursing Diagnosis Association
of gathering data is flawed, the information used to problem (NANDA) (2009) is an international group that classifies
solve could lead to an inaccurate conclusion. nursing diagnoses. Nursing diagnoses are not the same as
medical diagnoses. A nursing diagnosis is formulated by
Critical Thinking gathering physical, psychological, social, emotional, and spiri-
tual data. Nursing diagnoses may be actual or potential client
and Problem Solving problems. Medical diagnoses can only be made by a physician,
Require Discipline or appropriate licensed individual, and is based on a specific
Critical thinking and problem solving require an individual pathological disease process being experienced by the client.
to put aside religious and political views, racial bias, and After the nurse gathers data, the information is prioritized
anything else that could cloud a solid unbiased judgment. To and a nursing diagnosis is chosen. The ability to prioritize data
ensure that unbiased decisions are being made, the nurse must is based on critical thinking and problem-solving skills that
remain objective and neutral when providing client care. For the nursing student learns to prepare him for the challenges of
example, if a known recovering drug addict states he is experi- the nurse’s role. The nurse must also be aware that significant
encing pain postoperatively and requests pain medication, the others play a major role in the client’s recovery process. For
nurse must remain unbiased and treat the client’s current pain example, the nurse may choose a nursing diagnosis based on
level regardless of his previous history. the client/family connection. The nurse assesses the family
of a young mother who has just become a paraplegic due to
an automobile accident. The nurse notices the client’s hus-
Nursing Guideline band and four young children and that the husband appears
to Critical Thinking overwhelmed and frequently corrects the children for small
indiscretions. While talking to the client, the nurse assesses
and Problem Solving the behavior of the husband, using critical thinking and
The nursing process, originating from Ida Jean Orlando, is problem-solving skills, to determine how the accident has af-
formulated to guide nurses when problem solving. Nettina fected the family dynamics and how it may affect the family
(2009) states, “The nursing process is a deliberate, problem- when the client returns to her home. The nurse decides to use
solving approach to meeting the health care and nursing needs the nursing diagnosis of Ineffective Coping related to change
of patients” (p. 5). The five steps in the nursing process are in family dynamics as evidenced by the client stating the hus-
assessment, nursing diagnosis, planning, implementation, and band is usually very patient with the children.
evaluation. The nursing process is circular in that one must
continue to collect data and make changes as the information Planning
dictates. The nursing process provides a guideline, or “road Planning can also be defined as goal setting. The goal of the
map,” to aid in problem solving. client is the desired result that the client works toward achiev-
ing. The goal of the nurse, in the nursing process, is to assist
Assessment the client to achieve the best outcome. The nurse formulates
Assessment provides subjective and objective information, a plan with the client that assists the client to achieve his great-
and includes taking the client’s vital signs, acquiring data by est potential under given circumstances. Again, this requires
visualizing the client physically and watching for client actions critical thinking and problem solving. The nurse must be able
and responses, touching the client, and smelling for odors. to view the entire picture and understand what is involved for
The nurse should listen to what the client says, the tone used, the client to achieve peak performance. Going back to the pre-
and the body’s sounds by actively listening through a stetho- vious example of the client in the automobile accident who is
scope. Secondary sources, such as lab test results, are also now a paraplegic, the nurse must define what the client’s role
considered. The LPN/LVN is taught to make observations,
collect data, and respond to particular situations. Registered CRITICAL THINKING
nurses are taught to perform assessment and delegate accord-
ing to state board of nursing guidelines.
New nursing students use concrete thinking: “This is Goals and outcomes
what I see, so this is what is happening.” The nursing student
must learn to reframe that concrete thinking into critical
thinking: “This is what I see; is what I am seeing consistent
with the history the client is telling me? Is the client’s body How are goals and outcomes different?
language supporting what he is telling me? Does the body
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and children. After the nurse fully understands the situation

and activities that need to be carried out, the nurse can then
arrange for team members to join as needed. The nurse may
suggest to the health care provider that a physical therapist
and occupational therapist become involved in the client’s
morning care. The nurse is expected to keep an accurate re-
cord of the client’s progress toward the stated goal in relation
to the plan implemented. This provides communication be-
tween the nurse and the health care team and allows changes
to be made as needed. If advancement toward the client’s goal
is not being achieved, a change is needed in the client’s plan
to compensate for unexpected deviances or stumbling blocks
to obtain the best outcome.
Evaluation
Some individuals confuse evaluation with the assessment step.
Assessment provides subjective and objective information;
evaluation provides a judgment about an outcome. Evalu-
ation requires the nurse to measure factual results against
planned expectations to determine success. All individuals
involved in the client’s plan of care should be included in the
systematic determination of how well the plan is working,
and if the plan needs modifications to improve outcomes.
(© andresr/shutterstock)
For example, regarding the paraplegic, the nurse reads over

the records of the physical therapist and finds the client has
developed an exaggerated fear preventing her from transfer-
ring from the bed to the wheelchair on her own. With this in-
formation the nurse communicates the concern to the health
Figure 1-4 The health care team works together to formu- care provider.
late a plan of care for a client.
Critical Thinking
was and what her family duties were before the accident. The and Problem Solving
goal is to assist the client to find a way to continue her normal
function and duties both in her family and life in general. As-
Are Circular
sisting the client and husband to understand that there will be The nursing process does not stop with evaluation; assess-
some return to the family’s preaccident existence will aid the ment for client changes continues and proceeds through each
client and husband to cope by focusing on a plan formulated nursing process step until the client goal is met; in this way it
to achieve the highest functional ability for the client. Once is circular in nature. Critical thinking and problem solving are
there is an understanding of the goal, there must be a plan to also circular in nature. However, there is a danger in circular
obtain the goal. Achieving the goal requires a joint effort by thinking; critical thinkers and problem solvers can become
the health care team; the nurse decides what team members bogged down with data and forget to look at the entire picture.
are needed to achieve the goal and involves them in the plan A classic example of this occurs when a nurse becomes so
of care (Figure 1-4). involved in watching a monitor that the client is not carefully
After the goals have been established, the expected out- assessed and her verbal concerns are ignored. Technology
comes can be identified based on those goals. An expected provides many lifesaving tasks; however, monitors are not
outcome is a detailed, specific statement describing the critical thinkers and they malfunction from time to time. The
methods to be used to achieve the goal. It includes direct nurse must critically think and focus on both the client and the
nursing care, client teaching, and continuity of care. Out- monitors—not just the monitors—when assessing and treating
comes must be measurable, realistic, and time limited. Several a client.
expected outcomes may be required for each goal.
Critical Thinking
Implementation and Problem Solving
Implementation requires the nurse to plan client activities
in such a way as to promote goal attainment. In the previous to a Higher Standard
paraplegic example, the client’s day will be arranged to pro- A potential error when processing information is to make as-
gressively allow the client to accomplish pre-paraplegic duties sumptions about what is not known as fact. A nurse is suscep-
and activities. The nurse will decide how to assist the client tible to this type of error when doing an initial data collection
to overcome barriers. This will require the client to learn new or assessment. For example, a 20-year-old woman came into
ways of doing things. The nurse will also encourage the client the emergency department having severe abdominal pain.
to look for new methods of accomplishing daily activities. The The nurse noted that the client appeared to be in good health
nurse should problem solve on how to include the husband as evidenced by shiny hair, healthy teeth, pink undertone
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color to skin, but with slightly dry mucous membranes and and the nurse notices a wedding band. The client has an
tenting of the skin possibly suggesting dehydration. The cli- unusual last name, and though the police are trying to locate
ent’s weight is proportionate to her height. She uses a tissue family, the nurse decides to look in the phone book, because
frequently stating she has sinus problems, but no other obvi- she was told the client is from the immediate area. However,
ous concerns were detected. The nurse asked if the client had the phone book revealed no individuals with the client’s last
any other recent abdominal pain, difficulty with bowel move- name. The policeman stated no cell phone was found at the
ments, or irregular menstrual cycles. The client stated she had accident site. The nurse thinks back to the wedding band and
not had any problems with pain until last night, had diarrhea recalls some nuns no longer wear habits but they still wear a
the previous day, but that when her sinuses were “messed up” thin silver or white gold wedding band with no engagement
the drainage caused diarrhea. She stated her menstrual cycle ring. The nurse then returns to the client and asks her to blink
was a little irregular, and had noted the change when she was once if she is a nun and twice if she is not. After establishing
“stressed out” over her first college exam. She also stated her that the woman is indeed a nun, the nurse requests permission
menstrual cycle had become “a little decreased after the first to call local Catholic Churches in an attempt to find someone
exam,” but that she found college stressful. She is an “A” stu- that can provide the nun’s medical history. After two nurses
dent, and graduated from high school with honors. The client witnessed the nun’s nonverbal consent, the local Catholic
stated the pain was periodic and involved the entire abdomen. Church was called and the nun’s medical history obtained.
The nurse heard no abnormal lung sounds, but during aus- This example shows judgments can and should be made us-
cultation of the abdomen, the nurse noted a faint sound she ing knowledge at hand, even if not totally clear, but clarifying
could not identify. At this point, the nurse stated she would information as evidence is revealed. The goal is to start with
like to listen to the client’s abdomen with a Doppler because given information, classify the information based on clarity
it amplifies sounds. The nurse asked the client if she could be (fact versus assumption), make a judgment, and continue to
pregnant. The client stated that there was no chance she was clarify the data as evidence presents.
pregnant and that her parents would “kick her out of college”
if she were to have sex without being married. The Doppler Accuracy
identified a second heartbeat that was later verified by a phy- It is important not to confuse clarity with accuracy. Clarity is
sician. Based on the client’s verbal statements, she was not the ability to understand something as it is being presented.
pregnant. However, the nurse did not make a quick decision Accuracy is the attention to truth within the understanding.
and considered other possibilities to ensure an accurate judg- For example, a client tells the nurse he does not have any
ment was made. blood pressure problems and the nurse notes the client’s ad-
Only factual data should be evaluated when analyzing cli- mitting blood pressure is within normal limits. In this example
ent information. The nurse should never make assumptions. it is clear the client feels he does not have blood pressure
Critical thinkers break information down to core components problems and the normal blood pressure seems to confirm
during problem solving. Another way of stating this is “Criti- the client’s statement. When the nurse reviews the client’s
cal thinkers routinely take their thinking apart” (Paul & Elder, medications, however, she finds the statement is inaccurate
2001, p. 52). because the client is taking blood pressure medication that
maintains the client’s blood pressure within normal limits. So,
Standards Related clarity does not ensure accuracy.
to Critical Thinking
and Problem Solving Precision
Precision is achieved when all clues or evidence supporting
Quality performance requires standards to measure achieve- the acquired data are confirmed. Precision results from look-
ments. Nurses are held to “standards of care” that promote ing for the details or specific information about the data. For
the highest level of client care under given circumstances. The example, a daughter takes her father to the emergency depart-
standard of care relies on how well a nurse critically thinks and ment stating that she thinks her father had a stroke. When
problem solves. One must understand more than the steps of the daughter entered the house, her father stated he had a
critical thinking and problem solving; there must be a stan- severe headache. He was confused, dizzy, and almost fell to
dard to measure the accuracy of critical thinking and problem the floor when attempting to stand. The statements made by
solving. Paul and Elder (2006) provide quality guidelines that the daughter are precise to some of the signs of stroke. So, at
can be applied to nursing. If a nurse learns to adhere to these this point it appears the daughter’s conclusion of a stroke is
guidelines, critical thinking skills will improve and promote on target. One could say the symptoms line up together and
accuracy in problem solving. Paul and Elder’s guidelines for support a theory.
critical thinking include clarity, accuracy, precision, relevance, However, if the evidence is examined more closely, the
depth, breadth, logic, significance, and fairness. nurse would find the father’s headache started small and be-
came severe, the confusion and dizziness have disappeared,
Clarity and, although he almost fell to the floor when trying to stand,
Clarity results when factual data are used to draw conclu- currently there is no sign of one-sided weakness. The preci-
sions. When factual data are lacking, clarity is decreased and sion or confirmation of supporting data related to a possible
can lead to inaccuracy. When clarity is compromised, the diagnosis of stroke no longer exists to support a diagnosis of
nurse must continue to analyze new evidence and change con- stroke. As the nurse discusses the situation with the father, she
clusions if indicated. Here is an example: A client comes into finds he had been in the basement shortly before his daughter
the emergency department. She has difficulty speaking became home. The client had given up driving a couple of weeks
cause of facial injuries. The client only has her driver’s license ago and he wanted to start his old car, in a closed garage, to see
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if it would still run. The precise details or specific information pertinent information was not obtained. The nurse assumed
no longer relates to known symptoms of a stroke. However, the client would faithfully take the blood pressure medication,
if carbon monoxide poisoning is considered, the precision as evidence supported that the client would be compliant and
(details and specific information) again aligns with a cluster of take the medication. The nurse failed to find out that one of
signs and symptoms pointing to carbon monoxide poisoning. the client’s children had become sick and a choice had to be
made between medication for the child and blood pressure
Relevance medication for the client. Depth is obtained by acquiring all of
Relevance is the importance of data in relation to the prob- the data needed to make a valid nursing judgment.
lem. Sometimes when an item is irrelevant to the task at hand,
the nurse discards it or relates it to an assumed fact or reason. Breadth
Danger lies in both of these choices. For example, a client Breadth is derived from a comprehensive understanding,
comes into the hospital with shortness of breath. The client or understanding from another individual’s vantage point.
is admitted and the nurse reviews medications and places Breadth views a situation from more than one angle. For ex-
them on the nursing history. The nurse writes the information ample, a teenager is admitted with new-onset diabetes. The
down while looking at what appears to have been a recently teen appears to be in good physical condition and is active in
filled bottle of Lasix, but the pills are blue. The data are irrel- seasonal sports. The client states his parents are “health nuts”
evant to the medication history and could be discarded. and the family eats balanced meals every day and sugar and
However, the nurse thinks for a moment and is troubled white flour are not allowed. The diabetic teen then confides
that the Lasix is blue. The nurse knows that various pharma- to the nurse that after sports practice the team goes out for
ceutical companies have medications that vary in shape and pizza and ice cream. The nurse states, “If your parents are
color from company to company, so the nurse could assume health nuts it should not be difficult to give up the pizza and
the medication is a “generic.” However, the nurse chooses to ice cream, especially if it is not allowed in your diabetic diet.”
give more thought to past experience related to Lasix and re- The nurse did not understand the family process and the cli-
calls it is always white and that she has never seen Lasix in any ent’s choices. She did not acknowledge the mind-set of the
other color. The nurse requests the client to allow the bottle client and recognize how important pizza and ice cream are
to be opened and one of the pills given to the pharmacy to to the client. In this scenario, the nurse did not use breadth,
identify and verify. The pharmacy identified the medication but imposed her thoughts on the client’s situation, alienated
not as Lasix, but as an over-the-counter medication (OTC) the client, and failed to acknowledge the client’s concerns. A
for discomfort. With this piece of data, the client believed a nurse demonstrates breadth by examining a situation from all
family member had used the bottle to store OTC medication angles or others’ viewpoint.
and that there was a mixup. He had not been taking Lasix,
but had been taking OTC medication. Thus, the mystery of Logic
why the client was short of breath and had a fluid overload Logic is being applied when data are categorized as impor-
was solved. If the nurse had dismissed the blue “Lasix” as ir- tant or not important to promote optimal outcomes. In other
relevant, the client could have continued taking them on dis- words, the data fit together to support a logical conclusion.
charge and been readmitted to the hospital in the future. The For example, a client arrives in the emergency room with an
physician may have also changed the client’s prescriptions open leg fracture and a severed artery leading to severe blood
trying to correct the client’s condition, thus causing more loss. Logic dictates the nurse take measures to stop or de-
financial hardship on the client and possibly other physical crease the bleeding before sitting down with the client to com-
repercussions. Relevance can therefore be defined as a con- plete five admission papers. The equation behind the logic is
nection between unrelated data to specific data regarding a that if blood continues to flow freely, the client may bleed to
client concern. When something appears irrelevant to a situ- death or have serious complications of blood loss. The client’s
ation it should not be immediately discarded, but examined history, though important, is less important than stopping the
from various angles. blood loss. In this case, the nurse acts logically by intervening
to stop the blood loss.
Depth
Depth is a measurement from the beginning of a matter to the Significance
end. If a nurse is getting a measurement of depth in relation to The importance of data is called its significance. For ex-
a client concern, the nurse will gather all factual information ample, a client goes to surgery and his vital signs are tem-
making sure to ask pertinent questions so data are not missed. perature 98.6°F (37°C), pulse 74 beats/minute, respirations
For example, a client comes back to the hospital having been 14 breaths/minute, and blood pressure 148/72. Later, when
discharged 5 weeks earlier. The nurse recalls the client had the client is 15 hours postoperative, his vital signs are tem-
been admitted with high blood pressure and left with what ap- perature 99.2°F (37.3°C), pulse 80 beats/minute, respira-
peared to be stabilized blood pressure with the use of medications 16 breaths/minute, and blood pressure 144/68. So, the
tion. Prior to discharge, the nurse confirmed the client could temperature is slightly elevated, as are the respirations and
afford blood pressure medication and understood physical pulse, and the client’s blood pressure has decreased slightly.
risks if not taken. The nurse is told the client is again being Is the change in vital signs significant? Should the nurse call
admitted with high blood pressure. The admission assessment the physician? The nurse knows any change is significant,
reveals the client’s salt intake has not been decreased, and but not necessarily something that needs immediate action.
the nurse proceeds to teach about salt intake related to high In this case, the nurse notes the vital sign changes are normal
blood pressure. This scenario shows the nurse functioning postoperatively, and does not act on the knowledge of the
on a shallow level, because assumptions were made and all change by calling the health care provider. The next day, the
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temperature is 101.5°F (38.6°C) and the nurse identifies the

change in temperature as significant and notifies the health BOX 1-3
care provider because an infection may be present. The nurse QuEStionS to ASk to BREAk down
evaluates the importance of the information (the priority at- infoRmAtion
tached to the information) and determines appropriate action
based on the information. 1. What is the problem?
2. What do we know about the problem? (How
Fairness is it defined? What information do we have
about the problem?)
Fairness occurs when individuals are treated equally and
without bias. For example, a client is admitted with back pain 3. What do we not know about the problem?
during the first shift. There is an order for the client to receive 4. Has this problem surfaced in the past? If so,
the medication Demerol 25 milligrams (mg) by mouth every how was it treated and what was the outcome?
4 hours. During admission, the nurse noted the client’s home 5. What are some ways that may correct the
dose was Demerol 25 mg every 6 hours. During the day the problem with known variables?
client states the pain is “out of control” and asks for more pain 6. Are resources available to correct the problem
medication. The client asks the nurse to call the health care and what are they?
provider, because the nurse stated no other pain medication 7. What plan appears to be achievable and will
could be given at this time. The physician orders 50 mg of provide the best outcome?
Demerol to be given now, and changes the order to Demerol
50 mg every 6 hours. An hour later the client states the pain
was “bearable,” or a 4 on a scale of 1 to 10.
The nurse reporting off tells the oncoming nurse that the variables. A good way for the student to break information
client must be a “drug addict,” because the client still had pain down is by asking questions (Box 1-3).
after 50 mg of Demerol. The nurse’s report contained error by Because critical thinking and problem solving require
omission; the oncoming nurse should have been informed the knowledge, the nurse should include other disciplines such
client’s home dose was 25 mg of Demerol every 6 hours. The as physicians, pharmacists, nurses who have specialized in an
first shift nurse’s report contained error because the client only area, dietitians, occupational therapists, physical therapists,
received an additional 25 mg of Demerol, as opposed to just and other resources. Critical thinking and problem solving
now starting on 50 mg of Demerol. To demonstrate fairness in involve a step-by-step process that is based on knowledge.
critical thinking, a nurse needs to relate all data precisely.
ROLES OF THE MEDICAL-
Critical Thinking SURGICAL NURSE
and Problem Solving Medical-surgical nurses are afforded experiences that in-
Require Knowledge clude interacting with clients with diverse clinical conditions.
Critical thinking and problem solving are learned. Nursing Clients on medical-surgical units are commonly recovering
students are assisted to learn prioritization based on knowl- from surgery, were hospitalized for an acute condition, or
edge. The same is true with critical thinking and problem may be in the final stages of a progressive or chronic disease
solving. As the nursing student learns about diseases and how process, such as cancer. Some health care organizations have
the body can be affected, the student will begin to break the designated medical and surgical units dedicated to caring for
information down and relate that knowledge to other known clients with oncological, orthopaedic, and neurological needs.
CASE STUDY
Practicing Critical Thinking Skills
Morning breakfast trays have been collected and the nurse is checking on her clients. When entering a
room she noticed the client’s forehead is wet. The client is alert and oriented, but does not feel well. The
nurse recalls the client is 18 hours postoperative and had a temperature of 99.9°F (37.7°C) earlier that
morning. The nurse palpates the client’s arm and notes it is cool and a little damp. The nurse knows the
client has diabetes, and recalls breakfast has been served.
1. What are the important observations (assessment/data collection)?
2. Prioritize the information (significance).
3. What could be a possible nursing diagnosis?
4. What is the first thing the nurse should consider (plan)?
5. What plan should the nurse act on (implementation)?
6. What do you think the outcome would be (evaluation)?
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thinking is the foundation of the nurse’s independent and

interdependent decision making. Critical thinking during
caregiving should encompass questioning, analysis, synthesis,
interpretation, reasoning, application, and creativity.
Educator
Client education has long been considered an important nurs-
(© waveBreakMedia ltd/shutterstock)
ing role. Teaching is essential in restoring a client’s health and
for the promotion of health. During the course of a nurse’s
work shift, there are frequent opportunities for teaching.
Nurses teach both clients and their families about aspects of
a healthy lifestyle. Additionally, the client may benefit from
education about individual topics such as a diet and exercise
regimen for a newly diagnosed client with diabetes mellitus, or
cast care for an orthopaedic client.
Figure 1-5 Medical-surgical nurses have various roles when One of the main areas of client education involves
providing client care. discharge planning. Discharge planning should begin upon
admission to the health care facility. Discharge planning in-
Additional facilities may blend medical and surgical clients cludes, but is not limited to, identification of client resources
together on the same unit. Nurses on medical and surgical and arranging for necessary equipment, supplies, and re-
units collaborate with a multidisciplinary health care team for sources once the client is in the home setting. It is important
the development and implementation of individualized plans for the client to be properly prepared for discharge and for
of care, client and family education, and discharge planning. teaching to occur throughout the hospital stay.
Various roles of the medical-surgical nurse include director Because education is an essential element of nursing
of care, caregiver, educator, and client advocate (Figure 1-5). care for clients, a process that nurses can use to organize and
deliver education is the ASSURE model, which incorporates
Robert Gayne’s (1985) nine events of instruction. First, the
Director of Care nurse will analyze the learner for receptiveness. Stating the
Nurses collaborate with members of the health care team in objectives provides a clear goal for the learning that needs to
an effort to smoothly coordinate care for the client. Strong take place. Selecting appropriate instructional methods, me-
leadership skills are essential. The ability to delegate appropri- dia, and material are important especially if the learner has
ately and evaluate the quality of care delivered to the client are physical limitations including vision, hearing, or language
crucial for the nurse. As a director of care, the nurse ensures impairments. The nurse should be prepared and creative in
the delivery of safe client and family-centered care. The care using a variety of media and materials. Having the learner
must be compassionate, evidence based, and of the highest demonstrate and perform a skill, such as self-injection of
quality to meet the diverse and continually changing chal- insulin for a client newly diagnosed with diabetes, assists the
lenges of the health care environment. Additional attributes of nurse to evaluate whether proper teaching and learning has
the director of care include creativity, autonomy, application occurred. Evaluation identifies whether teaching needs to
of proactive nursing expertise, critical thinking, and effective be revised.
leadership and management skills to ensure quality care. The
nurse should develop the fundamental skill set through par-
ticipation in quality control activities. As director of care, the
nurse must exhibit effective time management. MEMORY TRICK
ASSuRE
Caregiver Nurses can use the ASSURE memory trick to orga-
Nurses provide continuous care for clients 24 hours a day,
7 days a week, 365 days a year. The client is at the center of the nize and deliver education to clients. The ASSURE
nurse’s concern. The role as nurse caregiver is collaborative acronym represents:
as well as autonomous. Nurses perform data collection and A 5 Analyze the learner
physical assessments on clients based on nursing knowledge,
S 5 State the objectives
skill, and educational level. The assessment and data findings
drive the client’s plan of care. A client assessment includes S 5 Select instructional methods, media, and
gathering information about the health of the client, analyzing materials
and synthesizing the information, making judgments about
U 5 Utilize media and materials
the nursing interventions based on the data, and evaluating
client outcomes. Through collaboration with other members R 5 Require learner performance
of the health care team, care for the client is implemented and E 5 Evaluate and revise
evaluated.
Characteristics of a nurse caregiver should include (Adapted from Robert Gayne’s “The Nine Events of Instruction,” 1985)
compassion, skill, knowledge, and critical thinking. Critical
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Client Advocate performing procedures such as collecting specimens, adminis-

tering medications, and inserting catheters. Nurses employed
As a client advocate, the nurse assists the client and family in by the facility are expected to follow the guidelines in the
decision making with regard to options for care. Advocacy policy and procedure manuals. For situations not covered in
is a fundamental cornerstone of nursing. Clients depend on the policy and procedure manuals, the nurse is expected to
nurses to ensure that proper care has been received. The role exercise good judgment. In other words, the nurse is expected
of the nurse as client advocate actively pursues promotion of a to act in a reasonable and prudent manner.
client’s right for autonomy. At times, the nurse may serve as a What is meant by reasonable and prudent? In nursing, it
mediator between the client and others and shields the client’s means that the nurse is expected to act as would other nurses
right to self-determination. at the same professional level and with the same amount of
According to the American Nurses Association’s Code of education or experience. If most nurses respond to a particu-
Ethics for Nurses (2001), “Provision 3. The nurse promotes, lar situation in a certain way, and the nurse in question does
advocates for, and strives to protect the health, safety, and too, the nurse is acting in a reasonable and prudent manner;
rights of the patient” (p. 1). The nurse safeguards the client’s however, if most nurses respond differently than the nurse
right to privacy and confidentiality and acts in the best interest in question, the nurse is not behaving in a reasonable and
of the client. Nurses need to be knowledgeable about stan- prudent manner and can be held responsible or liable for
dards of practice and codes of ethics. damages. Liability is determined by whether the standards of
practice were adhered to.
JOB OPPORTUNITIES Nurses are practicing in a rapidly changing health care
industry. As the role of LPN/LVNs expands in the health care
The medical-surgical nurse’s expertise is called upon for jobs environment, reading and following the LPN/LVN standards
in occupational health, as well as for insurance companies and of practice is essential. The standards of practice provide
legal medical court actions. Opportunities for nurses outside guidelines for evaluating and measuring the quality of nurs-
of the traditional hospital jobs continue to grow. Nurses are ing care being given by the LPN/LVN. Nursing standards of
creating new areas for employment as the health care field practice are applicable in any practice setting.
continues to change, and the opportunities are endless. New
areas of interest include research, consulting, complementary
healing, informatics, robotics, technology, law, and travel CODE OF ETHICS
nursing. Professions determine ethical behavior for their members.
Several nursing organizations have developed codes as guide-
PROFESSIONAL AFFILIATIONS lines for ethical conduct. The Code for Licensed Practical/
Vocational Nurses, developed by the National Federation of
AND CERTIFICATIONS Licensed Practical Nurses, Inc. This code, providing motiva-
Medical-surgical nurses participate in professional affiliations tion for establishing, maintaining, and elevating professional
and certifications to demonstrate dedication and commit- standards, was adopted by NFLPN in 1961 and revised in
ment to excellence in client care. 1979 and in 1998. Each LPN/LVN entering the profession
inherits the responsibility to adhere to the standards of ethical
practice and conduct as set forth in this code.
STANDARDS OF PRACTICE
State boards of nursing have the responsibility of regulating EVIDENCE-BASED PRACTICE
nursing practice and setting educational guidelines for the
programs. They stipulate who may practice nursing in their re- Nurses use evidence-based practice (EBP) in making deci-
spective states through licensure. The related criteria usually sions about client care. EBP is nursing care that uses current
involve graduating from a state-approved program, passing best practice as evidenced by relevant valid research. Levin
the National Council Licensure Exam (NCLEX)®, and meet- (2006) defines EBP as “a framework for clinical practice that
ing certain legal and moral standards. The boards have au- incorporates the best available evidence with the expertise
thority to bring disciplinary action against a nurse for violation of the clinician and patient’s preferences and values to make
of its rules and regulations. Disciplinary action may include decisions about health care.” Houser (2008) describes EBP
revocation or suspension of the nurse’s license and/or a fine. as a three-legged stool in which “the stability of clinical deci-
From the nursing practice acts, guidelines have been sions requires a balance of the best scientific evidence, the
developed to direct nursing care. These guidelines are called client’s preferences, and the clinician’s expertise” (Rolloff,
standards of practice or standards of care. 2010, p. 290).
Standards of practice are also derived from other sources. The Institute of Medicine (IOM) has a goal that by
Professional organizations such as the American Nurses As- 2020, 90% of all clinical decisions will be supported by
sociation (ANA) for RNs and the National Federation of EBP (Olsen, Aisner, & McGinnis, 2007; Melnyk, Fineout-
Licensed Practical Nurses (NFLPN) for the LPN/LVN have Overholt, Stillwell, & Williamson, 2009). The challenge for
also developed standards of practice. Nursing care planning nurses is to become knowledgeable and skilled at utilizing
books, especially for specialized areas, are other resources for EBP. Adequate resources, time, and support are necessary
practice standards. to implement EBP. Throughout this text, EBP feature boxes
Policy and procedure manuals also represent stan- have been provided to demonstrate how EBP is utilized in
dards of practice. Each facility has identified specific ways of nursing.
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All areas of health care will soon be implementing the use

QUALITY AND SAFETY of electronic medical records. In 2012, the Affordable Care
EDUCATION FOR NURSES Act will institute a series of changes to standardize health care
billing and will require health plans to adopt and implement
The Robert Wood Johnson Foundation funded a project rules for secure and confidential exchange of electronic health
called the “Quality and Safety Education for Nurses” (QSEN). information (White House, 2011). The goal is to reduce
The overall goal of QSEN is to “address the challenge of pre- paperwork and administrative costs while reducing medical
paring nurses with the knowledge, skills, and attitudes (KSAs) errors and improving the quality of care. Health care facilities
necessary to continuously improve the quality and safety of are preparing for this change from paper documentation to
the healthcare systems in which they work” (QSEN, 2011a). electronic computerized records. According to Skiba (2010),
The National Advisory Board and the QSEN faculty used nurses will need to become literate in informatics to be able to
the IOM (2003) competencies to assist in defining six safety function in the health care delivery system.
and quality competencies for nursing: patient-centered care,
teamwork and collaboration, evidence-based practice, quality
improvement (QI), safety, and informatics. GENETICS AND GENOMICS
The QSEN project included three phases. The first phase
was to define the six competencies and create sets of knowl- Genetics is the study of individual genes and their transmission
edge, skills, and attitudes for each competency to be used in of traits and single-gene disorders from one generation to the
prelicensure nursing programs. The competencies and sets next. A human genome is the genetic material, complete DNA
of knowledge, skills, and attitudes serve as guidelines for cur- sequence, of an individual (Gallo, Angst, & Knafl, 2009; Kirk &
riculum development, continuing education programs, and Tonkin, 2009). Genomics is the study of all the genetic material
transition to practice. Phase 2 involved pilot nursing programs and how the genes interact with each other and the environment
implementing the competencies into their curriculum and (Trossman, S., 2006; Gallo et al., 2009; Kirk & Tonkin, 2009).
sharing the results on the QSEN website. Phase 3 includes The Human Genome Project (HGP) was an interna-
developing faculty expertise in teaching the competencies, tional research endeavor to sequence (place in order) all the
promoting innovation in teaching the competencies, and human genetic material and map the location of genes on all
including the competencies in textbooks, licensing, accredi- chromosomes. In 2003 the HGP’s mission of sequencing the
tation, and certification standards (QSEN, 2011b). QSEN human genome was completed. The research study showed
identifies its website as a comprehensive resource for safety that there are approximately 20,500 human genes and more
and quality education for nurses. For more information visit than 1,800 genes that cause disease (National Human Ge-
QSEN at http://www.qsen.org. nome Research Institute, 2010a, 2010b, 2010c). This genetic
information revealed how traits are passed from one genera-
tion to the next. As a result of this study, researchers can locate
INFORMATICS a gene that is thought to cause a disease within days, rather
than years as required prior to this study.
As computers and technology have evolved during the past Pharmacogenomics is an expanding field of research
several decades, the term nursing informatics has emerged. that evaluates how changes in genetic structure or organiza-
Nursing informatics is used in education, research, admin- tion affect an individual’s response to a certain drug (Kudzma
istration, and nursing practice (Figure 1-6). According to & Carey, 2009). The goal of pharmacogenomics is to develop
the American Nurses Association (2008), “Informatics is a specific drugs that will optimally affect each individual regard-
specialty that integrates nursing science, computer science, less of differences in genetic makeup (Figure 1-7). Health care
and information science to manage and communicate data, is on the verge of revamping the way prescriptions are ordered
information, knowledge and wisdom in nursing practice” and in determining the correct dose of medication for the ap-
(p. 1). propriate client. The results of this research will dramatically
affect the nurse’s knowledge of pharmacology and the way in
which medications are administered to clients with genetic
factors that affect the drug metabolism and to those without
these genetic factors.
CRITICAL THINKING
informatics
(© alexander raths/shutterstock)
1. How are nurses currently using informatics?

2. How will the Affordable Care Act change in-
formatics in nursing?
Research online to learn more about nursing
informatics.
Figure 1-6 Nurses use computers in practice to document
care and look up client information.
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No response
Clients receive no benefit with

severe adverse effects
After a blood test to check genetic
makeup, pharmacogenics makes
it possible to give an individual an
adjusted dose specifically
designed for his metabolism.
Clients have good benefit with

severe adverse effects
Patients with same diagnosis

and same prescription
Genetic makeup alters

response to drug. Normal dose
(delMar cengage learning)

Clients have good benefit with
no or minimal adverse effects
Figure 1-7 The goal of pharmacogenomics is to develop drugs that will optimally affect each individual regardless of variations in
genetics. Currently, drugs are given to the general population and each individual responds according to his specific genetic makeup.
Some of these individuals have adverse drug reactions. Pharmacogenomics makes it possible to give specific doses for an individual’s
metabolism according to genetic makeup.
more nurses understand genetics and genomics, the more they

5-Fluorouracil and Genetics can teach clients and assist in their care. It appears the future
5-Fluorouracil (5-FU) is used for the treatment of colorectal wave of nursing care will include genetic testing and observing
cancer. Two polymorphisms (different forms or morphs), for client responses that indicate the need for testing.
TSER*2 and TSER*3, are involved in the metabolism of Diseases known to have genetic alterations include
this drug. The TSER*3 allele causes high levels of a TS pro- Huntington’s chorea, Down syndrome, Alzheimer’s dis-
tein resulting in resistance to 5-fluorouracil. Clients with ease (AD), autism, attention deficit hyperactive disorder
one TSER*2 allele have 38% more tumor shrinkage than (ADHD), breast and ovarian cancer, colorectal cancer, and
those with two TSER*3 alleles (Kudzma & Carey, 2009). macular degeneration. However, since the HGP in 2003,
Clients with the TSER*2 allele are treated with radiation and genetic and genomic research on specific disease conditions
5-fluorouracil, which is the standard treatment. Clients with has grown and still awaits much more research for evidence-
two TSER*3 alleles receive the standard treatment and irino- based practice.
tecan (Camptosar). In these cases, genetic testing resulted in Genetic and genomic concepts are complex and nurses
improved responses in clients with the TSER*2 allele and with may wonder how they will affect the clinical nurse’s practice
two TSER*3 alleles. These findings show the value of genetic and client care. As nurses attain an understanding of the ef-
testing and the importance of nurses understanding the results fect genetics has on diseases, their nursing care takes on new
of genetic testing and the positive outcomes for clients. The dimensions. A genetic disorder not only affects the client, but
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CRITICAL THINKING
BESTPRACTICE
test for Age-Related macular Genetic disease
degeneration
Seventy-five to 80% of all age-related macular de- How would you respond if you were diagnosed
generation (AMD) is traceable to a genetic inher- with a disease that originated from a genetic
ited condition (ArcticDX Inc., 2010). Macula Risk® variation?
is a genetic test for AMD. The test is simple to per-
form and requires only a swab sample from the in-
side of the cheek that is then air dried and sent to
the lab. This test determines if an individual with concerns about these disorders. An entire chapter about ge-
a mild form of the disease is at risk for progressing netics, genomics, and their effect on nursing is available in the
to a more severe stage with vision loss. Research online resources that accompany this text.
has shown this test to be 100% accurate in identi-
fying the AMD genes (ArcticDX Inc., 2010).
CONCLUSION
Medical-surgical nursing is a specialty area that requires the
essential characteristics of prioritization and organization,
often is an immediate and extended family condition. The critical thinking, and innovative problem solving. The educa-
nurse makes sure the family understands the disorder, the im- tional process can guide a less experienced student through
plications of the disorder, and the need for follow-up care and critical thinking experiences to practice critical thinking and
treatment. Some clients and families may benefit from genetic problem solving. The medical-surgical nurse has various roles
counseling to discuss the disorder, the inheritance mode, including director of care, caregiver, educator, and client ad-
risk factors for others in the immediate and extended family, vocate. Nurses need to be knowledgeable regarding evidence-
diagnostic tests, treatment, and support for future decisions. based practice, quality and safety competencies, informatics,
The nurse supports the client and refers him to community and genetics to be able to function in today’s health care
and Internet resources to meet the sometimes overwhelming delivery system.
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CHAPTER 2
Assessing Family
Processes and Issues
KEY TERMS
authoritarian parenting distressed families healthy functioning families
authoritative parenting family crisis permissive parenting
LEARNING OBJECTIVES
2. Discuss examples of family diversity.
3. Explore the cultures of various types of families.
4. Define parenting styles.
5. Define a healthy family.
6. Define a distressed family.
7. Explore the dynamics of a potential family crisis.
8. List parental stressors.
9. Research available resources to meet client and family needs.
17
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INTRODUCTION
The client does not enter a health care facility as a lone entity.
The client belongs to a family and, thus, enters a health care
facility with the diversity, culture, and roles of that particular
family (Figure 2-1). As the nurse explores various family units
and different dynamics of family life, she can gain effective
insight into the client within the family unit.
Some clients are in families that have many characteris-
tics of a healthy family, while others come from varying de-
grees of distressed families. Learning about the characteristics
of healthy and distressed families provides a base for the nurse
to assess the dynamics of the client’s family unit.
This chapter discusses diverse family units and presents
some characteristics of healthy and distressed families and
provides examples of family types. Parenting styles and paren-
tal stressors are explained and the chapter closes with possible
resources the nurse can share with the client and family to
meet the unique needs of family life.
DIVERSE FAMILIES ACROSS

THE LIFE SPAN
(©Tracy WhiTeside/shuTTersTock)
Although many people may find the current concept of family
increasingly open to interpretation, the idea of what family is
has always been a dynamic concept. In the 1950s and 1960s,
America saw families portrayed in television and movies as
consisting of two individuals and their biologic offspring. Yet
even then, many actual American “families” did not fit into
that specific mold. Figure 2-1 Each family has its own diversity, culture, and
Throughout history, multiple generations lived under the roles.
same roof as a family. This type of extended family or multi-
generational household was quite common prior to the 1950s. differences that may present in the client’s families, but also
Now that baby boomers are living longer, more American be on the alert for differences that may affect the delivery of
families are inviting grandparents into the home that previ- care the client receives. Recognizing the unique strength of a
ously included only the nuclear family. In 2007, more than client’s family can sometimes help the nurse utilize members
3.6 million parents lived with an adult child. This statistic has in assisting the client on the road to recovery. Just as impor-
increased 67% since 2000 (Brandon, 2008). Consequently, tantly, being aware of unique characteristics of various types
there may be an appreciable increase in the number of house- of families may open communication and prevent recovery
holds including a parent, minor child, and a grandparent or a roadblocks when the family and health care professionals are
household of parents, adult child, and a grandparent. Some at odds.
reasons for these changes in multigenerational households How a parent encourages a child to comply with treat-
are economic hardships, an easier lifestyle with shared adult ment will most likely depend on the client’s culture. A child
responsibilities, and an increase in immigrants who live in of a middle class American family may be disciplined by
extended families (Brandon, 2008). withholding privileges (Friday evening out with friends) or
Family variations in society include intergenerational a possession (availability of a cell phone for a day) from the
(grandparent, parent, child or parent, child, and grandparent), child for noncompliance. Parents may even resort to time-
nuclear (married man and woman with children), attenuated outs where physical contact with parents is not allowed. Some
(single parent with children), gay and lesbian (two individu- parents may prefer to model the behavior role that they desire
als of the same sex), grandparents raising children (mother or in their children. It is important to recognize that the methods
father is not available and grandparents assume responsibility of parenting and ways of interacting with family members
of raising their child’s children), blended (child may come that one experienced while growing up will generally seem
from one or both parents through remarriage), incipient “right.” While recognizing the diverse ways in which a family
(married couple with no children), and cohabitating (couple functions is vital, it can never be used to ignore abuse of any
having never married). Gay and lesbian couples are forming individual.
families through adoption or through artificial insemination.
Some couples have their own children and adopt children
from other countries. Intergenerational Families
As our society moves toward embracing diversity, more is Intergenerational or multigenerational families are families in
learned about how similar, yet also uniquely different families which more than two related generations live together func-
can be (Figure 2-2). The nurse not only needs to be aware of tioning as a family. For parents to assist children from a state
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CHAPTER 2 Assessing Family Processes and Issues 19
(delmar cengage learning)

Figure 2-2 Diversity within the family structure.
EVIDENCE-BASED
PRACTICE
Multitasking the Electronic Gadgetry
Sources: Wallis, C. (2006). The multitasking generation. Retrieved September 4, 2010, from http://www.time.com/time/magazine/printout/
8,8816,1174696,00.html; Miller, P. (2010). Multi-tasking: Just an illusion? Retrieved April 29, 2010, from http://intro2psych.wordpress.com/
2010/03/25/multi-tasking-just-an-illusion
DiSCuSSion Ochs describes the influence of mul- and electronic gadgets are the media used
Elinor Ochs, director of the University titasking on the family as “consequential to accomplish more tasks. However, do
of California–Los Angeles’s Center on (significant, substantial) for the structure these gadgets give the brain adequate
Everyday Lives of Families, has conducted of the family relationship” (Wallis, 2006, downtime? Is multitasking interfering
research on families for over 26 years. Her p. 2). She and her team members found with our interpersonal relationships and
main focus was not on multitasking with that children only greeted a parent return- quality family time? Perhaps an honest
electronic instruments but she found that ing home from the workday one-third of appraisal of one’s electronic interaction is
it is “one of the most dramatic areas of the time. The children were too engaged in order. Then, personal and family deci-
change” since a previous study on the fam- in multitasking with their electronic sions can be made as to the amount of
ily 20 years earlier (Wallis, 2006, p. 2). In gadgets to greet the parent. They also electronic usage.
a study conducted with 32 families, she found that parents had difficulty enter- The nurse may be instrumental in
discovered the area of the brain, Brodmann’s ing into the child’s space when they were connecting family members when she sees
Area 10, which is used when multitasking. multitasking. They have several videos of families involved extensively in electronic
Her research and other research determined “parents actually backing away, retreating media and not interacting with each other.
that individuals can only give attention to from kids” who are engaged in electronic The nurse could ask the client and fam-
one high cognitive activity at a time. In multitasking (Wallis, 2006, p. 2). ily for time to explain procedures or ask
other words, one cannot read a textbook and open-ended questions to engage the fam-
discuss the content at the same time (Miller, iMPliCATionS foR PRACTiCe ily in discussions. The nurse can also share
2010). When a person multitasks, she uses Electronic gadgets play a prominent role this research information with the client
the Brodmann’s Area 10 to rapidly switch in our everyday lives. The press for time in and family for their consideration.
from one task to another task. our overstressed lives leads to multitasking
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Cr it iCa l t HiNKiNG
BOX 2-1
NuClear Families
Family
Reasons for the decrease in the number of nu-
clear family households include the following:
• Many women are not marrying, yet they are
Describe your present family. How does it differ
still having children.
from the family in which you were raised? What
• More couples are choosing to remain childless.
are your present family’s values? Goals? Interac-
• Many married couples are delaying starting a
tions with each other? Does each family member
family.
require the same personal space? Personal time?
• There are increasing numbers of couples co-
habitating but not marrying.
• The number of family households that include
of total dependence (infancy) to a state of complete indepen- biologically unrelated individuals is increasing.
dence (adulthood), two generations must live together for a • Men and women are marrying at later ages.
number of years as a family. Sometimes families have three or • The increased influx of immigrants includes
four generations living and functioning as a family in the same
extended families (Brandon, 2008; Lee & Srini-
home. The most common reason for three generations to re-
side in one house is that some of the family members require vasan, 2011).
some type of assistance. For example, a young unmarried,
unemployed teen mom may desperately need the help of her
parents in order to care for her infant. Her parents may provide With only one parent to deal with sick children, job per-
continued economic support until she is able to finish an edu- formance may suffer. Children of single-parent homes are at
cation and obtain employment. The parents may also provide greater risk for abuse and neglect that is likely related to the
babysitting and emotional support for their daughter. The stress of one parent handling everything. Despite the hard-
parents may provide mature guidance, experienced parent- ships, some families thrive. Some single-parent homes origi-
ing, and a unique relationship with their grandchild. Another nated as an intact family’s way of dealing with domestic abuse
example in which an extended family living arrangement may issues. In such circumstances, the single-parent home may be
be beneficial is when elderly parents need assistance. Assisted the healthier choice for the family unit.
living complexes are generally quite costly and an older parent
may not be able to live independently, yet not require a nurs-
ing home. While such an arrangement can be difficult for the Gay and Lesbian Families
“middle” generation if still parenting children, it may be the Growing variations of the nuclear family are families com-
first choice for many families. This is especially true of many prised of a gay or lesbian couple and children. These families
subcultures such as Asian American and African American. may add children to the family by various methods. A lesbian
or gay couple may have one or both partners parenting chil-
Nuclear Families dren from a previous traditional marriage. Some lesbian cou-
Most sources define the nuclear family as consisting of two ples choose artificial insemination as a way to expand a family.
married individuals with their biologic children. For many While a gay couple might choose surrogacy as an option,
communities this narrower standard of what is “family” may adoption is also now an option for many gay and lesbians.
actually be the minority family configuration. The decrease in Whether this variation to the nuclear family is one the
the number of nuclear family households is most likely due to nurse embraces, the increasing numbers of these families
a number of changing trends, as listed in Box 2-1. make it likely the nurse will care for a member from this fam-
ily variation. If unfamiliar with the family structure, the nurse
Single-Parent Families can politely ask a couple if a child undergoing diagnostic test-
ing for an unknown condition is biologically related to either
Single-parent homes arise in a variety of ways. Often a young partner. How that question is asked may set the tone for the
pregnant woman never marries and raises her child or chil- nurse/client relationship. Every family deserves and expects a
dren independently. In other situations, divorce occurs or a caring compassionate nurse.
partner leaves, leaving one parent to raise the children. Much
less commonly, a parent dies or becomes so incapacitated the
home functions as a single-parent home. A parent (father or Cr it iCa l t HiNKiNG
mother) may be in the military and deployed overseas, leaving
a mate to raise the children. This home functions as a single-
parent home until reunited with the military service person. Biologic Child
The mate left in the states not only has the responsibility
of the home, children, and job, but also the concern for the
mate’s safety. Regardless of the circumstances, individuals Using therapeutic communication, how would
parenting alone have a tremendous workload to shoulder. you inquire if a child was biologically related to
Unfortunately the financial responsibilities lie disproportion- either partner?
ately or completely with the single parent, adding a significant
burden to an already stressful task.
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relationship with Grandparents
Describe your relationship with your grandpar-

ents. How did the family in which you lived affect
the relationship with your grandparents?

Grandparents Raising
Grandchildren
When parents cannot raise their children, the first logical
choice is the child’s grandparents. Grandparents who serve
as alternate parents for their grandchildren experience a Figure 2-3 The nurse works within the cultural mores of
mixed blessing. While the bonds between grandparents and American families.
the grandchildren they raise can be as strong as the more
common family scenario of the parent/child, opportunities
for increased stress abound. Differences in how generations cultural variations of American families is a major part of be-
view the world are often increased as the decades between the ing culturally competent (Figure 2-3). One’s exposure to the
parental figure and children increase. Grandparents parenting customs of multiple families can be interesting and exciting,
today may have little experience in much of the technology but at other times puzzling. To become culturally competent,
that is an integral part of most children’s lives. read professional journals and books that address the beliefs,
Sexual mores are relaxed from previous generations and opinions, and traditions behind cultural differences. The fol-
grandparents may experience stress in an attempt to deter- lowing section provides a brief overview of some significant
mine reasonable rules and guidelines for older adolescents unique features of some subcultures found in our society. It is
and teens. Often grandparents take over the parental role important to note that while generalities are presented for vari-
when a serious family crisis develops in the grandchild’s im- ous subcultures, the individuals within those cultures may vary
mediate family. If a parent dies prematurely, is incarcerated, greatly. For example, while it may be common for Indian par-
or a substance abuser, the child’s grandparent(s) can be a safe ents to arrange the marriages of their children, not all families
haven. from India follow this custom. Just as families in an individual’s
neighborhood share many similarities, differences may abound
Stepfamilies and Blended within anyone’s own culture. Therefore, broad assumptions
about a particular culture need to be avoided. Most individuals
Families do not mind being asked how they prefer things or how they
Approximately one-third of children living in the United feel about something if the questioning is done with respect.
States will live in a stepfamily by the time they reach 18 years Probably one of the greatest truths we can learn from
old (Deal, 2011; Parke, 2007). Blended families, also com- exploring various cultures is that we all want to be treated with
monly referred to as stepfamilies, often consist of offspring special attention to our individual needs. Nurses lose a sense
from two different marriages and may include children from of caring when they approach all clients in the same manner
the new marriage. This may include an adult not biologically and ignore individual preferences. While most Americans
related to the children but now married to a biologic parent want a diagnosis and prognosis no matter the seriousness of
of the child. While blended families can and do function as each, someone from another culture may never wish to be
well as many nuclear families, there can be more challenges. told they have a negative prognosis. Most Americans would
There are often multiple relationships to work through and, if not ask a grandparent for input on making a major medical
disagreements occur, the stress can be intense. The older the decision, but many cultures pull from the wisdom of previous
children, the more difficult the transitions to a blended fam- generations to make decisions. A nurse working with a popu-
ily. Time and patience are needed. If signs of intense anger, lation from an unfamiliar culture has a unique opportunity to
depression, and exclusion of members are present, counseling learn that culture and to use that newly gained knowledge for
may be beneficial. self-improvement.
CULTURAL VARIATIONS Asian American Families

While generalizations do not always apply, they provide a
WITHIN FAMILIES foundation. If a nurse is working with a particular subculture
Misunderstandings, unintended slights, and disagreements within America, it is important to learn its cultural norms.
may arise when individuals from very different cultures in- Asian families tend to be stratified by age with elders receiv-
teract without understanding the other’s cultural customs ing much respect from others in the community (Salim-
and beliefs. Recognizing and successfully working within the bene, 2005). To maintain harmony, Asian clients may imply
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BESTPRACTICE
CulTuRAl CONSIDERATIONS Transforming Care at the Bedside
The Robert Wood Johnson Foundation (RWJF)
asian Pacific islander Families
and the Institute for Healthcare Improvement are
in america may Originate
sponsoring a nurse-led initiative to improve cli-
from the Following areas:
ent care within top-level hospitals. The program
• Pacific Islander—mostly Hawaiians, Guamanians, is called Transforming Care at the Bedside (TCAB).
and Samoans The studies conducted in the selected hospitals led
• Southeast Asians—mostly from Vietnam, Thai- to a higher quality care level and improved nurse
land, Burma, Philippines, Laos, and Cambodia teamwork, provided nurses with leadership oppor-
tunities, and involved the clients and their families
in personal care decisions. The American Organiza-
tion of Nurse Executives is working with the RWJF
compliance when they do not understand or agree with a to bring the program to hospitals nationwide.
treatment plan (Salimbene, 2005). One change that was brought about by TCAB
was a daily morning interdisciplinary team meeting
Hispanic Families that includes the night shift nurse, the oncoming
The term Hispanic actually refers to several different regional nurse, the physician, the client, and family mem-
and cultural backgrounds. It often refers to individuals who bers. The team discusses events that occurred with
view themselves as being of Spanish origin. However, most the client during the night. Each person shares
individuals originating from Latin America prefer the term during the meeting. One family that participated
Latino. Within the Hispanic population, there is a wide vari- in the TCAB study stated the meeting lowered the
ance in cultural norms and even language syntax and dialects. stress felt by the client and family. Another posi-
Hispanic cultures are patriarchal and take a broad definition tive result was clients and families involved in the
of family. Families include not only the nuclear family but also
TCAB program stated they “appreciated being
grandparents, aunts, uncles, cousins, and at times even close
family friends (Clutter & Nieto, 2011). asked for their opinions” (Lewis, 2009, p. 53).
The leading causes of illness and death in Hispanics are
heart disease, cancer, accidents, stroke, and diabetes. Access to
needed medical care is often limited due to lack of insurance cov-
erage. The uninsured rate for Hispanics was 32.1% in 2007, the
highest of any racial or ethnic group in the United States (U.S. Native American Families
Department of Health and Human Services [DHHS], 2009b). Many Native American cultures are based on a matriarchal
society. The extended family is important in Native American
African American Families families and is often involved in health care decisions. The
family may wait for the family’s eldest female to arrive before
African American families are structured in a variety of ways a major medical decision is made. Tribal medicine is valued
but generally have a mother heading the household. About and is often used in conjunction with Western medicine. It
47% of African American families fall into this category (San- is important to discern what other methods may be used to
tana, 2011). Another variation is the grandmother caring treat a condition. Major health issues with Native Americans
for grandchildren either in a multigenerational household include heart disease, high infant death rates, type 2 diabetes,
with the children and mother or with the grandmother and alcoholism, and tuberculosis.
children alone. Grandmother heads of households are more
common in inner cities.
In 2005, the leading causes of death for African Ameri- Amish Families
cans were heart disease, stroke, cancer, asthma, influenza and Old order Amish families separate themselves from main-
pneumonia, diabetes, HIV/AIDS, and homicide. The death stream society due to religious convictions. Contact with
rate for these conditions was higher than for Caucasians modern technology and the outside world is kept at a mini-
(DHHS, 2009a). mum. They are a patriarchal society. Dress and farm housing
African American families tend to care for their elderly is similar to that of the 19th century. The houses are generally
without institutional help. This results in many young African constructed without electricity. Although owning a television
American grandmothers being sandwiched with responsi- or automobile is generally prohibited, Amish will accept rides
bilities between caring for grandchildren and elderly parents. for transportation needs or use a personal cell phone or a
However, it is important not to stereotype all families. Many neighbor’s phone as needed (Amish Brochure, 2007).
African American families have excelled both economically Amish communities are very closely knit. Families are
and educationally so that a significant portion of the African larger and it is common for families to receive significant
American population lives in the middle to upper class. support from extended family members. Many are uninsured
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farmers so a medical condition requiring hospitalization is

viewed as a crisis to be addressed by the entire community.
If hospitalized, a large group of family members may stand Promote
psychosocial
vigil at the hospital to offer support to the client and family development
of the client. Folk remedies are quite common in the Amish and growth
culture. Reflexology, herbal therapies, and chiropractics are
commonly employed. Amish children are frequently behind
Provide
schedule on immunizations, and prevention health screenings Teach social
economic
are not commonly done due to minimal financial resources for etiquette
support
medical bills (Kraybill, 2011).
Family
Families of Middle contributes to
the growth of
Eastern Descent its members
Families of Middle Eastern descent include populations from
Provide
Iran, Iraq, Pakistan, and Indonesia. Many, but not all, are security,
Promote
Muslim. Families are patriarchal. Even adult children follow acceptance,
health and
the father’s authority, whose advice is highly respected. Fami- wellness
and love
lies, even extended, are very involved in the lives of all family
Promote
members.

spiritual and
It is important to note that in the Muslim religion to personal
speak of impending death is a taboo. Only Allah knows the fu- growth and
ture. Therefore, suggesting a visit from clergy because death is development
imminent would be inappropriate. It is often considered kind
and compassionate to withhold a negative prognosis from a
family member so that hope is not lost. Information may need Figure 2-4 Factors that contribute to the growth of family
to be shared slowly, continually assessing the client’s readiness members.
for information (Salimbene, 2005).
FAMILY ROLES Figure 2-4 to see ways the family can contribute to the growth
When individuals think of family, the people who are most of its members.
important to them come to mind. Parents, siblings, and one’s
children are the individuals who not only help shape one’s life Psychosocial Growth
but are really what is important and significant in life. When
a family functions well, it can be a powerfully altering force and Development
behind the growth of all family members. The psychosocial, Families assist members in psychosocial development and are
physical, and spiritual makeup of individuals is most likely involved in many stages of that development. Erik Erikson’s
formed within the context of family. Without the nurturance theory on psychosocial development is well accepted. His
and support of one’s family, the young child’s survival is not theory has eight stages of development beginning in infancy
possible unless an alternate family individual/unit steps in to and continuing throughout the life span (Erikson, 1968). Fig-
take that role. When the family functions well, members help ure 2-5 shows Erikson’s eight stages of development.
to foster movement toward self-fulfillment and self-actualiza-
tion. Unfortunately, some families fail to play a healthy role in
the development of some individuals. Situations of neglect,
Economic Support
abuse of members, substance abuse, and mental illness can While economic support throughout childhood and adoles-
all result in devastating effects on a human being. Refer to cence is the norm in America, the support given to young
adults and family groups may vary from one subculture to the
next. For example, in a subculture such as the Amish, the entire
Cr it iCa l t HiNKiNG community works together to maintain the family economi-
cally. Whether working construction, factory work, or farming,
Psychosocial, Physical, the financial well-being of a family does not rest entirely on its
individual members. When financial crises occur, such as large
and spiritual Development medical bills, the entire community works to help the strug-
gling family. This simple lifestyle generally assures, regardless
1. How did your family mold your psychosocial, of the crisis, that food and shelter will be available.
physical, and spiritual thinking/living/being? In contrast to the Amish community, consider a young
2. How did your family help develop your self-
married couple struggling to survive in mainstream America
working two minimum-wage jobs. There may be no support
fulfillment and self-actualization?
from extended family members. Once children arrive, carry-
ing the weight of financial burden in a low-socioeconomic
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Industry vs. Inferiority Trust vs. Mistrust

Six to 12 years Birth to 18 months
Encouragement and praise Parents caring
from family for consistently for an infant
accomplishments in responding to cues and
school promotes the desire caring for the dependant
to achieve and learn. infant helps the infant
Failure to achieve a sense build trust in the world.
of industry will result in a
sense of inferiority.
Autonomy vs.
Initiative vs. Guilt Shame & Doubt
Three to six years 18 months to
Parents must balance three years
applying restrictions to Children gain autonomy
keep children safe when parents teach them
against the freedom tasks they can accomplish
needed to foster independently. Frequent
exploration and initiative. criticism, reproach and
parental disapproval
leads to shame.
Integrity vs. Despair Establishing Identity vs. Role Confusion
65 years and beyond 12-18 years

At this time in life, Establishing one's identity is
grand parenting is a major joy. It the major task for the
is a time to review one's life, adolescent. At this stage, the
learning to accept both failures opinion of peer and friends are
and successes. more important than the
opinion of family.
Generativity vs.
Stagnation Intimacy vs. Isolation
Middle adult Young adulthood

35-65 years to 35 years
A major task of this stage Major tasks is to establish
is parenting. Mid-life crisis. close relationship. During
Realize they are getting older. this time life partner is often
Often decide they are not doing found.
with their life what they had
planned. May change job or go
back to school.
Figure 2-5 Erikson’s eight stages of development. (Top lefT To BoTTom righT: © greenland/shuTTersTock, © phanlop88/shuTTersTock, © BoBBy deal/realdealphoTo/shuTTersTock, © Jaimie
duplass/shuTTersTock, © monkey Business images/shuTTersTock, © paul hakimaTa phoTography/shuTTersTock, © goodluz/shuTTersTock, © goodluz/shuTTersTock)
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88021_ch02_ptg01_017_029.indd 24 12/28/11 4:56 PM
family can be a major life struggle. Meeting the weekly food

bills and monthly housing bills can leave little for other neces- MEMORY TRICK
sities such as clothing and health care needs. In fact, more and
more families are without adequate health care coverage and Ways Families Can Foster Personal
live from paycheck to paycheck (U.S. Census Bureau, 2009). Growth and Development
For many such families a fear of financial crises is a major
stressor. Those who are undereducated and immigrants are To remember ways families can promote personal
at special risk for a financial crisis. A lack of education and dif- growth and development of family members, recall
ficulty with the English language make it harder to survive the the mnemonic TOPP:
tough economy. In 2008, the number of families considered Encouragement to Take chances and risk failure
to be living in poverty was close to 8.1 million (U.S. Census
Bureau, 2011). Hispanic and African American households Offers support during struggles
fair the worst, while Asian households have the highest eco- Positive rather than negative slant on world views
nomic means (U.S. Census Bureau, 2010).
Encouragement to reach full Potential
Health Promotion
and Wellness their religious or spiritual beliefs, she can better serve that
Much of who we are, in terms of how we treat our health, client. A client facing a major illness with a serious prognosis
derives from what we learned within our families. Everything may struggle with spiritual issues.
from food choices to exercise patterns and activity levels End-of-life decisions are greatly influenced by the spiri-
derive from learned family habits. It is quite common for an tual beliefs found in a family. Support from family and church
extremely obese adult to remember a childhood of consum- members can provide great benefit to the family. A family that
ing too many calories coupled with minimal physical activity. nurtures spiritual growth and development is often a family
Nurses can play a large role in helping to educate parents on better prepared to face crises. Strengths found in families that
habits that promote health. Choosing healthy foods often foster personal growth and development are encouragement
takes learning what unhealthy options to avoid. Foods high to take chances and risk failure, a positive rather than negative
in trans fats, saturated fats, and increased calories are choices slant on world views, encouragement to reach full potential,
to avoid. Fruit and vegetable consumption is encouraged. and support during struggles.
Maintaining a healthy activity level in families can also be
a challenge. Parents understandably no longer feel safe in
letting children run around outside for most of the day, yet
in past generations this highly active lifestyle was the norm PARENTING STYLES
for children. Many parents entertain their children by letting Parenting involves the creation of an environment geared
them watch television or video games. Younger and younger toward assisting in the growth and development of a depen-
individuals are developing type 2 diabetes, in the past con- dent infant/child. The interactions or dynamics between par-
sidered primarily a condition only seen in middle-aged or ent and child within that environment are also a significant
older adults. The nurse can encourage, educate, and support aspect of parenting. When the concept of parenting styles
families on their quest for good health. The nurse who is is considered, it generally defines how parents interact with
knowledgeable in nutrition, exercise, disease prevention, and children to maintain cooperation and compliance (Cherry,
health screening is in a unique position to foster health and 2011). Three styles of parenting are authoritarian, authorita-
wellness in families. tive, and permissive. The styles of parenting may blend or
overlap in some families. In addition, children within a fam-
Spiritual and Personal ily may be parented in different styles. For example, a male
Growth and Development offspring in some cultures can expect to receive a more per-
missive style of parenting, while female offspring within that
What do you believe about God? What are the most impor- same culture may be more likely to experience an authoritar-
tant priorities in your life? Are you happy with whom you are? ian style of parenting.
What do you want to accomplish with your life? The answers
to many of these questions lie in how one’s family fostered the
spiritual and personal growth of the individual. For some cul- Authoritarian
tures, the passing of beliefs and education in spiritual develop- Authoritarian parenting was the most common style of
ment is a major strength. Some families spend significant time parenting prior to the 1960s and is still a widespread style of
and energy on activities that promote spiritual development parenting. Today it is commonly seen in the lower socioeco-
such as church, mosque, or synagogue attendance or other nomic levels of society and practiced within several subcul-
special religious events, while others do not. tures of American society (U.S. Department of Education,
This is a very personal part of what helps to form the 2010). In this style of parenting, there is a clear division of
foundation of a family and may have a significant impact in the who is in control and who must obey. Parents set the rules and
spiritual development of each family member. For example, distribute consequences and rewards depending on the child’s
a family of Christian Scientist believers will tend to avoid adherence to the parents’ rules and guidelines. Authoritarian
medical interventions and view such as a last resort. If a nurse parents generally do not feel the need to explain their expec-
understands not only the client and family’s culture, but also tations but rather teach the children that the parent is the
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person in charge in the family and the decision maker (U.S.

Department of Education, 2010). Parents using this form of BOX 2-2
parenting style may or may not use corporal punishment. One CHaraCTerisTiCs OFTeN seeN iN
disadvantage noted by opponents of this style is that children HealTHY FuNCTiONiNG Families
are not provided enough opportunity to learn decision-
making skills, because decisions are made by the parents. • Displays of warmth and affection toward each
Some believe this form of parenting may work well for chil- other are common.
dren with conduct disorders. Children who have a tendency • Clear roles exist yet flexibility and adaptability
to run wild may need the high degree of structure and author- to change are present.
ity this style of parenting provides. • Each member is valued and respected.
• Basic physiological, psychosocial, and spiritual
Authoritative needs are addressed.
• Good communication exists between
Authoritative parenting is also described as democratic or
active parenting. This is the parenting style favored by health members.
care professionals. This style provides behavioral guidelines • Anger is successfully managed without mem-
and encourages children to think about the consequences of bers verbally or physically attacking each other
behavior. Parents delineate clear behavioral expectations but (Fredenburg, 2010; Hewitt, 2011).
encourage children to question and discuss personal respon-
sibility for their own behavior with the consequences of the
behavior. Parents are significantly involved in monitoring the
child’s behavior and providing explanations for expectations. common to distressed families. It is very important to note
Parents actively reinforce the child’s positive behavior. that some healthy functioning families may have one or more
of these characteristics, yet manage to work well together and
maintain positive nurturing interactions with each other.
Permissive
Permissive parenting can be described as a “hands-off” ap- POTENTIAL FAMILY CRISIS
proach to parenting. The parent tends to place a high value
on individual freedom and the concept of learning from one’s The vast majority of families do not escape life crises. Many fami-
own mistakes. Rules are minimal and often not consistently lies pull together, work hard, and manage to cope. For some un-
enforced. Parents do not take an active role in shaping the fortunate individuals, a family crisis can mean the destruction
child’s behavior (U.S. Department of Education, 2010). Some of the family unit or the start of a pattern of unhealthy defense
children raised with this style of parenting may struggle with mechanisms. The divorce of parents, the suicide of a member, a
recognizing boundaries or limits. They may have difficulty child running away, or substance abuse by a family member can
cooperating and compromising with others. The child may all result in fractures in the family structure.
find rules outside the home difficult to follow. Some feel this Assistance outside the family unit may be needed when
style of parenting may work for shyer or timid children who a crisis develops. Reaching out for help beyond the family is
need ample encouragement and who may be easily discour- a very healthy coping mechanism when members are over-
aged when reproached. Some view permissive parenting as whelmed in their attempts to manage a crisis. Nurses are in
neglectful because of minimal parental interventions (U.S. a unique position to refer a family to the appropriate agen-
Department of Education, 2010). cies that may offer guidance and assistance. Two of the most
heart-breaking family crises for nurses to observe are child
abuse and domestic spousal abuse. The fact that one member
CHARACTERISTICS FOUND
IN HEALTHY FAMILIES
A family should not strive for perfection. Individuals who BOX 2-3
love each other still have conflict. However, when members CHaraCTerisTiCs COmmON
love, support, encourage, and care for one another, each indi- TO DisTresseD Families
vidual has the greatest chance of reaching their full potential.
Box 2-2 lists characteristics often seen in healthy function- • Neglect of basic needs
ing families. • Poor communication between members, in-
cluding dishonesty, hostility, sarcasm, silent
treatment, and frequent misunderstandings
CHARACTERISTICS • Substance abuse issues in one or more members
OF DISTRESSED FAMILIES • Financial instability
Unhappiness within a group of individuals may have multiple • Family members not all treated with equal re-
causes and variables that play into the dynamics of that group. spect or equal value
When it is a family group that is unhappy, distressed, or func- • Anger control issues in one or more members
tioning poorly, the impact on the members can be profound. • Power struggles and poorly defined roles
Many perceive fulfillment and happiness in life with harmony • Unrealistic expectations of family members
within the family unit. Distress in one’s family life can over- (Moneyworth, 2009)
shadow the other good parts. Box 2-3 lists characteristics
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of a family is the cause of another member’s intense suffering marriages. Beginning a marriage and then becoming a parent
is very difficult to witness. These and other potential family within months is a challenge to a new marital relationship.
crises are explored further in the following sections. Some women enter parenthood without the support of a hus-
band or partner and are in an even more challenging situation.
Domestic Violence Not all women experiencing unplanned pregnancy choose to
parent the child. Adoption and terminating the pregnancy are
Family functioning, like many aspects of human behavior, two possible choices made by women. Counseling is recom-
occurs on a spectrum. While some families excel in the sup- mended with either decision. It is important for the nurse to
port offered to members, other families unfortunately are a recognize that many unplanned pregnancies occur because of
destructive force in the lives of their members. Domestic vio- birth control failures.
lence occurs at the lowest end of distressed family functioning.
In this situation, one or more members actually physically lash
out at one another. Verbal and emotional abuse frequently ac- Family Member with Cancer
companies domestic violence. A diagnosis of cancer in one family member has a far-reaching
impact on all members. Cancer may be openly discussed and
Family Member approached as a battle for the entire family. In other situa-
tions, the family member with cancer may choose or be left to
with Mental Illness battle the diagnosis alone.
When someone in the family has a mental illness, generally While a group approach certainly may offer more sup-
all family members feel affected. When it is a parent dealing port, both the client with cancer and the family may not feel
with mental illness, the impact on the children is often directly comfortable or capable of addressing these crises as a team. At
related to how well the parent’s mental illness is managed. times, open dialogue between the client with cancer and fam-
When a parent’s mental illness, such as depression, panic at- ily members can facilitate the development of a supportive en-
tacks, or bipolar disorder, is not under control, children are vironment. A family member may initially be in denial about
often forced to assume adult responsibilities. the diagnosis because facing the potential loss of someone so
loved is too painful. At other times members pull back because
Familial Genetic Disorders they are not sure what to do that would be helpful for the cli-
ent with cancer. The nurse can offer suggestions to the family
Families challenged by a member or members living with a ge- member on how to support a loved one with cancer. Box 2-4
netic disorder need to work through a variety of difficult feel- lists the many ways family members can offer support.
ings. Parents of a first child with a recessive genetic disorder
experience shock at the time of diagnosis. For many individu-
als it is difficult to fathom that they can carry a gene causing a
genetic defect, but themselves be unaffected by the condition. BOX 2-4
Besides dealing with the child’s genetic disorder diagnosis, the
couple struggles in deciding to have more children. Parents suPPOrT FrOm FamilY memBers
wrestle with guilt. It can be devastatingly difficult to watch a Ways in which family members may offer sup-
loved child struggle with a disease passed on by the parent. port to a family member with cancer include but
Additional community support is often needed. Support are not limited to:
groups are often available for the more common genetic dis-
• Lend a listening ear. Something as frightening
orders in larger communities, while support groups for rarer
disorders can be found on the Internet. as cancer requires continual open dialogue.
• Go to treatment and/or physician appoint-
Teen Pregnancy
ments with the family member.
• Take on the family member’s household re-
Teen pregnancy is on the decrease, but the United States still sponsibilities when fatigue from treatment
has the highest teen birth rate of any Western industrialized occurs.
country (Centers for Disease Control and Prevention [CDC], • Continue to enjoy life with family. Day excur-
2011a; Singh & Darroch, 2000).
sions, movies, picnics, dining out, and gather-
The impact of teen pregnancy is not only hard on the
family, but can be challenging for the girl. Only 50% of teen ings with family members are uplifting.
mothers who give birth receive a high school diploma by the • Do not block out unpleasant talk and do not
age of 22, compared to 90% of women who had not given force talk about what the future holds. Follow
birth (CDC, 2011a; Perper, Peterson, & Manlove, 2010). the family member’s lead on what she chooses
Some factors that contribute to teen pregnancy are poverty, to discuss.
parents with lower education levels, single-parent family, and • Encourage all family members to share the
impaired school performance and peer relationships (CDC, load.
2011a; Hoffman, 2008). • Journal events, phrases said, thoughts, and
feelings.
Unplanned Pregnancy • Take one day at a time.
More than half of pregnancies in women from ages 18 to 19 • Be there physically and emotionally for a fam-
are unplanned (CDC, 2011b). In addition, unplanned preg- ily member with cancer.
nancies have and will continue to be the catalyst for many
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Guilt, however irrational, often accompanies the myriad

of feelings that occur when a loved one struggles with cancer. PARENTAL STRESSORS
Guilty feelings from being healthy when a loved one is sick or Many parental stressors are unique to the developmental stages
feeling guilty that they could not prevent a loved one from ex- and age of the children in the family. Each parent is also unique
periencing cancer may occur. Counseling for family members in which developmental stages or ages they perceive as most
may be useful. More and more cancer victims are becoming challenging. Many parents find infanthood, when an offspring is
cancer survivors. While this is wonderful, living in the shadow the most dependent and needy, to be the most draining. Yet for
of a previous diagnosis with cancer can be hard for both the others, raising teens results in high-stress parenting. In addition,
cancer survivor and the family of the cancer survivor. Support dealing with parental stress may correlate to various individual
groups for clients with cancer and cancer survivors can be characteristics of the parent. The individual who is less flexible
extremely beneficial. and easily frustrated will likely find parenting a bigger challenge.
Conversely, the individual who can adjust easily to frequent
Family Member changes and has a naturally easygoing approach to life will fare
better when faced with the inherent stress of parenting. Box 2-5
with Chronic Illness lists potential stressors for parents.
Dealing with a family member diagnosed with a chronic ill-
ness is difficult for both the individual and the family of that
individual. Management of Parental
Stressors
Child Abuse The family may experience stressors from a variety of fronts,
making it difficult to maintain a healthy balance. The loss of
Child abuse is increasing in the United States. In 2007, an
estimated 3,535,501 or 47.2 out of every 1,000 children were extended family ties, unemployment, lack of job security, and
alleged victims of child abuse in the United States and Puerto rising health care costs make the inherently stressful task of
Rico (DHHS, 2007). The very young are at highest risk for raising young children all the more difficult. Some families
the most severe form of child abuse, child fatality (DHHS, cope well with stressors, but many do not. Unfortunately,
2007). Children younger than 4 years of age account for when the level of stress within a family with young children
75.7% of child fatalities and those younger than 1 year of age becomes too high, child abuse can occur. It is vital that those
accounted for 42.2% of child fatalities (DHHS, 2007). Indi- in a position to help stressed families do so. Triggers for un-
viduals with the ultimate responsibility of caring for these chil- healthy levels of stress experienced by parents may present
dren prove most often to be the perpetrator of the crime. In within the family as well as in the environment of the family.
2007, 80.1% of child fatalities caused by fatal abuse or neglect Stress may result when there is a challenging match between
involved either one or both of the parents (DHHS, 2007). It a parent and child.
is very important to note that all 50 states have some type of Stressors can be triggered by the temperamental fit be-
mandatory abuse and neglect laws. The most recent amend- tween parent and child. The individual temperaments of both
ment of this law is titled the Keeping Children and Families the parent and child are often poorly recognized variables
Safe Act of 2003. While all states require certain institutions that can factor heavily into the degree of stress experienced
and professions to report child abuse, many states have within a family system. The philosophy that proper or well-
broadened statutes to require any person with knowledge of planned parenting will result in children who eat, sleep, and
possible abuse to report it. behave well has placed unrealistic expectations on parents.
These unrealistic expectations likely contribute to unhealthy
stress levels on some homes. Parents of a child with a difficult
Family Member temperament need support and suggestions for managing
with Substance Abuse their child rather than blame. It is important for the nurse to
assess the temperament and interactions between the parent
When a family member struggles with substance abuse, and child. If the family needs guidance to become a produc-
other members often have to deal with anger. While issues of tive family unit, relate concerns to the physician or clinical
chronic illness or mental illness are a challenge for families, it manager. Healthful resources dealing with parental stressors
is easier to offer support when conditions cannot be blamed can be as varied as the stressors themselves. The nurse is often
on the individual. Even when research suggests a genetic link in a unique position to be aware of resources that are helpful
to the susceptibility to addiction, it is disheartening to watch a to both parents and children.
loved one continue to struggle with substance abuse.
Familial Resources
Divorce Families differ greatly on the amount of support offered
The majority of Americans are familiar with divorce. Individu- to members with small children. In some African cultures,
als have a significant chance of coming from a divorced fam- the mother is tended to for a full month after birth. She has
ily or eventually divorcing once they are married. Potential minimal child care responsibilities and has meals prepared for
stressors associated with divorce may negatively affect the her. In America, it is not uncommon for a mother to return
health of those affected. Domestic abuse, issues of infidelity, home from the hospital with full housekeeping and infant care
and custody battles over children have a significant impact on responsibilities, at times with other children to care for also.
one’s life and may be overwhelming. Supportive counseling Familial resources providing support for parents dealing with
may be required to work through the turmoil of emotions that parental stressors may or may not be available. Unfortunately,
present when a marriage ends. when familial support is present, it is not always accessed.
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BOX 2-5 BOX 2-6

POTeNTial PareNTiNG sTressOrs COmmON resOurCes FOr Families
infanthood • YMCA/YWCA. This organization offers child
• Uncontrolled crying care, fitness programs, disease prevention pro-
• Feeding problems grams, etc.
• Poor sleeping habits • Head Start. This federally funded agency pro-
• Frequent illnesses (e.g., ear infections) vides both education programs and health
physicals to preschool children. Some commu-
Toddler/Preschool
nities even provide services for younger ages.
• Temper tantrums
• Local universities. Many colleges provide
• Irrational fears
outreach programs for the community. Col-
• Bedtime problems
leges with counseling or graduate psychology
• Eating problems
programs often offer low-cost counseling to
• Biting
families.
• Toilet training
• Negative behavior
• Whining
parenting, but offers of help may not be forthcoming if the need
Five- and six-Year-Olds is not apparent. Parents should be encouraged to utilize respite
• Fighting with siblings time when others in the extended family are willing to help. For
• Interrupting example, the mother and father of a new infant who have not
• Bed-wetting slept due to multiple nighttime awakenings should ask for a
• Bedtime problems respite night of child care. If a complete night of babysitting is
• Eating problems not possible, daytime babysitting may make it possible for a re-
• Challenging rules and boundaries storative nap. Children with behavioral issues also have parents
who need a break. A daily schedule of interacting with a toddler
school-aged Children or a child with attention-deficit/hyperactivity disorder (ADHD)
• Fighting with siblings or friends is not easy. An aunt or uncle’s offer to take a niece or nephew out
• Bed-wetting for the afternoon benefits both the child and the parent. Familial
• Reluctance to help with household resources are too frequently underutilized.
responsibilities
• Bullying or being bullied Community Resources
• Avoiding homework The amount and type of resources available to families in
• Fighting bedtime routines communities across America vary greatly. Box 2-6 lists agen-
• Whining cies and groups that operate in many communities.
• Back talk and disrespectful attitude
Health and Educational Resources
Teenagers
Health-related and educational resources available to families
• Teen reluctance to share in household are also frequently underutilized. A major reason for this is
responsibilities that advertising is expensive. Nurses working in the commu-
• Teen’s academic achievement may be less val- nity are often in a good position to share information about
ued than maintaining social commitments important resources with those who need them most. Many
• Teen displays behaviors that challenge bound- hospitals offer free parenting and disease prevention classes as
aries and rules a part of their community outreach programs. In many com-
• Teen believes parents’ opinions are less valued munities the local newspaper has a weekly section on health-
than others’ opinions related education offerings. Nurses can play an active role in
• Teen reluctance to communicate with parents promoting such classes and seminars.
• Rude and insolent behaviors when interacting
with parents CONCLUSION
Each client is involved in a family unit and each diverse family
has its own culture and dynamics. Some families are healthy,
There are several roadblocks to utilizing the important help while others experience distress and family crises. A compe-
parents experiencing parental stressors need. Grandparents, tent nurse assesses the client’s needs within the family setting
aunt, uncles, and even older siblings can help ease the stress of and refers them to resources that can help meet these needs.
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CHAPTER 3
Communicating with Clients
with Personal and Family Issues
KEY TERMS
cliché empathy stressors
confrontation productive sympathy
LEARNING OBJECTIVES
2. List several communication traits found in healthy functioning families.
3. Define several traits counterproductive to healthy family communication.
4. Describe ways the nurse may facilitate therapeutic communication for families struggling
with health issues.
5. Discuss challenges the nurse may face when engaging in therapeutic communication with
families or clients.
6. Define productive confrontation.
7. List guidelines to use when communicating with clients from a different culture.
30
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CHAPTER 3 Communicating with Clients with Personal and Family Issues 31
other members. Many components are necessary for healthy

communication. The following are communication traits and
tendencies common to healthy functioning families:
• Use of active listening
• Honest, forthright communication
• Members feel sense of security and acceptance
• Flexibility
• Openness
(© Rob MaRMion/ShutteRStock)
• Encourages other family members
• Sense of fairness (a give-and-take approach)
• Sense of trust
• Feelings of love and kindness easily displayed
• Respect for all members (Carini, 2009; Lad, 2011; Scott,
Figure 3-1 A nurse frequently listens to a client’s apical 2010)
pulse, but does she really hear what is truly being said?
COMMUNICATIVE TRAITS
INTRODUCTION OR TENDENCIES
George Bernard Shaw was once quoted as saying, “The single
IN DISTRESSED FAMILIES
biggest problem with communication is the illusion that it has Families become distressed or dysfunctional in a variety of
occurred” (Prince-Paul & Exline, 2010). For some families ways. For some, alcohol or substance abuse contributes to
and individuals, communication skills are a natural strength. family problems. In some families, patterns of interaction
They are used as part of effective coping mechanisms and passed from generation to generation set the stage for dys-
used to help deal with stressors. For other individuals, how- function. Families that deal with abuse or have an extremely
ever, ineffective communication skills only serve to make a strict authoritarian foundation are often continuing learned
difficult situation that much harder. And sadly, when inef- patterns. Major illness in parents, partner, or child or the
fective or poor communication occurs, it is not always recog- presence of mental illness can also place the family at risk for
nized (Figure 3-1). dysfunction.
The following are traits or tendencies seen more com-
monly in distressed families:
COMMUNICATION WHEN • Passive-aggressive tendencies: Negative or aggressive feel-
PERSONAL OR FAMILY ings expressed indirectly or displayed by unwillingness
ISSUES ARE PRESENT to cooperate. Some behaviors seen in passive-aggressive
individuals are pouting, giving the cold shoulder, giving the
When an individual or family members are experiencing silent treatment, stubbornness, intentional forgetfulness, or
struggles or personal issues, coping may be significantly tardiness.
hampered because communicating effectively at such times • Defensiveness: Defensive behavior is seen when a person
becomes a greater challenge. For example, the individual quickly assumes others are blaming or confronting them.
facing diabetes will have much to work through before reach- For example, one party simply stating they are “tired” may
ing a point of confidence and perceived control of diabetes. prompt another to feel they are being accused of not doing
But achieving an adequate level of confidence in managing their share.
diabetes takes emotional resources. One vital skill in coping
with health and other life crises is good communication. If the • Power struggles.
client or family with which the nurse is interacting is weak in • Conflict avoidance: Conflict avoidance is the intentional
the area of communication, facilitation and intervention may evasion of potentially uncomfortable confrontations or dis-
be required. This chapter explores some of the complexities agreements. For example, a mother may ignore her teenage
associated with communicating with individuals or families son arriving home at 2 a.m. rather than address it and risk
navigating through health issues. Information and insight is an argument.
also provided on how to help those individuals and families • Lack of trust.
who are struggling with communication. • Suppression of emotions.
• Angry outbursts, verbal abuse (Preller, 2006).
COMMUNICATIVE TRAITS • Dishonesty.
• Negativity.
OR TENDENCIES • Denial (UIUC Counseling Center, n.d.).
IN HEALTHY FAMILIES • Hidden agendas.
In healthy families, members use communication to help • Desire to “win” every argument or “always be right” (Scott,
meet their individual needs and also to provide support to 2006b).
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THERAPEUTIC COMMUNICATION
Therapeutic communication involves many components. It
involves active listening and focuses on what the client is at-
tempting to convey. Active listening is really listening to what
the client is saying and attempting to understand the situation
from the client’s perspective (Estes, 2010). Take in the voice
tone, pitch, and inflections. Watch that the body language
corresponds to what is said. Often it requires exploration and
clarification to ensure accurate understanding. At times, the
use of humor, touch, silence, or even confrontation may be
appropriate (Antai-Otong, 2008).
When it is not possible to offer an answer or options to
(DelMaR cengage leaRning)

a client communicating concerns, communication validation
may help. Assure the client that it is normal for the client to be
both experiencing stress and desiring to talk about whatever
personal or family issues are occurring. Validate that you re-
spect their unique experience (Antai-Otong, 2008).
A nurse who is able to imagine one’s self in circumstances
similar to what the client is experiencing is able to convey em- Figure 3-2 A nurse shows empathy to a client.
pathy (Antai-Otong, 2008). Family and clients will certainly
CRITICAL THINKING experience distressing life circumstances that never occurred

in the nurse’s life. While it may be easier to offer support to cli-
ents when the nurse knows just what they are going through,
Three Needed Qualities it is not the only way to be supportive. Certainly a nurse who
has experienced pregnancy loss will be in a better position to
communicate understanding to the client who has just experi-
enced a miscarriage. However, even when we personally have
Joan Vivaldelli shares a therapeutic communica-
not experienced the same loss or level of emotional pain our
tion she had with the family of a client dying clients have, our words can communicate that we care about
with cancer. She recognized that the family was their loss or sadness (Figure 3-2). Sometimes just honestly
struggling with the death of the wife’s mother saying “I don’t know how I would handle this” helps to make
and realized the family needed as much support the significance of what the client is experiencing recognized.
as the client. Through this experience, she real- Conversely, an offer of sympathy may hinder therapeu-
ized there were three qualities that made the tic communication with a client. Many individuals do not
communication effective: compassion, discern- feel comfortable when they imagine someone “feels sorry
ment, and trust. Compassion is an attitude that for them.” Indicating that what the person is experiencing is
connects with and imagines the emotions of horrible and hard to even imagine, can make one feel isolated
another and responds with gentleness, concern,
and alone.
and presence (Beauchamp & Childress, 2001).
Discernment is the ability to cut through the situ- KEYS TO EFFECTIVE LISTENING
ation and make a decision with limited regard
Active listening can take time. If a client is distressed, it is not
for personal emotions or outside influences that
always easy to discern what he is most concerned about or
distract (Beauchamp & Childress, 2001). Trust is a what he specifically is trying to ask. Seemingly intense concern
vital component that, if shattered, has the ability over the potential side effects of chemotherapy could actually
to impair healing (Pellegrino & Thomasma, 1993). be masking a deeper concern about the success rate for remis-
For the element of trust to exist, the client needs sion with chemotherapy. If you answer the client’s questions,
to trust the nurse, and the nurse needs to trust offer reassurance and support, yet the client still appears dis-
the client (Vivaldelli, 2007). tressed, it may be beneficial to delve further. Some questions
(Note: The definitions of compassion, discern- that help clarify a client’s unresolved concerns are:
ment, and trust are based on two classical works 1. What else is on your mind?
in medical ethics, morality, and virtues.) 2. Are you still concerned about . . . ?
1. Reflect on the meaning of compassion, dis- 3. There are many things to consider. What else do you
cernment, and trust. feel needs to be (discussed, explored, addressed)?
2. Write your own definition of compassion, dis-
cernment, and trust.
Practice excellent active listening skills and let the client
know you want to hear their “story.” Give the client your full
3. How will you integrate these concepts into
attention by avoiding interruptions and premature interpre-
your nursing? tations. Give evidence of understanding through restating
or summarize what you heard (Antai-Otong, 2008). Just as
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important is recognizing when your client is not ready to have Nurses interacting with families dealing with such issues
you communicate information to them. Bad news may need should be prepared for unique challenges.
to be delivered in small chunks to allow the client time to pro-
cess the information. If multiple stressors are present, some
of them may need to be resolved before more bad news can be Divorced Families
processed (Hardy & Kell, 2009). Some families or partners who experience divorce manage to
work through to a point of normal functioning. Yet, for many
experiencing divorce, family peace or even family civility
SPECIAL COMMUNICATIVE seems impossible. Unfortunately, divorce is a major life crisis
CHALLENGES FOR NURSES that continues to bring new challenges. When an individual or
family has unresolved issues related to divorce, health crises
The nurse wanting to engage in meaningful or therapeutic could be that much harder to work through. Medical insur-
communication with a client and/or the client’s family may ance coverage, consent for minor children’s procedures, and
face many challenges. Generally, in order for significant mean- hospital visiting times are just a few of the issues that can com-
ingful communication to occur between the client and nurse, plicate matters. When the communication processes within
the client must feel that a warm and genuine relationship the family are dysfunctional, the challenges for the nurse can
exists between the two parties (Michalopoulos & Michalo- be immense.
poulos, 2009). Understanding how family members interact with each
Clients should sense that the nurse can imagine how other is an important first step. For example, if a father who
they feel and respects them. Even then, outside challenges left the family has been ostracized, he may not be the best
may present that are directly related to the rigors of working choice for shared information given by the physician. The
in health care today. Less time with each individual client can nurse may need to take on a more active role to ensure that
have a negative effect on communication. Due to minimal important information is relayed.
time for client/nurse interactions, shortcuts may be taken. For Divorce frequently involves unresolved issues of anger
example, the hurried nurse may be quick to judge what the that complicate communication. Outside assistance may be
problem is or may try to guess what the client is attempting to needed if communication is significantly hampered. Clergy,
convey to save time. social workers, or ombudsmen may be of assistance.
Lack of time may also factor into the nurse not taking the
time to observe important nonverbal cues the client may be
sending. Simultaneously assessing an IV line and pump while Domestic Violence
attempting to talk to the client may impede the nurse’s ability Issues of domestic abuse present an extremely difficult com-
to focus on what the client is trying to communicate. municative climate. While the abuser will most likely want
Assumptions may result in the nurse giving quick advice to impede communication outside the family unit, the nurse
rather than offering to discuss various options (Antai-Otong, may also unwittingly fail to foster communication. When pre-
2008). When under significant time constraints and the stress sented with the harsh reality of domestic abuse, nurses may
of heavy client loads, the nurse may respond with a cliché inadvertently pull back from the situation. Although at first
such as “Everything will be alright.” The use of a trite or fre- the nurse may be unsure about how to best help a client in an
quently used phrase, like a cliché, results in the client feeling abusive relationship, doing nothing is not an option. In such
unheard. Clichés are often perceived as a signal that no further complex situations, a team of health care providers may need
discussion is warranted. to explore how best to help the client.
Last, the health care provider may jump to conclusions
about what the client’s needs are, based on past interactions
with clients in similar circumstances. It is important to re- PRODUCTIVE CONFRONTATION
member that responses to the stressors associated with health-
related issues can be as unique and varied as the individuals The word confrontation often has a negative meaning for many
themselves. Nine out of 10 clients who have experienced a individuals. Angry feelings, harsh words, and conflict are often
diagnosis of cancer may have the possibility of death weighing associated with the term. In reality, confrontation, when used
heavily on their mind. The tenth client may need to talk about constructively, can be a powerful tool when change is needed.
how chemotherapy and a potential hospital stay may impact Confrontation may be useful when a client is engaging in
the care of their pets. While the nurse may feel that worrying maladaptive or poor defense mechanisms such as denial or
about a pet should be lowest on the client’s list of concerns, it rationalization (Antai-Otong, 2008).
may be the client’s only focus. Remember to focus on the cli- Productive confrontation can be an important part of
ent’s most pressing worries before moving to other topics that the communication process between the nurse and client if
need to be addressed. As long as the client is worried about his this technique is used in a respectful, tactful, and nonthreat-
problem, he may not hear the other topics discussed. ening manner (Figure 3-3). Doing so can help to facilitate the
client’s move toward self-examination and opportunities for
growth (Antai-Otong, 2008).
AREAS OF SPECIAL CHALLENGE Confrontation may prove useful in the following client
FOR FAMILIES circumstances:
Even families without the obvious problems seen with divorce 1. Lack of compliance productive confrontation scenario:
or abuse may struggle with healthy communication. Unfor- Client (teenager with diabetes): Most of the time I’m
tunately, for families with these special challenges, the road pretty good at eating and taking my insulin, but
to constructive communication can be especially difficult. I’m too busy to always grab some food. At least my
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use. What would happen to your family if this hap-

pened to you? It’s not a chance I’d want to take.
3. Denial resulting in delay or lack of needed treatment pro-
ductive confrontation scenario:
Nurse: I know the nurse practitioner gave you your posi-
tive pregnancy results. Would you like to schedule
your next prenatal appointment?
Client: It just doesn’t make sense that I’m pregnant. I
was so careful. I think I’ll wait to see if I miss another
(©blaj gabRiel/ShutteRStock)
period before I make an appointment.
Nurse: The pregnancy test is a very good indicator of
pregnancy. Do you think the test is wrong?
Client: I’m not saying anyone made a mistake; it’s just I
don’t feel pregnant and I think I would know.
Nurse: In the early weeks of pregnancy, women nor-
Figure 3-3 The nurse confronts the client with respect and mally don’t notice any major differences. But a urine
tact and in a nonthreatening manner.
pregnancy test and physical examination are pretty
conclusive of a diagnosis of pregnancy. In addition,
the nurse practitioner was able to hear fetal heart
family and friends know how I behave when my tones with the Doppler. Do you remember listening
blood sugar is low. to the fast heart rate and her telling you it was the
Nurse: What do your family or friends do for you when baby’s heart rate?
you show signs of hypoglycemia from an insulin dose Client: I guess. It’s just that I don’t want to believe it; I’m
not followed by eating? not at all prepared.
Client: Oh, they carry some instant glucose or I have Nurse: Let’s talk about that more.
some in my purse they can give me. My mom always 4. Rationalizations used to continue unhealthy behavior pro-
keeps an injection of glucagon with her. ductive confrontation scenario:
Nurse: What could happen if just one time family or Nurse: This is your fourth emergency department
friends weren’t there when you were showing signs (ED) visit for an acute asthma attack this year. Has
and symptoms of severe hypoglycemia? your physician adjusted your asthma management
Client: Oh, well, I guess someone else would help me. regimen?
Nurse: Before you developed diabetes, would you have Client: Yes, he added Advair to my asthma drugs, but
known what to do if you came across a person in a I’ve gotten by with just an inhaler for years. I’m
severe hypoglycemic state? trying to improve my health in other ways. I’ve lost
Client: Well, no. weight and eat better now.
Nurse: So if you’re severely hypoglycemic and family or Nurse: Unfortunately, that doesn’t reduce the risk of a
friends aren’t around, what could happen? life-threatening asthma attack. Repeated ED visits
Client: If no one knew to check my bracelet or even to manage your asthma is not a valid way to control
what to do in a diabetic emergency, I could go into a your asthma. Frequent acute attacks put you in real
coma before help arrived. danger. Severe asthma attacks can be deadly and
Nurse: Do you want to take that big of a risk by not eat- you certainly can’t always count on fast access to
ing after taking your insulin? an ED.
Client: I guess not. Client: You’re right, they seem to be happening more
frequently, no matter what else I do.
2. Repeated evidence of risky behaviors productive confron-
tation scenario:
Psych client: I only “snort coke” when I’m out with
friends on the weekends, really only a couple week- CHALLENGING
ends a month at the most. COMMUNICATION
Nurse: So you feel then that you don’t have a problem ACROSS CULTURES
with that?
Communicating with another individual born in the same
Psych client: Well it’s not like I’m addicted. I still work,
city, under similar socioeconomic conditions and with many
love my family, and provide for them. It’s something
of the same life circumstances, is not a guarantee that the two
I enjoy and have under control.
individuals will always connect and understand what the other
Nurse: Did you know that cardiac arrest could occur is trying to convey. Even then, one person may use sayings or
in healthy individuals with any episode of cocaine use a different meaning for a phrase that may be unclear to
use? the receiver of that communication. Imagine then how much
Psych client: I’ve never heard of that. opportunity for misunderstanding exists when the life experi-
Nurse: It can happen to anyone using cocaine, even ences of two individuals are quite varied. Many individuals
those who use cocaine occasionally for recreational find connecting with those from a culture different than their
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own to be enriching. However, it can be a unique challenge to to interacting only with a client’s spouse for example,
communicate across cultures when important health-related with a Hispanic client, several family members may be
issues are involved. While the guidelines for interacting and involved in all health discussions.
communicating between cultures will vary, some general 4. Not all cultures view Western medicine as the final
guidelines may prove useful for the nurse: authority. Discuss with your client what alternative
1. Don’t make the assumption that everyone wants to be forms of medicine they may be using. For example,
treated the way you want to be treated. For example, Asian clients may use a mixture of Eastern and Western
while you may wish to know your exact diagnosis and medicine (Salimbene, 2005).
prognosis no matter the gravity of the situation, those
from certain cultures, such as Middle Eastern families,
often filter a diagnosis for clients and may choose not to CONCLUSION
be told bad news. Family is a vital element of society with its own unique values,
2. Cultures vary on comfort with eye contact, touch, and culture, characteristics, diversity, and traditions. The purpose
personal space when communicating. Adjust to your of the family includes promoting the personal, spiritual, and
client’s cultural preferences once you learn them. Asian psychosocial growth and development of an individual in a
clients for example wish to avoid having their heads supportive, safe environment. Each family has its own distinc-
touched. tive characteristics, some healthier than others. Parenting
3. In many cultures, the entire family is involved when skills—whether well developed or lacking—are passed from
health-related decisions are being made. Determine one generation to the next. Throughout each stage of life,
with the client who they wish to be involved when dis- the family is confronted with stressors that can be managed
cussing important matters. While the nurse may be used productively.
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UNIT SUMMARY
• Characteristics of the medical-surgical nurse include orga- • Pharmacogenomics is an exploding field of research that
nization, prioritization, and critical thinking. evaluates how changes in genetic structure or organization
• Critical thinking is a systematic process of reasonable re- affect an individual’s response to a certain drug.
flective thinking that leads to an action or belief. • Several diseases are caused by an alteration in an individu-
• Problem solving is taking facts and developing an entire al’s genetic makeup.
holistic picture. • The nurse’s role with a client who has a genetic disorder
• The nursing process is used to help guide the nurse in pro- is supporting the client and family, relating accurate facts
moting optimal client outcome, and is an ongoing process. about the genetic disorder, and referring the client to reli-
• Critical thinking and problem solving can be taken to a able resources for assistance.
higher level by incorporating clarity, accuracy, precision, • Families are diverse and, to be effective, the nurse shows
relevance, depth, breadth, logic significance, and fairness. acceptance to all types of family units.
• Director of care, caregiver, educator, and client advocate • Each family has its own culture.
are roles of the medical-surgical nurse. • Healthy family members love, support, encourage, and
• Standards of practice guidelines have been developed care for one another.
from the nursing practice acts to direct nursing care. • In distressed families, basic needs are not met and mem-
• A code of ethics provides motivation for establishing, bers have poor communication techniques with ill-defined
maintaining, and elevating professional standards. roles. Family members are not treated with equal respect
• Evidence-based practice is nursing care that uses current or value.
best evidence that is supported by relevant valid research. • A family crisis can mean the destruction of the family
• The Quality and Safety Education for Nurses (QSEN) unit or the start of a pattern of using unhealthy defense
project established six competencies to prepare nurses mechanisms.
with the knowledge, skills, and attitudes (KSAs) necessary • The three styles of parenting are authoritarian, authorita-
to improve the quality and safety of health care systems. tive, and permissive.
• The six QSEN competencies are patient-centered care, • The individual who can adjust easily to frequent changes
teamwork and collaboration, evidence-based practice and has a naturally easygoing approach to life will fare bet-
(EPB), quality improvement (QI), safety, and informatics. ter when faced with the inherent stress of parenting.
• Nursing informatics is used in education, research, admin- • A healthy functioning family communicates openly, hon-
istration, and nursing practice. estly, kindly, and with candor in a trusting environment.
• The Human Genome Project that was completed in 2003 • In some families, patterns of interaction passed from gen-
sequenced the genome, mapped the location of genes on eration to generation set the stage for dysfunction.
all chromosomes, and increased our understanding of the • Effective communication between the nurse and client is
human genome. based on a warm and genuine relationship.
• Genetics is the study of individual genes and their trans- • Productive confrontation can be an important part of the
mission of traits and single-gene disorders from one gen- communication process between the nurse and client if
eration to the next. this technique is used in a respectful, tactful, and non-
• Genomics is the study of all the genetic material and how threatening manner.
the genes interact with each other and the environment
including cultural and psychosocial factors.
THEORY TO PRACTICE
1. Consider the roles of the medical-surgical nurse. Interview and observe several medical-
surgical nurses during your clinical to see if they are actively functioning in all four roles.
Are medical-surgical nurses functioning in any other roles? If so, what are the roles and how
much time are they functioning in those roles? Which role does the nurse view as the most
important role in her job? In postconference, share and discuss as a group the results of the
observations and interviews. Compare and contrast your findings with each other.
2. At the end of the clinical day, practice using SBAR or I-SBAR-R to report off to the primary
nurse caring for your client. Organize and prioritize the client data that you need to share
with the nurse.
3. According to the text, the family can contribute to the growth of its members by promot-
ing psychosocial development and growth, providing economic support, promoting health
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and wellness, promoting spiritual and personal growth and development, providing security,
acceptance, and love, and teaching social etiquette. Write a paper stating how your family’s:
A. Economic support contributed to your growth as an individual.
B. Provision of security, acceptance, and love helped you develop into the person you are
today.
C. Promotion of psychosocial development and growth shaped your values and beliefs.
4. Research health-related and educational resources for families that are available in your
community. Bring your findings to the clinical postconference and share them with your
classmates.
5. List reasons some people may find productive confrontation difficult.
6. Think of a situation that you would like to address with productive confrontation. Write out
the scenario using the productive confrontation examples presented in Chapter 3.
NCLEX-STYLE REVIEW QUESTIONS

1. Which of the following is the priority when organiz- 5. An example of a diverse family unit is the intergen-
ing and prioritizing client care? erational family. This type of family:
1. Medication administration 1. has neither parent available to raise the children
2. Collaboration and the grandparents assume responsibility.
3. Client safety 2. consists of a married man and woman with
4. Communication children.
2. Which of the following are steps in the nursing pro- 3. has children from one or both parents through
cess that guide nurses when problem solving? remarriage.
(Select all that apply.) 4. has more than two generations living in the same
1. Nursing diagnosis household functioning as a family.
2. Assessment 6. Characteristics of a healthy family include: (Select
3. Planning all that apply.)
4. Therapeutic communication 1. warmth and affection toward each other.
5. Evaluation 2. focusing on psychosocial needs.
6. Properly identifying client 3. silent treatment between members.
3. Creativity, autonomy, application of proactive nurs- 4. flexibility and adaptability to change.
ing expertise, critical thinking, and effective leader- 5. a demonstration of nonequal respect and value.
ship and management skills to ensure quality care 6. financial instability.
are attributes of which medical-surgical nursing 7. When assisting a client and her family through a cri-
role? sis, the nurse can: (Select all that apply.)
1. Educator 1. offer suggestions to family members on how to
2. Caregiver support the loved one with cancer.
3. Client advocate 2. recognize that families may be in denial because
4. Director of care to lose a loved one may be too painful to accept.
4. Using current best evidence that is supported by rel- 3. recognize that a family may not be comfortable
evant valid research is an example of: or capable of addressing the crisis as a team.
1. informatics. 4. recommend a community support group to a
2. evidence-based practice. couple with a child with a genetic disorder.
3. client advocacy. 5. remember that many unplanned pregnancies
may be because of birth control failures.
4. quality and safety competencies.
6. support children with a mentally ill parent
because they may be forced to assume adult
responsibilities.
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8. A parent sits down and talks with a preteen about 12. A mother is silently crying outside the room where
the physical effects of smoking. Neither of the par- her daughter is dying of leukemia. The nurse can
ents smokes. The parents encourage the preteen to communicate therapeutically with the mother by:
discuss personal consequences if he chooses to start 1. ignoring the mother so as not to embarrass her
smoking. This parenting style is: and acting very busy with charting.
1. authoritative parenting. 2. saying, “I’m sorry. I know how you feel.”
2. authoritarian parenting. 3. saying, “I know this is hard. I don’t know how I
3. permissive parenting. would handle this.”
4. laissez-faire parenting. 4. saying, “I’m giving your daughter the best care I
9. The most effective way for parents to respond to pa- can.”
rental stressors is to: 13. Some common communicative challenges for nurses
1. become frustrated with the child’s behavior. are: (Select all that apply.)
2. recognize that the teenage years are the most 1. less available time to spend with each client.
stressful for parents. 2. guessing what the client is attempting to convey
3. have a naturally easygoing approach to life. to save time.
4. adjust with difficulty to frequent changes. 3. not taking the time to observe important nonver-
10. A teenager picks up the keys to his car and states bal cues the client is sending.
he is going to pick up some printer paper so he can 4. focusing on the client’s most pressing concerns
finish his homework assignment. His mother asks, before moving to other pressing topics.
“Would you stop on your way home and bring some 5. giving quick advice rather than offering to discuss
milk for dinner?” He responds, “Sure, I know you options.
have been busy lately. I can still get my paper com- 6. jumping to conclusions about the client’s needs,
pleted this evening.” This scenario is an example of based on past interactions with clients in similar
which healthy communication trait? circumstances.
1. Encouragement of family member 14. Productive confrontation:
2. Flexibility 1. facilitates the client’s move toward self-
3. Openness examination and opportunities for growth.
4. Sense of fairness 2. is a waste of time and only ends in angry feelings
11. A young girl is sitting at a table when her brother or harsh words.
approaches the chair next to her and starts to sit 3. is a weak communication tool when change is
down. The girl states, “No, I want mother to sit next needed.
to me.” The boy yields and states, “OK, I’ll sit by 4. lacks respect and is done in a threatening manner.
dad.” The girl immediately starts yelling to her fa-
ther, “Dad, Dad, Dad.” When he acknowledges her,
she says, “Come sit here by me.” This scenario is an
example of which type of a distressed family com- For additional content, activities, games, and
munication technique? more, visit the White Premium Website at
1. Passive-aggressive www.cengagebrain.com.
2. Power struggle Use the access code printed in the front of
3. Conflict avoidance this book to log on to this free resource today!
4. Desire to “win” every argument or “always be
right”
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Institute of Medicine Quality and Safety Education for Nurses
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Concepts Integral to
UNIT 2
Medical-Surgical Nursing
4 Complementary and Alternative Therapies / 45
5 Inflammation and Infection / 64
6 Caring for Clients in Shock / 80
7 Pain Assessment and Management / 108
8 Cancer / 133
9 Palliative and End-of-Life Care / 159
Health care settings are multifaceted, challenging, rewarding, and

changing. Critical thinking and sound nursing judgments are essential
in the present health care environment. Nurses confront and adapt to
changes in technology, information, and resources by building a solid
foundation of accurate, essential information. Having a firm knowledge
base of the concepts integral to medical-surgical nursing allows the
nurse to meet the changing needs of clients.
This unit is a comprehensive presentation of various concepts inte-
gral to medical-surgical nursing. When a nurse is caring for a medical-
surgical client it is essential to view the client holistically. The nurse will
assess the client’s use of complementary and alternative therapies,
risk for infection, and pain level. The medical-surgical client may also
experience inflammation from trauma or stages of shock from blood
loss. Perhaps the client has been diagnosed with cancer and needs
surgery and/or end-of-life care. This unit brings together various topics
that apply to a medical-surgical client.
88021_ch04_ptg01_043_063.indd 43 12/28/11 5:01 PM

Chapter 4, Complementary and Alternative Therapies, provides
the learner with detailed descriptions of complementary and alterna-
tive treatment methods that are currently being used in holistic nursing
practice. Historical influences on contemporary practice, modern trends,
alternative and complementary interventions, mind/body techniques,
biofeedback, spiritual therapies, manipulation and body-based strate-
gies, energy therapies, biologically based therapies, and other method-
ologies are presented and discussed in this chapter.
Chapter 5, Inflammation and Infection, provides an overview of in-
flammation and infection including the chain of infection, body defenses,
stages of the infectious process, and hospital-acquired infections. Also
discussed are nursing interventions to reduce the risk of infection.
Chapter 6, Caring for Clients in Shock, addresses the various etiolo-
gies, nursing management, and treatments for the five basic types of
shock: hypovolemic shock, cardiogenic shock, septic shock, neurogenic
shock, and anaphylactic shock.
Fear of pain is a common human phenomenon. Chapter 7, Pain As-
sessment and Management, describes pain and explains the conduc-
tion pathways including the gate control theory. Specific guidelines are
provided to assist the nurse in thoroughly assessing pain. Three general
principles of pain management are identified with a detailed explanation
of pharmacological and nonpharmacological nursing interventions to
provide client comfort.
Chapter 8, Cancer, explains cancer cells and presents information so
the nurse can competently assess clients, learn medical interventions,
observe and manage complications, and assist the client in coping with
the complex aspects of cancer.
Loss and grief are a part of life. Chapter 9, Palliative and End-of-Life
Care, takes an honest look at grief and provides guidelines for appropri-
ate nursing actions to assist the client through this difficult, emotional
time. The holistic needs of the dying person and his family are described
with an effective plan of care to meet those needs. The chapter closes
with tips that help nurses cope with their own feelings and thoughts as
they care for the client and family.
88021_ch04_ptg01_043_063.indd 44 12/28/11 5:01 PM

CHAPTER 4
Complementary
and Alternative Therapies
KEY TERMS
acupressure curing neurotransmitters
acupuncture energy therapies phytochemicals
allopathic free radicals psychoneuroimmuno
alternative therapies healing endocrinology (PNIE)
antioxidant healing touch shaman
aromatherapy hypnosis shamanism
biofeedback imagery therapeutic massage
bodymind meditation therapeutic touch
complementary therapies neuropeptides touch
LEARNING OBJECTIVES
2. Describe the influences of history on current complementary and alternative modalities.
3. Discuss the connection between mind and body and how this affects a person’s health.
4. Explain the concept of the nurse as an instrument of healing.
5. Differentiate the various mind/body, body-movement, energy healing, spiritual, nutritional,
and other modalities that can be used as complementary therapies in client care.
6. Evaluate the use of complementary and alternative modalities.
45
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46 UNIT 2 Concepts Integral to Medical-Surgical Nursing
restoring balance to a person’s life through baths, massage,

INTRODUCTION music, laughter, art, herbs, and simple surgery (Keegan,
Our Western society generally equates health and healing 2001). Many of our current therapies, such as massage, art
with medicine, surgery, and other technological interventions. therapy, and herbal therapy, have origins in ancient Greek
Many other cultures, however, promote healing through faith, traditions.
ritual, magic, and other nonmedical approaches.
The use of complementary therapies (therapies used
in conjunction with conventional medical therapies) and
The Far East
alternative therapies (therapies used instead of conven- Healing systems of the Far East have traditionally integrated
tional or mainstream medical modalities) is becoming more body, mind, and spirit into a system balancing energy between
prevalent among the general public. According to the Na- the individual and the universe. The practices of traditional
tional Center for Complementary and Alternative Medicine Chinese medicine (TCM) have been used for centuries and
(2010c), more than one-third of U.S. adults are using some are not considered to be an alternative therapy in Asia. It is
form of complementary or alternative medicine (CAM). a lived philosophy of health and well-being. Restoring and
This chapter addresses complementary/alternative maintaining a balance of vital energy is the goal of TCM. Life
(C/A) treatment methods that are currently being used in energy qi (pronounced “key”) or chi (pronounced “chee”) are
holistic nursing practice. Nurses must think critically be- the words used to describe the vital energy that is the focus of
fore recommending or implementing any of these therapies. the philosophical principles of TCM. Fundamental elements
Whether simply discussed with clients or performed, nurses include balancing opposing forces of yin and yang (e.g., light–
should understand the ramifications. dark, cold–hot, and female–male). Assessment and diagnostic
techniques of the TCM practitioner are very different from
the allopathic (traditional medical and surgical treatment)
LEGAL ASPECTS approach of Western medicine. The five senses are used to
assess the client by looking, listening, feeling, smelling, and
Because more and more states are regulating C/A therapies, tasting (if needed).
nurses must know the laws that govern these therapies in the Chinese medicine is used to treat a range of human
states in which they work. Some states have outlawed certain diseases and illnesses, such as allergies, asthma, headaches, in-
therapies or consider them experimental procedures, whereas fertility, and cancer. The nurse’s role in care of the client who
other states require licensure or certain educational stan- may integrate TCM with allopathic medicine for treatment
dards before allowing practitioners to perform C/A therapies. of disease is to be sure that the client is aware of potential
Nurses who perform C/A therapies not in accordance with interactions of prescribed medications and treatments with
the laws of their respective states could have legal charges filed prescribed herbs.
against them. Herbs are an important part of traditional Chinese heal-
Employer policy and the nurse’s job description must ing practice. A discussion of the use of herbs in contemporary
also be checked to determine whether performing C/A health practices appears later in this chapter.
therapies is within the nurse’s scope of practice at that agency. Traditional Chinese healing techniques are being studied
Employer malpractice insurance policies typically do not and used by contemporary Western health care providers.
cover situations where a client is injured as a result of a C/A Acupuncture, one technique of traditional Chinese medi-
therapy. The financial risk of any nurse who engages in C/A cine, applies needles and heat to various points on the body to
therapies will be lowered by having insurance that specifically alter the energy flow (Figure 4-1). The Mayo Clinic (2009)
covers those therapies. has acknowledged the efficacy of acupuncture in treating low
back pain, headaches, fibromyalgia, migraines, osteoarthritis,
postoperative dental pain, chemotherapy-induced nausea and
HISTORIC FOUNDATION vomiting, menstrual cramps, and tennis elbow. Acupuncture
People have tried to relieve pain and cure ills throughout may not be safe for clients with bleeding disorders or those
history. Early cave drawings depict healers. Primitive healers taking anticoagulants.
believed that magic and superstition caused diseases, resulting
in the intertwining of religious beliefs and health practices.
Practices and remedies based in ancient traditions are being India
rediscovered and used. A brief look at ancient Greek, Far For more than 5,000 years, the people of India have practiced
Eastern, Indian, and shamanistic practices will highlight their Ayurvedic medicine emphasizing “certain lifestyle interven-
influences on modern C/A modalities. tions and natural therapies to regain a balance between the
body, mind, and the environment” (Bloomington Hospital,
2010). The term ayurveda (“the science of life”) refers to
Ancient Greece India’s traditional medicine, which has an underlying spiritual
In the ancient Greek culture, health was perceived as main- basis. The life energy (prana) is moved through the body by
taining balance in all dimensions of life. In Greek mythology, a “wind,” or Vata, which regulates every type of movement.
Asclepius was the god of healing. Temples (called Asclepi- Vata, Kapha, and Pitta are the three metabolic principles
ons) were beautiful places for people (regardless of ability (doshas) that “express particular patterns of energy-unique
to pay) to worship, rest, and restore themselves. Their sys- blends of physical, emotional, and mental characteristics”
tem of healing used symbols, myths, and rites administered (Chopra, 2008). Kapha is the energy responsible for body
by specially trained priest-healers. Illnesses were treated by structure. Pitta is the transformative process between Vata
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CHAPTER 4 Complementary and Alternative Therapies 47
Seeking wisdom about the universe, establishing a re-

lationship with the creator, and avoiding death are all feats
accomplished through ritualized processes performed by
the shaman. The shaman uses special objects, such as power
animals, fetishes, and totems, as well as dances, ritual songs,
food, and clothing. Ritual chants, imagery, drumming, and
hallucinogenic drugs may be used to create a trance-like state
through which the shaman contacts the spirit world. The
contemporary practices of hypnosis and guided imagery have
roots in shamanistic traditions.
CURRENT TRENDS
The public perception of C/A treatment methods has been
changing during the past few decades. In the late 1960s and
early 1970s, the “natural,” “new age,” and “self-help” move-
ments began to attract followers, first among consumers and
later among health care practitioners. During that time period,
there was a growing trend toward rejection of traditional med-
icine because of its perceived invasiveness, painfulness, cost,
and ineffectiveness. A rekindled interest in Eastern religions,
lifestyle, and medicine has fueled the development of contem-
(© Alfred Wekelo/ShutterStock)
porary holistic, C/A modalities. In 1992, the U.S. government
established the Office of Alternative Medicine (OAM) at the
National Institutes of Health and allocated $2 million to dis-
seminate information about complementary and alternative
medicine to practitioners and the public.
Then in late 1998, Congress established the National
Center for Complementary and Alternative Medicine
Figure 4-1 Auricular acupuncture. (NCCAM), which replaced the OAM. NCCAM (2010c) is
the federal government’s lead agency for scientific research on
CAM with a mission to explore complementary and alterna-
and Kapha. Each person is born with a unique balance of the tive healing practices in the context of rigorous science, train
three doshas. The dominant dosha determines temperament, CAM researchers, and disseminate authoritative informa-
body type, and susceptibility to certain illnesses. tion to the public and professionals. NCCAM groups CAM
The areas of energy concentration in the body are called practices into four broad categories or types (Table 4-1).
chakras. These areas can become blocked and stagnant, caus- Some CAM practices may overlap or fall into more than one
ing illness. Ayurvedic healers try to activate chakra energy for category. In 2007, the NCCAM (2010c) reported that 38% of
self-healing. American adults were using some form of C/A.
The primary goals in the Ayurvedic system are prevent- The profession of nursing is evolving from a traditional
ing illness and restoring health by inner searching and spiritual Western medical model of client care to an integrative model
growth. In contemporary practice, Ayurvedic intervention that incorporates healing tools from cultures and customs
may consist of yoga, herbs, diet, and exercise; methods to other than our own (Fontaine, 2005). Nursing practice is
cleanse the body, such as steam baths, cathartics, and detoxify- advancing toward a holistic approach to healing the whole
ing massage; and nasal purging. person through integration of complementary and alternative
practices with conventional medical treatments into client
Shamanistic Practices health care for individuals, families, and communities (Dos-
sey, Keegan, & Guzzetta, 2004; Falsafi, 2001).
Part of being human is a need to understand and explain
life processes (i.e., birth, health, illness, and death). In many
cultures, both modern and ancient, ritualized practices have Mind/Body Research
been used to keep peace with the great spirits, to harness their Traditional medicine is founded on the belief that the body,
power, to promote power, and to prevent death. mind, and spirit are separate entities. A relatively new field
Shamanism refers to the practice of entering an altered of science, called psychoneuroimmunoendocrinology
state of consciousness with the intent to help others. The (PNIE), describes the connection of thought with physical
shaman is a folk healer–priest who uses natural and super- reactions. This word envelops the relationship of neural mes-
natural forces to help others and who is skilled in many forms sages from thoughts, emotions, feelings, and attitudes into
of healing, has an extensive knowledge of herbs, and serves as molecular responses from the immune and endocrine systems
guardian of the spirits. Illness is believed to be the result of (Dossey et al., 2004). The power of thought is the basis of
spirit loss. Shamans work with the spirits to encourage their mindfulness-based healing therapies.
full return to the individual. The shaman functions as both All body cells have receptor sites for neuropeptides,
priest and healer and has access to the supernatural. amino acids produced in the brain and other sites in the body
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CRITICAL THINKING
Table 4-1 NCCAM Categories
of CAM with Examples
Alternative Methods
CATEGORIES EXAMPLES
Mind/Body Medicine Meditation, yoga, acu-

puncture, deep-breathing A close friend has AIDS and is experiencing a
exercises, guided imagery, great deal of pain and discouragement. She
hypnotherapy, progressive wants to find alternative methods to ease the
relaxation, qi gong, t’ai chi pain. She confides to you that she believes there
may be a cure available at the holistic health
Natural Products Dietary supplements, herbal center. How do you best help your friend in this
products, vitamins, minerals,
situation?
probiotics
Manipulative and Chiropractic therapy, osteo-

Body-Based pathic manipulation, massage
Practices clients that promote health and well-being. As the nurse and
client become therapeutic partners, wholeness and healing are
Other CAM Practices Movement therapies, Pilates, achieved for the client, family, group, and community.
light therapy, healing touch, Nurses as holistic caregivers may use C/A techniques
qi gong, Reiki, magnetic to promote clients’ well-being. The focus of care in these
fields, energy fields, practices is healing as opposed to curing. The word healing
Ayurvedic medicine comes from the Anglo-Saxon word hael, meaning “to make
whole, to move toward, or to become whole.” It is important
Adapted from the National Center for Complementary and Alternative
Medicine, 2010, http://nccam.nih.gov/health/whatiscam to understand that healing is not curing (ridding one of
disease), but is instead a process activating the individual’s
forces from within. The nurse as a healing facilitator enters
into a relationship with the client to assist the client by being
that act as chemical communicators. Neuropeptides are re- a guide. The objective is to assist the client in releasing inner
leased when neurotransmitters (chemical substances pro- resources for healing. Nurses have the important role of edu-
duced by the body that facilitate nerve-impulse transmission) cating clients about nontraditional interventions throughout
signal emotions in the brain. Pert, of the National Institutes the life span (Table 4-2).
of Health, wrote in 1986 that “the more we know about neu-
ropeptides, the harder it is to think in the traditional terms of
a mind and a body. It makes more sense to speak of a single COMPLEMENTARY
integrated entity, a ‘body-mind’” (Pert, 1986). AND ALTERNATIVE THERAPIES
Cells can be directly affected by emotions. This means that
people can affect their health by what they feel and think. There Many C/A therapies are used in holistic nursing practice.
are many examples of people who are terminally ill hanging on These interventions are categorized as mind/body, spiritual,
to life until the occurrence of a specific event, such as a child manipulative and body based, energy therapies, biologically
coming to visit or a grandchild’s graduation or marriage. based, and other methodologies.
This complex, intermeshed system of psyche and body
chemistry is now called the bodymind, an inseparable con-
nection and operation of thoughts, feelings, and physiological
functions. BESTPRACTICE
Use of Complementary/
Holism and Nursing Alternative Therapy
The growing acceptance of the concept that body, mind, Nurses wanting to use C/A therapies should:
and spirit are interconnected is the basis for the expansion
of the holistic health movement. The physiological, psycho- • Ask the client if he or she is currently using C/A
logical, sociocultural, intellectual, and spiritual aspects of and, if so, which therapy, the purpose of using
each individual are considered in holism. Holistic nursing has the therapy, and the outcome.
been described by the American Holistic Nurses Association • Educate the client about C/A prior to using it.
(AHNA) as embracing “all nursing practice which has healing • Create a supportive environment of healing
the whole person as its goal” (Dossey et al., 2004). Nurses conducive to C/A therapy.
who embrace their personal and professional lives within a • Obtain the necessary training, certification, or
holistic perspective are aware that their presence, attention, licensure.
and intention are essential elements of wholeness and heal- • Be aware of the potential risks.
ing. Living within the framework of holism, nurses use their • Provide nonjudgmental supportive counsel.
knowledge, nursing concepts and theories, expertise, and in-
tuition to discover patterns of health for themselves and their
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Table 4-2 Suggested Complementary

Therapies throughout the Life Span
STAGE SUGGESTED COMPLEMENTARY
OF LIFE THERAPIES
Infants • Massage (modified)

• Movement (rocking)
• Music
(©zhu difeng/ShutterStock)
Young • Massage • Humor
Children • Music • Imagery
• Play • Art/drawing
School-Age • Massage • Imagery

Children
Figure 4-2 Meditation promotes calmness and lowers
• Music • Aromatherapy stress.
• Play • Yoga
• Humor • T’ai chi
• Animal-assisted Mind/Body Interventions
therapy Mind/body interventions are methods by which an individual
can, independently or with assistance, consciously control
Adolescents All therapies discussed in this chapter, as some sympathetic nervous system functions (e.g., heart rate,
appropriate to the condition respiratory rate, and blood pressure). When the client is learn-
ing how to perform these techniques, an assistant is involved;
Adults All therapies discussed in this chapter, as later, however, the client can perform them independently.
appropriate to the condition Self-regulatory techniques include meditation, relaxation,
Older • Massage (lighter pressure and other
imagery, biofeedback, and hypnosis.
Adults modifications for body’s status)
• Animal-assisted therapy
Meditation
Meditation, a quieting of the mind by focusing attention
• Aromatherapy (with precautions)
on a sound or image or one’s own breathing, is an ancient
• Any other therapy discussed in this art (Figure 4-2). The person is no longer aware of worries or
chapter, as appropriate to the condition preoccupations, and stress is reduced. Health benefits from
and with precautions reduced stress include decreased respiration, heart rate, and
Terminally • Massage • Prayer
oxygen consumption; improved mood; spiritual calm; and
Ill
heightened awareness.
• Reflexology • Any other thera- Nurses can assist clients with meditation by explaining
• Energy therapies pies discussed what it is and answering any questions. When the client is in a
(delmAr cengAge leArning)
• Music in this chapter, comfortable position, instruct in a calm voice to concentrate

as appropriate to on inhaling and exhaling. If the client’s mind wanders, a refo-
the condition and cus on breathing is needed. This should be practiced every day
with precautions for 15 minutes.
Meditation has proved particularly beneficial for clients
in labor.
CASE STUDY
Complementary Therapies
A female client is diagnosed with stage 3 breast cancer. She is considering surgery to remove the tumor
and cancer therapy options, yet she would like to know more about complementary therapies (CT) for
health recovery and health promotion. Her medical team is not familiar with complementary and alterna-
tive therapies.
1. As the nurse on the health care team for this client, what interventions can be provided to promote
support for this client during this time?
2. How can the nurse create a more informed health care team when clients ask about CT?
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Relaxation Table 4-3 Using All Five Senses

Progressive muscle relaxation (PMR) is one method for in Imagery
achieving relaxation. It employs the alternate tensing and
relaxing of muscles. Clients are instructed to concentrate on SENSE IMAGERY
a certain body area (the jaw, for instance), tense the muscles
for a count of 5, then relax the muscles for a count of 5. This Visual See the white, fluffy clouds.
process is repeated for muscle groups over the entire body Auditory Hear the waves on the beach.

until the client has achieved a state of overall relaxation.
Kinesthetic Feel yourself floating in the water.
Nurses can use relaxation techniques to reduce pain and
stress in clients. Gustatory Taste the tartness of the lemonade.
Olfactory Smell the hotdogs cooking on the grill.
Imagery
Imagery is a technique of using the imagination to visualize
a pleasant, soothing image. The client is encouraged to use Nurses can use guided imagery with clients capable of
as many of the senses as possible to enhance the formation hearing and understanding the nurse’s suggestions (Box 4-1).
of vivid images. Table 4-3 presents examples of using all five For example, show and explain a chart of the stages of bone
senses in imagery. healing to a client who has experienced a fracture and ask the
client to imagine this sequential activity in his body.
With guided imagery, the nurse can promote a sense of
CLIENT TEACHING
CLIENT well-being in clients and help them change their attitudes
TEACHING or behaviors about their disease, treatment, and healing
ability, and offer them instruction in using imagery as a
Progressive Muscle Relaxation self-help tool (Keegan, 2001). Research has shown positive
Explain the purpose and process of progressive effects of imagery when used with guidance from a trained
muscle relaxation, then have the client:
health care practitioner (Dossey et al., 2004). Although
imagery and visualization are effective complementary
• Assume a comfortable position in a quiet therapies for health and healing, contraindications should
environment. be noted for clients with mental disorders who are sensitive
• Close eyes and keep them closed until the exer- to traumatic images.
cise is completed.
• Breathe in deeply to a count of 4.
• Hold breath for a count of 4.
Biofeedback
• Breathe out to a count of 4.
Biofeedback measures physiological responses, which assist
individuals to improve their health by using signals from their
• Continue to breathe slowly and deeply.
own bodies. The biologic functions commonly measured are
• Tense both feet until muscle tension is felt. muscle tension, skin temperature, heart rate, sweat gland ac-
• Hold a gentle state of tension in both feet for a tivity, and brain wave activity. Biofeedback works by teaching
count of 5. clients to “recognize how their bodies are functioning and to
• Tighten the muscles only until tense, but not control patterns of physiological functioning” (Association
painful. for Applied Psychophysiology and Biofeedback, 2008). Bio-
• Slowly release the tension from the feet. feedback is effective for urinary incontinence, hypertension,
• Recognize the difference between tension and chronic pain, epilepsy, and Raynaud’s disease (University of
relaxation. Maryland Medical Center, 2011).
• Repeat the previous steps.
• Gently tense the muscles of both lower legs. Hypnosis
• Continue the process with all muscle groups in a The practice of hypnosis was once overshadowed by mystery
toe-to-head direction. and misconception. Today, with the expanding knowledge of
• After tensing and releasing all muscle groups, the human mind, hypnosis is being used more. Therapeutic
take in a few more deep relaxing breaths and hypnosis induces an altered state of consciousness or aware-
scan your body for any areas that remain tense.
ness resembling sleep and during which the person is more
receptive to suggestion. Hypnosis does not magically cure
Concentrate on tensing and relaxing the mus-
anything. Nurses desiring to use hypnosis in their practices
cles in those areas. must be aware of their scope of practice as defined by their
• Breathe in deeply to a count of 4. respective state boards of nursing.
• Hold breath for a count of 4.
• Breathe out to a count of 4.
• Resume your usual breathing pattern.
Spiritual Therapies
• Slowly stretch and open your eyes. A state of health depends on one’s relationship not only to
the physical and interpersonal environments but also to the
This takes approximately 20 to 30 minutes and is
spiritual part of self. The idea of a relationship between spiri-
most effective with repetition. tuality and health is not new. “From the earliest time of the
shaman we have witnessed the mysterious spiritual element
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preparing for healing, the practitioner adapts a passive and

BOX 4-1 receptive mood to be a channel for divine power. The ill per-
GUIDED IMAGERY son’s belief enhances but is not necessary for healing.
• Allow 10 to 20 minutes for this exercise.
• Provide a quiet, comfortable environment.
Healing Prayer
• Set a goal for the session such as “pain relief”
When praying, people believe they are communicating di-
rectly with God or a higher power. Prayer, an integral part of a
or “relaxation.”
person’s spiritual life, can affect well-being. Florence Nightin-
• Assess the client by asking him or her to de- gale (1969) recognized that prayer helps connect individuals
scribe a relaxing setting. to nature and the environment. Medical research is currently
• Allow the client to use sensory details of the investigating the effects of prayer on physical health.
setting that include a visual image, the feeling
(e.g., temperature, wind, sun), and the scents Shamanism
(e.g., evergreen, ocean breeze, lavender). Add Shamanism was discussed earlier in this chapter.
music or be quiet for the auditory sense.
• Once the client is in a comfortable position,
soften your voice to say:
Manipulative
• Bring your attention to the rhythm of your and Body-Based Methods
breathing. As you breathe in and out, allow Body-based methods use techniques of manipulating or mov-
an image to develop of a comfortable set- ing various body parts to achieve therapeutic outcomes.
ting. In this setting you are relaxed and feel Movement/exercise, yoga, t’ai chi, and chiropractic treatment
a sense of peace. Bring to mind the colors are discussed in the following sections.
of the setting, the feel of the environment,
the details of the setting as they surround
Movement/Exercise
you, and any comforting scents or aromas The therapeutic intervention and health-promoting activ-
that allow you to feel at peace. Take a mo- ity of movement is associated with athletic exercise, dance,
ment to enjoy this image.
celebration, and healing rituals. The primary goal of exercise
is fitness (muscle strength, endurance, flexibility, and cardio-
• When you are ready, allow yourself to
vascular and respiratory health). There are many other posi-
imagine the pain or areas of tension as a tive outcomes of exercise, such as sleeping better and having
round ball of light. Bring your awareness more energy.
to this light. Then, become aware of your Nurses can help clients use movement as therapy through
ability to dim this light, slowly turning the range-of-motion exercises, stretching exercises, and physical
light down to release the pain and tension. therapy. Movement is an effective method through which
(Allow 2–3 minutes of quiet.) people of all ages can improve their level of functioning.
• When you are ready, allow yourself to cre-
ate a memory of this feeling of relaxation Yoga/Yoga Therapy
and comfort. As you rest, bring your aware- Yoga (meaning “union” in Sanskrit) integrates mental, physi-
ness to areas of your body that need heal- cal, and spiritual energies to promote health and wellness.
ing. Allow this feeling to facilitate healing The basic elements of yoga are proper breathing, posture, and
throughout your body. movement. The breathing is believed to promote relaxation
and enhance the flow of prana (vital energy). Yoga develops
(From Understanding Complementary and Alternative Therapies,
by M. Downey, 2009, manuscript submitted for publication.)
an awareness of the mind/body connection in relation to
body movement, weight distribution, and position. Tradi-
tional yoga has always been primarily concerned with healthy
individuals and promoting health by maintaining the balance
and flow of life forces.
of healing . . . the connection of the healer with the divine” The focus of yoga therapy is to holistically treat various
(Keegan, 1994). psychological or somatic dysfunctions ranging from back
Many cultures accept the inseparable link between the problems to emotional distress. Yoga is used for a variety of
state of one’s soul (life energy or spirit) and the state of one’s health conditions, including depression, high blood pres-
health. Scientists (especially psychoneuroimmunologists) are sure, stress, and asthma. Research suggests that yoga may
beginning to validate that individuals have inner mechanisms reduce heart rate and blood pressure, increase lung capacity,
of healing. Many religions have ideologies about health, ill- positively affect specific brain or blood chemical levels, and
ness, and healing. improve body composition and muscle relaxation (NCCAM,
2011b). Yoga improves overall strength, flexibility, and fitness.
Faith Healing
At the heart of spiritual or faith healing is the belief that prac- T’ai Chi
titioners must purify themselves and reach a state of unity The philosophy of looking for harmony with nature and
with God or a higher power before faith healing can occur. the universe through complementary (yin and yang) bal-
This process is usually accomplished through prayer. When ance is the basis for t’ai chi. When there is perfect harmony,
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BESTPRACTICE
Preparing for Chiropractic Therapy
Encourage clients considering the use of chiroprac-
tic services to first undergo a comprehensive health
assessment to rule out any contraindications.
(© michAeljung/ShutterStock)
chiropractic therapy (NCCAM, 2010a). Clients should check
with their insurance company prior to seeking treatment to
verify coverage.
Energy Therapies
Figure 4-3 T’ai chi offers health benefits including tension One category of C/A therapies incorporated into nursing
and stress reduction. practice in the past 25 years is the energy therapies, or the
use of the hands to direct or redirect the flow of the body’s
energy fields and enhance balance within those fields. These
everything functions spontaneously, effortlessly, perfectly, therapies are effective for many problems and can restore
and according to the laws of nature. If one moves to the right, harmony in all aspects of health. These therapies can be used
one must also move to the left. T’ai chi is a series of slow, with persons of all ages and at all stages of wellness and illness.
purposeful movements with controlled rhythmic breathing Energy therapies have their roots in traditional Chinese,
(Figure 4-3). ancient Eastern, and Native American philosophies. The
Those who regularly practice t’ai chi believe that it en- fundamental concept is that individuals have a life force,
hances agility, stamina, and balance and that it boosts energy or energy that is not confined to physical skin boundaries.
and bestows a sense of well-being. The entire t’ai chi form can Figure 4-4 illustrates the energy field that extends beyond a
take as little as 7 minutes or as long as an hour to practice. person’s physical body.
T’ai chi has been shown to increase muscle tone, stamina, and An individual’s energy field consists of energy layers in
flexibility and to improve balance, muscle mass, posture, and constant flux. They can be reduced or otherwise adversely
strength in older people (NCCAM, 2011a).
Chiropractic Therapy
Chiropractic therapy is based on the principle that the brain
sends vital energy to every organ in the body via the nerves
originating in the spinal column. Disease, body disharmony,
or malfunction results from vertebral subluxation complex
(spinal nerve stress). The body is rebalanced and realigned
using chiropractic “spinal adjustment” techniques. The goal of
chiropractic care is to awaken the client’s own natural healing
ability by correcting any areas of vertebral subluxation com-
plex. Vitality, strength, and health are thus promoted.
Chiropractic services have gained increasing acceptance
in the United States. Insurance coverage for chiropractic
services is extensive. Many health maintenance organizations
and private health insurance companies provide coverage for
LIFE SPAN CONSIDERATIONS

T’ai Chi Chih
A research trial conducted by the University of
California (Irwin, Olmstead, & Motivala, 2008) con-
(© deoSum/ShutterStock)
cluded that t’ai chi chih can improve sleep quality

in older adults ages 59 to 86 years with moderate
sleep complaints. T’ai chi chih can be considered a
useful nonpharmacological approach to improve
sleep quality in older adults.
Figure 4-4 Layers of the human energy field extending be-
yond the physical boundaries.
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affected by any type of trauma, illness, or distress. The energy

system can also be positively affected intentionally by the use
of a practitioner’s hands. The primary focus is to restore the
optimal flow of life energy through the energy fields.
Many energy therapies are being used by nurses today,
such as touch, therapeutic massage, therapeutic touch, and
healing touch. Other therapies are acupressure and reflexol-
ogy, both of which involve deep-tissue body work and require
advanced training for the practitioners.
(© Yuri ArcurS/ShutterStock)
Touch
The most universal C/A therapy is touch. Touch is the
means of perceiving or experiencing through tactile sensation.
Although it was used in all ancient cultures and shamanistic
traditions for healing, the advent of scientific medicine and
Puritanism led many healers away from the purposeful use of Figure 4-5 Touch promotes bonding between nurse and
touch. Note that touch carries with it taboos and prescriptions client.
that are culturally dictated. Some cultures are very comfortable
with physical touch; others specify that touch may be used only
in certain situations and within specified parameters. Therapeutic Massage
The nurse must be sure to convey positive intentions
when touching. If in doubt, the nurse should not touch until Therapeutic massage is the application of hand pressure
effective communication has been established with the client. and motion to improve the recipient’s well-being. It involves
Touch is important in nursing practice, because it: rubbing, kneading, and using friction. Massage therapy is
recognized as highly beneficial and is prescribed by many
• Is an integral part of assessment. physicians. Many states now have licensing requirements for
• Promotes bonding between nurse and client (Figure 4-5). massage practitioners.
• Is an important means of communication, especially when
other senses are impaired.
• Assists in soothing, calming, and comforting.
• Helps keep the client oriented.
SAFETY
Precautions for Massage
• Increased circulation may be harmful in people
with heart disease, diabetes, hypertension, or
kidney disease.
CULTURAL CONSIDERATIONS • Never attempt massage in areas of circulatory
abnormality, such as aneurysm, varicose veins,
Touch
phlebitis, thrombus, or necrosis, or in areas of
• Ask permission before touching a client. tissue injury, inflammation, open wounds, der-
• Tell the client what is going to happen. matitis, joint or bone injury, recent surgery, or
• The meaning of touch and the body areas sciatica.
acceptable to touch vary from culture to culture.
CASE STUDY
Massage Therapy
A 42-year-old male is admitted to the medical-surgical observation unit prior to vasectomy surgery. He is
experiencing a great deal of anxiety in anticipation of his postoperative pain related to this procedure. The
client proposes that he be given neck and back massage therapy along with the customary preoperative
medications.
1. How can the nurse facilitate the use of massage therapy as a therapeutic regimen for this client’s com-
fort and relaxation?
2. Describe assessment measures that are used to determine the effectiveness of the massage therapy
treatments.
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Traditionally, back rubs were given by nurses to provide Acupressure and Shiatsu
comfort to hospitalized clients. Massage techniques can be
used with all age-groups and are especially beneficial to those Both acupressure and shiatsu are based on the Chinese merid-
who cannot move. A back rub or massage results in relaxation, ian theory, which states that the body is divided into meridian
increased circulation of the blood and lymph, and relief from channels through which qi, or energy, flows. Cold, damp, fire,
musculoskeletal stiffness, spasm, and pain. bacteria, or viruses may block the flow of qi, causing disease
in the body. Acupressure is a technique of releasing blocked
energy within an individual when specific points (Tsubas)
Therapeutic Touch along the meridians are pressed or massaged by the practi-
Therapeutic touch, based on the ancient practice of the tioner’s fingers, thumbs, and heel of the hands. When the
laying on of hands, consists of finding alterations in a per- blocked energy is freed, the disease subsides. Shiatsu, a Japa-
son’s energy field and using the hands to direct energy to nese form of acupressure, also uses the forearm, elbow, knee,
achieve a balanced state. Therapeutic touch is based on four and foot to activate the points. Both acupressure and Shiatsu
assumptions: relieve tension and many stress-related ailments. Contraindi-
• A human being is an open energy system. cations to acupressure and shiatsu include phlebitis, deep vein
thrombosis, hematoma, deep tissue injury, and tissue trauma.
• Anatomically, a human being is bilaterally symmetrical. Shiatsu treatment is holistic, with the aim of aiding the
• Illness is an imbalance in an individual’s energy field. whole body to heal rather than focusing on the area where
• Human beings have natural abilities to transform their con- symptoms are most obvious. The aim is for the Shiatsu prac-
ditions of living (Krieger, 1993). titioner to assist the client’s body to heal naturally by encour-
aging the client’s energy to move into a more balanced state
Therapeutic touch is easily learned in workshops, can (Shiatsu Society, 2011).
be done either with hands on or off the body, complements
medical treatments, and has shown reasonably consistent
and reliable results. The relaxation response may be seen in Reflexology
the client in 2 to 5 minutes after a treatment has begun, and Reflexology is a noninvasive complementary modality that
some clients fall asleep or require less pain medication after a involves the application of pressure by the use of the practi-
treatment. tioner’s hands, fingers, and thumb to the client’s feet, hands,
and ears with specific thumb, finger, and hand techniques.
Healing Touch The fundamental concept of reflexology divides the body into
10 equal, longitudinal zones running the length of the body,
Healing touch is an energy therapy in which the hands from the top of the head to the tip of the toes. These 10 zones
are used to clear, energize, and balance the energy field. correspond to the 10 fingers and toes. The foot is viewed as
Janet Mentgen, a nurse, developed it. The healing touch a microcosm of the entire body (Figure 4-6). Reflexology
practitioner realigns the energy flow, which reactivates the theory states that illness is evident as calcium deposits and
mind/body/spirit connection to eliminate blockages to acids in the corresponding part of the person’s feet. Pressing
self-healing. certain points on the feet brings an autonomic nervous system
Healing touch can be administered in a few minutes or response or reflex. Reflexology induces an optimal state of
in 30- to 90-minute sessions. The North American Nursing relaxation, which is conducive to healing. It promotes health
Diagnosis Association International (NANDA, 2009) lists by relieving pressures and accumulation of toxins in the cor-
Disturbed Energy Field, defined as a “disruption of the flow responding body part. Reflexology can be used as a comple-
of energy surrounding a person’s being [resulting] in dishar- mentary therapy for chronic conditions such as asthma, sinus
mony of the body, mind, and/or spirit,” as one of their ap- infections, migraines, irritable bowel syndrome, constipation,
proved nursing diagnoses. Implicit in this therapy is the need and kidney stones.
for follow-up or sequential treatments as well as discharge
planning and referral to assist the client in adequately meeting
goals. Biologically Based Therapies
In the past 20 to 30 years, nutritional interventions for preven-
tion and treatment of disease have generated increasing inter-
est among consumers and health care providers. This section
BESTPRACTICE addresses the C/A nutritional and herbal approaches.
Contraindications for Touch CRITICAL THINKING

It is important to know when not to touch:
• It may be difficult for persons who have been Reflexology
neglected, abused, or injured to accept touch
therapy.
• Touching those who are distrustful or angry A client asks the nurse to rub his foot in a par-
may increase negative behaviors. ticular spot because that is where his reflexologist
• Persons with burns or overly sensitive skin may rubs to relieve his abdominal pain. How should
not benefit from touch. the nurse handle this situation?
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Pituitary
Head/Sinus
Neck/Thyroid/
Parathyroid
7th Cervical
Thymus
Lung Eye/Ear
Lung/Heart
Arm Spinal Region Arm
Shoulder Shoulder
Diaphragm/
Solar Plexus Stomach
Gallbladder Liver Spleen

Adrenal Glands
Pancreas
Waistline
Transverse Colon Descending Colon
Ascending
Colon Kidney
Small Intestine
Ileocecal
Valve Bladder

Tailbone Area Sigmoid Colon
Helper Area
to Lower back
Figure 4-6 Foot reflexology chart indicates points on the foot that reflexively correspond to other areas of the body.
Phytochemicals value. Phytosterols (plant sterols) are structurally similar to

cholesterol and act in the intestine to decrease cholesterol
Currently, certain foods are being studied for their medicinal absorption. Research has shown that phytosterols effectively
value. Phytochemicals are “non-nutritive plant chemicals reduce low-density lipoprotein (LDL) cholesterol when
that have protective or disease preventive properties” (Phyto- given as supplements (Ostlund, 2004). Increasing the intake
chemicals, 2011). Phyto is the Greek word for “plant.” There- of phytosterols may reduce coronary heart disease with mini-
fore, phytochemicals are plant chemicals. These chemicals mum risk.
have several functions, including storage of nutrients and pro-
vision of structure, aroma, flavor, and color. Phytochemicals
protect against cancer and prevent heart disease, stroke, and Herbs
cataracts. Phytochemicals are found in fruits and vegetables. Herbs and plants have been used for centuries in the care of
No single fruit or vegetable contains all phytochemicals. the sick. Many of the drugs used today originally were plant
The consumption of a wide variety of fruits and vegetables remedies passed from one generation to the next.
provides the best supply. The major sources of phytochemi- Although herbs may have medicinal value (Table 4-4),
cals are onions, garlic, leeks, chives, carrots, sweet potatoes, some can cause potentially harmful herb–drug interactions
squash, pumpkin, cantaloupe, mango, papaya, tomatoes, cit- when used with prescribed medications. It is important during
rus fruits, grapes, strawberries, raspberries, cherries, legumes, assessment to ask specifically about the client’s use of herbal
soybeans, tofu, and the cruciferous vegetables (broccoli, and vitamin supplements. Feverfew, ginseng, and garlic pro-
cauliflower, brussels sprouts, and cabbage). Nurses can use long the body’s clotting time. Encourage clients to reveal the
this information to encourage clients to eat more fruits and use of herbs to their primary care provider.
vegetables.
Antioxidants
Antioxidants are substances that prevent or inhibit oxida-
tion, a chemical process whereby a substance is joined to oxy- BESTPRACTICE
gen. In the body, antioxidants prevent tissue damage related
to free radicals, which are unstable molecules that alter Use of Medicinal Plants
genetic codes and trigger the development of cancer growth Be cautious in the casual use of plants to treat self
in cells. Vitamins C and E, beta-carotene (which is converted or others. “Natural” substances can be harmful if
to vitamin A in the body), and selenium are antioxidants. An- not processed properly, and many plants (including
tioxidants may prevent heart disease, some forms of cancer,
some herbs) can be poisonous.
and cataracts. Other vitamins, minerals, trace elements, and
enzymes are being investigated for their possible therapeutic
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56
Table 4-4 Common Herbs for Health Promotion
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CLINICAL
ADMINISTRATION/ CAUTIONS/ CONSIDERATIONS
HERB REPORTED USES AVAILABILITY INTERACTIONS AND ASSESSMENTS
Aloe (Aloe vera) Used topically to treat minor Capsules, cream, extract, gel, Internal administration of dried • Assess clients for cardiac or
burns, sunburn, cuts, abrasions, jelly, and juice. aloe juice is contraindicated for renal disease/medications, ste-
acne, and stomatitis. Teach client to use aloe internally pregnancy and lactation and for roids, and diuretics.
Internally used as a stimulant only under the supervision of a children under 12 years of age. • Assess for pregnancy and
laxative (little evidence base). qualified herbalist. Avoid with kidney and cardiac lactation.
Possible antidiabetic action re- disease and bowel obstruction. • Assess fluid and electrolyte
lated to the thromboxane inhibi- Aloe may enhance the effects of balance.
tor (TXA2) effects. cardiac medications, diuretics, • Assess for allergy (see
and steroids. contraindications).
Hypersensitivity (allergy) to garlic,
onions, or tulips may indicate
sensitivity to aloe.
Bilberry (Vaccinium Improvement of night vision, pre- Bilberry can be taken orally in the Contraindicated for pregnancy, • Assess clients for use of anti-
myrtillus) vention of cataracts, macular de- form of capsules, tinctures, fluid lactation, and children. coagulants, antidiabetics, and
UNIT 2 Concepts Integral to Medical-Surgical Nursing
generation, diabetic retinopathy, extract, and fresh berries. Interactions: Anticoagulants (hep- antiplatelets.
myopia, and glaucoma. arin, warfarin), antiplatelet agents • Assess and monitor vision
Treatment of varicose veins, (aspirin), nonsteroidal anti- changes.
hemorrhoids, and postoperative inflammatory drugs (NSAIDs), • Monitor blood glucose.
hemorrhage. insulin, and oral antidiabetics. • Assess for pregnancy and
lactation.
Black cohosh Used as a smooth-muscle re- Capsules, extract, powdered ex- Contraindicated for use in preg- • Assess for menopausal and
(Cimicifuga laxant, antispasmodic, diuretic, tract, and tincture. Standardized nancy after first trimester be- menstrual irregularities: dura-
racemosa) antidiarrheal, astringent, anti- products should be used for ad- cause of uterine stimulation. This tion of cycle, flow, pain, and hot
tussive, and antiarthritic; more ministration of black cohosh. herb should not be used during flashes.
commonly known for hormone lactation or given to children. • Assess history of client for fi-
balance in perimenopause and Interactions: Black cohosh may broids and ovarian cysts.
for dysmenorrhea. interfere with antihypertensive • Assess use of other hormonal
Possible decreased uterine and hormone replacement products such as estro-
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spasms in first trimester of preg- therapies. gen, progesterone, and oral
nancy and, for children, as an contraceptives.
antiasthmatic.
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Capsicum Capsicum (peppers) can be used Capsules, tablets, and tincture, Minimal research has been done • Assess for use of alpha-
(cayenne, chili, topically for treatment of arthritis, topical cream/gel/lotion (0.025%– to support the use of capsicum adrenergic blocking agents,
or hot peppers) diabetic neuropathy, herpes zos- 0.075% concentration) for ap- during pregnancy and lactation or clonidine, MAOIs, and
88021_ch04_ptg01_043_063.indd 57
(Capsicum annum) ter, peripheral circulation, pso- proximately 2 weeks for pain for children. methyldopa.
riasis, and Raynaud’s disease. relief (up to q.i.d.). Hypersensitivity (allergic reaction) • Assess for improvement of
Internal use for promotion of car- is a contraindication. Capsicum symptoms in topical use such
diovascular health, arthritic and in any form should not be used as psoriasis, peripheral vascular
muscular pain, gastric protection on open wounds, on abrasions, effects, diabetic neuropathy, or
for peptic ulcers, and cold and flu or near the eyes. herpes zoster.
symptoms. Interactions: For internal applica- • Assess for gastrointestinal con-
tion, avoid concurrent use with ditions such as peptic ulcers
alpha-adrenergic blockers, cloni- and irritable bowel syndrome.
dine, monoamine oxidase inhibi-
tors (MAOIs), and methyldopa.
Chamomile Used to treat anxiety and insom- Capsules, cream, fluid extract, lo- Contraindicated for pregnancy • Assess for hypersensitivity (see
(Matricaria nia, as a digestive aid and an tion, tea, and tinctures. and lactation. Allergies to sun- contraindications).
chamomilla) anti-inflammatory, and to pro- flowers, ragweed, or asters • Assess client’s sleeping pat-
mote wound healing. (echinacea, feverfew, milk thistle) terns if taking chamomile.
may cause hypersensitivity to • Assess for use of alcohol, seda-
chamomile. tives, and anticoagulants before
Asthmatics should avoid administering this herb.
chamomile.
Interactions: Avoid using alcohol,
anticoagulants, and sedatives
when taking chamomile because
of the enhanced effects of these
substances when used with this
herb.
Cinnamon Used as an antifungal, anal- Essential oil, fluid extract, pow- Contraindicated for pregnancy, • Assess for hypersensitivity in
(Cinnamomum) gesic, appetite stimulant, and der, and tincture. lactation, and small children. the form of wheezing or a rash.
antidiarrheal. Dosage for passive bleeding is to No known drug interactions. • Discontinue this herb if these
Cinnamon is also reported to use the essential oil in combina- symptoms are present and ad-
treat the common cold, abdomi- tion with Erigeron oil, diluted in minister an antihistamine.
nal pain, passive internal bleed- carrier oil.
ing, hypertension, and bronchitis.
(Continues)
CHAPTER 4 Complementary and Alternative Therapies
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58
Table 4-4 Common Herbs for Health Promotion (Continued)
CLINICAL
88021_ch04_ptg01_043_063.indd 58
Echinacea Primarily used as an immune Capsules, fluid extract, juice, Contraindicated for pregnancy, • Assess for hypersensitivity to
purpura (Echinacea support for the common cold, in- powder, sublingual tablets, tea, lactation, and children under this herb and to daisies.
angustifolia) fluenza, and bacterial infections. and tincture. 2 years of age. • Teach clients not to use this
Echinacea may be used to pro- For prevention of colds and infec- Caution should be used for per- herb longer than 8 weeks.
mote wound healing, bruises, tions, the root tincture is recom- sons with autoimmune diseases
burns, scratches, and leg ulcers. mended at ½ teaspoon b.i.d. (HIV/AIDs), lupus erythematosus,
Do not use this herb longer than multiple sclerosis, tuberculosis,
8 weeks. and hypersensitivity.
Interaction: Echinacea may de-
crease the action of econazole
vaginal cream.
Feverfew Used to treat arthritis, fever, Capsules, fresh herb, extract, Contraindicated for pregnancy, • Assess client for hypersensitiv-
(Chrysanthemum menstrual irregularities, and tablets, and tinctures. lactation, and children. Avoid if ity to feverfew.
parthenium) threatened miscarriages. It may hypersensitive to feverfew. • Assess for effects of this herb.
be effective for prevention of mi- Interactions: None known. • Assess for side effects such as
graine headaches. mouth ulcers and muscle and
joint pain.
Garlic (Allium Cholesterol-lowering effects for Capsules, extract, fresh garlic Do not use with anticoagulants • Assess client for hypersensitiv-
sativum) decreasing low-density lipopro- bulbs, oil, powder, and syrup. because of prolongation of ity to garlic.
tein (LDL) and triglycerides and bleeding. • Assess lipid levels if used for
raising high-density lipoproteins Because of potentiation of insulin lipid lowering or cholesterol
(HDL). and oral antidiabetics when tak- reduction.
It may regulate blood sugar and ing garlic, insulin dosages may • Assess client’s diabetic regimen
decrease blood pressure and need to be adjusted. (insulin or oral antidiabetics).
platelet aggregation. Garlic may stimulate labor and • Assess coagulation studies and
cause colic in infants and is con- CBC.
traindicated for pregnancy and • Assess for use of
lactation. Persons with hyperthy- anticoagulants.
roidism should avoid consuming
garlic because of the side effect
of reducing iodine uptake.
Garlic increases clotting time and
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should be avoided for persons
undergoing surgery.
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Ginger root Prevents nausea and vomiting Capsules, extract, fresh and dried Contraindicated for pregnancy, • Assess client for allergies to
(Zingiber officinale) and acts as a digestive aid, pe- root, powder, tablets, tea, and lactation, and hypersensitivity ginger.
ripheral circulatory stimulant, and tincture. reactions. Not recommended for • Assess for use of anticoagu-
88021_ch04_ptg01_043_063.indd 59
antioxidant. May treat migraine persons with cholelithiasis. lants and antiplatelets.
headaches and induce platelet Interactions: It may potentiate • Assess for effectiveness of
aggregation. bleeding if used with anticoagu- ginger for intended use (i.e.,
lants and antiplatelets. nausea).
Ginkgo (Ginkgo An antioxidant that may improve Capsules, fluid extract, tablets, Ginkgo is contraindicated for • Assess clients for allergic reac-
biloba) peripheral vascular circulation. tea, and tincture. pregnancy, lactation, and chil- tion to this herb.
Used to reduce peripheral vas- dren. Avoid use in persons with • Assess for use of anticoagu-
cular insufficiency and cerebral coagulation disorders and hemo- lants, platelet inhibitors, and
dysfunction in Alzheimer’s dis- philia or with allergies to ginkgo. MAOIs.
ease. Also used for treatment of Interactions: This herb may in-
arthritis, mild depression, dizzi- crease bleeding. Use with antico-
ness, headaches, and intermit- agulants, platelet inhibitors, and
tent claudication. MAOIs should be avoided.
Horse Decreases capillary permeabil- Standard forms of horse chestnut Contraindicated for pregnancy, • Assess client for allergic
chestnut ity. Used to treat venous insuf- include extract and tincture. lactation, and children. May reaction.
(Aesculus ficiency, phlebitis, and varicose cause hepatotoxicity and renal • Assess for bleeding tendencies.
hippocastanum) veins. dysfunction in high doses. • Assess lab values for hepatic
Possible effectiveness for edema, Interactions: Anticoagulants, as- (AST, ALT, and bilirubin levels)
hemorrhoids, inflammation, and pirin, and salicylates. and renal (BUN and creatinine)
prostate enlargement. functioning.
Kava kava (Piper Sedative and sleep enhancer. Beverage, capsules, extract, tab- Do not combine with alcohol or • Assess clients for allergies.
methysticum) Used for anxiety, stress, restless- lets, and tinctures. central nervous system (CNS) • Assess for use of alcohol, an-
ness, depression, and muscle depressants. Persons with tidepressants, barbiturates,
relaxation. Parkinson’s disease, allergies, Parkinson’s medications, ben-
Possible effectiveness as an anti- and major depressive disorders zodiazepines, sedatives, and
epileptic and antipsychotic. should not use this herb. Kava is CNS depressants.
contraindicated for pregnancy,
lactation, and children under
12 years of age.
Interactions: Sedatives, CNS de-
pressants, antiparkinsonians.
(Continues)
CHAPTER 4 Complementary and Alternative Therapies
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60
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Table 4-4 Common Herbs for Health Promotion (Continued)
CLINICAL
Milk thistle Used for treatment of liver toxic- Tincture. Contraindicated for pregnancy, • Assess client for allergies to this
(Silybum marianum) ity due to poisonous mushrooms, lactation, and children. Avoid use herb.
cirrhosis of the liver, chronic hep- with allergies to herbs and plants • Monitor liver lab values (AST,
atitis C, and liver transplantation. from the aster family. ALT, and bilirubin).
Interactions: Drugs that are me- • Assess for use of drugs that are
tabolized via the liver. metabolized by the liver.
St. John’s wort Used to treat mild to moderate Capsules (sublingual), cream, and Contraindicated for pregnancy, • Assess for allergies to
(Hypericum depression and anxiety. Used tincture. lactation, and children. Avoid use St. John’s wort.
perforatum) topically as an anti-inflammatory with allergies to this herb. • Assess for use of antidepres-
for hemorrhoids, vitiligo, and Interactions: Alcohol, amphet- sants, antiretrovirals, and
burns. amines, immunosuppressants, sedatives.
antiretroviral agents, MAOIs,
selective serotonin reuptake in-

hibitors (SSRIs), sedatives, and
tricyclics.
Saw palmetto Reports of effectiveness for Berries, capsules, extract, tab- Contraindicated for pregnancy, • Assess for allergic reaction.
(Sabal serralata) chronic cystitis and to increase lets, and tea. lactation, and children. • Assess for urinary retention, fre-
breast size, sperm count, and Interactions: Anti-inflammatories, quency, urgency, and nocturia.
sexual potency are related to saw hormones, immunostimulants. • Assess client’s use of anti-
palmetto use. Most notably, this inflammatory drugs, hormones,
herb is used for treatment of be- and immunostimulants.
nign prostatic hypertrophy (BPH).
(Adapted from Understanding Complementary and Alternative Therapies, by M. Downey, 2009, manuscript submitted for publication.)
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• Tea tree is said to have antifungal effects and boosts the im-
LIFE SPAN CONSIDERATIONS mune system.
• Roman chamomile decreases anxiety, promotes relaxation,
Essential Oils and treats infections.
Essential oils should be used with caution in elderly • Rosemary stimulates the digestive system and immune sys-
tem and is mentally stimulating and uplifting.
persons. These clients are usually more sensitive
to essential oils than are adults and teenagers and Aromatherapists have used oils to treat specific ailments.
thus require smaller amounts and less concentrated Some essential oils have antibacterial properties and are used
forms of the essence. in a variety of pharmaceutical preparations. These oils should
be used intelligently and with caution.
Humor
Other Methodologies Therapeutic humor includes any intervention that promotes
Iridology, aromatherapy, humor, animal-assisted therapy, health and wellness by stimulating a playful discovery, ex-
music therapy, and play therapy are also used by holistic pression, or appreciation of the absurdity or incongruity of
practitioners. life’s situations (Association for Applied and Therapeutic
Humor, 2011). It is probably the least understood but the
Iridology easiest to do.
To avoid giving offense, it is important to determine the
According to Caradonna (2008), iridology began more than client’s perception of what is humorous. Whether a given
100 years ago when two physicians began observing eyes and situation is considered humorous or offensive will vary greatly
organizing their findings. Iridology is the study of the iris, from culture to culture and person to person. Good taste and
or colored part, of the eye. It is theorized that the fibers and common sense should serve as guides.
pigmentation of the iris reflect information about a person’s Nurses can promote humor in various ways. A humor
physical and psychological makeup. cart (a cart filled with cartoon and joke books, silly noses, and
magic tricks) allows clients to select their own humor tools. A
Aromatherapy “humor room” may be made available where clients can watch
Aromatherapy is the therapeutic use of concentrated es- comedy videos or play fun games with visitors or other clients.
sences or essential oils extracted from plants and flowers. Humor has many therapeutic outcomes. Norman Cous-
Essential oils diluted in oil for massage or in warm water for ins, former chairperson of the Task Force in Psychoneuro-
inhalation may be stimulating, relaxing, or soothing. Accord- immunology at the School of Medicine at UCLA, tells how
ing to the National Association for Holistic Aromatherapy his recovery from an incurable connective tissue disorder,
(2011), the top 10 essential oils are the following: ankylosing spondylitis, was enhanced by watching films and
movies that made him laugh daily (Cousins, 1979). Humor
• Peppermint is useful in treating headaches, muscle aches, can effectively relieve anxiety, improve respiratory function,
and digestive disorders. promote relaxation, enhance immunological function, and
• Eucalyptus boosts the immune system, relieves muscle ten- decrease pain by stimulating endorphin production.
sion, and treats respiratory problems.
• Ylang-ylang aids in relaxation and depression. Animal-Assisted Therapy
• Geranium balances hormones and skin. Animals were used in England in 1792 at York Retreat,
• Lavender promotes relaxation and is used to treat wounds where psychiatric clients cared for rabbits and poultry
and burns. (McConnell, 2002). It was 1944 before animals were used in
• Lemon has antibacterial, deodorizing, anti-infective, and a therapeutic setting in the United States. In animal-assisted
antidepressant properties. therapy (AAT), a prepared handler and trained animal work
• Clary sage helps with insomnia, relaxation, and pain/ one-on-one with a client toward identified short- and long-
discomfort. term goals. Currently, AAT is used as a complementary
therapy for people in both acute and long-term care settings
(Figure 4-7).
Dogs are the animals most often used in AAT. Animal-
SAFETY assisted therapy has many applications, including overcoming
physical limitations, improving mood, lowering blood pres-
Aromatherapy sure and triglyceride levels, and improving socialization skills
• Essential oils are very potent and should never and self-esteem (Mullet, 2008).
be used in an undiluted form, be used near the
eyes, or be ingested orally. Music Therapy
• Because some people are allergic to certain oils, Therapeutic use of music consists of playing music to elicit
a small skin-patch test should be done before positive changes in behavior, emotions, or physiological
generalized application. response. Music encourages clients to actively participate in
their health care and recovery and complements other treat-
ment modalities.
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Creative Therapies
Modalities such as aromatherapy, music therapy,
art therapy, humor, and animal-assisted therapy are
among the group of creative and sense-
complementary interventions in health care. These
therapies are therapeutic in a variety of clinical situ-
ations and especially for older adults who may have
difficulty verbally expressing their feelings.
CULTURAL CONSIDERATIONS
Music and Culture
• Each culture and each generation within each
(© iofoto/ShutterStock)
culture has its own preferred type of music.

• Music that is soothing to one client may be ir-
ritating to another.
• Either ask which type of music the client would
prefer or allow the client to bring music.
Figure 4-7 Animal-assisted therapy provides health
benefits.
A CD player, iPod, or MP3 player with headphones play-
ing music can be a useful tool for immobilized clients, those
Music is good to use with imagery, because it enhances waiting for diagnostic tests, or those waiting for surgery. Some
the relaxation response and heightens images. All music influ- facilities allow clients to choose the type of music played while
ences human behavior by triggering brain processes that affect they undergo procedures such as cardiac catheterization.
a client’s cognitive, emotional, and physical functions. Music Pleasurable sound and music can reduce stress, perception of
radiates throughout society and culture and is easily accessible pain, anxiety, and feelings of isolation. Music can be very use-
(Center for Music Therapy, 2010). ful to help adults relax.
EVIDENCED-BASED
PRACTICE
Effects of Music Listening on Adult Clients’ Preprocedural Anxiety
Source: Gillen, E., Biley, F., & Allen, D. (2008). Effects of music listening on adult patients’ pre-procedural state anxiety in hospital. International
Journal of Evidence-Based Healthcare, 6(1), 24–49.
Discussion adult hospital clients’ preprocedural anxi- implicAtions For prActicE

A client’s anticipation of an invasive ety. Participants in the review were adult This research has important significance
procedure is likely to provoke feelings of day clients, ambulatory clients, and inpa- for clients who experience preprocedural
anxiety and stress. Factors that contribute tients who were about to undergo any type anxiety. Listening to music is an easy,
to the development of anxiety and stress of clinical procedure. The results of the noninvasive, and cost-effective method
include an unfamiliar environment, loss review revealed that listening to music had that nurses can utilize to help reduce a cli-
of control, or perceived or actual physical a consistently positive and statistically sig- ent’s anxiety before a procedure and will
risk. The purpose of this review was to de- nificant effect on reducing psychological benefit the client psychologically.
termine the best available evidence on the parameters of preprocedural state anxiety.
effectiveness of music listening in reducing
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CRITICAL THINKING Play Therapy

Play therapy is especially useful with children. Toys are used
Comfort Therapies to allow children to learn about what will be happening to
them and to express their emotions and their current situa-
tions. Drawing and artwork also provide a way for children to
share their experiences. When language ability is reduced or
In the hospice setting, it is common for family not yet well developed, play therapy and drawings constitute a
members to ask about comfort therapies that method for children to communicate their needs and feelings
they may be able to provide for the client. to care providers.
1. What complementary therapies can a nurse
teach family members?
2. What precautions would the nurse include
CONCLUSION
in the teaching of these complementary The use of complementary and alternative therapies is becom-
therapies? ing more prevalent among the general population. Nurses
3. What evaluative measures can the nurse
need to be educated and aware of the various complemen-
tary and alternative modalities that are being utilized by the
teach the family members to determine
public, and how these methods influence the health of the
whether the complementary therapy that is client. Current nursing practice is advancing toward a holistic
provided is effective for the client? approach to healing the whole person through integration of
complementary and alternative practices with conventional
medical treatments.
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CHAPTER 5
Inflammation and Infection
KEY TERMS
acquired immunity contact transmission pathogens
agent emerging infectious diseases portal of entry
airborne transmission flora portal of exit
antibodies hospital-acquired infection reservoir
asepsis host sterilization
aseptic technique humoral immunity superinfection
bacteria immunization surgical asepsis
carriers infection vector-borne transmission
chain of infection infectious agents vehicle transmission
communicable agents inflammation virulence
communicable diseases medical asepsis virus
community-acquired infections mode of transmission
LEARNING OBJECTIVES
2. List the chain of events that occur in an infectious process in the transmission of infection.
3. Distinguish between symptoms of inflammation and infection.
4. Identify measures for preventing infection in a healthy person with an intact immune
system.
5. List measures for preventing infection in the immunocompromised client.
6. Identify the factors that increase an individual’s susceptibility to infection.
64
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CHAPTER 5 Inflammation and Infection 65
• Swelling (edema, a detectable accumulation of increased

INTRODUCTION interstitial fluid) results from fluid and leukocytes entering
Inflammation and infection are an indication that a foreign the tissues from the circulatory system.
substance has broken through the body’s natural defenses. • Loss of function results from both pain and swelling and is
With inflammation, the body is attempting to rally its de- the body’s way of resting the injured part.
fense measures to prevent a worsening of the situation. With • Pus (purulent exudate), resulting from infection, is a secre-
infection, the invader is stronger than the host, and either an tion made up of white blood cells, dead cells, bacteria, and
inflammatory condition has progressed into an infection, or other debris.
an infection has developed without an inflammation. Either
condition can become life threatening, depending on what The inflammatory process intensity is usually in propor-
else is occurring with the client and the general state of health. tion to the degree of tissue injury. An inflammatory response
There are measures a healthy person can take to decrease the is typically local and confined to the site of injury. It may,
chances of developing either an inflammation or an infection. however, become systemic, as in the case of the client who
There are also measures a person with a compromised im- develops a fever. Inflammation is categorized according to its
mune system can take. duration (acute, subacute, or chronic) and according to the
type of exudates produced. An acute inflammation begins im-
mediately after injury and has a duration of less than 2 weeks.
INFLAMMATION Subacute inflammation is a reactive sign of inflammation
that has a gradual onset and may become a chronic or severe
Inflammation is a nonspecific cellular response to tissue reaction. Chronic inflammation may take weeks to develop
injury. Tissue injury caused by bacteria, trauma, chemicals, and lasts longer than an acute inflammation. Characteristics
heat, or any other occurrence releases substances, produc- of inflammation include local vascular changes (as described
ing dramatic secondary changes in the injured tissue. This above) with exudates formed. The exudates consist of fluid
entire complex of tissue changes in response to injury is called that leaked out of the blood vessels, dead cells, and products
the inflammatory process (Table 5-1). The body’s response that they release as they are dying. The exact composition of
to injury produces characteristic local and systemic signs of the exudates varies according to the tissue involved and the
inflammation. severity and length of the inflammatory response. Types of
Inflammation, while not necessarily the result of invad- exudate are sanguineous, serous, serosanguineous, or puru-
ing microorganisms, does have signs and symptoms similar to lent (Table 5-2).
those of an infection. The primary signs of inflammation and
infection are as follows:
Medical Management
• Redness (erythema) results from increased blood flow to Management of inflammation varies according to the general
the area. condition of the client and the severity of the inflammation.
• Heat results from increased blood flow and metabolism in Goals for management of a client with an acute inflammation
the area. are to minimize complications of the edema that accompanies
• Pain results from increased pressure on pain sensors in the inflammation, reduce the inflammatory response, and moni-
area. tor the systemic response.
Table 5-1 Stages of the Inflammatory Process

STAGE DESCRIPTION RESULT
1 Initial injury causes release of chemicals: histamine, Initiates the inflammation process.
bradykinin, serotonin, prostaglandins, and lymphokines.
2 Blood flow increases to the injured area. Produces characteristic redness and
warmth.
3 Increased capillary permeability leaks large amounts of plasma “Walls off” infection; results in nonpitting
into the damaged tissue; tissue spaces and lymphatics are edema.
blocked by fibrinogen clots.
4 Leukocytes infiltrate damaged tissue and engulf the bacteria Produces purulent exudate (pus).
and necrotic tissue. After several days, these leukocytes die
(Delmar Cengage learning)
and form a cavity of necrotic tissue and dead leukocytes.

5 Destroyed tissue cells are replaced by identical or similar Promotes tissue healing or the formation
structural and functioning cells and/or fibrous tissue. of fibrous (scar) tissue, which may reduce
the functional capacity of the tissue.
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agents. Diseases produced by these agents are referred to as

Table 5-2 Types of Exudate communicable diseases.
NAME OF
EXUDATE DESCRIPTION Flora
Sanguineous Pertaining to blood, or containing Flora are microorganisms that occur or have adapted
large amounts of blood; indicates to live in a specific environment, such as intestinal, skin,
capillary damage severe enough vaginal, or oral flora. There are two types of flora: resident
to allow RBCs to escape from and transient. Resident (normal) flora are microorganisms
plasma that are always present, usually without altering the client’s
Serous Pertaining to or resembling serum; health; an example would be Propionibacterium on the skin.
it appears watery, contains few Resident flora prevent the overgrowth of harmful microor-
cells ganisms; only when the balance is upset does disease result.
Transient flora are microorganisms that are episodic (of
Serosanguineous Thin and red in appearance and
limited duration); an example would be Staphylococcus au-
composed of both blood and
reus. They attach to the skin for a brief period of time but do

serum
not continually live on the skin. Transient flora are usually
Purulent Containing pus, which is composed acquired from direct contact with the microorganisms on
of leukocytes, liquefied dead tissue environmental surfaces.
waste, and living and dead bacteria
Pathogenicity and Virulence

Although most microorganisms found in the environment do
not cause disease and infection, some do. Disease-producing
MEMORY TRICK microorganisms are called pathogens; pathogenicity refers
RICE to the ability of a microorganism to produce disease. Viru-
lence refers to the frequency with which a pathogen causes
The acronym RICE is used to remember the treat- disease. The factors affecting virulence are the strength of the
ment for areas of inflammation or other tissue pathogen to adhere to healthy cells, the ability of a pathogen
injury: to damage cells or interfere with the body’s normal regulat-
ing systems, and the ability of a pathogen to evade the attack
R = Rest
of white blood cells (WBCs). Five types of microorganisms
I = Ice can be pathogenic: bacteria, viruses, fungi, protozoa, and
rickettsia.
C = Compression
E = Elevation
Bacteria
Bacteria are small, one-celled microorganisms that lack a
true nucleus or mechanism to provide metabolism. There-
fore, bacteria need an environment that will provide food for
Supportive care of the client with inflammation involves survival. Bacteria can be spherical, rodlike, spiral, or curving
comfort measures such as rest, elevation, wrapping of the af- in shape, usually appearing as single cells, pairs, chains, or
fected area, and administration of analgesics. groups. Although most bacteria multiply by simple cell divi-
Heat, cold, or both may be applied and need a physi- sion, some forms of bacteria produce spores, a resistant stage
cian’s order. Typically, physicians order cold (ice) on the that withstands unfavorable environments. When proper
affected area for 24 to 72 hours to control the inflammation, environmental conditions return, spores germinate and form
especially when pain and edema are present. After that time, new cells. Spores are difficult to kill because of their resistance
heat is ordered to assist in quickly removing the accumulated to heat, drying, and disinfectants. The growth rate of bacteria
waste products. If the edema is interfering with adequate tis- is affected by environmental factors such as changes in tem-
sue perfusion, anti-inflammatory agents such as steroids or perature and nutrition. The optimal temperature for patho-
NSAIDs may be ordered. If the inflammation is secondary to genic bacteria is 98.6°F (37°C).
the presence of a foreign body, removal of the foreign body Bacteria can be found in all environments, yet not all
may be necessary. bacteria are harmful or cause disease. Only a small percent-
age of bacteria are actually pathogenic. Common bacterial
INFECTION infections include diarrhea, pneumonia, sinusitis, urinary tract
infections, cellulitis, meningitis, gonorrhea, otitis media, and
Infection is the invasion and multiplication of pathogenic impetigo.
microorganisms in body tissue that results in cellular injury;
an example is strep throat. These microorganisms are called
infectious agents. Infectious agents capable of being trans- Viruses
mitted to a client by direct or indirect contact, through a ve- Viruses are organisms that can live only inside cells. They
hicle (or vector) or airborne route, are called communicable cannot get nourishment or reproduce outside cells. Viruses
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contain a core of deoxyribonucleic acid (DNA) or ribonucleic

acid (RNA) surrounded by a protein coating. Some viruses
Agent
have the ability to create an additional coating called an enve- An agent is an entity that is capable of causing disease. Agents
lope, which helps protect the cell from attack by the immune that cause disease may be as follows:
system. Viruses damage the cells they inhabit by blocking the • Biological agents. Living organisms that invade the host,
normal protein synthesis of the cells and by using the cell’s causing disease, such as bacteria, viruses, fungi, protozoa,
mechanism for metabolism to reproduce. and rickettsia
The same viral infection may cause different symptoms • Chemical agents. Substances that can interact with the body,
in different individuals, based on the individual’s immune causing disease, such as food additives, medications, pesti-
response to the invading virus. Some viruses will immediately cides, and industrial chemicals
trigger a disease response, whereas others may remain latent
for many years. Common viral infections include influenza, • Physical agents. Factors in the environment that are capable
measles, common cold, chickenpox, hepatitis B, genital her- of causing disease, such as heat, light, noise, and radiation.
pes, and HIV.
Reservoir
Fungi The reservoir is a place where the agent can survive. Colo-
Fungi grow in single cells, as in yeast, or in colonies, as in nization and reproduction take place while the agent is in
molds. Fungi obtain food from dead organic matter or from the reservoir. A reservoir that promotes growth of pathogens
living organisms. Most fungi are not pathogenic and make up must contain the proper nutrients (such as oxygen and or-
many of the body’s normal flora. Disease from fungi is found ganic matter), maintain proper temperature, contain mois-
mainly in individuals who are immunologically impaired. ture, maintain a compatible pH level (neither too acidic nor
Fungi can cause infections of the hair, skin, nails, and mucous too alkaline), and maintain the proper amount of light expo-
membranes. sure. The most common reservoirs are:
• Humans
Protozoa • Animals
Protozoa are single-celled parasitic organisms with the ability • Environment
to move. Most protozoa obtain their nourishment from dead • Fomites (objects contaminated with an infectious agent,
or decaying organic matter. Infection is spread through inges- such as bedpans, urinals, bed linens, instruments, dressings,
tion of contaminated food or water or through insect bites. specimen containers, and other equipment)
Common protozoan infections include malaria, gastroenteri- Humans and animals can have symptoms of the infec-
tis, and vaginal infections. tious agents or can be strictly carriers of the agent. Carriers
have the infectious agent but are symptom free. The agent can
Rickettsia be spread to others in both instances.
Rickettsia are intracellular parasites that need to be in living
cells to reproduce. Infection from rickettsia is spread through
fleas, ticks, mites, and lice. Common rickettsia infections Portal of Exit
include typhus, Rocky Mountain spotted fever, and Lyme The portal of exit is the route by which an infectious agent
disease. leaves the reservoir to be transferred to a susceptible host. The
agent leaves the reservoir through body secretions including:
• Sputum, from the respiratory tract
CHAIN OF INFECTION • Semen, vaginal secretions, or urine, from the genitourinary
Neither a susceptible host nor the presence of a pathogen tract
means that an infectious process will occur. The chain of • Saliva and feces, from the gastrointestinal tract
infection describes the development of an infectious pro- • Blood
cess. An interactive process involving an agent, host, and • Draining wounds
environment is required. This interactive process involves
several essential elements, or “links in the chain,” for trans- • Tears
mission of microorganisms to occur. Figure 5-1 identifies
the six essential links (elements) in the chain of infection.
An infectious process cannot occur without the transmis- Modes of Transmission
sion of microorganisms. Therefore, knowledge about the The mode of transmission is the process of the infectious
chain of infection facilitates control or elimination of mi- agent moving from the reservoir or source through the portal
croorganism transmission by breaking the links in the chain. of exit to the portal of entry of the susceptible “new” host.
Breaking the chain of infection is achieved by altering the Most infectious agents have a usual or primary mode of trans-
interactive process of the agent, host, and environment. In mission, but some microorganisms may be transmitted by
the chain of infection, the main concern is biological agents more than one mode (Table 5-3). Depending on the agent,
and their effect on the host. Each of the six links in the chain almost anything in the environment can become a potential
of infection is discussed next. mode of transmission.
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Intact immune Biological Agent

system
Exercise 1. Cleansing
Immunization
Disinfection
Proper nutrition
Sterilization
Susceptible Reservoir
6. 2.
Host or Source
Skin integrity
Proper hygiene
Sterile technique
Change dressings
Proper disposal Clean equipment

of needles or sharps
Clean linen
Portal of Exit
Portal of Entry 5. 3. from Reservoir
to Host
or Source
Wearing gloves, masks,

gowns, goggles
Medical or surgical Clean dressing over wounds

asepsis
Proper disposal of 4. Covering mouth and nose
contaminated objects when coughing or sneezing

Mode of
Hand hygiene
Transmission
Figure 5-1 The chain of infection: preventive measures follow each link of the chain.
Contact Transmission organism can remain airborne. The longer the particle is sus-
pended, the greater the chance it will find an available port
The most important and frequent mode of transmission is of entry to the human host. A disease that relies on airborne
contact transmission. This involves the transfer of an agent transmission is measles. Contaminated droplets containing
from an infected person to a host by direct contact with the the measles virus are in the spray from sneezing. The droplet
infected person, indirect contact with the infected person can find a portal of entry through the mucous membranes or
through a fomite, or close contact with contaminated secre- conjunctiva.
tions (Figure 5-2). Sexually transmitted diseases are spread
by direct contact. Common viral infections (cold, measles,
flu) are spread by close contact with contaminated secretions. Vehicle Transmission
Vehicle transmission occurs when an agent is transferred
Airborne Transmission to a susceptible host by contaminated inanimate objects such
Airborne transmission occurs when a susceptible host as water, food, milk (Figure 5-3), drugs, and blood. Cholera is
contacts droplet nuclei or dust particles that are suspended transmitted through contaminated drinking water, and salmo-
in the air. Particle size influences the length of time that the nellosis is transmitted through contaminated meat.
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Table 5-3 Modes of Transmission

MODE EXAMPLES
Contact Direct contact of health care provider
with client:
• Touching
• Bathing
• Rubbing
• Toileting (urine and feces)
• Secretions from client
Indirect contact with fomites:
• Clothing
• Bed linens
• Dressings
• Health care equipment
• Instruments used in treatments
• Specimen containers used for

laboratory analysis
• Personal belongings
• Personal care equipment
• Diagnostic equipment
Airborne Inhaling microorganisms carried by

moisture or dust particles in air:
Figure 5-2 Care must be taken when handling body fluids
to prevent the transfer of infectious agents through contact.
• Coughing
• Talking
• Sneezing
Vehicle Contact with contaminated inanimate

objects:
• Water
• Blood
• Drugs
• Food
• Urine

Vector-borne Contact with contaminated animate

hosts:
• Animals
• Insects
Figure 5-3 Vehicle transmission occurs through

contamination of inanimate objects, such as milk.
Vector-Borne Transmission
Vector-borne transmission occurs when an agent is trans-
ferred to a susceptible host by animate means such as mosqui-
toes, fleas, ticks, lice, and other animals (Figure 5-4). Lyme • Respiratory tract, by inhaling contaminated droplets (such
disease, malaria, and West Nile virus are examples of diseases as cold, influenza, measles)
spread by vectors. • Genitourinary tract, through contact with infected vaginal
secretions or semen (as in sexually transmitted infections)
Portal of Entry • Gastrointestinal tract, by ingesting contaminated food or
water (e.g., typhoid, hepatitis A)
A portal of entry is the route by which an infectious agent • Circulatory system, through the bite of insects (such as mos-
enters the host. Portals of entry include the following: quito bites resulting in malaria)
• Integumentary system, through a break in the integrity of • Transplacental, through transfer of microorganisms from
the skin or mucous membranes (e.g., infections of surgical mother to fetus via the placenta and umbilical cord (includ-
wounds) ing HIV, hepatitis B)
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Special Considerations
for the Older Adult
The older adult may be at increased risk for infec-
tion because of the normal aging process. As a
person ages, the skin, respiratory tract, kidneys, im-

mune system, and GI system decrease in function.
The systems function adequately during periods of
homeostasis. However, when physiological stress
is placed on the person, the systems are unable to
Deer tick
adequately protect the person from an infection.
Other factors that increase an older adult’s risk for
Figure 5-4 Lyme disease and other infections are caused by infection include inadequate nutrition (especially
the bite of a tick.
inadequate protein intake), a delayed inflamma-
tory response, disorientation, agitation, inconti-
Host nence, unsteadiness leading to falls, lethargy, and
A host is an organism that can be affected by an agent. A general fatigue. An older adult client may present
human being is usually considered a host. A susceptible host with acute confusion when infection is present.
is a person who has no resistance to an agent and thus is vul- Additional factors include living in group settings
nerable to disease. For example, an individual who has not where the older adult is exposed to many people
received the measles vaccine is more likely to contract the who may have infections, and taking medications
infection because of the lack of immunity to the infectious that may decrease the already-reduced immune
agent. A compromised host is a person whose normal body
system’s ability to respond adequately. Older
defenses are impaired and is therefore susceptible to infec-
tion. For example, a person with a common cold or superficial adults are taught methods to improve their nutri-
burns is at greater risk for infection because of the impaired tional status, to use aseptic measures of protection
state of the body system mechanisms. (hand washing, care when drinking from a public
Characteristics of the host influence the susceptibility to water fountain), to obtain routine immunizations,
and severity of infections. These include: and to recognize the atypical signs of infection
and know when to notify the primary health care
• Age. As a person ages, immunity declines, thus increasing
susceptibility to infection. provider. The Centers for Disease Control and Pre-
vention (CDC) (2010c) recommends that individuals
• Concurrent diseases. The existence of comorbid diseases
indicates an environment susceptible to infection. 65 years of age and older receive the influenza
(flu) vaccine annually and also the pneumococcal
• Stress. An individual experiencing a compromised emotional
state may have altered or decreased immune system response. vaccine, tetanus (lockjaw), herpes zoster (shingles),
and diphtheria vaccines.
BESTPRACTICE
• Immunization/vaccination status. Individuals who are not
Influenza Immunization fully immunized are at greater risk for infection.
On February 24, 2010, vaccine experts voted that • Lifestyle. Lifestyle practices such as having multiple sex
everyone 6 months of age and older should get a partners or sharing intravenous drug needles increase an
flu vaccine each year starting with the 2010–2011 individual’s potential for illness.
influenza season. The CDC’s Advisory Committee • Occupation. Forms of employment that involve an in-
on Immunization Practices voted for “universal” flu creased exposure to pathogens might include dealing with
chemical agents (such as asbestos) or handling sharp in-
vaccination in the United States to expand immu-
struments (such as scalpels).
nization protection against the flu to more people.
• Nutritional status. Individuals who maintain targeted weight
While everyone should get a flu vaccine each flu
for height and body frame are less prone to illness.
season, it is especially important that certain peo-
ple get vaccinated either because they are at high
• Heredity. Some individuals are naturally more susceptible
to infection than others.
risk of having serious flu-related complications or
because they live with or care for people at high Interaction between agent and host occurs in the envi-
risk for developing flu-related complications. ronment, which is everything other than the agent and host.
Many of the conditions promoting transmission of microor-
(CDC, 2010b)
ganisms reflect changes in the relationship between humans
and their environments.
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INFECtION CONtROL
Chain of Infection
Cleansing
Cleansing is a potential hazard to the nurse
How is the chain of infection applicable to every- from the splashing of contaminated material
day life in a person’s home? onto the body. Nurses should wear gloves,
masks, and goggles during cleansing.
INFECtION CONtROL
COMMUNITY/HOME HEALTH CARE
First Line of Defense
Hand hygiene is the first line of defense against
Disinfection
infection and is the single most important prac- In the home, Lysol and bleach are common disinfec-
tice in preventing the spread of infection. tants capable of eliminating some pathogens. The
recommended concentration of bleach solution is one
part bleach to nine parts water (CDC, 2010a).
BREAKING THE CHAIN Disinfection

OF INFECTION Disinfection is the elimination of pathogens, except spores,
Nurses focus on breaking the chain of infection by applying from inanimate objects. Disinfectants are chemical solutions
proper infection-control practices to interrupt the transmis- used to clean inanimate objects. The U.S. Environmental
sion of microorganisms. Specific strategies can be directed at Protection Agency licenses intermediate and low-level disin-
breaking or blocking the transmission of infection from one fectants. The Food and Drug Administration regulates high-
link in the chain to the next. A discussion regarding each of the level disinfectants. Common disinfectants are alcohol, sodium
six links follows (refer back to Figure 5-1). hypochlorite, quaternary ammonium, and phenolic solutions.
A germicide is a chemical that can be applied to both ani-
mate (living) and inanimate objects to eliminate pathogens.
Between Agent and Reservoir Antiseptic preparations such as alcohol and silver sulfadiazine
The first link in the chain of infection is between the agent and are germicides.
the reservoir. The keys to eliminating infection at this point in
the chain are cleansing, disinfection, and sterilization. These Sterilization
practices prevent the formation of a reservoir where infectious Sterilization is the process of destroying all microorganisms
agents can live and multiply. including spores. Equipment that enters normally sterile tis-
sue or blood vessels must be sterilized. Methods of achieving
Cleansing sterilization are moist heat (steam), dry heat, and ethylene
Cleansing is the removal of soil or organic material from oxide gas. The method of sterilization depends on the object
instruments and equipment used in providing client care. to be sterilized and the kind and amount of contamination.
Nurses often cleanse instruments after assisting or performing Autoclaving sterilization, which uses moist heat or steam,
invasive procedures. To reduce the amount of contamina- is the most common sterilization technique used in the hos-
tion and loosen the material on reusable objects, the objects pital setting. Boiling water is not an effective sterilization
are cleansed before sterilization or disinfection. Cleansing measure because some viruses and spores can survive boiling
involves the use of water, mechanical action, and, sometimes, water.
a detergent. Contaminated objects are cleansed using a soft-
bristled brush to scrub the surface. The steps for proper
cleansing are:
Between Reservoir
1. Wet the object with cold water; warm water coagulates
and Portal of Exit
Promoting proper hygiene, changing dressings and linens,
the proteins in organic material and makes them stick.
and ensuring that clean equipment is used in client care are
2. Apply detergent and scrub the object under running ways to break the chain of infection between the reservoir and
water using a soft-bristled brush. the portal of exit. The goal is to eliminate the reservoir for the
3. Rinse the object under warm running water. microorganism before a pathogen can escape to a susceptible
4. Dry the object before sterilization or disinfection. host.
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equipment to avoid being splashed with contaminated waste

COMMUNITY/HOME HEALTH CARE products or secretions.
Sterilization at Home
Between Portal of Exit
The CDC (2011) recommends boiling water as the
preferred way to kill harmful bacteria and para-
and Mode of Transmission
sites. Bringing water to a rolling boil for 1 full The goal in breaking the chain of infection between the portal
minute will kill most organisms. Chemical contami-
of exit and the mode of transmission is to prevent the exit of
the infectious agents. Clean dressings must be maintained
nants in water will not be removed by boiling.
on all wounds. Clients should be encouraged to cover their
mouths and noses when sneezing or coughing, and the nurse
must do so as well. Gloves must be worn when caring for a
Proper Hygiene client who may have infectious secretions, and care must be
taken to properly dispose of any contaminated article.
Educate clients on the importance of maintaining the cleanli-
ness and integrity of the skin and the mucous membranes.
Clean skin, hair, and nails maintain the body’s normal flora Between Mode of Transmission
and eliminate transient flora from the client’s system. Bathing
and hand hygiene are important ways to eliminate the poten-
and Portal of Entry
tial for infection. Clients should be encouraged to practice To break the chain of infection between the mode of trans-
daily bathing and teeth brushing. Clients who are unable to mission and the portal of entry, asepsis must be ensured and
perform these activities independently should be assisted. barrier protection worn when the care of clients involves
contact with body secretions. Gloves, masks, gowns, and
goggles are barrier protection that can be used. Proper hand
Change Dressings hygiene and proper disposal of contaminated equipment and
Any open injury or other break in skin integrity represents a linens are ways to prevent transmission of microorganisms to
potential reservoir for infectious agents and portal of exit for other clients and health care workers. A thorough discussion
a pathogen to be transferred to another individual. Dressings of asepsis and disposal of contaminated items is included later
on open or oozing wounds must be changed regularly. To in this chapter.
protect both yourself and the client from infection, follow
proper aseptic technique when changing dressings.
Between Portal of Entry
Clean Linens and Host
Bed linens, gowns, and towels are catchalls for body secre- Maintaining skin integrity and using sterile technique for cli-
tions. Infectious agents can be easily transferred from one ent contacts are methods of breaking the chain of infection
individual to the next through contact with a client’s linens. between portal of entry and host. Avoiding needlesticks by
Linens must be changed regularly, and soiled linens must be properly disposing of sharps also reduces the potential for
properly disposed. When changing linens, take care to keep infection by denying a portal of entry. The goal at this point in
the soiled articles from contact with your uniform. This will the chain is to prevent the transmission of infection to a client
prevent being infected from the soiled linens or passing the or health care worker who is not infected.
infection on to other clients.
Clean Equipment Between Host and Agent

All equipment used in the care of a client must be cleansed Breaking the chain of infection between host and agent means
and disinfected after each use. Although many items such eliminating infection before it begins. There are many ways
as disposable gowns can be discarded after use, items such to reduce the risk of acquiring infection: Proper nutrition,
as beds must be thoroughly cleansed after each use. Clients exercise, adequate rest and sleep, and immunizations allow
should be instructed never to share care items. Any nondis- an individual to maintain an intact immune system, thus pre-
posable equipment used in an invasive procedure (such as venting infection. Table 5-4 lists additional ways for a healthy
equipment used in an operating room) must be sterilized be- person to prevent infection.
fore being used again. Wear gloves and masks when cleansing
Proper Nutrition
Proper nutrition assists the body’s immune system to func-
tion properly. Clients need adequate amounts of protein in
BESTPRACTICE their diets to maintain and repair tissue as well as to produce
the antibodies needed to fight infection. A balanced diet also
The Client Who Is Bedridden allows the body to maintain appropriate acid–base balance.
Be alert to the formation of pressure ulcers in cli-
ents who are bedridden. Open ulcers are a possible
Exercise
Exercise maintains the body’s metabolic rate and, therefore,
source for infection if left untreated.
allows the body to maintain the antibodies and energy neces-
sary to ward off infection.
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Table 5-4 Infection Prevention Measures: Healthy Person

PREVENTIVE MEASURE RATIONALE
Adequate nutrition Eating a well-balanced nutritious diet will help keep all body systems functioning properly,
plus assist the body in fighting off invaders such as microorganisms.
Adequate fluid intake Drinking adequate amounts of fluid will ensure adequate urine output, which helps flush
toxins and other foreign substances from the body.
Normal weight for age and Maintaining a body weight that is neither underweight nor overweight will help the cardiac
height system be more capable of functioning as it should.
Smoking cessation or never Smoking causes lung cancer, decreased respiratory function, and decreased immune
starting to smoke system functioning.
Decreased stress, both Stress has been implicated in the onset of many physical and emotional disorders and

physical and emotional also decreases immune system functioning.
Adequate exercise Participating in exercise to the limits of a person’s ability will boost immune system
functioning as well as the person’s sense of well-being.
Rest and Sleep CLIENT TEACHING

Rest and sleep are basic to a client’s health and well-being. The
quality of rest and sleep can have a significant impact on a person’s
health. Adequate levels of rest and sleep provide a restorative func- Inappropriate Use of Antibiotics
tion needed for physiological and psychological healing. • Do not pressure the physician or nurse practi-
tioner to prescribe antibiotics for every illness.
Immunization Antibiotics are not always appropriate. They are
Immunization is the process of creating immunity, or resis- not effective against viruses.
tance to infection, in an individual. Many immunizations are • When antibiotics are prescribed, the client
given in early childhood (e.g., measles, mumps, and rubella). should take all of the medication as directed.
Immunization for the flu must be given every year and for Antibiotics taken only until the client feels bet-
tetanus every 10 years. ter allow the microorganisms to become resis-
tant to the antibiotic, and the antibiotic will no
BODY DEFENSES longer be effective.
• Antibiotics also destroy normal flora microor-
A host’s immune system is a defense against infectious agents. ganisms, so other illnesses may ensue.
The immune system is able to recognize “self” and “nonself”;
that is, the immune system recognizes what is not consistent
with the genetic composition of the host (self). These agents
are called antigens (nonself). An immune response against an
antigen protects the body from infection. multiplication. The balance of normal flora may become dis-
rupted, allowing pathogenic organisms to proliferate, causing
Nonspecific Immune Defense infection or superinfection.
The nonspecific immune defense protects the host from
all microorganisms; it does not depend on prior exposure Mucous Membranes
to an antigen. Nonspecific immune defenses are skin and Mucous membranes also are a physical barrier to infectious
normal flora; mucous membranes; coughing, sneezing, agents. Mucus produced by these membranes entraps in-
and tearing reflexes; elimination and acidic environment; fectious agents and inhibits bacterial growth. For example,
and inflammation. the cilia of the respiratory tract trap and propel mucus and
microorganisms away from the lungs, thereby reducing the
Skin and Normal Flora potential for infection.
The skin, the first line of defense against infection, serves as
a physical barrier to infectious agents. Skin cells, shed daily, Coughing, Sneezing, and Tearing Reflexes
remove potentially harmful microorganisms. Sebum, a sub- The cough and sneeze reflexes forcibly expel mucus and
stance produced by the skin, contains fatty acids that kill some microorganisms from the respiratory tract. Tears protect the
bacteria. The normal flora residing on the skin and in the body eyes by continually flushing away microorganisms. Tears also
compete with pathogenic flora for food and inhibit pathogen contain bactericides, which are bacteria-killing chemicals.
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Elimination and Acidic Environment

Elimination and an acidic environment usually prevent growth
SAFETY
of pathogenic organisms. Resident flora of the large intestines
prevent the growth of pathogens. The mechanical process of Incubation Period
defecation removes microorganisms with the feces. Urine acid- Always verify the incubation period of a suspected
ity prevents microbial growth. Urination flushes and cleans infection. Remember that a client may be able to
the bladder neck and urethra of microorganisms and prevents transmit the infection to another person before
microorganisms from ascending into the urinary tract. the onset of symptoms.
Normal vaginal flora prevent growth of several patho-
gens. At puberty, lactobacilli ferment and produce sugars in
the vagina that lower the pH to an acidic range. The acidic
environment of the vagina prevents pathogenic growth.
1. Localized infections are limited to a defined area or single
Inflammation organ with symptoms that resemble inflammation (red-
Inflammation is a nonspecific cellular response to tissue in- ness, tenderness, and swelling), such as a cold sore.
jury. Refer to the Inflammation section earlier in the chapter 2. Systemic infections affect the entire body and involve
for a detailed discussion of inflammation. multiple organs, such as AIDS.
All infections progress through four stages: incubation,
Specific Immune Defense prodromal, illness, and convalescence.
The specific immune defense is a response specific to the
invading antigen. It is activated when phagocytes fail to com- Incubation Stage
pletely destroy the antigen. This causes production of T lym- The incubation period is the time between entry of an infectious
phocytes (T cells), which regulate the immune response by agent in the host and the onset of symptoms. During this time,
activating other cells. The T cells move to the injured area and the infectious agent invades the tissue and multiplies to produce
release chemical substances called lymphokines. Lymphokines an infection. The client is typically infectious to others during
attract other phagocytes and lymphocytes to the injured area the latter part of this stage. For example, the incubation period
and assist in antigen destruction. for varicella (chickenpox) is 2 to 3 weeks; the infected person
The T cells also stimulate the production of B cells, is contagious from 5 days before any skin eruptions to no more
which become plasma cells, producing antibodies specific to than 6 days after the skin eruptions appear.
the antigen. Antibodies are protein substances that destroy
the antigen. The stimulation of B cells and the production of
antibodies are collectively known as humoral immunity. Prodromal Stage
Memory B cells are formed to remember the antigen The prodromal stage is the time from the onset of nonspecific
and prepare the host for future antigen invasion. When the symptoms until specific symptoms begin to manifest. The
antigen enters the body again, the immune response occurs infectious agent continues to invade and multiply in the host.
faster by rapidly producing antibodies. The formation of A client may also be infectious to other persons during this
these antibodies is referred to as acquired immunity, which time period. In the client with chickenpox, a slight elevation
protects the individual against future invasions of already ex- in temperature will occur during this stage, followed within
perienced antigens such as lethal bacteria, viruses, toxins, and 24 hours by eruptions on the skin.
even foreign tissues.
The process of vaccination (inoculation with a vaccine Illness Stage
to produce immunity against specific diseases) provides ac- The illness stage is the time when the client has specific signs
quired immunity. There are three types of vaccines: and symptoms of an infectious process. The client with chick-
1. Dead organisms that are no longer capable of causing enpox will experience a further rise in temperature and contin-
disease but still have their chemical antigens, such as ued outbreaks of skin eruptions for at least 2 to 3 more days.
typhoid, whooping cough, and diphtheria
2. Toxins that have been chemically treated so their toxic Convalescent Stage
nature is destroyed but their antigens are still intact, The convalescent stage is from the beginning of the disappear-
such as for tetanus and botulism ance of acute symptoms until the client returns to the previous
3. Live organisms that have been attenuated (rendered state of health. The client with chickenpox will see the skin
incapable of causing the disease yet still have the spe- eruptions and irritation begin to resolve during this stage.
cific antigen), such as for poliomyelitis, yellow fever,
measles, smallpox, and many other viral diseases (Guy-
ton & Hall, 2005) ACQUIRED INFECTIONS
Hospital-Acquired
TYPES AND STAGES Infections
OF INFECTIONS A hospital-acquired infection is an infection acquired in
Infection is the result of tissue invasion and damage by an a hospital or other health care facility that was not present
infectious agent. There are two types of infections: or incubating at the time of the client’s admission. They also
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include those infections that become symptomatic after the Cr it iCa l t HiNKiNG
client is discharged and infections passed among medical
personnel. Hospital-acquired infections are also called nosoco-
mial infections or health care–associated infections. These types Hospital-Acquired Infections
of infections typically fall into four categories: urinary tract,
surgical wounds, pneumonia, and septicemia.
Most hospital-acquired infections are transmitted by health Why are hospital-acquired infections such a huge
care personnel who fail to practice proper hand hygiene or who problem?
fail to change gloves between client contacts. Infection control is
an issue wherever the client may be found, not just in the acute
hospital. Many nursing home residents, frequently debilitated,
undernourished, and/or unable to meet their personal needs
independently, will develop infections. Many people in various to protect against certain diseases. The risk for developing a
states of health are living at home; they, too, are susceptible to superinfection increases when the dosage of antibiotic being
an infectious process occurring in their bodies. used is high, when more than one antibiotic is being used
Certain groups of persons are at higher risk for develop- at the same time, or when broad-spectrum antibiotics are
ing hospital-acquired infections. These include the elderly prescribed. Certain antibiotics are more likely to cause su-
and people who are immunocompromised, debilitated, mal- perinfections than are others. An example of this is a female
nourished, or severely ill. Measures to prevent infection being treated with an antibiotic for pneumonia; the antibiotic
become even more important when caring for these persons destroys the normal flora of the genital tract and she develops
because they have a lowered ability to fight the pathogens. a vaginal yeast infection.
The hospital environment provides exposure to a vari- Ways to manage a superinfection include discontinuing
ety of organisms to which the client has not typically been the current antibiotic and replacing it with one to which the
exposed in the past. Certain organisms have been implicated organism present is sensitive or culturing the infected area to
more than others in causing or leading to hospital-acquired identify the organism present (there may be a new organism)
infections. These organisms include methicillin-resistant and, if necessary, administering another antibiotic that is ef-
Staphylococcus aureus (MRSA), vancomycin-resistant Staphy- fective against this new organism.
lococcus aureus (VRSA), vancomycin-resistant enterococcus
(VRE), and Clostridium difficile. As these infections become
more prevalent, organisms are mutating such that medica-
EMERGING INFECTIOUS
tions effective today may not be effective tomorrow. DISEASES
The CDC defines emerging infectious diseases as diseases
Community-Acquired of infectious origin with human incidences that have increased
within the past two decades or are likely to increase in the near
Infections future (CDC, 2010d). According to the CDC (2010c) these
A community-acquired infection is one that is acquired diseases include:
outside of a health care setting or that is present upon a client’s
admission to the hospital. This type of infection is frequently • New infections that result from changes in or evolution of
distinguished from a hospital-acquired infection by the caus- existing organisms
ative organism, and is usually more sensitive to antibiotics. • Known infections spreading to new populations or geo-
Organisms causing influenza or pneumonia are common graphic areas
sources of community-acquired infections. • Previously unrecognized infections that appear in places
undergoing ecological changes
Superinfection • Breakdown in public health measures or old infections
reemerging as a result of antimicrobial resistance in known
Another problem that can occur during treatment of an infec- agents or breakdowns in public health measures
tion is termed a superinfection. This is an infection caused
when the anti-infective used to treat the initial infectious Emerging infectious diseases are important partially be-
process also destroys the body’s natural flora, which is present cause their incidence has not stabilized and because people
today travel more frequently and farther than ever before. The
possibility of transferring a “new” disease from its country of
origin to a new area is much greater now. Other factors that play
BESTPRACTICE a part in helping these emerging infectious diseases spread are
urban crowding, increased illegal IV drug use especially when
sharing needles, promiscuous sexual behaviors, and population
Health Care–Associated Infections
movements that occur during times of war or famine.
Each year, 1.7 million health care–associated infec- The CDC leads efforts against emerging infections, from
tions occur in the United States. These infections AIDS, hantavirus pulmonary syndrome, and avian flu, to
increase the client’s length of stay, costing nearly tuberculosis and West Nile virus infection. The agency pub-
$20 billion annually for the associated extended lishes a journal titled Emerging Infectious Diseases that commu-
nicates the efforts being taken against the threat of emerging
care and treatment (Wright, 2008).
infections. The journal can be accessed at http://www.cdc
.gov/ncidod/eid/index.htm.
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NURSING PROCESS MEMORY TRICK

Data Collection Infection
Assessment data guide the prioritization of the client’s prob- A nurse can use the memory trick INFECTION to
lem and identification of appropriate nursing diagnoses. remember signs and symptoms of infection and
Clients at risk for infection require frequent reassessment fol- important nursing assessment skills to use when as-
lowed by appropriate changes in the plan of care, goals, and
sessing a client for an actual or potential infection.
nursing interventions.
The health history and physical examination data cor- I = Inflammation (swelling) is a sign of infection.
related with the laboratory results identify those clients at risk N = Need to auscultate lungs for crackles or wheezes.
for infection. Appropriate risk appraisals may be incorporated
into the nursing health history interview. F = Feels warm or hot (skin) to the touch.
E = Erythema (redness) appears at the site of the
Subjective Data infection.
Relevant data regarding the client at risk for infection are obtained C = Check client’s temperature for a fever.
in the health history. A comprehensive assessment also involves
appraising the client’s environment to detect potential hazards T = Tender (sore or painful) at the site of the
and the client’s self-care abilities. Reviewing such factors as work infection.
environment, immunization status, and other health-related is- I = Inspect site of infection for secretions or exudates.
sues may help identify actual or possible infection risks.
O = Observe and practice proper hand hygiene
Objective Data protocol.
Objective data are gathered through the physical examination N = Need to report abnormal lab values to the
and the diagnostic and laboratory findings. physician.
Physical Examination
A complete health assessment includes a systematic physical Diagnostic and Laboratory Data
examination, generally conducted from head to toe, to obtain
objective data relative to the client’s health status and presenting The laboratory indicators for an infection are:
problems. When assessing the client to determine the level of • An elevated leukocyte (white blood cell [WBC]) and WBC
risk for infection, focus the physical examination on: differential:
• Range of motion and mobility (A client with limited mobil- • Neutrophils. Increased in acute, severe inflammation
ity is at risk for developing joint contractures, skin break- • Lymphocytes. Increased in chronic bacterial and viral infections
down, and muscle atrophy.) • Monocytes. Increased in some protozoan and rickettsial
• Localized redness, warmth, swelling, pain, and loss of use in infections and TB
a specific body part • Eosinophils and basophils. Unaltered in an infectious process
• Fever with an increase in pulse and respirations; weakness; • An elevated erythrocyte sedimentation rate (ESR): in-
anorexia, nausea, vomiting, and/or diarrhea; enlarged and/ creased in the presence of inflammation
or tender lymph nodes • An elevated pH of involved body fluids (gastric, urine, or
• Secretions or exudate of the skin or mucous membranes; vaginal secretions): indicative of microorganism presence
hydration status • Positive cultures of involved body fluids (blood, sputum,
• Auscultation of the lungs for crackles or wheezes urine, or other drainage): indicative of microorganism
growth (Guyton & Hall, 2005)
BESTPRACTICE Nursing Diagnosis

After data collection and analysis, identify a nursing diag-
Questions Related nosis. The North American Nursing Diagnosis Association
to Infection Control (NANDA) identifies one nursing diagnosis related to infec-
tion: Risk for Infection.
• What do you do to stay healthy? Risk for infection is an increased risk for being invaded by
• What health care concerns do you have? pathogenic organisms (NANDA, 2009). The risk factors that
• Have you recently been in contact with some- increase a client’s susceptibility to infections are as follows:
one who has an infectious disease?
• Inadequate primary defenses (broken skin, traumatized tis-
• When do you wash your hands?
sue, decrease in ciliary action, stasis of body fluids, change
• Have you traveled out of the country, espe- in pH of secretions, and altered peristalsis)
cially to underdeveloped countries, in the past
• Inadequate secondary defenses (decreased hemoglobin,
6 months? leukopenia, suppressed inflammatory response)
• Inadequate acquired immunity
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COMMUNITY/HOME HEALTH CARE
Clients at Risk for Infection Medical and Surgical Asepsis
Clients at risk for infection should have follow-up
visits by the home health nurse to measure the effec-
tiveness of client teaching and to assess resources in How are medical asepsis and surgical asepsis the
the home to prevent the transmission of infections. same? How are they different?
• Immunosuppression the risk of infection. Outcomes provide direction for nursing care
• Tissue destruction and increased environmental exposure to reduce the risk of infection. Client and caregiver education
• Chronic disease about identifying potential hazards and health promotion prac-
tices is another critical element of the care plan.
• Malnutrition
• Invasive procedures
• Pharmaceutical agents Implementation
• Trauma Nurses are responsible for providing the client with a safe
environment, including prevention of hospital-acquired in-
• Rupture of amniotic membranes
fections. Nursing interventions to reduce the risk of infection
• Insufficient knowledge to avoid exposure to pathogens center around ensuring asepsis and properly disposing of
(NANDA, 2009) infectious materials to reduce or eliminate infectious agents.
Clients who are at risk for infection may have other associ- There are two types of asepsis: medical and surgical. Asepsis
ated physiological and psychological concerns. The common refers to the absence of microorganisms. Aseptic technique
nursing diagnoses that often accompany Risk for Infection include: is the infection-control practice used to prevent the transmis-
sion of pathogens. The use of aseptic technique decreases the
• Imbalanced Nutrition: Less Than Body Requirements or More risk and spread of hospital-acquired infections.
Than Body Requirements The term medical asepsis refers to those practices used to
• Ineffective Protection reduce the number, growth, and spread of microorganisms. It is
• Impaired Tissue Integrity also called clean technique. In medical asepsis, objects are generally
• Impaired Oral Mucous Membrane referred to as “clean” or “dirty.” Clean objects are considered to
have the presence of some microorganisms that are usually not
• Impaired Skin Integrity
pathogenic. Dirty (soiled) objects are considered to have a high
• Deficient Knowledge number of microorganisms, some being potentially pathogenic.
This list indicates several related problems that must be con- Common medical aseptic measures used for clean or dirty objects
sidered when planning care for the client at risk for infection. are hand hygiene, daily changing of linens, and daily cleansing of
floors and hospital furniture.
Surgical asepsis, or sterile technique, consists of those
Planning/Outcome practices that eliminate all microorganisms and spores from
an object or area. Surgical asepsis relates to surgical hand
Identification washing, establishing and maintaining sterile fields, donning
The nurse collaborates with the client and other health care pro- surgical attire (caps, masks, and eyewear), and using sterile
viders to determine goals, outcomes, and interventions to reduce gloves and gowning, with closed gloving.
CASE STUDY
Infection
J.W., age 43, an elementary school teacher, has just been admitted to the medical floor. His initial assess-
ment reveals BP 145/92, T 103°F (39.4°C), P 96 beats/min, R 36 breaths/min. He reports discomfort
when he attempts to take a deep breath, and frequent coughing with production of yellow-green mucus.
He has been healthy, and has no chronic illnesses. He takes no routine medications except a daily multivi-
tamin. He has had no routine immunizations since childhood. No one else in his family is ill.
1. What diagnostic tests would you expect to see as part of his medical orders?
2. What other orders would you expect to see on his chart?
3. Assessment data would include what specific information?
4. Are any measures necessary to protect his family, his school class, or his colleagues from the same in-
fectious process as he has?
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SAMPLE NURSING CARE PLAN
The Client at Risk for Infection

F.S., a 38-year-old homeless person, was struck and dragged by a speeding car as he crossed the street. He was taken to the
hospital by ambulance. His left leg is broken, and there are lacerations and abrasions on his right side, arm, and leg. The
left leg is in a cast and the lacerations have been sutured. F.S. grimaces when he tries to move his legs, but he does not ver-
balize pain. F.S. is very thin and says that he has not eaten for 2 days.
NURSING DIAGNOSIS 1 Risk for Infection related to inadequate primary defenses as evidenced by lacerations
and abrasions

Tissue Integrity: Skin & Mucous Membranes Wound Care
Nutritional Status Nutrition Management
PLANNING/OUTCOMES NURSING INTERvENTIONS RATIONALE
F.S. will not have developed an infec- Use proper hand hygiene before Reduces microorganisms on hands.
tion in the lacerations and abrasions and after caring for F.S.
at discharge. Use sterile technique when caring Prevents introduction of microorgan-
for lacerations and abrasions. isms into lacerations and abrasions.
Apply antibiotic ointment on Promotes healing of abrasions.
abrasions, as ordered.
Keep bed linens clean and dry. Removes any drainage that may har-
bor microorganisms.
Administer oral antibiotics, as Prevents or cures infection.
ordered.
EvAlUATION
F.S. has some redness around one laceration.
NURSING DIAGNOSIS 2 Acute Pain related to physical injury as evidenced by facial grimacing
Pain Control Pain Management
Symptom Severity Analgesic Administration
Hope Instillation
F.S. will experience increased comfort Use pain scale to determine level Provides objective measure of pain.
and will verbalize that pain is under of discomfort.
control within 24 hours. Assist client to a position of com- Reduces pain and swelling by increas-
fort and elevate extremities. ing blood return to the heart.
Administer analgesics, as ordered. Provides comfort.
EvAlUATION
F.S. states that he is experiencing less discomfort by 16 hours but that he still desires pain medication.
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CONCEPT CARE MAP 5-1
NURSING DIAGNOSIS
Imbalanced Nutrition: Less Than Body Requirements related to economic factors as evidenced by extreme thinness and not having
eaten for 2 days
NOC: Nutritional Status: Nutrient Intake
NIC: Nutrition Management
CLIENT GOAL
F.S. will eat balanced meals while hospitalized.
NURSING INTERVENTIONS SCIENTIFIC RATIONALES

1. Assist F.S. to select foods high in protein, vitamins A and 1. Wound healing depends on the availability of protein,
C, calcium, zinc, and copper. vitamins, and minerals.
2. Provide between-meal snacks, especially milk or milk 2. Snacks will increase overall caloric intake; increased protein
products. will promote wound healing; increased calcium will promote
bone healing.
(DELMAR CENgAgE LEARNINg)

EVALUATION
Is F.S. eating balanced meals while hospitalized?
CONCLUSION
Evaluation Nurses are responsible for providing quality care that incorpo-
Evaluation of the effectiveness of nursing care is based on rates principles of infection control and management of infec-
the achievement of goals and expected outcomes. Keeping tion and inflammation. These principles are a major component
the client free from infection requires frequent reassessment of a safe environment. Within this chapter the concepts of
followed by timely adjustments made in the plan of care in inflammation, infection, including the chain of infection, body
order for nursing interventions to be effective. It is important defenses, stages of the infectious process, and hospital- and
for the client to remain free of infection during hospitalization community-acquired infections are addressed. Discussion of
as well as develop a true awareness of the factors that increase measures that nurses can implement to provide effective nursing
the risk for infection. care for clients at risk for infection is provided.
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CHAPTER 6
Caring for Clients in Shock
KEY TERMS
anaphylactic shock hypotonic septic shock
cardiac output hypovolemic shock spinal shock
cardiogenic shock hypoxia vasopressors
catecholamines neurogenic shock
hypertonic perfusion
LEARNING OBJECTIVES
2. Describe factors that contribute to the various types of shock.
3. Identify clients at risk for developing different types of shock.
4. Verbalize the signs and symptoms for the various types of shock.
5. Collect pertinent assessment data related to clients in shock.
6. Review common diagnostic tests to differentiate between the different types of shock.
7. Remember common medications used to treat shock.
8. Assist in the development of a nursing care plan for a client in shock.
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CHAPTER 6 Caring for Clients in Shock 81
INTRODUCTION MEMORY TRICK

Shock is the body’s response to inadequate tissue perfusion, CHANS
and if left untreated will progress into cell death, organ failure,
and a life-threatening emergency. Because shock is a condi- An easy memory trick to remember the five types
tion and not a disease, a variety of causes contribute to the of shock is CHANS.
five main types of shock: hypovolemic, cardiogenic, septic, C 5 Cardiogenic
neurogenic, and anaphylactic. Table 6-1 lists the classification
of shock, the characteristics, and the causes for each type. The H 5 Hypovolemic
nurse caring for a client experiencing shock must be knowl- A 5 Anaphylactic
edgeable of the signs and symptoms, necessary assessment
skills, and appropriate treatment. Prompt nursing care is es- N 5 Neurogenic
sential for a positive client outcome. S 5 Septic
HYPOVOLEMIC SHOCK
Hypovolemic shock is a decrease in the client’s circulating 2007). In addition, third spacing fluid shifts within body
blood volume that leads to inadequate tissue perfusion (the cavities, such as the abdominal cavity, can cause hypovolemic
passage of blood through tissues or vasculature). Inadequate shock when fluids that are normally intravascular leak into the
tissue perfusion deprives the cells from oxygen, resulting peritoneum or similar spaces, causing an intravascular fluid
in hypoxia, the inability of the cell to maintain normal volume deficit that results in decreased blood flow to tissues.
metabolic activities including energy production and waste In rare cases, fluid shifts resulting in hypovolemic shock
removal from a lack of oxygen. As a result, the body cells are induced from infusing a large amount of a hypotonic
become injured and die, leading to organ damage and failure, intravenous (IV) solution, such as 0.45% normal saline.
and potentially the client’s death. Hypotonic solutions are those with a lower serum osmolal-
There are multiple causes of hypovolemic shock with ity than that of the intracellular interstitial compartments.
the most common cause being acute blood loss from trauma These solutions cause fluid to leave the vascular compart-
(Kelley, 2005). Clients who have sustained severe burns may ment and shift into the cells or interstitial compartments.
develop hypovolemic shock due to massive evaporation of Large infusions of this type of fluid leave the client intravas-
water from the damage to the skin surface. In some cases, cli- cularly dehydrated.
ents with severe vomiting and diarrhea develop hypovolemic The term mild hypovolemic shock is used when less than
shock from significant fluid loss and secondary electrolyte 20% of the circulating blood volume is lost. Moderate shock
imbalances that cause fluid shifts (Garretson & Malberti, occurs when blood loss volume is between 20% and 40%, and
Table 6-1 Classification of Shock

TypeS of SHoCk CHaraCTeriSTiCS CauSeS
Anaphylactic shock A massive release of inflammatory media- A Type 1 hypersensitivity reaction caused when an
tors such as histamine, prostaglandins, or allergen comes in contact with the body through
leukotrienes causing vasodilation and tissue ingestion, skin contact, or inhalation.
hypoperfusion.
Cardiogenic shock The pumping ability of the heart is dimin- An acute myocardial infarction, cardiac tam-
ished so that insufficient blood volume ponade, severe mitral regurgitation, ventricular
is pumped out to the cells, tissues, and rupture, and medications such as metoprolol
organs. (Lopressor) or clopidogrel (Plavix).
Hypovolemic shock A decreased circulating blood volume results An acute blood loss from trauma, fluid shifts, or
in inadequate tissue perfusion and oxygen- loss from surgery; fluid loss from burns, vomiting,
ation for normal cell function. or diarrhea; and severe electrolyte imbalances.
Neurogenic shock Disrupted autonomic nervous system control Acute spinal cord injury, including temporary spi-
leads to decreased vascular tone, hypoten- nal shock or permanent paralysis leads to this type
sion, and bradycardia resulting in inadequate of shock.
tissue perfusion.
Septic shock A widespread inflammation causing a loss of An infection from sources including bone, blood,
vascular tone resulting in hypotension, hy- invasive lines, GI tract, GU tract, pulmonary, car-
poxia, and multiple end-organ failure. diac, skin, and the central nervous system.
(Adapted from Garretson & Malberti, 2007).
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BESTPRACTICE
Collaborative Care
The health care team works together and collabo-
rates in providing the appropriate care quickly and
efficiently for the client with hypovolemic shock.
Goals of collaborative care include restoring fluid
balance and preventing complications from the
fluid deficit. The client’s nurse is an integral part of
the team in communicating changes in the client’s
status to the health care provider and relaying the
health care provider’s orders to other ancillary ser-
vice members including respiratory therapists and
pharmacy staff.
Clear, effective communication and collabora-
tion is integral because immediate action is needed
to correct the hypovolemia and prevent deteriora-
tion in the client’s status. Most clients experiencing
hypovolemic shock will be in an emergency depart-
(© beerkoff/ShutterStock)
ment, surgical or postanesthesia care room, or in-

tensive care unit. Transfer between these locations
is common. Thus, effective collaboration and clear
communication are essential in providing the client
with a positive outcome.
figure 6-1 Treatment for hypovolemic shock consists of
restoring fluid volume by blood transfusion and intravenous
rehydration with IV fluids.
adults ages 20 to 30 are also at risk because trauma is the
main cause of death in this age group, and motor vehicle ac-
severe shock results when the client has lost more than 40% cidents are common.
of her circulating blood volume (Kelley, 2005). Most average- Early signs of hypovolemic shock are subtle changes in
size adults have a total blood volume of 5 liters and do not the client’s vital signs that are often missed until they become
become symptomatic until at least 500 mL of blood volume more pronounced and the client’s body is compensating less.
is lost (Neighbors & Tannehill-Jones, 2009). Treatment con- Early signs include mild tachycardia and mild hypotension
sists of restoration of fluid volume by blood transfusion and (low blood pressure). In hypovolemic shock, the client’s
intravenous rehydration with IV fluids (Figure 6-1). systolic blood pressure falls below 90 mm Hg, or 40 mm Hg
The actual incidence of hypovolemic shock is not below the client’s normal baseline blood pressure. The client
known because it is a secondary condition that results from presents with anxiety, restlessness, delayed capillary refill, and
blood or body fluid loss. Thus, its incidence in the popula- increased respiratory rate. Kidney function decreases result-
tion cannot be estimated. While hypovolemic shock could ing in a urine output of less than 10 mL/hr. The client’s skin
happen to anyone, small children are more susceptible than feels cool, clammy, and may appear mottled. If hypovolemia
adults because their bodies are very sensitive to fluid losses is not corrected, the client may start to experience severe
and they become dehydrated quickly. Teenagers and young tachycardias, arrhythmias, and chest pain. As shock becomes
severe the client will demonstrate a change in consciousness
with possible unconsciousness. This is usually a late sign in a
cascade of events (Garretson & Malberti, 2007).
SAfeTy Several tests may be ordered to evaluate the client expe-
riencing hypovolemic shock. Table 6-2 lists and discusses the
Medications Affecting common diagnostic tests for hypovolemic shock.
Tachycardic Response
The nurse needs to be aware that clients who are Medical-Surgical
on beta-receptor blocking agents, such as meto-
prolol or atenolol medications, may not become
Management
tachycardic until the later stages of shock. The Medical
tachycardic response may be blunted due to these Treatment of hypovolemic shock is based on correcting circu-
medications (Kelley, 2005). lating blood volume and identifying and treating the cause of
the volume loss. Supplemental oxygen is administered to the
client immediately to help correct hypoxemia (Murch, 2005).
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Table 6-2 Common Diagnostic Tests for Hypovolemic Shock

TeST Name DeSCripTioN Normal aDulT ValueS
Arterial blood gas (ABG) Measures the dissolved oxygen, carbon dioxide, pH, pH 7.35–7.45
and bicarbonate levels of arterial blood. pO2 75–100 mm Hg
pCO2 35–45 mm Hg
HCO3 20–26 mEq/L
O2 saturation 95–100%
Blood urea nitrogen (BUN) Measures the amount of BUN (a chief end product of 5–20 mg/dL
protein metabolism) in serum. Is an indicator of renal
function and fluid status.
Creatinine Measures the amount of creatinine in serum. Is an Men 0.8–1.8 mg/dL
indicator of renal function and fluid status. Women 0.6–1.6 mg/dL
Electrolyte panel Measures the calcium, magnesium, phosphorus, po- Calcium 8.5–10.5 mEq/L
tassium, and sodium levels in the blood. Magnesium 1.6–2.6 mEq/L
Phosphorus 3–4.5 mg/dL
Potassium 3.5–5.5 mEq/L
Sodium 136–145 mEq/L
Chloride 98–106 mEq/L
Hematocrit Measures the percentage of RBC mass to whole Men 40–54%
blood volume. Women 38–47%
Hemoglobin Measures the amount of this oxygen-carrying protein Men 14–18 g/dL
attached to RBCs in the serum. Women 12–16 g/dL
Serum osmolality Measures the number of dissolved particles per unit 280–295 mOsm/kg H2O
of blood. Is an indicator of serum concentration (fluid
(Delmar cengage learning)

status)
White blood cell (WBC) count Measures the number of WBCs per milliliter of blood. 4.8–10.8 K/mL
Is an indicator of immune status and infection.
Initially, oxygen is administered via nasal cannula or mask. result in intracellular dehydration or accidental intravascular
However, clients experiencing severe shock require mechani- volume overload. This is especially dangerous in the client
cal ventilation and intubation. with impaired cardiac function who is at risk for heart failure
Both blood products and IV fluid products may be or- (Garretson & Malberti, 2007).
dered to treat the hypovolemia, and the physician will base
the choice of replacement type on the cause of the fluid loss.
If blood loss is solely responsible for the client’s hypovole-
mia, the physician may order predominately blood product
replacement consisting of whole blood (plasma) or packed
red blood cells. Many physicians will give only intravenous
fluids as the source of replacement if the volume deficit
is less than 1,500 mL, and prescribe blood products if the
volume loss is greater than this amount or the main cause
of the hypovolemia (Garretson & Malberti, 2007). Com-
monly prescribed fluids include lactated Ringer’s or normal
saline (0.9% sodium chloride), which not only help correct
the volume loss, but also help with electrolyte replacement
(© blenD imageS/ShutterStock)
(Figure 6-2).
Hypertonic solutions are those with a higher osmotic
pressure than another solution and frequently refers to IV
solutions with a higher osmotic pressure than the intracellular
and interstitial fluids. The nurse should be aware that the ad-
ministration of a large amount of hypertonic fluid such as al-
bumin can cause significant fluid shifts as fluid leaves the cells figure 6-2 IV fluid products are commonly ordered to treat
and enters the vascular space as a result of diffusion and can hypovolemia.
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Electrolyte replacement may be necessary, especially if CRITICAL THINKING

large amounts of fluids are needed to correct the client’s hy-
povolemia. Hypokalemia is common in this client population Complications
after large amounts of fluids have been infused. Also, either
hyponatremia or hypernatremia may also occur, depending of Hypovolemic Shock
on the type of intravenous solution used. Less commonly,
calcium imbalance may be present. The nurse should take 1. List three complications of hypovolemic
care to remember that cardiac arrhythmias can occur as a shock.
result of electrolyte imbalance. The nurse will need to draw
2. Why is fluid overload serious for the client?
frequent blood samples to check electrolyte levels as well as
measure the client’s hemoglobin, hematocrit, and oxygen-
ation levels, which may be altered by large blood transfusions
or fluid infusions. Epinephrine (Adrenaline), norepinephrine levarterenol
(Levophed), norepinephrine (Noradrenaline), phenylephrine
Diet (Neo-Synephrine), dobutamine (Dobutrex), and dopamine
(Intropin) are the most commonly used vasopressor medi-
During hypovolemic shock, diet and fluids are administered cations (medications that induce vasoconstriction through
as tolerated. If the client can drink fluids, she is encouraged direct action on the alpha receptors of the vasculature) (Gar-
to increase oral fluid consumption. Increasing oral intake aids retson & Malberti, 2007). Phenylephrine (Neo-Synephrine)
in the correction of fluid deficit. Oral consumption of fluids may also be used and is known for its purely vasoconstrictive
during hypovolemic shock will not be sufficient to correct the action and its lack of effects on the client’s heart rate (Bro-
imbalance alone, but should be encouraged as long as the cli- yles, Reiss & Evans, 2007). Dobutamine and dopamine both
ent is able to take fluids orally. Clients experiencing hypovole- have significant inotropic (increased cardiac contractility and
mic shock are frequently critically ill and may be mechanically pumping power) effects. They also cause vasoconstriction at
ventilated. Supplemental nutrition via a feeding tube may be higher doses, but can worsen tachycardia. Epinephrine and
initiated. Clients who are critically ill require adequate nutri- norepinephrine both have positive inotropic effects and cause
tion for healing, and without it, recovery is prolonged. Often, peripheral vasoconstriction as well with fewer tachycardic ef-
such clients are in a hypermetabolic state and may even have fects than dopamine, resulting in increased cardiac output as
higher caloric needs than normal (Daniels & Nicoll, 2012). well as improving hypotension, and make them a good choice
The physician may order a dietitian consult to assist in defor the treatment of hypovolemic shock.
termining the client’s caloric needs if tube feedings are being The nurse should consider that the use of any of these
administered. medications is secondary to fluid restoration because the
primary treatment of hypovolemic shock is restoration of the
Pharmacological client’s circulating intravascular volume. In addition, adequate
Multiple medications may be used to assist in the correction volume needs to be restored before any of these medications
of the client’s hypotension, low cardiac output (the amount are started (Garretson & Malberti, 2007). Common adverse
of blood pumped from the left ventricle over a set amount of effects of the sympathomimetic (cardiac stimulant) class of
time; usually expressed in liters per minute), oliguria, acidosis, drugs described above include significant tachycardia, palpi-
and respiratory changes associated with the shock cascade. tations, tremors, headache, and overstimulation of the central
Table 6-3 lists common medications used in the treatment of nervous system. The nurse should monitor the client closely
hypovolemic shock. and report these adverse effects to the physician if present
Table 6-3 Common medications used in the Treatment

of Hypovolemic Shock
meDiCaTioN DoSage aCTioN
adrenaline (Epinephrine) IV: 0.1–1 mg as needed Vasopressor/cardiac stimulant

SC or IM: 0.2–0.5 mg as needed
dobutamine (Dobutrex) 2–40 mcg/kg/min Inotrope
dopamine (Intropin) 5–20 mcg/kg/min Inotrope/vasopressor
milrinone lactate (Primacor) 0.375–0.75 mcg/kg/min Phosphodiesterase inhibitor, inotrope
nitroglycerin (Nitrostat) 0.3-mg, 0.4-mg, or 0.6-mg sublingual Vasodilator
tablet
nitroprusside sodium (Nitropress) 0.5–5 mcg/kg/min Vasodilator

norepinephrine (Noradrenaline) 2–30 mcg/kg/min Catecholamine, vasopressor
phenylephrine (Neo-Synephrine) IV: 10 mg by continuous IV infusion Vasopressor
using 250–500 mL D5W
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EVIDENCED-BASED
PRACTICE
Comparison of Dopamine and Norepinephrine in the Treatment of Shock
Source: De Backer, D., Biston, P., Devriendt, J., Madl, C., Chochrad, D., Aldecoa, C., et al. (2010). Comparison of dopamine and norepinephrine
in the treatment of shock. New England Journal of Medicine, 362(9), 779–789.
DISCUSSION or norepinephrine as first-line vasopressor IMPLICATIONS FOR PRACTICE

Dopamine and norepinephrine are recom- therapy to restore and maintain blood This research has important significance
mended as first-line vasopressor medica- pressure. The results revealed that there to nurses working with clients in shock.
tions in the treatment of shock. This was no significant difference in the rate Knowledge of first-line vasopressor medi-
research was undertaken to explore the of death between clients with shock who cations and their side effects are important
ongoing controversy about whether one were treated with dopamine as the first- for the nurse to observe for in the client
medication is superior to the other. The line vasopressor agent and those who were taking dopamine and norepinephrine.
trial included 1,679 patients; 858 were treated with norepinephrine. However, Nurses need to assess for arrhythmias, es-
assigned to dopamine and 821 to norepi- the use of dopamine was associated with a pecially in clients taking dopamine.
nephrine. Clients with shock were ran- greater number of clients experiencing ar-
domly assigned to receive either dopamine rhythmias (24% vs. 12%).
(Broyles et al., 2007). Another extremely important consid- physician. The nurse is responsible for obtaining blood and
eration with the administration of vasopressor medications is urine specimens. Most clients in hypovolemic shock have
that significant tissue damage and even death (necrosis) can Foley catheters, and the nurse needs to closely monitor urine
occur if these medications, especially dopamine, are leaked output every 1 to 2 hours and provide Foley catheter care. Ex-
into the tissue. It is imperative for the nurse to monitor the cli- cept for the client whose hypovolemia is mild and is corrected
ent’s IV site closely for any signs of infiltration or extravasation quickly, the majority of clients in hypovolemic shock are
of the IV fluid into the skin and, if present, to take immediate critically ill and are in the intensive care unit for management
action to contact the physician and change the infusion site (Figure 6-3). The nurse monitors the cardiac rhythm of the
(Josephson, 2004). Central line administration rather than client, paying close attention to worsening tachycardia and
infusion through a peripheral vein is optimum and carries less for any arrhythmias or changes suggesting cardiac ischemia
risk of infiltration or extravasation. (inadequate coronary blood flow).
Clients with respiratory compromise or severely altered
Activity mental status are mechanically ventilated, and the nurse
Client activity will be as tolerated. If the client is experiencing needs to work with the respiratory therapist to ensure that the
weakness, safety will be a concern. The nurse needs to educate client’s endotracheal (ET) tube is suctioned frequently and
the client to ask for assistance with activity and positioning as free of kinks and safely secured from dislodgement. All clients
needed. Because the nurse’s goal is to encourage blood flow will have intravenous access and be receiving IV fluids, and
and adequate oxygenation to the client’s heart and brain, the the nurse is responsible for monitoring the IV site for infec-
client should be positioned with legs elevated above head tion or signs of infiltration. Appropriate care should be taken
and chest to allow gravity to assist with shunting of blood to
these vital organs or as ordered by the physician (Neighbors
& Tannehill-Jones, 2009). After adequate blood volume has
been restored and the client’s blood pressure has returned to
normal range, frequent position changes of the client every 1
to 2 hours is important to prevent pressure ulcers and to as-
sist in mobilization of lung secretions to prevent pneumonia
and improve the client’s comfort. The client in hypovolemic
shock will be on bed rest. As the client recovers, the physician
will order increased activity, such as dangling at bedside with
(© anDrew gentry/ShutterStock)
assistance, up in chair with assistance, and progressing to am-

bulating with assistance.
Nursing Management
Nursing management of the client in hypovolemic shock is
complex. The nurse observes the client for changes in vital
signs, paying special attention to blood pressure, heart rate, figure 6-3 Clients with hypovolemic shock are closely mon-
and pulse oximetry readings and reports changes to the itored in the intensive care unit.
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during administration of blood products to assess for infusion

reactions according to institutional policy. As previously men- BOX 6-1
tioned, the nurse must be alert to any signs of fluid overload QUeSTIONS TO ASK AND
as a result of the rapid administration of large amounts of IV OBSeRVATIONS TO MAKe WHeN
fluids. The nurse should slow the infusion and call the physi- COLLeCTING DATA: SUBJeCTIVe DATA
cian immediately if signs of distended neck veins, increased
respiratory rate, coarse respirations, decreased pulse oximetry, • Are you feeling light-headed, weak, or dizzy?
crackles on auscultation, or frothy sputum are present and • Do your hands or feet feel cold?
elevate the head of the client’s bed. • Are you having chest pain or shortness of
The client who is critically ill needs frequent position breath?
changes. If stable enough, the client is turned every 2 hours to • Do you feel anxious or have a feeling of im-
prevent skin breakdown. The nurse pads pressure points with pending doom?
pillows and makes sure tubes and lines are out from under the • Are you having chest palpitations?
client. The physician may order a pressure reduction mattress,
some of which are motorized and inflatable. The nurse may be
responsible for inflating and deflating this and ensuring that it
is working properly. Some of these units can be preset to auto Subjective Data
rotate the client from side to side at a set interval.
The nurse should allow adequate time for the client to The nurse will take a health history to assess for the symptoms
sleep between nursing interventions. Many clients in the in- the client is experiencing. Common subjective findings for hy-
tensive care setting experience serious sleep deprivation. This povolemic shock are feelings of light-headedness, rapid pulse,
lack of sleep can inhibit healing and even lead to delirium. and weakness. The client may report feeling cold. As the client’s
In addition to caring for the client, the nurse is also status deteriorates, she may report worsening anxiety, shortness
instrumental in allaying the client’s fears by frequent explana- of breath, and chest pain (Garretson & Malberti, 2007). The
tions of her actions, justification of procedures that are being client may express fear of the unknown or fear of death. She may
done, and reassuring the client as much as possible. The nurse have pain from the insertion of lines or tubes. Examples of ques-
is responsible for relaying information to the client’s family. tions that the nurse may ask to gather subjective information
It helps to have the client or close family member designate from the client with hypovolemic shock are listed in Box 6-1.
a member of the family to be the contact person for the ex-
tended family, and that contact person can relay the informa- Objective Data
tion to the rest of the family. The nurse must also abide by the A physical examination provides objective data to determine
client’s right to privacy, even for the client who is critically ill, the degree of hypovolemic shock. Common objective find-
and refer to the people listed on the client’s HIPAA list when ings are weak and thready pulse, cool and clammy skin, and
giving out information. hypotension. Early objective data include mild tachycardia
and mild hypotension. As the body decompensates, the cli-
ent becomes more tachycardic, hypotensive, and tachypneic
NURSING PROCESS (elevated respiratory rate). The client may be anxious at the
onset of the hypovolemia, but as she progresses into shock
Data Collection will become lethargic, and later unresponsive. Urinary output
The assessment of the client with hypovolemic shock consists diminishes early on, and in the later stages of hypovolemic
of collecting subjective and objective data to formulate nursing shock it is less than 10 mL/hr and appears concentrated. In
diagnoses for the client. The assessment process is not static, severe shock, cardiac arrhythmias and evidence of cardiac
but is continuous throughout the client’s care. The nurse re- ischemia on EKG may be evident (Garretson & Malberti,
vises the goals and changes the care plan based on the continu- 2007). Objective data the nurses assesses for in the client with
ous gathering of information while caring for the client. hypovolemic shock are listed in Box 6-2.
Nursing diagnoses for a client in hypovolemic shock include the following:

NurSiNg plaNNiNg/ NurSiNg
DiagNoSeS ouTComeS iNTerVeNTioNS raTioNale
Anxiety related to subjec- The client will verbalize a Provide emotional support to Demonstrating empathy and
tive sense of uneasiness decrease in the level of the client. concern for the client allevi-
and threat of death anxiety. ates anxiety.
Explain the treatment regimen Reducing a client’s knowl-
ordered by the physician. edge deficit leads to de-
creased anxiety.
Inform the client about diagnos- Being informed of status may
tic testing results. alleviate the client’s anxiety.
Explain all procedures before An explanation of procedures
they are performed. prior to performing them
helps alleviate anxiety.
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Deficient Fluid Volume The client will maintain a Administer IV fluids as ordered The administration of IV
related to active fluid vol- normal serum osmolal- by the physician. fluids aids in correcting the
ume loss ity and a systolic blood volume deficit and corrects
pressure of 90 mm Hg or hypotension.
greater. Administer blood products as Acute blood loss can result in
ordered. a fluid deficit and transfusion
can aid in correcting this.
Closely monitor the client’s uri- Oliguria indicates inadequate
nary output. fluid volume status and an
increased urinary output in-
dicates normalization of fluid
volume.
Encourage slow position Deficient fluid volume in-
changes during activity. creases the risk of orthostatic
hypotension, which increases
the risk of falls during activity.
Ineffective Peripheral Tis- The client will maintain a Administer oxygen as ordered to Ineffective tissue perfusion
sue Perfusion related to pulse oximetry of 94% or maintain normal pulse oximetry. causes cellular hypoxia; ad-
a decrease in circulating above and have palpable ministration of supplemental
blood volume peripheral pulses. oxygen can alleviate this.
Place client in supine, or modi- This position increases ve-
fied Trendelenburg position nous return to the client’s
if systolic blood pressure is brain, heart, and vital signs.
<80 mm Hg.
Administer vasopressors, as or- Vasopressor medications
dered by the physician. improve tissue perfusion by
reversing hypotension.
Evaluation: Evaluate each outcome to determine how it has been met by the client.
BOX 6-2 CLIeNT TEACHING

CLIeNT TEACHING
QUeSTIONS TO ASK AND
OBSeRVATIONS TO MAKe WHeN Hypovolemic Shock
COLLeCTING DATA: OBJeCTIVe DATA The client and family are taught to monitor and re-
• Obtain vital signs including temperature, port any changes in the client’s physical and mental
pulse, respiratory rate, and blood pressure. condition. When the client is able to get up from
• Note client’s pulse oximetry for evidence of the bed to chair or ambulate, the nurse will need
hypoxia. to inform the client and family that the client will
• Review the results of diagnostic testing includ- need to be up with assistance only and avoid quick
ing ABGs and lab tests. position changes to prevent orthostatic hypoten-
• Perform physical examination and assess client sion. The nurse informs the client and family of lab
for evidence of weak and thready pulses, cool and other diagnostic test results. The nurse educates
or clammy skin, peripheral edema, tachycar- the client on why frequent blood draws and me-
dia, and decreased capillary refill. chanical ventilation are necessary. When administer-
• Assess client for signs of respiratory distress ing vasopressors to an alert client with a peripheral
including elevated respiratory rate and periph- IV, the nurse educates the client on the potential
eral cyanosis. vesicant properties of the medication and to report
• Perform neurological exam and note any de- any discomfort at the IV site immediately. The client
creased level of consciousness. and family are educated regarding the plan of care
• Measure client’s urinary output and note any for hypovolemic shock and the role of the multiple
oliguria. tubes and lines used with a client who is critically ill.
• Analyze client’s EKG for any arrhythmias or The client’s family is taught the importance of good
ischemia. hand washing before touching the client.
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88021_ch06_ptg01_080_107.indd 87 12/28/11 5:27 PM
Cardiogenic shock is primarily found in older adults since

CARDIOGENIC SHOCK coronary artery disease affects the adult and older adult popu-
Cardiogenic shock is the term used to describe the hypo- lation. Obesity, diabetes, previous MI, or preexisting coronary
tension, cellular hypoxia, and inadequate tissue perfusion artery disease (CAD) and family history of CAD are risk fac-
resulting from decreased cardiac output as a result of cardiac tors for developing cardiogenic shock. Older adult female MI
disease, usually a major myocardial infarction (MI), also clients are more likely to develop cardiogenic shock than older
known as a heart attack. This condition has a 50% mortality adult male MI clients (Garretson & Malberti, 2007).
rate, and is the single most common serious complication of The most common cause of cardiogenic shock is acute
an acute MI (Garretson & Malberti, 2007). myocardial infarction (Garretson & Malberti, 2007). Cardiac
Regardless of the cause of the cardiogenic shock, the cell death as a result of interrupted coronary blood flow causes
severely reduced cardiac output leads to hypotension, cel- left ventricular failure resulting in hypotension and shock.
lular hypoxia, and organ damage and can eventually result in Generally, the myocardial infarction must be fairly severe to
organ failure and death. When the coronary arteries become cause cardiogenic shock. Other causes include cardiac tam-
hypoxic, the heart becomes hypercontractile and the work- ponade, severe mitral regurgitation, ventricular septal rupture,
load of the heart is increased. Hypotension also stimulates and cardiac arrhythmias. In extremely rare cases, medications
catecholamines, which further increase vasoconstriction and such as clopidogrel or metoprolol can cause this condition as
increase the cardiac workload and decrease the cardiac output well. Cardiac tamponade occurs when pressure against the
even more. The overworked pump becomes congested and pericardial sac or a buildup of fluid within the pericardium
blood backs up into the pulmonary circulation and conges- constricts the heart, decreasing filling of the cardiac cham-
tive heart failure results. The lack of normal cellular perfusion bers and severely limiting cardiac output. Ventricular septal
causes multiple organ failure and can lead to death. rupture is often a result of a severe myocardial infarction
Symptoms of cardiogenic shock are similar to those for involving the ventricular septum. Necrosis of these septal
hypovolemic shock and include cool, clammy skin, weak and cells causes weakness of the wall and rupture occurs, causing
thready peripheral pulses, tachycardia, increased respiratory mixing of the atrial and ventricular blood and severely limiting
rate, decreased urinary output, lower extremity edema, car- cardiac output, resulting in cardiogenic shock. Tachyarrhyth-
diac ischemic EKG changes, anxiety and possible feelings of mias with a very fast rate can result in cardiogenic shock if the
doom, chest pain, shortness of breath, and hypotension (Gar- rate is fast enough that the filling time during diastole is so
retson & Malberti, 2007). short that the heart cannot adequately fill and congestive heart
Treatment is multifactorial and is centered on restoring failure and shock result.
pump function and easing the workload of the heart. Phar- Regardless of the cause, inadequate ventricular function
macological modalities are used to treat the shock symptoms causes hypotension and decreased tissue perfusion. As the
and support the heart. In addition, treatments such as the client’s blood pressure falls, catecholamines (chemicals
insertion of an intra-aortic balloon pump or ventricular assist released by the adrenal gland in response to stress) such as
devices and even cardiac transplantation are performed to epinephrine and norepinephrine are released, causing va-
treat this condition. soconstriction and increasing systemic vascular resistance,
Cardiogenic shock occurs in approximately 5% to 10% which increases the workload of the heart. This increases the
of clients with an acute MI (Garretson & Malberti, 2007). oxygen demand of the cardiac muscle. But the reduced coro-
nary blood flow from the decreased left ventricular function
CRITICAL THINKING
Cardiogenic Shock
Amish families
When an Amish family member becomes ill and is
1. With cardiogenic shock, the priority is to re-
hospitalized, it is common for the extended family
store the client’s what?
to come and stay until the family member is dis-
2. List six different hospital departments that
charged. The Amish view illness as a disruption of
will collaborate in the care of the cardiogenic
the entire family unit.
shock client.
Although it may seem that they never leave,
3. Which staff member is the liaison between
having close family around is important to the
the entire team and is responsible for much
Amish client’s well-being and will decrease the cli-
of the communication when caring for a cli-
ent’s anxiety. It is important for nurses to consider
ent in cardiogenic shock?
that the more at ease the client feels, the faster she
4. The dietitian may see the client in consult
can start to heal. The nurse should try to incorpo-
and do teaching about what?
rate the Amish client’s family into some of the care
5. What type of rehabilitation will be ordered
if possible. For example, an elderly Amish female
client may feel more comfortable having a family for a client recovering from cardiogenic
member bathe and dress her and comb her hair. shock?
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of ventricular septal rupture or cardiac tamponade. A chest

BOX 6-3 x-ray may identify a cause of cardiac tamponade or show
CLINICAL MANIfeSTATIONS evidence of cardiomegaly (enlarged heart), which raises the
Of CARDIOGeNIC SHOCK suspicion of valvular disease or cardiomyopathy as a precipi-
tating factor. Cardiac output measurements gauge improve-
• Low urine output (less than 10 mL/hr) ment or worsening of the client’s status. CVP measurements
• Hypotension (systolic BP less than 80 mm Hg, guide the physician in deciding whether or not to administer
or 30 mm Hg below client’s baseline) IV fluids. Lab work such as hemoglobin and hematocrit can
• Tachycardia demonstrate anemia, which may be corrected with blood
• Hypothermia transfusion if present since anemia can result in coronary
• Elevated respiratory rate hypoxia and aggravate coronary artery disease or a hypoper-
• Decreased pulse oximetry fusion state. Electrolyte levels are drawn because imbalances
• Ischemic changes on EKG can be the cause of serious arrhythmias that can result in
• Cool pale extremities
cardiogenic shock.
• Anxiety and restlessness in the early stages
• Altered mental status in the later stages
Diet
• Cyanosis of extremities and circumoral areas Diet is as tolerated. If the client is critically ill, she will likely be
• Jugular venous distention (JVD) NPO (nothing by mouth) and may be on a ventilator. In this
• Shortness of breath
case, the client receives tube feedings. A dietitian is consulted
to determine the client’s caloric needs and which tube feeding
• Weak thready peripheral pulses
is best for the client. The nurse is responsible for administer-
ing the feedings, assessing for intolerance such as vomiting or
abdominal distention, and checking for appropriate tube place-
ment. Another option for the ventilated client is total parenteral
results in hypoxia of the cardiac cells and worsens the cascade. nutrition (TPN). This is an intravenous infusion of electro-
The cardiac cells that are hypoxic are then able to pump even lytes, lipids, vitamins, and minerals, and full caloric intake for
less effectively and congestive heart failure symptoms as well 24 hours for the client. TPN is infused through a central venous
as symptoms of pulmonary edema begin to appear in the cli- catheter or central line catheter. Less critically ill clients who are
ent. Eventually, the other organs also become hypoxic, pro- alert enough to eat will be on a low-fat, low-sodium diet.
gressing to organ failure and possible death.
Common early signs and symptoms of cardiogenic shock
are mild tachycardia, slight decrease in the client’s blood Pharmacological
pressure, decreased urinary output, anxiety, and restlessness. Medications are used as a first-line treatment method
Later signs include weak, thready peripheral pulses, peripheral (Table 6-5). Inotropes (medications increasing the contrac-
edema, cool extremities, and cyanosis of the extremities and tility of the heart) and vasopressors are the most commonly
circumoral areas. Other signs include worsened tachycardia used. Inotrope medications include dopamine hydrochloride
and hypotension, increased respiratory rate, cardiac arrhyth- (Dopamine) and dobutamine hydrochloride (Dobutrex).
mias, and EKG evidence of cardiac ischemia. Reports of Milrinone lactate (Primacor) is also used but may cause wors-
shortness of breath and chest pain are common. As the shock ened hypotension and is used with caution. Vasopressors used
worsens the client’s level of consciousness will fall and eventu- include phenylephrine hydrochloride (Neo-Synephrine) and
ally the client becomes unresponsive. Box 6-3 lists the clinical norepinephrine (noradrenaline) or norepinephrine bitar-
manifestations of cardiogenic shock. trate (Levophed). In certain clients, vasodilator medications
If the client has a pulmonary artery catheter (Swan-Ganz including nitroglycerin or sodium nitroprusside are used be-
catheter) in place for cardiac output monitoring, the cardiac cause severe vasoconstriction causes the heart to work harder
output will generally be less than 2.2 L/min compared to a during pumping, and a small amount of vasodilators may
healthy client’s 4 to 8 L/min. The central venous pressure improve the heart’s pumping ability significantly.
(CVP) reading is elevated due to venous congestion from the For a client with early MI-induced cardiogenic shock, a
congestive failure (Garretson & Malberti, 2007). thrombolytic such as a tissue plasminogen activator (TPA)
is used in a select group of clients because reperfusion of the
blocked coronary artery improves the heart’s ejection frac-
Medical-Surgical tion. Typically this type of medication is useful only before the
Management client is in significant shock.
Other modalities such as percutaneous thrombolytic
Medical coronary angioplasty (PTCA) may be used at the onset of an
The treatment of cardiogenic shock centers around identi- acute MI to restore blood flow to the affected coronary artery
fying the cause because this must be identified before the and improve the heart’s contractility. As an alternative, emer-
shock can be corrected. Table 6-4 lists common diagnostic gency coronary artery bypass surgery (CABG) also provides
testing used in the care of the client with cardiogenic shock. significant enough coronary artery reperfusion to restore the
All clients are placed on oxygen. An EKG tracing and tropo- heart’s pumping ability and bring the client out of cardiogenic
nin level (cardiac enzyme released during cardiac cell death, shock. Study results have shown similar survival outcomes be-
marker for acute MI) can be obtained to identify a myocar- tween PTCA and CABG (Garretson & Malberti, 2007).
dial infarction as the cause of the shock. An echocardiogram In a client who is severely ill, insertion of an intra-aortic
provides evidence as to valvular function or shows evidence balloon pump (IABP) is used to improve ventricular function
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Table 6-4 Common Diagnostic Tests for Cardiogenic Shock

ABG Measures the dissolved oxygen, carbon dioxide, pH, and pH 7.35–7.45
bicarbonate levels of arterial blood. pO2 75–100 mm Hg
pCO2 35–45 mEq/L
HCO3 22–26 mEq/L
Cardiac catheterization Catheter is inserted into femoral artery and threaded into No atherosclerotic plaques
client’s heart. Injection of dye outlines stenotic areas in coro- or stenosis noted within the
nary arteries, providing an estimate of valvular function. coronary arteries. Ejection
fraction 50–75%.
Chest x-ray Provides a two-dimensional image of the lungs without using Lungs without evidence
contrast media. Used to detect the presence of fluid within of pulmonary edema. No
the interstitial lung tissue or the alveoli; tumors or foreign evidence of cardiomegaly or
bodies; and the presence and size of a pneumothorax. The widened mediastinum.
size of the heart can also be determined by chest x-ray.
Echocardiogram Ultrasound placed on chest wall obtains sonographic picture Ejection fraction 50–75%.
of client’s heart valves and cardiac output. No significant valvular
disease.
Electrolytes Measures levels of the most common minerals within the Sodium 136–145 mEq/L
blood: sodium, potassium, calcium, chloride, magnesium, Potassium 3.5–5.5 mEq/L
and phosphate. Calcium 8.5–10.5 mg/dL
Chloride 98–106 mEq/L
Magnesium 1.6–2.6 mg/dL
Phosphate 3–4.5 mg/dL
Hematocrit Measures percentage of RBC mass to whole blood volume. Men 40–54%
Women 38–74%
Hemoglobin Measures the amount of the oxygen-carrying capacity of the Men 14–18 g/dL
blood, protein attached to RBCs. Women 12–16 g/dL
Serum osmolality Measures the number of dissolved particles per unit of blood. 280–295 mOsm/kg H2O
Is an indicator of serum concentration (fluid status).
Troponin level Serum test measuring cardiac enzyme released into the <0.6 ng/mL

blood with cardiac injury, usually indicative of an MI.
WBC count Measures number of WBCs per milliliter of blood. Is an indi- 4.8–10.8 K/mL
cator of immune status and infection.
and perfusion. This is a catheter with a balloon attached to a pneumatic pump to circulate blood from the ventricle to the
the end that is inserted into the client’s femoral artery and aorta and assist the failing heart.
sits in the descending aorta. The balloon is connected to a
machine that inflates the balloon during systole to increase
perfusion to the coronary arteries and reduce systemic after- Activity
load (pressure in the vascular system against which the heart The client in cardiogenic shock with significant hypotension
has to pump). is placed either in supine, a modified Trendelenburg position,
In the most severely ill clients in whom death is imminent or passive leg elevation (Bridges & Jarquin-Valdivia, 2005). If
and cardiac function is severely diminished, a left-ventricular the client is hemodynamically stable, has any symptoms of pul-
assist device (LVAD) is inserted to aid the heart’s pumping monary congestion or respiratory distress, and has significant
power while the client awaits cardiac transplantation. This lower extremity edema, care is taken to not elevate the legs,
unit is attached to the client’s left ventricle and aorta and uses which can lead to rapid venous return of the fluid in the legs
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Table 6-5 Common medications used in the Treatment

of Cardiogenic Shock
meDiCaTioN DoSage aCTioN
dopamine hydrochloride (Intropin) 5–20 mcg/kg/min Inotrope/vasopressor

dobutamine hydrochloride (Dobutrex) 2–40 mcg/kg/min Inotrope
milrinone lactate (Primacor) 0.375–0.75 mcg/kg/min Phosphodiesterase inhibitor
norepinephrine (Noradrenaline) 2–30 mcg/kg/min Catecholamine

phenylephrine (Neo-Synephrine) IV: 10 mg by continuous IV infusion Vasopressor
using 250–500 mL D5W
nitroglycerin (Nitrostat) 5 mcg/min–200 mcg/min Vasodilator
nitroprusside sodium (Nitropress) 0.5–5 mcg/kg/min Vasodilator
back to the already congested heart and pulmonary system and endotracheal tube and for suctioning when needed. The nurse
worsen the client’s dyspnea. The client is repositioned every 1 collaborates with respiratory therapy to make sure the ventila-
to 2 hours with the pressure points padded with pillows. tor settings are as prescribed and that the endotracheal tube is
When the client is in active cardiogenic shock, bed rest is in the correct position.
ordered. When the client is hemodynamically stable, some of The prevention of skin breakdown is essential, and the
the lines are removed and the client is extubated. Then the cli- nurse will reposition the client every 1 to 2 hours to prevent
ent is assisted out of bed to a chair and eventually ambulated skin breakdown and worsening respiratory status. If alert, the
with assistance. client will likely be anxious and the nurse needs to provide
emotional support. The nurse is significantly involved in
Nursing Management communication with the family and in educating them about
what is going on with the client. The nurse monitors the client
Caring for the client in cardiogenic shock has multiple re- for adverse reactions to any prescribed medications, such as
sponsibilities. The nurse assesses the client for changes in vital worsening tachycardia as a side effect of dopamine or of any
signs that signify worsening or improving status and relates extravasation of the client’s IV site. If the client has vasopres-
the changes to the physician. Frequent measurements of sors running through a peripheral IV, the nurse monitors the
blood pressure, heart rate, and respiratory rate are performed. IV site closely for infiltration.
The majority of clients in cardiogenic shock have invasive If the client has had an IABP inserted, the nurse is respon-
monitoring lines such as an arterial line (a catheter inserted sible for dressing the insertion site according to institutional
in the radial artery in the wrist with a sensor measuring the policy, usually every 72 hours. She will need to observe the site
client’s blood pressure), and blood pressure measurements for any evidence of infection or bleeding and closely monitor
are recorded continuously. The nurse monitors pulse ox- peripheral pulses for evidence of occlusion because the cath-
imetry for changes in oxygen level and makes sure that the eter sits in the descending aorta and may cause occlusion of
client is receiving the prescribed amount of oxygen. Clients peripheral circulation.
who are severely ill are mechanically ventilated, and the nurse The client who has an LVAD needs meticulous insertion
is responsible for monitoring for kinking or clogging of the site care and sterile dressing changes according to institutional
policy. The nurse needs to monitor the settings on the LVAD
CRITICAL THINKING console to ensure that the device is working properly. Most
LVAD units have a clear area on the pneumatic hose and the
Complications nurse is responsible for assessing this area for clots.
of Cardiogenic Shock Clients in cardiogenic shock require frequent monitoring
of intake and output. Most clients have Foley catheters and the
nurse needs to provide catheter care according to institutional
1. List two major complications of cardiogenic policy. Frequent monitoring of urinary output, often every 1 to
shock. 2 hours, is required and is a good indicator of renal perfusion.
2. What does hypoxia to the brain lead to?
3. Inadequate perfusion to the kidneys can lead
to renal failure as well as activation of which NURSING PROCESS
hormone that further causes salt retention
and lower extremity edema, worsening the
Data Collection
client’s congestive heart failure? The assessment of the client in cardiogenic shock consists of
4. Inadequate perfusion to the gut can lead to
collecting and analyzing both objective and subjective data
about the client’s status. The assessment is a continuous pro-
what?
cess as the nurse reformulates and revises nursing care based
on changes in the client’s status.
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BOX 6-4 BOX 6-5
QUeSTIONS TO ASK AND QUeSTIONS TO ASK AND
OBSeRVATIONS TO MAKe WHeN OBSeRVATIONS TO MAKe WHeN
COLLeCTING DATA: SUBJeCTIVe DATA COLLeCTING DATA: OBJeCTIVe DATA
• Are you feeling anxious or fearful? • Monitor vital signs including temperature,
• Are you blaming yourself for your condition? pulse, respiratory rate, and blood pressure.
• Are you noting any light-headedness or • Assess the client’s pulse oximetry reading.
dizziness? • Monitor the EKG tracing.
• Do you have a headache? • Review and report ABG results.
• Do your hands or feet feel cold? • Analyze diagnostic lab test results includ-
• Do you notice any shortness of breath? ing chest x-ray, echocardiogram, and cardiac
• Are you having any chest pain or tightness? catheterization.
• How much do you understand about the • Perform a physical exam including breath
current disease process and your plan of sounds, heart sounds, and warmth and color
care? of extremities, presence of peripheral pulses,
• Do you feel rested in the mornings? urinary output, and capillary refill.
Subjective Data Objective Data

Subjective data are gathered during the nursing health his- The nurse gathers objective data about the client (Box 6-5).
tory and the head-to-toe assessment (Box 6-4). The client This includes information about the client’s blood pressure
in cardiogenic shock often feels anxious and fearful and is and how she is responding to medications. The nurse moni-
encouraged to express these feelings and concerns. Physical tors the client’s urinary output for increase or decrease and
symptoms that the client may verbalize include feelings of assesses the skin for actual breakdown. The nurse palpates
light-headedness, dizziness, and of feeling cold. The client the client’s peripheral pulses for evidence about perfusion and
may report having chest pain or chest pressure. If the client assesses the skin for color and temperature. The client’s pulse
is receiving IV nitroglycerin, she may mention a headache oximetry data and ABGs provide information regarding tissue
because this is a common side effect of nitroglycerin. As symp- hypoxia. Urinary output is monitored every 1 to 2 hours to
toms escalate the client may experience shortness of breath or assess renal perfusion.
feelings of doom.
CLIeNT TEACHING
CLIeNT TEACHING
Cardiogenic Shock
The client and family are educated regarding the importance of slow position changes to minimize the ortho-
static blood pressure changes that may occur. The nurse will discuss the rationale about the medical treatment
the client is receiving such as why the client is positioned a certain way and the need for IV fluids or monitoring
lines. The client and family will have questions about the risk or side effects of invasive lines and why so many are
necessary. Often, monitor alarms are of concern and it is helpful if the nurse describes their function to the client.
The nurse teaches the client about how to use the call button and makes sure the family knows how to contact
her. Family members need to understand that rest is important, so the nurse encourages them to keep visits brief.
If the client has a balloon pump in place or an LVAD inserted, the client and family will have questions about
these devices and it is important to discuss safety measures such as avoiding cords on the floor and the impor-
tance of the “look but don’t touch” rule. The nurse will teach about the importance of good hand washing prior
to visiting and the need for family and friends to abstain from visiting if ill. If the client is ill enough to be placed
on the transplant list, she and her family will have many questions about the procedure, complications, and long-
term care. Often a transplant team person is involved in teaching and answering questions regarding this, but the
client’s nurse will undoubtedly need to answer some questions for the client’s family as well. It is important for
the client and family to understand the long-term side effects of transplant medications and the need for long-
term compliance and follow-up.
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Nursing diagnoses for a client in cardiogenic shock include the following:

Disturbed Sleep Pattern The client will get at least Organize care to minimize night- The more frequent the inter-
related to frequent night- 6 hours of sleep during time interruptions. ruptions, the less sleep the
time interruptions the night hours and will be client gets.
interrupted as infrequently Keep voice low when speaking Speaking loudly inhibits the
as possible. with colleagues in the hall and client’s sleep.
minimize extraneous noises.
If the client is not confused, Both of these interventions
keep the room lights dim and aid sleep.
door partially shut.
Decreased Cardiac Out- The client will maintain a Closely monitor vital signs for Subtle changes in the vital
put related to altered systolic blood pressure of changes and inform physician signs including blood pres-
heart rate/rhythm at least 90 mm Hg. so the client’s treatment regi- sure, heart rate, respiratory
men can be changed. rate, and pulse oximetry can
indicate decreased cardiac
output.
Administer IV fluids and vaso- These modalities help in-
pressors as ordered. crease the client’s cardiac
output.
Monitor client during activity These symptoms are in-
for tachycardia, shortness of dicative of decreased cardiac
breath, and decreased blood output.
pressure.
Excess Fluid Volume The client will not develop Closely observe client for in- These are symptoms of fluid
related to compromised evidence of pulmonary creased respiratory rate, de- volume excess that need to
regulatory mechanism edema such as increased creased pulse oximetry, increased be communicated to the
respiratory rate, rales on edema, crackles on auscultation physician.
pulmonary exam, short- of lung sounds, and JVD.
ness of breath, and de- Administer diuretics as ordered. Diuretics help reduce the
creased pulse oximetry. blood volume and treat pul-
monary edema and conges-
tive heart failure symptoms.
Teach client about the impor- Excess salt intake increases
tance of a low-sodium diet. fluid retention.
SEPTIC SHOCK Although a client’s central nervous system (CNS) would nor-
mally respond to hypotension by stimulating the CNS, the
Septic shock is an inflammatory cascade of events that is significant amount of hypoxia caused by the sepsis renders the
caused by endotoxins released from bacteria within the body brain unable to do this.
that results in hypotension, hypoperfusion, and hypoxia. The terms sepsis and septic shock are often used inter-
There are many different potential sources of sepsis-causing changeably. Generally, the term sepsis refers to a state of wide-
infection, including the blood, bone, cardiovascular system, spread infections in which a client’s inflammatory responses
gastrointestinal system, urinary tract, pulmonary system, and are mediated and a cascade of events occurs that, if not cor-
soft tissue as well as central nervous system. Box 6-6 lists the rected, results in shock that is termed septic shock because
top 10 sources of septic shock infections. During the septic the initial infection was the cause. Septic shock is sepsis that
process, bacteria release endotoxins into the bloodstream has progressed to the point that the client is experiencing sig-
and an inflammatory cascade is triggered that causes general- nificant and persistent hypotension, systemic hypoperfusion,
ized inflammation throughout the body, interstitial edema, and circulatory failure despite adequate resuscitation efforts
hypotension, and ultimately decreased cellular perfusion and (Wood, Lavieri, & Durkin, 2007).
hypoxia (Figure 6-4). Clotting mediators are also released, A client’s risk of sepsis increases with age, and thus ad-
increasing the client’s risk of stroke or of peripheral embolus. vanced age is a risk factor for developing sepsis. Other clients
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significant sepsis the body cannot reset itself to maintain ho-

BOX 6-6 meostasis and shock results. Mild sepsis is generalized infec-
TeN SOURCeS Of SePTIC tion that is not characterized by symptoms of shock. Severe
SHOCK INfeCTIONS sepsis is sepsis that results in shock and is characterized by
hypotension, widespread hypoperfusion, and organ failure.
1. Blood: bacteremia Symptoms of organ failure include low urinary output, mental
2. Bone: osteomyelitis status changes, metabolic acidosis noted on ABGs, abnormal
3. Cardiovascular system: endocarditis and liver function testing and ascites, significant hypotension, and
pericarditis hypoxemia.
4. Central nervous system: meningitis The widespread inflammatory response cascade found in
5. Pulmonary: pneumonia sepsis starts with the SIRS. Endotoxins released from the bac-
6. Invasive lines: central venous catheters, Swan- teria causing the infection enter the bloodstream and stimulate
Ganz lines, arterial lines, IABP catheters the SIRS. White blood cells and cytokines are stimulated and
7. Soft tissue: cellulitis and wound infections
trigger vasodilation and abnormal capillary permeability, the
activation of neutrophils, and the aggregation and adhesion
8. Intra-abdominal: diverticulitis, appendicitis,
of platelets to the endothelium. This results in widespread
peritonitis, perforated bowel, ischemic bowel hypotension and edema and is responsible for the fever and
9. Surgical wounds: incisions, deep abscesses microthrombi found in the client with sepsis. The sympathetic
10. Urinary tract: urinary tract infections, kidney nervous system is triggered by the baroreceptors in the carotid
infections, catheter-related infections arteries and aorta, and epinephrine and norepinephrine are
released, resulting in vasoconstriction. Because of the body’s
tendency to shunt blood to the core organs such as the heart
at risk are newborns, infants, and those who are immuno- and brain, the extremities become cool and clammy. The
compromised, malnourished, debilitated, or have diabetes. blood is also shunted away from the GI tract, skin, lungs, and
Approximately 750,000 people have sepsis annually in the kidneys. The decreased renal perfusion stimulates the renin-
United States, and almost 215,000 of those clients do not sur- angiotensin system and aldosterone is released, causing further
vive (Wood et al., 2007). Sepsis holds a 40% to 50% mortality sodium retention and temporarily maintaining the client’s
rate despite advances in antibiotic and medical therapy. blood pressure until the body can no longer compensate.
The initial inflammatory cascade involved in sepsis is Early symptoms of septic shock include warm, flushed
termed the systemic inflammatory response syndrome (SIRS) skin, fever above 100.4°F (38°C), mild tachycardia, and el-
and generally acts to maintain homeostasis. However, during evated respiratory rate above 20 breaths/min, and a WBC
count lower than 4,000 or greater than 10,000 (Table 6-6).
At this point the client’s blood pressure and pulse oxim-
etry are usually normal. As sepsis progresses the client may
become anxious, start to show mild hypotension, hypoxia,
higher fever, and more significant mental status changes.
Tachycardia worsens and metabolic acidosis occurs. As the
sepsis progresses into septic shock, the client exhibits severe
tachycardia, cool and clammy extremities, weak and thready
peripheral pulses, and significant hypotension as well as hy-
poxia and respiratory distress. The client may be unresponsive
and have minimal urine output. Complications of septic shock
include end-organ failure or organ damage. This includes
damage to the brain, heart, lungs, liver, abdominal organs, and
kidneys. The most significant complication is death.
Complications of treatment include adverse reactions to
antibiotics administered resulting in renal failure or allergic
reactions. Clostridium difficile colitis is a common complica-
tion from the use of broad-spectrum antibiotics. Oral thrush,
vaginal candidiasis, and yeast in the urine can result from the
use of broad-spectrum agents.
Medical-Surgical
Management
(© rainDrop/ShutterStock)
Medical
Finding and treating the cause of septic shock is essential to
the client’s long-term prognosis. Infectious disease specialists
may be asked to consult on the case and assist the primary
physician. The primary course of treatment is intravenous
figure 6-4 The client with septic shock experiences signifi- antibiotics, fluid resuscitation, and vasopressors as well as
cant and persistent hypotension. supplemental oxygenation. The treatment of sepsis centers
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Table 6-6 Common Diagnostic Tests for Septic Shock

ABG Measures the dissolved oxygen, carbon dioxide, pH, pH 7.35–7.45

and bicarbonate levels of arterial blood. pO2 75–100 mm Hg
pCO2 35–45 mm Hg
-
HCO3 20–26 mEq/L
Blood cultures Two separate venous samples are drawn and exam- No bacterial growth noted.
ined for the presence of bacteria.
BUN Measures the amount of BUN (a chief end product of 5–20 mg/dL
protein metabolism) in serum. Is an indicator of renal
function and fluid status.
Complete blood count (CBC) Measures serum hemoglobin, hematocrit, platelet Hemoglobin:
count, and WBC count. Men 14–18 g/dL
Women 12–16 g/dL
Hematocrit:
Men 40–54%
Women 38–47%
Platelet count:
150–450 K
White blood cell count:
4.8–10.8 K/mL
Creatinine Measures the amount of creatinine in serum. Is an indi- Men 0.8–1.8 mg/dL
cator of renal function and fluid status. Women 0.6–1.6 mg/dL
EKG Noninvasive testing that measures the electrical activity Normal sinus rhythm, no
of the heart and records the heart rhythm. arrhythmias.
Lactate dehydrogenase (LDH) Serum specimen is examined for presence of LDH, 48–115 units/L
which is indicative of tissue ischemia, necrosis, or
acidosis.
Partial thromboplastin time Serum test that identifies abnormalities in clotting 60–70 sec
(PTT) pathway.
Prothrombin time (PT) Serum test measuring the time to form a fibrin clot. 10–13.4 sec

Urinalysis with culture Evaluates urine for evidence of infection, provides Leukocyte esterase-negative
urine-specific gravity indicating urine concentration. WBC less than 4–5 per field
Specific gravity 1.010–1.030
around identifying the cause and treating the pathogen as because of the significant tachycardia it can cause at the dose
specifically as possible while supporting the body’s circulatory often required for significant vasoconstriction. As a rule,
and respiratory symptoms. vasoconstrictors should not be initiated until hypovolemia
Initially, broad-spectrum antibiotics are administered, is corrected, or decreased organ perfusion may occur (Gar-
but the therapy will later be altered according to blood culture retson & Malberti, 2007). Some low-dose vasodilators such
and sensitivity results. Clients with sepsis receive a combi- as nitroglycerin or nitroprusside are administered to lower
nation of antibiotics to cover aerobic as well as anaerobic systemic vascular resistance (SVR) if high SVR is considered
bacteria and provide some cross-sensitivity to guard against to be a contributor to the client’s low cardiac output.
resistant infections. It is not uncommon for a client’s tempera- Generally, a large-access intravenous line, such as a
ture to spike even more after antibiotics have been started as central venous catheter, is inserted to allow for multiple IV
even more endotoxins are released from the bacteria. medications to be given and to allow blood to be drawn from
Vasopressors are given to help correct hypotension. the line. Critically ill clients with sepsis have an arterial line
These include dopamine hydrochloride (Dopamine), nor- inserted for continuous blood pressure monitoring as well
epinephrine bitartrate (Levophed), phenylephrine hydro- as ABG monitoring. Other invasive lines include numerous
chloride (Neo-Synephrine), and epinephrine (Adrenaline). peripheral IV sites and a pulmonary-artery (Swan-Ganz) line,
Dopamine hydrochloride (Dopamine) is used with caution which directly measures fluid status by measuring pressures in
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CRITICAL THINKING
BOX 6-7
NURSING CONSIDeRATIONS
Anxiety fOR THe ADMINISTRATION
Of DROTReCOGIN ALfA
• Must be administered through a dedicated IV
Clients in septic shock may experience anxiety, a
catheter without concomitant administration
sense of uneasiness, or feelings of doom related
of any other fluids.
to their deteriorating health condition or threat
• Must be administered at a continuous rate of
of death.
24 mcg/kg/hour for 96 hours.
1. How does the nurse assess a client for
• Nursing personnel need to ensure that a
anxiety? screening checklist is completed prior to ad-
2. What subjective and objective signs and
ministration to identify clients with contrain-
symptoms are indicative of anxiety? dications to administration. High-risk clients
3. Write three questions that the nurse could
include those with recent hemorrhagic stroke,
ask a client to assess for anxiety. active or recent internal bleeding, those with
4. What are five things that the nurse can do to
recent trauma with increased risk for bleeding,
decrease a client’s anxiety? and clients who have an epidural catheter.
• Must be administered through an IV infusion
pump.
• Infusion must be discontinued 2 hours prior to
the heart. This provides information about the client’s cardiac
output and venous oxygen level. any procedure carrying risk of bleeding such
Most clients have Foley catheters, and urinary output is as surgery or insertion of invasive lines.
closely monitored. Clients who are critically ill are often me- • The infusion may be resumed 2 hours after a
chanically ventilated and pulse oximetry and ABG readings are minor procedure or 12 hours postoperatively
frequently assessed. All clients receive supplemental oxygen, for a major procedure/surgery.
which is titrated according to pulse oximetry and ABG readings. (Adapted from Garretson & Malberti, 2007)
Diagnostic data obtained include blood cultures, CBC, com-
plete chemistry, and ABGs. Generally, two sets of blood cultures
are obtained with a 15-minute interval so that bacterial growth
can be measured. Aerobic as well as anaerobic cultures are ob- are avoided because of their immunosuppressive effects (Gar-
tained. The client’s cardiac rhythm is monitored and if ischemia retson & Malberti, 2007). Methylprednisolone (Solu-Me-
is suspected an EKG is obtained and cardiac enzymes are drawn. drol) is the steroid of choice and is administered IV every 6
A chest x-ray assesses for pulmonary causes of infection. to 8 hours.
Another recent advance in the treatment of clients with
Surgical septic shock is the development of the drug drotrecogin
alfa (Xigris), a recombinant activated protein C that has
If the client is a postsurgical client, wound cultures are immunoglobulin-like effects and is given to severely ill clients
obtained. If a surgical incision or wound is considered the with sepsis who are at risk for death. This protein seems to
source, the incision may be opened up to expose the source of interrupt the sepsis-associated coagulopathy associated with
the infection. If a surgical implant such as an artificial knee is severe sepsis but is reserved for the most critically ill clients
considered the source, this may also be removed. because of its side effects. The side effects include a signifi-
cantly increased risk of bleeding, so it is contraindicated in
Diet clients with active or recent internal bleeding, recent hemor-
The diet for a client with sepsis is usually as tolerated without rhagic stroke, presence of an epidural catheter, or trauma.
any specific restrictions. Special nutritional needs do exist Nursing considerations for administering drotrecogin alfa are
for the client who is critically ill and unable to take oral fluids listed in Box 6-7.
because of being unresponsive or mechanically ventilated and
may include TPN or tube feedings. Caloric needs are often Activity
even higher than normal in these clients, especially as meta- A client who is critically ill will be placed on bed rest. If he-
bolic needs are higher when clients are febrile, so dietitian modynamically unstable, the client will be placed in supine,
input is helpful in determining the dietary needs for the client a modified Trendelenburg position, or passive leg elevation
or to calculate feeding tube or TPN rate/concentration. (Bridges & Jarquin-Valdivia, 2005). Clients on bed rest are
repositioned every 1 to 2 hours to prevent pressure ulcers
Pharmacological and stasis of lung secretions, which would increase the risk
Glucocorticoids are used in the septic client because of the of pneumonia. The client recovering from sepsis is weak and
anti-inflammatory effects that they possess. Typically, low- may require physical therapy. Assistance will be needed when
dose glucocorticoids are used and high-dose glucocorticoids getting out of bed to a chair and ambulating.
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Nursing Management BOX 6-8

The nursing management of the client in septic shock is com- QUeSTIONS TO ASK AND
plex. The nurse observes the client for subtle changes in vital OBSeRVATIONS TO MAKe WHeN
signs that could indicate worsening of health status, paying COLLeCTING DATA: SUBJeCTIVe DATA
special attention to blood pressure, heart rate, and pulse ox-
imetry readings as well as the client’s temperature. The nurse • Do you feel abnormally cold or warm?
is responsible for collecting blood and urine specimens. Blood • Do you feel anxious or fearful?
cultures are obtained from indwelling intravenous catheters, • Do you feel weak or dizzy?
including peripheral IV lines and central lines, and are also • Do you know what type of infection caused
drawn from the client to rule out any source of contamination your sepsis?
or infection in the intravenous lines.
• How much do you understand about your cur-
The nurse is responsible for changing IV site dressings ac-
cording to institutional policy and obtaining ABG specimens. rent disease process?
The client who is critically ill is likely to be ventilated and the • Do you have questions about your current
nurse is responsible for measuring oxygen status as well as treatment regimen?
observing for any kinks in the endotracheal tubing. The nurse
works with respiratory therapy staff for suctioning and repo-
sitioning of the ET tube. Frequent oral care is necessary if the
client is intubated. BOX 6-9
All clients with septic shock have a Foley catheter and
need urinary output measured every few hours to assess fluid QUeSTIONS TO ASK AND
status. Proper Foley catheter care is important to prevent OBSeRVATIONS TO MAKe WHeN
catheter-related infections. Adequate rest is necessary so the COLLeCTING DATA: OBJeCTIVe DATA
nurse should allow adequate time for the client to sleep be-
• Obtain vital signs including temperature,
tween interruptions if possible.
pulse, respiratory rate, and blood pressure.
• Note client’s pulse oximetry readings for evi-
NURSING PROCESS dence of hypoxia.
• Review results of diagnostic testing including
Data Collection ABGs, EKG tracings, chest x-ray, and lab tests
The assessment of the client with septic shock includes col- (see Table 6-6, Common Diagnostic Tests for
lecting subjective and objective data to create nursing diag- Septic Shock).
noses and plan care for the client. The assessment process is • Perform a physical examination of client
not limited to first contact with the client, but is continuous including:
and needs to be revised as necessary according to the client’s • Color and temperature of the skin
responses to the nurse’s plan and the client’s change in health
• Skin turgor
status. The nurse revises the plan of care and changes the cli-
ent’s goals based on the subjective and objective data gathered • Level of consciousness
while caring for the client. • Lung sounds
• Heart sounds
Subjective Data • Presence of peripheral pulses
• Capillary refill
Subjective data gathered includes client statements of symp-
toms experienced as a result of the septic shock (Box 6-8).
Common subjective findings indicative of septic shock in-
clude feelings of being chilled, warm, and anxious. As the findings include a bounding pulse during the hyperdynamic
shock progresses and hypotension begins, the client may re- phase of septic shock before hypotension sets in. If the client
port feeling weak and dizzy and will have cold extremities and has a pulmonary-artery catheter, the cardiac output is initially
a rapid pulse. As the client’s condition deteriorates, the client elevated above the normal 4 to 8 L/hr and then eventu-
may verbalize feelings of doom and worsening anxiety. Other ally drops and becomes very low as the client’s septic shock
subjective data that the nurse can inquire about to formulate progresses.
her plan of care include information about the client’s under- As the shock progresses, the client will have weak thready
standing of her disease process and current regimen. pulses, cool and clammy extremities, decreased level of con-
sciousness, and worsening hypotension. Tachycardia worsens
Objective Data and low urine output, generally less than 10 mL/hr, occurs.
Objective data are gathered by completing a physical exam If the septic shock progresses to severe, the client becomes
and reading the client’s monitors (Box 6-9). Early on, data re- unresponsive, the pulse oximetry shows hypoxia, and arterial
veal mild tachycardia and temperature elevation. Assessment blood gases indicate acidosis.
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Nursing diagnoses for a client in septic shock include the following:

Activity Intolerance related The client’s pulse oximetry Assess for signs of hypotension Activity increases oxygen
to imbalance between and cardiac output will not or hypoxia and defer activity if demand and will worsen hy-
oxygen supply/demand decrease as a result of present. potension and hypoxia.
activity. Balance the client’s activity with This improves the client’s ac-
rest periods. tivity tolerance.
If the client demonstrates hy- Signs of activity intolerance
poxia, hypotension, or weakness are increased hypoxia, hypo-
during activity, the activity should tension, and client weakness.
be discontinued. When these signs appear, cli-
ent activity is stopped.
Ineffective Thermoregula- The client will maintain a Administer antipyretics if the cli- Fever increases metabolism
tion related to illness and normal body temperature. ent is febrile. and oxygen demands.
trauma Monitor for hypothermia and use Hypothermia increases pe-
warming blankets as ordered by ripheral vasoconstriction,
the physician to maintain a nor- which decreases tissue
mal body temperature. perfusion.
Closely monitor the client’s Clients with septic
temperature. shock exhibit ineffective
thermoregulation.
Ineffective Peripheral Tis- The client will maintain a Place the client in supine, a modi- This increases perfusion to
sue Perfusion related to systolic blood pressure of fied Trendelenburg position, or the brain, heart, and lungs,
trauma >90 mm Hg and will main- passive leg elevation if systolic which are the vital organs.
tain palpable peripheral blood pressure is <80 mm Hg.
pulses and normal pulse Administer oxygen as ordered to This helps correct hypoxia
oximetry readings. maintain normal pulse oximetry induced by diminished tissue
and ABGs. perfusion.
Administer vasopressors as Maintaining a normal blood
ordered. pressure improves tissue
perfusion.
CLIeNT TEACHING
CLIeNT TEACHING
Septic Shock
A significant amount of education is needed for a client in septic shock and the family. The nurse teaches about
the expected plan of care and potential side effects of the antibiotics and keeps the client and family apprised of
lab results and how therapy will be altered accordingly. The nurse also discusses potential complications of septic
shock. If the physician has ordered drotrecogin alpha, the nurse needs to discuss the potential side effects with
the client or the client’s family if the client is incapacitated. An explanation is given to the family as to the need
for several invasive lines and numerous diagnostic tests.
The need for adequate sleep, keeping visiting to an appropriate time, and the need for thorough hand wash-
ing are explained.
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CASE STUDY
The Client with Septic Shock
A 52-year-old female, B.B., arrives at the emergency department in a downtown Los Angeles hospital with
complaints of a low-grade fever for the past few days as well as a cough, shortness of breath with exertion,
and purulent sputum. She was driven by her daughter. She has been a one-pack-per-day smoker for the
past 25 years. Her health history includes recurrent bronchitis approximately two times per year for the
past few years, type 2 diabetes, obesity, and hypertension. She also has rheumatoid arthritis. Her current
medications are metoprolol 50 mg daily, metformin 500 mg bid, hydrochlorothiazide 25 mg daily, Altace
5 mg daily, ASA 81 mg daily, and Remicade infusions every 3 months. She does see a rheumatologist for
management of her rheumatoid arthritis. The client tells the triage nurse that she took her blood pressure
on her home monitor and noted that it was 88/46 mm Hg and that her heart rate was 110 just before leav-
ing home. Due to her light-headedness this morning she did not take either of her antihypertensives. She
ate a light breakfast and her fasting blood sugar upon awakening this morning was 356. She states that she
normally runs a fasting blood sugar of <150 mg/dL.
Subjective data gathered by the nurse include reports of shortness of breath at rest that is worsened
with activity, the client stating that she has a productive cough with yellow-green sputum, and pain in the
anterior chest with coughing. B.B. also feels light-headed and notes that she is feeling weak, fatigued, and
anxious. B.B.’s daughter states that her mother is acting “out of it” and tried to find her jacket before leav-
ing the house although the temperature is 102°F outside today.
Objective data include a blood pressure of 82/40 mm Hg and heart rate of 118 beats/min. Room
air pulse oximetry is 88% and the respiratory rate is 32 breaths/min. B.B. exhibits some evidence of mild
respiratory distress and has a moist cough. She does answer questions, but is confused as to the year and
thinks she is still at her home. She falls asleep between questions. Her tympanic temperature is 102.5°F
(39°C). Skin turgor is mildly diminished and >3 sec. Neck veins show no evidence of JVD. Lung sounds
include bilateral crackles in the lower lobes. Heart sounds are rapid but rhythm is regular and no murmurs
were heard. B.B.’s abdomen is soft with hypoactive bowel sounds. Extremities are slightly cool to the touch
with thready pedal pulses bilaterally. No post-tibial pulses were palpable. Nail beds are slightly dusky and
capillary refill is 3.5 sec.
The results of B.B.’s diagnostic testing are of concern. Her chest x-ray shows bilateral lower lobe in-
filtrates consistent with bilateral pneumonia. EKG shows sinus tachycardia with no evidence of ischemia.
WBC is 21,500. Hemoglobin is 13.5 mg/dL and hematocrit is 42%. BUN is 46 and creatinine is 2.3. Urine
specific gravity is >1.03. Blood cultures were drawn but the results are still pending. ABG results reveal an
oxygen saturation of 89%, pH of 7.35, pO2 of 65 mm Hg, PCO2 of 51 mm Hg, and an HCO3 of 20. The
emergency department physician diagnoses B.B. with early septic shock caused by pneumonia. The physi-
cian orders broad-spectrum IV antibiotics, normal saline IV bolus of 1 L during the next 30 min, oxygen
via nasal cannula at a flow rate of 4 L/min, and has asked for a Tylenol suppository 325 mg rectally to be
given to B.B. The physician asked that B.B. be maintained in a supine position and instructed the nurse to
call him if B.B.’s blood pressure did not reach 90 mm Hg within 5 min of having the IV bolus started. No
vasopressors were initiated yet. The nurse is to repeat B.B.’s ABGs in 30 min and have respiratory therapy
on standby for possible intubation.
1. Why would the physician order a fluid bolus to be given rather than go ahead and initiate a vasopres-
sor right away for B.B.’s hypotension?
2. If a vasopressor is started for B.B., what are the names of a few that might be appropriate in this
situation?
3. What are some risk factors that B.B. has for septic shock?
4. List a priority nursing diagnosis for this client.
5. What would be an appropriate plan/outcome for this client?
6. List several nursing interventions with rationales for this client.
7. Write a potential evaluation statement pertaining to B.B’s attainment of the plan/outcome.
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NEUROGENIC SHOCK
Neurogenic shock is a potential complication of a spinal cord
injury that results in hypotension, bradycardia, low perfusion,
and hypoxia to body tissues as a result of the interruption of
the sympathetic nervous system response. An acute spinal cord
injury causes the physiological response of spinal shock, which
is a term used interchangeably with neurogenic shock, but is
not the same. Spinal shock is the result of an acute spinal cord
injury and affects clients with cervical and higher level thoracic
(© wavebreakmeDia ltD/ShutterStock)
injuries. This is a physiological response causing flaccidity and
paralysis below the level of the injury and results in complete
loss of motor and sensory function below the level of injury.
This includes the loss of reflex activity, sexual functioning,
bowel and bladder control, and autonomic responses.
Neurogenic shock is a more severe form of spinal shock in
which the sympathetic innervation of the spinal cord is lost, but
parasympathetic function continues. This occurs if the injury
level is above thoracic vertebra number 6. In this syndrome, the figure 6-5 The nurse assesses for cardiac changes including
sympathetic innervations are lost but parasympathetic stimula- bradycardia and arrhythmias.
tion that can cause bradycardia and vasodilation will continue,
which results in severe hypotension and hypoperfusion. In ad-
dition, the body is unable to receive sympathetic stimulation to extremities, decreased urinary output, peripheral cyanosis,
the hypothalamus which regulates temperature and hypother- and increased respiratory rate. The client is anxious in early
mia results and further aggravates the client’s status. shock, and as the hypotension and hypoxia progress the client
Neurogenic shock occurs as a result of an acute spinal becomes less responsive. She may report shortness of breath,
cord injury. A physiological response to an acute spinal cord chest pressure, or chest pain during hypotension.
injury results in the complete loss of motor and sensory func- Studies have shown that the severity of spinal shock and
tion below the level of the injury. The sympathetic nervous neurogenic shock is directly related to the severity of the spinal
system is inhibited because the damaged spinal column cord injury. Symptoms can last 4 to 6 weeks postinjury (Kras-
cannot relay the sympathetic impulses to the brain. Since sioukov et al., 2007). Symptoms can occur as quickly as within
the heart cannot receive sympathetic nervous stimulation 30 to 60 minutes of the injury (Daniels & Nicoll, 2012).
to increase the heart rate, vascular tone, and contractility to Complications of neurogenic shock include end-organ
maintain homeostasis and hemodynamic stability, symptoms failure and death as well as worsening of the client’s spinal
of hypotension and bradycardia result. The loss of vascular cord function due to decreased spinal perfusion. End-organ
tone occurs because the sympathetic nervous system cannot damage includes brain damage, pulmonary infarcts, myocar-
relay the information to the brain, which in turn stimulates dial infarction from hypoxemia and bradycardia, ischemic gut
the release of epinephrine and norepinephrine from the from hypoperfusion, stress ulcers, liver failure, and renal fail-
adrenal glands to cause vasoconstriction. Bradycardia occurs ure. Significant skin breakdown can occur from the prolonged
because the sympathetic nervous system is not stimulated bed rest, and decubitus ulcers are common.
(Figure 6-5). The autonomic nervous system directly affects
the rate-controlling sinus node of the heart and controls the
release of epinephrine resulting in an increased heart rate in Medical-Surgical
response to hypotension. Management
The inhibition of the release of the epinephrine and nor-
epinephrine and the lack of their effects to maintain hemody- Medical
namic homeostasis is what causes the client’s shock symptoms. The treatment of neurogenic shock consists of correction of the
The client with neurogenic shock will initially present with client’s hypotension and hypoperfusion states through IV fluid
spinal shock symptoms, which include flaccidity and paralysis administration, vasopressors, supplemental oxygen, and respira-
below the level of injury, loss of bowel and bladder control, loss tory support if needed. The client’s neurogenic shock state may
of reflex activity, and abnormal increase or absence of sweat- last up to 6 weeks, and thus long-term support may be needed.
ing below the level of injury. She may also be exhibiting some The lack of sympathetic nerve conduction makes assessment of
cardiac arrhythmias; flushing and warmth above the level of the client’s status and response to treatment difficult because
injury, which is consistent with autonomic dysreflexia; and some the client will not exhibit hypotension-related tachycardia nor
orthostatic hypotension before the shock sets in. The symptoms fluid-overload–related tachycardia if the client is overhydrated
of neurogenic shock are hypotension, bradycardia, and hypo- as a result of treatment (Daniels & Nicoll, 2012).
thermia. The client’s blood pressure is less than 90 mm Hg sys- Intravenous fluid administration is a first-line treatment
tolic. The bradycardia may be severe, with the heart rate ranging option but the client must be closely monitored for signs and
between 60 beats per minute to asystole. Table 6-7 lists common symptoms of fluid overload because the heart rate response
diagnostic tests ordered for a client with neurogenic shock. to volume depletion or excess will not be present. Symptoms
The client in neurogenic shock exhibits some of the of fluid deficit are worsened hypotension and hypoxemia,
same signs and symptoms as the other four types of shock decreased skin turgor, and decreased urinary output. Symp-
such as weak and thready peripheral pulses, cool and clammy toms of fluid volume excess include elevated respiratory rate,
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Table 6-7 Common Diagnostic Tests for Neurogenic Shock

ABG Measures the amount of dissolved oxygen, carbon diox- pH 7.35–7.45

ide, pH, and bicarbonate levels of arterial blood. pO2 75–100 mmHg
pCO2 35–45 mmHg
HCO3 20–26 mEq/L
O2 saturation 95-–100%
BUN Measures the amount of BUN (a chief end product of pro- 5–20 mg/dL
tein metabolism) in the serum. An indicator of renal func-
tion and fluid status.
CBC Measures serum hemoglobin, hematocrit, platelet count, Hemoglobin:
and WBC count. Men 14–18 g/dL
Women 12–16 g/dL
Hematocrit:
Men 40–54%
Women 38–47%
Platelet count:
150–450 K
4.8–10.8 K/mL
Creatinine Measures the amount of serum creatinine. Is an indicator Men 0.8–1.8 mg/dL
of renal function and fluid status. Women 0.6–1.6 mg/dL
EKG Noninvasive testing that measures the electrical activity of Normal sinus rhythm, no
the heart and records the hear rhythm. arrhythmias

LDH Serum specimen is examined for presence of LDH, which 48–115 units/L
is indicative of tissue ischemia, necrosis, or acidosis.
Urine specific gravity Provides information regarding the concentration of the Specific gravity 1.010–1.030
client’s urine, an indicator of fluid status.
worsening hypoxemia, crackles or rhonchi on lung exam, Long-term use of these medications (up to 6 weeks) may
generalized edema, and distended neck veins. The physician be needed. The medications are weaned slowly to assess the
may choose to administer either crystalloid fluids (lactated client’s response.
Ringer’s solution, NS, etc.) or colloidal fluids (Hespan, hu- Supplemental oxygen is administered to improve tissue
man albumin). Colloidal fluids will often correct the client’s perfusion and hypoxemia. The physician orders the rate of
hypotension faster but carry a higher risk for fluid overload. flow to be titrated according to the client’s pulse oximetry.
Depending on the severity of the neurogenic shock as well as
Diet the level of the spinal cord injury, the client may need respira-
tory support including mechanical ventilation.
No specific dietary restrictions are needed for the client with Since the client with an acute spinal cord injury is immobi-
neurogenic shock. The diet depends on the client’s level of lized for an extended period of time, the prevention of deep vein
consciousness. If fully alert and not mechanically ventilated thrombosis (DVT) is a priority. Antiembolism stockings are ap-
she may be able to tolerate a regular diet. Clients who are criti- plied bilaterally to improve venous return and decrease the risk
cally ill and also mechanically ventilated receive either TPN or of DVT formation. Anticoagulants may also be administered.
tube feedings. The dietitian is consulted to determine caloric
needs for the client. Preventing constipation due to immobil-
ity is a priority, and diet should include adequate fiber. Activity
Clients with acute spinal cord injury are maintained in a flat
position to avoid tension or flexing of the spinal cord. Clients
Pharmacological are on bed rest for extended periods of time and may have
The use of vasopressor medications is another first-line a mechanical bed that will auto-rotate them at set intervals.
treatment. These include dopamine hydrochloride (Dopa- The client who does not have one of these beds needs to be
mine), dobutamine hydrochloride (Dobutrex), and norepi- repositioned every 2 hours. Upon recovery and when the
nephrine bitartrate (Levophed). The physician orders these physician has ordered it, the client may be able to get up in
IV medications to be titrated to maintain the client’s systolic the chair or even ambulate if spinal cord function is returning.
blood pressure above 90 mm Hg and the mean arterial These clients are extremely debilitated and weak from pro-
pressure above 80 to 90 to improve spinal cord perfusion. longed bed rest and need significant assistance with mobil-
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ity. Slow position changes are made to minimize orthostatic

hypotension. BOX 6-10
Nursing Management OBSeRVATIONS TO MAKe WHeN
COLLeCTING DATA: SUBJeCTIVe DATA
The nursing management of the client with neurogenic shock
is multifaceted. A major priority for the nurse is monitoring • Are you feeling anxious or fearful?
vital signs for evidence of worsening or improving status. In • What questions do you have about your cur-
particular, the nurse closely monitors the heart rate, blood rent condition and plan of care?
pressure, pulse oximetry, and EKG tracing. IV vasopressors • Are you having any pain?
and fluids are administered as ordered. When administering • Have you noticed any shortness of breath?
IV vasopressors, the nurse monitors the client for symptoms • Are you noticing any chest pain or
of extravasation and infuses the vasopressors through a central
palpitations?
line if possible. Titration of the vasopressors is according to
physician order and client response, and the nurse should be • At what level of your body does your sensa-
knowledgeable about the side effects and mode of action of tion stop?
each vasopressor. Fluid administration is according to physi- • Do you have any sense of the need to urinate
cian’s order and the nurse closely monitors for symptoms and or defecate?
signs of fluid overload. The physician is immediately con- • Are you feeling weak or dizzy?
tacted if any symptoms are present. • Do you feel cold?
Another priority for the nurse is maintaining the client’s
safety and ensuring stability of the client’s neck and back dur-
ing position changes to prevent further spinal cord injury.
Position changes should be slow to minimize orthostatic hy- gathered includes the client’s physical status regarding the
potension. Clients have Foley catheters and are incontinent of respiratory, cardiovascular, neurological, gastrointestinal, and
stool and need frequent perineal hygiene. The nurse promotes urinary symptoms. The nurse will also assess the client’s level
bowel health by assessing for constipation, to which spinal of anxiety.
cord clients are prone. Monitoring the frequency of the cli-
ent’s bowel movements is important. Objective Data
The nurse performs a thorough head-to-toe exam of the cli-
ent to obtain objective data (Box 6-11). Additional sources of
NURSING PROCESS objective data include diagnostic tests, vital signs, EKG data,
and pulse oximetry.
Data Collection
Nursing process is the process by which the nurse caring for the
client in neurogenic shock gathers subjective and objective data BOX 6-11
about the client to formulate nursing diagnoses. The nurse ana-
lyzes the data to formulate a plan of care, develop client goals QUeSTIONS TO ASK AND
and evaluate if the goals have been met. The client is reassessed OBSeRVATIONS TO MAKe WHeN
and the plan is altered according to the client’s response. COLLeCTING DATA: OBJeCTIVe DATA
• Obtain vital signs including blood pressure,
Subjective Data temperature, respiratory rate, heart rate.
The client in neurogenic shock is monitored for subjective • Monitor pulse oximetry readings.
cues as to how the client is feeling emotionally and physi- • Evaluate results of ABGs.
cally. Subjective information gleaned by the nurse includes • Monitor lab results: CBC, chemistry with elec-
the client’s level of understanding about the disorder and the trolytes, liver and renal functions, urine spe-
plan of care (Box 6-10). Additional subjective information
cific gravity, and osmolality.
• Assess client’s heart rhythm and EKG tracing.
MENTAL HEALTH • Inspect skin for color, coolness, and for evi-
CONNECTIONS dence of skin breakdown.
• Palpate peripheral pulses for evidence of
Anxiety perfusion.
• Assess client’s level of consciousness and anxi-
A client in shock—whether it is hypovolemic, car-
ety levels.
diogenic, septic, neurogenic, or anaphylactic—
• Evaluate level of sensation and movement of
will experience a certain level of anxiety. The
client’s body.
nurse needs to assess clients in shock for anxiety
• Assess activity tolerance, including orthostatic
and provide emotional support and nursing in-
hypotension.
terventions to help lower the client’s anxiety and
• Auscultate lung sounds for crackles (rales) or
alleviate fears and concerns.
rhonchi indicating fluid overload.
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Nursing diagnoses for a client in neurogenic shock include the following:

Ineffective Thermoregula- The client will maintain Monitor client’s temperature ev- Ineffective thermoregulation
tion related to illness and body temperature above ery 4 hrs or according to policy. is part of the spinal cord in-
trauma 98°F (36.7°C) and below jury and neurogenic shock
100°F (37.8°C). sequelae.
Apply warming blanket to main- Neurogenic shock, especially
tain normal temperature accord- hypotension, may result in
ing to physician’s orders. hypothermia.
Administer antipyretics accord- Neurogenic shock may re-
ing to physician’s orders if client sult in hyperthermia in some
is febrile. clients, increasing metabolic
demands and potentially
worsening tissue ischemia.
Ineffective Peripheral Tis- The client’s blood pres- Titrate vasopressors as ordered Normalizing the client’s
sue Perfusion related to sure will be maintained to keep blood pressure and blood pressure levels im-
trauma above 90 mm Hg systolic mean arterial pressure within proves tissue perfusion and
and pulse oximetry will guidelines set by physician. oxygenation.
stay above 94%. Monitor client’s temperature and Fever increases the body’s
administer ordered antipyretic metabolic demands and can
as indicated. worsen hypoxia.
antibodies. Upon a subsequent exposure to that particular an-

CLIeNT TEACHING
CLIeNT TEACHING tigen, the immune response is mediated and the anaphylactic
reaction occurs. Common antigens are foods including milk,
Neurogenic Shock eggs, seafood, peanuts, chocolate, strawberries, and tomatoes.
Food additives and preservatives, dyes, medications, insect
Neurogenic shock is a complex, life-threatening stings and venoms, pharmacologicals, or diagnostic agents
condition and may be prolonged up to 6 weeks. such as iodine are other common antigens. In some cases
The nurse educates the client and family regard- such as exposure of the body to agents such as radiopaque
ing the expected clinical course and keeps them contrast dye, aspirin or NSAIDs, and other medications, a
updated on the client’s progress. The family is edu- direct inflammatory response is mediated and no previous
cated about diagnostic tests and results. The family exposure is needed. Within the past decade, reactions to latex
will have questions about equipment in the room, have become more common, prompting health care facilities
to adopt latex-free policies.
especially if the client is mechanically ventilated
Physiological changes within the body in response to
and on multiple IV medications.
anaphylactic reactions include bronchoconstriction, severe
The client and family need to understand hypotension, tachycardia, hypovolemia, and tissue hypoper-
the importance of maintaining safety for the cli- fusion as well as a febrile response. Symptoms of this type of
ent with altered sensation and movement. This reaction include shortness of breath, coughing, chest tightness
includes the judicious use of braces or assistive or chest pain, weakness, and dizziness. Feelings of tightening
devices. The family is taught that the client is at of the throat and generalized itching or abdominal pain and
risk for orthostatic hypotension and needs to be up headache can occur. Additional signs include hypotension,
with assistance during recovery. tachycardia, fever, hives, swelling of face and lips, and general-
ized edema.
Anaphylactic shock is a severe hypersensitivity reaction
to a foreign substance, frequently mediated by IgE, causing
widespread mast cell and histamine release, which results in
ANAPHYLACTIC SHOCK severe hypotension, bronchoconstriction, hypovolemia, air-
way edema, and arrhythmias. Approximately 1% to 17% of the
anaphylactic shock occurs when the body reacts to a U.S. population is considered at risk for a reaction. The high-
foreign substance (antigen) as the result of an overreactive est “at-risk” clients have penicillin allergies and insect sting re-
and misdirected immune response. Generally, the body de- actions. Up to 1% of individuals with an anaphylactic reaction
velops an immune response to an antigen through a sensiti- die, but only 1,000 people are estimated to die annually in the
zation process mediated through immunoglobulin E (IgE) United States because of anaphylactic shock.
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SAfeTy
food Allergies
COLLABORATIVECARE
According to the Center for Anaphylactic Support Collaboration
(2010), “For infants and very young children, the
Anaphylactic shock is life threatening and requires
most common food allergies are to cow’s milk and
emergency collaboration between nursing staff,
eggs. In adults, the most common food allergen is
physicians, and respiratory therapy. Pharmacy staff
seafood” (p. 1).
may be needed for immediate mixing of drugs.
Because this is a life-threatening emergency with
quick onset, many hospitals have “rapid response”
teams in place to respond to such emergencies. If
Anaphylactic shock results when a major immune cas- the client is in the emergency department, many
cade including mast cells and histamine is released through staff members will likely be needed to coordinate
exposure to an antigen. After the body has been exposed to effective care.
an antigen, it produces IgE antibodies specific to that antigen.
The IgE antibodies, which have a strong affinity for mast cells
and basophils, attach to receptors on cell membranes. Upon
the individual’s next exposure to the antigen, the antigen at-
taches itself to IgE antibodies on the cell membranes of the agonist aerosols if wheezing is present. If client is unre-
mast cells and basophils. This causes the cell membrane to sponsive, she will need mechanical ventilation and ET tube
break down, releasing chemical mediators of inflammation placement. Bag-mouth ventilations may be administered
into the circulation. These inflammatory mediators cause until artificial airway is secured. Circulatory support measures
increased vascular permeability, resulting in hypotension and include administration of IV fluids running wide open; usually
angioedema, bronchoconstriction via smooth muscle contrac- normal saline or lactated Ringer’s solutions are preferred. A
tion, and coronary vasoconstriction. Histamine is the primary large-bore IV should be used.
chemical mediator and has three subtypes, one of which also
increases gastric acid production and increases ulcer risk. Leu- Diet
kotriene is another slower acting chemical mediator that has Clients recovering from anaphylactic reaction do not have any
a longer duration of action than antihistamines and typically dietary restrictions except to avoid food allergens or additives
causes bronchoconstriction. Bradykinin is another chemical that are suspected allergens.
mediator that is present in smaller amounts but is more potent
than histamine. Pharmacological
Symptoms of anaphylactic reaction can occur within Epinephrine, which contains alpha and beta properties, is
minutes to hours of the antigen exposure. Mild anaphylactic the drug of choice and can be administered intravenously,
reactions cause itching, hives, and some angioedema as well subcutaneously, or via ET tube (Figure 6-6). IV adminis-
as nasal congestion, rhinorrhea, hoarseness, excessive saliva- tration is the preferred route. Epinephrine causes vasocon-
tion, headache, nausea and vomiting, or diarrhea. More severe striction and decreased vascular permeability and reverses
reactions leading to anaphylactic shock manifest in severe hy- bronchoconstriction. An Epi-Pen is a commercially available
potension, tachycardia, bronchoconstriction with wheezing, subcutaneous, single-use prefilled injection that is injected
tachypnea, and cyanosis as well as chest pain and arrhythmias. into the outer thigh for anaphylactic reactions. Clients need
Syncope, seizures, and cardiac arrest may also occur. Rare a prescription for this and it can be purchased at most retail
symptoms include pelvic pain, vaginal bleeding, and urinary pharmacies.
incontinence from smooth muscle constriction.
The most serious complication of anaphylactic shock
is death. Other complications are organ damage secondary
to prolonged hypoperfusion and include renal failure, cere-
bral hypoxic changes, respiratory distress syndrome, cardiac
ischemia or MI, ischemic gut syndrome, and possible hepatic
failure. Table 6-8 lists common diagnostic tests for anaphy-
lactic shock.
(© gila photography/ShutterStock)
Medical-Surgical
Management
Medical
Emergency treatment measures include respiratory and circu-
latory support measures as well as the administration of epi-
nephrine. Respiratory support measures include application figure 6-6 Epinephrine can be administered subcutaneously
of supplemental oxygen and the administration of beta- via Epi-Pen injector or syringe.
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Table 6-8 Common Diagnostic Tests for anaphylactic Shock

ABG Measures the dissolved oxygen, carbon dioxide, pH, and pH 7.35–7.45
bicarbonate levels of arterial blood. pO2 75–100 mm Hg
pCO2 35–45 mm Hg
HCO3 20–26 mEq/L
BUN Measures the amount of BUN (a chief end product of pro- 5–20 mg/dL
tein metabolism) in serum. Is an indicator of renal function
and fluid status.
CBC Measures serum hemoglobin, hematocrit, platelet count, Hemoglobin:
and WBC count. Men 14–18 g/dL
Women 12–16 g/dL
Hematocrit:
Men 40–54%
Women 38–47%
Platelet count:
150–450 K
4.8–10.8 K/mL
Creatinine Measures the amount of creatinine in serum. Is an indica- Men 0.8–1.8 mg/dL
tor of renal function and fluid status. Women 0.6–1.6 mg/dL
EKG Noninvasive testing that measures the electrical activity of Normal sinus rhythm, no
the heart and records the heart rhythm. arrhythmias.

LDH Serum specimen is examined for presence of LDH, which 48–115 units/L
is indicative of tissue ischemia, necrosis, or acidosis.
Urine specific gravity Provides information regarding the concentration of the Specific gravity 1.010–1.030
client’s urine, an indicator of fluid status.
CRITICAL THINKING
SAfeTy
Use of an epi-Pen epi-Pens
Do not inject the Epi-Pen intravenously or into the
buttocks because it may not be effective for a se-
Use a current drug book or the Internet to
vere reaction. Keep the Epi-Pen at room tempera-
research Epi-Pens and answer the following
ture and do not expose to extreme heat or direct
questions.
sunlight. Administration of more than one Epi-Pen
1. Who should have them?
may be needed.
2. How can they be obtained?
3. How are they used?
4. Are there any side effects?
Second-line drugs include Benadryl, an antihistamine,
which works to continue to decrease histamine release. Cor-
ticosteroids may also be administered to reduce the release of
inflammatory mediators. Histamine receptor-2 (H2) receptor positioned sitting partially upright to ease breathing. Slow posi-
blockers reduce gastric acid production, which decreases the tion changes are important to avoid orthostatic hypotension.
risk of stress ulcers.
Nursing Management
Activity Nursing management of the client with anaphylactic shock
A severely hypotensive client is placed in the Trendelenburg focuses on quickly establishing an IV site and attending to
position or supine position. The hemodynamically stable client the CAB’s (compressions, airway, and breathing) of the cli-
who is having symptoms of bronchoconstriction needs to be ent. If the client is not breathing, the nurse initiates CPR.
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MEMORY TRICK BOX 6-12

CABs OBSeRVATIONS TO MAKe WHeN
Nursing management of the client with anaphylac- COLLeCTING DATA: SUBJeCTIVe DATA
tic shock focuses on attending to the CABs of the • When did you first start to notice symptoms?
client: • Do you know what triggered this attack?
C 5 Compressions • Have you experienced similar allergic reactions
A 5 Airway in the past?
• Have you taken any medications for this reac-
B 5 Breathing
tion such as Benadryl or an Epi-pen?
• Are you taking any beta blocker medications?
• What other medications are you currently on?
Preferably, respirations are given by a bag-mask-valve setup • Are you short of breath or noticing wheezing
or the client is intubated with an ET tube. The client needs to or tightness in your chest?
immediately receive epinephrine and supplemental oxygen. • Are you having chest pain or palpitations?
If outside the hospital environment and the client does not • Do you feel faint or dizzy?
have IV access, subcutaneous epinephrine in the form of the • What other allergies or sensitivities do you
Epi-Pen should be given. Otherwise, the nurse should prepare have?
to give epinephrine via an IV site. Intravenous fluids such as
0.9% normal saline or lactated Ringer’s are administered. The
nurse obtains immediate vital signs and starts cardiac moni-
toring and makes arrangements to have the ordered blood
work obtained.
BOX 6-13
NURSING PROCESS OBSeRVATIONS TO MAKe WHeN
Data Collection COLLeCTING DATA: OBJeCTIVe DATA
Subjective Data • Monitor vital signs including heart rate, blood

pressure, temperature, and respiratory rate.
Caring for the client in anaphylactic shock includes obtaining
• Assess the client’s pulse oximetry reading.
subjective data and a client interview (Box 6-12). The client
is questioned about the potential source of the allergen if • Observe for respiratory distress such as
known, previous exposures, medication allergies, and current tachypnea, tripod stature, stridor, and chest
symptoms. The nurse inquires about the onset of the expo- retractions.
sure and any medications already taken such as Benadryl or • Auscultate lungs for audible wheezing.
an Epi-Pen. • Monitor the EKG tracing.
• Evaluate client’s general appearance and pres-
Objective Data ence of significant angioedema.
The physical examination, vital signs, EKG, pulse oximetry • Perform a general physical exam including
readings, and diagnostic test results provide objective data lung sounds, heart sounds, and extremities for
(Box 6-13). The client’s response to the initiated treatment evidence of edema.
provides data for the nurse to create a plan of care.
Nursing diagnoses for a client in anaphylactic shock include the following:

Impaired Gas Ex- The client’s ABGs will Administer supplemental oxygen Supplemental oxygen increases
change related to demonstrate normal pH as ordered to maintain normal the partial pressure of oxygen,
ventilation-perfusion and pulse oximetry read- pulse oximetry. improving gas exchange.
ings will be 95% and Administer epinephrine as or- Epinephrine causes beta-
above. dered via IV, subcutaneous route agonist response of broncho-
(Epi-Pen), or endotracheal tube. dilation, improving oxygen
exchange.
Administer IV fluids as ordered. Hypovolemia worsens
hypotension.
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Administer corticosteroids as Corticosteroids decrease air-
ordered. way inflammation and inhibit
mediators of inflammation.
Deficient Knowledge re- The client will verbalize Educate the client about the Increased knowledge of disease
lated to disease process an understanding of the pathophysiology of anaphylactic process may increase compli-
and unfamiliarity with basic physiology of her shock. ance of avoidance of antigen.
information resources reaction and the probable Educate client about proper use Client will have increased
antigen and will demon- of Epi-Pen. chance of successful use in
strate appropriate use of the future.
an Epi-Pen.
Educate client about use of This over-the-counter medi-
Benadryl for other anaphylactic cation can ameliorate some
symptoms. of the other less serious ef-
fects of anaphylactic-type
reactions in the future.
Ineffective Peripheral Tis- The client will maintain a Administer epinephrine as This will correct hypotension,
sue Perfusion related to systolic blood pressure of ordered. thereby increasing tissue
trauma greater than 90 mm Hg. perfusion.
Administer supplemental Aids in reversing hypoxia
oxygen. caused by hypotension and
hypoperfusion.
Administer IV fluids as ordered. IV fluids help correct hypo-
tension, thereby increasing
tissue perfusion.
CONCLUSION
Shock is the body’s response to inadequate tissue perfusion, The nurse caring for a client experiencing shock needs to
and if left untreated will progress into cell death, organ failure, be knowledgeable about the signs and symptoms, necessary
and a life-threatening emergency. Hypovolemic, cardiogenic, assessment skills, and appropriate treatment for each type of
septic, neurogenic, and anaphylactic shock share common shock. Prompt nursing care is essential for a positive client
manifestations of hypotension, hypoperfusion, and hypoxia. outcome.
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CHAPTER 7
Pain Assessment
and Management
KEy TERmS
acupuncture endorphins patient-controlled analgesia (PCA)
acute pain epidural analgesia perception
adjuvant medications gate control pain theory phantom limb pain
afferent pain pathway hypnosis progressive muscle relaxation
analgesia intrathecal analgesia recurrent acute pain
analgesics ischemic pain referred pain
ceiling effect mixed agonist-antagonist reframing
chronic acute pain modulation relaxation techniques
chronic nonmalignant pain myofascial pain syndromes somatic pain
chronic pain neuralgia tolerance
colic nociceptors transcutaneous electrical nerve
cryotherapy noxious stimulus stimulation (TENS)
cutaneous pain pain transduction
distraction pain threshold transmission
efferent pain pathway pain tolerance visceral pain
LEARNING OBJECTIVES
2. Describe the types of pain.
3. Discuss the gate control theory of pain.
4. Identify the four components of pain conduction.
5. List three guidelines included in a thorough pain assessment.
6. Identify three general principles of pain management.
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7. List the nurse’s responsibilities in administration of analgesics.
8. Identify site of action of nonopioid and opioid analgesics.
9. Describe three examples of nonpharmacological measures for pain relief.
10. List nursing diagnoses for and relating to pain.
11. Discuss nursing interventions that promote comfort.
12. Assess client’s pain relief.
the intensity of discomfort the client is feeling cannot be

INTRODUCTION measured with an instrument. McCaffery and Pasero (1999)
Pain is a phenomenon found in all specialties of nursing. say it best by defining pain as “whatever the person experi-
Regardless of the setting, including neonatal intensive care, encing it says it is, existing whenever he says it does” (p. 17).
intraoperative, home care, or clinics, pain management can be All nursing actions are based on what pain means to the
challenging. While other health care team members address client. The first and most important step in assessing a cli-
pain management with clients, the nurse spends the most time ent’s pain is to believe the client. The client’s description of
with the client experiencing pain. For example, in an acute the pain experience, or self-report, should be the basis of all
care setting, the physician orders the analgesics (substances care decisions. Without it, care will be ineffective (Teeter &
that relieve pain) for the client but may spend only 10 to Kemper, 2008a).
15 minutes a day with that client. Nurses are present 24 hours Because of widespread undertreatment of pain, in
a day, administer the medications, assess the client’s response, 1995 the American Pain Society launched an international
and report the response to the physician. The nurse’s role can campaign to raise awareness about the problem and to pro-
be pivotal in relieving the client’s pain. mote the routine assessment of pain by health care providers.
The experience of pain can have a significant impact on a This quickly led to the incorporation of pain assessment into
client’s health. It is a personal experience affecting all aspects the daily activities of clinicians as the “fifth vital sign” after
of an individual’s health, including physical well-being, mental the Joint Commission initiated pain management quality
status, and effectiveness of coping mechanisms. This chapter standards of care in 2001. However, research conducted by
provides an overview of the complex phenomenon of pain, the U.S. Veterans Administration showed no improvement
including pain definitions, pain physiology, and pain assess- in pain management after adopting this strategy (Mularski et
ment. Strategies to control pain are also discussed, including al., 2006). Assessment itself is not enough to ensure adequate
pharmacological, noninvasive, and invasive techniques. pain management for clients. Health care providers must act
on the assessment findings (Teeter & Kemper, 2008a).
Although pain has had many definitions throughout his-
DEFINITIONS OF PAIN tory, research in pain physiology shows that pain is a complex
phenomenon. Pain is often difficult for clients to describe and
The phenomenon of pain is referenced as far back as the nurses to understand, yet it is among the most common con-
Babylonian clay tablets. Aristotle (4th century b.c.) de- cerns leading individuals to seek health care. Until recently,
scribed pain as an emotion, being the opposite of pleasure. pain was viewed as a symptom that required diagnosis and
Although emotions certainly play an important role in pain treatment of the underlying cause. It is now clear that pain
perception, there is much more to the experience than the itself can be detrimental to the health and healing of clients.
feelings involved. Pain control, not just relief from pain once it occurs, must be
In the Middle Ages, pain had religious connotations. Pain recognized as a priority in the care of clients in all settings.
was seen as God’s punishment for sins or as evidence that an
individual was possessed by demons. This definition of pain
is still embraced by some clients who might tell the nurse that NATURE OF PAIN
the suffering is their “cross to bear.” Pain relief may not be
the goal for those individuals who believe in this definition of Pain experience may be a signal of tissue damage, as in the
pain. Spiritual counseling may need to be implemented before pain of cancer and chronic illness. Pain can also be a protective
this person is willing to work toward relief. mechanism to prevent further injury, as when a client guards
The International Association for the Study of Pain or protects an injured body part. Pain, as a warning of poten-
(IASP) has developed the most widely accepted definition of tial tissue damage, may be absent in people with hereditary
pain: “an unpleasant sensory and emotional experience asso- sensory neuropathies, congenital nerve or spinal cord abnor-
ciated with actual or potential tissue damage, or described in malities, multiple sclerosis, diabetic neuropathy, alcoholism,
terms of such damage” (IASP, 2011). This definition incorpo- leprosy, and nerve or spinal cord injury.
rates both the sensory and the emotional components of pain.
It also acknowledges that evidence of actual tissue damage is
not required in order for the pain to be considered real.
COMMON MYTHS ABOUT PAIN
Many pain experts emphasize the subjective nature of Pain is often misunderstood and misjudged because it is sub-
pain. Unlike a blood pressure or blood glucose measurement, jective (depends on the client’s perception) and cannot be
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Table 7-1 Common Myths about Pain

MYTH FACT
The nurse is the best judge of a client’s pain. Pain is a subjective experience; only the client can judge the level and
severity of pain.
If pain is ignored, it will go away. Pain is a real experience that is appropriately treated with medical and
nursing interventions.
Clients should not take any measures to re- Pain control and relief measures are effective in lowering the pain level,
lieve their pain until the pain is unbearable. which will help clients function more normally and comfortably.
Most complaints of pain are purely psycho- Most clients honestly report their perception of pain, both physical
logical (e.g., “it’s all in your head”); only “real” and emotional, and need effective intervention and teaching; physical
pain manifests in obvious physical signs such responses vary greatly depending on experience and cultural norms,
as moaning or grimacing. and visible expressions of pain are not always reliable indicators of its
severity.
Clients taking pain medications will become Addiction is unlikely when analgesics are carefully administered and
addicted to the drug. closely monitored.
Clients with severe tissue damage will experi- Individuals’ perceptions of pain are subjective; the extent of tissue dam-
ence significant pain; those with lesser damage is not necessarily proportional to the extent of pain experienced.
age will feel less pain.

Clients ask for pain medication when they Many clients do not ask for medication because they are afraid of side
need it. effects, do not want to bother the nurse, have cultural norms and beliefs
against it, or believe pain is inevitable and untreatable.
objectively measured through a laboratory test or diagnostic

data. A client’s report of the level of pain varies based on
Pain Categorized by Nature
cultural and experiential background. In addition, the nurse’s It is important to understand the difference between acute
interpretation of a client’s pain can be filtered through the and chronic pain because they each present a different clini-
nurse’s biases and expectations. Some common myths related cal picture.
to pain are discussed in Table 7-1.
Acute Pain
Acute pain has a sudden onset, relatively short duration, mild
TYPES OF PAIN to severe intensity, with a steady decrease in intensity over a
period of days to weeks. Once the noxious stimulus (un-
Pain is described by its origin or cause and by its nature or derlying pathology) is resolved, the pain usually disappears
description. Pain categorized by its origin is either cutane- (Table 7-2). It is usually associated with a specific condition,
ous, somatic, or visceral; by its nature, it is either acute or injury, or tissue damage caused by disease. As healing occurs,
chronic. acute pain diminishes. Everyone has experienced acute pain
(e.g., toothaches, headaches, needlesticks, skinned knees,
burns, muscle pain, childbirth, postoperative pain, a sprained
Pain Categorized by Origin ankle, and fractures). The client is usually able to pinpoint the
Cutaneous pain is caused by stimulating the cutaneous hurt. Acute pain is often described as sharp, although deep
nerve endings in the skin and results in a well-localized pain may be described as dull and aching. The client exhibits
“burning” or “prickling” sensation; tangled hair that is pulled elevated heart rate, respiratory rate, and blood pressure and
during combing causes cutaneous pain. Somatic pain is may become diaphoretic and have dilated pupils. These signs
nonlocalized and originates in support structures such as resemble those of anxiety, which often accompanies acute
tendons, ligaments, and nerves; twisting an ankle results in pain. Behaviors include crying and moaning, rubbing the site
somatic pain. Visceral pain is discomfort in the internal of pain, guarding, frowning, grimacing, and verbal complaints
organs, is less localized, and is more slowly transmitted than of the discomfort.
cutaneous pain. Pain originating from the abdominal organs Recurrent acute pain is repetitive painful episodes
is often called referred pain because pain is not felt in the that recur over a prolonged period or throughout the client’s
organ but instead is perceived at the spot where the organs lifetime. Pain-free intervals alternate with painful episodes.
were located during fetal development, making it difficult to Examples of recurrent pain seen in adults include migraine
assess (Figure 7-1). headaches, sickle cell crises pain, and angina.
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CHAPTER 7 Pain Assessment and Management 111
A B
Perforated
Heart
duodenal ulcer
Liver
Pancreatitis
Liver colic Penetrating
duodenal ulcer
Heart
Biliary colic
Cholecystitis, Stomach Stomach

pancreatitis, Cholecystitis
duodenal Renal colic
ulcer
Ovary Liver
Small Ureteral Pancreatitis,
intestinal colic renal colic
pain

Appendicitis
(most
common Colon
location) Rectal lesions
pain
Figure 7-1 Areas of referred pain: A, anterior view; B, posterior view.
Chronic Pain Chronic acute pain occurs almost daily over a long pe-
Chronic pain is usually defined as long-term (lasting riod, months or years, and may never stop. Cancer and severe
6 months or longer), persistent, nearly constant, or recurrent burns are examples of pathophysiology leading to chronic
pain producing significant negative changes in the client’s life. acute pain. Sometimes the pain ends only at the time of death,
Chronic pain may last long after the pathology is resolved. In as in clients with terminal cancer (McCaffery & Pasero,
the United States, one in four individuals lives with chronic 1999). This type of pain is also called progressive pain.
pain. Chronic pain is the reason for more than 80% of all phy- Chronic nonmalignant pain, also called chronic be-
sician visits (National Pain Foundation, 2009). nign pain, occurs almost daily, lasts for at least 6 months, and
Table 7-2 Acute versus Chronic Pain

ACUTE CHRONIC
Time span Less than 6 months More than 6 months
Location Localized, associated with a specific injury, Difficult to pinpoint

condition, or disease
Characteristics Often described as sharp, diminishes as Often described as dull, diffuse, and aching
healing occurs
Physiological signs • Elevated heart rate • Normal vital signs

• Elevated BP • Normal pupils
• Elevated respirations • No diaphoresis
• May be diaphoretic • May have loss of weight
• Dilated pupils
Behavioral signs • Crying and moaning • Physical immobility

• Rubbing site • Hopelessness
• Guarding • Listlessness
• Frowning • Loss of libido

• Grimacing • Exhaustion and fatigue
• Statement of pain • Expresses pain only when asked
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ranges from mild to severe in intensity. Three critical charac-

teristics of chronic nonmalignant pain have been identified by PHYSIOLOGY OF PAIN
McCaffery and Pasero (1999): When pain occurs, sensory input from injured tissue causes
• Caused by non–life-threatening causes peripheral nociceptors (receptive neurons for painful sen-
• Not responsive to currently available pain relief methods sations) and central nervous system (CNS) pain pathways
to enhance future responses to pain stimuli. Long-lasting
• May continue for the rest of the client’s life changes in cells within the spinal cord afferent (ascending)
Examples of pathophysiology leading to chronic nonma- and efferent (descending) pain pathways may thus occur
lignant pain include the following: after a brief noxious stimulus.
Physiological responses (such as elevated blood pressure,
• Many forms of neuralgia (paroxysmal pain that extends respiratory rate, and pulse rate; dilated pupils; perspiration;
along the course of one or more nerves) and pallor) to even a brief acute pain episode will show adap-
• Low-back pain tation within minutes to a few hours. The body cannot sustain
• Rheumatoid arthritis the extreme stress response physiologically for more than
• Ankylosing spondylitis short periods. The body conserves its resources by making
• Phantom limb pain (a form of neuropathic pain that oc- physiological adaptations: a return to normal or near normal
curs after amputation with pain sensations referred to an blood pressure, respiratory rate, and pulse rate; pupil size;
area in the missing portion of the limb) and dry skin with little evidence of poor perfusion, even with
continuing pain of the same intensity.
• Myofascial pain syndromes (a group of muscle disor-
ders characterized by pain, muscle spasm, tenderness, stiff-
ness, and limited motion) Stimulation of Pain
The specific action of pain depends on the type of pain. Cu-
When chronic nonmalignant pain is severe enough to disable taneous pain rapidly travels through a simple reflex arc from
the client, it is identified as chronic intractable nonmalignant the nerve ending (point of pain) to the spinal cord at approxi-
pain syndrome. mately 300 feet per second, with a reflex response evoking
Signs and Symptoms an almost immediate reaction. This is the reason when a hot
stove is touched, the person’s hand jerks back before there is
The signs and symptoms of chronic pain can look very dif- conscious awareness of damage (Figure 7-2). After a hot stove
ferent from those of acute pain. The body cannot tolerate is touched, a sensory nerve ending in the finger skin initiates
the sympathetic nervous system signs for a long period and, nerve transmission that travels through the dorsal root gan-
therefore, adapts. Vital signs will often be normal, with no ac- glion to the dorsal horn in the gray matter of the spinal cord.
companying pupil dilation or perspiration. Lack of these signs The impulse then travels though an interneuron that synapses
may prompt some health care workers to question the client’s with a motor neuron at the same level in the spinal cord. This
description of pain. motor neuron stimulating the muscle is responsible for the
The hopelessness, listlessness, loss of libido (sex drive), swift movement of the hand away from the hot stove.
and weight of chronic pain are similar to those of depression. In the case of the hot stove, the sensory neuron also syn-
The client often describes exhaustion and fatigue. Behaviors apses with an afferent sensory neuron. The impulse travels
include no complaint of pain unless asked and physical inactiv- up the spinal cord to the thalamus, where a synapse sends the
ity or immobility leading to functional disability. The crying, impulse to the brain cortex. Once the impulse is interpreted,
moaning, guarding, and grimacing that most clinicians associ- the information is consciously available. Then the person is
ate with pain are absent. Treatment of chronic pain is more aware of the location, intensity, and quality of pain. Previous
complex than that of acute pain. Chronic pain is viewed by pain experience adds the affective feature to the pain experience.
experts as a disease state rather than a symptom. Management Descending or efferent motor neuron response moves from
includes identifying the cause of pain, recognizing emotional the brain through the spinal cord, synapsing with a motor neu-
and environmental factors contributing to the pain, and reha- ron in the spinal cord, and innervates the muscle.
bilitation to improve the client’s functional abilities. Refer to
Chapter 67 for more information on depression and pain.
BESTPRACTICE
PURPOSE OF PAIN Pain in Americans
Pain serves as a protective mechanism. If a person touches a
hot stove, the pain signal causes the person to pull the hand According to statistics compiled by the American
away immediately. The skin would be seriously burned if the Pain Foundation in 2007, pain impacts the every-
pain sensation was not felt. day lives of more Americans than cancer, diabe-
Pain can be a diagnostic tool. The quality and duration tes, and heart disease combined—an estimated
of the pain give important clues in determining a client’s 76.5 million Americans per day. Adults between
medical diagnosis. For example, in acute appendicitis, the cli- the ages of 45 and 64 were the most likely to re-
nician looks for rebound tenderness (the pain increases after port pain; adults over age 65 were least likely. This
applying firm pressure for several seconds and then quickly may reflect age-related changes in pain perception
releasing the pressure) when palpating the abdomen. This
or the underassessment of pain in the elderly.
particular type of pain helps confirm the diagnosis of appendi-
citis rather than other gastrointestinal disorders.
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Brain
Cortex
Synapse
Associative
neuron
Spinal Cord
Motor (efferent) neuron
Sensory (afferent) neuron Skin
Gray matter
Cell body of neuron Ganglion Pain

stimulus
Sensory neuron
Muscle

Synapse
Simple reflex arc Complex
reflex arc Reflex
Motor neuron muscle
ending in muscle response
Figure 7-2 Reflex arcs.
The transmission of visceral pain impulses is slower and

less localized than that of cutaneous pain. Internal organs SAfety
(including the gastrointestinal tract) have few nociceptors,
which is the reason visceral pain is poorly localized and is felt Ischemic Pain
as a throbbing sensation or dull ache; however, internal organs
are very sensitive to distention. The cramping pain of colic Administer supplemental oxygen and pain medica-
(acute abdominal pain) results when: tion quickly to clients with ischemic pain to mini-
mize oxygen deprivation and prevent infarction
• Constipation or flatus distends the stomach or intestines.
(tissue death).
• There is hyperperistalsis, as in gastroenteritis.
• Something tries to pass through an opening that is too
small.
The physiology of ischemic pain, or pain occurring Substances released from injured tissue in acute pain epi-
when the blood supply to an area is restricted or cut off com- sodes lead to stress hormone responses. There is an increase
pletely, also differs. Blood flow restriction causes inadequate in metabolic rate, enhanced breakdown of body tissue, in-
oxygenation of the tissue supplied by those vessels and inad- creased blood clotting, impaired immune function, and water
equate removal of metabolic wastes. The onset of ischemic retention. The fight-or-flight reaction is triggered, leading to
pain is most rapid in an active muscle and much slower in a tachycardia and negative emotions.
passive muscle. Examples of ischemic pain are muscle cramps,
myocardial infarction, angina pectoris, and sickle cell crisis.
When ischemic pain occurs in a muscle that continues to The Gate Control Theory
work, a muscle spasm (cramp) occurs. If the blood supply to Pain transmission and interpretation theories try to describe
the heart is completely cut off or severely restricted and not and explain the pain experience. Early pain theorists focused
restored quickly, a myocardial infarction occurs. on the neuroanatomical and neurophysiological mechanisms.
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Melzack and Wall (1965) proposed the gate control

pain theory, which was the first one recognizing that psy-
chological aspects of pain are as important as physiological
aspects. The gate control theory combined cognitive, sensory,
and emotional components—in addition to the physiological
aspects—and proposed that they can act on a gate control Brain
system to block the individual’s perception of pain. The ba-
sic premise is that transmission of potentially painful nerve
impulses to the cortex is modulated by a spinal cord gating
mechanism and by CNS activity. As a result, the level of con-
scious awareness of painful sensation is altered. Spinal cord
The theory suggests that nerve fibers that contribute
to pain transmission come together at a site in the dorsal
horn of the spinal cord. This site is thought to act as a gating
mechanism that determines which impulses will be blocked Gate Gate
and which will be transmitted to the thalamus. The image of a A open closed B
gate is useful in teaching clients and their families about pain Dorsal
relief measures. If the “gate” is closed, the signal is stopped horns
before it reaches the brain, where awareness of pain occurs.
If the gate is open, the signal will continue on through the
spinothalamic tract to the cortex, and the client will feel the
pain (Figure 7-3). Whether the gate is opened or closed is
influenced by impulses from peripheral nerves (the sensory
components) and nerve signals that descend from the brain
(motivational-affective and cognitive components). For ex-
ample, stimulation of some types of peripheral nerves by cuta-
neous stimulation such as massage can close the gate, whereas
stimulation of the nociceptors will open the gate.
If a person is anxious, the gate can be opened by signals
sent from the brain down to the mechanism in the dorsal horn Small-
of the spinal cord. On the other hand, if the person has had diameter
fibers
positive experiences with pain control in the past, the cogni-
tive influence can send signals down to the gating mechanism

and close it. The gate theory offered a great benefit by sug-
gesting new approaches to relieving both acute and chronic
Small-
pain. Pain could be relieved by blocking the transmission of diameter Pain sensation
pain impulses to the brain by both physical modalities and by fibers
altering the individual’s thought processes, emotions, or other
behaviors. Figure 7-3 Gate control theory: A, An “open gate” allows
nerves to transmit pain sensation to the brain. B, A “closed gate”
Conduction of Pain Impulses stops nerve transmission of pain sensation to the brain.
Conduction of pain impulses refers to the physiological

processes that occur from the initiation of the pain signal to
the realization of pain by the individual. Four processes are
involved in the conduction of this signal, as illustrated in
FACTORS AFFECTING
Figure 7-4. The first, transduction, occurs when a noxious THE PAIN EXPERIENCE
stimulus triggers electrical activity in the endings of affer- According to McCaffery and Pasero (1999), the client is the
ent nerve fibers (nociceptors). Once the signal is triggered, only authority on the existence and nature of his or her pain.
transmission occurs. The impulse travels from the receiving Age, previous experience with pain, drug abuse, and cultural
nociceptors to the spinal cord. Projection neurons then carry norms account for the differences in a clients’ individual re-
the message to the thalamus, and the message continues to sponses to pain.
the somatosensory cortex. Then the third step, perception
(awareness) of pain, occurs. Here neural messages are con-
verted into the subjective experience. The fourth process, Age
modulation, is a CNS pathway that selectively inhibits pain Age can greatly influence a client’s perception of pain. Indi-
transmission by sending blocking signals back down to the viduals may continue pain behaviors learned as children and
dorsal horn of the spinal cord. Pain modulation is controlled may be reluctant to admit pain or seek medical care because
by two endogenous (developing within) analgesic systems they fear the unknown or fear how treatment may impact their
(painkillers): endorphins and enkephalins. Endorphins (en- lifestyle. Older adults may ignore their pain, believing it is a
dogenous opiate-like substances) bind to the opioid receptor consequence of aging. Family and health care members may
sites and decrease the perception of pain. Enkephalins also thoughtlessly support this idea and be less responsive to an
decrease the pain perception in the pain pathway. older client’s complaints of pain.
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Spinothalamic 3 Perception
2 Transmission tract neuron
of pain
Cortex and limbic
systems perceive
the pain
3
Pain impulse
is carried via
the spinothalamic
tract to the brain
Spinothalamic
Opioid tract neuron 4 Modulation
receptors
Neurotransmitters
and endogenous
1 Transduction
ction Nociceptor opioids are released
from the brain stem
2
Cell damage from the 4
noxious stimulus causes the
release of K + x Neuron from
brain stem
Na+ Na+ Na+

+++++ - - - - - +++++ Pain transmission
- - - - - +++++- - - - - is blocked and
K+ K+ Nociceptor analgesia
- - - - - +++++ - - - - -
+++++ - - - - - +++++
1 is produced
Na+ Na+ Na+ Opioid
receptors
Action potential is created and Nociceptor
moves to the spinal cord via
afferent nerve fibers

Figure 7-4 Conduction of pain impulses.
Previous Pain Experiences

Previous experience with pain often influences clients’ reac-
LIfe SPAN CONSIDeRAtIONS tions. Past coping mechanisms may affect clients’ judgments
about how pain will affect their lives and which measures
elders and Pain they can use to successfully manage the pain on their own.
Teaching clients about pain expectations and management
Older clients often live with pain, believing that methods can often allay their fears and lead to successful pain
nothing can be done. Pain often is not reported management.
by older clients because they fear being labeled
a “bother” or “complainer.” A competent caring
nurse encourages the client to request pain relief
Drug Abuse
as needed.
According to a research study by Compton (1999) and an ar-
ticle by Savage, Kirsh, & Passik (2008), a drug abuser is likely
to be less tolerant of pain than someone who does not use
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drugs. Drug abuse may cause changes in the central nervous CRITICAL THINKING
system, resulting in an exaggerated neurophysiological re-
sponse to painful stimuli. To keep a drug abuser comfortable,
withdrawal must be prevented. Reflections on Pain
Cultural Norms 1. List ways you respond to pain.

Cultural differences in pain responses can lead to pain man-
2. When you see a client in pain, what are your
agement problems. Studies on people from various cultures
found no significant difference among the groups in the thoughts?
intensity level at which pain becomes perceptible. The same 3. Did that client respond to pain in the same
studies showed that the intensity level or duration of pain the way you respond to pain?
client was willing to endure differed significantly. Cultural val-
ues guide the expression of pain. Some cultures tolerate pain
and “suffering in silence,” whereas others fully express pain,
including physical and emotional responses. Be careful not to experience and cultural background help determine how pain
equate the level of pain expression with the level of actual pain is demonstrated, nurses’ cultures and experiences help deter-
experienced but consider cultural and other influences that mine which pain behaviors are viewed as acceptable. Be aware
affect the expression of pain. of these values and avoid biases when assessing client pain and
planning client care. Once a self-assessment about pain has
been conducted, the nurse is ready to assess the client.
JOINT COMMISSION STANDARDS Pain as the fifth vital sign is assessed and recorded along
with the client’s temperature, pulse, respiration, and blood
Each institution should have clearly defined standards for
pressure. Pain assessment tools are the most effective method
pain management. The Joint Commission Pain Management
for identifying the presence and intensity of pain in clients.
Standards of Care has made pain management a priority and
Good nursing practice uses pain assessment tools and accepts
requires that pain be assessed on admission and throughout
the results of the tools (Figure 7-5). Using the “PQRST”
the client’s stay in an institution. Relating to pain manage-
mnemonic shown in Memory Trick is an ideal way for a nurse
ment, health care organizations are expected to:
to assess a client’s pain.
• Recognize the right of clients to appropriate assessment
and management of their pain. Subjective Data
• Assess pain in all clients. The first step in pain assessment is gathering subjective infor-
• Record the results of the assessment in a way that facilitates mation regarding the client’s pain. A client’s pain threshold
regular reassessment and follow-up. and pain tolerance level are determined. The pain threshold
• Educate relevant providers in pain assessment and is the intensity level at which a person feels pain. It varies with
management. each individual and with each type of pain. A client’s pain
• Determine competency in pain assessment and tolerance is the intensity level or duration of pain the client
management. is able or willing to endure.
The client’s description of the pain covers several qual-
• Establish policies and procedures that support appropriate
ifiers, including its location, onset and duration, quality,
prescription or ordering of pain medications.
• Ensure that pain does not interfere with participation in
rehabilitation.
• Educate clients and their families about the importance of MEMORY TRICK
effective pain management. Pain Assessment: PQRSt
• Include clients’ needs for symptom management in the
discharge planning process. P 5 What Provokes the pain (aggravating
• Collect data to monitor the appropriateness and effec- factors) and Palliative measures (alleviating
tiveness of pain management (Integrative Pain Center of factors)
Arizona, 2003; Joint Commission, 2009; Teeter & Kemper, Q 5 Quality of pain (gnawing, pounding, burn-
2008b). ing, stabbing, pinching, aching, throbbing,
and crushing)
NURSING PROCESS R 5 Region (location) and Radiation to other

body sites
The nursing process provides the framework for managing a
client’s pain. S 5 Severity (quantity of pain on 0–10 scale:
0 5 no pain and 10 5 worst pain experi-
enced) and Setting (what causes the pain)
Data Collection t 5 timing (onset, duration, frequency)
Assessment of the client’s pain is a crucial nursing function.
During the assessment process, be aware of your own values (Adapted from Estes, 2010)
and expectations about pain behaviors. Just as the client’s
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COMPLETE WITH 1ST DOSE OF PAIN MEDICATION INITIALS SIGNATURE
1. Onset and frequency (When did it start?) (How often)

2. Provokes (What makes it worse?)
3. Radiates?
4. Severity/Intensity (What is an acceptable level of pain [0–10])
5. Timing/Duration (How long does it last?)
6. Past & Current analgesic/alternative modalities that make it better.
7. Does your pain affect: sleep__ appetite__ physical activity__ emotions__

social relationships__ Source of Side Effects: Safety:
COMMENTS: Information 1Nausa/Vomiting 1Bed low
1Patient 2Resp. Depression 2Call bell in reach
2Child 3Pruritus 3Side rails 2
Pediatrics/Noncommunicative Clients (0–10)
A. Verbal/Vocal B. Body Movements C. Facial D. Touching (localizing pain) 3Parent 4Urinary Retention 4Side rails 4
0positive 0moves easily 0smiling 0no touching 4Nurse 5Altered Mental Status 5Bed alert
1other complaint, whimper 1neutral shifting 1neutral 1reaching, patting
5Family 6None 6Family/Sitter
2pain, crying 2tense, flailing arms & legs 2frown, grimace 2grabbing
3screaming 3clenched teeth 6Other
Nonpharmacological Interventions Pediatrics Mode of Administration LEVEL OF CONSCIOUSNESS KEY (LOC)*

1Cold 7Massage 1. Alert, engages in conversation; puposefully travels with eyes, if mute
2Distractions 8Music 13Holding PCA SQ Rectal (R) 2. Lethargic, drowsy, sedate—focuses on personal interchange—but unable to
3Environmental Control 9Positioning 14Rocking IV PO Nasal (N) maintain focus
4Exercises 10Relaxation 15Pacifier IM SL 3. Responds only to maximal stimulation (shaking). Response only a grunt or
5Heat 11TENS 16Security Epidural (EP) moan—not a clear sentance.
6Imagery 12Spiritual Care object Transdermal (TD) 4. Coma—unable to respond at all.
Character: Evaluation of
Date/ Location Severity Pharmacologic// Mode of Source of B P R LOC Safety Time of Initails
Dull, Interventions/
Time of Pain Stabbing, Rating (Med Name)/ Adminis- Information Evaluation Frequency
Pressure, Rating 0–10
0–10 Nonpharmacologic tration Side
Sharp, Response/
Throbbing Effects Comments
CHRISTUS SPOHN HEALTH SYSTEM
PAIN MANAGEMENT FLOW SHEET

PATIENT CARE SERVICES
2006
2763751 NEW: 07/99

REVISED: 05/30/2001
FM15
Figure 7-5 Pain assessment and management. (Courtesy of CHristus spoHn HealtH system, Corpus CHristi, tX)
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Quality
BESTPRACTICE Ask the client what the pain feels like, and record the words
used to describe the pain. Clients may use sensory-type words,
Location of Pain such as “pricking,” “radiating,” “burning,” or “throbbing.”
Other clients use words that have an affective connotation,
During intershift report on a postoperative cli- such as “fearful,” “sickening,” or “punishing.” Other words
ent recovering from abdominal surgery, the used may be evaluative, such as “miserable” or “unbearable.”
nurse reported that the client had stated she had The quality of pain provides information that may be useful in
pain and had been medicated with IM Demerol. diagnosing the cause of the pain. For example, pain described
When greeting her client, the nurse asked the cli- as “burning” or “freezing” is usually neuropathic in origin.
ent about the pain she had experienced during
the night. The client replied, “Oh, it is fine now, Intensity
I only had a headache.” The night nurse had as- The client may have difficulty in judging the intensity of pain;
sumed the client’s pain was in her surgical site and however, it is important to obtain an estimate of the severity
chose the medication accordingly. The headache of the pain. This information allows the clinician to evaluate
probably could have been relieved with a milder
the effectiveness of pain relief measures tried by comparing
intensity before and after the interventions.
medication. All reports of pain must be thoroughly
Clients can use a pain intensity scale to rate their pain
assessed before implementing any interventions. (Figure 7-6). The Simple Descriptive Pain Intensity Scale or a
visual analog scale (VAS) is best used by showing the scale to
the client and asking the client to point to the spot on the scale
that corresponds to the present pain. The pain scale most
intensity, aggravating factors (variables that worsen the pain, frequently used with adolescent and adult clients is the verbal
such as exercise, certain foods, or stress), alleviating factors 0-to-10 scale. It needs no equipment or supplies and requires
(measures the client can take that lessen the effect of the pain, only one question: “On a scale of 0 to 10, with 0 being no pain
such as lying down, avoiding certain foods, or taking medica- at all and 10 being the worst pain possible, how much do you
tion), associated manifestations (factors that often accom- hurt right now?” If there are multiple painful areas, this ques-
pany the pain, such as nausea, constipation, or dizziness), and tion can be asked regarding each area. A study by Twycross
what pain means to the client. and colleagues (1996) showed that pain ratings of 4 or higher
Whenever subjective and objective data conflict, the subjec- on a 0-to-10 scale interfered with client activities and that
tive reports of pain are to be considered the primary source. scores of 6 and 7 markedly interfered with client quality of life.
Location
CLIeNt TEACHING
CLIeNt
The client can point to the location of the pain on the client’s
own body or locate it on a body diagram on a pain assessment TEACHING
tool. Ask the client if there is more than one site of pain; if
the pain radiates and, if so, to where; and if the pain is deep Pain at Night
or superficial. Teach the client that pain is commonly worse at
Onset and Duration night, when there are fewer distractions. If the
client knows this fact, he will not attribute the in-
Ask the client how long the pain has existed; what, if anything,
creased pain to complications.
triggers its onset; and if there are any patterns to the pain (e.g.,
whether it is worse at certain times of the day or night).
Simple Descriptive Pain Intensity Scale

A
No Mild Moderate Severe Very Worst

pain pain pain pain severe possible
pain pain
0-10 Numeric Pain Intensity Scale
B
0 1 2 3 4 5 6 7 8 9 10
No Moderate Worst
pain pain possible
pain
Figure 7-6 Pain intensity scales: A, Simple Descriptive Pain Intensity Scale; B, a 0-to-10 numeric pain intensity scale. (Courtesy of aCute pain
management: operative or meDiCal proCeDures anD trauma. CliniCal praCtiCe guiDeline [aHCpr publiCation no. 92–0032])
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0 1 2 3 4 5
No hurt Hurts Hurts Hurts Hurts Hurts
little bit little more even more whole lot worst
Alternate
0 2 4 6 8 10
coding
Figure 7-7 Wong/Baker FACES Pain Rating Scale (from HoCkenberry, m. J., Wilson, D., anD Winkelstein, m. l., Wong’s essentials of peDiatriC nursing, eD 7, st. louis, 2005, p. 1259. useD
WitH permission. CopyrigHt mosby)
This study, along with other studies (e.g., Cleeland & Syrjala, (which can be seen even in clients under general anesthesia)
1992) and clinical experience, has led clinicians to believe that continues, and the body physiologically pays the price. Clients
a pain level of 3 indicates a need to change the pain interven- also wake up with more pain than they had going to sleep,
tion plan with an increase in analgesics and other medications, thereby requiring even more intervention (pharmacological
or interventions (Office of Quality and Performance, U.S. De- and nonpharmacological) to reduce the pain.
partment of Veterans Affairs, 2008). Clients must be taught
how to correctly use a pain intensity scale. Meaning of Pain
Although developed for use with children, the FACES Because of the motivational-affective components of the pain
Pain Rating Scale (Figure 7-7) can be used effectively with cli- experience, the meaning of pain can have a great impact on
ents when a language barrier exists. Another pain assessment how the client perceives the pain. A frequently cited classic
tool is the “Painometer” developed by Dr. Gaston-Johansson study on this phenomenon was conducted by Beecher (1956),
(Mattson, 2000). The client positions a pointer between “no who compared the pain perceived by soldiers wounded in bat-
pain” and “worst possible pain.” Quantifying numbers are on tle to pain perceived by civilians with similar surgical wounds.
the back. The client also indicates the quality of pain by select- He found that only 32% of the soldiers required narcotics for
ing sensory and affective descriptors from a list. pain relief, whereas 85% of the civilians needed the narcotics.
The Abbey Pain Scale was developed to assess pain This was interpreted that for the soldiers, the wound repre-
in elderly clients who cannot express their pain because of sented a ticket away from the battlefield; for the civilians, the
dementia or other cognitive or verbal issues (Abbey, 2007) surgical wound was a depressing event.
(Figure 7-8). The Australian Pain Society recommends using Explore with the client what implications the pain may
the pain scale while assessing a client during movement, for have for the individual. Does it mean that the client’s cancer
example, during a shower, ambulating in the hall, or turning is metastasizing? Or that the client’s condition is worsening?
from side to side (Gibson, Scherer, & Gouck, 2004). After All these interpretations may influence the pain experience
nursing interventions, nonpharmacological and/or pharma- for the client.
cological, are taken to address the pain, the nurse reassesses
the client’s pain level in an hour to evaluate the effectiveness Objective Data
of the pain-relieving intervention (Abbey, 2007). As discussed when addressing acute versus chronic pain, the
Aggravating and Alleviating Factors objective data often present a different picture depending on
the type of pain the client is experiencing.
Ask the client about what makes the pain worse and what
makes the pain better, including behaviors or activities that Physiological
influence the pain. This information helps develop the plan of Acute pain activates the sympathetic nervous system, and the
care for the client in pain. If specific activities relieve the pain, client may exhibit elevated heart rate, elevated respiratory
incorporate them into the care plan. Being aware of activities rate, elevated blood pressure, diaphoresis, pallor, muscle ten-
that increase the pain can allow for interventions that may pre- sion, and dilated pupils. These signs resemble those of anxiety,
vent the pain. For example, if physical therapy exercises trigger which often accompanies acute pain. The signs and symptoms
an increase in pain, administer an analgesic according to phy- of chronic pain show adaptation and, therefore, are different
sician’s or nurse practitioner’s orders before the treatment. from those of acute pain, with vital signs being normal and no
accompanying pupil dilation or perspiration.
Associated Manifestations
The initial pain assessment includes the impact of pain on
the activities of daily living. Pain may cause changes in sleep
patterns or the ability to work and carry out the many roles in
a client’s life. Pain may affect appetite, mood, sexual function- CULTURAL CONSIDERATIONS
39-1
ing, or the ability to participate in recreational activities. If
pain is interfering with daily life, the client’s quality of life is Language Barrier and Pain
greatly affected.
Pain is fatiguing. It requires a significant amount of The FACES Pain Rating Scale is used effectively
energy to deal with pain. The longer a person has pain, the with clients when a language barrier exists. A
greater the level of fatigue. Although there is no conscious translator is used initially to explain what the faces
awareness of pain during sleep, there may be dream-state represent.
awareness (McCaffery & Pasero, 1999). The stress response
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Image not available due to copyright restrictions
Behavioral The client in chronic pain may demonstrate behaviors

Acute pain behaviors may include crying and moaning, rub- similar to those of depression, such as hopelessness, listless-
bing the site of pain, restlessness, a distorted posture, clenched ness, and loss of libido and weight. Chronic pain often leads
fists, guarding the painful area, frowning, and grimacing. The to physical inactivity or immobility, which can lead to func-
client usually speaks of the discomfort and may be restless or tional disability. Distraction (focusing attention on stimuli
afraid to move. other than pain) may also be used by clients. According to
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be continued or changed. Perform the pain assessments when

BESTPRACTICE the intervention should be providing the most relief. For ex-
ample, the onset of intravenous morphine is rapid, peaking ap-
Assessing the effect of Pain on Sleep proximately 20 minutes after administration. If the client has
not obtained relief by 20 minutes, the intravenous morphine
Questioning clients about the effect pain has on was ineffective, and the plan of care needs to be revised.
their sleep habits clarifies the intensity of the pain
and its effect on the clients’ patterns of daily liv- Recording Pain Assessment Findings
ing. Ask the client whether the pain: Pain assessment is of little value unless the information is
• Prevents the client from falling asleep. recorded in a manner easily understood by the health care
• Makes it difficult to find a comfortable sleeping team. A flow sheet provides one place to document most of
position. the information used to make pain management decisions,
• Wakes the client from a sound sleep. including pain rating, vital signs, analgesic administered, and
• Prevents the client from falling back to sleep.
level of arousal. The client’s report of pain must be accepted
and recorded, with pain management decisions based on that
• Leaves the client feeling tired and unrefreshed
report.
after sleeping.
Nursing Diagnoses
The two primary nursing diagnoses used to describe pain are
CRITICAL THINKING Acute Pain and Chronic Pain. According to the North Ameri-
can Nursing Diagnosis Association International (2009),
Acute Pain is defined as “an unpleasant sensory and emotional
Assessing Pain experience arising from actual or potential tissue damage or
described in terms of such damage . . . [with] sudden or slow
onset of any intensity from mild to severe, with an anticipated
A 38-year-old client is unable to rate his pain on a or predictable end and a duration of less than 6 months”
0-to-10 scale. What actions should the nurse take (p. 354). Chronic Pain is defined the same as Acute Pain, with
to perform a pain assessment on this client? the last phrase replaced by “constant or recurring without an
anticipated or predictable end and a duration of greater than
(Teeter & Kemper, 2008a)
6 months” (p. 355).
Pain may be the etiology (cause) of other problems
(e.g., Impaired Physical Mobility, related to arthritic hip pain).
Whether the pain is addressed in the problem statement or
McCaffery and Pasero (1999), clients often minimize the the etiology is determined by the client’s primary problem.
pain behaviors they are able to control for several reasons, Many diagnoses can be related to the client in pain depending
including: on the effects of the pain:
• To be a “good” client and avoid making demands. • Activity Intolerance
• To maintain a positive self-image by not being a “sissy.” • Anxiety
• Distraction makes pain more bearable (young children are • Constipation
particularly adept at this).
• Exhaustion.
Client pain behaviors include splinting of the painful
area, distorted posture, impaired mobility, anxiety, insomnia,
attention seeking, and depression. Occasionally, a discrep- CULTURAL CONSIDERATIONS
39-1
ancy exists between pain behaviors observed by the nurse
(objective data) and the client’s self-report of pain. Discrep- Perception of Pain
ancies between behaviors and the client’s self-report can Culture determines the way persons derive mean-
result from good coping skills (e.g., relaxation techniques or
ing from their lives and also determines appropri-
distraction), anxiety, stoicism, or cultural differences in pain
behaviors. Whenever these discrepancies occur, they should ate behaviors. One’s cultural upbringing teaches
be addressed with the client and the pain management plan behaviors, including those that are exhibited when
renegotiated accordingly. in pain. People from different cultures use differ-
ent types of words to describe pain (e.g., in sensory
Ongoing Assessment or emotional terms). These differences should not
The initial assessment obtains a baseline set of information be ignored, but be careful not to prejudge a client
about the client’s pain, while subsequent assessments provide based on cultural background or ethnicity. Because
information regarding the effectiveness of the interventions. of the unique experience of pain, the person will
Physiological and behavioral signs and, most important, the exhibit individualized behaviors even though they
client’s subjective pain ratings of the intensity all help the are influenced by cultural upbringing.
health care team determine whether the interventions should
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• Deficient Knowledge (specify) mild pain, with medication available as “backup.” Cases of mod-
• Disturbed Body Image erate to severe pain may use nonpharmacological techniques as
• Disturbed Sleep Pattern effective adjunctive, or complementary treatment.
There are three categories of pain control interventions:
• Fatigue pharmacological, noninvasive, and invasive. Each category
• Fear is discussed separately, but these methods are often used in
• Hopelessness combination.
• Impaired Social Interaction
• Ineffective Breathing Pattern Pharmacological Interventions
• Ineffective Coping Caring for a client experiencing pain is a collaborative pro-
• Ineffective Role Performance cess. Drug therapy is the mainstay of treatment for pain
• Ineffective Self-Health Management control. The American Pain Society (APS) provides pain
management guidelines that can be used as a framework for
• Powerlessness providing drug therapy in pain control (APS, 2006; Gordon
et al., 2005). These guidelines are based on pain management
Planning/Outcome research and thus are termed evidence based. These guidelines
Identification represent concise information that can help nurses, physi-
cians, and other health care workers effectively administer
When planning care, mutual goal setting with the client expe- medications for pain relief. The word action incorporates
riencing pain is of utmost importance. The nurse and client these principles of pain management and can be recalled by
work together to develop realistic outcomes. Consider both using the ACTION acronym shown in Memory Trick (Teeter
nonpharmacological and pharmacological interventions. & Kemper, 2008b).
Often, several approaches must be combined for adequate The World Health Organization (WHO) (1990) has
relief to be obtained. No matter which type of intervention is made worldwide relief of cancer pain one of its primary goals.
being utilized, general principles apply: individualization, pre- To help meet this goal, it developed an analgesic ladder to
vention, and utilization of a multidisciplinary approach. help the clinician determine which analgesic to prescribe
(Figure 7-9). Step 1 is for mild pain and includes a nonopioid
Individualize the Approach with or without an adjuvant medication. If pain persists or
A variety of pain relief measures can be tried in many com- increases, an opioid for mild to moderate pain can be added
binations until the goal of pain relief is reached. This often (step 2). Step 3, for pain that continues or increases despite
means some trial-and-error use of interventions until the right step 2 treatments, recommends an opioid for moderate to
combination is found. It is important to include measures severe pain with or without a nonopioid or an adjuvant.
that the client believes will be effective. The cognitive com- All the nonopioids have ceiling doses; that is, if the dose
ponent of pain perception can have a powerful influence on is increased above a certain level, no additional pain relief is
the effectiveness of interventions. This may mean including provided, only an increase in adverse or toxic effects. This
folk remedies or nonscientific relief measures. It is important is important to remember for clients who are receiving sev-
to keep an open mind. This comes with the caution to avoid eral medications that contain a nonopioid. For example, a
those remedies that may harm the client. client may be prescribed both acetaminophen for fever and
Use a Preventive Approach

Pain is much easier to control if it is treated before it gets MEMORY TRICK
severe. Interventions are implemented when pain is mild or
when it is anticipated. For example, medicate a client before Principles of Pain Management
a painful dressing change or treatment rather than waiting for Use the acronym ACtION to recall the principles of
the pain to occur. pain management:
Use a Multidisciplinary Approach A 5 Assess clients for pain at regular intervals.
Pain relief is a complex phenomenon requiring input from C 5 Choose a variety of interventions for pain.
various members of the health care team. The nurse’s role is t 5 treat pain promptly to avoid escalation of
pivotal in managing a client’s pain. The physician also plays a pain.
key role, diagnosing and treating the medical cause of the pain,
which includes prescribing appropriate medications. In com- I 5 Include client-specific cultural, spiritual, and
plex cases, other professionals, such as physical therapists, psy- developmental considerations in the pain
chologists, social workers, or chaplains, may be needed. The management plan.
multidisciplinary team approach is the most successful way to O 5 Optimize the pain management plan through
manage chronic pain and improve the quality of a client’s life.
ongoing evaluation.
Implementation N 5 Negotiate pain interventions and goals with

the client to enhance adherence to the plan.
Pharmacological and nonpharmacological interventions can
both be effective in caring for clients in pain. Nonpharmacologi- (APS, 2006; Gordon et al., 2005; Teeter and Kemper, 2008b)
cal techniques may be the primary intervention in some cases of
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WHO Analgesic Ladder

CLIeNt TEACHING
CLIeNt TEACHING
Freedom
from pa
in timed-Release tablets
Opioid for
Mild
Severe pa to
3 Emphasize that the extended-release tablets be-
in ep
Non-opioid St come immediate release if crushed (e.g., for a cli-
Adjuvant ent who has difficulty swallowing the tablet).
Pain pers
is ting or in
creasing
Opioid fo
r Mild to
Moderate 2
pain e p
Non-opio
Adjuvant
id St When this client reports having pain, which analgesic should
the nurse administer? Which route? Which dose? How fre-
Pain p quently? The nurse has a large responsibility in making these
ersis ting o decisions but also has autonomy.
r incre
asin g McCaffery and Pasero (1999) identify the following as
Mild the responsibilities of the nurse in administering analgesics:
pain
Non- 1
opioid
e p • Determine whether to give the analgesic, and if more than
St
Adjuv
ant
one is ordered, which one.
• Assess the client’s response to the analgesic, including as-
sessing the effectiveness in pain relief and occurrence of any
side effects.
Figure 7-9 The WHO analgesic ladder gives guidelines for • Report to the physician when a change is needed, includ-
choosing analgesic therapy for cancer pain based on the level of ing making suggestions for changes based on the nurse’s
pain the client is experiencing. (Courtesy of WorlD HealtH organization, 2008. useD WitH knowledge of the client and pharmacology.
permission)
• Teach the client and family regarding the use of analgesics.
Percocet (a combination drug containing acetaminophen Principles of Administering Analgesics
and oxycodone) for pain. Be sure to consider both sources of “How an analgesic is used is probably more important than
acetaminophen to ensure that the client does not exceed the which one is used” (McCaffery & Pasero, 1999). Principles
24-hour ceiling dose of 4 grams. Liver necrosis can result from should be applied in the administration of analgesics, no mat-
acetaminophen overdose. ter which one is given.
Opioids are recommended on steps 2 and 3 of the Establishing and maintaining a therapeutic serum level
WHO pain relief ladder. Weak opioids (step 2) include co- is important. Peaks and valleys often occur when analgesics
deine, hydrocodone, and oxycodone. Most often, these drugs are administered in the traditional prn (as-needed) manner.
are administered orally in combination products containing When the dose is administered on an intermittent schedule, a
acetaminophen. As noted previously, dosing of combination larger dose is often required, causing the client to have a peak
products is limited by the ceiling dose of nonopioids. Strong serum drug level in the sedation range. The client must wait
opioids (step 3), such as morphine, hydromorphone, and for the return of pain before requesting the next dose of anal-
fentanyl, are given for severe pain (Teeter & Kemper, 2008b). gesic. Depending on the length of time it takes to obtain the
Combining analgesics and the use of adjuvant medication medication and, once taken, to reestablish an adequate blood
provides effective pharmacological intervention for clients level, there could be a period of up to an hour or so without
with pain. Adjuvant medications are those drugs used to adequate pain control.
enhance the analgesic efficacy of opioids, to treat concurrent
symptoms that exacerbate pain, and to provide independent Preventive Approach
analgesia for specific types of pain. The ladder recommends Pain is much easier to control if treated when it is anticipated
that the analgesic, plus or minus an adjuvant, be chosen based or at a mild intensity. Once pain becomes severe, the analge-
on the level of pain the client is experiencing. This ladder gives sics ordered may not be effective enough to relieve it. Many
health care workers guidelines in determining if the drug regi- clinicians still teach their clients to wait to take medication
men is appropriate for the client with cancer pain. until they are sure they really need it. This practice leads to un-
controlled pain. There are two ways the preventive approach
Nurses’ Role in Administration of Analgesics may be implemented:
The nurse spends the most time with the client in pain and is
the team member who most often assesses the effectiveness • ATC (around the clock). When pain is predictable, for ex-
of pain control interventions. When analgesics are prescribed, ample, the first few days following surgery or with chronic
the nurse often has choices of drug, route, and interval. For ex- cancer pain, the medication is administered on a scheduled
ample, the postoperative client may have the following orders: basis. This prevents the peaks and valleys of serum drug
level that can lead to oversedation or toxicity and recur-
• Morphine 2.5 to 15 mg IV every 2 to 4 hours prn severe rence of pain, respectively. If the analgesics are ordered by
pain the physician to be given prn, it can still be a nursing mea-
• Vicodin one to two tabs every 3 to 4 hours prn moderate sure to administer the drugs ATC, as long as they are given
pain within the time constraints of the order.
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medications orally, the client’s diagnosis, and assessment

CLIeNt TEACHING
CLIeNt TEACHING of the client’s response to the current route. Intravenous
administration provides the most rapid onset of pain relief.
Pain Management All other routes require a lag time for absorption of the
analgesic into the circulation. In postoperative pain, IV is
• It is import to take or request pain medication the preferred route for opioids when the oral route is not
before the pain becomes severe and more dif- appropriate. If IV access is not available, sublingual, rectal,
ficult to control. or transdermal routes are considered.
• Numerous nonpharmacological approaches With cancer pain, the oral route is preferred. If the cli-
can be used to augment pharmacological pain ent is unable to take oral medications, rectal and transder-
management. mal routes are preferred because they are less invasive than
• Pain management is individual. (The client may other routes (Agency for Healthcare Research and Quality,
2007). In addition, tolerance develops at a slower rate with
be taking different medications or dosages than
the oral route compared to the more invasive routes.
other individuals.)
• Choice of drug. If one drug is not providing relief or has un-
acceptable side effects, another analgesic is tried.
The key to administering an analgesic is to monitor the
• PRN (Latin for pro re nata, which means “as required”). client’s response to it. This includes assessing the effectiveness
Pain is not always predictable, therefore prn dosing may of pain relief and the occurrence of side effects.
be required. For some clients this may be used in addition
to scheduled dosing for “breakthrough” pain (pain that Classes of Analgesics
surpasses the level of analgesia, or pain relief without Three classes of drugs are used for pain relief: (a) nonopioid
anesthesia, that the steady level of analgesics is providing). analgesics, (b) opioid analgesics, and (c) analgesic adjuvants,
Examples of this include a cancer client on prolonged- which were discussed earlier (WHO, 2008).
release morphine who needs extra analgesics to participate
in activities such as shopping or receiving visitors. Another Nonopioids
example would be the orthopedic client who is receiving The medications in this category are useful for a variety of
regularly scheduled analgesics for postoperative pain who painful conditions, including surgery, trauma, and cancer
needs additional pain relief for therapy sessions. To imple- (APS, 1999). The indications include mild to moderate pain,
ment the preventive approach with prn dosing, the medica- and they are used in conjunction with opioids. These drugs
tions are given as soon as the pain appears, or when it is differ from opioids in several ways in that they:
anticipated to begin.
• Are subject to the ceiling effect.
Titrate to Effect • Do not produce the effect of tolerance or physical
Because of the unique nature of the pain experience, the an- dependence.
algesic regimen needs to be titrated until the desired effect is • Are antipyretic and should not be given in cases where they
achieved. This involves adjusting the following: may mask an infection.
• Dosage. Some clients may require more or less than the Ketorolac tromethamine (Toradol) is the only nonste-
standard dose. Many factors may influence the pharmaco- roidal anti-inflammatory drug (NSAID) available in paren-
kinetics in an individual client. The individual’s response teral form and has proven useful in clients on NPO status who
is assessed, and the dosage of the analgesic is regulated would benefit from an NSAID. Even when administered in-
accordingly. In clients with chronic cancer pain, opioid tramuscularly or intravenously, ketorolac produces significant
analgesics are increased until pain relief is obtained or gastric irritation and the potential for gastric bleeding. The
unacceptable side effects occur. This may be done because most frequent use of ketorolac is orally or intramuscularly in
of the lack of a ceiling effect (the dosage beyond which adults, but some pediatric centers have used it intravenously
no further analgesia occurs) in pure opioids. The lack of under strict supervision for a limited course (less than 5 days)
a ceiling effect means there is no limit to the dose that can in children and adolescents with great success.
be given. For example, cancer clients have been known to
receive more than 1 gram per hour intravenously. Because Action
the dosage is gradually increased, the client develops a tol- Action of these drugs is thought to inhibit prostaglandin for-
erance (requiring larger and larger doses of an analgesic to mation. If prostaglandins are inhibited, the sensory neurons
achieve the same level of pain relief) to the side effects of are less likely to receive the pain signal. Thus, this class of
the opioid. analgesics works in the peripheral nervous system.
• Interval. Some clients metabolize analgesics faster than oth-
ers. For example, young adults tend to metabolize opioids Opioids
faster, therefore they may need more frequent doses. Older The opioid analgesics fall into three classes: pure opioid
clients tend to metabolize them slower, so they require a agonists, partial agonists, and mixed agonist-antagonists
longer interval between doses. (a compound that blocks opioid effects on one receptor type
• Route. The appropriate route is chosen depending on how while producing opioid effects on a second receptor type).
rapidly pain relief is required, the client’s ability to take Pure agonists produce a maximal response from cells when
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BESTPRACTICE LIfe SPAN CONSIDeRAtIONS

types of Nonopioid Drugs effects of Meperidine (Demerol)
• Salicylates. These include aspirin and other In the elderly, most of whom show decreased glo-
salicylate salts. Common side effects of aspi- merular filtration rates, there is generally a higher
rin include gastric disturbances and bleeding peak and longer duration of action of meperidine
caused by the antiplatelet effect. Some of the because it takes longer to excrete the opioid as
salicylate salts, such as choline magnesium tri- well as its toxic metabolite, normeperidine.
salicylate (Trilisate) and salsalate (Salgesic), have
fewer gastrointestinal and bleeding effects than
aspirin.
• Acetaminophen. This nonsalicylate is similar to Side Effects
aspirin in its analgesic action but has no anti-
The only limiting factor in the use of pure agonist opioids
inflammatory effect. Its mechanism of action for
is the degree of side effects, particularly respiratory depres-
pain relief is not known. sion and constipation. Other side effects include pruritus
• NSAIDs. The effectiveness of these drugs varies, and nausea, but the degree to which they are present from
with some being close to the effectiveness of each medication varies among individuals. Clients must be
aspirin and acetaminophen, whereas others are instructed regarding these normal responses to opioids and
much stronger. Clients tend to vary in response, informed that it does not mean that they are allergic to them.
so once the maximum recommended dose has A true allergy to opioids would be indicated by a rash or hives
been tried with ineffective results, it would be that start after receiving the opioid, a local histamine release at
worth trying another NSAID. The drugs in this the site of infusion, or anaphylaxis. Clients also need to know
group inhibit platelet aggregation and are con- that the pruritus and nausea generally subside after 4 to 5 days
of opioid therapy. In the meantime, an antihistamine such as
traindicated in clients with coagulation disor-
diphenhydramine hydrochloride (Benadryl) or hydroxyzine
ders or on anticoagulation therapy.
hydrochloride (Atarax, Vistaril) may be used for pruritus,
and an antiemetic such as metoclopramide hydrochloride
(Clopra) or trimethobenzamide hydrochloride (Tigan) can
they bind to the cells’ opioid receptor sites. Morphine (the be used to treat the nausea.
gold standard against which all other opioids are measured), Almost all medications used to treat side effects have their
fentanyl, methadone (Dolophine), hydromorphone hydro- own side effect of sedation. Thus, there is the possibility of a
chloride (Dilaudid), and codeine are pure agonists. Meperi- cumulative effect of severe sedation. These medications must
dine (Demerol), although classified as a pure agonist, is not be used with caution and appropriate monitoring until the
recommended except in clients with a true allergy to all other client’s response is determined. Ondansetron hydrochloride
narcotics because of its neurotoxicity. Meperidine produces (Zofran) is one antiemetic on the market with little, if any,
clinical analgesia for only 2.5 to 3.5 hours when given intra- sedative effect. It received Food and Drug Administration
muscularly in adults. approval for use with postoperative nausea and is effective in
Unlike the NSAIDs, pure agonist opioids are not subject to clients with refractory nausea and vomiting unresponsive to
the ceiling effect. As the dosage is increased, pain relief increases. other antiemetics. The current cost per dose, close to $100 in
many hospitals, limits its use to the extreme nausea associated
Action with cancer chemotherapy or to clients with refractory nausea
and vomiting.
Opioids act in the CNS by binding to opiate receptor sites
on afferent neurons. The pain signal is stopped at the spi-
nal cord level and does not reach the cortex where pain is
perceived.
BESTPRACTICE
Constipation and Opioids
BESTPRACTICE Clients who are expected to require opioid anal-
gesics for more than 1 or 2 days should be admin-
Ketorolac tromethamine (toradol)
istered a stool softener as soon as they are taking
Ketorolac should not be given to a client with fluids orally. While they are still NPO, a glycerin or
any history of renal dysfunction, gastric irritation, bisacodyl (Dulcolax) suppository is administered if
bleeding problems, low platelet count, or allergy the client has not had a bowel movement in 1 or
to aspirin or other NSAIDs. 2 days.
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Mixed agonist-antagonist opioids are believed to be sub- medication, and pain relief are related and how to maintain a
ject to the ceiling effect for pain relief, as well as a ceiling effect pain-relief diary. A Velcro®-sealed wrist pouch is applied to the
for respiratory depression. Mixed agonist-antagonist opioids client with one or two doses of the prescribed oral analgesic,
activate one opioid receptor type while simultaneously block- even controlled substances, in the pouch. The client notifies
ing another type. Butorphanol tartrate (Stadol), pentazo- the nurse when a dose is taken so that it can be replaced. If
cine hydrochloride (Talwin), and nalbuphine hydrochloride the client does not comply with the oral PCA policy, it is
(Nubain) are the most frequently used in pain management. discontinued.
Opioid antagonists include naloxone (Narcan) and nal- Medication on Demand (MOD®) is another method of
trexone hydrochloride (ReVia), with the most commonly oral PCA. The facility pharmacy places eight doses of oral
used being naloxone (Narcan). They work by blocking opioid medication in the medication tray, which is then loaded into
stimulation of receptor sites. Naloxone effectively reverses the device. The cover is closed, locking the medication se-
opioid side effects of sedation, respiratory depression, and curely inside. The MOD® locks to an IV pole for easy client ac-
nausea, and it completely reverses any pain control. cess as shown in Figure 7-11A. The client accesses the MOD®
with his radio-frequency identification (RFID) wristband,
Alternative Delivery Systems dials in his pain level from 0 to 10 by touching the pad on the
Opioids are administered in more than just the traditional front of the device, and receives the prescribed medication.
oral, subcutaneous, intramuscular, intravenous, and rectal The device is programmed to respond only to a specific cli-
routes. ent’s RFID wristband. Once the client accepts the medication,
the device has a lockout interval so the client cannot receive
Patient-Controlled Analgesia more than the prescribed dose. At the end of the lockout time,
Patient-controlled analgesia (PCA) is most often deliv- a light on the MOD® illuminates, indicating that the client
ered by a device that allows the client to control the delivery can have medication when needed. Nurses may access the
of intravenous, epidural, or subcutaneous pain medication device with a programmed RFID card. The device stores the
in a safe, effective manner through a programmable pump information for reference, printing, or inclusion in the client’s
(Figure 7-10). This system helps eliminate the time required electronic medical record (Figure 7-11B).
for the nurse to draw up the medication and allows the cli-
ent control over the pain. The pump has the safety feature of Epidural/Intrathecal Analgesia
“locking out” once a maximum dose is reached. This prevents Epidural analgesia refers to administering the opioid via
the client from overdosing. The PCA has been successfully a catheter that terminates in the epidural space, the space
used with many types of pain and in many settings, including outside the dura mater that protects the spinal cord. Intra-
postoperative, pediatrics, and home health. thecal analgesia refers to administering the drug directly
Requirements for using a PCA pump are the cognitive into the subarachnoid space. These types of analgesia may be
ability to understand how to use the pump and the physical administered as a one-time injection by the anesthesiologist
ability to push the button. The nurse teaches the client and or via a catheter that has been placed. Both of these routes
family about the PCA pump and pain medication, how to are occasionally referred to as intraspinal anesthesia. Because
activate the pump, and that the client is the only one to ac- the opioid is delivered close to the site of action, these routes
tivate the pump. The nurse explains the pain rating scale to require much lower doses of opioid (usually morphine [Dura-
the client and continues to regularly monitor the client’s pain morph] or fentanyl [Sublimaze] are used) for pain relief. The
even when the client is using the pump. Teach the client to incidence of systemic side effects is also much lower with
“push the button” only when medication for pain is needed. these routes. Duration is longer than systemic routes because
The client or family notifies the nurse if the medication is not one dose of intrathecal morphine can last 24 hours.
controlling the pain so that alternative measures can be taken.
Oral PCA is used in some hospitals and is becoming in- Transdermal Analgesia
creasingly popular (Rosati et al., 2007). Client teaching is the Another route of opioid administration is the transdermal
key for success. The client must understand how pain, pain patch. The only opioid drug currently available via this route
is fentanyl (Duragesic). This medication is on an adhesive
patch that attaches to the skin. It is available in 25, 50, 75, and
100 mcg/hr dosages. The fentanyl transdermal patch allows
slow infusion of the drug through the skin. The fentanyl patch
is indicated for continuous pain with high dosage require-
ments. The advantage of this route is that it is simple to apply
and effective for 72 hours. The disadvantage is that dosage
adjustments are difficult to make because of the slow infusion
rate. In addition, side effects may not be reversed as rapidly as
when opiates are administered via the oral route.
Local Anesthesia
Local anesthetics are effective for pain management in a
variety of settings. Topical anesthetics are available for
teething, sore throats, denture pain, laceration repair, and
intravenous catheter insertions. One topical anesthetic,
Figure 7-10 Client on IV patient-controlled analgesia. EMLA cream, is a mixture of local anesthetics, combining
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After completing a teaching module with hands-on

instructions, the client obtains oral pain medication
as needed from the MOD®. An illuminated
ready light appears indicating to the client that
the lockout interval has passed and medication
is now available when needed. The client obtains
medication as needed without requesting the
medication from a nurse. To get the medication,
the client:
1. Indicates his pain level
from 0–10 on the pain
scale. This activates
the radio frequency
identification (RFID)
reader within the MOD®
device.
2. Swipes the RFID
wristband across the
MOD®’s faceplate.
3. Removes the pre-
scribed dose of
pain medication and
self administers the
medication.
A B
Figure 7-11 Oral patient-controlled analgesia device called Medication on Demand (MOD®): A, MOD® is locked to an IV pole for
client accessibility. The facility pharmacy places oral medication in the medication tray, which is then loaded into the device. B, Guide-
lines for obtaining medication from the MOD®. (images Courtesy of avanCen)
prilocaine (Citanest) and lidocaine (Xylocaine). It produces the open wound surface in place of local anesthetic infiltra-
complete anesthesia for at least 60 minutes when topically tion with a needle. This allows pain-free cleansing of the
applied on intact skin. Another topical anesthetic, TAC, is laceration as well as suturing. Adrenaline (epinephrine) and
available for anesthesia during closure of lacerations. It is cocaine cause vasoconstriction, therefore, TAC cannot be
a combination of tetracaine hydrochloride (Pontocaine) used in areas supplied by end-arteriolar blood supply such
0.5%, adrenaline (epinephrine) 1:2000, and cocaine 11.8% as a client’s digits, ears, or nose. It also is contraindicated on
in a normal saline solution that can be applied directly to burned or abraded skin because this could lead to increased
systemic absorption of cocaine and tetracaine, thus placing
the client at risk for seizures.
LIfe SPAN CONSIDeRAtIONS Noninvasive Interventions

Noninvasive relief measures consist of cognitive-behavioral
Opioid Analgesia in the elderly strategies and physical modalities that use cutaneous stimula-
• Cheyne-Stokes respiratory patterns are not un-
tion. These treatments can be used to supplement pharmaco-
logical therapy and other modalities to control pain. Clients
usual during sleep in the elderly and should not
and their families can also be instructed to utilize these treat-
be used as a reason to restrict appropriate opi- ments at home and in inpatient settings.
oid pain relief unless accompanied by unaccept-
able degrees of arterial desaturation (less than Cognitive-Behavioral Interventions
85%). The cognitive-behavioral interventions influence the cognitive
• The elderly are more sensitive to sedation and and the motivational-affective components of pain perception.
respiratory depressant effects and experience a These methods can not only influence the level of pain, but
higher peak and longer duration of effect from also help the client gain a sense of self-control. (Refer to the
opioid medications. Complementary and Alternative Therapies section in Chap-
• Opioid dose titration must be based on anal- ter 4 for more information on mind/body interventions.)
gesic effects and degree of side effects, such as
Trusting Nurse–Client Relationship
sedation, urinary retention, constipation, respi-
ratory depression, or exacerbation of Parkin-
Establishing a therapeutic relationship is the foundation for
effective nursing care. The clients most likely to be comfort-
son’s disease.
able are those who trust their nurses to be there, to listen, and
to act.
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returns in full force. For this reason, the most appropriate use
BESTPRACTICE of distraction techniques is for the relief of brief, episodic pain.
It can be effective for procedural pain or the period between
Using Distraction administration of an analgesic and the onset of the drug. Ex-
amples of distraction include the following:
Distraction should never be the only pain manage-
• Active listening to recorded music (have the client tap fin-
ment intervention used, but it can be very helpful
gers in rhythm to the beat)
while waiting for other techniques to take effect.
• Recite a poem or rhyme
• Describe a plot of a novel or movie
• Describe a series of pictures
Relaxation Guided Imagery
Relaxation techniques (a variety of methods used to de- Guided imagery uses one’s imagination to provide a pleas-
crease anxiety and muscle tension) result in decreased heart ant substitute for the pain. It incorporates features of both
rate and respiratory rate and decreased muscle tension. The relaxation and distraction. The client imagines a pleasant
body’s response to pain is almost “tricked” into reversing itself experience, such as going to the beach or the mountains. The
when relaxation exercises are implemented. experience should use all five senses to fully involve the client
Relaxation exercises help reduce pain by decreasing in the image.
anxiety and decreasing reflex muscular contraction. There The images chosen need to be ones that are pleasant for
are a wide variety of relaxation techniques, including focused the client. Describing an ocean cruise would not be appropri-
breathing, progressive muscle relaxation, and meditation. ate for a person who becomes seasick.
Simple techniques are used during episodes of brief pain (e.g.,
during procedures) or when pain is so severe that the client is Humor
unable to concentrate on complicated instructions.
The old saying “Laughter is the best medicine” carries some
To teach simple relaxation techniques, the nurse instructs
truth to it. Although there is nothing very funny about pain,
the client to (a) take a deep breath and hold it, (b) exhale
laughing has been shown to provide pain relief. The act of
slowly and concentrate on going limp, and (c) start yawning
laughing can cause distraction from the pain, induce relax-
(McCaffery & Pasero, 1999). The yawning triggers a condi-
ation (by taking deep breaths and releasing tension), release
tioned response in the client (i.e., the body associates yawn-
endorphins, and provide a pleasant substitute for pain. Nor-
ing with relaxation and will relax when the client yawns). The
man Cousins (1979) relates obtaining 2 hours of pain relief
technique can be enhanced if the nurse starts yawning. It is so
from watching episodes of the Candid Camera television show
contagious that even the client compromised by severe pain
and Marx Brothers films. This technique can be implemented
will usually start yawning with the nurse.
by encouraging the client to watch humorous movies, read
A more complex technique is progressive muscle re-
funny books, or listen to comedy routines. Because different
laxation, a strategy in which muscles are alternately tensed people see humor in different types of situations, be sensitive
and relaxed. This type of technique is especially useful for
to what the client views as funny.
clients who do not know what muscle relaxation feels like. By
purposely contracting and releasing the muscle groups, the Biofeedback
client is able to compare the difference and identify feelings of
relaxation. Meditative relaxation techniques are also available, Biofeedback is a method that may help the client in pain to
including audiotapes sold in most bookstores. relax and relieve tension. Individuals learn to influence their
Relaxation is a learned response. The more frequently the physiological responses to stimuli and thus alter their pain
client practices these techniques, the more skilled the body experience.
will be in learning to relax. Ideally, the best time to teach the
client these methods is when pain is controlled or before the Cutaneous Stimulation
pain occurs (e.g., in the preoperative period). The technique of cutaneous stimulation involves stimulating
the skin to control pain. It is theorized that this technique
Reframing provides relief by stimulating nerve fibers that send signals
Reframing is a technique that teaches clients to monitor to the dorsal horn of the spinal cord to “close the gate.” The
their negative thoughts and replace them with more positive main advantage of these therapies is that many techniques are
ones. For example, teach a client to replace an expression such easy for the nurse to implement and easy to teach the client
as “I can’t stand this pain; it’s never going away” with one such and family to perform. They are not usually meant to replace
as “I’ve had similar pain before, and it’s gotten better.” analgesic therapy, but to complement it.
Distraction Hot and Cold Application

Distraction focuses one’s attention on something other than In addition to stimulating nerves that can block pain transmis-
the pain, therefore placing pain on the periphery of awareness. sion, superficial heat application increases circulation to the
Successful use of distraction does not eliminate the pain; it area, which promotes oxygenation and nutrient delivery to
makes it less troublesome. The main disadvantage of distrac- the injured tissues. It also decreases joint and muscle stiffness.
tion is that as soon as the distractive stimuli stop, the pain Heat is contraindicated in cases of acute injury because it can
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CLIeNt TEACHING
CLIeNt TEACHING SAfety
Hot or Cold Applications teNS Contraindications
Teach the client or family that hot or cold • No electrodes are placed in the area over or sur-
applications: rounding demand cardiac pacemakers.
• Must have at least one layer of towel between • No electrodes are placed over the uterus of a
the heating or cooling device and the skin. pregnant woman.
• Should not exceed 20 minutes when placed on
the skin (NSW Health, 2005).
• Should not be applied to tissue that has been
exposed to radiation therapy (James Cancer
Hospital & Solove Research Institute, The Ohio Transcutaneous Electrical Nerve Stimulation
State University Medical Center, 2010). Transcutaneous electrical nerve stimulation (TENS)
is the process of applying a low-voltage electrical current to
the skin through cutaneous electrodes. This modulates pain
transmission, as do other cutaneous stimulation methods,
increase the initial response of edema. It is also contraindi- but also distracts the client from pain. Research supports the
cated in rheumatoid arthritis flare-ups and over topical ap- effectiveness of using TENS for the relief of postoperative
plications of mentholated ointments. Heat treatments should pain (Agency for Health Care Policy and Research, 1992;
be limited to 20- to 30-minute intervals because maximum Rakel & Frantz, 2003). It has also been used successfully in
vasodilation occurs in that time. many pain syndromes (e.g., chronic low-back pain, menstrual
Cryotherapy (cold applications) induces local vasocon- cramps, temporomandibular joint syndrome, and phantom
striction and numbness, therefore altering the pain sensations. limb pain). It is administered by specially trained health pro-
It is contraindicated in any condition where vasoconstriction fessionals, usually a physical therapist. Other modalities of
might increase symptoms (e.g., peripheral vascular disease). pain management should not be abandoned while a trial of
For best results, cold therapy should be limited to 20- to TENS occurs.
30-minute intervals. Either heat or cold can be used as cuta-
neous stimulation unless one is specifically contraindicated. Exercise
Cold often provides faster relief. If the client has used heat or Exercise is an important treatment for chronic pain because
cold before, incorporate the modality that the client believes it helps mobilize joints, strengthens weak muscles, and helps
will be the most effective. Combining the two might provide restore balance and coordination. Do not use passive range
better relief. An example of this would be to apply a hot pack of motion if it increases discomfort or pain. Immobilization
for 4 minutes, followed by an ice pack for 2 minutes, repeated is frequently used to stabilize fractures or for clients with
four times. In a hospital setting, a physician order is required episodes of acute pain. Prolonged immobilization can lead to
for this therapy. muscle atrophy and cardiovascular deconditioning.
Acupressure and Massage Psychotherapy
One of the first responses to pain is to rub the painful part. Psychotherapy may be beneficial to some clients, particularly
People seem to instinctively understand the pain-relieving those:
aspects of this intervention. In addition to blocking the pain • Who are clinically depressed
transmission through nerve stimulation, massage can also
promote relaxation. Acupressure is a type of massage that • Who have a history of psychiatric problems
consists of continuous pressure on or the rubbing of acu- • Whose pain is difficult to control
puncture points. Massage is based on the same principles as Some psychotherapists use hypnosis (altered state of
acupuncture, but needles are not used. Massage also provides consciousness when a person is more receptive to suggestion)
a form of nonverbal communication that can be therapeutic
on its own.
Mentholated Rubs CRITICAL THINKING
Ointments or lotions containing menthol are thought to pro-
vide relief by providing a counterirritation to the skin. The
menthol gives the client the perception that the temperature Noninvasive Intervention
of the skin has changed (becoming either warmer or cooler).
This alters the sensation of pain or provides a distraction from
the pain. Client response varies to mentholated rubs; some
How would you decide which noninvasive inter-
gain effective relief, but others have poor results. Their use is
contraindicated on broken skin, on mucous membranes, or if vention to use with a client?
pain increases.
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to help clients alter pain perception. Hypnosis can be effective Destructive or ablative procedures are used to destroy
but should be used only by specially trained professionals. part of the nervous system that conducts pain. By interrupting
the pain signal, it is prevented from reaching the cortex where
Positioning realization of pain occurs. These procedures are reserved for
The final noninvasive technique is proper positioning and clients with terminal illness.
body alignment. Moving the client with the least possible
stress on joints and skin will minimize exposure to painful Radiation Therapy
stimuli. This includes supporting joints appropriately and Radiation can be used as a palliative measure for pain relief
maintaining wrinkle-free sheets. in clients with cancer. It can relieve both metastatic pain and
pain caused by tumors at the primary cancer site. It enhances
Invasive Interventions other pain management strategies, such as analgesic therapy,
Invasive interventions are meant to complement behavioral, because it is aimed specifically at the cause of the client’s pain.
physical, and pharmacological therapies in those clients who When administered for pain relief, the smallest dose of radia-
do not obtain relief from those measures alone. Invasive tion is utilized to minimize side effects.
measures are indicated primarily for chronic cancer pain and
in some cases of chronic benign pain. These procedures are Acupuncture
usually tried only when noninvasive measures have been at- Acupuncture is the insertion of small needles into the skin
tempted first with poor results. at specific (hoku) sites. The sites are chosen after the prac-
titioner takes a detailed history and uses traditional Asian
Nerve Block diagnostic techniques. The needles used for acupuncture have
Neural blockade is the process of injecting a local anesthetic rounded ends that enter the skin without cutting the tissue.
or neurolytic agent into a nerve. An anesthetic agent may be The practitioner may twirl or vibrate the needles manually
injected to act as a diagnostic tool in order to identify the or electrically. It is important for the nurse to keep an open
nerves involved in a pain syndrome. A neurolytic agent is a mind when the client chooses this therapy, or the client may
chemical agent that causes destruction of the nerve and, there- be reluctant to discuss its use.
fore, creates an interruption in the pain signal.
Neurosurgery
Neurosurgical measures for pain control include neurostimu- Evaluation
lation procedures and destructive or ablative procedures. Evaluating pain management interventions is ongoing, focus-
Neurostimulation procedures involve the implantation of ing primarily on the client’s subjective reports. Objective data
electrical stimulation devices that send impulses to different to evaluate pain management include the following:
parts of the nervous system. Some of these devices stimulate • Continued use of pain assessment tools
areas of the brain; others stimulate the spinal cord. Relief is
thought to be provided by blocking the afferent fiber input at • Client’s facial expression and posture
the spinal cord level or by stimulating release of endorphins • Presence (or absence) of restlessness
using the body’s ability to modulate pain. • Vital sign monitoring
CASE STUDY
Client with Arthritic Pain
C.S. is a 76-year-old male with arthritis. He and his wife are residents of a nursing home. His wife is bed-
ridden because of a cardiac disorder. Each day, C.S. sits at his wife’s bedside and talks to her. Today, C.S.
is agitated and short with his wife. He is moving slowly, his knees are edematous, and he winces when he
walks.
1. List factors that may indicate that C.S. is experiencing pain.
2. Identify factors that may be impacting C.S.’s pain experience.
3. Describe the nursing actions necessary to perform a comprehensive pain assessment of C.S.
Adapted from Caring for Clients with Pain, by M. Teeter and D. Kemper, 2008b, manuscript submitted for publication.
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the Client with Chronic Pain

S.J., a 48-year-old woman, injured her back 3 years ago while lifting some boxes of paper at work. Since that time,
she has had four epidural steroidal injections for the pain associated with two ruptured disks. Her pain has been in-
termittent, with some alleviation from the epidural injections. Her last epidural was 3 months ago. She arrives at the
clinic stating, “I just don’t know how I can go on like this. The pain has been tolerable until last night. I’m hurting so
bad!” She is tearful and pacing, saying, “It hurts too much when I sit down.” Verbalizes pain is “9” on a 1-to-10 pain
intensity scale. Blood pressure is 148/90. Pulse is strong and regular at 92 beats/min. She has guarded movements.
NURSING DIAGNOSIS 1 Chronic Pain, related to muscle spasm and lower back pain as evidenced by back injury
3 years ago and client’s statement “I just don’t know how I can go on like this. The pain has been tolerable until last
night. I’m hurting so bad!”

Comfort Level Pain Management
Pain Control Medication Management
Coping Enhancement
PLANNING/OUtCOMeS NURSING INteRVeNtIONS RAtIONALe
S.J. will verbalize a decrease in pain. Assess S.J.’s level of pain, deter- Determines a baseline for future
mining the intensity at its best assessment.
and worst.
Listen to S.J. while she discusses Decreases anxiety by communicat-
the pain; acknowledge the pres- ing acceptance and validating her
ence of pain. perceptions.
Discuss reasons pain may be in- Helps S.J. understand her pain.
creased or decreased.
S.J. will practice selected noninvasive Teach relaxation techniques such Reduces skeletal muscle tension and
pain relief measures. as deep breathing, progressive anxiety, which potentiates the per-
muscle relaxation, and imagery. ception of pain.
Teach S.J. about the use of medi- Lack of knowledge and fear may
cation for pain relief. Provide ac- prohibit S.J. from taking analgesic
curate information to reduce fear medications as prescribed.
of addiction.
Encourage S.J. to rest during the Fatigue increases the perception of
day. pain.
EvAlUATION
After practicing relaxation techniques, S.J. rates her pain as a 2 to 3 on the pain intensity scale. S.J. demonstrates the
use of deep breathing and progressive muscle relaxation.
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CONCePt CARe MAP 7-1
NURSING DIAGNOSIS 2
Anxiety related to chronic pain as evidenced by pacing and tears
NOC: Coping; Anxiety Reduction
NIC: Anxiety Reduction; Anticipatory Guidance
CLIENT GOALS
1. S.J. will verbalize an increase in psychological and physiological comfort level.
2. S.J. will demonstrate ability to cope with anxiety as evidenced by normal vital signs and a verbalized
reduction in pain intensity.

1-1. Assess S.J.’s level of anxiety. 1-1. Determines baseline for future assessment.
2-1. Encourage S.J. to verbalize angry feelings. 2-1. Provides an outlet for her anger.
2-2. Speak slowly and calmly. 2-2. Avoids escalating S.J.’s anxiety level
and increases the likelihood of her
comprehension.
EVALUATION

After practicing relaxation techniques, how does S.J. rate her pain on a pain intensity scale?
Is S.J. verbalizing decreased pain intensity?
After a relaxation session, are S.J.’s vital signs within normal ranges?
CONCLUSION
Pain is subjective and is defined in intensity by the client. A
nurse’s personal perceptions of pain—how to express pain,
source of pain, and control of pain—may affect his care of
clients. Once a nurse evaluates personal thoughts and feelings
about pain, he is more equipped to care for a client in pain.
The chapter provides the nurse with quality methods for as-
sessing pain and interventions for managing it.
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CHAPTER 8
Cancer
KEY TERMS
alopecia carcinoma oncology
anorexia chemotherapy palliative surgery
antineoplastic curative surgery photodynamic therapy (PDT)
benign cytotoxic radiotherapy
biologic response modifier (BRM) differentiation reconstructive surgery
bone marrow transplantation leukemia sarcoma
(BMT) lymphoma stomatitis
cachexia malignant tumor marker
cancer metastasis vesicant
carcinogen neoplasm
LEARNING OBJECTIVES
2. Explain how the action of cancer cells differs from that of normal cells.
3. Describe the role of the nurse in cancer detection.
4. Discuss three medical treatments for cancer.
5. Describe complications that can occur in advanced cancer.
6. Discuss ways the nurse can aid the client in coping with cancer.
133
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approximately 569,490 Americans were expected to die from

INTRODUCTION cancer. This means daily that more than 1,500 individuals
Cancer is a disease resulting from the uncontrolled growth of would die from cancer (ACS, 2010).
abnormal cells, which causes malignant cellular tumors. One Smoking is responsible for at least 30% of all cancer
in three Americans will develop some type of cancer. Cancer is deaths and 87% of lung cancer deaths (ACS, 2010). About
the second-leading cause of death in the United States and can one-third of the 569,490 cancer deaths estimated for 2010 are
develop in individuals of any race, gender, age, socioeconomic related to poor nutrition, physical inactivity, and obesity and,
status, or culture. It is not a single disease but, rather, a group therefore, could be prevented (ACS, 2010).
of more than 200 different diseases that can attack any tissue
or organ of the body.
According to the American Cancer Society (ACS), in the PATHOPHYSIOLOGY
1930s fewer than one in five cancer clients survived 5 years Cancer is a disease characterized by neoplasia, an uncon-
after diagnosis. In the 1940s, one in four survived 5 years. trolled growth of abnormal cells. Unlike normal cells, which
Today, 68% of people diagnosed with cancer will be alive in reproduce in an orderly manner and grow for a purpose,
5 years (ACS, 2003, 2010). Survival rates are influenced by cancer cells develop rapidly and undiscriminatingly, and they
the type of cancer, the progression of the disease at diagnosis, serve no useful function because they grow at the expense
and the client’s response to the treatment. of healthy tissue (Figure 8-2). Neoplasms, any abnormal
growth of new tissue, can be found in any body tissue. Neo-
INCIDENCE plasms may be benign (not progressive and, thus, favorable
for recovery) or malignant (becoming progressively worse
In the United States, men have a one in two lifetime risk of and often resulting in death).
developing cancer, whereas women have a risk of one in three Benign neoplasms are not cancerous and are usually
(ACS, 2010). Incidence and mortality rates are usually greater harmless. They grow slowly, are encapsulated and well de-
for African Americans than for Caucasians. The incidence of fined, and do not spread to neighboring tissues. Unless their
cancer is greater in the elderly population than in any other location interferes with vital functions, benign neoplasms are
age group. In men, the most common cancers are prostate, associated with a favorable prognosis.
lung, colorectal, and urinary bladder; in women, they are Malignant neoplasms form irregularly shaped masses
breast, lung, colorectal, and uterine cancer (Figure 8-1). with finger-like projections. They usually multiply quickly
The ACS estimates that 1,529,560 new cancer cases and spread to distant body parts through the bloodstream
were diagnosed in the United States in 2010. In 2010, or the lymph system. This process is called metastasis.
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CHAPTER 8 Cancer 135
exposure is combined with cigarette smoking. Tobacco may

act synergistically with other substances to promote cancer
development. Occupational exposure to coal tar, creosote,
arsenic compounds, or radium constitutes a risk factor for
development of skin cancer. The effects of carcinogenic
agents are usually dose dependent. The larger the dose or the
longer the duration of exposure, the greater the risk of cancer
development. It is estimated that 80% of all cancers are asso-
ciated with environmental exposures and might be prevented
if exposure is avoided. The Occupational Safety and Health
(© SebAStiAn KAulitzKi/ShutterStocK)
Administration (OSHA) has established safety standards and
levels of exposure for those likely to be exposed to chemical
carcinogens at work.
In 1993, the U.S. Environmental Protection Agency
(EPA) declared secondhand smoke a human carcinogen. Ap-
proximately 3,000 nonsmoking adults die each year of lung
cancer from breathing secondhand smoke (ACS, 2008).
Figure 8-2 Cancer cell.
Lifestyle Factors
Patterns of metastasis will differ depending on the type of Lifestyle factors include the use of tobacco, sun exposure,
cancer. alcohol consumption, and diet. Tobacco accounts for nearly
Cancers are usually named according to the site of the one in five deaths in the United States (ACS, 2008). Tobacco
primary tumor or to the type of tissue involved. The four main use includes cigarettes, cigars, pipes, and smokeless forms
classifications of cancer according to tissue type are as follows: (e.g., snuff and chewing tobacco). The same carcinogens are
found in all forms of tobacco, causing cancer of the oral cav-
• Lymphomas (cancers occurring in infection-fighting or- ity, esophagus, pharynx, and larynx. When tobacco is smoked,
gans, such as lymphatic tissue) it can also cause cancer of the lung, pancreas, uterus, cervix,
• Leukemias (cancers occurring in blood-forming organs, kidney, and bladder.
such as the spleen, and in bone marrow) Overexposure to the sun’s ultraviolet rays over long
• Sarcomas (cancers occurring in connective tissue, such as periods of time is the cause of many skin cancers. The most
bone) serious form of skin cancer is melanoma. The ACS (2008)
• Carcinomas (cancers occurring in epithelial tissue, such
as the skin)
The exact mechanism that causes cancer is unknown, CLIENT TEACHING
but most authorities believe that cancer develops from a
combination of factors rather than from a single factor. En- Dietary Guidelines to Reduce
vironmental, genetic, and viral factors have been implicated the Risk of Cancer
in the development of cancer. Chemical substances that
initiate or promote the development of cancer are known as • Choose most foods from plant sources.
carcinogens. These agents are thought to alter the DNA in • Eat five or more servings of fruits and vegeta-
the cell nucleus. bles each day, especially green and dark-yellow
vegetables and those in the cabbage family.
• Consume other foods from plant sources
RISK FACTORS including breads, cereals, pastas, beans (le-
Many risk factors, such as environmental, lifestyle, genetic, gumes), and soy products.
and viral, may increase an individual’s chances of developing • Limit intake of high-fat foods, particularly from
cancer. animal sources.
• Choose foods low in fat.
Environmental Factors • Limit consumption of meats, especially red
The first environmental carcinogen was discovered in 1760, meats and high-fat meats.
when Percival Pott noted that chimney sweeps had a very • Be physically active and achieve and maintain a
high rate of what is now known to be scrotal cancer because healthy weight.
they were exposed to cancer-causing oils in the soot that • Physical activity can help by balancing caloric
was rubbed into their clothing. Since that time, hundreds of intake with energy expenditures or by other
chemical carcinogens have been identified. mechanisms.
Many individuals come into contact with cancer-causing • Limit or eliminate consumption of alcoholic
agents through occupational exposure. Industrial chemicals, beverages.
such as asbestos or vinyl chlorides, have been found to be
(ACS, 2002, 2008)
carcinogenic. For workers who handle these chemicals, the
risk of developing cancers is greatly increased if occupational
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Esophageal cancer
Heavy alcohol consumption
Smoking
Skin Cancer Lung cancer

Excessive exposure to Cigarette smoking
ultraviolet radiation (sun) Asbestos, arsenic and radon
Fair complexion exposure
Work with coal, tar, pitch, or Secondhand smoke
creosote
Breast cancer
Family history
Stomach Cancer High-fat diet
Family history Obesity after menopause
Diet heavy in smoked, Early menarche, late
pickled, or salted foods menopause
Alcohol consumption
Postmenopausal estrogen and
progestin
First child after 30
Colorectal cancer
Testicular cancer
Family history
(immediate relatives) Undescended testicles
Low-fiber diet Consumption of hormones by
mother during pregnancy
History of rectal polyps
Cervical cancer
Prostate cancer

Multiple sexual partners
Increasing age
Having sex at an early age
Family history
Exposure to human papilloma virus
Diet high in animal fat
Smoking
Figure 8-3 Risk factors for cancer.
estimated 62,480 newly diagnosed cases of melanoma in by-products of storage. Food substances that may reduce
2008. Other factors predisposing a person to skin cancer are cancer risk include cruciferous vegetables (cabbage, broccoli,
family history, multiple nevi, and atypical nevi. cauliflower, brussels sprouts, kohlrabi); possibly vitamins A,
Heavy alcohol consumption has also been implicated in E, and C; and selenium. Research suggests that an increase in
mouth, throat, esophageal, and liver cancers. Alcohol is hy- dietary fiber may help prevent colon cancer. On the basis of
pothesized to cause 5% of cancer deaths. Alcohol and tobacco current knowledge, the ACS has offered dietary guidelines to
used together greatly increase the risk of oral and esophageal reduce cancer risk.
cancers. The combined effect of alcohol and tobacco is greater
than the sum of their individual effects (ACS, 2008). Despite
the epidemiological evidence linking alcohol to cancer, the ex- Genetic Factors
act carcinogen in alcohol has yet to be determined. Figure 8-3 Some families have a high incidence of certain types of can-
shows some risk factors for cancer. cer. Women whose mothers, grandmothers, or sisters have
Some studies suggest that obesity is a significant risk had breast cancer have twice the risk of developing cancer as
factor for breast, colon, endometrial, and prostate cancers. those whose first-degree relatives have not had the disease
Studies have also shown that diets high in salt-cured, smoked, (ACS, 2008). Leukemia and cancers of the colon, stomach,
and nitrite-cured foods increase an individual’s risk for can- prostate, lung, and ovary may also run in families. Therefore,
cer of the stomach and esophagus. Some foods have been relatives of persons with these cancers should be carefully
found to contain carcinogens in the forms of additives or as monitored.
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CLIENT TEACHING MEMORY TRICK

Lifestyle Guidelines to Reduce Warning Signs of Cancer
the Risk of Cancer The professional nurse educates individuals about
• Do not smoke or use tobacco in any form. the warning signs of cancer. The seven warning
• Avoid overexposure to the sun and indoor tanning. signs can be easily remembered through an
• Eat a healthy diet. acronym, CAUTION:
• Get plenty of exercise. C 5 Change in bladder or bowel habits, such as
• Have a physical examination on a routine basis, absence of urination or bowel movement or
including a mammogram, Pap smear, and excessive urination or stool.
testicular and colon examinations. A 5 A sore that does not heal within a realistic
• Get plenty of sleep (6 to 8 hours per night). period of time.
• Keep weight within normal limits.
• Practice regular self-examinations and see your U 5 Unusual bleeding or discharge from any
physician if any changes are noted. body orifice, such as the vagina, the nipple,
• Know and follow health and safety rules at the or the penis. The unusual discharge can
workplace. be bloody, purulent, clear, or viscous. The
• Avoid unprotected sexual behaviors. keywords are unusual and any body orifice.
T 5 T
hickening or the presence of a lump in the
breast, testicle, or any part of the body.
Cr it iCa l t HiNKiNG I 5 I ndigestion or difficulty swallowing for a
prolonged period of time.
O 5 O
bvious change in a wart or mole, such as
Teaching Risk Factors for Cancer
color, size, texture.
N 5 N
agging cough or hoarseness that is
A neighbor, a 45-year-old female, asks you if there prolonged.
is anything she can do to “cancer-proof” her life- If any of these warning signs are observed,
style. She tells you that there have been several encourage client to see a health care provider.
incidences of cancer diagnosed in family members,
Courtesy of Daniels, R., & Nicoll, L. (2012). Contemporary medical-surgical
although none have been in her immediate fam-
nursing, 2nd edition. Clifton Park, NY: Delmar, Cengage Learning.
ily. What is the best answer you can give her?
Viral Factors
Although viruses have been linked to several cancers, their
exact role is unclear. It has been theorized that they incorpo- Cancer Detection
rate themselves into the genetic structure of the cell. Herpes
simplex II virus and some of the human papillomaviruses that
are transmitted sexually are known to predispose women to Which diagnostic tests should a person have as
cervical cancer. Reducing the number of sexual partners can part of a routine physical to detect cancer?
reduce the risk of contracting these viruses.
DETECTION site of the cancer. They include laboratory studies or blood

tests, radiological studies, endoscopy, cytology, and biopsy.
When cancer develops, the earlier it is detected the more Nurses educate clients about such tests as well as assist in cli-
likely it is to be treated successfully. In some cases, a diagnosis ent preparation.
is made before symptoms become apparent. Cancer is usu- Although no one blood test can confirm a cancer diagno-
ally found by the affected individual, who notices a warning sis, some malignancies do alter the chemical composition of
sign, or by a health care provider during a checkup. A cancer the blood. Specialized laboratory tests have been developed
checkup is recommended every 3 years for persons ages 20 to to detect tumor markers, substances such as specific pro-
39 years and annually for those ages 40 years and older. Risk teins, antigens, genes, hormones, or enzymes that are found
assessment is the first step in cancer prevention. The cancer in the serum and indicate the possible presence of malignancy.
examination includes both a medical history of exposures to Tumor markers are not 100% accurate because benign pro-
environmental agents and a comprehensive family history. cesses can also cause elevations; they are, however, useful in
If cancer is suspected, various diagnostic studies are monitoring response to treatment or detecting a relapse. (See
performed depending on the suspected primary or metastatic Table 8-1 for cancer-screening guidelines.)
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Table 8-1 Screening Guidelines

AGE TO BEGIN
SITE (yEArS) rECOMMENDATIONS PrEFErrED/ALTErNATIVE
Colorectal 50 One of the following initially: annual fecal Combination testing rather than a single
occult blood or fecal immunochemical test diagnostic test.
with at least 50% test sensitivity for cancer;
stool DNA test; flexible sigmoidoscopy
every 5 years; double-contrast barium
enema every 5 years; colonoscopy every
10 years; CT colonography every 5 years.
Prostate 50 Protein-specific antigen (PSA) test Begin at age 45 for African American men
and digital rectal exam (DRE) for men and men with a strong family history.
who have a life expectancy of at least
10 years.
Since there is some controversy
regarding these tests, discuss the
benefits and limitations of these tests with
the physician.
Breast 20 Beginning at age 20, breast self-exams Women at increased risk (mutations in

monthly and clinical breast exams every breast cancer susceptibility genes BRCA1
3 years. and BRCA2, familial history of breast and/
Beginning at age 40, add annual or ovarian cancer, and chest radiation
mammograms and annual clinical breast therapy) may begin mammograms at an
exams. earlier age and in addition have an MRI.
The FDA has approved the use of
tamoxifen and raloxifene to decrease the
risk of breast cancer in women at high
risk for breast cancer. Women should
discuss the risks and benefits of taking
these drugs with their physicians.
Cervical 18, or 3 years Conventional Pap test annually or liquid- A woman age 30 or older with three normal
after beginning based Pap test every 2 years. After test results in a row may be screened
vaginal total hysterectomy with cervix removal, every 2–3 years with conventional or
intercourse screening is not necessary unless the liquid-based Pap test. As an alternative,
surgery was performed as treatment for human papillomavirus (HPV) DNA testing
cervical cancer. and Pap test could be done every 3 years.
High-risk women may get screened more
often. Women 70 years of age and older
with three or more consecutive normal Pap
tests and no abnormal Pap test in the past
10 years may choose to stop screening.
Endometrium 35 Annual screening with biopsy for women All women at menopause should be
with or at risk for hereditary nonpolyposis educated about risks and symptoms and
colon cancer (HNPCC). be encouraged to report any unexpected
spotting or bleeding.
Cancer 20 At health examinations, have thyroid, Health counseling on risks of smoking,

checkup testicles, ovaries, lymph nodes, oral sun exposure, diet intake, risk factors,
cavity, and skin examined for cancer. sexual activity, and environmental and
occupation hazards.
ACS, 2007b, 2009.
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Routine x-rays, CT scans, and MRIs are used widely to

COMMON DIAGNOSTIC TESTS identify malignant tumors. These radiological tests are not
Common diagnostic tests for clients who present with symp- detailed in the following tables because they are described in
toms of cancer are listed in Tables 8-2, 8-3, and 8-4. several chapters in the medical-surgical system chapters.
Table 8-2 Common Laboratory Diagnostic Tests for Cancer Detection

LABOrATOry ExPLANATION/ SIGNIFICANCE OF TEST NurSING
TESTS NOrMAL VALuES rELATING TO CANCEr rESPONSIBILITIES
Acid phosphatase An enzyme found in the Monitors prostate cancer No food or fluid restrictions.
(elevated) prostate gland, seminal treatment—decreased levels
fluid, liver, RBCs, and other indicate successful treatment
tissues. and elevated levels indicate
possible metastasis.
Normal: 0–0.80 units/L Elevated levels:
• Prostate cancer
• Multiple myeloma
• Cancer of the breast and bone
• Cancer metastasis to the bone
Alkaline An enzyme found at higher Elevated levels: May or may not be fasting prior
phosphatase levels in the liver, biliary • Primary or metastatic liver to the test depending on the
(elevated) tissues, and bone. cancer method.
Normal: 30–120 units/L • Metastatic bone tumor
Bence Jones Immunoglobulins typically Presence of protein: Instruct the client for a clean-
protein found in the urine of clients • Multiple myeloma catch or 24-hr urine specimen.
with multiple myeloma. • Chronic lymphocytic leukemia Instruct the client not to
Normal: negative • Lymphoma contaminate specimen with
toilet paper or stool.
• Tumor metastases to bone
Send specimen immediately to
the lab.
CA-15-3 Tumor marker is used Elevated in metastatic breast Explain purpose of test to client.
to monitor treatment cancer and some cases Fasting is not required.
effectiveness or return of ovarian, lung, and liver
of breast cancer or carcinoma. It is also elevated
metastasis. with fibrocystic breast disease.
Normal: 0–25 units/mL
CA-19-9 Tumor marker in Elevated levels indicate Fasting is not required.

gastrointestinal tumors. pancreatic cancer.
Normal: 0–35 units/mL Monitor the effectiveness of Not sensitive enough to use
pancreatic cancer. as a routine screening test for
cancer.
CA-125 Tumor marker especially Monitor the treatment Fasting is not required.
helpful in making the effectiveness of ovarian cancer. Explain the purpose of the test.
diagnosis of ovarian cancer. Since the test is negative in
Normal: 0–35 units/mL 25% of women, it is not the only
test used to diagnose ovarian
cancer.
(Continues)
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Table 8-2 Common Laboratory Diagnostic Tests for Cancer Detection (Continued)

LABOrATOry ExPLANATION/ SIGNIFICANCE OF TEST NurSING
CEA (carcino- CEA is found in clients with Monitor the treatment Fasting is not required.
embryonic antigen) cancer, especially colorectal effectiveness of colorectal Note whether the client smokes
cancer. cancer. or has a disease that will alter
Normal: results, such as hepatitis,
Smoker: ,5 ng/mL cirrhosis, or colitis.
Nonsmoker: ,2.5 ng/mL
Fecal occult blood Tests for the presence of Utilized as possible indicators of Medications such as
test (FOBT) (fecal blood in the stool. colorectal cancer. anticoagulants, aspirin, iron
immunochemical Normal: negative for blood preparations, NSAIDs, and
test [FIT] or stool steroids may cause a false-
for occult blood positive result, whereas vitamin C
[Guaiac]) may cause a false negative. Red
meat should not be ingested for
3 days prior to the test.
For premenopausal women, wait
at least 4 days after menstrual
period or 72 hrs after barium
enema.
PSA (prostate- Serum proteases enzyme Elevated in prostatic cancer. Fasting for 8 hrs prior to test.
specific antigen) that is present in the male
prostate.
Normal:
Total PSA: 0–4 ng/mL
Total PSA after radical
prostectomy: 0.0–0.3 ng/mL
Men, 60–69 years:
0.0–5.0 ng/mL
Men, 70–79 years:
0.0–6.3 ng/mL
Serum calcitonin A hormone produced by the A tumor marker to detect thyroid Fasting for 8 hrs prior to test.
thyroid gland. cancer and cancer of the lung, Contraindicated in term
Normal: basal ,151 pg/mL breast, and pancreas. pregnancy.
Data adapted from Pagana, K., & Pagana, T. (2010). Mosby’s manual of diagnostic and laboratory tests (4th ed.). St. Louis, MO: Mosby Elsevier;
Daniels, R. (2010). Delmar’s guide to laboratory and diagnostic tests (2nd ed.). Clifton Park, NY: Delmar Cengage Learning.
Table 8-3 radiological Studies for Cancer Detection

rADIOLOGICAL ExPLANATION/ SIGNIFICANCE OF TEST NurSING
TEST NOrMAL VALuES rELATING TO CANCEr rESPONSIBILITIES
Mammogram Normal: breast tissue with no Screen for breast cancer and Explain the procedure to
tumors or abnormalities other breast conditions. the client. The breast will be
compressed, possibly causing
discomfort for several seconds.
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Table 8-4 Other Diagnostic Tests for Cancer Detection

DIAGNOSTIC ExPLANATION/ SIGNIFICANCE OF TEST NurSING
Endoscopy A fiber-optic tube is inserted Diagnostic tool to visualize After the procedure, monitor
into a body orifice to cancerous growths. vital signs, observe for bleeding,
visualize the structures. and assess for procedural risks
Normal: no growths or (e.g., return of the gag and
abnormalities in the body swallowing reflexes following a
structures bronchoscopy performed under
local anesthesia).
Cytology Examination of body cells Determines if tissue is Explain the purpose and
for premalignancy or premalignant, malignant, and determine that the client
malignancy. infectious process, or atypical. understands the procedure.
Normal: negative for Used to diagnose leukemia,
premalignant or malignant breast and lung tumors,
cells lymphoma, cervical and vaginal
cancer, and other malignancies.
Biopsy Excision of a small amount Diagnostic test for cancerous NPO at midnight on the day of
of tissue cells. the test.
Apply pressure until bleeding
stops.
cells are more aggressive in growth and may display unchar-

STAGING OF TUMORS acteristic behaviors, leading to a poorer prognosis. Grading
Staging determines the extent of the spread of cancer. The criteria vary for different neoplasms.
TNM classification proposed by the American Joint Com-
mission on Cancer is one of the most frequently used systems.
The T refers to the anatomic size of the primary tumor; N, TREATMENT MODALITIES
the extent of lymph node involvement; and M, the presence
or absence of metastasis (Table 8-5). Use of this internation- After cancer is diagnosed, staged, and graded, a medical treat-
ally recognized staging system for tumors ensures a reliable ment plan is developed. The most common treatment meth-
comparison of clients in many different hospitals. Staging is ods used are surgery, radiation therapy, and chemotherapy
important because it influences decisions about treatment (use of drugs to treat illness); biotherapy/immunotherapy,
modalities and helps predict overall prognosis. photodynamic therapy, hormone therapy, targeted therapy,
and bone marrow transplantation also are used. These meth-
ods may be used alone or in combination.
GRADING OF TUMORS
Normal body cells have individual characteristics that allow Surgery
them to perform different body functions. This process is Surgery is the oldest form of cancer treatment and remains the
called differentiation. Tumor cells that retain many of most common method of treatment today. Surgery is classi-
the identifiable tissue characteristics of the original cell are fied as curative, palliative, or reconstructive.
termed well differentiated. Tumor cells having little similarity The goal of curative surgery is to heal or restore to
to the tissue of origin are termed undifferentiated. Tumor health; this involves excising all of the tumor, the involved sur-
grading is based primarily on the degree of differentiation rounding tissue, and the regional lymph nodes. Surgery most
of malignant cells. Grading evaluates tumor cells in com- often has curative results when performed in the early stages
parison with normal cells. Pathologists indicate tumor cell of cervical, breast, or skin cancer.
grades by using the Roman numerals I through IV; the Because 70% of clients show evidence of metastasis at
higher the grade, the higher the number and the worse the diagnosis, cure is not always possible, and palliative surgery
prognosis. Thus, a grade I tumor is the most differentiated, may be necessary. This surgery is effective in relieving symp-
and a grade IV tumor is the most undifferentiated (or least toms in more advanced stages of cancer, although it does not
differentiated). Tumors containing poorly differentiated alter the course of the disease. It is usually performed in an
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Table 8-5 Staging of Tumors: TNM Classification

STAGE TuMOr LyMPH NODE METASTASIS
I ,2 cm diameter No involvement No evidence

Mobile
Often superficial
Confined to organ of origin
II 2 to 5 cm diameter Palpable, mobile No evidence

Not as mobile .2 to 3 cm diameter
Extension into adjacent tissue Firmer than normal
III a .5 cm diameter No involvement No evidence

Not mobile
Regional involvement
III b ,2 to .5 cm diameter .2 to 3 cm diameter No evidence

Mobile or not mobile Firmer than normal
Localized or extended
IV a .10 cm diameter No involvement No evidence

Extension into another organ; major or .2 to 3 cm diameter
arteries, veins, or nerves; or bone Firmer than normal
IV b No evidence to .10 cm diameter 3 to 5 cm diameter No evidence

Partially mobile
Firm to hard; or .5 cm diameter
Extended and fixed to bone, large blood
vessels, skin, or nerves

IV c No evidence to .10 cm diameter No evidence to .10 cm diameter Solitary or multiple
Fixed and destructive
Extension to second or distant stations
attempt to relieve complications such as obstructions or to more sensitive to radiation than others. Better vascularized,
surgically interrupt nerve pathways for intractable pain. It may better oxygenated cells, and those that divide rapidly are the
also be used to insert special access devices or to place tubes most sensitive.
for enteral nutrition. It is used alone or as an adjunct to other therapies. As
reconstructive surgery is performed to reestablish a single treatment modality, it is most often used when the
function or rebuild for a better cosmetic effect. Reconstructive disease is localized. Preoperative radiation is frequently used
surgery to areas such as the head, neck, breast, and extremities to reduce the tumor mass before surgery. Postoperative
minimizes deformity. The surgery can be completed all at radiation therapy is frequently used to decrease the risk of
once or done in stages. local recurrence after surgery. Some chemotherapeutic drugs
increase the sensitivity of cancer cells to radiation and thus
Radiation Therapy are used together with radiation. Radiation therapy is classi-
fied as curative or palliative. It is frequently used to alleviate
Radiation therapy is the second most common method of symptoms of metastasis, such as pain.
treating cancer. Radiation therapy, or radiotherapy, uses There are two types of radiation therapy: external radia-
high-energy ionizing radiation to kill cancer (Figure 8-4). tion and internal radiation.
Ionizing radiation penetrates tissue cells and deposits energy
within them. This intense energy causes breakage in chromo-
somes within the cell, thus preventing the ability of the cell External Radiation
to replicate. Cell death occurs hours, days, or even years after External radiation, or teletherapy, is performed with special
treatment, depending on the rate of mitosis. equipment that can deliver high-energy radiation. Treat-
The goal of radiation therapy is to eradicate malignant ments are usually administered on an outpatient basis, di-
cells without causing harm to healthy tissues. Some cells are vided over many days or weeks. Customized shielding blocks
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CLIENT TEACHING
External Radiation
• Do not wash off the skin markings used to des-
ignate reference points for treatment.
• Client is alone in the room during treatment.
• Client must lie absolutely still.
• Treatment typically lasts 1 to 3 minutes.
• Treatment is usually painless.
Internal Radiation
Internal radiation delivers radioactive isotopes directly within
the body. Clients treated with internal sources of radiation
(© li wA/ShutterStocK)
are a source of radioactivity. Isotopes are introduced into the
body by sealed or unsealed sources.
With sealed sources, radioactive elements are encap-
sulated in special containers such as tubes, wires, needles,
seeds, or capsules (Figures 8-6). These containers are
Figure 8-4 An external beam radiation therapy machine implanted close to the cancer cells to deliver a highly con-
that precisely delivers high-energy radiation to the cancer centrated dose of radiation to the cancer cells. Radioactive
location. implants are used in the treatment of cancers of the tongue,
lip, breast, vagina, cervix, endometrium, rectum, bladder,
are created to protect healthy tissues, and immobilization and brain.
devices are used to maintain the exact position for each treat- Because sources are sealed, body fluids are not radioac-
ment (Figure 8-5). Dyes or tattoos may be used to designate tive. Personnel caring for clients who have sealed sources
reference points on the skin. must still be familiar with the hazards of radiation, however.
Nursing care is directed toward client teaching, safety, and Generally, the degree of exposure is dependent on three
performing interventions that provide relief from side effects. factors:
Undesirable side effects that are most likely to occur include
varying degrees of skin reactions and gastrointestinal discom- • The distance between the individual and the source
fort, such as abdominal cramping, diarrhea, loss of appetite, (Figure 8-7)
and fatigue. Treatments have a cumulative effect and may thus • The amount of time an individual is exposed
produce symptoms after the therapy has been completed. • The type of shielding provided
Prostate gland
Needle releasing seeds
Ultrasound probe
Prostate gland
Figure 8-5 A plastic mold is made to conform to an

individual’s body, ensuring that the client receives radiation
to the exact spot with each treatment. (AdApted From nAtionAl cAncer inStitute
At the nAtionAl inStituteS oF heAlth, 2007) Figure 8-6 Radiation seeds implanted in a prostate gland.
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Mitosis
Anaphase
hase
se
esis
a
ase
Teloph
Metap
okin
ph
e)
as
Pro
Cyt
ph
1 Hour
h
wt
gro
G1
nd
rs
eco
(firs
ou
2H
G2 (s
t
growth phase)
9 Hou
rs
3 feet 9 feet
S (s
Figure 8-7 Radiation dose decreases with distance.
ynt
10
he
(courteSy oF the u.S. nucleAr regulAtory commiSSion) Ho
urs
sis
ha
p
se

) ch
rom
osom
SAFETy es replicated
Internal Radiation Inter phase
Client care is modified based on the three factors

Figure 8-8 Stages of the cell cycle.
related to the degree of exposure to sealed-source
radiation by:
• Preparing everything outside of the room so
CCS drugs attack cancer cells when the cells enter a
that as little time as possible is spent close to certain phase of reproduction. These agents are most effec-
the client. tive against rapidly growing tumors. Many of the drugs are
• Having several nurses assigned to care for the “schedule dependent” because they produce a greater cell kill
client so that the time of exposure for each when given in multiple, repeated doses.
nurse is lessened. CCNS drugs can destroy cancer cells in any phase of the
• Wearing a lead apron or other shielding device, cell cycle and are used for large tumors that have fewer actively
as provided. dividing cells. These drugs are not schedule dependent but,
rather, dose dependent. This means that the number of cells
destroyed is determined by the amount of drug given.
Anticancer agents are cytotoxic (toxic to cells) and
destroy both normal and abnormal cells. They are most effec-
Radioactive isotopes also are placed in suspensions or so- tive against cells that reproduce rapidly, such as those in bone
lutions as unsealed sources of radiation. They are given orally, marrow, gastrointestinal lining, hair follicles, and the ova and
parenterally, or instilled into intrapleural or peritoneal spaces. sperm. Because cells multiply at their most rapid rate at the
Some radioactive elements used in unsealed radiation beginning of the disease, the drugs work best against cancer
sources are eliminated in body secretions, including urine and in its earliest stages.
stool; thus health care workers must take special precautions Many of these drugs are given in combination with or
to avoid exposure. Agency policies and procedures as well as after radiation or surgery to achieve maximum effect. They
Standard Precautions are followed closely. Unsealed sources are usually given intermittently over an extended period. Drug
are not usually radioactive as long as the sealed sources. resistance can occur.
The most common routes of administration are oral
and intravenous. A few drugs are given topically, subcutane-
Chemotherapy ously, or intramuscularly. Recently, other methods have been
Chemotherapy is used to cure, prevent, or relieve cancer introduced to increase the local concentration of the drug at
symptoms. Drugs used in chemotherapy are called antineo- the tumor site, including intrathecal injection and intracavity
plastics because they inhibit the growth and reproduction of instillation. Table 8-6 lists some commonly used drugs.
malignant cells. To understand how anticancer drugs work, Careful attention is given to intravenous administration.
one must have a basic understanding of the cell cycle. Leakage of fluid from the vein into the surrounding tissues
Almost all anticancer drugs kill cancer cells by affecting during infusion is called extravasation. Because most chemo-
DNA synthesis or function, but they vary in how they exert therapeutic drugs are irritating to the tissues, extravasation
their activity within the cell cycle (Figure 8-8). Most chemo- is a potentially serious problem, especially if the drugs ad-
therapeutic drugs are classified as cell-cycle specific (CCS) or ministered are vesicants. These agents are so irritating that
cell-cycle nonspecific (CCNS). they can cause blistering and even necrosis. All sites must be
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Table 8-6 Drugs Commonly used in Chemotherapy
Antimetabolites (CCS) Antibiotics (CCNS) Antihormonal Agents (CCNS)

cytarabine (Cytosar) dactinomycin (Cosmegen)* flutamide (Eulexin)
fluorouracil (Adrucil 5-FU) daunorubicin (Cerubidine)* goserelin acetate (Zoladex)
methotrexate (Mexate, Folex) doxorubicin hydrochloride tamoxifen (Nolvadex)
6-mercaptopurine (Purinethol) (Adriamycin)*
mitomycin (Mutamycin)*
mithramycin (Mithracin)
bleomycin (Blenoxane)
Vinca Plant Alkaloids (CCS) Hormones (CCNS) Nitrosoureas (CCNS)

vinblastine sulfate (Velban)* diethylstilbestrol (DES) carmustine (BiCNU)
vincristine sulfate (Oncovin)* megestrol acetate (Megace) lomustine (CeeNU)
medroxyprogesterone acetate
(Depo-Provera)
testosterone (Histerone, Testoderm)
tamoxifen citrate (Nolvadex)
Alkylating Agents (CCNS) Corticosteroids Miscellaneous Agents

busulfan (Myleran) dexamethasone (Decadron) etoposide (VePesid)
chlorambucil (Leukeran) hydrocortisone sodium succinate L-asparaginase (Elspar)
cisplatin (Platinol) (Solu-Cortef) procarbazine hydrochloride
cyclophosphamide (Cytoxan) prednisone (Deltasone) (Matulane)
mechlorethamine hydrochloride
(Mustargen)*
melphalan (Alkeran)
thiotepa (Thiotepa)
Frequently Used Combinations

CAF cyclophosphamide, doxorubicin, and fluorouracil or 5-FU (Adrucil)
CHOP cyclophosphamide, doxorubicin, vincristine (Oncovin), and prednisolone
C-VAMP cyclophosphamide, vincristine, doxorubicin, and methyl-prednisolone
CVP cyclophosphamide, vincristine, and prednisone
ECF epirubicin, cisplatin, and fluorouracil
FEC fluorouracil, epirubicin, and cyclophosphamide
MMM mitomycin, methotrexate, and mitoxantrone
MOPP mechlorethamine hydrochloride (Mustargen), vincristine, procarbazine, and

prednisone
MVP mitomycin, vinblastine, and cisplatin
* Vesicant drug.
monitored carefully. Pain, swelling, redness, and the presence have reduced the length of hospitalizations for clients under-
of vesicles are all signs of extravasation. Additional signs in- going chemotherapy. Teaching clients and family members
clude the following: to monitor side effects in the home setting is thus an essential
function of the oncology (study of tumors) nurse.
• Pain or burning at the site or along the vein Clients also are advised that their lifestyle may need ad-
• Absent or sluggish blood return justment to accommodate the side effects of chemotherapy.
• Redness 6 to 12 hours later Clients are instructed to pace themselves according to their
• Swelling energy level and allow time for rest throughout the day. It is
• Diffuse hardening also important to inform clients that even between treatments
they may not have the same amount of energy as before treat-
If extravasation occurs, the drug is stopped immediately ment initiation. Many clients do not experience any adverse
and protocols for treatment initiated. effects, but some experience life-threatening toxicity. Nursing
Improved infusion techniques, control of symptoms such care of the client receiving chemotherapy requires not only
as nausea and vomiting, and cost-containment restrictions a thorough understanding of the drugs used to destroy the
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SAFETy COMMUNITy/HOME HEALTH CARE
Chemotherapy: Protective Equipment Home Care after Chemotherapy

and Personnel Contamination Teach clients receiving chemotherapy to monitor
• Because many chemotherapy drugs are carcino- the side effects of therapy at home.
genic, the nurse preparing and administering • Inspect the skin daily for any signs of rash or
the chemotherapy wears protective equipment. dermatitis, which indicates hypersensitivity to a
• All personnel involved in any aspect of handling drug.
chemotherapeutic agents receive instructions • Report taste loss and tingling in the face,
about the known risks of the drugs, the proper fingers, or toes, which may signal peripheral
use of protective equipment, the applicable skill neuropathy.
procedures, and the policies regarding pregnant • Report signs of dizziness, headache, confusion,
personnel. slurred speech, or convulsions, which are signs
• Any personnel handling blood, vomitus, or of central nervous system (CNS) toxicity.
excreta (waste discharge from the body) from • Report signs of unusual bleeding or bruising;
clients who have received chemotherapy within fever; sore throat; or mouth sores, which may
the previous 48 hours wears disposable latex signal developing myelosuppression.
gloves and a disposable gown. • Report signs of jaundice; yellowing of the eyes;
• Place contaminated linen in specially marked clay-colored stools; or dark urine, which signals
laundry bags according to agency procedures. developing hepatic dysfunction.
• Report a continued cough or shortness of breath,
which indicates developing pulmonary fibrosis.
cancer, but also skills in helping clients and families cope with
the side effects of the therapy. client is injected with a light-activated drug (Photofrin) that
targets cancerous cells. Twenty-four to 48 hours after inject-
ing the drug, a low-power laser light is directed by a fiber-optic
Biotherapy guide to the cancerous tissue area through an endoscope. The
Biotherapy, also called immunotherapy and biological therapy, light stimulates the drug to destroy the cancerous cells, but
stimulates the body’s natural immune system to suppress and the surrounding healthy tissue is not harmed. An advantage
destroy malignant cells. Biotherapy is completed with biologic of PDT is the client has the procedure performed on an out-
response modifiers (BrMs) that naturally occur in the patient basis with slight sedation and is relatively pain free.
bodies’ immune system or are drugs or substances developed There is less risk than with a surgical procedure, and there
in a laboratory (National Cancer Institute, 2006). Biotherapy are fewer side effects. The side effects of PDT are discomfort
is used after the tumor is removed with surgery, radiation, from local swelling, nausea, fever, and constipation. The client
and/or chemotherapy. Biological therapy currently used in- experiences sunburn, redness, and swelling if the skin and eyes
cludes interferons, monoclonal antibodies, interleukin-2, tumor are exposed to a bright light or sunlight.
necrosis factor, bacillus Calmette-Guérin (BCG), and hema-
topoietic growth factors [erythropoietin, interleukin-3, and
colony-stimulating factors (CSFs)]. An example of how a BRM
Hormone Therapy
Some cancerous cells need estrogen, progesterone, or testos-
works is hematopoietic growth factors (HGFs) that promote terone to grow. The goal of hormone therapy is to deprive
bone marrow production after a client has had cytotoxic che- the cancerous cells of these hormones. Clients may have the
motherapy or a bone marrow transplant. Erythropoietin stimu- ovaries (oophorectomy) or testicles (orchiectomy) removed.
lates the production of red blood cells and interleukin-3 and Another method of depriving the cells of hormonal stimula-
CSFs mature the cells (Cancer Treatment Centers of America, tion is to give women with early-stage breast cancer tamoxifen
2011). Side effects of biotherapy are usually less severe than citrate (Nolvadex) and to give men luteinizing hormone-
those seen in chemotherapy and include fever, chills, malaise, releasing hormone (LHRH). LHRH prevents the testes from
myalgia, weakness, nausea, diarrhea, rashes, and headache. producing testosterone. Tamoxifen is a systemic treatment
Because an anaphylactic reaction can occur, the client must and increases the chances for endometrial cancer. Hormone
be closely monitored. Some BRMs are still being evaluated in therapy is effective for a time in men, but eventually prostate
clinical trials such as melanoma and kidney cancer vaccines and cancer grows without hormone stimulation. The hormone
monoclonal antibodies (Nevada Cancer Institute, 2011). therapy is no longer effective when this occurs (Cancer Treat-
ment Centers of America, 2009c).
Photodynamic Therapy
Photodynamic therapy (PDT) has a 90% effective rate Targeted Cancer Therapy
when used for esophageal cancer and early-stage lung cancer Most targeted cancer therapies are in preclinical testing (animal
(Cancer Treatment Centers of America, 2009b). PDT is also research) and clinical trial (human research). Some drugs have
used as an investigation therapy for obstructive lung cancer: been approved by the U.S. Food and Drug Administration
Barrett’s esophagus: and head, neck, and skin cancer. The (FDA). The goal of targeted cancer therapy is to stop the growth
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and spread of cancer cells by preventing normal cells from chang- Any bleeding that does not stop in 5 minutes is reported. A
ing into cancerous cells at the molecular or cellular level. This soft toothbrush is recommended for oral care. Aspirin or any
therapy is more effective than present treatments and causes less medication containing acetylsalicylic acid is not given.
harm to healthy cells. An example of targeted therapy is STI-571,
or imatinib mesylate (Gleevec), which is a small-molecule drug
used to treat the gastrointestinal stromal tumor and chronic my- Nutritional Alterations
eloid leukemia (National Cancer Institute, 2006). Cytokines are substances secreted by the tumor in an attempt
to cannibalize the body and by the immune system to fight
the tumor. Cytokines make the body digest muscle for energy
Bone Marrow instead of using stored fat for this purpose. This state of mal-
Transplantation nutrition and protein (muscle) wasting is called cachexia. It
occurs in conjunction with lung, pancreatic, stomach, bowel,
Bone marrow transplantation (BMT) is used for cancers and prostate cancers but rarely with breast cancer.
that respond to high doses of chemotherapy or radiation ther- In some cases, untreated cachexia, rather than the cancer
apy. Treatment involves aspirating and storing a fraction of bone itself, is the cause of death. Untreated cachexia also decreases
marrow, exposing the client to high-dose drug therapy or total- the effectiveness of cancer treatments and increases the side
body irradiation, and then reinfusing the bone marrow after the effects of these treatments. Treating cachexia with drugs has
treatment is complete. The bone marrow used in transplanta- met with little success.
tion can be the client’s own marrow (autologous), marrow taken A registered dietitian understands cancer cachexia and
from an identical twin (syngeneic), or marrow taken from a his- can identify appetizing foods that are nutrient and calorie
tocompatibly matched donor, preferably a sibling (allogeneic). dense. Foods that appeal to the client are eaten anytime. The
Client expenses for BMT are high, ranging from $50,000 use of nutritional supplements is often recommended (Bauer
to $100,000 for an autologous transplant, and $100,000 to & Capra, 2005; Gill, 2007).
$200,000 for an allogeneic transplant unless covered or par- Hallmarks of malnutrition are a weight loss of 10% or more
tially covered by insurance (National Bone Marrow Trans- or a serum albumin level ,3.4 g/dL. Clients unable to maintain
plant Link, 2009). The average length of hospital stay is 35 sufficient oral intake for long periods are given enteral or total
to 40 days. Complications can be life threatening and include parenteral nutrition (TPN). Nutritional problems associated
infection, bleeding, gastrointestinal effects, renal insufficiency, with cachexia include anorexia, nausea and vomiting, altered
veno-occlusive disease (deposits of fibrin obstruct venules of taste sensation, mucosal inflammation, and dysphagia.
liver), and graft-versus-host disease (new bone marrow cells
recognize environment as foreign and try to destroy the host).
Clients who undergo autologous BMT do not experience Anorexia
graft-versus-host disease. Anorexia, or the loss of appetite, is a common concern among
individuals with cancer. It is generally best for these clients to
eat small, frequent, high-calorie (carbohydrate and fat-rich)
SYMPTOM MANAGEMENT meals. Try to ascertain the client’s likes and dislikes. Highly sea-
soned foods help increase taste. Clients are encouraged to eat
Cancer clients undergoing treatment experience a variety of when they are feeling best. Weight is monitored weekly.
secondary problems. One of the most important responsi-
bilities of the oncology nurse is to formulate nursing interven- Nausea and Vomiting
tions to manage these problems.
Nausea and vomiting usually occur within 3 to 4 hours after
chemotherapy is administered and may last up to 72 hours.
Bone Marrow Dysfunction Antiemetics are given before chemotherapy and continued
Cancer treatments kill both malignant cells and normal cells afterward as needed (Box 8-1). Small, frequent feedings of
in bone marrow. Blood counts are monitored carefully during
and after treatment.
A low white-cell count increases the risk of infection. A TEACHING
CLIENT TEACHING
decreased neutrophil count (,500 mm3) is an indicator that
special infection prevention measures should be initiated. Scru- Increasing Nutritional Intake
pulous hand hygiene is the most effective method of control-
ling bacterial infection. Personnel maintain strict asepsis when • Drink 4 ounces of a nutritional supplement be-
changing dressings or performing invasive procedures. Clients fore breakfast.
avoid contact with anyone who is ill. Antimicrobial soaps are • Eat breakfast (if desired), and then take a walk.
used for bathing clients. The skin and mucous membranes are Doing so will help build muscle and increase
inspected daily for signs of infection. Vital signs are taken every appetite.
4 hours and the client observed for fever and chilling. • Drink another 4 ounces of nutritional supple-
Clients with a platelet count of ,50,000 mm3 are moni- ment 1 hour before having a lunch consisting of
tored for bleeding. Their skin is inspected daily for bruises whatever foods are appealing.
or petechiae. Shaving is undertaken with an electric razor to • Have another 4 ounces of nutritional supple-
minimize the chance of cutting the skin. Stool and urine are ment at midafternoon and at bedtime.
monitored for occult blood. Observe the client for bleeding
• If not hungry for dinner, take another walk.
from the vagina, rectum, nose, mouth, and venipuncture sites.
If bleeding occurs, pressure is applied to the site for 5 minutes.
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BOX 8-1 TEACHING

CLIENT TEACHING
COMMONLy USED ANTIEMETICS
Stomatitis
prochlorperazine (Compazine)
metoclopramide (Reglan) • Use soft bristle toothbrush.
• Avoid flossing if bleeding or discomfort occurs.
ondansetron hydrochloride (Zofran)
• Avoid tobacco products and alcohol because of
lorazepam (Ativan) their drying effects.
dolasetron (Anzemet)
complex carbohydrates may be beneficial. Liquids are given Artificial saliva is ordered for severe dryness. A softer diet
30 to 60 minutes before meals. Although highly seasoned along with nutritional supplements is prescribed. Food pu-
foods may increase taste, they often also increase nausea and réed in a blender is easier to tolerate. Encourage clients to take
vomiting. Cool, bland foods are more easily tolerated. Avoid plenty of time to chew and swallow. Dry foods such as toast
foods with strong odors. Frequent mouth care helps remove can scratch the delicate tissues of the throat.
the taste of chemotherapy and increase the likelihood of the
client’s desire to eat. The client should be monitored for de-
hydration and electrolyte imbalances. Pain
Approximately 60% to 90% of all individuals with progressive
Altered Taste Sensation malignancy experience pain. The pain may be acute, but it is
more likely to be chronic (.3 months in duration). Pain usu-
Taste sensation is altered because cancer cells release sub- ally does not occur until the advanced stages of the disease.
stances that stimulate bitter taste buds, causing a bitter or The most common causes of pain are metastatic bone disease,
metallic taste in the mouths of some clients. Some find they venous or lymphatic obstruction, or nerve compression.
no longer enjoy the taste of red meat, and others say they have Pain causes anxiety, depression, and feelings of helpless-
an aversion to sweets. ness in addition to physical discomfort. It can affect the cli-
ent’s sleeping habits, eating patterns, and work, family, and
Mucosal Inflammation social relationships. Ultimately, pain can affect the client’s
Stomatitis, or inflammation of the mucous membrane of quality of life.
the oral cavity, occurs in one-half of cancer clients receiving Noninvasive pain-relief techniques are useful in pain
treatment. It usually occurs 7 to 14 days after chemotherapy management. They include cutaneous stimulation (heat,
administration and lasts 2 to 3 weeks. To minimize stomatitis, cold, massage), transcutaneous electrical nerve stimulation
assess for early signs and symptoms such as edema, ulceration, (TENS), relaxation techniques, imagery, and hypnosis. Most
erythema, excessive saliva, and infection. If the client is receiv- of these techniques are inexpensive and easy to perform. They
ing a chemotherapy drug that is known to cause stomatitis have few side effects and can usually be done in any environ-
(e.g., methotrexate), oral care is administered at least four ment. They also give the client some control over the treat-
times a day. ment of pain. Although not every client responds successfully
Avoid rough, chewy foods and acidic foods. Straws are to these measures, it is worthwhile to attempt them before us-
beneficial because food is taken in the back of the mouth and ing invasive techniques.
swallowed. Popsicles and frozen fruit bars sometimes help The Agency for Health Care Policy and Research (1994)
numb and lessen pain. Avoid commercial mouthwashes con- developed cancer pain guidelines for clients, family members,
taining alcohol. A saline rinse may be helpful after meals. If the
client has dentures, remove them at night. Viscous Xylocaine
rinses are ordered for pain. Lemon and glycerine swabs are
not used because lemon is irritating to mouth lesions. BEsTPRACTICE
Dysphagia Mucosal Inflammation
Dysphagia, difficulty swallowing, often occurs in clients • The condition of the client’s mouth provides a
with esophageal cancers, or in those receiving radiotherapy. clue to the appearance and integrity of other
areas of the gastrointestinal tract because mu-
cosal inflammation caused by cancer treatments
TEACHING
CLIENT TEACHING affects all mucosa.
• Mucositis (inflammation of the mucous mem-
Enhancing Taste Sensation brane) in the esophagus, also called esophagitis,
• Tart food usually enhances taste sensation. causes painful swallowing.
• Many foods taste better if they are cold or at • In female clients, mucosal inflammation is
room temperature. found in the vagina, causing pain, itching, and
• Using plastic utensils reduces metallic taste. discharge.
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and health care professionals. Some points emphasized by the

guidelines include:
• Cancer pain can be managed effectively through relatively
simple means in up to 90% of cancer clients in the United
States. Skin patches, slow-release tablets, and client-controlled
pumps are now available to complement standard drugs.
• The mainstay of pain assessment is the client self-report.
Because there is no standard test for pain, the nurse must
respect the client’s report of pain and regard it as the single
most reliable indicator.
(© cleo/ShutterStocK)
• The simplest dosage schedules and least invasive pain man-
agement modalities are used first. Nonopioids are the first
step in the analgesic ladder. They are tried first for mild to
moderate pain.
• Morphine is the most commonly used opioid for moder-
ate to severe pain because it is available in a wide variety of Figure 8-9 Woman with alopecia who had chemotherapy to
treat breast cancer.
dosage forms, it has well-characterized pharmacokinetics
and pharmacodynamics, and it is relatively low in cost.
Morphine can be given orally, subcutaneously, intramuscu- increase or decrease fatigue, such as nutritional intake. Hemo-
larly, intravenously, rectally, and intraspinally. It can also be globin and hematocrit are monitored for anemia.
given in sustained-release preparations.
• Health care providers work to prevent pain rather than try
to treat pain after it has occurred. Analgesics work better Alopecia
when given regularly around the clock before pain becomes Alopecia, the thinning or loss of hair, is induced by chemo-
severe. A major nursing responsibility is to teach the cli- therapy or radiation treatments (Figure 8-9). The extent of hair
ent to request pain medication before the pain becomes loss depends on the dose and duration of the therapy. Scalp
severe. When medication is ordered around the clock, the hair is most commonly affected, but pubic, axillary, and facial
nurse does not hesitate to wake the client to administer hair, even eyebrows and eyelashes, also are affected. The treat-
analgesics. ments cause hair loss by interfering with the growth processes
in the hair follicle. This results in weakening of the hair shaft,
If pain control is not achieved with noninvasive tech- thereby causing the hair to break off at the surface of the scalp.
niques or medications, neurosurgical procedures such as Hair loss usually begins 2 to 3 weeks after the initial treatment.
nerve blocks are an option. Drug-induced alopecia is not permanent. Hair usually begins
to grow back within 8 weeks after treatment is completed. The
Fatigue color and consistency of the hair may change.
Fatigue occurs as a direct result of cancer treatment or because
of anemia, chronic pain, stress, depression, insufficient rest, or Odors
inadequate nutritional intake. Although the etiology is not well Unpleasant odors emanating from the cancer client are a
understood, fatigue is often related to the effects of the tumor source of embarrassment. These odors are usually associated
progression (National Cancer Institute, 2010). Fatigue con- with drainage, exudates, or incontinence. Fortunately, meticu-
tributes to client noncompliance with the treatment regimen. lous nursing care can eliminate most offending odors. Change
Frequent rest periods are provided for the client. Assess soiled linens, drainage pads, and dressings immediately. Wash
for the presence and pattern of fatigue. Proper planning allows the client’s skin gently with soap and warm water. Protective
the client to be active when her energy level is higher, which in creams are used if the areas are not receiving radiation. Room
turn restores a greater sense of control. Evaluate factors that deodorizers are helpful but should be used cautiously because
TEACHING
CLIENT TEACHING
BEsTPRACTICE
Alopecia, Threat to Body Image
Pain Control in the Cancer Client
Encourage client to:
A major reason given for inadequate pain control • Buy a wig or hairpiece before treatment actu-
in the cancer client is the fear of inducing respira- ally begins so that it will match the client’s nor-
tory depression. This, however, is a rare occurrence mal hair.
in the cancer client. Therefore, nurses can adminis- • Wear hats, scarves, or bandanas to cope with
ter pain medications as prescribed and follow the the change in body image caused by hair loss.
other guidelines presented in this chapter to con- • Focus on other positive aspects rather than on
trol the client’s pain. just physical appearance.
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many clients experience nausea when exposed to the odors are supported and handled gently, and extreme care is taken
from room fresheners. Placing a drop of oil of wintergreen or when moving clients. Special devices such as splints are used
oil of cloves on a cotton ball near the ventilation system can for extra protection. Weight-bearing restrictions are ordered.
sometimes lend a light freshness to the environment.
Ascites
Dyspnea Abdominal cancers cause ascites, or fluid accumulation in the
One-half of all clients with terminal cancer experience dys- abdomen. Clients experience abdominal swelling and diffi-
pnea, or difficulty breathing. Possible causes include fluid culty breathing. Symptoms are treated temporarily with an in-
accumulation in the chest, infection such as pneumonia, vasive procedure called a paracentesis, wherein a small, plastic
fibrosis caused by radiation, and anemia. Lungs are auscul- tube is advanced through the abdominal wall and excess fluid
tated every 4 hours. Oxygen is ordered. Fluid is drained by is withdrawn. Chemotherapy drugs sometimes are instilled in
an invasive procedure called a thoracentesis. High-Fowler’s an attempt to prevent the fluid from returning.
positioning maximizes ventilation. Plan care to keep activity Visually assess the abdomen. A protruding abdomen indi-
to a minimum to balance oxygen requirements and oxygen cates ascites as well as intestinal distention and enlarged organs.
supply. Oxygen status is monitored with a pulse oximeter. Measure abdominal girth at the umbilicus daily with a tape mea-
Report a sustained reading of less than 90%. Avoid pulling the sure to monitor changes, then auscultate the abdomen in all four
privacy curtain or shutting the client’s door unless absolutely quadrants. Gurgling bowel sounds heard every 5 to 15 seconds
necessary because either of these actions reduces airflow and indicate normal peristalsis. Decreased or absent bowel sounds
creates more anxiety. indicate peritonitis or paralytic ileus. Fluid accumulation is con-
firmed by percussing for shifting dullness. When a large amount
Bowel Dysfunctions of fluid is present, fluid waves are seen. Gentle palpation is used
to detect pain and tenderness as well as abdominal masses. The
Cancer clients frequently exhibit changes in bowel patterns. nurse carefully documents any abnormal findings.
Constipation, diarrhea and subsequent perineal skin breakdown, Weigh the client daily to monitor weight gain. Fluid con-
and bowel obstructions are common elimination disorders. sumption is restricted. Good skin care, especially to the abdo-
Constipation results from decreased motility of the co- men, is essential. Fowler positioning maximizes ventilation.
lon. It is frequently caused by chemotherapy, opioid analgesic, Clients are observed closely for electrolyte imbalance if large
or inactivity. Monitor and record the frequency of the client’s amounts of fluids are withdrawn via paracentesis.
bowel movements. Constipation is an early sign of vincristine
toxicity. Fluid consumption is encouraged and a stool softener
is given daily. Clients at risk for constipation are started on a
Sexual Alterations
high-fiber diet, with increased intake of bran and prune juice. Many chemotherapy drugs interfere with sexual function-
Common causes of diarrhea include radiation therapy, ing and reproduction. Premenopausal women may become
chemotherapy, antibiotics, tube feedings, hyperosmolar dietary infertile. Those younger than 35 years of age may regain their
supplements, stress, and fecal impactions. Clients develop fluid fertility after therapy is completed. Men may experience im-
and electrolyte imbalances from constant diarrhea. If the cli- potence, decreased libido, interrupted sperm production, and
ent is receiving a chemotherapy drug known to cause diarrhea ejaculation problems. Women experience vaginal dryness.
(such as fluorouracil [Adrucil] or doxorubicin hydrochloride Encourage clients and their partners to express their feel-
[Adriamycin]), a low-residue and lactose-free diet is encour- ings and concerns to each other and to explore other avenues
aged. Instruct the client to avoid foods that stimulate the gastro- of sexual expression, such as cuddling, kissing, and stroking.
intestinal tract, such as warm liquids and coffee. Birth control is practiced during therapy and for 1 or 2 years
Bananas (which are high in potassium) and sports drinks after therapy (depending on physician recommendation) to
(which contain sodium and potassium) help replace lost fluids ensure that all chemotherapy drugs are eliminated and will
and electrolytes without irritating the gastrointestinal tract. have no ill effects on a pregnancy. Eggs and sperm may be
The perineum is kept clean and dry after each loose stool. saved before treatment.
Note signs of fluid and electrolyte imbalances, such as thirst,
dry mucous membranes, and decreased skin turgor. The po-
tassium level is monitored. Measure and record the amount,
MEDICAL EMERGENCIES
frequency, and characteristics of all client bowel movements.
Antidiarrheal medications such as Lomotil or Imodium are
given for loose stools. Sitz baths help soothe sore or broken-
M edical emergencies occur in approximately 20% of cli-
ents with advanced-stage cancer. Early recognition and
treatment can prevent irreversible complications and improve
down tissues. the quality of life. Four complications with which to be famil-
Bowel obstructions occur more commonly in conjunc- iar are hypercalcemia, spinal cord compression, superior vena
tion with advanced abdominal malignancies and are suspected cava syndrome, and cardiac tamponade.
if the client has received radiation or has adhesions from
previous surgeries. Symptoms include nausea, vomiting, and
abdominal pain. Surgery is required to relieve the obstruction. ■ HYPERCALCEMIA
Pathological Fractures
Pathological fractures are a major problem in cancers that
H ypercalcemia occurs commonly and can be a potentially
fatal complication if not detected early. It is found most
often in clients with malignant tumors that have metastasized
metastasize to bone. These cancers weaken the bone to the to bone, such as breast cancer. The condition occurs when the
point that normal activities cause painful breaks. Thus, limbs serum calcium level rises .10.5 mg/dL.
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Early symptoms of hypercalcemia, such as nausea, vomit-

ing, constipation, and weakness, may be overlooked because PSYCHOSOCIAL
these are common side effects of many cancer therapies. Later
symptoms such as dehydration, renal failure, coma, and car-
ALTERATIONS
diac arrest develop swiftly.
Hypercalcemia is treated aggressively with intravenous
normal saline and furosemide (Lasix), which increase cal-
P erhaps of all the problems that clients with cancer experi-
ence, none is more challenging than the associated psy-
chosocial alterations. The mere diagnosis of cancer invokes
cium excretion. Clients also are given drugs to decrease bone fear and misunderstanding. A myriad of emotions may surface
reabsorption. Monitor the serum calcium level when Lasix is initially. These may range from deep depression to denial and
administered. Teach clients early symptoms of hypercalce- total refusal of treatment. Anxiety, sadness, and withdrawal
mia so they recognize a recurrence. These clients are also at are common. Some clients may express feeling like the disease
increased risk for pathological fractures because calcium has is a punishment for something they have done. Each client
been released from the bones, leaving them very fragile. responds differently to the diagnosis, depending on individual
coping mechanisms and support systems.
Research has identified effective and ineffective coping
■ SPINAL CORD COMPRESSION mechanisms. Clients who seek information or share feelings
S
tend to cope more effectively than do those who submit to
pinal cord compression can result in permanent paralysis treatment and procedures without asking questions or who
if not treated promptly. Cancers of the lung, breast, and use small talk to avoid discussing threatening issues.
prostate carry the greatest risk of metastasizing to the spinal Cancer affects not only the client, but the client’s family
cord. The chief symptom of metastasis to the spinal cord as well. Responses of family members to the disease have a
is back pain. The discomfort is aggravated by lying down, significant impact on the client’s coping. The client and family
coughing, or moving, and may be relieved by sitting upright. face issues such as loss of control, changes in body image, and
Treatment is aimed at reducing tumor size to decrease financial burdens, which can be a huge problem.
pressure on the spinal cord. Radiation, surgery, and steroid The nurse has several roles in this context. The client
therapy are used. Pain medications are given frequently, and needs time and space to adjust to the diagnosis. Be available to
clients are supported carefully during transfers. offer support and reassurance. Answer questions, but do not
bombard the client with information. Interpret information
given by the physician and help the client formulate questions
■ SUPERIOR VENA CAVA to ask the physician. Encourage the client to express feelings
SYNDROME and fears about the illness.
The initial treatment is very frightening for most cancer
S uperior vena cava syndrome is a collection of symptoms

caused by an obstruction of the superior vena cava. It
occurs more frequently in conjunction with lung cancer and
clients. Allay anxiety by giving information about the treat-
ment’s purpose, adverse reactions, and signs and symptoms to
report to the physician. Explaining procedures and answering
lymphomas. Typically, clients experience dyspnea and swell-
ing of the face and neck. Edema in the upper extremities, chest
pain, and coughing may also occur. Central nervous system MENTAl HEAlTH
symptoms such as headache, visual disturbances, and altera- CONNECTIONs
tion in consciousness rarely occur.
The goal of treatment is to reduce tumor size. Radiation Psychosocial Aspects of Cancer
along with diuretics is usually ordered. Administer oxygen as The client and caregivers wrestle with many
ordered and provide a calm, restful environment. Encourage
thoughts and feelings as they deal with the di-
the client to limit activities and lie in Fowler’s position. Care-
fully monitor respirations. Lower extremities should not be agnosis of cancer. A competent nurse is aware
elevated, as doing so will increase venous return to an already of the possibility of some of these issues and
engorged area. offers a listening ear as the client and caregivers
express their views.
• Clients may see themselves as burdens to
■ CARDIAC TAMPONADE their families.
C ardiac tamponade is caused by the formation of pericar-

dial fluid, which reduces cardiac output by compressing
the heart. Tumor metastasis to the pericardium is associated
• Family caregivers may be angry that their
own needs must go unmet.
• Family caregivers may feel inadequate with
with lung cancer, breast cancer, Hodgkin’s disease, lym- regard to caring for the client.
phoma, melanoma, gastrointestinal tumors, and sarcoma. • Medical equipment such as a hospital bed,
Common symptoms of cardiac tamponade include a rapid, commode chair, or wheelchair may need to
weak pulse; distended neck veins during inspiration; ankle or be brought into the home. These may have
sacral edema; pleural effusion; ascites; enlarged spleen; leth- an impact on family members’ state of mind
argy; and altered consciousness. and disposition with regard to the family
Treatment is aimed at aspirating the fluid constricting member with cancer.
the heart (pericardiocentesis). Reassure the client, explain the
procedure, and administer medication for pain.
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questions in simple language help the client and family re- physician, nurse, social worker, physical therapist, and home
gain a feeling of some control. Treatment modalities cause health aide, as well as various volunteers. The team functions
many discomforts, but if the client knows what to expect, the to ensure that the client’s plan of care is carried out and that
distress can generally be handled. Symptom management is family members receive adequate support. The family is in-
critical in preventing lifestyle disruptions. structed in ways to provide care. Bereavement counseling is
Families and clients facing the terminal phase of cancer offered to help family members deal with their loss.
are confronted with a complex set of problems. The client and
family face separation and impending death. Some families
demand that extraordinary measures be taken to keep the NURSING PROCESS
client alive. Some search for meaning in life and experience a
genuine closeness. Give the client and family privacy and time
to share feelings. Sometimes, the only psychosocial support
Data Collection
the client needs is to have someone sitting by the bedside. Subjective Data
Touch, especially at times when words are hard to find, can The client interview serves as a forum for ascertaining the
often be the most comforting intervention. client’s perception of the illness, treatment, and prognosis;
As the client’s condition deteriorates, physical needs health practices; and health concerns. The client’s significant
become more pronounced. Focus on keeping the client com- other also is interviewed to ascertain support systems.
fortable and free of pain. Hospice care is designed to provide
spiritual, emotional, and physical support during the final days
of illness. The goal of hospice is to keep the client as comfort- Objective Data
able as possible. Pain relief and symptom management are Vital signs are measured, and a head-to-toe assessment is
stressed. The focus is shifted from cure to care. Care is given performed. Past hospital records are reviewed along with the
in an institution, but most hospice care is given in the home. current record. Laboratory reports, biopsy results, treatment
Hospice care is medically managed and nurse coordinated. modalities, and comments from other health care profession-
Members of the hospice team typically include a chaplain, als are studied.
Nursing diagnoses for a client with cancer include the following:

NurSING PLANNING/ NurSING
DIAGNOSES OuTCOMES INTErVENTIONS rATIONALE
Fear related to cancer The client will express Review the client’s previous ex- Explore client’s view of can-
diagnosis anxieties and fears to perience with cancer to ascer- cer and teach appropriate
family and/or health care tain any current misconceptions facts to replace any incorrect
providers. based on past beliefs. concepts.
Encourage the client to share Determines client’s thoughts
feelings regarding the diagnosis about the diagnosis to de-
to facilitate identification of cop- velop coping strategies.
ing strategies.
Explain hospital routines and fo- Accurate descriptions that
cus on the recommended treat- convey what the client can
ment, including its purpose and expect eases fears associ-
potential side effects. ated with the unknown. Calm,
reassuring environment also
enhances coping abilities.
Anticipatory Grieving The client will express Discuss the loss of body func- Open, honest discussions
related to potential loss grief to family and/or tion with the client. Ask what the help the client cope with the
of body function health care providers. loss of body function means to situation. Be aware that mood
the client. swings, hostility, and other
negative behaviors often
occur.
Encourage the client to seek Support team helps client
help and support from close cope with situation.
family members.
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Imbalanced Nutrition: The client will maintain Encourage the client to eat a Maintains needed nutrition
Less than Body Require- body weight. high-calorie, nutrient-rich diet. during illness and chemo-
ments related to side Supplements are useful. Some therapy.
effects of chemotherapy clients benefit from frequent,
small meals and snacks. Foods
high in protein, such as cheese,
fish, and poultry, are also
recommended.
Provide oral hygiene before and Assists in preventing sto-
after meals. matitis. Also, it makes food
more palatable.
Administer antinausea and an- Prevents nausea and vomit-
tiemetics approximately 30 min ing so nutritional needs can
before meals. Mints, hard can- be met with meal.
dies, and saltine crackers may
help if the client reports a metal-
lic taste.
Nondietary interventions include Pleasant surroundings im-
varying the surroundings, using prove mealtime environment
small plates, eating at a table and enhance appetite.
with friends, and minimizing
food odors.
Monitor intake and output along Assess fluid balance.
with daily weight.
Risk for Impaired Skin The client will maintain Assess skin frequently for side A reddening or tanning ef-
Integrity related to skin integrity. effects of cancer therapy. fect develops with radia-
chemotherapy and tion. Skin reactions such
radiation as rashes, pruritus, and
alopecia develop with
chemotherapy.
Use lukewarm water and soap Skin often becomes sen-
to gently wash the client’s skin. sitive during radiation
treatments.
Risk for Infection The client will remain free Monitor vital signs at least ev- Elevated temperature may
related to side effects of infection. ery shift. White blood count is indicate infection. Low WBC
of chemotherapy monitored and protective isola- count decreases the client’s
tion is instituted if the count falls ability to fight infection.
,500 mm3.
Educate the client, staff, and Chemotherapy and radiation
visitors in all aspects of infec- decreases the client’s blood
tion prophylaxis. Thorough hand cell count and the ability of
hygiene is the most important the immune system to fight
means of preventing and con- infection. Therefore, sev-
trolling the transmission of eral measures are taken to
organisms. Fresh flowers and prevent client exposure to
raw fruits and vegetables trans- bacteria or viruses.
mit microbes and therefore are
eliminated. The client should not
be exposed to anyone who has
an infection or who has been
recently vaccinated against or
exposed to a communicable
disease. Visitors are limited.
(Continues)
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Risk for Injury related to The client will remain Every shift, assess the client for Chemotherapy depletes the
altered clotting factors free of injury related to signs of bleeding (petechiae, ec- platelet count, affecting the
secondary to side effects bleeding. chymoses, hematomas, bleed- ability of the blood to clot.
of chemotherapy ing gums, epistaxis, tarry stools,
hematuria, frank or prolonged
bleeding from puncture sites)
because transfusions may be
indicated.
Monitor platelet count, which is The platelet count indicates
an indicator of clotting ability. the ability of blood to clot
Institute special precautions if effectively.
the count falls ,50,000 mm3.
Apply pressure to all puncture Prevents prolonged bleed-
sites for 3 to 5 minutes. ing, which causes damage
to underlying tissues such as
nerves.
Instruct the client to use a soft Soft toothbrush prevents
toothbrush or sponge for oral some damage to the oral mu-
hygiene to prevent damage to cosa, which is prone to bleed
oral mucosa, which is particu- easily.
larly susceptible to bleeding.
Instruct the client to use an An electric razor prevents the
electric razor when shaving. client from cutting self and
bleeding.
Fatigue related to The client will experience Plan frequent rest periods for Provides rest periods as
analgesics, anemia, less fatigue. the client to restore energy, and needed and utilizes times
stress, increased schedule activities when the cli- when client has energy to en-
metabolism, and ent has the most energy. joy others and life events.
chemotherapy Monitor nutritional intake, Good nutrition meets energy
because adequate nutrients needs and supplies miner-
are necessary to meet energy als, vitamins, and nutritional
needs. needs to make the body
function well.
Recognize that weakness Client may fall or lose balance
places the client at increased more easily.
risk for injury. Because fatigue
may make activities of daily liv-
ing difficult to complete, assis-
tance may need to be provided.
SAMPLE NurSING CArE PLAN
The Client with Lung Cancer

A.B. is a 54-year-old carpenter. He is admitted with pain over his left scapula and radiating to his left arm. He de-
scribes having dyspnea and a productive cough. He denies any recent weight loss but does acknowledge experi-
encing extreme fatigue for the last 2 months. A.B. has been a chronic smoker for 20 years. A chest x-ray reveals an
area of density in the left lung. A needle biopsy confirms small-cell lung cancer. A computed tomography (CT) scan
confirms extrathoracic involvement. His physician referred A.B. to an oncologist for palliative chemotherapy. A.B. is
to receive his first treatment of cisplatin (Platinol) and etoposide (VePesid). A.B. states that he is not sure about this
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SAMPLE NurSING CArE PLAN (Continued)

treatment because it will not cure him and he does not know how he will keep breathing. He has never before been
hospitalized.
NURsING DIAGNOsIs 1 Death Anxiety related to unfamiliar surroundings and uncertainty regarding change in
health status as evidenced by A.B.’s statement that he does not know how he will keep breathing and the fact that
he has never before been hospitalized

Anxiety Control Anxiety Reduction
Acceptance: Health Status Coping Enhancement
Fear Control Emotional Support
A.B. will share his feelings regarding Ascertain what the physician has Helps decrease fear of the unknown.
his dyspnea. told A.B. and what conclusions A.B. Identifies the source of any miscon-
has reached. Encourage A.B. to ception that is increasing anxiety.
share his feelings concerning cancer.
A.B. will express less anxiety about Maintain frequent contact with Reassures A.B. that he is not alone.
being in the hospital. A.B. Explain the hospital routine An unfamiliar environment increases
and care A.B. will receive. anxiety.
EvAlUATION
A.B. shares his feelings about his diagnosis and treatment regimen. A.B. exhibits less anxiety about the change in his
health status and hospitalization.
NURsING DIAGNOsIs 2 Impaired Gas Exchange related to decreased lung capacity and increased secretions as
evidenced by dyspnea, productive cough, and dense area in left lung

Respiratory Status: Gas Exchange Airway Management
Respiratory Status: Ventilation Respiratory Monitoring
Tissue Perfusion: Pulmonary Oxygen Therapy
A.B. will report less dyspnea with Monitor pulmonary status by auscul- Provides information regarding pul-
oxygen saturation .90%. tating breath sounds; checking rate, monary status changes indicating
depth, and pattern of respirations; either improvement or onset of com-
evaluating skin color for cyanosis; plications.
and monitoring pulse oximetry.
Position A.B. in Fowler’s position. Promotes expansion of lungs and re-
spiratory muscles.
Administer oxygen at prescribed Corrects hypoxemia and provides
level. oxygen for metabolic needs.
Administer opioids with caution. Opioids can depress the respiratory
center.
Monitor amount, color, and con- Changes in sputum suggest infection
sistency of sputum. or change in pulmonary status.
Plan care and treatments within Oxygen demands increase with
A.B.’s tolerance. activity.
EvAlUATION
Adequate ventilation with oxygen saturation .90% is maintained.
(Continues)
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SAMPLE NurSING CArE PLAN (Continued)

NURsING DIAGNOsIs 3 Acute Pain related to tumor growth and tissue destruction as evidenced by verbal report
of pain over left scapula radiating to left arm

Pain Control Pain Management
Comfort Level Medication Management
Emotional Support
A.B. will report less pain after pain- Provide routine comfort measures Noninvasive pain-relief techniques
relief measures. such as repositioning and backrub. are helpful in pain management.
Teach A.B. to request pain medica- Keeps pain under control.
tion before onset of pain.
Have A.B. rate pain on a scale of 0 Provides a method of evaluating the
to 10 (0 5 no pain and subjective experience of pain.
10 5 worst pain).
Teach A.B. relaxation techniques. Decreases the perception of pain.
Document A.B.’s response to the Identifies effectiveness of pain-relief
pain-control regimen and adjust as techniques.
needed.
EvAlUATION
A.B. reports less pain; ,2 on a scale of 0 to 10.
NURsING DIAGNOsIs 4 Fatigue related to chronic pain and dyspnea as evidenced by client’s description of dys-
pnea and extreme fatigue for 2 months

Activity Tolerance Activity Therapy
Energy Conservation Energy Management
A.B. will report feeling less fatigued. Plan care to allow for rest periods. Helps conserve energy.
Assess for related factors such as Reduces fatigue.
nutritional imbalances, lack of
sleep, and causes of stress.
Have A.B. rate fatigue on a scale Identifies peak energy and exhaus-
of 0 to 10 (0 5 not tired, 10 5 tion times.
total exhaustion) for a 24-hour
period.
Teach energy-conservation strat- Decreases physical and
egies such as planning ahead, psychological stress.
setting priorities, scheduling rest
periods, and resting before a dif-
ficult task.
EvAlUATION
A.B. exhibits less fatigue in light of having frequent rest periods daily.
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CONCEPT CARE MAP 8-1
NURSING DIAGNOSIS
Anticipatory Grieving related to loss of body function as evidenced by A.B.'s statement that he
does not know how he will keep breathing
NOC: Coping, Grief Resolution
NIC: Anticipatory Guidance, Coping Enhancement, Grief Work Facilitation
NURSING GOAL
A.B. will verbalize his loss and develop coping
skills as he acknowledges his illness as terminal.

1. Provide opportunities for A.B. to express 1. Helps identify A.B.’s coping strategies.
his feelings.
2. Answer all of A.B.’s questions honestly. 2. Helps A.B. cope.
3. Encourage A.B.’s participation in his care. 3. Gives A.B. a greater sense of control.
4. Encourage family support and visits from 4. Assures A.B. that he is not alone and
friends. provides time to discuss concerns openly.
5. Utilize appropriate referrals to professionals, 5. Facilitates the grief process and spiritual
such as clergy, as needed. care.
EVALUATION

Has A.B. come to terms with the reality of his
diagnosis and prognosis?
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CASE STUDY
Prostate Cancer
J.D. is a 70-year-old man with a history of prostate cancer, which was treated with palliative hormones and
radiation. His admitting diagnosis is adenocarcinoma of the prostate with widespread bone metastasis.
J.D. is married and has one grown daughter, who often helps with his care. His chief concern is severe back
pain. The physician has ordered intrathecal morphine sulfate and aspirin 10 g for pain relief.
The following questions will guide your development of a nursing care plan for this case study.
1. List symptoms typically seen in clients diagnosed with prostate cancer.
2. Identify the population most at risk for developing prostate cancer.
3. List three possible risk factors for prostate cancer.
4. Discuss the rationale for the physician’s orders including aspirin along with morphine sulfate.
5. Discuss the rationale for benzodiazepines not being used for pain relief.
6. List the subjective and objective data the nurse would want to obtain.
7. When you walk into J.D.’s room, he greets you with a smile and continues talking and joking with his
daughter. While assessing him, you note that his vital signs are normal. You ask him to rate his pain on
a scale of 0 to 10. He pauses to think about it, then rates the pain at 8. In the chart, you must record
your nursing assessment by circling the appropriate number on the scale. Which number do you think
you should circle?
8. Write three individualized nursing diagnoses and goals for J.D.
9. Discuss which oncological emergency J.D. is most likely to develop.
CONCLUSION (Murph, 2010). By including the psychosocial care, a nurse

A diagnosis of cancer affects the entire family. A nurse works provides a “whole-person approach” (Murph, 2010, p. 533).
effectively with cancer clients and their families when she has Giving competent care to the client with cancer requires an
an understanding of what cancer is, how it is diagnosed and interdisciplinary approach. This chapter provides an under-
staged, treatment modalities and side effects, how to pro- standing of cancer and gives the nurse tools that can be used
vide psychosocial care, and community resources available to holistically address the client and families’ needs.
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CHAPTER 9
Palliative and End-of-Life Care
KEY TERMS
advance directive dysfunctional grief mourning
algor mortis end-of-life (EOL) care palliative care
anticipatory grief grief postmortem care
autopsy Health Care Surrogate Law resuscitation
bereavement hospice rigor mortis
breakthrough pain life review shroud
Cheyne-Stokes respirations liver mortis situational loss
complicated grief loss titrating the dose
death rattle maturational loss traumatic imagery
disenfranchised grief mortuary uncomplicated grief
LEARNING OBJECTIVES
2. Discuss the various losses that affect individuals at different stages of the life span.
3. Identify characteristics of an individual experiencing grief.
4. Compare and contrast adaptive grief and pathological grief.
5. Discuss the stages of the normal grieving process.
6. Describe the holistic needs of the dying person and family.
7. Plan care for a dying client.
8. Describe nursing responsibilities when a client dies.
9. Discuss ways that nurses can cope with their own grief.
159
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INTRODUCTION
Nurses encounter clients every day who are responding to
grief associated with losses. Some losses that individuals expe-
rience are the desired job of a lifetime, a financial risk, a cher-
ished relationship, or physical loss of a loved one. Competent
nurses have an understanding of the major concepts related to
loss and grieving so they can support clients in these challeng-
ing times. This chapter presents information on how nurses
can interact with and meet the special needs of families and
clients experiencing loss and terminal illness.
LOSS
Loss is any situation, either potential, actual, or perceived,
wherein a valued object or person is changed or is not acces-
sible to the individual. Everyone experiences losses because
change is a major constant in life. Loss can be actual (e.g., a
child is lost in the woods) or anticipated (a client with diabetes
is faced with having a foot amputated). The loss can be tan-
gible (an object that can be touched or that has financial value)
(© Andrew Lever/ShutterStock)
or intangible (something that cannot be physically touched).
For example, when a person is not selected for a job, the tan-
gible loss is income, and the intangible loss is self-esteem.
Losses also occur as a person moves from one develop-
mental stage to another. An example of such a maturational
loss is the toddler who loses the bottle after learning to drink
from a glass. A situational loss takes place in response to
external events generally beyond the individual’s control, such Figure 9-1 This man grieves the loss of his wife through a
as losing a job when the company is bankrupt. divorce.
The four major categories of loss are loss of significant
other, loss of aspects of self, loss of external objects, and loss
of a familiar environment.
Loss of Familiar Environment
The loss of a familiar environment occurs when a person
Loss of Significant Other moves away from familiar surroundings, for instance, to
Losing a loved one is a very significant loss. Such a loss can another home or a different community, to a new school, or
result from moving to a different area, separation, divorce, or to a new job. A client who is hospitalized or institutionalized
death. At first, one may feel shock or anger. The grief some- may also experience loss when faced with new surround-
times feels like the pain will never let up (Figure 9-1). ings. This type of loss evokes anxiety related to fear of the
unknown.
Loss of Aspect of Self
Loss of an aspect of self can be physiological or psychological. GRIEF
Physiological loss includes loss of physical function or loss Grief is a series of intense psychological and physical
resulting from disfigurement or disappearance of a body part, responses occurring after a loss. These responses are nec-
as is the case with amputation or mastectomy. Loss of a physi- essary, normal, natural, and adaptive responses to the
cal aspect of self can result from trauma, illness, or a treatment loss. Loss moves the individual to the adaptive process of
methodology such as surgery. Psychological aspects of self mourning, the period during which grief is expressed and
that may be lost include a sense of humor, ambition, or enjoy- integration and resolution of the loss occur. Bereavement
ment of life. These feelings of loss may result from life events is the period of grief that follows the death of a loved one
such as losing a job or failing at a task that the individual (Figure 9-2).
deems important.
Loss of an External Object Stages of Grief

Whenever an object that a person highly values is changed or Three recognized stages of grief are shock, reality, and
damaged or disappears, loss occurs. The type and amount of recovery.
grieving depends on the significance of the lost object to the
individual. For instance, an individual who loses a family heir- Shock Stage
loom in a fire may react not only to the lost financial value of The period of shock may last from only days to a month or
the piece but also to the lost sense of history and heritage that more. The person may describe feeling “numb.” It is an emo-
the piece represented. tional numbness rather than a physical one.
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CHAPTER 9 Palliative and End-of-Life Care 161
BESTPRACTICE
Successful Grieving
The person experiencing successful grieving will:
• Consciously recognize that a significant loss has
occurred.
• Progress through the stages of grief.
• Use adaptive coping behaviors, such as interact-
ing with others, participating in and completing
tasks, and having a positive attitude.
(deLmAr cengAge LeArning)

uncomplicated grief to describe the grief reaction normally
following a significant loss. Uncomplicated grief has a fairly
predictable course that ends with relinquishing the lost object
and resuming the duties of life.
The grieving person may feel angry, hopeless, or sad and
may express feelings of depression. A person who is grieving
Figure 9-2 Older adults may grieve intensely over the loss may experience loss of appetite, weight loss, insomnia, rest-
of a person or situation that has been a part of their lives for lessness, indecisiveness, impulsivity, and inability to concen-
many years. trate or carry out daily activities.
Reality Stage Anticipatory Grief

A painful experience begins when the individual consciously Anticipatory grief is the occurrence of grief before an
realizes the full meaning of the loss. Anger, guilt, fear, frustra- expected loss actually occurs. Anticipatory grief may be
tion, and/or helplessness may be the expressed reactions. experienced by both the person’s family and the terminally
ill person. This process promotes early grieving, freeing
Recovery Stage emotional energy for adapting once the loss has occurred.
During the last stage, recovery, the loss is integrated into the Although anticipatory grieving may be helpful in adjusting
reality of the individual’s life. The person exhibits adaptive to the loss, it also has some potential disadvantages. For ex-
behaviors and begins to live again, doing things that were ample, in the case of the dying client, the family members may
formerly enjoyed. distance themselves and not be available for support. Also, if
the family members have separated themselves emotionally
Types of Grief from the dying client, they may seem cold and distant and,
thus, not meet society’s expectations of mourning behavior.
Grief is a normal, universal, response to loss. Grief drains This response can, in turn, prevent the mourners from receiv-
people, both physically and emotionally, and relationships ing their own much-needed support from others (Pritchett &
often suffer. Different types of grief include uncomplicated, Lucas, 2002b).
anticipatory, dysfunctional, and disenfranchised grief.
Nurses assist many individuals to understand the normal
grieving process. Nurses who understand these types of grief Dysfunctional Grief
are better prepared to assist others. Dysfunctional grief is a demonstration of a persistent pat-
tern of intense grief that does not result in reconciliation of
Uncomplicated Grief feelings. The person experiencing dysfunctional (or patho-
Uncomplicated grief is what many individuals would logical) grief does not progress through the stages of grief.
refer to as normal grief. Engle (1961) proposed the term The dysfunctionally grieving person cannot reestablish a rou-
tine. The professional caregiver is attuned to these behaviors
and refers the pathologically grieving person to professional
counseling.
MEMORY TRICK
Grief Stages Disenfranchised Grief
A memory trick to recall the grief stages is SRR:
Disenfranchised grief is a grief one experiences that cannot
be shared because it is not socially acceptable, seemingly in-
S 5 Shock significant to others, or not known by one’s family or friends.
R 5 Reality The individual may not acknowledge the sense of loss, feels
guilt, or feels pressured to “get on with life.” Examples of dis-
R 5 Recovery enfranchised grief are extreme sadness over the loss of a pet
when this mourning might be viewed by others as excessive or
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BESTPRACTICE
Factors Affecting Loss
and Grief
Identifying Dysfunctional Grief Variables affecting the intensity and duration of grieving are:
Normal and dysfunctional grief are differentiated • Developmental stage
in that the person experiencing dysfunctional grief • Religious and cultural beliefs
is unable to adapt to life without the deceased • Relationship with the lost person or object
person. Dysfunctional grief can take several forms: • Cause of death
• Chronic grief is the inability to conclude
grieving. Developmental Stage
• Delayed grief occurs when grief work does not Depending on the client’s place on the age/development
take place at the time of loss. continuum, the grief response to a loss will be experienced dif-
• Exaggerated grief describes the situation when ferently. For example, a pregnant woman will, to some degree,
grief is experienced as overwhelming. experience loss after delivery of a first child (loss of freedom,
• Masked grief occurs when grief is covered up by independence, and self-focused life), even when the child is
maladaptive behaviors such as apathy, irritabil- normal and healthy. Certain kinds of loss at key developmen-
tal points may have a profound effect on a person’s ability to
ity, and unstable moods or a physical symptom
both work through the resulting grief and achieve the tasks of
such as loss of libido, with the person being un-
the given developmental stage. For example, an adolescent
aware of the connection to the loss and grief. who has lost a parent may have difficulty forming an intimate
relationship with members of the opposite sex.
Childhood
inappropriate, a mother’s sadness over a miscarriage because Children vary in their reactions to loss and in the ability to
a lengthy period of mourning may not be publicly expected comprehend the meaning of death. It is important to un-
despite the mother’s intense feelings of loss and despair, or derstand the way a child’s concept of death evolves because
one’s grief over the loss of a relationship that is not publicly the concept varies with developmental level and may affect
known or accepted. mastery of developmental tasks (Table 9-1). Children who
Table 9-1 Perception of Death by Children and Adolescents

DEVELOPMENTAL POTENTIAL DEVELOPMENTAL
STAGE PERCEPTION DISRUPTIONS
Infancy, toddlerhood • Unaware of death. • Death of primary caregiver during the first
• Aware of changes in normal routine. 2 years of life may have significant long-lasting
• Reacts to family’s expressions of grief. psychosocial implications.
Preschool • Believes death is a temporary • Loss of either parent may have significant
separation. psychosocial implications, especially between
• Reacts to the gravity of death as they ages 4 and 6 years (because of magical thinking,
see parents or others react. wherein children may believe death is their fault).
• Problems with development of sexual identity,
depending on the gender of the parent lost, the
child’s identification with that parent, and the
child’s present state of sexual identity.
School age • Comprehends that death is inevitable • Potential nightmares.

and final. • Potential death-avoidance behaviors (e.g., hiding
• Conjectures about and is inclined to under the covers, leaving the lights on, closing
personify death (“the boogie-man”). closet doors).
• Possible intense guilt and a sense of responsibil-
ity for the death.
Preadolescence and • Acknowledges that death is final. • Loss of a parent may cause difficulty in forming
adolescence • Comprehends that death is inevitable. an intimate relationship with members of the op-
• Preadolescents: may worry about dy- posite sex.
ing; adolescents: seem to deny that
they could die.
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are grieving need honest explanations about death using terms CRITICAL THINKING
they can understand.
Adolescence Perceptions of Death
Physical attractiveness and athletic abilities are valued by most
adolescents. Because adolescents seek approval of their peer
group, when the adolescent experiences the loss of a body Find a classmate from a different cultural back-
part or function, grief includes fear of being rejected. After a ground than yours. How does your classmate’s
disfiguring accident, grief is usually very intense. Even though perception of death differ from yours?
they have an intellectual understanding of death, adolescents
believe themselves to be invulnerable and, thus, immune to
death; they reject the possibility of their own mortality.
Early Adulthood Relationship with the Lost
In the young adult, grief is often precipitated by loss of role
or status. For example, significant grief may be caused by un-
Person or Object
employment or the breakup of a relationship. The concept of Generally, the grief experienced is more intense the more in-
death in this age-group reflects primarily spiritual beliefs and timate the relationship was with the deceased. The death of a
cultural values (Figure 9-3). child is generally thought to be exceptionally painful because
it upsets the natural order of things; parents do not expect
Middle Adulthood their children to die before them. Parents experiencing grief
The potential for experiencing loss increases during middle usually have intense responses and reactions (Figure 9-4).
adulthood. The death of parents often occurs during this
developmental phase. As an individual ages, it can be espe- Cause of Death
cially threatening when peers die, because these deaths force The intensity of the grief response also varies depending if the
acknowledgment of one’s own mortality. cause of death was unexpected, traumatic, or a suicide.
Late Adulthood Unexpected Death
Most individuals recognize the inevitability of death during The bereaved have particular difficulty achieving closure
late adulthood. It is challenging for elders to experience the when the loss occurs as a result of an unexpected death.
death of age-old friends or to find themselves the last one of Survivors are shocked and bereaved after an unanticipated
their peer group left living. Older adults often turn to their death for example, from an aneurysm, heart attack, or stroke.
children and grandchildren as sources of comfort and com- Usually, the bereaved can work through the grieving process
panionship. Cultivating friendships in all age-groups helps without complications.
prevent loneliness and depression.
Traumatic Death
Religious and Cultural Beliefs Complicated grief is associated with traumatic death such
An individual’s grief experience is significantly affected by as death by accident, violence, or homicide. Survivors are not
religious and cultural beliefs. Every culture has rituals for necessarily predisposed to complications in mourning but
care of the dying and beliefs about the significance of death. often have more intense emotions than those associated with
Other beliefs regarding an afterlife, redemption of the soul, a normal grief.
supreme being, and reincarnation can assist the individual in Following a violent death, the bereaved may undergo
grief work. traumatic imagery (imagining the feelings of horror felt
Figure 9-3 Young adults usually grieve loss of a role, such Figure 9-4 The couple discusses grief over the loss of a
as employment or the breakup of a relationship. child.
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CulTuRAl CONSIDERATIONS
Cultural Diversity and Death
Different cultures have unique views of death and acceptable displays of emotion at the time of death. The fol-
lowing table outlines these views.
Cultural Group Role of Family Display of Emotion Care of Dying in Home

African Health care providers should Expected and common. Families frequently care for
American communicate with the spouse dying elders in the home.
or oldest family member about
the dying client.
Chinese Family may prefer dying cli- Express sorrow at parents’ fu- Some believe bad luck will
American ent not be told of terminal neral; the first son is in mourn- occur if client dies in the
illness or imminent death or ing for 72 days and cannot home and others think the
may prefer a family member wear red clothing or marry client’s spirit will get lost if
tell the client. during that time. death occurs in the hospital.
Family may use amulets or
cloths.
Filipino Health care providers should Expected. Dying client may desire to
American communicate with the head of die in the home.
the family and not in the pres-
ence of the client.
Hispanic or Extended families care for the Vocal expression of grief Some believe the spirit will
Latino American dying client. Families share shows respect for the dead get lost if the client dies in
information and decision client. the hospital.
making. Use of amulets, rosary beads,
and prayers is common.
The family may desire to care
for the body after death and
have some time alone with
the deceased person.
Native American Decisions are made in family Family does not mourn in the Beliefs differ with each
meetings. client’s presence. tribe. Some believe coming
Family members may not dis- Eye contact is avoided and in contact with a dying or
cuss impending death. a respectful distance is dead body requires cleans-
maintained. ing. Therefore, some may
avoid contact because of
this belief.
Data from “Cultural Considerations in End-of-Life Care” by P. Mazanec and M. Tyler, 2003, American Journal of Nursing, and S. Russell, 2005, American
Academy of Ambulatory Care Nursing Viewpoint.
by the victim or reliving the terror of the incident). Trau- Only when this problem is identified and the survivors are
matic imagery is a common occurrence in cases of traumatic encouraged to express their intense feelings will they be able
death. Such thoughts, coupled with intense grief, can lead to move through the normal, adaptive grieving process.
to post-traumatic stress disorder (PTSD) in the survivors.
Nurses’ awareness of the possibility of PTSD and alertness Suicide
for the presence of symptoms is important. Symptoms may The loss of a loved one to suicide is frequently compounded
include: by feelings of guilt by the survivors for failing to recognize clues
that may have permitted the victim to receive help. The feel-
• Chronic anxiety ings of guilt and self-blame can change into anger at the victim
• Psychological distress for inflicting such pain. Having a suicide in the family may
• Sleep disturbances, such as recurrent, terror-filled evoke feelings of shame. Survivors may be prohibited from suc-
nightmares cessfully resolving their grief by the negative stigma of suicide.
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Nursing Care of the BESTPRACTICE

Grieving Client
Nurses can assist people to grieve by encouraging them Adaptive Grieving
to experience their feelings to the fullest in order to work
through them. Providing support and explaining to the How long does the process of adaptive grieving
bereaved that it will take time to grieve the loss and to gain take? The length of time necessary for grief resolu-
some closure to the relationship are both important nursing tion is as individual as the person experiencing it
responsibilities. and depends on the intensity of the grief. Grief is
After the loved one dies, the caregiver feels grief and considered to be a “long-term process” (Corless,
relief. Caregivers often feel guilty for feeling relieved. Assure Germino, & Pittman, 2006). Grief work takes time.
them these feelings are very normal, because caregiving is There are no definite time frames within which
exhausting, leaving one with little emotional and physical re- grief should occur. Each person grieves in his own
serve. The nurse assists the caregiver to find ways to fill his life
way and at his own pace.
with meaningful activities.
Assessment
Determining the personal meaning of the loss is the beginning
of a thorough assessment of the grieving client and family. Implementation
The person’s progress through the grieving process is another
key assessment area. The stages of grieving are not necessarily Basic to therapeutic nursing care is an understanding of
mastered sequentially, but instead individuals may move back the significance of the loss to the client. The nurse must
and forth through the stages of grief. spend time listening to understand the client’s perspective.
Even if the client does not respond according to the nurse’s
belief system or expectations, the nurse must demonstrate
Nursing Diagnosis acceptance. The nurse’s nonjudgmental, accepting attitude
The North American Nursing Diagnosis Association Interna- is essential during the bereaved’s expression of all feelings,
tional (NANDA) defines Complicated Grieving as “the experi- including anger and despair. The nurse avoids personalizing
ence of death and accompanying bereavement fails to follow and using defensive behaviors by communicating an under-
normative expectations and manifests in functional impair- standing of the client’s anger. The expression of grief is not
ment” (NANDA, 2009, p. 265). The other grieving diagnosis only appropriate but also essential for therapeutic resolution
is Risks for Complicated Grieving. of the loss.
Grieving people need reassurance, support, and coun-
Planning/Outcome Identification seling. One mechanism of support on a long-term basis
is support groups. The nurse must be informed about the
When planning care for the grieving client, it is important to
availability of such groups within the community in order to
clarify the expected outcomes. Some expected goals for the
make appropriate referrals. Members of support groups have
person experiencing grief are:
experienced similar losses. Discussions in support groups de-
• Accept the loss. crease the feelings of loneliness and social isolation that are so
• Verbalize feelings of grief. common in the grief experience.
• Share grief with significant others.
• Renew activities and relationships. Evaluation
People follow their own time schedule for grief work. Be-
Some of these expected outcomes will take a long time to cause it takes months or years for grief resolution, nurses usu-
achieve, and some must be achieved before others are mas- ally do not have the opportunity to know when the bereaved
tered. For example, to accept the loss, the person must begin family completes its grief work. The nurse does have a unique
to share grief with others by verbalizing those feelings. Two of opportunity to lay the foundation for adaptive grieving by en-
the expected outcomes are discussed below. couraging the family to verbalize their experience and share
their feelings with significant others. The foundation for
Acceptance of the Loss evaluation is the goals mutually established with client and
Individuals are able to reach some acceptance and resolution family. It is important for nurses to teach grieving individuals
of feelings about the loss only by going through grief work. that resolution of the loss is generally a process of lifelong
Often, people try to find some meaning in their situations. adjustment.
This search involves introspection, for which spiritual support
may be therapeutic.
DEATH
Renewal of Activities and Relationships Historically, death has been considered as natural as birth, as
The basis of grief work revolves around accepting the fact simply the last stage of life. Significant changes in the percep-
that the needs met by key people in life can be met by other tion of death have occurred in the past three decades. In some
people in other ways. Knowing that the deceased cannot be cases, dying and death are no longer simple matters but are
replaced, healing must occur so that new relationships may issues involving ethical concerns and, in some cases, legal in-
begin. tervention by the court system.
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Each person dies a unique death, just as each person lives (DNR) order from a physician if this is in agreement with the
a unique life. Death may be sudden and unexpected, caused client’s wishes and with the advance directives. In the absence
by accident or heart attack, for example, or death may be of such an order, resuscitation will be initiated.
prolonged, coming after a distressing long-term illness. For In many states a Health Care Surrogate Law is imple-
the older person who dies during sleep, death comes quietly. mented when there is no advance directive. This law varies
Those who choose to die on their own terms by suicide plan from state to state but basically provides a legal means for
their deaths. certain individuals to make decisions for the client when the
Health care workers must understand the ethical and client cannot do so. The spouse is the first person who would
legal issues surrounding dying and death. Understanding the act in the interests of the client, then children in the event
stages of death and dying and the signs of impending death there is no spouse.
will help prepare the nurse to render sensitive, effective care,
both to the client and family and to the client’s body after
death. Nurses must also come to terms with their own mortal- Ethical Considerations
ity and feelings about death if they are to provide comfort to Death is often fraught with ethical dilemmas that occur al-
dying clients and their families. Health care workers can learn most daily in health care settings. Ethics committees in many
a great deal about life from the dying client. health care agencies develop and implement policies to deal
with end-of-life issues. These committees are interdisciplin-
ary and may have clergy and attorneys as well as health care
Legal Considerations providers as members. Ethical decision making is a complex
The Patient Self-Determination Act (PSDA) is part of the issue. Determining the difference between killing and allow-
Omnibus Budget Reconciliation Act (OBRA) of 1990. This ing someone to die by withholding life-sustaining treatment
act provides a legal means for individuals to specify the cir- methods is one of the most difficult dilemmas.
cumstances under which life-sustaining measures should or The American Nurses Association (ANA) distinguishes
should not be rendered to them. The individual’s choices are mercy killing (euthanasia or assisted suicide) and relieving
identified in advance directives. An advance directive is any pain. Euthanasia is viewed as unethical, whereas pain relief is
written instruction recognized under state law, including a a central value in nursing. The ANA’s position is that increas-
durable power of attorney for health care or a living will. The ing doses of medication to control pain in terminally ill clients
act applies to hospitals, home health agencies, long-term care is ethically justified, even at the expense of maintaining life
facilities, hospice programs, and certain health maintenance (ANA, 2008).
organizations (HMOs). According to the PSDA, all clients
entering the health care system through any of these orga-
nizations must be given information and the opportunity to Stages of Dying and Death
complete advance directives if they have not already done Elizabeth Kübler-Ross (1997a, 1997d) identified in her clas-
so. In many states, just signing these documents may not be sic works five stages of dying that are experienced by clients
adequate for carrying out client wishes. They may also need to and their families (Table 9-2). Every client does not move
indicate their desires regarding intubation, artificial feeding, through each stage sequentially. These stages are experienced
blood transfusions, chemotherapy, surgery, and transfer to the for varying lengths of time and in varying degrees. The client
hospital (for residents in skilled care facilities). may express denial and then, a few minutes later, express ac-
Although a durable power of attorney for health care and ceptance of the inevitable and then anger. An important value
living will are legal documents, they do not prevent resusci-
tation (support measures to restore consciousness and life).
The medical record must have a written do-not-resuscitate LIFE SPAN CONSIDERATIONS
Reactions to Impending Death
BESTPRACTICE • Persons of all ages generally experience the
same feelings and emotions as they progress
Care of the Dying Client through a terminal illness.
Dying was once considered to be a normal part of • Persons of any age who have endured a long
the life cycle. Today, it is often considered to be a illness may view death as a release from their
medical problem that should be handled by health suffering.
care providers. Technological advances in medicine • Persons of any age may find it difficult to reach
have led to depersonalized and mechanical care acceptance if they have unfinished business.
of those who are dying. Our highly technological • Many people receive satisfaction from life re-
world calls for application of high-touch interven- view (a form of reminiscence wherein a client
tions with the dying. In other words, appropriate attempts to come to terms with conflict or to
care of the dying is administered by compassionate gain meaning from life and die peacefully).
nurses who are both technically competent and able • Elderly clients may welcome death, especially if
to demonstrate caring. Death is not the enemy— they have outlived everyone who was near and
lack of caring is (Hvizdos, 2000; West, 2011). dear to them.
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Table 9-2 Kübler-Ross’s Stages MEMORY TRICK

of Dying and Death
Stages of Dying and Death
STAGE EXAMPLE
A memory trick for recalling the stages of dying
Denial Verbal: “No, I don’t believe that.” and death is DA-B-DA:
Behavioral: Client diagnosed with leu- D 5 Denial
kemia and refuses to consider treat- A 5 Anger
ment options.
B 5 Bargaining
Anger Verbal: “Why me, why?”
D 5 Depression
Behavioral: Client is demanding and
demonstrates aggressive behavior. A 5 Acceptance
Bargaining Verbal: Client prays, “Please, just let

me live to see my new grandbaby.”
Behavioral: Client makes deals with response. The anger may be directed at self, God, others, the
caregivers or God. environment, and the health care system. In the client’s eyes,
whatever is done is not the right thing. Family members may
Depression Verbal: “I just want to be alone.” be greeted with silence or with outbursts of anger. Their re-
Behavioral: Client turns away and sponse, in turn, may be anger, guilt, or despair.
closes eyes.
Bargaining
Acceptance Verbal: “I am ready. I feel at peace The client attempts to postpone or reverse the inevitable by
now.” bargaining. The client’s bargaining represents an attempt to
Behavioral: Client gets legal and finan- postpone death and usually has self-imposed limitations. For ex-
cial affairs in order and says goodbye ample, a client may ask to live long enough to see the first grand-
to family and friends. child in exchange for giving money to a charity. Most clients
Data from On Death and Dying, by E. Kübler-Ross, 1997a.
bargain in silence or in confidence with their spiritual leader. It is
not uncommon for a client to live long enough for some special
event (a wedding or birth), then die shortly afterward.
Depression
of Kübler-Ross’s work is that it has increased sensitivity to the
Depression resulting from the realization that death can no
dying client’s needs.
longer be delayed is different from dysfunctional depression
because it helps the client detach from life and makes it easier
Denial to accept death. Depression in this sense is a therapeutic ex-
During the first stage of dying, the initial shock can be very perience for the dying person. Clients sometimes feel aban-
overwhelming, making denial a useful tool of coping. It is an doned, as persons who were once friends begin to visit less
essential, protective mechanism that may last for only a few and less, sometimes severing ties with the client even before
minutes or may manifest for months. death; this may compound the client’s feelings of depression
In some clients, denial manifests as “doctor shopping” and hopelessness.
(not to imply that second opinions are not sometimes neces-
sary) or insisting that there must have been a mix-up or mis- Acceptance
take in the diagnostic tests. In other clients, denial manifests Every dying client may not reach the final stage, acceptance.
as simply avoiding the issue. Their daily routines are the same Peace and contentment come with acceptance. The client of-
as though nothing in their lives has changed. Given time, most ten expresses feeling that all that could be done has been done.
people will eventually move past the stage of denial. It is important to reinforce the client’s feelings and sense of
Clients may choose to be selective in the use of denial. personal worth. Many clients will make an effort to get all of
For example, clients try to protect certain family members or their personal and financial affairs in order.
friends from the truth by using denial. Clients may also use Sleep is required to fill a physical and emotional need,
denial from time to time to set aside thoughts of illness and not to avoid reality. The client may limit visitors to those
death in order to focus on living. people with whom he feels comfortable and safe. The most
significant forms of communication at this time are touch and
Anger moments of silence.
Anger often follows the initial stage of denial. The client’s
security is threatened by the unknown, with the normal daily END-OF-LIFE CARE
routines becoming disrupted. This stage is typically very dif-
ficult for family and caregivers because they often feel useless End-of-life (EOL) care is nursing care of terminally ill
in terms of helping their loved one through the situation. clients that focuses on meeting the physical and psychosocial
Since the client has no control over the situation, anger is the needs of the client and his family. Attention is directed to the
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control of symptoms, identification of client needs, the pro- problems experienced by clients and families during end of
motion of interaction between the client and significant oth- life. The nurse addresses pain control and the management
ers, and the facilitation of a peaceful death. The nurse focuses of other physical problems (Hull, 2008). The client needs to
on improving the quality of life for the dying client during the know that he has the nurse’s support as an advocate for his care
final stage of life and ensures a dignified and peaceful death. and well-being. (For more definition of palliative care and to
As a member of the interdisciplinary team responsible for pro- see palliative care in action go to http//www.getpalliativecare
viding EOL care, the nurse plays a critical role in identifying .org and search for palliative care videos.)
client needs and in supporting family members through the
EOL experience (Hull, 2008).
The decision to abandon aggressive treatment should Hospice Care
not be regarded as a sign of “immediate death.” Palliative and Hospice is care for people who are terminally ill and was
hospice care evolved over the years to bridge the gap between founded on the concept of allowing individuals to die
cure-focused treatments and EOL care. Both approaches with dignity surrounded by those who love them. Clients
serve as coordinated, multidisciplinary efforts developed pur- enter hospice care either at home or in a hospice center
posefully to address the needs of the client and family facing a when aggressive medical treatment is no longer an option or
terminal illness (Hull, 2008). when the client refuses further medical care. Hospice care
is based on the belief that meaningful life can be achieved
during terminal illness and that care of the dying is best
Palliative Care supported in the home setting or hospice center, free from
Terminally ill clients are often given palliative care, or care technological interventions to prolong physiological dying
that relieves symptoms, such as pain, but does not alter the (Hull, 2008).
course of disease. Palliative care is an approach that focuses on Hospice is a coordinated program of interdisciplinary
the seriously ill client and family and is most often provided in services provided by professional caregivers and volunteers.
the home, hospital setting, or long-term care facilities (Hull, Hospice care does not hasten life, nor does it prolong death
2008). through artificial means. Instead, it assists the client and fam-
In palliative care, the goal is to ensure the highest possible ily in understanding the death process and how best to enjoy
quality of life for the client and family (Hull, 2008). A primary life until the end (Figure 9-5) (Hull, 2008).
aim is to help the client feel comfortable, safe, and secure. The
nurse can do much to increase the client’s feelings of safety by Differentiating Palliative Care
being available when needed. Holding the client’s hand and
listening are therapeutic measures. and Hospice Care
Care delivered by an interdisciplinary team empha- Although used interchangeably, the terms palliative care and
sizes the management of psychological, social, and spiritual hospice care are different in several ways. For example, pal-
liative care can start much earlier in the disease process than
Rituals Following Death
• Judaism practices burial of the dead within
24 hours. A 7-day period of mourning, called
Shiva, begins the day of the funeral.
• In the Islamic faith, men wash the body of a
man and women wash the body of a woman
after death.
• Buddhists believe that after death, the body
should not be disturbed by movement, talking,
or crying.
• Hindus pour holy water into the mouth of the
dying person. The eldest son arranges for the
funeral and cremation within 24 hours of death.
Embalming is forbidden.
• Jehovah’s Witnesses believe that the soul dies
with the body, but 144,000 will be resurrected
at the end-time and will be born again as spiri-
tual sons of God.
• Native Americans believe that the spirit lives on
after death. Ancestor worship is practiced. Figure 9-5 A garden is a place of solace for a hospice client
and family. (courteSy of viSiting nurSe And hoSpice home, fort wAyne, in)
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Table 9-3 Approaches in End-of-Life Care

DIMENSIONS PALLIATIVE CARE HOSPICE CARE
Recipient of care Anyone with a serious illness regardless of Life expectancy of 6 months or less
life expectancy
Services provided Symptom management Symptom management

Physical therapy Provision of medications, medical supplies,
Client and family counseling and equipment
Spiritual care Coverage for short-term inpatient care
Grief support
Volunteer services
Care settings Home care Hospice inpatient care

Ambulatory/outpatient Hospice home care
Acute care
Long-term care
Third-party coverage Some treatments and medications may be Medicare Hospice Benefit
covered by Medicare, Medicaid, and private Medicaid Hospice Benefit
insurers Some private insurers
Data from Palliative and End of Life Care, by E. Hull, 2008. Manuscript submitted for publication.
hospice care, which is usually offered in the last 6 months

of life. Table 9-3 explains the two approaches in EOL care BOx 9-1
(Hull, 2008). INFORmATION GAThERED IN
ASSESSmENT OF ThE DyING CLIENT
Nursing Care • Client and family goals and expectations
of the Dying Client • Client’s awareness that illness is terminal
Despite health care advances, care of clients who are termi- • Client’s stage of dying
nally ill remains a challenging and rewarding reality for many • Identification of support systems
nurses. The death process is typically a very emotional time • History of positive coping skills
for clients and their families; compassionate and sensitive • Client perception of unfinished business to be
nursing care that respects clients’ wishes and that meets their completed
physical needs can help bring peace and dignity to this natural Adapted from “Death and Dying,” by K. Pritchett and P. Lucas,
process. 2002a. In Psychiatric–Mental Health Nursing: Adaptation and
Growth (4th ed., pp. 206–207), by B. S. Johnson (Ed.), Philadelphia:
Assessment Lippincott Williams & Wilkins.
A thorough assessment of the client’s holistic needs is the

basis for nursing interventions. Assessment of the dying client
includes an ongoing collection of data regarding the strengths behalf” (NANDA, 2009, p. 184). The client may also exhibit
and limitations of the dying person and the family. Refer Death Anxiety, “apprehension, worry, or fear related to death
to Box 9-1 for information to gather when assessing a dying or dying” (NANDA, 2009, p. 244).
client.
Planning/Outcome Identification
Nursing Diagnoses The major goals of nursing care are the physical, emotional,
The nurse’s assessment of the dying client may lead to several and mental comfort of the client. The goals of nursing care
diagnoses. One NANDA-approved nursing diagnosis that for the dying client are the same as those goals developed for
is applicable for many dying clients is Powerlessness, that is, all clients who are unable to meet their own needs. The dy-
“the perception that one’s own action will not significantly ing client should be treated as a unique individual worthy of
affect an outcome; a perceived lack of control over a current respect instead of a diagnosis to be cured. Many dying clients
situation or immediate happening” (NANDA, 2009, p. 190). do not fear death but are anxious about a painful death or dy-
Another response that is often experienced by the dying is ing alone.
described by the diagnosis Hopelessness, “a subjective state in Promoting optimal quality of life includes treating the
which an individual sees limited or no alternatives or personal client and family with respect and providing a safe environ-
choices available and is unable to mobilize energy on own ment for expressing their feelings. Planning should focus on
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MENTAL HEALTH
CONNECTIONS
Planning Care for the Dying Client
• Schedule time to spend with the client.
• Identify areas of special concern to the client
and make referrals when appropriate (e.g.,
social worker consult for information on
equipment rental).

• Promote and protect individual self-esteem
and self-worth.
• Balance the client’s needs for assistance and
independence.
• Meet the physiological needs of the client
and family. Figure 9-6 Establishing a caring and trusting relationship
helps the client come to terms with a terminal illness.
• Respect the client’s confidentiality.
• Provide factual information to the client and
family and answer all questions. Fluids and Nutrition
• Offer to contact clergy or other spiritual Dying clients are rarely hungry and gradually stop eating and
leader. drinking. Refusal of food and fluids is a natural part of the
dying process. A study of clients dying of cancer found the
Adapted from “Death and Dying,” by K. Pritchett and P. Lucas,
2002a. In Psychiatric–Mental Health Nursing: Adaptation and Growth
clients did not feel hunger or thirst (Robert Wood Johnson
(4th ed., p. 208), by B. S. Johnson (Ed.), Philadelphia: Lippincott Foundation, 2004). In fact, hospice workers found that clients
Williams & Wilkins. who are not given artificial nutrition and hydration are more
comfortable than those who receive it (Robert Wood Johnson
Foundation, 2004). When artificial nutrition and hydration
meeting the client’s and family’s holistic needs, as specified are withheld, symptoms of nausea, vomiting, abdominal pain,
in the Dying Person’s Bill of Rights. It is as relevant today as loss of bladder control, and shortness of breath decrease.
when it was written in 1975. When planning care, the nurse Artificial nutrition often increases the client’s agitation and
should make every effort to be sensitive to the rights of the risk of aspiration pneumonia. When clients are nearing death
dying client. and artificial nutrition and hydration are stopped, the client
dies within 3 to 14 days. Health care personnel noticed that
the dying process was peaceful and that the clients did not
Implementation experience pain or distress (Robert Wood Johnson Founda-
The first priority is to communicate caring to the client and tion, 2004).
family. Powell (1999) found that the presence of a comfort- The client’s wishes must always take precedence in every
ing nurse made a tremendous difference to the client. LaDuke situation. Family members must be given truthful and accu-
(2001) suggests holding a client’s or family member’s hand rate information when a comatose client has not previously
and saying “I will not leave you.” This assurance of the nurse’s made his wishes known, so appropriate decisions for the
presence is a powerful way to show caring. client can be made. The American Dietetic Association, the
The nurse should approach the client in denial with American Medical Association, and the ANA agree that it is
understanding and the knowledge that moving between the ethically, legally, and professionally acceptable to discontinue
stages of dying is enhanced by a trusting nurse–client relation- nutritional support if that is the terminally ill client’s request.
ship. Establishing rapport facilitates the client’s verbalization
of feelings (Figure 9-6). A safe environment established by the Mouth, Eyes, and Nose
nurse allows the client to express personal, real-time feelings. The administration of oxygen and mouth breathing increase
Nurses must understand that clients are not angry with them the need for meticulous oral care. Saliva substitutes and mois-
but, rather, with the situation they are experiencing. turizers can be used to alleviate discomfort. Regular use of
toothpaste and a toothbrush may be adequate. The tongue
Physiological Needs should be gently brushed. Offer ice chips and sips of favorite
Physiological needs are essential for existence, according to beverages frequently. Apply petroleum jelly to the lips to pre-
Maslow’s hierarchy of needs. Therefore, they must be met vent dryness. To maintain the client’s comfort, give oral care
before all other needs. Areas that are often problematic for every 2 to 3 hours.
the terminally ill client are respirations; fluids and nutrition; If the client’s eyes remain open, apply an ophthalmic lu-
mouth, eyes, and nose; mobility; skin care; and elimination. bricating gel to the conjunctiva every 3 to 4 hours or artificial
tears or physiological saline solution every 15 to 30 minutes.
Respirations A cotton ball is used to gently wipe the eye from inner to outer
Oxygen is frequently ordered for the client experiencing la- canthus (one wipe per cotton ball) to remove any discharge.
bored breathing. Suctioning may be needed to remove secre- The nares may become dry and crusted. Oxygen given
tions that the client is unable to swallow. by cannula can further irritate the nares. A thin layer of
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water-soluble jelly applied to the nares alleviates discomfort. The benefits of a urinary catheter greatly outweigh the risks in
The elastic strap of the oxygen cannula is not applied too such circumstances.
tightly, lest it cause discomfort. If oxygen tubing is placed
behind the ears, the area is assessed for irritation and skin Comfort
breakdown. The primary activities for promoting physical comfort include
pain relief, keeping the client dry and clean, and providing
Mobility a safe, nonthreatening environment. The nurse who has a
Mobility decreases as the client’s condition deteriorates. The caring, respectful attitude increases the client’s psychologi-
client requires more assistance as he becomes less able to cal comfort. Fear of a painful death is almost universal. Pain
move about in bed or get out of bed. Physical dependence is a subjective, personal experience, and the client is the best
increases the risk of complications related to immobility, such judge of the severity of the pain. Many, but not all, dying cli-
as atrophy and pressure ulcers. These complications, which ents experience pain. In the position statement on pain relief
increase both cost of care and client discomfort, can be pre- for terminally ill clients, the ANA states that promotion of
vented by attentive nursing care. comfort is the major goal of nursing care (ANA, 1996, 2008).
Reposition the client at least every 2 hours. Remember Comfort is to be maximized by managing pain and other
that the client may have other disorders that contribute to dis- causes of discomfort.
comfort related to mobility, such as arthritis or lung disease. The client must know that caregivers accept and believe
Maintain body alignment with the use of pillows and other reports of pain and that they will intervene to alleviate or pre-
supportive equipment and use positioning techniques to vent the pain. Ask the client to rate the pain on a scale from 0
facilitate ease of breathing. Perform passive range-of-motion to 10, with 0 being no pain and 10 being severe pain. Pain is
exercises at least twice a day to prevent stiffness and aching defined as what the client states it is, and the nurse administers
of the joints. The client may wish to be in a reclining type of pain medication according to the client’s statement of need.
chair several times a day. Use a wheelchair to increase the cli- To maintain a therapeutic blood level, medication must
ent’s environmental space and give the client more mobility, be given around the clock and not “as needed.” A nonnarcotic
control, and independence. analgesic may be effective in early stages for mild, intermittent
pain. As the pain increases, the client may need to start on
Skin Care morphine, titrated at increments until adequate pain relief is
Prevention of pressure ulcers is a priority. They are painful, achieved without severe side effects. Finding the lowest dose
can cause secondary complications, and are costly to treat. and the longest interval that will relieve pain is called titrating
Two preventive measures are passive range-of-motion exer- the dose. The dosage that is used is the one that controls the
cises every 1 to 2 hours and regular repositioning every hour pain to the satisfaction of the client and that causes minimal
to hour and a half. Turning the client with the use of a draw side effects. The dose is individual and continually assessed to
sheet decreases pain and prevents skin shearing. The use of air remain therapeutic in controlling pain.
mattresses or air beds reduces pressure to all body surfaces. The World Health Organization (WHO) has a three-step
In addition, keeping the skin clean and moisturized will pro- ladder that guides pain administration and titration. Clients
mote healthy tissue. Inspect the skin once or twice daily, with with mild pain are given acetaminophen (Tylenol) or nonste-
special attention paid to pressure points and areas where skin roidal anti-inflammatory drugs (NSAIDs); for moderate pain,
surfaces rub together. Gentle massages with soothing lotion a weak opioid or combination agents, such as oxycodone/
are comforting and decrease skin breakdown by improving hydrocodone and acetaminophen or tramadol (Ultram); and
circulation. Areas of nonblanching erythema or actual skin for severe pain, strong longer acting opioids, such as mor-
breakdown should not be massaged. Apply hydrocolloid phine, hydromorphone hydrochloride (Dilaudid), fentanyl
dressings to bony prominences to protect them from pressure (Duragesic), or oxycodone (OxyContin) (Webster & Dove,
and skin breakdown. Bed baths are adequate if the client can- 2007). Treatment starts at the level of the client’s pain and
not get into the tub or sit in a shower chair. does not have to start at the first step.
Elimination
Side effects of pain medications and a lack of physical activity BESTPRACTICE
may cause constipation. For clients with adequate oral in-
take, foods with high-fiber content and fluids can be effective Adjuvant Therapy
preventive measures. Constipation can also be alleviated by
administering suppositories, if necessary, and maintaining a Adjuvant therapy may be effective. Nonsteroidal
scheduled time for bowel elimination. A commode with pad- anti-inflammatory agents are beneficial for bone
ded arms can be more comfortable than a toilet. metastases, tricyclic antidepressants and antiseizure
The client may become incontinent of bowel and blad- medications for neurogenic pain, antidepressants
der. After each incontinent episode, clean the skin with for terminally ill clients, and steroids for headaches
peri-washes, and apply a moisture barrier. Urine and fecal related to cerebral edema. Nonpharmacological
material on the skin will quickly lead to excoriation and skin techniques can be used along with medication.
breakdown. Relaxation techniques, guided imagery, massages,
Indwelling catheters are not a first choice for bladder and repositioning may enhance the action of the
management; however, for some clients, the discomfort of us-
medications.
ing a bedpan, getting out of bed to use the toilet or commode,
or the need for frequent cleaning may cause agonizing pain.
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When the client cannot verbalize his pain, note the non-
verbal behavior. Nonverbal clues of pain are decreased activity COmmUNITy/hOmE hEALTh CARE
or restlessness, furrowed brow, grimacing, crying, moaning,
withdrawal from others, guarded or stiffened posture, irrita- Equipment to Increase Client Comfort
bility, elevated blood pressure, and increased pulse. If the fur-
The following equipment can be rented and
rowed brow comes and goes, it may indicate mental activity of
dreams and hallucinations. Assess other nonverbals to obtain may qualify for payment by Medicare or private
the total pain picture. insurance:
Monitor the client’s responses with regard to pain rating • An electric hospital bed with overhead tra-
and respiratory rate. For example, 30 mg of morphine sulfate peze allows the client some control of the
given orally may provide pain relief, but if the respiratory rate environment.
drops from 12 to 6 per minute, adjust or change the medica- • A commode promotes the client’s independence
tion. If the same dose given to another client provides minimal in elimination.
relief and the client is alert and displays no change in respira- • A lifting device eases getting the dependent cli-
tions, the next dose is increased (Webster & Dove, 2007).
ent out of bed.
Pain medication is given by the least invasive route of ad-
ministration, preferably oral or buccal mucosa, then IV or sub- • Handheld shower and chair for the bathtub or
cutaneous, with intramuscular rarely used. The rectal route shower are helpful.
is also used when medication cannot be given orally. If the • Devices such as cushions for chairs and special
dying client has diminished liver or renal function, continuous mattresses for the bed provide comfort.
administration of morphine causes an accumulation of active • An overbed table for eating and other activities
metabolites leading to terminal delirium. Fentanyl is the drug is useful.
of choice at this point because it has no active metabolites to • Comfortable chairs close to the bed facilitate
accumulate and cause toxicity (Webster & Dove, 2007). visits of friends and family.
Monitor the client for breakthrough pain, or sud-
den, acute, temporary pain that is usually precipitated by
a treatment, a procedure, or unusual activity of the client.
A supplemental dose of medication is then required. If the For many clients, maintaining a well-groomed appear-
precipitating factor is known (e.g., dressing changes), give ance is important. When the client can no longer make re-
medication 30 to 60 minutes before the procedure. Table 9-4 quests or give directions for care, caregivers should presume
describes care given to a client during EOL care. that the client would prefer to maintain the same grooming
habits as were previously preferred. Shaving the male client’s
Physical Environment beard or cleaning and trimming the client’s fingernails and
The client’s comfort can be significantly increased by a sooth- toenails, for instance, will help the client maintain a well-
ing physical environment. Soft lighting may enhance vision. groomed appearance and will also promote client dignity.
Complying with the client’s request for a night-light is also Combing and brushing the hair not only improves appearance
helpful in creating a pleasant and nonthreatening environ- but is also a comforting and relaxing activity for many clients.
ment. If possible, the client should be offered the opportunity Dressing and undressing may become a cumbersome,
to have the bed or a chair near a window to increase the range frustrating, and fatiguing activity. The client who spends time
of the environment. Since body temperature falls as circula- up and about may choose attractive pajamas, housecoats,
tion becomes more sluggish, a lightweight comforter will dusters, or exercise suits. Advise individuals who may be pur-
increase warmth without adding much weight. Help eliminate chasing clothing for the client to select items that are loose
environmental odors by ensuring adequate ventilation, daily fitting, have few fasteners, and are washable.
cleaning of the room, removal of leftover food, and frequent Spiritual Needs
linen changes. Noise can be distracting and anxiety provok-
ing, so the nurse and visitors should comply with the client’s Dying persons may experience confusion, anger at their god,
wishes with regard to the use of radio and television. The crises of faith, or other types of spiritual distress. Nurses have
telephone can be removed from the room if the client finds the opportunity to play a major role in promoting the dying
the ringing disturbing. client’s spiritual comfort.
Dying clients are most vulnerable. The moral health and
Psychosocial Needs integrity of the broader community can be measured in part
Death presents a threat to one’s psychological integrity as by the way we respond to their needs. Dying is a personal and
well as to one’s physical existence. The dying person is often often a lonely process. Listen as a client expresses values and
tethered to tubes and electronic gadgetry in an intensive care beliefs related to death. Therapeutic nursing interventions
unit. The client is held captive in a tangle of technology and is that address the spiritual needs of the dying client include:
kept at a distance from the supportive presence and touch of • Using touch
family and friends. • Playing music
Technology cannot replace concern, touch, compassion, • Praying with the client
or human companionship. By their presence, nurses and fam-
ily can humanize the dying person’s environment. Invite and • Communicating empathy
encourage families to participate in the client’s care if they • Contacting clergy if requested by the client
desire to do so and the client is willing. • Reading religious literature aloud at the client’s request
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Table 9-4 Nursing Management during End-of-Life Care

PHYSIOLOGICAL
RESPONSE CONTRIBUTING FACTORS NURSING INTERVENTIONS
Pain Terminal illness Assess for pain frequently and thoroughly.

Fear and anxiety Administer pain medications in a timely manner and around
the clock.
Address breakthrough pain in a timely manner.
Do not delay or deny pain medication for the terminally ill client.
Evaluate effectiveness of pain medication frequently.
Dyspnea Fear and anxiety Assist with relaxation techniques.

Primary lung tumors Administer prescribed medications to relieve dyspnea (anxio-
Lung metastases lytic, bronchodilators, corticosteroids, diuretics, opioids).
Pleural effusion Administer prescribed oxygen therapy.
Restrictive lung disease Teach client and family energy conservation techniques.
For home or hospice care, offer electric bed, lift chair, and
bedside commode.
Anorexia Fear and anxiety Feed the client when hungry.

Treatment Assess for nausea and vomiting.
Complications of disease Offer culturally appropriate foods.
process Provide frequent mouth care, especially following vomiting
episodes.
Weakness fatigue Terminal illness Assess loss of tolerance for activities.

Treatment Provide frequent rest periods.
Change in metabolic demands Time nursing interventions to conserve energy.
Constipation Medications Encourage foods high in fiber.

Immobility Increase fluid intake as tolerated.
Dehydration Encourage activity.
Nausea and vomiting Complications of disease Encourage the client to avoid eating if nauseated.
process Suggest small meals of cool nonodorous foods.
Medications Encourage the client to eat slowly.
Delirium Use of opioids and steroids Reorient to time, place, and person frequently.
Ensure frequent nursing rounds.
Provide a quiet, well-lit room.
Administer sedatives and benzodiazepines.
Data from Palliative and End of Life Care, by E. Hull, 2008, Manuscript submitted for publication.
Table 9-5 provides information about various religions’ Each family group has its unwritten rules, its leaders and
views with regard to withdrawal of life support, death, and followers, and its methods for coping with crises. The family’s
organ donation. equilibrium is threatened by the impending death. If family
members have limited coping skills and inadequate support
Support for the Family systems, they need assistance and guidance from the caregiv-
The presence of the nurse is extremely important. It shows ers. Nurses must remember that the rules and coping mecha-
support and caring not only for the client but for the family nisms used by the family may not always coincide with the
as well. Family members may have increased guilt because of values and beliefs of the staff and that the client’s and family’s
feelings of helplessness. The nurse encourages family mem- wishes must be respected to the extent possible.
bers to speak to, touch, read to, sing to, pray with, or just sit The relationship with the family does not always end
with the client. This can give family members a sense of pur- with the client’s death. Staff members may attend visitations,
pose, ease feelings of helplessness, and provide more pleasant funerals, or memorial services. If a hospice was involved, the
memories in the future. family may participate in a bereavement support program. If
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Table 9-5 Religions and Death and Dying Issues

LIFE SUPPORT
WITHDRAWAL IN
RELIGION TERMINAL ILLNESS DEATH ORGAN DONATION
Judaism Allowed under the right • Suicide is forbidden. • Permitted because the
circumstances (when life • Burial should occur within 24 hours. procedure saves life.
support is serving only to • Cremation is forbidden. • Rejected by Orthodox
impede a natural death). Jews.
• Autopsy is permitted if it will save
future lives.
Islam Permitted if only serving • Suicide is forbidden. • Permitted.

to prolong death or if cli- • Relatives and friends are present.
ent’s condition is medically • Autopsy is permitted to solve a crime
hopeless. or provide further medical knowledge.
Catholicism/ Controversial; permit- • Prayers are offered at time of death. • Permitted.

Orthodoxy ted if client’s condition is • Burial and cremation are permitted.
hopeless. • Autopsy is permitted.
Protestantism Permitted if client’s condi- • Prayers are offered at time of death. • Permitted, although may
tion is hopeless. • Burial and cremation are permitted. be rejected by some Bap-
• Autopsy is permitted. tists or Pentecostals.
Jehovah’s Permitted if serving only to • Suicide is not approved. • Individual choice.

Witness prolong death or if quality of • Autopsy is permitted if legally neces-
life is nonexistent. sary.
Buddhism Acceptable for those on • Suicide is criticized. • Controversial.

threshold of death. • Cremation is common.
Hinduism Supported to allow a natural • Suicide is forbidden. • Discouraged because of

death. • Prefer to die at home. disturbing the body after
• Embalming is forbidden. death.
• Autopsy is discouraged.
Mormons A client or family decision. • Cremation is discouraged. • A family decision.

• Autopsy is a family decision.
Native Life support is viewed as • Complex beliefs about death and • Discouraged because
Americans unnatural and, therefore, treatment of the body; some are for- of death and burial
unnecessary. bidden to touch a dead body. practices.
• Ancestral worship.
• Often believe the spirit of the person
continues to live.
Christian Most have advance direc- • Practitioner should always be notified • Do not donate or receive
Science tives to avoid medical treat- at death. organs because the
ment; however, no illness is • Autopsy is permitted. spiritual cause of organ
seen as hopeless. • Cremation is usual practice. failure is not treated with
an organ transplant.
Unitarian Support withdrawal of life • Suicide is a tragedy. • Permitted.

support when quality of • Autopsy is permitted as needed.
life is poor and suffering is
great.
Data from Zator Estes, 2010.
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death and then rally to live several more days. Clients often
CLIENT TEACHING
CLIENT TEACHING live until a family member arrives for a last good-bye. The
client who has had a long illness and is ready to die may need
Guidelines for Teaching “permission” to die from a loved one, who says, “It’s okay, you
a Family Caregiver can go now.” Some clients may not wish to die when anyone
is present and will wait to take the last breath until alone in
Use the following guidelines when teaching a fam- the room.
ily caregiver how to care for his loved one: It is never easy for the family, even when death is ex-
• Use adult-education principles. pected. The family should be simply and thoroughly informed
• Frequently reinforce material. about what will happen before and after the client’s death,
• Provide information about the nature and ex- including:
tent of the disease process. • Physical changes that occur just before and following death
• Explain the purpose of palliative care yet main- • Death pronouncement
tain a sense of realistic hope. • Postmortem care
• Reassure client and family by informing them of
• Body removal
available community resources; tell them that
they are not alone. Impending death is signaled by a series of irrevocable
• Discuss steps for caregiver to follow if an emer- events (Hull, 2008):
gency arises at home by providing written • The lungs are unable to provide adequate gas diffusion.
instructions, including persons to be contacted • The heart and blood vessels are unable to maintain ad-
and important telephone numbers. equate tissue perfusion.
• The brain ceases to regulate vital centers.
Cheyne-Stokes respirations (breathing characterized
the client was a resident in a long-term care facility, family by periods of apnea alternating with periods of dyspnea) most
members may return to visit other residents with whom they often herald pulmonary system failure. Secretions accumulate
became acquainted. in the larynx and trachea, causing noisy respirations, often
called the death rattle.
Learning Needs The heart fails in its pumping function, resulting in poor
The nurse’s role is to provide the client and family members perfusion, ischemia, and cell death. The skin becomes cool
with support and information. For example, they may not re- and, possibly, very pale, cyanotic, jaundiced, or mottled. The
alize that the dying person needs to conserve energy. Family pulse becomes rapid, irregular, weak, and thready. Death is
activities are best scheduled early in the morning or following several hours away if a peripheral pulse is strong and easily
a period of rest by the client. The nurse may need to point out palpated. Cold, cyanotic extremities and irregular respirations
to the family this type of commonsense approach, because indicate that death is imminent.
simple interventions such as these can be overlooked during Inadequate cerebral perfusion hinders the brain’s ability
this highly charged emotional time. to integrate vital functions. The client may be confused and
Client and family learning needs may relate to: lethargic and may respond only to direct visual, auditory, or
• Information about physical condition and treatment
regimen COmmUNITy/hOmE hEALTh CARE
• Anticipating a medical crisis
• Inexperience with the personal threat of death When the Client Dies at home
• Unfamiliarity with what to do in case of an emergency out- (Preparing for an Expected Death)
side the hospital
Have the family prepare:
Impending Death • A list of names, with telephone numbers, of

people they wish to notify of the death includ-
There is no way to predict how long a client may be in the tering the name and telephone number of the fu-
minal stages of illness. A client may have signs of impending neral director.
Instruct the family:
CRITICAL THINKING • Whom to call (physician or hospice nurse or fu-
neral director).
• Whom not to call (ambulance and emergency
Caring for a Dying Client
services).
• To record the time of death, last medications
given, the condition of the client during the last
Think about caring for a dying client. How can
few hours, and the last time the client was seen
you prepare to care for a dying client?
by the nurse.
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tactile stimulation. Pupils no longer react to light and become

fixed. The client may “talk” to dead loved ones. A frown or BESTPRACTICE
tight facial muscles may indicate pain or discomfort. A client
in a coma will move only in response to deep pain. Analgesics Postmortem Care
should not be withdrawn from a client in a coma.
The care of the client does not cease during this final Follow these guidelines when caring for a client’s
stage of life. The nursing actions previously described should body after death:
be continued. Tell the client in brief, simple terms what is • Treat the body with dignity and respect.
happening as care is rendered. The family should be allowed • Bathe and put a clean gown on the body—and
and encouraged to continue their participation if that is their
place an incontinent pad under the client’s hips.
wish. Caution family members that the dying client can hear
even in the absence of verbal response, so all comments and • Remove dressings and tubes, unless these must
conversation should continue to be respectful. remain in place for an autopsy.
There may be other indications that death is near. The • Place the body in alignment with the head
client may report seeing someone who has died or angels elevated.
or hearing someone or beautiful music. These experiences • Place dentures in a denture cup and send with
should be accepted as a natural step in the process of dying. the body.
When the final breath is taken, the heart stops beating. Within • Comb the client’s hair.
a few minutes, cerebral death (the point at which brain cells
die) occurs, and brain activity ceases.
Physical signs of death are:
person’s mouth. Jaw muscles relax after death, so dentures of-
• Absence of a heartbeat
ten fall out and are lost or broken. Put them in a hospital den-
• Cessation of respirations ture cup without water and send them with the body to the
• Mottling of skin or skin that is cool to the touch funeral director. After the family has viewed the body, place
• Eyelids remain slightly open identification tags on the body’s toe and wrist. Sometimes the
• Jaws relaxed and mouth slightly open body is placed in a plastic or fabric shroud (a covering for
• No response to name, touch, or environmental sounds the body after death) and tagged. Next, transport the body to
the morgue according to the agency’s policy, where it is kept
• Eyes fixed on a certain spot until it is transported to a mortuary (funeral home). In some
• No eye blinking in response to touch or air movement over institutions, the body is kept in the room until the funeral di-
the eyes rector arrives. The nurse is also responsible for returning the
• Release of bowel and bladder contents (Hull, 2008) deceased’s possessions, such as jewelry, eyeglasses, clothing,
and all other personal items, to the family.
Care after Death Information for Funeral Director
Meeting the needs of the grieving family and caring for the de-
ceased body are nursing responsibilities. Treat the body of the Harvey (2001) explains information that is important to
deceased with respect by maintaining privacy and preventing the funeral director when preparing the body. The cause of
damage to the body. Postmortem care is given immediately death influences which procedures are used. For example, a
after death but before the body is moved to the mortuary (see client with liver or renal failure has a high level of ammonia
Best Practice). in the body. A special solution will have to be used for this
After death, several physiological changes occur. Body client because the ammonia neutralizes the formaldehyde
temperature decreases, resulting in a lack of skin elasticity generally used. If a client had tuberculosis (TB) or any other
(algor mortis). To avoid skin breakdown, the nurse must communicable disease, special procedures will be followed to
therefore use caution when removing tape from the body. prevent spreading the disease. If the client weighed more than
Liver mortis, a bluish-purple discoloration of the skin, is 300 pounds (136 kg), the funeral director will need extra staff
a by-product of red blood cell destruction. It usually begins for transferring the body.
within 20 minutes of death (Harvey, 2001; Iserson, 2010).
This discoloration occurs in dependent areas of the body; the Legal Aspects
nurse should therefore elevate the head of the bed 30 degrees The physician is legally responsible for determining the cause
to prevent discoloration of the head and neck. If the body is of death and signing the death certificate in most states. In cer-
moved on a stretcher, keep the head elevated on two pillows. tain situations, the RN may be responsible for certifying the
Rigor mortis, the natural stiffening of muscles after death, death. Some institutions require two nurses to certify death.
begins within 2 to 6 hours after death (Iserson, 2010). The Nurses must know their legal responsibilities as defined by
funeral director will have the best results if embalming is their respective state boards of nursing.
completed before rigor mortis sets in. Position the body in a
natural position.
When preparing the body for family viewing, endeavor to Autopsy
make the body look natural and comfortable. This means pre- An autopsy is the examination of the body after death by a
paring and positioning the body as previously described. If the pathologist to determine the cause of death. It is mandated in
client wore dentures, they should not be put in the deceased situations where an unusual death has occurred. For example,
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a violent death or an unexpected death is a circumstance

necessitating an autopsy. For an autopsy to be performed in BESTPRACTICE
other situations, families must give consent. The funeral direc-
tor must know whether an autopsy is to be performed. Care for yourself during Grief
Organ Donation Here are some tips for nurses to care for them-
Organ donation for transplantation requires sensitivity and selves when dealing with grief:
compassion from the health care team. Health care facilities • Do what nurses do well: care. Help the family
must have a policy regarding the referral of a potential organ and your feelings of helplessness will diminish.
donor to appropriate organ procurement agencies. The Cen- • Plan time for your own grieving.
ters for Medicare and Medicaid Services requires hospitals • Allow for crying to help ease the pain.
to notify a local organ-procurement organization (OPO) of • Learn when to ask your coworkers for help.
a client in imminent death or who has died so that the person • Express your feelings of grief to someone you
who initially approaches the family is an OPO representative can trust.
or “designated requestor” (Truog, 2008). When an organ(s)
• Find support within your facility from counsel-
is donated, the OPO representative coordinates the entire
process, including finding organ recipients (OrganDonor.Gov, ors, support groups, and clergy.
2008). • Use rituals to say good-bye to the deceased cli-
The organs and tissues that can be transplanted are liver, ent and bring closure.
lungs, heart, kidneys, pancreas, skin, bones (middle ear bones (Sherman, 2004)
and long bones), and corneas. The average waiting time is
230 days for a heart, 1,068 days for a lung, 796 days for a liver,
1,121 days for a kidney, and 501 days for a pancreas. Trans-
plantation must occur within 4 to 6 hours for heart and lungs, of the common defense mechanisms against grieving, such as
12 to 24 hours for liver and pancreas, and 48 to 72 hours for being strong, keeping busy, and suffering in silence. Nurses
kidneys (OrganDonor.Gov, 2008). must talk about the intense emotions associated with caregiv-
ing instead of pretending that they do not experience grief.
According to Sherman (2004) burnout may be starting to
Care of the Family overwhelm a person if that person experiences the following:
The nurse provides invaluable support to the family of the • A loss of energy, spark, joy, and meaning in life
deceased at the time of death. It is extremely important to
inform the family of the circumstances surrounding the • Detachment from surroundings
death. The nurse offers information about viewing the body • A feeling of being powerless to make a difference
and contacts support people (e.g., other relatives, clergy). • Increased smoking or drinking
The nurse may even help the family with decisions regarding • Unusual forgetfulness
transportation, a funeral home, and removal of the deceased’s • Constant criticism directed toward others
belongings. Sensitive and compassionate interpersonal skills
are essential when providing information and support to • Consistent inability to get work done
families. Providing coffee, tissues, and light snacks are small • Uncontrolled outbursts of anger
gestures that convey sensitivity to the family and friends and • Perception of clients and their families as objects
are appreciated. • Surrender of hobbies or interests
To effectively cope with their own grief, nurses need edu-
Nurse’s Self-Care cation, support, and assistance when coping with the death of
Working with dying clients can evoke both personal and pro- clients. Sherman (2004) suggests the following ways to cope:
fessional stress in the nurse. Grief is a common experience for • Take time to cry with and for clients.
nurses because many nurses are confronted with death and
loss daily. Smith-Stoner and Frost (1998) describe a part of • Get physical: run, walk, bike, play tennis.
the psyche called the shadow self, where stresses are stored. • Ask colleagues to help with tasks; do not try to be “Super-
Unresolved sadness is called shadow grief. Everyone has a nurse.”
shadow self and may have some shadow grief. Nurses often • Connect to a place of worship; pray.
have a great deal of shadow grief, which, if not released, may • Look for joy in work—laughter is a great healer.
cause illness and burnout. Frequent exposure to death can • Create a caring circle of friends.
interfere with the nurse’s effectiveness because of subsequent • Listen to music.
anxiety and denial.
Nurses are at particular risk for experiencing negative The nurse’s own fears and doubts about death may sur-
effects from caring for dying clients, whether working in a hos- face and cause anxiety about feelings of mortality. Caring for
pital, a hospice, a long-term care facility, or the home. They the dying client and the client’s family is emotionally draining,
may not wish to confront their grief and will often use some so nurses must remember to care for themselves.
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The Client with a Terminal Illness/Cancer of the Lung

V.P., an 84-year-old widow, was diagnosed with cancer of the right lung 6 months ago. After a right lower lobectomy,
she was discharged to a local skilled-care facility and planned to go home after completing her radiation therapy. After
completing the treatments, V.P.’s condition began deteriorating. She did not want to go home, so discharge plans were
discontinued. Now she is frequently short of breath, has dyspnea, requires pain medication, and needs some assistance
with activities of daily living because of fatigue. She frequently grimaces and says, “I hurt.” Her nutritional intake is very
little because of swallowing difficulties. V.P. gets up only to use the commode. Her two adult children and four grand-
children live nearby and visit often. They want to assist their mother to get her affairs in order, but she resists their ef-
forts. The family is trying to make V.P.’s remaining time as serene and comfortable as possible, but V.P. often defies their
attempts.
NURSING DIAGNOSIS 1 Chronic Pain related to disease progression as evidenced by verbal statements, body lan-
guage, and the need for pain medication

Pain: Disruptive Effects Pain Management
Pain: Psychological Response Analgesic Administration
Pain Control Coping Enhancement
PLANNING/OUTCOmES NURSING INTERVENTIONS RATIONALE
V.P. will verbalize relief from pain. Give analgesics as ordered. Administering regular doses of anal-
gesics is more effective than waiting
until the pain begins.
Have client rate pain on a scale The client should be given analgesics
of 0 to 10, with 0 being no pain when pain is experienced. Morphine
and 10 being severe pain, to assess is the drug of choice for severe pain
the need for morphine. Give mor- associated with cancer.
phine as ordered, titrated at incre-
ments until adequate pain relief is
achieved.
Monitor for signs of breakthrough Breakthrough pain is often precipi-
pain. If the precipitating factor tated by activity or stress and supple-
is known, give medication 30 to mental medication is required.
60 minutes before the event. Med-
icate as soon as possible for unpre-
dictable breakthrough pain.
Assure V.P. that the nurses will Provides reassurance that everything
help her manage the pain and possible will be done to manage the
keep it under control. pain.
Reposition frequently and give Promotes psychological comfort.
back massages for comfort. Assist
with relaxation techniques if client
agreeable.
Monitor bowel elimination. Pain medication often causes
constipation.
EVALUATION
V.P.’s body language and verbal statements indicate freedom from pain.
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SAMPLE NURSING CARE PLAN (Continued)

NURSING DIAGNOSIS 2 Ineffective Coping related to terminal illness as evidenced by inability to communicate ef-
fectively with family members and to accept their help

Coping Coping Enhancement
Self-Esteem Counseling
Social Interaction Skills Emotional Support
PLANNING/OUTCOmES NURSING INTERVENTIONS RATIONALE
V.P. will express her feelings openly. Consult V.P. on all aspects of care. Allows V.P. to express her feelings
Give complete information. Pro- and validates those feelings as being
vide opportunities to express feel- normal and expected.
ings. Acknowledge V.P.’s feelings
and let her know that crying and
grieving are beneficial.
Listen for clues indicating unfin- Life review is a process of reflection
ished business that needs to be and pondering on one’s past and ac-
completed. Encourage the process cepting one’s life as being meaning-
of life review. ful and valuable.
V.P. will maintain a satisfying rela- Encourage family visits. Provide Families need privacy in order to feel
tionship with her family. privacy. free to express their emotions.
EVALUATION
V.P. still resists family’s assistance.
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CONCEPT CARE mAP 9-1
NURSING DIAGNOSIS 3
Ineffective Breathing Pattern related to diminished lung function as evidenced by dyspnea and
shortness of breath
NOC: Respiratory Monitoring, Anxiety Reduction
NIC: Vital Signs Status, Anxiety Control
CLIENT GOAL
V.P. will be free from moderate or severe
dyspnea.

1. Teaching breathing exercises and 1. Enhances gas exchange in the alveoli.
effective coughing techniques.
2. Allow adequate time for physical 2. Physical exertion increases dyspnea.
activities. Postpone activity if dyspnea
is present. Provide as much assistance
as needed.
3. Administer low-flow oxygen if blood 3. Effective only if indicated by blood gases.
gases indicate need.
4. Encourage client to drink 8 to 10 4. Liquefies respiratory secretions and
glasses of fluid each day. promotes hydration.
5. Humidify the air with a cold-water 5. Enhances breathing.
vaporizer.
6. Assess respiratory system frequently. 6. Identifies complications at early stages.

EVALUATION
Is V.P. free from moderate and severe dyspnea?
CONCLUSION they need in preparation for death. Dame Cicely Saunders,

the founder of the first modern hospice, stated, “How people
Loss and grief are a part of life. As a client nears death, the die remains in the memories of those who live on” (Pitorak,
nurse’s role is to prepare the family for the death. These inter- 2003, p. 42). The nurse and health care team have an oppor-
ventions are learned and continue to improve throughout the tunity to make this inevitable life event a positive one for the
nurse’s career. The nurse can ask the client and family what client and family.
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UNIT SUMMARY
Chapter 4 Complementary Chapter 6 Caring for Clients in Shock

and Alternative Therapies • The five types of shock are hypovolemic, cardiogenic, sep-
• More health care consumers are using nontraditional tic, anaphylactic, and neurogenic shock.
treatment modalities. • Common manifestations of all five types of shock are hy-
• Healing is not curing. It is regaining balance and finding potension, hypoperfusion, and hypoxia.
harmony and wholeness as changes take place within the • Complications of each type of shock are multiorgan failure
individual. and death.
• No one can heal another, but a nurse can act as a guide • Common medications used to treat all five kinds of shock
and support system for the client. are vasopressors and IV fluids.
• Some of the mind/body modalities used by nurses • Hypovolemic shock is caused by fluid loss from burns,
are meditation, relaxation, imagery, biofeedback, and acute blood loss secondary to trauma, electrolyte imbal-
hypnosis. ance, dehydration, or large amounts of isotonic IV rehy-
• Body-movement modalities include movement and exer- dration. Hypovolemic shock is treated with IV hydration
cise and chiropractic therapy. and blood transfusions as the primary treatment, and with
• Energy therapies can be used with clients of all ages and in vasopressors as the second-line treatment.
various stages of illness and wellness. • Cardiogenic shock occurs most commonly as a result of an
• Nutritional/medicinal therapies include the use of antioxi- acute myocardial infarction. Other causes include septal
dants and herbal therapy. rupture, severe mitral regurgitation, cardiac tamponade,
and rarely medications such as clopidogrel or metoprolol.
• Other modalities such as aromatherapy, humor, animal- Cardiogenic shock is treated with IV hydration, vasopres-
assisted therapy, music therapy, and play therapy are valu- sors, and inotropes. In significant shock an intra-aortic
able adjuncts to conventional treatment. balloon pump or left ventricular assist device is inserted. In
the most clients who are critically ill, cardiac transplanta-
Chapter 5 Inflammation tion is a treatment option.
and Infection • Septic shock occurs as a result of overwhelming infection
• The inflammatory process is a normal part of healing. and release of endotoxins in the bloodstream causing in-
Inflammation is a term describing what happens when the creased vascular permeability. Treatment of septic shock
normal body defenses are not adequate to eliminate the includes IV hydration, antibiotics, and vasopressors.
problem. • Neurogenic shock occurs from acute spinal cord injury
• Certain individuals are more susceptible to developing rending the sympathetic nervous system unable to control
inflammation and/or infection than others; these include heart rate and blood pressure. Treatment is temporary
those who are very young or very old, malnourished, or support through vasopressors and respiratory support if
immunocompromised. needed.
• Flora are microorganisms that occur or have adapted to • Anaphylactic shock results from immune-mediated wide-
live in a specific environment. spread inflammatory mediator response causing increased
• Pathogens are microorganisms that cause disease; they vascular permeability, edema, hypotension, and broncho-
include bacteria, viruses, fungi, protozoa, and rickettsia. constriction. Treatment consists of emergency administra-
• The elements of the chain of infection include the agent, tion of epinephrine, IV hydration, and vasopressors.
the reservoir, the portal of exit, the modes of transmission,
the portal of entry, and the host.
• The body has two primary defenses: the nonspecific im- Chapter 7 Pain Assessment
mune defense, which protects the host from all microor- and Management
ganisms regardless of previous exposure, and the specific • Pain may be defined as “an unpleasant sensory and emo-
immune defense, which reacts to a specific antigen that the tional experience associated with actual or potential tissue
body has previously experienced. damage” (International Association for the Study of Pain,
• Infections progress through four stages: incubation, pro- 2008) and “whatever the client says it is, existing whenever
dromal, illness, and convalescence. the client says it does” (McCaffery & Pasero, 1999).
• Hand hygiene must be performed before and after every • The gate control theory proposes that several processes
client contact and after removing gloves. It is the most (sensory, motivational-affective, and cognitive) combine
important procedure for preventing hospital-acquired to determine how a person perceives pain.
infections. • Assessment of pain helps establish a baseline of data and
• Other means of preventing the spread of infection include helps evaluate the effectiveness of interventions.
cleansing equipment, cleansing soiled linen, changing • Factors influencing pain perception include age, previous
dressings over wounds, practicing barrier precautions, experience with pain, and cultural norms.
maintaining skin integrity, and receiving all appropriate • The subjective data to gather include location of pain, on-
immunizations. set and duration, quality, intensity (on a scale of 0 to 10),
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aggravating and relieving factors, and how pain affects the • Surgery is the treatment of choice for early cancers.
activities of daily living. • Chemotherapy is the treatment of choice for metastatic
• The three general principles to follow with pain relief mea- cancers. It is also the treatment most responsible for in-
sures are (a) individualize the approach, (b) use a preven- creasing cancer cure rates in recent years.
tive approach, and (c) use a multidisciplinary approach. • Lung cancer is the leading cause of cancer death among
• The nurse has a great deal of autonomy in administer- men and women. Eighty percent of all cases are related to
ing analgesics, which leads to specific responsibilities for smoking.
which the nurse is accountable. • Quality of life, not quantity of life, is the ultimate goal for
• Pharmacological agents can be therapeutic for clients ex- clients living with cancer.
periencing pain; however, the medications should not be
the only interventions used. Chapter 9 Palliative and End-of-Life
• Noninvasive treatments for pain relief are measures that Care
can supplement pharmacological and invasive treatments • Loss is when someone (or something) of value is no
for pain relief. longer available. It is a universal response.
• Invasive techniques are interventions used when the non- • Grief is a psychological response to loss evidenced by deep
invasive and pharmacological measures do not provide ad- sorrow and mental anguish.
equate relief. Methods include nerve blocks, neurosurgery, • The difference between pathological and normal grief is
radiation therapy, and acupuncture. the inability of the individual to adapt to life without the
loved one.
Chapter 8 Cancer • Kübler-Ross identified five psychological stages of the
• Cancer is the second most common cause of death in the dying process: denial, anger, bargaining, depression, and
United States. acceptance.
• Most cancers are curable if treated early. • Complicated grief is associated with traumatic death such
• Benign neoplasms are localized and encapsulated and do as suicide, accident, or homicide.
not spread. • Each person dies a unique death.
• Malignant neoplasms spread to neighboring tissues via • Hospice care is an alternative to hospitalization when ag-
blood and lymph. gressive medical treatment is no longer an option.
• Biopsy is the most accurate diagnostic test for cancer. • After death, the nurse’s focus is on supporting the family
• The most common medical treatments for cancer are and caring for the client’s body.
surgery, radiation, and chemotherapy. They may be used • Nurses must care for themselves in order to provide com-
alone or in combination. passionate, quality care to the dying person and family.
THEORY TO PRACTICE
Chapter 4 Complementary and Alternative Therapies
1. Identify local sources for information about various complementary and alternative therapies.
2. Identify which CAM therapies listed within the chapter are currently being used, or that can
be implemented, on the clinical unit you are working on?
3. Utilize the chapter content to match the appropriate CAM therapy at right with the following
clinical client scenarios. Explain your rationale for each match.
Client Scenario CAM Therapy
1. Older adult experiencing difficulty sleeping A. Acupuncture
Rationale:
2. Middle-aged adult with chronic conditions such as B. Herb (garlic)
sinus infections, migraines, irritable bowel syndrome,
and constipation
Rationale:
3. A client waiting for surgery C. T’ai chi
Rationale:
4. A client who states, “I want to lower my cholesterol D. Reflexology
level naturally”
Rationale:
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5. A male client diagnosed with benign prostatic E. Music therapy

hypertrophy
Rationale:
6. A chemotherapy client experiencing nausea, vomiting, F. Herb (saw palmetto)
headaches, fibromyalgia, and low back pain
Rationale:
Chapter 5 Inflammation and Infection
1. List and explain three things that you can do in the clinical setting to prevent the spread of
infection.
2. Observe peers and staff in the clinical setting for methods used to break the chain of infec-
tion. Discuss observations in postconference with your clinical group and instructor.
Chapter 6 Caring for Clients in Shock
Read the client case study and answer the questions that follow it.
Abdominal Aortic Aneurysm
N.W. is an 85-year-old client who underwent an emergent abdominal aortic aneurysm
repair 24 hours ago in the hospital where you are employed. He was initially stable
after surgery but is in the intensive care unit for monitoring. His hemoglobin on morn-
ing labs was 12.5 and systolic blood pressure has been running 120 to 130 mm Hg on
maintenance IV fluid at 125 mL/hr. During the past hour N.W. began reporting severe
pain in the midabdomen radiating through to his back. Five minutes ago, he noted
a tearing sensation in the area and his systolic blood pressure plummeted to 70/35,
heart rate increased to 143 beats/min and he became unresponsive. His skin is cool
and clammy and his feet are cyanotic. When you enter the room he is still sitting up in
bed but the newspaper he was reading is laying in his lap now.
1. What type of shock is this client likely experiencing?
2. What do you think is the probable source of his pain and cause of his shock?
3. What are some very early nursing interventions that you can do to improve his blood pres-
sure and decrease complications of his shock?
4. What is the most important laboratory test to order on this client first?
Chapter 9 Palliative and End-of-Life Care
Spend a clinical day with a hospice home nurse or in a hospice inpatient facility. Journal what you learned
about death, a dying client, family interactions with clients, nursing care provided, support systems within
organization/facility. How does the hospice nurse handle the stress of caring for dying clients?
NCLEX-STYLE REv IEw QUESTIONS

Chapter 4 Complementary 2. A 40-year-old female client is being treated for high
and Alternative Therapies blood pressure and diabetes. She tells the nurse that
1. When assessing a client’s use of complementary she has read about herbal preparations that may
and alternative therapies for pain management, the enhance the metabolism of insulin in the body. The
nurse would gain more information from the client nurse’s response should be:
when asking which of the following questions in the 1. “There is no evidence that this herbal therapy is
interview? effective for diabetes.”
1. “Which pain medications have you used in the past?” 2. “You must consult your physician about this
2. “What therapies are most effective for managing herb.”
your pain?” 3. “The type of diabetes that you have is controlled
3. “Have you discussed acupuncture with your only with diet, exercise, and insulin injections.”
medical physician?” 4. “You should search for studies that investigate
4. “What is your experience with traditional Chi- the effects of this herb on diabetes management.”
nese medicine?”
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3. A 17-year-old male is admitted to the emergency 8. A client is being discharged home, and prevention of
department following a skateboarding accident. He infection is part of his treatment plan. Which of the
sustained a fractured pelvis and possible skull frac- following statements made by the client regarding
ture. The physician has requested low doses of pain prevention of infection indicates that further teach-
medication until the client’s neurological status is ing is needed by the nurse?
stable. The client is restless and reporting pain as 9 1. “I need to keep my bed linens clean and dry.”
on a scale of 0 to 10. Which of the following meth- 2. “I need to take my antibiotic as ordered.”
ods of relaxation can the nurse use to complement 3. “I need to wash my hands only before I change
the effects of the pain medication and increase the my dressings because I will be wearing gloves.”
client’s comfort? 4. “I need to keep my dressings clean and dry.”
1. Imagery, gentle massage to nontraumatized ar- 9. A client with AIDS is admitted to the hospital with
eas, and music renal insufficiency, elevated liver enzymes, jaundice,
2. Herbs, Ayurvedic medicine, and biofeedback pneumonia, elevated WBC, fever, and diarrhea.
3. Chiropractic therapy, craniosacral therapy, and Which of the following types of infection is the cli-
yoga ent experiencing?
4. Hypnosis, prayer, and naturopathy 1. Systemic infection
4. In contemporary practice, Ayurvedic interventions 2. Humoral infection
include: (Select all that apply.) 3. Localized infection
1. antibiotics. 4. Transient infection
2. herbs. 10. A client with a sinus infection blows his nose in a
3. detoxifying massage. facial tissue and asks the nurse to dispose of it. The
4. nasal purging. nurse puts on gloves before touching the used facial
5. chemotherapy. tissue because she knows that the facial tissue is
6. yoga. identified as which of the following links in the chain
5. The nurse explains the basic elements of yoga to a of infection?
client who is considering taking a yoga class. Which 1. Portal of entry
of the following statements indicates that the client 2. Mode of transmission
needs further teaching? 3. Portal of exit
1. “Yoga integrates mental, physical, and spiritual 4. Susceptible host
energies to promote my health and wellness.” 11. A client with an infected abdominal incision is
2. “The basic elements are proper breathing, pos- brought to the primary care clinic. Which of the fol-
ture, and movement.” lowing assessments will the nurse be able to make?
3. “Yoga can holistically treat my back problems 1. Pinpoint pupils, hypothermia, and elevated blood
and emotional distress.” pressure
4. “The nurse will use her hands to redirect my en- 2. Decreased respirations, low blood pressure, and
ergy flow.” constricted pupils
3. Clammy skin, dilated pupils, slow pulse, and low
Chapter 5 Inflammation and Infection
blood pressure
6. A client with chickenpox will exhibit a slight eleva- 4. Fever, localized redness, warmth, swelling, and
tion in body temperature followed within 24 hours pain
by eruptions on the skin during which stage of
infection? 12. The nursing care plan of a client who is at risk for an
infection is likely to include:
1. Incubation
1. use clean gloves for all procedures.
2. Prodromal
2. take a daily multivitamin.
3. Illness
3. use proper hand hygiene before and after provid-
4. Convalescent
ing care.
7. Which of the following is not a risk factor that in- 4. administer intravenous antibiotic.
creases a client’s susceptibility to infection?
1. Noninvasive procedure Chapter 6 Caring for Clients in Shock
2. Chronic disease 13. Which of the following clients is at greatest risk for
3. Malnutrition developing hypovolemic shock?
4. Rupture of amniotic membranes 1. A 45-year-old client taking the medication
Metoprolol
2. A 32-year-old client who has a central venous
catheter
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3. A 21-year-old client who has severe third-degree 17. For a client in shock, the pulse oximetry data and ar-
burns in his chest and arms terial blood gases provide information regarding the
4. A 50-year-old client with an acute spinal cord client’s:
injury 1. tissue hypoxia.
14. A 21-year-old client experienced multiple bee 2. immune status.
stings while mowing his backyard. He became light- 3. serum concentration.
headed, felt his lips and tongue severely swell, and 4. cardiac enzymes.
started having difficulty breathing. His roommate
was also working outside, observed the incidence, Chapter 7 Pain Assessment
and immediately called 911. Upon arrival at the and Management
emergency department, the nurse should ask which 18. According to McCaffery and Pasero, pain may be
of the following questions of the client during the defined as:
health history? (Select all that apply.) 1. discomfort resulting from identifiable physiologic
1. “Are you experiencing any chest pain or or iatrogenic sources.
palpitations?” 2. a syndrome of behavioral and physical manifes-
2. “Have you experienced in the past any similar al- tations that can be objectively identified by the
lergic reactions?” nurse.
3. “Have you experienced any recent weight loss?” 3. whatever the patient says it is, existing whenever
4. “Have you taken any medications for this reac- and wherever the patient says it does.
tion such as Benadryl or an Epi-Pen?” 4. a sensory response to noxious stimuli.
5. “Have you felt excessively fatigued or tired during 19. Which of the following is a useful tool for assessing
the past month?” the intensity of pain that is easy to use?
6. “What other allergies or sensitivities do you 1. The gate control scale
have?” 2. Acute pain monitor
15. A nurse is teaching a client with severe peanut aller- 3. Numeric pain scale
gies how to use an Epi-Pen. Which of the following 4. Pressure pain monitor
statements indicates that the client understands how
20. B.L., 45, has experienced chronic low back pain
to correctly use an Epi-Pen?
since a fall 8 years ago. He describes his pain as “a
1. “I should not inject the Epi-Pen into my veins or gnawing, constant dull pain” that makes him feel
buttocks.” tired. The nurse caring for him recognizes that one
2. “I should keep an Epi-Pen in my car for of the differences between acute and chronic pain
emergencies.” characteristics is:
3. “I need to make sure that I inject the Epi-Pen into 1. acute pain is more severe.
my muscle layer.” 2. chronic pain is often described as dull and is dif-
4. “I can only use one Epi-Pen per anaphylactic ficult to localize.
reaction.” 3. chronic back pain is often not real.
16. A client is admitted to the hospital unit with warm, 4. acute pain is more diffuse and difficult to
flushed skin, fever above 100.4°F (38°C), mild describe.
tachycardia and elevated respiratory rate above
21. N.J., 84 years old, is recuperating from a total hip
20 breaths/min, and a white blood cell count of
replacement. Morphine, 8 mg IV q4h prn, is pre-
14,000. The physician has diagnosed the client with
scribed for N.J. Her respiratory rate is 18 breaths/
the early stages of septic shock. The nurse under-
min, her pulse rate is 96 beats/min, and her blood
stands that the primary course of treatment for this
pressure is elevated slightly above her normal level.
client is:
She is reporting severe pain, 8 on a scale of 0 to 10.
1. ensuring stability of the client’s neck and back The most appropriate initial nursing intervention is:
during position changes to prevent further spinal
1. to question the physician regarding the dosage
cord injury.
amount for a client this age.
2. intravenous antibiotics, fluid resuscitation,
2. to turn her and then reevaluate her need for opi-
and vasopressors as well as supplemental
oid analgesia.
oxygenation.
3. to administer the medication as ordered.
3. fluid restoration to restore the client’s circulating
4. to advise N.J. to cough and breathe deeply since
intravascular volume.
you are unable to give her anything for pain until
4. positioning the client in a supine or Trendelen-
her respiratory rate is 20.
burg position.
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22. O.R., 55 years old, is hospitalized with an exacerba- 3. is convenient for nursing staff.
tion of rheumatoid arthritis. She has a favorite televi- 4. allows the client control of pain relief.
sion show she watches every afternoon. She reports 27. Which factor is most important when determin-
feeling comfortable during this show and seldom ing whether PCA should be used for a client’s pain
requests pain medication when she is watching it. management?
The nurse’s assessment of this phenomenon is that: 1. The client’s developmental and cognitive abilities
1. the assessment of pain that prompted hospitaliza- 2. The client’s weight
tion is inaccurate. 3. The length of the surgical procedure
2. O.R. is bored and the boredom usually makes her 4. The preferences of the surgeon
pain seem worse.
3. inactivity is the best approach to O.R.’s pain. Chapter 8 Cancer
4. distraction is an effective modifier of the pain ex-
perience for O.R. 28. The nurse carefully monitors the client’s intravenous
chemotherapy. An early indicator that extravasation
23. Which of the following Joint Commission pain may be occurring is when:
management standards apply to the bedside nurse? 1. the fluid stops infusing.
(Select all that apply.) 2. edema is noted at the site.
1. Identify symptoms of pain in the client 3. blood returns when the bottle is lowered.
2. Understand the institutional standards of pain 4. burning occurs at the site.
management
3. Assess factors impacting the pain experience 29. A client with breast cancer states that the doctor
4. Order the appropriate pain medication for the says he is going to prescribe hormone therapy.
client Which of the following hormones would probably
be ordered?
5. Implement pain management techniques
1. Thyroxin
6. Evaluate the effectiveness of pain management
techniques 2. Parathormone
3. Progesterone
24. The client’s family expresses concern that the client 4. Testosterone
could overdose with a PCA. The most appropriate
response by the nurse is: 30. A client with cancer develops a low white cell count.
1. “Overdose is not possible with PCA.” She is placed on neutropenic precautions. Which of
2. “The client receives extensive teaching prior to the following menu selections would be best?
PCA use, which should prevent overdose.” 1. Meat loaf, mashed potatoes, green beans, and
3. “The client can stop drug administration but not fruit gelatin
initiate it, so it is unlikely he will get too much 2. Meat loaf, mashed potatoes, marinated carrots,
medication.” and a garden salad
4. “The PCA pump is programmed with spe- 3. Meat loaf, mashed potatoes, chef salad, and
cific dose limits, reducing the chances of tapioca
overmedication.” 4. Meat loaf, mashed potatoes, green beans, fruit
salad, and a cookie
25. A client with terminal cancer is receiving morphine
via PCA. The client is grimacing and moaning occa- 31. When stomatitis develops, it is best to encourage the
sionally but sleeping for short intervals. Respiratory client to:
rate is 20 breaths/min, heart rate is 100 beats/min, 1. drink plenty of orange juice.
and blood pressure is 140/90 mmHg. What is the 2. use lemon and glycerine swabs frequently.
most accurate assessment of this client’s pain? 3. brush teeth before and after eating.
1. The client is able to sleep, so the pain is 4. rinse with commercial mouthwash as needed.
manageable. 32. Clients receiving radiation are encouraged to:
2. The client is exhibiting respiratory depression 1. wash and dry the skin carefully and apply lotion.
and should not receive more medication. 2. not bathe.
3. The client may need additional pain medication 3. not apply deodorants or lotions.
or an increase in dosage. 4. wash the skin with soap and apply baby powder.
4. The client can be assumed to be comfortable. 33. The client asks the nurse to explain the implications
26. The nurse is providing preoperative teaching to a of the TNM system. His physician told him “the news
client who will most likely receive PCA after surgery. is not good; your tumor is classified as T2 N2 M1.”
The nurse tells the client that the primary reason for The nurse’s response is based on the knowledge that:
utilizing PCA is that it: 1. this is a local classification system used by the
1. is cost effective. physicians at this particular hospital.
2. results in use of less medication.
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2. this is an international system used by oncolo- 39. A defining characteristic of the NANDA nursing di-
gists as a standardized method of defining a tu- agnosis Anticipatory Grieving is:
mor and tumor activity. 1. prolonged denial or depression.
3. the numbers used are indicative of tumor growth 2. unsuccessful adaptation to loss.
and spread, with the smaller numbers meaning 3. social isolation or withdrawal from others.
more aggressive growth. 4. an expression of distress at potential loss.
4. only the physician can interpret any findings to 40. The purpose of the Patient Self-Determination Act
the client. is to:
34. A difference between normal cells and cancer cells is 1. serve as an order for “do not resuscitate.”
that cancer cells: 2. designate a guardian for an incompetent client.
1. adhere to their area of origin. 3. provide a means, instead of a will, to designate
2. are well differentiated. what is to be done with a person’s property,
3. multiply at will. money, and personal possessions.
4. cannot move freely around the body. 4. provide a legal means for individuals to state
35. Which of the following are risk factors for cancer? those circumstances under which life-sustaining
(Select all that apply.) treatment should or should not be provided to
1. Use of oral birth control pills them.
2. Consumption of a high-fiber diet 41. One of the major goals of hospice care is:
3. Heavy alcohol consumption 1. freedom from pain and other symptoms.
4. Use of smokeless tobacco instead of smoking 2. free care for all dying clients and their families.
cigarettes 3. to cure the client using very aggressive medical
5. Consumption of five servings of fruits and veg- treatment.
etables daily 4. to transfer all dying clients to the hospital when
6. Multiple sexual partners with unprotected sex death is imminent.
36. A nurse is caring for a client with advanced cancer. 42. A client is in the last stages of dying. The nurse
The first nursing intervention priority is: assesses for the signs of impending death, which
1. support limbs and gently turn client to prevent a include:
pathological fracture. 1. flushed warm skin.
2. monitor ascites by measuring abdominal girth at 2. very slow regular pulse rate.
the umbilicus. 3. inability to hear.
3. listen to the client share her concerns about los- 4. Cheyne-Stokes respirations.
ing her hair. 43. Nursing care of a grieving client includes: (Select all
4. administer oral morphine sulfate for break- that apply.)
through pain. 1. telling the grieving client that he will feel better
37. The nurse meets the psychosocial needs of the client soon.
with cancer and his family’s needs by: 2. assuring the grieving client that feeling relief after
1. conversing on a superficial level so she does not a long illness is normal.
always have to think about her condition. 3. exploring ways to fill his life with meaningful
2. allowing the client personal time to adjust to the activities.
diagnosis but answer questions and provide sup- 4. encouraging him to feel his feelings to the fullest
port as needed. so that he can work through the feelings.
3. allaying anxiety by not giving any information 5. leaving him alone so that he can work through
about treatment options or adverse reactions. the feelings on his own.
4. providing all the physical care for the client so the 6. explaining that each person works through grief
family is not involved with these needs. in his own way and in his own timing.
Chapter 9 Palliative and End-of-Life 44. A dying client tells God that he will become a pas-
tor if he is healed. The nurse knows that the client is
Care
experiencing what stage of death and dying?
38. S.R., age 11 years, was left with a distant relative 1. Denial
2 weeks ago. Her parents have not returned or 2. Anger
called. S.R. is experiencing a(an): 3. Bargaining
1. physical loss. 4. Depression
2. situational loss.
3. maturational loss.
4. anticipational loss.
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45. A client is in hospice care. To meet the physiologi- 47. A terminally ill client enters the hospital and the
cal comfort needs of the client, the nurse: (Select all daughter presents the client’s advanced directive
that apply.) papers and states she is the durable power of attor-
1. accepts and believes the client’s expressions of ney. The client has not signed a do-not-resuscitate
pain. (DNR) form. The daughter leaves the hospital and
2. cleans the skin and applies a moisture barrier af- the client codes. The nursing staff:
ter urination. 1. starts resuscitation because there is no DNR or-
3. reads scripture passages as requested by the der from a physician.
client. 2. does not start resuscitation because the client is
4. provides soft lighting in the room. terminal.
5. applies petroleum jelly to the lips. 3. does not start resuscitation but places a call to the
6. listens as the client shares his fears. daughter for her decision regarding resuscitation
46. A terminally ill client is agitated and keeps stating, “I desires.
want to talk to my children, all of my children!” The 4. starts resuscitation but then stops when no DNR
nurse’s best response is: order is found.
1. “I know you are upset. Let me reposition you and
make you more comfortable.”
2. “You seem agitated. Tell me the reason you want For additional content, activities, games, and
to speak with your children.” more, visit the White Premium Website at
3. “I know you want to talk with your family. Tell www.cengagebrain.com.
me how I can help you speak to your children.” Use the access code printed in the front of
4. “It is late at night, and your children are in bed. this book to log on to this free resource today!
Try to go to sleep.”
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RESOURCES
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American Holistic Nurses Association (AHNA) T’ai Chi Association
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American Massage Therapy Association (AMTA)
http://www.amtamassage.org Chapter 5
Association for Applied and Therapeutic Humor Agency for Healthcare Research and Quality (AHRQ)
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Chapter 6 Caring Connections
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http://www.cdc.gov National Quality Forum (NQF), National Framework
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(OSHA) Partnership for Caring: America’s Voices
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Chapter 8
United Network for Organ Sharing
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Nursing Care
UNIT 3 of Clients with Fluid
and Electrolyte Needs
10 Assessing and Caring for Clients with Fluid and Electrolyte
Disturbances / 199
11 Assessing and Caring for Clients with Acid–Base

Disturbances / 221
12 IV Therapy / 246
Homeostasis is the maintenance of the body’s internal environment

within a narrow range of normal values. It is an ongoing process, with
changes constantly occurring in the body. In health, normal homeo-
static mechanisms function to maintain fluid, electrolyte, and acid–
base balance. In illness, one or more of the regulating mechanisms
may be affected, or an imbalance may become too great for the body
to correct without treatment.
The focus of this unit is to provide a comprehensive presentation
of nursing care for clients with fluid and electrolyte or acid–base dis-
turbances and those undergoing IV therapy.
Chapter 10, Assessing and Caring for Clients with Fluid and Elec-
trolyte Disturbances, discusses the role of diffusion, osmosis, and
filtration in the human body. The fluid compartments, the fluids con-
tained in them, and the function of those fluids as well as the way the
kidneys work to maintain fluid and electrolyte balance are addressed.
The chapter details the causes, assessment data, nursing diagnoses,
nursing interventions, and criteria for evaluating the effectiveness of
nursing care for clients with sodium, potassium, calcium, and mag-
nesium imbalances. The principles of nursing management for clients
receiving fluids and electrolytes via oral supplements, intravenous so-
lutions, enteral feedings, and total parenteral nutrition are discussed.
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Chapter 11, Assessing and Caring for Clients with Acid–Base Dis-
turbances, provides the learner with detailed descriptions of acid–base
imbalances along with explanations of related treatment and nursing
care by applying the steps of the nursing process. Acid–base balance is
necessary to maintain normal body function.
The acid–base imbalance determines the plan of care the nurse de-
velops with the client and the interdisciplinary team. The four types of
acid–base imbalance covered in the chapter are respiratory acidosis,
respiratory alkalosis, metabolic acidosis, and metabolic alkalosis.
Chapter 12, IV Therapy, explains IV equipment and the differences
in IV fluids. A brief explanation of IV drip calculations is presented with
an explanation of regulating the IV flow rate. IV medication administra-
tion is a serious responsibility because the drug is given directly into the
bloodstream and steps to correct an error must be taken immediately.
Various methods of administering medications via IV are explained and
accompanied by photos demonstrating the process.
Assessment criteria prior to blood administration are delineated and
guidelines explained for administering blood products. The blood trans-
fusion process is explained with a thorough explanation of the symp-
toms of various types of transfusion reactions.
The LPN/LVN role in IV therapy and blood transfusions varies from
state to state. It is the responsibility of LPN/LVNs to know the rules and
regulations of the state board of nursing in the state where they are
practicing.
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CHAPTER 10
Assessing and Caring for Clients
with Fluid and Electrolyte
Disturbances
KEY TERMS
anion hemolysis mixture
atom homeostasis molecule
cation hydrostatic pressure osmolality
compound hypertonic solution osmolarity
crenation hypotonic solution osmosis
decomposition infiltration osmotic pressure
dehydration interstitial fluid permeability
dialysis intracellular fluid (ICF) selectively permeable
diffusion intravascular fluid membrane
edema intravenous (IV) therapy semipermeable
electrolyte ion membrane
element isotonic solution synthesis
extracellular fluid (ECF) isotope turgor
filtration matter
LEARNING OBJECTIVES
2. Discuss the various physiological processes that accomplish homeostasis in the body.
3. Identify the basic chemical organization and physical principles of the body.
4. Describe and give examples in the body of diffusion, osmosis, and filtration.
5. Name the fluid compartments, the fluids contained in them, and the function of those
fluids.
6. Describe the way the kidneys work to maintain fluid and electrolyte balance.
199
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200 UNIT 3 Nursing Care of Clients with Fluid and Electrolyte Needs
7. Detail causes, assessment data, nursing interventions, and criteria for evaluating
effectiveness of care for clients with a nursing diagnosis of Deficient Fluid Volume
or Excess Fluid Volume.
8. Detail causes, assessment data, nursing diagnoses, nursing interventions, and criteria for
evaluating the effectiveness of nursing care for clients with sodium, potassium, calcium,
and magnesium imbalances.
9. Relate principles of nursing management for clients receiving fluids and electrolytes via
oral supplements, intravenous solutions, enteral feedings, and total parenteral nutrition.
10. Use the nursing process to plan care for a client experiencing a fluid and electrolyte
imbalance.
When the body loses the ability to maintain homeostasis

INTRODUCTION and the internal environment changes, the body’s physiologi-
The external environment within which we live undergoes cal processes can be interrupted or changed, leading to disease,
continual changes, both small and large. For example, the disorder, or death. In essence, then, maintaining homeostasis
daily and seasonal temperatures may fluctuate over a wide is essential to life. Because the processes of homeostasis
range. The light intensity is bright on sunny days and less involve many chemical and physical processes, it is necessary
so on cloudy days. The humidity may be either high or low. to examine some of these before studying homeostasis in
These are just a few of the many factors that constantly change more detail.
in the external environment. Our bodies must continually
adjust to such changes in the external environment. In order
for life to continue, however, our internal environment—the
CHEMICAL ORGANIZATION
one inside our bodies—must remain relatively constant, The human body is highly organized. This organization exists
varying only slightly within narrow ranges. This internal envi- in increasing levels of complexity. Most basic is the chemical
ronment consists of the various body fluids such as the fluid level. To understand the higher levels of organization, it is
inside cells, the blood, tissue fluids that bathe the cells, and necessary to know something about basic chemical and physi-
other fluids. Maintenance of the internal environment within cal principles.
very narrow limits is termed homeostasis (equilibrium).
Elements
HOMEOSTASIS Cells consist of living matter. Matter is anything that occupies
space and possesses mass. All matter has certain physical prop-
Homeostasis is an ongoing process; that is, the body simply erties such as color, odor, hardness, and density. Matter also
does not reach a state of equilibrium and remain there. Small has extensive properties such as size, shape, and weight. Matter
changes constantly occur in response to physiological pro- is composed of basic substances called elements. Elements
cesses. The body must therefore continuously make subtle are made of tiny units called atoms. Atoms of each element
adjustments to maintain the constancy of the internal envi- are alike. Different elements have different kinds of atoms.
ronment within a normal range. Currently, 112 elements are recognized. Some examples are
Homeostasis is accomplished by various physiological iron, gold, carbon, hydrogen, oxygen, nitrogen, and copper.
processes and the coordinated activities of the organ systems. Many of the elements occur in the human body in varying
Some examples are as follows: amounts. Some are present in large amounts, and others are
• The gastrointestinal (GI) system changes large, complex found in only trace amounts. Four of the elements, oxygen,
molecules of ingested food to simpler, less complex mole- carbon, hydrogen, and nitrogen, constitute more than 95% of
cules that can be utilized by the cells of the body to produce the total body weight of the elements. Some of the elements
the energy necessary for life. and their function in the body are presented in Table 10-1.
• The respiratory system supplies the cells with the constant
source of oxygen required to release the energy from the
products of digestion. It also eliminates carbon dioxide, the
Atoms
waste product produced by the cells as a result of energy An atom is the smallest unit of chemical structure, and no
production. chemical change can alter it. Atoms are made up of three
basic particles: protons, neutrons, and electrons. Protons and
• The blood acts as a transport mechanism, carrying the neutrons are similar in size. Protons, however, have a positive
products of digestion along with hormones and oxygen to electrical charge, whereas neutrons have no charge. Together,
the cells, where these substances are utilized. they form the nucleus of the atom. Because the protons have
• It also transports carbon dioxide from the energy-releasing a positive charge and the neutrons are neutral, the nucleus of
processes of the cells to the lungs, where it will be eliminated. an atom has a positive charge. The electrons have a negative
• All the activities of the various organ systems are integrated charge and move in an orbit around the nucleus. There are as
and coordinated through the nervous system and the endo- many electrons as protons, rendering the overall atom neutral.
crine system. The number of protons in an atom is called its atomic number.
200
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CHAPTER 10 Assessing and Caring for Clients with Fluid and Electrolyte Disturbances 201
Table 10-1 Elements Occurring in the Human Body

ApprOxiMATE
% OF BODy
ElEMEnT WEigHT FunCTiOn
Major Elements
Oxygen (O) 65.0 Found in both organic and inorganic compounds; as a gas, is necessary in
metabolizing glucose and other chemical compounds into energy
Carbon (C) 18.5 Found in all organic compounds such as carbohydrates, protein, lipids, and
nucleic acids; necessary for cellular respiration
Hydrogen (H) 9.5 Found in many organic and inorganic compounds; in ionic form, involved in
pH; component of water; necessary for life
Nitrogen (N) 3.2 Important in proteins, which are the body’s building blocks, an energy source,
and a component of hormones
Calcium (Ca) 1.5 Important element in bone and tooth composition; involved in nerve
conduction, muscle contraction, and blood clotting
Phosphorus (P) 1.0 Found in bones, teeth, the high-energy carrying compound adenosine
triphosphatase (ATP), some proteins, and nucleic acid
Potassium (K) 0.4 Major electrolyte in intracellular fluid; important in muscle contraction and
transmission of nerve impulses; activates enzymes; influences cellular osmotic
pressure; involved in kidney function and acid–base balance
Sulfur (S) 0.3 Found in some proteins, nucleic acids, and some vitamins and hormones
Sodium (Na) 0.2 Constitutes major electrolyte in extracellular fluid; important in osmoregulation
and acid–base balance; necessary for nerve transmission and muscle
contraction
Chlorine (Cl) 0.2 Found in extracellular fluid; important in water balance, acid–base balance,
and production of hydrochloric acid in the stomach
Magnesium (Mg) 0.1 Important to muscle and nerve function and bone formation and in some coenzymes
Essential Trace Elements

Present in the human body in minimal amounts, constituting approximately 0.1% of body weight; have known functions
Cobalt (Co) Important component of vitamin B12
Copper (Cu) Necessary for formation of hemoglobin and for bone development
Chromium (Cr) A cofactor involved with enzymes for fat, cholesterol, and glucose metabolism
Fluorine (F) Gives hardness to teeth and bones
Iodine (I) Necessary for synthesis of thyroid hormone
Iron (Fe) Necessary for transportation of oxygen by hemoglobin
Manganese (Mn) Necessary in activating some enzymes
Selenium (Se) Acts with vitamin E as an antioxidant; component of teeth
Zinc (Zn) Found in some enzymes; needed for protein metabolism and carbon dioxide
transport
Other Trace Elements
Have probable, but as yet undetected, functions
Aluminum (Al) Nickel (Ni) Arsenic (As) Tin (Sn) Boron (B) Silicon (Si) Cadmium (Cd) Vanadium (V)
The simplest element is hydrogen. It has an atomic number of approximately equal to the atomic weight. Thus, hydrogen
1. One proton with a positive charge forms the nucleus, and has an atomic weight of 1.
one electron moves in an orbit around the nucleus. Hydrogen
atoms may or may not have a neutron. A hydrogen atom is Isotopes
illustrated in Figure 10-1. The number of protons in the nucleus is the same for all atoms
Depending on the element, other atoms may have more of a given element, but the number of neutrons may vary in
than one proton and one electron and may have neutrons. atoms of the same element. For instance, all hydrogen atoms
The number of protons and neutrons in the nucleus is have one proton and one electron; however, some hydrogen
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same ratio under similar conditions, it is possible to predict

1e -
the nature of a chemical change.
When atoms of two or more different elements combine
(react), they form a compound. For example, if one atom of
sodium (Na) and one atom of chlorine (Cl) react, they form
1P+ a molecule of the compound called sodium chloride. This is

expressed in the following equation:
Na 1 Cl NaCl
Compounds can be divided into two groups. Those
without carbon are inorganic compounds, and those with
Figure 10-1 Hydrogen atom showing positively charged carbon are organic compounds. By using chemical equations,
proton in the nucleus and negatively charged electron in orbit. chemical changes, called reactions, can be shown. Sometimes,
different substances are combined in no specific way, and
the components do not have a definite ratio every time. For
atoms have one neutron in the nucleus, while others have two instance, water, sugar, and table salt mixed without being
(Figure 10-2). Atoms of the same element that have different measured will yield different results depending on the ratio of
atomic weights (i.e., have a different number of neutrons) are each substance. Such a combination is called a mixture. Its
called isotopes. All the isotopes of a given element react the composition may vary each time the components are mixed.
same way chemically. Chemical reactions occur whenever atoms join together
Some isotopes, called radioactive isotopes, have an or separate. They join together by forming bonds, and they
unstable nucleus, which decomposes and gives off energy in separate by breaking bonds. Either way, new combinations
the form of radiation. This radiation can be in the form of alpha, result. When two or more atoms (reactants) bond and form
beta, or gamma rays. All are damaging to cells. Alpha radiation a more complex molecular product, the reaction is called
is the least harmful, and gamma radiation is the most harmful. synthesis. A sample equation would be as follows:
Iodine, oxygen, and cobalt are examples of elements having ra-
2H 1 O H2O
dioactive isotopes. Some of the radioactive isotopes are useful
as biologic markers and can be used to track metabolic path- hydrogen and oxygen yields water
ways of food. Others such as iodine-131 can be injected into When the bonding between the atoms in a molecule is
the body and used to track the circulation of blood. Still others broken and simpler products are formed, the reaction is called
such as cobalt-60 are used in cancer treatment. decomposition. If a molecule of sodium chloride is decom-
posed, it forms sodium and chlorine. This can be expressed
Molecules and Compounds as follows:
Atoms of the same element can unite with each other to form NaCl Na 1 Cl
a molecule. For example, atoms of hydrogen unite to form a sodium chloride yields sodium and chloride
hydrogen molecule. This can be expressed in a chemical equa-
tion using the chemical symbol for hydrogen: (decomposition)
H1H H2 It is important to understand that when synthesis occurs,

energy is tied up in the bonds formed during the reaction.
In this reaction, the atoms on the left are the reactants, the When decomposition occurs, energy is released. In the cells
arrow is read as “yield,” and the last symbol is the product—a of the body, these kinds of chemical reactions are repeatedly
molecule of hydrogen. A chemical equation uses the chemi- occurring: Molecules form and decompose. Body cells can
cal symbols of elements and shows the ratios by which they utilize these reactions to form energy sources and to free
combine. Because atoms of elements always combine in the energy to drive the various metabolic processes of the cells.
1e - 1e -
Ions
When some compounds are placed in water, they decompose, or
ionize. The result is an ion, an atom bearing an electrical charge.
An ion with a positive charge is called a cation; an ion with a
1N o negative charge is termed an anion. For example, sodium chlo-
No
1P+ 1P+ ride in water dissociates to form sodium ions bearing a positive
1N o charge and chloride ions bearing a negative charge (Figure 10-3).
Because the atoms in this combination are charged, they will

conduct electricity. The reaction can be shown as follows:
NaCl Na1 1 Cl2
A B sodium chloride yields sodium and chloride
(cation) (anion)
Figure 10-2 Isotopes of hydrogen: A, Deuterium has one
positively charged proton and one neutron in the nucleus and A compound that dissociates into ions in water is called
one electron in orbit. B, Tritium has one positively charged an electrolyte. Many electrolytes are extremely important in
proton and two neutrons in the nucleus and one electron in orbit. body chemistry.
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Solute
(the thing being dissolved) GASES
Na Cl Two important gases in the body are oxygen (O2) and carbon
dioxide (CO2). Because these elements are gases, their mol-
ecules are free and can move swiftly in all directions. Oxygen
enters the body through the lungs and is transported by the
red blood cells throughout the body to the cells. The cells
H2O H2O use oxygen in the release of energy from glucose and other
H2O Na+ Cl– molecules. This energy is needed by the cells to carry out their
H2O Cl– activities. As a result of the energy-releasing processes, carbon
H2O H2O

dioxide is produced by the cells and transported in the blood
to the lungs, where it is eliminated.
Solvent Electrolyte solution
(does the dissolving) (result of the
dissolving process) SUBSTANCE MOVEMENT
Substances must be able to both enter and leave cells. For
Figure 10-3 Dissociation of electrolytes. example, oxygen and various end products of digestion must
enter a cell through the cell membrane for use by the cell.
Waste products from cellular processes must be eliminated
from the cell. Various ions must also both enter and leave cells.
WATER Everything that enters and leaves the cell must pass through
the cell membrane. Thus, the cell membrane serves not only
Water constitutes approximately 60% of the total body weight as an envelope around the cell but also as a gatekeeper, regu-
of an adult and is involved in many of the physical and physi- lating which substances can enter and leave the cell.
ological processes of the body. Because water is so integral to The cell membrane is a very thin and delicate, but
the body’s processes, fluctuations in the amount of water in complex and living, elastic covering around each cell. It
the body can have harmful or even fatal consequences. consists of inner and outer layers of phospholipids in which
Water is the major component of blood. Approximately protein molecules are embedded. Many small channels pass
92% of the body’s organic and inorganic compounds dissolve through the membrane. These channels allow some water
in this water into less complex molecules and atoms and then molecules and some water-soluble substances to pass through
are transported throughout the body. Necessary substances the membrane. The ability of a membrane to permit sub-
such as oxygen and nutrients from the GI system are carried to stances to pass through it is called permeability. Because a
the cells, where they are utilized. Cellular waste products such cell membrane allows passage of only certain substances, it
as carbon dioxide, urea, and excessive minerals are carried by is called a selectively permeable membrane. An artificial
water to sites of elimination: carbon dioxide to the lungs and membrane such as cellophane is known as a semipermeable
urea and minerals to the kidneys. membrane (Kee, Paulanka, & Polek, 2010).
Water also absorbs heat resulting from muscle contrac- Some substances can pass through the cell membrane
tions and distributes this heat over the body. Water in the without energy expenditure on the part of the cell. This is
form of perspiration released from sweat glands in the skin called passive transport. The passage of other substances
can cool the body by evaporation. Water also can break apart requires an expenditure of energy by the cell. This is called
the bonds in large molecules such as starches to form smaller active transport.
molecules in the digestive process. This type of reaction is
called hydration.
Passive Transport
There are several types of passive transport: diffusion, osmo-
sis, and filtration.
Diffusion
Body Water and Body Size Diffusion is the tendency of molecules of either gases, liq-
The amount of body water is inversely proportional uids, or solids to move from a region of higher molecular
to body size. The smaller the body, the higher the concentration to a region of lower molecular concentration
water content: until an equilibrium is reached. This movement is caused by
the kinetic energy in molecules. Kinetic energy causes the
Embryo: 97% molecules to move constantly, colliding with one another and
Infant: 70% to 80% knocking each other about, thus causing them to move farther
Child: 60% to 77% apart. An example is a drop of black ink placed in a glass of
Adult: 60% water; over time, the glass of water will turn a uniform black
Older Adult: 45% to 55% color because of diffusion, as shown in Figure 10-4.
Body water diminishment in older adults is related
In the body, oxygen moves by diffusion from the lungs to
the bloodstream because the oxygen concentration is higher
to tissue loss.
in the lungs and lower in the blood. Carbon dioxide moves by
diffusion from the bloodstream, where the concentration of
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Semipermeable
membrane Osmosis

Figure 10-4 Diffusion is the spreading of particles from an A B C
area of greater concentration to an area of lesser concentration.
Dye put into a beaker of water gradually spreads throughout Figure 10-5 The process of osmosis.
the water.
carbon dioxide is higher, to the lungs, for elimination. The size 95% water. There would be more water outside than inside
of the channels in the cell membrane can prevent large mol- the cell; thus, water would pass through the membrane into
ecules from passing through the membrane. Some substances, the cell. Because the cell membrane is elastic, the cell would
such as glucose molecules, combine with carrier molecules, increase in size as a result of the water accumulation within
which carry them into the interior of the cell, where they are it facilitated by the process of osmosis. The pressure exerted
released. against the cell membrane by the water inside the cell is called
The term dialysis is used when diffusion is employed to osmotic pressure.
separate molecules out of a solution by passing them through A solution that has the same molecular concentration as
a semipermeable membrane. Dialysis is the process used in the cell is called an isotonic solution. It neither increases
the artificial kidney. As blood from a client circulates through nor decreases the size of the cell. A solution that has a lower
a machine, small, toxic waste molecules such as urea leave the molecular concentration than the cell is called a hypotonic
blood and pass through the semipermeable membrane by solution. Placing cells in a hypotonic solution causes them to
diffusion and out into the surrounding fluid. The blood, thus swell, possibly to the point of eventual rupture. The rupture
cleaned, is then returned to the body. of red blood cells due to osmosis is called hemolysis. As red
blood cells swell, the hemoglobin contained within passes to
Osmosis the outside of the cell and into the solution surrounding the
cell, rendering the blood cells no longer capable of carrying
Osmosis is the diffusion of water through a semipermeable oxygen. A solution that has a higher molecular concentration
membrane from a region of higher water concentration to a than the cell is called a hypertonic solution. When placed
region of lower water concentration. In a solution undergoing in such a solution, water leaves the cell, and the cell decreases
osmosis, only the water (solvent) molecules move through in size. In the case of red blood cells, they shrivel and become
the membrane; the dissolved molecules do not (Figure 10-5). wrinkled. This shrinkage, called crenation, leaves the cells
If a cell, having both a membrane that will not allow incapable of functioning.
sodium chloride to pass through and a molecular concentration In persons who have lost large volumes of blood, it is
of 10% sodium chloride, were placed in a container with a 5% sometimes necessary to administer additional fluids to main-
sodium chloride solution, the cell would contain 10% sodium tain blood pressure. Generally, normal saline can be used.
chloride and 90% water, and the 5% solution in which it was This 0.9% sodium chloride solution has approximately the
placed would contain 5% dissolved sodium chloride and same osmotic concentration as blood. Because it is isotonic, it
will not damage the cells. Figure 10-6 shows osmosis in cells
with different solution concentrations.
Cr it iCa l t h in k in g
Filtration
Substance Movement: In filtration, fluids and the substances dissolved in them are
Class Activity forced through cell membranes by hydrostatic pressure—
the pressure the fluid exerts against the membrane. The mol-
ecules passing through the membrane are determined by the
During class, place a tea bag into a glass of warm size of the pores in the membrane. Tissue fluids are formed by
water. Allow time for the students to record their filtration. As blood passes through the capillaries, hydrostatic
observations. Ask the students to write an expla- pressure exerted by the pumping action of the heart causes
nation of which type(s) of substance movement some of the liquid fraction of the blood (but not the cells) to
occurred using the correct terminology (Science
pass out of the capillaries, resulting in formation of the tissue
fluid (Figure 10-7). As the blood circulates through the capil-
Spot, 2011).
laries of the kidneys, the hydrostatic pressure of the blood
causes many materials to leave the blood through the filtration
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Cell membrane
Inside of cell
Outside of cell
Cytoplasm
Molecules
+ Water Transported to be
molecules transported
are in a are in a
greater lesser
concentration concentration
Red blood cells Hypotonic solution Hemolysis
A Carrier

Carrier Energy Carrier- picking up
"unloading" supplied molecule a molecule
transported by ATP complex to be
molecule molecules shuttling transported
in the cell across across the
+ 0.9%NaCl No change membrane the cell cell membrane
membrane
Figure 10-8 Active transport of molecules from an area of

Red blood cells Isotonic solution lesser concentration to an area of greater concentration.
B
move the molecules in or out of the cell. In active transport,

Blood the cell must use energy to move the molecules. For instance,

+ + in the body, sodium ions are in higher concentration in the
3%NaCl
fluids surrounding the cell than inside the cell. Although
some sodium ions can diffuse into the cell, the cell actively
Red blood cells Hypertonic solution Crenation transports them through the membrane to the outside. Active
C transport is accomplished by means of carrier molecules,
which can latch onto specific molecules and transport them
Figure 10-6 Osmosis is the movement of water through a in or out of the cell. This process requires an expenditure of
membrane from an area of lower concentration to one of higher cellular energy (Figure 10-8). Examples of important ions
concentration. A, In a hypotonic solution, the water moves into transported by this process are calcium, sodium, potassium,
the cells, causing them to swell and burst. B, In an isotonic solu- and magnesium.
tion, cells are normal in size and shape because the same amount
of water is entering and leaving the cells. C, In a hypertonic solu-
tion, cells are losing water because water moves from an area of FLUID AND ELECTROLYTE
lower concentration (inside the cell) to an area of higher
concentration (outside the cell).
BALANCE
Human life is suspended in a saline solution having a salt con-
centration of 0.9%. This solution, which both surrounds the
Interstitial cells and is contained within them, constitutes the body fluids.
Capillary wall space
The water and electrolytes composing these body fluids come
from ingested water and nutrients, and from the water that
Capillary bed results from metabolism.
Blood pressure exceeds Blood pressure is less

For life to continue and the cells to function properly,
interstitial pressure than interstitial pressure the body fluids must remain fairly constant with regard
to the amount of water and the specific electrolytes of which
they are composed. Water is essential because it is the basic
A Arterial end of capillary B Venous end of capillary component of all body fluids. Water is involved in many of
the metabolic processes in the body and is a by-product of
Figure 10-7 Filtration: A, Pressure in the arteriole is greater some of these reactions. The various electrolytes all have
than interstitial (between the cells) pressure, causing fluid with essential roles in cellular physiological processes. If some
dissolved substances to move out of capillaries. B, Pressure in of either is lost, it must be replaced, and if either water or
venules is less than interstitial fluid pressure, causing fluid and an electrolyte is in excess, it must be removed. Maintaining
waste products to move back into the capillaries. the consistency of this fluid environment is the process of
homeostasis.
For cells to survive and carry out their multitude of
process. These materials pass into the tubules of the kidneys, physiological functions, they need both a continuing source of
where the toxic waste products are removed to form urine. The water, nutrients, and oxygen and a mechanism to remove cel-
urine is then eliminated from the body. lular wastes. These physiological processes affect the amount
of water, the pH, and the ions both inside and outside the
cells. A balance must be maintained between the components
Active Transport of the fluids inside and outside the cell. Because the ions are
In the processes discussed thus far, the movement of molecules dissolved in water, these two components are tied together:
depends on the concentration of molecules or on pressure. Anything affecting the amount of water in the body will affect
In other words, the cells do not have to expend energy to the ion concentration.
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The difference in the ion concentration inside the cell

and outside the cell is due primarily to the cell’s ability to
Intravascular pump some ions inside and pump others out. If the intracel-
9% lular fluid becomes hypertonic to the extracellular fluid, water
from the extracellular fluid will move by osmosis into the cell
to restore the balance and vice versa.
A fluid balance also occurs between the interstitial fluid
and the plasma. This balance is regulated primarily by hydro-
Intracellular Extracellular static pressure (blood pressure) and osmotic pressure. When
65% 35% the circulating blood passes from the arterioles into the capil-
laries, the pressure in the capillaries is higher than that in the
Interstitial interstitial fluid. This forces some of the water from the plasma
26%
out of the capillaries and into the interstitial fluid. Because of

osmotic pressure, some of the water in the interstitial fluid
is forced back into the capillaries in the area where they join
the venules. Some water is also returned to the bloodstream
through the lymphatic system. If the amount of interstitial
fluid returned to the circulatory system lessens and the fluid
accumulates in the tissue spaces, the tissues become swollen.
Figure 10-9 Body fluid compartments of an adult. This condition is called edema. Several conditions can cause
edema, including kidney or liver disease and heart disorders.
Many of these conditions can have serious consequences.
When more water is lost from the body than is replaced,
Body Fluids dehydration occurs. Among the various causes of dehy-
Much of the body weight of an average adult is due to the dration are water deprivation, excessive urine production,
water in the body fluids surrounding the cells and contained profuse sweating, diarrhea, and extended periods of vomit-
within them. The fluid around the cells cushions them and ing. As water is lost, the amount of water in the interstitial
serves as the medium of exchange. Everything that enters or fluid decreases. Water then moves from the cells to the tissue
leaves the cells must pass through this fluid layer. spaces by osmosis, causing an electrolyte imbalance. Circula-
There are two kinds of body fluids. They can be thought tory impairment occurs, which in turn affects the kidney’s
of as being contained within two separate containers, called ability to function normally. This condition is corrected by
compartments. The intracellular fluid (iCF) compartment supplying water and the appropriate electrolytes.
contains all the water and ions inside the cells. By far the larg-
est amount of water in the body, approximately 65%, is found
within this compartment. Regulators of Fluid
The extracellular fluid compartment contains the remain- and Electrolyte Balance
ing body fluids, called extracellular fluid (ECF), or fluid There must be a balance in the amounts of fluids and elec-
outside the cells. These can be further subdivided into inter- trolytes consumed and lost daily. Under typical conditions,
stitial, intravascular, and other fluids. interstitial fluid is the the average adult loses some water through the skin, lungs,
fluid in the tissue spaces around each cell. The intravascular and GI tract and loses the largest amount of water through
fluid is the plasma in the blood vessels and the lymph in the urine production. This can amount to a per-day fluid loss of
lymphatic system (Figure 10-9). There are also small amounts approximately 2,500 mL, depending on conditions.
of other specialized body fluids such as synovial fluid, cerebro-
spinal fluid, serous fluid, aqueous and vitreous humor, and the
endolymph and perilymph. The proportions of extracellular Skin
fluid and intracellular fluid vary with age. In the average adult, an estimated water loss of 300 to 500 mL
Generally speaking, the major ions in the extracellular per day occurs by diffusion through the skin. Because the
fluid are sodium (Na1), chloride (Cl2), and bicarbonate person is not aware of this water loss, it is called insensible loss.
(HCO32), although other ions do occur. In the intracellular Water is also lost through the skin by perspiration. The total
fluid, the major ions are potassium (K1), phosphate (PO42 2), amount of water lost through perspiration varies depending
and magnesium (Mg11), with lesser amounts of other ions on environmental factors and body temperature.
present. There are also large numbers of protein molecules
bearing a negative charge. Lungs
In the average adult, an estimated insensible water loss of 400
Exchange between to 500 mL per day occurs with expired air, which is saturated
with water vapor. This amount varies with the rate and depth
the Extracellular of respirations.
and Intracellular Fluids
Water and ions moving between the extracellular and intracel- Gastrointestinal Tract
lular fluids must first pass through the selectively permeable Although a large amount of fluid—approximately 8,000 mL
cell membrane. This movement is governed primarily by per day in the average adult—is secreted into the gastro-
osmosis. Diffusion and active transport also play a role. intestinal tract, almost all of this fluid is reabsorbed by the
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body. In adults, approximately 200 mL of water are lost per Thirst

day in feces. Severe diarrhea can cause a fluid and electro-
lyte deficit because the GI fluids contain a large amount of Water consumption usually occurs in response to the sensa-
electrolytes. tion of thirst. This mechanism is poorly understood. It is
generally believed to be brought about by the loss of body
fluids, which in turn causes a dryness in the mouth and the
Kidneys thirst sensation. Replacing the lost fluids by water consump-
The kidneys play a major role in maintaining fluid balance by tion causes the sensation to diminish. The thirst mechanism
excreting 1,000 to 1,500 mL of water per day in the average appears to be regulated by the hypothalamus in the brain.
adult. The excretion of water by healthy kidneys is propor- Dehydration is one of the most common and most seri-
tional to the fluid ingested and the amount of waste or solutes ous fluid imbalances that can result from poor monitoring
excreted. of fluid intake. One nursing goal is to ensure that all clients
When an extracellular fluid volume deficit occurs, hor- understand both the role that water plays in health and the
mones play a key role in restoring the extracellular fluid way to maintain adequate hydration.
volume. Release of the following hormones into circulation
causes the kidneys to conserve water:
• Antidiuretic hormone (ADH). Released by the posterior
DISTURBANCES IN
pituitary gland; acts on the distal tubules of the kidneys to ELECTROLYTE BALANCE
reabsorb water. In health, normal homeostatic mechanisms function to main-
• Aldosterone. Produced in the adrenal cortex; causes the tain electrolyte balance. In illness, one or more of the regu-
reabsorption of sodium from the renal tubules, leading to lating mechanisms may be affected, or an imbalance may
water retention in the extracellular fluid, thereby increasing become too great for the body to correct without treatment.
its volume. Electrolytes are measured by laboratory analysis of a blood
• Renin. Released by the juxtaglomerular cells of the kidneys; sample. Table 10-3 lists foods rich in sodium, potassium, and
promotes vasoconstriction and the release of aldosterone. calcium. Table 10-4 lists the types, causes, signs and symp-
toms, and nursing interventions for electrolyte imbalances.
The interaction of these hormones with regard to renal func-
tions serves as the body’s compensatory mechanism to main-
tain homeostasis. Sodium
Sodium is the main electrolyte that promotes the reten- Sodium (Na1) is the major electrolyte in extracellular fluid. It
tion of water. An intravascular water deficit causes the renal regulates fluid balance through osmotic pressure that results
tubules to reabsorb more sodium into circulation. Because from water following sodium in the body. Sodium stimulates
water molecules go with the sodium ions, the intravascular conduction of nerve impulses and helps maintain neuromus-
water deficit is corrected by this action of the renal tubules. cular activity. Excretion occurs primarily via the kidneys.
The normal serum sodium for an adult is 136 to 145 mEq/L.
Fluid and Food Intake Critical values are <130 or >160 mEq/L (Daniels, 2010;
Fluids must be replaced in the amounts lost. The primary Daniels & Nicoll, 2012).
source of fluid replacement is water consumption. Approxi-
mately 60% may be obtained in this way, with an additional
30% being obtained from foods and 8% to 10% being a prod-
uct of metabolism (metabolic water), for a total of 2,600 mL. Table 10-3 Foods rich in Sodium,
Table 10-2 illustrates fluid balance. potassium, and Calcium
SODiuM pOTASSiuM CAlCiuM
Table 10-2 Average Fluid loss
and gains in 24 Hours Processed/prepared Banana Milk
foods: canned Orange Yogurt
inTAKE OuTpuT vegetables, soups, Apricot Cheese
luncheon meats, Cantaloupe Tofu/soybeans
Oral liquids 1,300 mL Urine 1,000–1,500 mL frozen foods, potato Dried fruit Almonds
chips, snack foods, Avocado Broccoli
Water in 1,000 mL Stool 200 mL olives, pickles Raw carrots Spinach
food Baked potato
Sodium-containing
condiments: soy Spinach
Water from 300 mL Insensible
sauce, salad Milk
metabolism losses
dressings, sauces, Yogurt
Lungs 400–500 mL Meat
dips, ketchup,
Skin 300–500 mL mustard, relishes Fish
Total 2,600 mL Total 2,600 mL (average) Natural foods:

meat, poultry, dairy,
Adapted from Nutrition and Diet Therapy (10th ed.), by R. Roth, 2011,
Clifton Park, NY: Delmar Cengage Learning.
vegetables
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Table 10-4 Electrolyte imbalances

ElECTrOlyTE
AnD TypE OF
iMBAlAnCE CAuSES OF iMBAlAnCE SignS AnD SyMpTOMS nurSing inTErVEnTiOnS
Sodium
Hyponatremia • Sodium deficit Hypotension, tachycardia, Monitor serum sodium lab results.
(serum sodium • Water excess edema, headache, leth- Assess for physical manifestations.
level <136 mEq/L) • Prolonged vomiting, argy, confusion, muscle Encourage foods and fluids high in
diarrhea, excessive perspi- weakness and twitching, sodium if ordered. Monitor I&O.
ration, burns, or gastric or abdominal cramps, Teach the client about sodium-rich
intestinal suctioning dry mucous membranes, foods. Administer IV solution as
dry skin ordered.
• Syndrome of inappropriate
ADH (SIADH)
• Diuretics
Hypernatremia • Excess sodium Muscle twitching, tremor, Monitor serum sodium lab results.
(serum sodium • Loss of water hyperreflexia, agitation, Limit foods and fluids high in sodium
level >145 mEq/L) • Decreased renal function restlessness, stupor, if ordered. Assess for physical
increased body tempera- manifestations. Monitor I&O.
ture, tachycardia
Potassium
Hypokalemia • Excessive loss of gastric Muscle weakness, para- Teach the client about potassium-
(serum potassium fluids lytic ileus, polyuria, poly- rich foods. Administer oral potassium
level <3.5 mEq/L) • Use of diuretics dipsia, EKG changes, replacement as ordered. Administer
elevated blood glucose IV potassium as ordered. Monitor and
level assess heart rate, rhythm, and EKG
readings. Monitor serum potassium lab
results. Monitor I&O. Assess for physi-
cal manifestations. Encourage foods
and fluids high in potassium if ordered.
Hyperkalemia • Renal disease Anxiety, irritability, Be prepared to administer IV calcium
(serum potassium • Extensive trauma diarrhea, abdominal gluconate. May need to prepare client
level >5.5 mEq/L) • Insulin deficiency cramping, EKG changes, for dialysis and/or the administration of
cardiac arrest Kayexalate. Monitor serum potassium
lab results. Monitor I&O. Assess for
physical manifestations. Monitor and
assess heart rate, rhythm, and EKG
readings.
Calcium
Hypocalcemia • Hypoalbuminemia Anxiety, irritability, Teach the client about calcium-rich
(total serum • Renal failure tetany, abdominal and foods. Monitor serum calcium lab
calcium • Chronic diarrhea muscle cramps, positive results. Monitor I&O. Assess for physi-
<8.5 mg/dL) Chvostek’s sign, positive cal manifestations. Monitor and assess
• Hormonal and electrolyte
Trousseau’s sign, weak heart rate, rhythm, and EKG readings.
influence
heart contractions, Administer oral calcium replacement as
fractures ordered. Encourage foods and fluids
high in calcium if ordered.
Hypercalcemia • Increased use of calcium Depression, signs of heart Monitor serum calcium lab results.
(total serum supplements block, pathological frac- Monitor I&O. Assess for physical
calcium • Renal dysfunction tures, kidney stones manifestations. Monitor and assess
>10.5 mg/dL) • Diuretics heart rate, rhythm, and EKG readings.
• Use of steroids
• Hyperparathyroidism
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Table 10-4 Electrolyte imbalances (Continued)

ElECTrOlyTE
AnD TypE OF
iMBAlAnCE CAuSES OF iMBAlAnCE SignS AnD SyMpTOMS nurSing inTErVEnTiOnS
Magnesium
Hypomagnesemia • Diarrhea, Hyperirritability, Monitor serum magnesium lab
(serum magnesium • Steatorrhea tetany-like symptoms, results. Monitor I&O. Assess for
level <1.6 mEq/L) • Chronic alcoholism increased tendon physical manifestations.
reflexes, hypertension,
• Diabetes mellitus
cardiac dysrhythmias
malnutrition
• Chronic use of laxatives
acute renal failure
• Acute myocardial infarction
Hypermagnesemia • Renal insufficiency Bradycardia, cardiac Monitor serum magnesium lab
(serum magnesium • Laxatives and antacids with arrest, hypotension, results. Monitor I&O. Assess for
level >2.6 mEq/L) magnesium EKG changes, muscle physical manifestations. Monitor
• Severe dehydration weakness, paralysis, and assess heart rate, rhythm, and
CNS depression, confu- EKG readings.
• Diabetic ketoacidosis
sion, flushing
Phosphate
Hypophospha- •
Malnutrition Muscle weakness, Use safety precautions to prevent
temia (serum •
Chronic alcoholism fatigue, tremors, bone falls or injury. Monitor serum phos-
phosphorus level •
TPN administration vomiting pain, seizures, coma, phorus lab results. Monitor I&O.
<3.0 mg/dL) weak pulse, anorexia, Assess for physical manifestations.
•
Chronic diarrhea
bone changes
•
Hyperparathyroidism
•
Burns
•
Diuretics
•
Aluminum-containing
antacids
• Respiratory alkalosis
Hyperphospha- • Chemotherapy Tetany, hyperreflexia, Monitor serum phosphorus lab
temia (serum • Renal insufficiency flaccid paralysis, muscle results. Monitor I&O. Assess for
phosphorus level • Hypoparathyroidism weakness, tachycardia, physical manifestations.
>4.5 mg/dL) abdominal cramps
• Metabolic and respiratory
acidosis
Chloride
Hypochloremia • Prolonged diarrhea or Tremors, twitching, Monitor serum chloride lab results.
(serum chloride diaphoresis hypotension, slow, Monitor I&O. Assess for physical
level <98 mmol/L) • Vomiting shallow breathing manifestations.
• Gastric surgery
• Gastric suctioning
Hyperchloremia • Dehydration Weakness, deep and Monitor serum chloride lab results.
(serum chloride • Hypernatremia rapid breathing, lethargy Monitor I&O. Assess for physical
level >106 mmol/L) • Metabolic acidosis manifestations.
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Hyponatremia
A subnormal serum sodium value indicates hyponatremia.
SAFETy
The cause is either a sodium deficit or a water excess. A hypo-
osmotic state exists: The water moves out of the vascular Potassium Chloride
space, into the interstitial space, and then into the intracellular • Use IV route only when hypokalemia is life
space, causing edema. Hyponatremia may be caused by pro- threatening or when oral replacement is not
longed vomiting, diarrhea, or gastric or intestinal suctioning. feasible.
This can be life threatening. • Always dilute potassium chloride in a large
amount of IV solution.
Hypernatremia • Never administer more than 10 mEq/L of IV
An elevated serum sodium level indicates hypernatremia. potassium chloride (KCl) per hour; the normal
Excess sodium or a loss of water causes a rise in the extracel- dose of IV KCl is 20 to 40 mEq/L infused over an
lular osmotic pressure and pulls water out of the cells and into 8-hour period.
the extracellular space.
• Never give KCl intramuscularly (IM) or as an IV
bolus; potentially fatal hyperkalemia may result.
Potassium • Monitor the IV site frequently for early signs of
Potassium (K1) is the major electrolyte in intracellular fluid. infiltration, because potassium is caustic to the
Its concentration inside cells is approximately 150 mEq/L. tissues.
The normal value range of extracellular (serum) potassium
is narrow: 3.5 to 5.5 mEq/L. Critical values are <2.5 or
>6.5 mEq/L (Daniels, 2010). Consequently, the slightest
changes can dramatically affect physiological functions. Potas-
sium maintains normal nerve and muscle activity, especially of
the heart, and osmotic pressure within the cells. It also assists Calcium
in the cellular metabolism of carbohydrates and proteins. The Calcium (Ca11) plays an essential role in bone and teeth
kidneys prefer to retain sodium and excrete potassium, even integrity, blood clotting, muscle functioning, and nerve
when both electrolytes are depleted. When potassium is lost impulse transmission. Vitamin D is required for absorption
from cells, sodium and hydrogen move into the cells. This aids of calcium from the GI tract. Only 1% of the body’s calcium
in regulating acid–base balance. Intracellular potassium deficit is found in the blood plasma (serum). Normally, 50% of
may coexist with an excess of extracellular potassium. the serum calcium is ionized (physiologically active), with
the remaining 50% being bound to protein. Free, ionized
Hypokalemia calcium is needed for cell membrane permeability. The cal-
A low serum potassium level indicates hypokalemia. Excessive cium that is bound to plasma protein cannot pass through the
loss of gastric fluids and the use of diuretics can place the client capillary wall and, therefore, cannot leave the intravascular
at risk for hypokalemia and an acid–base imbalance (metabolic compartment. Total serum calcium concentration measures
alkalosis). Potassium-wasting diuretics, such as furosemide both the ionized calcium and the calcium bound to albumin.
(Lasix) or chlorothiazide (Diuril), can cause hypokalemia. The normal value range of total serum calcium concentra-
tion for an adult is 8.5 to 10.5 mg/dL. Critical values are <7.0
Hyperkalemia or >12 mg/dL. Values for the older adult are slightly lower
(Daniels, 2010; Daniels & Nicoll, 2012).
An elevated serum potassium level indicates hyperkalemia.
Clients with renal disease develop hyperkalemia because
potassium cannot be excreted adequately by the kidneys. Hypocalcemia
Extensive trauma causes potassium to be released from the Hypocalcemia is indicated by a low serum calcium level. Alka-
cells and enter the bloodstream, leading to hyperkalemia. losis, elevated serum albumin, and the rapid administration of
Hyperkalemia inhibits the action of digitalis. This condition is citrated blood increase the activity of calcium binders, thereby
much more critical than is hypokalemia. decreasing the amount of free calcium.
BestPractice
BestPractice
Hypokalemia
Hypokalemia can cause cardiac arrest when: Serum Calcium
• The potassium level is <2.5 mEq/L. Approximately 50% of serum calcium is bound
• The client is taking digitalis (a drug that to protein. When evaluating laboratory results,
strengthens the contraction of the myocardium correlate the serum calcium level with the serum
and slows down the heart rate). Hypokalemia albumin level. Any change in serum protein will
enhances the action of digitalis, causing toxicity. result in a change in the total serum calcium.
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CLIENT teaching SAFETy

Calcium and Vitamin D Magnesium Level
Vitamin D is necessary for the absorption of calcium When the serum magnesium level reaches
from the GI tract. Clients who do not get adequate 10 to 15 mEq/L, respiratory paralysis may occur.
exposure to the sun or who use sunscreen (which
is needed to prevent skin cancer) may not make
enough vitamin D to support adequate calcium
absorption. Advise these clients to consult their Hypermagnesemia
physicians regarding a vitamin D supplement.
A serum magnesium level of >2.6 mEq/L indicates hyper-
magnesemia (Daniels, 2010). This condition rarely occurs if
kidney function is normal. An increased magnesium level is as-
sociated with uncontrolled diabetes (ketoacidosis), renal fail-
ure, and ingestion of magnesium antacids (Maalox, Mylanta)
Hypercalcemia or laxatives (milk of magnesia, magnesium citrate [Citromal]).
An elevated total serum calcium level indicates hypercal-
cemia. Generally, three separate evaluations of either total
serum calcium or ionized serum calcium are performed before Phosphate
a diagnosis of hypercalcemia is made. Hypercalcemia is often Phosphate (PO42 2) is the main intracellular anion. It appears
a symptom of an underlying disease such as metastatic bone as phosphorus in the serum, where the normal value range is
tumors, Paget’s disease, acromegaly, or hyperparathyroid- 3 to 4.5 mg/dL (Kee et al., 2010). Phosphorus is critical for nor-
ism, all of which increase bone reabsorption and, thereby, mal cell functioning. Most phosphorus is found combined with
foster the release of calcium into circulating blood. Calcium- calcium in teeth and bones. Phosphate and calcium exist in an
containing antacids and excess calcium from the diet may also inverse relationship (i.e., as one increases the other decreases).
cause hypercalcemia.
Hypophosphatemia
Magnesium A client with a low serum phosphorus level has hypophos-
11
Most magnesium (Mg ) is found in intracellular fluid and in phatemia. Rarely does this condition result from decreased
combination with calcium and phosphorus in bone, muscle, dietary intake. More commonly, it stems from respiratory
and soft tissue. Blood serum contains only approximately 1%. alkalosis. Intense, prolonged hyperventilation can cause
Magnesium plays an important role as a coenzyme, in the severe hypophosphatemia.
metabolism of carbohydrates and proteins, and as a mediator,
in neuromuscular activity. It is the only cation that is found in Hyperphosphatemia
higher concentration in cerebrospinal fluid than in extracel- A client with an elevated serum phosphorus level has
lular fluid. When a magnesium deficiency develops, the body hyperphosphatemia. This condition most commonly results
conserves magnesium at the expense of excreting potassium. from renal failure with resultant decreased renal phosphorus
A close relationship exists between magnesium, calcium, and excretion. Excessive use of phosphate-containing laxatives or
potassium in the intracellular fluid: A low level of one results phosphate enemas may cause hyperphosphatemia.
in low levels of the other two. The normal serum magnesium
level for an adult is 1.6 to 2.6 mEq/L (Daniels, 2010).
Chloride
Hypomagnesemia Chloride (Cl2) is the major anion in extracellular fluid.
Chloride functions in combination with sodium to maintain
A serum magnesium level of <1.6 mEq/L indicates hypomag-
osmotic pressure. It also assists in maintaining acid–base bal-
nesemia (Daniels, 2010), which most commonly results from
ance. When the carbon dioxide level increases, bicarbonate
chronic alcoholism. Increased renal excretion is associated with
shifts from the intracellular compartment to the extracellular
prolonged diuretic therapy or use of gentamicin (Garamycin),
cyclosporin (Sandimmune), or cisplatin (Platinol).
BestPractice
BestPractice Hyperphosphatemia
A client with hyperphosphatemia generally
Hyperalimentation remains asymptomatic unless hypocalcemia results,
Total parenteral nutrition (TPN) provided continu- in which case the client may describe both tingling
ously (hyperalimentation) and without a magne- sensations around the mouth and in the fingertips
sium supplement can cause hypomagnesemia. as well as muscle cramps.
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BOX 10-1
HEALTH HISTORy ASSESSMENT
Vomiting QUESTIONS
• What recent illnesses have you experienced?
• What prescription medications are you
A client has been vomiting for 3 days and is unable
currently taking?
to keep anything down. Besides fluid volume defi-
• Do you have any chronic illnesses that affect
cit, what other problems would you expect to find?
the way you breathe? If so, please describe the
illnesses.
• What over-the-counter medications including
compartment. Chloride, in an effort to maintain homeostasis, herbs are you currently taking?
then moves into the intracellular compartment. The kidneys
• Have you recently traveled outside of the
selectively excrete chloride or bicarbonate ions depending on
continental United States? If so, where?
the acid–base balance. The normal serum chloride range is
98 to 106 mmol/L (Daniels, 2010). • What type of work do you do regularly?
• What types of environmental allergies do you
Hypochloremia have?
• Have you been diagnosed with diabetes? If
A low serum chloride level indicates hypochloremia. Excess
so, what are your last several blood glucose
losses of chloride may result from prolonged diarrhea or dia-
phoresis. Loss of hydrochloric acid related to vomiting, gastric readings?
suctioning, or gastric surgery may cause hypochloremia. • Have you or anyone else noticed a difference
in the odor of your breath?
Hyperchloremia • Have you had any recent changes in your
kidney function?
An elevated serum chloride level indicates hyperchloremia,
which usually occurs in conjunction with dehydration, hyper- • What types of respiratory illnesses have you
natremia, or metabolic acidosis. experienced recently?
• Have you experienced any changes in your
appetite recently?
NURSING PROCESS • What types of foods including fruits do you
The nursing process assists the nurse in planning client care. eat on a regular basis?
• Have you noticed any difference in the way
Data Collection your heart feels?
• Have you experienced any unusual muscle
Assessment data are used to identify clients who have poten- weakness or loss of strength?
tial or actual alterations in fluid volume. Electrolyte imbal-
• Have you recently experienced diarrhea,
ances are identified primarily with laboratory data, while fluid
vomiting, headache, or dehydration?
balances are identified primarily with the health history and
physical examination.
Health History Physical Examination

The nursing history should elicit data in the following areas:
Because fluid alterations may affect any body system, the
• Lifestyle (sociocultural and economic factors, stress, exercise) nurse performs a complete physical examination and identi-
• Dietary intake (recent changes in the amount and types of fies all abnormalities.
fluid and food, increased thirst)
• Weight (sudden gain or loss) Daily Weight
• Fluid output (recent changes in the frequency or amount of Changes in the body’s total fluid volume are reflected in body
urine output) weight. For instance, each liter (1,000 mL) of fluid gained or
lost is equivalent to 1 kilogram (2.2 lb) of weight.
• Gastrointestinal disturbances (prolonged vomiting, diar-
rhea, anorexia, ulcer, hemorrhage) Vital Signs
• Fever and diaphoresis The client with an elevated temperature is at risk for dehy-
• Burns, trauma, draining wounds dration related to an increased loss of body fluid. Changes
• Disease conditions that can upset homeostasis (renal disease, in the pulse rate, strength, and rhythm may indicate fluid
endocrine disorders, neural malfunction, pulmonary disease) alterations. Fluid volume changes may cause the following
• Therapeutic programs that can produce imbalances (special pulse changes:
diets, medications, chemotherapy, IV fluid or total parenteral • Deficient Fluid Volume. Increased pulse rate and weak pulse
nutrition [TPN] administration, gastric or intestinal suction) strength.
Box 10-1 lists health history assessment questions to ask a • Excess Fluid Volume. Increased pulse strength and third
client experiencing a fluid and/or electrolyte imbalance. heart sound.
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Inspect chest wall movement, count the respiratory

rate, and auscultate the lungs to assess respiratory changes.
Rate and depth changes may cause respiratory acid–base
imbalances or may indicate a compensatory response to meta-
bolic acidosis or alkalosis.
The degree of fluid volume deficit can be assessed by
blood pressure measurements. Fluid volume deficit can lower
the blood pressure. A narrow pulse pressure (lower than

20 millimeters of mercury [mm Hg]) may indicate severe
hypovolemia (fluid volume deficit).
Intake and Output
The client’s I&O should be measured and recorded for a
24-hour period to assess for an actual or potential imbalance.
A minimum intake of 1,500 mL is essential to balance urinary Figure 10-10 Assessing skin turgor.
output and the body’s insensible water loss. All liquids taken
by mouth (e.g., soup, ice cream, gelatin, juice, and water) and
liquids administered through tube feedings (nasogastric or
jejunostomy) and parenterally (IV fluids and blood or its com-
ponents) are included. Output includes urine, vomitus, diarrhea,
SAFETy
and drainage from tubes such as gastric suction or surgical drains.
Fluid Measurements
Thirst To protect both the nurse and the client from
Thirst is the most common indicator of fluid volume deficit. transfer of microorganisms, Standard Precautions
The hypothalamus triggers a thirst response when there is a are always followed during fluid administration
decrease in extracellular fluid volume or an increase in plasma and output measurement.
osmolality.
Food Intake
Ingested food also helps maintain extracellular fluid volume.
One-third of the body’s fluid needs are met.
position. Increased skin turgor, which occurs in conjunction
Skin with edema, manifests as smooth, taut, shiny skin that cannot
Edema and skin turgor are two important indicators of fluid, be grasped and raised.
electrolyte, and acid–base balances. Buccal (Oral) Cavity
Edema The nurse should inspect the buccal cavity. With fluid volume
The main symptom of fluid volume excess is edema. It may be deficit, saliva decreases, causing sticky, dry mucous mem-
confined to a specific area (localized) or occur throughout the branes and dry, cracked lips. The tongue has longitudinal
body (generalized). The skin is taut, shiny, smooth, and pale in furrows.
localized edema. Assess and palpate edematous areas for color, Eyes
tenderness, and temperature. Firmly press your thumb against
the edematous area or a dependent portion of the client’s The eyes should be inspected for sunkenness, dry conjunc-
body (hands, arms, feet, ankles, legs, or sacrum) for 5 seconds. tiva, and decreased or absent tearing, all signs of fluid volume
Release pressure and observe for indentation on the skin (Estes, deficit. Puffy eyelids (periorbital edema or papilledema) are
2010). Edema is not normally present (Daniels & Nicoll, signs of fluid volume excess. The client may have a history of
2012). Pitting edema is rated on a 4-point scale, as follows: blurred vision.
10: no pitting
11: 0 to ¼-inch pitting (mild) Cr it iCa l t h in k in g
12: ¼ to ½-inch pitting (moderate)
13: ½ to 1-inch pitting (severe)
14: greater than 1-inch pitting (severe) Pitting Edema
Turgor
Skin turgor refers to the normal resiliency of the skin, a reflec- Nursing assessment reveals a client with new-
tion of hydration status. When skin is pinched and released, onset (12) pitting edema of both hands and
it springs back to a normal position because the cells and (14) pitting edema of both ankles. What nurs-
interstitial fluid exert outward pressure. To measure the cli- ing action is warranted for (12) pitting edema?
ent’s skin turgor, use the thumb and forefinger to grasp and What nursing action is warranted for (14) pitting
raise and then release a small section of skin (Figure 10-10).
edema?
Dehydration is the main cause of decreased skin turgor,
which manifests as lax skin that returns slowly to the normal
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88021_ch10_ptg01_197_220.indd 213 12/28/11 5:36 PM
measured in serum osmolality include electrolyte ions

(i.e., sodium and potassium) and electrically inactive sub-
stances (i.e., glucose and urea). Water and sodium are the
main entities controlling the osmolality of body fluids.
Serum sodium is responsible for 90% of the serum osmolal-
ity (Daniels, 2010). The normal range of serum osmolality is
280 to 300 mOsm/Kg (Daniels, 2010). The value increases
with dehydration and decreases with water excess.

In clinical practice, the terms osmolality and osmolarity
(the concentration of solutes per liter of cellular fluid) are of-
ten used interchangeably to refer to the concentration of body
fluid; however, these terms actually have different meanings,
in that osmolality refers to the concentration of solutes in the
total body water rather than in cellular fluid. The appropriate
Figure 10-11 Client position when assessing jugular vein term to use in conjunction with IV fluid therapy is osmolarity.
distention.
Urine Osmolality
Urine osmolality measures the number of solute particles
Jugular and Hand Veins in a defined amount of solution. The particles measured are
Circulatory volume is assessed by measuring venous filling of nitrogenous waste (creatinine, urea, and uric acid), with urea
the jugular and hand veins. With the client in a low Fowler’s being predominant. Urine osmolality varies greatly with diet
position: and fluid intake and reflects the kidney’s ability to concen-
trate urine. The normal range of urine osmolality is 500 to
1. Palpate the jugular (neck) veins. Fluid volume excess 800 mOsm/kg (Daniels, 2010).
causes a distention in the jugular veins (Figure 10-11).
2. Place the client’s hand below heart level and palpate Urine pH
the hand veins. Fluid volume deficit causes decreased The measurement of urine pH reveals the hydrogen ion con-
venous filling (flat hand veins). centration in the urine, indicating the urine’s acidity or alka-
linity. The pH of the urine should be within normal range (4.5
Neuromuscular System to 8.0) when the kidney buffering system is compensating for
Fluid and electrolyte imbalances may cause neuromuscular either metabolic acidosis or alkalosis. This is considered a sign
alterations. The muscles lose tone, becoming soft and flabby, of normal function; however, when the renal compensatory
and reflexes diminish. Calcium and magnesium imbalances function fails to respond to the blood pH, the urine pH will
cause an increase in neuromuscular irritability. To assess for either increase, with acidosis, or decrease, with alkalosis.
neuromuscular irritability, the tests for Chvostek’s sign and
Trousseau’s sign are performed. Other neurological signs of
fluid, electrolyte, and acid–base imbalances include inability
Nursing Diagnosis
to concentrate, confusion, and emotional lability. The North American Nursing Diagnosis Association Inter-
national (NANDA-I, 2009) identifies the primary nursing
Diagnostic and Laboratory Data diagnoses for clients with fluid imbalances as Deficient Fluid
Volume, Excess Fluid Volume, Risk for Deficient Fluid Volume,
Laboratory tests can reveal imbalances before clinical symp- and Risk for Imbalanced Fluid Volume. Numerous secondary
toms are evident in the client; however, unless clients are nursing diagnoses may also apply.
having the tests for some other reason, symptoms are detected
first. Deficient Fluid Volume
Hemoglobin and Hematocrit Indices Deficient Fluid Volume is defined as “decreased intravascular,
The hemoglobin (Hgb) level decreases in the event of severe interstitial, and/or intracellular fluid. This refers to dehydra-
hemorrhage. Hematocrit (Hct) is affected by changes in tion, water loss alone without change in sodium” (NANDA-I,
plasma volume. For instance, with severe dehydration and 2009). The many causes of fluid volume deficit include:
hypovolemic shock, hematocrit increases. Conversely, over-
hydration decreases hematocrit.
Osmolality BestPractice
Osmolality is a measurement of the total concentration of
dissolved particles (solutes) per kilogram of water. Osmolal- Urine Osmolality
ity measurements are performed on both serum and urine Urine osmolality is more accurate than urine
samples to identify changes in fluid and electrolyte balance. specific gravity as an indicator of hydration.
Serum Osmolality Some medications and the presence of glucose
and protein solutes in urine can give a false high
Serum osmolality is a measurement of the total concentration
specific gravity reading.
of dissolved particles per kilogram of water in serum, recorded
in milliosmoles per kilogram (mOsm/kg). The particles
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88021_ch10_ptg01_197_220.indd 214 12/28/11 5:36 PM
• Excessive fluid loss resulting from diaphoresis, vomiting,

diarrhea, hemorrhage, burns, ascites, wound drainage, Table 10-5 Clinical Manifestations
indwelling tubes, or suction of Edema
• Diabetes insipidus
pulMOnAry EDEMA pEripHErAl EDEMA
• Diabetes mellitus
• Addison’s disease (adrenal insufficiency) Cough Pitting edema in extremities
• Gastrointestinal fistula or draining abscess Pink, frothy sputum Edematous area: tight,
• Intestinal obstruction Dyspnea smooth, dry
Cold, clammy skin Shiny, pale, cool skin
Assessment findings in the client with fluid volume defi-
cit include thirst and weight loss of an amount consistent with Engorged neck and hand Puffy eyelids
the degree of dehydration. Marked dehydration manifests as veins Weight gain
dry mucous membranes and skin; poor skin turgor; low- Crackles and wheezes in

grade temperature elevation; tachycardia; respirations of lungs
28 or greater; decreased (10 to 15 mm Hg) systolic blood Tachypnea
pressure; slowed venous filling; decreased urine output (less Tachycardia
than 25 mL/hr); concentrated urine; elevated Hct, Hgb,
and blood urea nitrogen (BUN); and acidic blood pH (less
than 7.4).
Severe dehydration is characterized by the symptoms
of marked dehydration plus a flushing of the skin. Systolic
blood pressure continues to drop (60 mm Hg or below), and intravascular, interstitial, and/or intracellular fluid. This re-
behavioral changes (restlessness, irritability, disorientation, fers to body fluid loss, gain, or both” (NANDA-I, 2009). The
and delirium) occur. The signs of fatal dehydration are anuria greatest risk factor is a client undergoing a major invasive
and coma, leading to death. procedure.
Excess Fluid Volume Other Nursing Diagnoses

Excess Fluid Volume is defined as “increased isotonic fluid In clients with a fluid imbalance, the relationship between the
retention” (NANDA-I, 2009). Fluid volume excess is primary nursing diagnoses previously discussed and the sec-
related to excess fluid in either the tissues or the extremities ondary nursing diagnoses is reciprocal: The primary nursing
(peripheral edema) or the lung tissues (pulmonary edema). diagnoses influence and are influenced by the secondary nurs-
The several causes of excess fluid volume include: ing diagnoses. Some commonly identified secondary nursing
diagnoses include:
• Excessive fluid intake (e.g., IV therapy, sodium)
• Impaired Gas Exchange
• Excessive loss or decreased intake of protein (chronic diar-
rhea, burns, kidney disease, malnutrition) • Decreased Cardiac Output
• Compromised regulatory mechanisms (kidney failure) • Ineffective Breathing Pattern
• Decreased intravascular movement (impaired myocardial • Anxiety
contractility) • Risk for Injury
• Lymphatic obstruction (cancer, surgical removal of lymph • Risk for Infection
nodes, obesity) • Impaired Oral Mucous Membranes
• Medications (steroid excess) • Deficient Knowledge (specify)
• Allergic reactions
The client with fluid volume excess will exhibit acute Planning/Outcome
weight gain; decreased serum osmolality (lower than Identification
275 mOsm/Kg), Hgb, Hct, protein, albumin, and BUN; Holistic nursing care requires collaborating with each client to
increased central venous pressure (greater than 12 to 15 cm identify goals for each nursing diagnosis. These individualized
H2O); and signs and symptoms of edema. The clinical expres- goals should reflect the client’s abilities and limitations.
sions of edema are relative to the area of involvement, either Nursing interventions are selected and prioritized to sup-
pulmonary or peripheral (Table 10-5). port the client’s achievement of expected outcomes based on
the goals. For example, if vomiting and diarrhea along with
Risk for Deficient Fluid Volume dry mucous membranes and a 5% weight loss led to a nursing
Risk for Deficient Fluid Volume is defined as “at risk for ex- diagnosis of Deficient Fluid Volume, the goals might include to
periencing vascular, cellular, or intracellular dehydration” relieve vomiting and diarrhea and achieve the proper balance
(NANDA-I, 2009). The many factors that place a client at risk of intake and output.
for fluid volume deficit were listed previously.
Implementation
Risk for Imbalanced Fluid Volume The nurse has a responsibility to collaborate with and advo-
Risk for Imbalanced Fluid Volume is defined as “at risk for a cate for clients to ensure they receive appropriate and ethical
decrease, increase, or rapid shift from one to the other of care based on practice standards. The data obtained from the
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CONCEPT CARE MAP 10-1 DEFICIENT FLUID VOLUME
NURSING DIAGNOSIS
Deficient Fluid Volume related to inadequate fluid intake
CLIENT GOAL EVALUATION

The client will have adequate fluid Did the client achieve adequate fluid volume
volume and electrolyte balance as and electrolyte balance?
evidenced by urine output > 30 mL/hr.
Did the client have urine output > 30 mL/hr?

1. Encourage client to drink prescribed 1. Clients may need reminded to drink
fluid amounts. especially if they have lost their sense of thirst.
2. Assist client if he is unable to reach 2. This allows for the client to continue intake
for and/or hold drink. of oral fluids.
3. Provide oral mouth care. 3. Mouth care promotes a feeling of freshness
and encourages fluid intake.
4. Administer parenteral fluids as ordered. 4. Parenteral fluid is an effective fluid replacement
that is used to prevent shock and restore
fluid balance.
(Courtesy of JaniCe eilerman, rn, msn, lima, ohio)
history serve as the basis for formulating expected outcomes The nurse is responsible for performing frequent assess-
and selecting nursing interventions appropriate to the client’s ments and monitoring for adverse effects of fluid and elec-
natural patterns as revealed in their history. trolyte therapy to prevent complications. Nursing activities
Interventions related to changes in fluid, electrolyte, related to assessment and implementation often involve the
or acid–base balance are based on the goal of maintaining same measurements (e.g., weight and vital signs). Common
homeostasis and regulating and maintaining essential fluids interventions that promote reaching expected outcomes for
and nutrients. Clients’ adaptive capabilities are kept in mind restoring and maintaining homeostasis are discussed next.
when selecting interventions based on the clients’ perceptions
of their support systems, strengths, and options.
Student Activity
BestPractice
Loss of Gastric Juices
Review the chart of a client who has been
Clients who lose excessive amounts of gastric receiving IV fluids for at least 48 hours for the
juices, either through vomiting or suctioning, are following information: vital signs, subjective and
prone to not only fluid volume deficit but also objective assessment findings, intake and output
metabolic alkalosis, hypokalemia, and hypona- records, lab results, and medications adminis-
tremia. Gastric juices contain hydrochloric acid, tered. What conclusions can you make about the
pepsinogen, potassium, and sodium. client’s fluid, electrolyte, and acid–base balance?
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88021_ch10_ptg01_197_220.indd 216 12/28/11 5:36 PM
Monitor Daily Weight COMMUNITy/HOME HEALTH CARE

One of the main indicators of fluid and electrolyte balance is
weight. The accurate measuring and recording of the client’s Considerations for Measuring I&O
daily weight is a vital responsibility. This information along
with other clinical findings determines fluid therapy require- • Ask for client and family input when selecting
ments for the client. household items for intake measurement.
• Provide containers for measuring output, adapt-
Measure Vital Signs ing the urinary container to home facilities, and
The client’s acuity level and clinical situation determine the teach client and family about proper washing
frequency of vital sign measurement. For example, vital signs and storage of the containers.
are taken every 15 minutes until stable on the typical postop- • Teach proper hand hygiene.
erative client, whereas vital signs should be monitored con- • Provide written instructions on what is to be
tinuously on the client in shock or hemorrhaging. Vital signs measured.
and other clinical data are used to determine the amount and • Leave a sufficient number of I&O forms to last
type of fluid therapy. until the nurse’s next visit.
• Identify the parameters for evaluating a discrep-
Measure Intake and Output ancy between the intake and the output and
Intake and output (I&O) measurements monitor the client’s for notifying the nurse or physician.
fluid status over a 24-hour period. Agency policy for I&O may
vary regarding:
• Times for charting (e.g., every 8 hours versus every
12 hours)
• Time when 24-hour totals are calculated
SAFETy
• Definition of “strict” I&O Remove Gloves before Charting
Review the client’s 24-hour I&O calculations to evaluate To prevent the transfer of microorganisms when
fluid status. Intake should exceed output by 500 mL to offset the I&O form is removed from the client’s room,
insensible fluid loss. Measurements of I&O and daily weight remove gloves and perform hand hygiene before
are critical interventions because they are used to evaluate the recording the amount of drainage on the form.
effectiveness of rehydration or diuretic therapy.
Having an accurate I&O measurement requires the
efforts of the client and family. The client and family must be
taught how to measure and record the I&O.
Nothing by Mouth
Provide Oral Hygiene Clients are designated NPO as prescribed by the physician.
Providing oral hygiene that promotes both client comfort and Based on agency policy and clarification from the physician,
the integrity of the buccal cavity is an important responsibility. the client may be allowed small amounts of ice chips when
The condition of the client’s buccal cavity and the type of fluid designated NPO. The NPO status may be required to:
imbalance dictate the frequency of oral hygiene.
• Avoid aspiration in unconscious, perioperative, and pre-
Initiate Oral Fluid Therapy procedural clients who will receive anesthesia or conscious
sedation.
Depending on the client’s clinical situation, oral fluids may be • Rest and heal the GI tract when there is severe vomiting or
totally restricted, commonly referred to as nothing by mouth diarrhea or a GI disorder (inflammation or obstruction).
(NPO, which is from the Latin non per os), or they may be
restricted or encouraged. • Prevent more loss of gastric juices in clients on nasogastric
suctioning.
Clients who are NPO should receive oral hygiene every
1 to 2 hours or as needed to prevent alterations of the mucous
BestPractice membranes and for comfort.
“Strict” I&O
• “Strict” I&O measurement usually involves BestPractice
accounting for incontinent urine, emesis, and
Mouthwashes
diaphoresis and might require weighing soiled
bed linens. Mouthwashes with alcohol or glycerin and swabs
• Gloves should always be worn when handling with lemon or glycerin may feel refreshing, but
soiled linen. these ingredients dry the mucous membranes.
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Restricted Fluids
Fluid intake is commonly restricted when treating fluid BestPractice
volume excess related to heart and renal failure. Intake may
be restricted to 200 mL in a 24-hour period. Fluid Replacement
The way fluids are limited should be determined in
collaboration with the client. For example: Fluid replacement is based on weight loss.
A 2.2-pound (1-kg) weight loss is equivalent
• Half of the allowed fluid might be divided between breakfast to 1 liter (1,000 mL) of fluid loss.
and lunch.
• The remaining half might be divided between the evening
meal and before bedtime, unless the client must be awak-
ened during the night for medication.
electrolytes, nutrients, or medications by the venous route.
Encourage Fluid Intake The physician prescribes IV therapy to prevent or treat fluid,
Encouraging the intake of oral fluids, mainly water, is some- electrolyte, or nutritional imbalances. There are specific nurs-
times done when treating clients who are at risk for dehy- ing responsibilities during IV therapy. Specifically, the nurse
dration or who have renal and urinary problems (kidney must:
stones). Compliance is obtained through client education • Know why the IV fluid is prescribed.
and honoring client preferences regarding the timing and • Document client understanding.
type of liquids. A client might, for example, be requested
to consume 2,000 mL over a 24-hour period. Explain that • Select, according to agency policy, the appropriate
this is only eight glasses or one glass every 2 hours. Also tell equipment.
the client that ice, gelatin, soups, and ice cream all count as • Obtain the correct prescribed solution.
liquid. • Assess the client for allergies to iodine, tape, ointment, or
antibiotic preparations used for skin preparation of the
Maintain Tube Feeding venipuncture site.
The client who cannot ingest oral fluids but has a normal GI • Administer the fluid at the prescribed rate.
tract can have fluids and nutrients administered through a • Observe for signs of infiltration (seepage of the fluid into
feeding tube as prescribed by a physician. the interstitial tissue as a result of accidental dislodgement
of the needle from the vein) and other complications that
Monitor Intravenous Therapy are fluid specific.
Fluid volume is replaced parenterally when fluid loss is • Document in the client’s medical record the implementa-
severe or the client cannot tolerate oral or tube feedings. tion of the prescribed IV therapy.
intravenous (iV) therapy is the administration of fluids,
Evaluation
Evaluation is an ongoing process. When evaluating whether
BestPractice the time frames and expected outcomes are realistic (such
as whether the intake and output are within 200 to 300 mL
Temperature of Fluids of each other), the focus should be on the client’s responses
Clients should drink room-temperature fluids. Hot such as vital signs within normal limits, the IV infusion rate
or cold fluids may increase peristalsis and abdomi-
maintains the client’s hydration, and the IV site remains free
from erythema, edema, and purulent drainage. The nursing
nal cramping.
care plan should be modified as necessary to support the cli-
ent’s expected outcomes.
SAMplE nurSing CArE plAn
The Client with Excess Fluid Volume

When brought to the emergency department by his granddaughter, R.W., a 68-year-old widower, stated, “I can’t
breathe.” R.W. has a history of hypertension and heart disease, and he is obese. The practitioner ordered a stat chest
x-ray, CBC, and electrolytes, which revealed pulmonary congestion (x-ray), decreased Hct, and decreased Hgb. The
physical assessment results were as follows: Wt 162; TPR 97.6, 98, 30 (labored); BP 186/114; shortness of breath, crack-
les; constant cough; pitting edema (ankles); and engorged neck veins. R.W. stated, “I thought I could stop taking the
heart medication and eat what I wanted when I felt good again.”
NursiNg DiagNosis 1 Excess Fluid Volume related to a compromised regulatory mechanism as evidenced by
edema, shortness of breath, crackles, decreased Hgb and Hct, and jugular vein distention.
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SAMplE nurSing CArE plAn (Continued)

Nursing outcomes Classification (NoC) Nursing interventions Classification (NiC)
Cardiac Pump Effectiveness Fluid Management
Respiratory Status: Ventilation Medication Management
Fluid Balance Fluid Monitoring
R.W. will have a balanced I&O for Measure and document hourly Monitors fluid status.
2 days. I&O; restrict fluids as ordered.
Administer diuretics as ordered Increases excretion of fluids and
and document response. electrolytes.
R.W. will identify a specific amount Weigh daily at the same time, Allows weight to be compared
of weight to lose over the next with the same scale, and with R.W. from one day to another.
6 months. wearing the same clothing.
Discuss with R.W. the need for Allows R.W. to voice his thoughts
weight loss. about weight loss and provides an
avenue to determine number of
pounds to be lost.
R.W. will show normal hydration Measure and document vital Monitors R.W.’s response to
status before discharge. signs every hour until shortness therapy.
of breath subsides, then every
2 hours.
Hourly assess heart sounds; breath Provides information for use in
sounds; rate, rhythm, and depth of modifying the plan of care.
respirations; and the position R.W.
takes to relieve the shortness of
breath.
evaluatioN
Output for the first 3 hours was 2,020 mL; on day 2, I&O indicated fluid balance. R.W. identified the need to lose
30 pounds over the next 6 months. R.W. demonstrated normal hydration status, as shown by normal levels of Hct
and Hgb, BP 156/92, normal breath sounds, and absence of shortness of breath, jugular engorgement, and periph-
eral edema.
NursiNg DiagNosis 2 Deficient Knowledge related to information misinterpretation as evidenced by R.W.’s

statement “I thought I could stop taking the heart medication and eat what I wanted when I felt good again.”
Nursing outcomes Classification (NoC) Nursing interventions Classification (NiC)

Knowledge: Disease Process Teaching: Disease Process
Communication: Receptive Ability Teaching: Prescribed Medication
Memory Medication Management
R.W. will demonstrate an understand- Assess R.W.’s knowledge of hyper- Provides a basis for educating
ing of the causes of fluid excess and tension; decreased cardiac output; R.W. about causes, aggravating
the role of heart medications, foods, digitalis; the effects of a large and alleviating factors, and effects
and exercise in assisting with weight abdominal girth on breathing; of fluid excess.
reduction. and foods low in sodium, fats,
and carbohydrates.
evaluatioN
R.W. was unable to verbalize understanding of how weight, high-sodium diet, and failure to take his heart medica-
tions caused the fluid excess. He was referred to home health for client teaching.
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CONCLUSION balance are addressed. Details of the causes, assessment data,

nursing diagnoses, nursing interventions, and criteria for
The chapter discusses the role of diffusion, osmosis, and filtra- evaluating the effectiveness of nursing care for clients with
tion in the human body. The fluid compartments, the fluids sodium, potassium, calcium, and magnesium imbalances are
contained in them, and the function of those fluids as well as discussed. The principles of nursing management for clients
the way the kidneys work to maintain fluid and electrolyte receiving fluids and electrolytes are reviewed.
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CHAPTER 11
Assessing and Caring
for Clients with Acid–Base
Disturbances
KEY TERMS
acid buffer potential hydrogen (pH)
acidosis carbon dioxide (CO2) respiratory acidosis
alkalosis carbonic acid respiratory alkalosis
arterial blood gas (ABG) metabolic acidosis salt
base metabolic alkalosis
bicarbonate oxygen toxicity
LEARNING OBJECTIVES
2. Discuss the role of acids, bases, salts, and pH.
3. Describe the three important buffer systems that occur in body fluids.
4. Identify clients at risk for developing acid and base imbalances.
5. Review signs and symptoms of acid and base imbalances.
6. Identify common diagnostic tests used for clients with an acid or base imbalance.
7. Describe medical management for clients with an acid or base imbalance.
8. Differentiate the causes, assessment data, and nursing management of respiratory
and metabolic acidosis and alkalosis.
9. Use the nursing process to plan care for a client experiencing an acid–base imbalance.
221
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The hydrochloric acid reacts with the sodium hydroxide

INTRODUCTION to form a molecule of water and a molecule of a salt—sodium
The human body is highly complex and must continually adjust chloride. When salts are placed in water, they dissociate into
to changes in the external environment within which we live. In a cation and an anion. For instance, in water, the sodium
health, normal homeostatic mechanisms function to maintain chloride would dissociate into Na1 and Cl2. One reason
an acid–base balance. In illness, one or more of the regulating salts are of great biologic importance is that many of the
mechanisms may be affected, or an imbalance may become too compounds that dissociate into ions in living cells are salts.
great for the body to correct without treatment. The body must For example, sodium and chlorine ions are present in great
therefore continuously make subtle adjustments to maintain the amounts in body fluids. Many other salts occur in lesser
constancy of the internal environment within a normal range. amounts.
This chapter addresses the assessment and care of a
client with an acid or base imbalance. Chemical substances
important for life including acids, bases, and salts and the role
pH
Acid and bases are classified as either strong or weak by the
of pH are discussed. The three buffer systems (bicarbonate, number of hydrogen ions or hydroxyl ions they produce when
phosphate, and protein) that work to regulate the pH level they dissociate. Strong acids release many hydrogen ions;
are explained in detail. A discussion of each acid and base weak acids release relatively few. The same is true of hydroxyl
imbalance assists the nurse in providing evidence-based nurs- ions in strong and weak bases. The acidity or alkalinity of
ing care and with the ability to evaluate the effectiveness of a a solution is determined by the concentration of hydrogen
care plan. ions in the solution. Potential hydrogen (pH) indicates
the hydrogen ion concentration in a solution, expressed as a
ACIDS, BASES, SALTS, AND pH number from 0 to 14. A solution with a pH of 7 is neutral (i.e.,
it is neither an acid nor a base). A solution with a pH greater
Chemical substances important for life are acids, bases, and than 7 is a base, or alkaline. A solution with a pH less than 7
salts; pH is the measure of acid and base strength. is an acid. The higher above 7 the pH, the more alkaline the
solution; the lower below 7 the pH, the more acidic the solu-
Acids tion. pH is of great biologic importance. The human body can
tolerate only very slight changes in pH. For example, the pH
An acid is any substance that in solution yields hydrogen ions of human blood ranges from 7.35 to 7.45 (Figure 11-1). Blood
bearing a positive charge. As an example, hydrochloric acid pH above or below this range can cause severe or even fatal
(HCl) in water dissociates as shown: physiological problems.
HCl H1 1 Cl2 Although small amounts of acids may enter the body
hydrochloric acid yields hydrogen and chloride through food intake, the greatest source of acids—and
thus H1 ions—is cellular metabolism, resulting in products
The hydrogen ion characterizes this as an acid. Important including lactic acid, phosphoric acid, pyruvic acid, and
acids in the body are hydrochloric acid, produced in the many fatty acids. When blood pH falls below 7.35 as a result
stomach, and carbonic acid, formed when the carbon dioxide of an elevated concentration of H1 ions, acidosis occurs.
released from cells reacts with some of the water in the extra-
cellular fluid (all body fluids except for those contained within
the cells). 14
13
Bases 12
Alkalosis
A base is a substance that when dissociated produces ions 11 (Low H+)
that will combine with hydrogen ions. For example, when
10
sodium hydroxide dissociates in water, it forms a sodium ion
bearing a positive charge and a hydroxyl ion bearing a negative 9
charge as shown following: 8
7.8 Death
1 2
NaOH Na 1 OH
sodium hydroxide yields sodium and hydroxyl 7.35 – 7.45 Normal pH of arterial blood
7.0 Neutral
The hydroxyl ion is capable of combining with a hydro- 6.8 Death
gen ion to form water. Sodium bicarbonate is an example of a 6
base found in the body. 5
4
Salts 3
Acidosis
(High H+)
A salt is formed when an acid and a base react with each other. 2
Salts result from the neutralization of an acid by a base, as
1
illustrated by the following reaction:
0
HCl 1 NaOH H2O 1 NaCl
hydrochloric and sodium yield water and sodium Figure 11-1 The pH of human blood ranges from 7.35
acid hydroxide chloride to 7.45.
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CHAPTER 11 Assessing and Caring for Clients with Acid–Base Disturbances 223
Rarely does blood pH fall to 7 or become acidic because In the body, bicarbonate helps stabilize pH by combining
death will usually occur first. As acidosis increases, the reversibly with hydrogen ions. Most of the body’s bicarbonate
central nervous system (CNS) becomes involved, and the is produced in red blood cells, where the enzyme carbonic
client may become unconscious. The heartbeat may become anhydrase accelerates the conversion of carbon dioxide to
weak and irregular, and blood pressure may decrease or even carbonic acid. The production of bicarbonate is illustrated in
disappear. the following reversible equation:
When blood pH increases above 7.45, alkalosis occurs.
Alkalosis is a condition characterized by an excessive loss of CO2 1 H2O H2CO3 H1 1 HCO32
hydrogen ions. This happens less often than does acidosis. carbon water carbonic hydrogen bicarbonate
Symptoms of alkalosis include a heightened state of nervous dioxide acid
system activity, resulting in spasmodic muscle contractions,
convulsions, and even death. When the hydrogen ion concentration increases in the
extracellular (outside the cell) space, the reaction shifts to-
ward the left. A decreased concentration of hydrogen ions
BUFFERS drives the reaction to the right.
Buffers are substances that attempt to maintain pH range,
or H1 ion concentration, in the presence of added acids or Phosphate Buffer System
bases. Buffers usually occur in pairs in the body fluids. They The phosphate buffer system is involved in regulating the
act to keep the pH of body fluids within normal range. If body pH of intracellular fluid and the fluid of the kidney tubules.
fluids become acidic, buffers in the body fluids combine with It has two phosphate compounds: sodium monohydrogen
the excess hydrogen ions and restore normal pH. Likewise, phosphate (NaHPO4) and sodium dihydrogen phosphate
if the body fluids become alkaline, other buffers in the blood (NaH2PO4). In the presence of a strong acid such as
combine with the strong bases, converting them to weak bases hydrochloric acid, the sodium monohydrogen phosphate
and restoring normal pH. reacts with the acid to form a weak acid (sodium dihydro-
Three important buffer systems occur in body fluids: the gen phosphate) and a salt (sodium chloride), thus raising
bicarbonate buffer system, the phosphate buffer system, and the pH.
the protein buffer system. Because a change in pH of one fluid
may bring corresponding changes in the pH of other fluids, an HCl 1 NaHPO4 NaH2PO4 1 NaCl
interplay between buffer systems acts to maintain the body’s hydro- and sodium yield sodium and sodium
pH. The buffer systems react quickly to prevent excessive chloric monohydrogen dihydrogen chloride
changes in the hydrogen ion concentration. acid phosphate phosphate
When sodium dihydrogen phosphate encounters a strong

Bicarbonate Buffer System base such as sodium hydroxide, a weak base (sodium mono-
The bicarbonate buffer system is found in both the extracel- hydrogen phosphate) and water are formed.
lular and intracellular fluids and is the body’s primary buffer
system. It has two components: carbonic acid (H2CO3) and NaOH 1 NaH2PO4 NaHPO4 1 H2O
sodium bicarbonate (NaHCO3). When a strong acid such as sodium and sodium yield sodium and water
hydrochloric acid is added to this buffer system, the acid will hydroxide dihydrogen monohydrogen
react with the sodium bicarbonate and form a weaker acid phosphate phosphate
(carbonic acid) and a salt (sodium chloride).
HCl 1 NaHCO3 H2CO3 1 NaCl Protein Buffer System
hydrochloric and sodium yield carbonic and sodium Proteins are complex substances formed when amino acids
acid bicarbonate acid chloride bond. Each amino acid contains a carboxyl group (COOH)
The strong acid is converted into a weak acid, and the pH and an amino group (NH2). The carboxyl group can ionize
is raised toward normal. and release hydrogen, thus acting as an acid. The amino group
If a strong base such as sodium hydroxide is added to this can accept hydrogen, thus acting as a base. This ability allows
buffer system, the carbonic acid will react with it to form a proteins to act as a buffer system. The protein buffer system is
weak base (sodium bicarbonate) and water. found inside cells, especially in the hemoglobin of red blood
cells, where the proteins can act to maintain the pH inside the
NaOH 1 H2CO3 NaHCO3 1 H2O cell. They are also found in the plasma.
sodium and carbonic yield sodium and water
hydroxide acid bicarbonate
The strong base, which initially raised the pH, is con-
ACID–BASE BALANCE
verted to a weak base, which will lower the pH toward normal. As described earlier, the body maintains a normal pH within
It is vital to note that hydrochloric acid and sodium hydroxide the relatively narrow range of 7.35 to 7.45. Body pH is main-
are substances that are not normally added to the blood. They tained by the buffer systems, the respiratory system, and the
are used here only as good examples of the way buffers work. kidneys. A pH below 7.35 is termed acidosis, and a pH above
This buffer system normally buffers organic acids found in 7.45 is termed alkalosis. Either of these conditions can be
body fluids. brought about by respiratory or metabolic changes.
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Regulators of Acid–Base BESTPRACTICE

Balance
The body has three main control systems that regulate Pulse Oximeter Reading
acid–base balance to counter acidosis or alkalosis: the buf-
fer systems, respirations, and renal control of hydrogen ion Warming a client’s cold hand will provide more
concentration. These systems vary in their reaction times accurate results from a pulse oximeter.
in regulating and restoring balance to the hydrogen ion
concentration.
Buffer Systems
The bicarbonate, phosphate, and protein buffer systems form in which oxygen is transported through the body. At sea
(discussed earlier) react quickly to prevent excessive changes level, the normal range is 75 to 100 millimeters of mercury
in the hydrogen ion concentration. (mm Hg) (Daniels, 2010). The rate at which the oxygen/
hemoglobin reaction occurs is influenced by pH. The rate
decreases as the pH value decreases.
Respiratory Regulation The PCO2 or PaCO2 in the blood is a reflection of the
of Acid–Base Balance efficiency of gaseous exchange in the lungs. At sea level, the
The respiratory system helps maintain acid–base balance by normal range is 35 to 45 mm Hg. If the alveoli are obstructed
controlling the content of carbon dioxide in extracellular fluid. or damaged by disease, carbon dioxide cannot be eliminated
The rate of metabolism determines the formation of carbon and will combine with water to form carbonic acid, which in
dioxide. Various intracellular metabolic processes continu- turn causes acidosis. Conversely, in a person who is hyperven-
ously form carbon dioxide in the body. The carbon in foods is tilating, too much carbon dioxide is eliminated, which may
oxidized (joined with oxygen) to form carbon dioxide. trigger alkalosis.
It takes the respiratory regulatory mechanism several The SaO2 is the percentage of oxygen that combines with
minutes to respond to changes in the carbon dioxide con- hemoglobin in the blood. The normal range is 95% to 100%
centration of extracellular fluid. With the increase of carbon saturation. This value, along with the PO2 and hemoglobin
dioxide in extracellular fluid, respiration increases in rate and levels, indicates the degree to which the tissues are receiving
depth so that more carbon dioxide is exhaled. As the respira- oxygen. Oxygen saturation can also be measured with a pulse
tory system removes carbon dioxide, less carbon dioxide is oximeter, a noninvasive technique.
present in the blood to combine with water to form carbonic Determining the amount of bicarbonate (HCO3) in the
acid. Likewise, if the blood level of carbon dioxide is low, blood is important because, along with carbonic acid, bicar-
respirations decrease to maintain a normal ratio between carbonate is a major buffer in the blood. The two substances
bonic acid and basic bicarbonate. occur in a ratio of 20 parts bicarbonate to 1 part carbonic acid.
Regardless of the carbonic acid and bicarbonate values, the
pH of the blood will remain in the normal range as long as
Renal Control of Hydrogen the ratio remains 20:1. The normal range for HCO3 at sea
Ion Concentration level is 22 to 26 mEq/L (Daniels, 2010). The carbonic acid
The kidneys control extracellular fluid pH by eliminating either level is always 3% of the PCO2 level.
hydrogen ions or bicarbonate ions from body fluids. If the
bicarbonate concentration in the extracellular fluid is greater
than normal, the kidneys excrete more bicarbonate ions,
Disturbances
making the urine more alkaline. Conversely, if more hydrogen in Acid–Base Balance
ions are excreted in the urine, the urine becomes more acidic. The acid–base imbalances are respiratory acidosis and
The renal mechanism for regulating acid–base balance cannot alkalosis and metabolic acidosis and alkalosis. In determining
readjust the pH within seconds, as can the extracellular fluid whether the acid–base imbalance is caused by a respiratory
buffer system, nor within minutes, as can the respiratory or a metabolic alteration, the key indicators are bicarbonate
compensatory mechanism, but it can function over a period of and carbonic acid levels (Figure 11-2). Table 11-1 lists
several hours or days to correct acid–base imbalance. those changes in laboratory values that indicate the various
acid–base imbalances.
Diagnostic and
Laboratory Data RESPIRATORY ACIDOSIS
The biochemical indicators of acid–base balance are assessed Respiratory acidosis is defined as the retention of carbon
by measuring the arterial blood gases (ABGs). The ABG dioxide (Daniels & Nicoll, 2012). Carbon dioxide (CO2) is
test measures the levels of oxygen and carbon dioxide in arte- a gas that is a waste product of the respiratory system that even-
rial blood. The test assesses pH, partial pressure of oxygen tually decreases the arterial pH level, which is the potential
(PO2 or PaO2), partial pressure of carbon dioxide (PCO2 of hydrogen (Lewis, Dirksen, Heithkemper, Bucher, &
or PaCO2), saturation of oxygen (SaO2), and bicarbonate Camera, 2010). The pH level in the arterial blood ranges
(HCO3). pH has already been discussed. from 7.35 to 7.45. As the CO2 level increases, the pH level
The PO2 or PaO2 expresses the amount of oxygen that decreases because of the chemical reaction occurring at the
can combine with hemoglobin to form oxyhemoglobin, the cellular level. The chemical reaction occurs as the CO2 com-
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Related to Respiratory Function Related to Metabolism in the Body Respiratory acidosis occurs when there is an abnormal
accumulation of CO2. Clients that have disease processes
Balance that compromise the respiratory system are at greater risk
for respiratory acidosis. Infants and elderly clients are at risk
for respiratory acidosis because of alterations experienced
in the rate and depth of respirations. Infants may have im-
H2CO3 HCO3– mature lungs which slow the response that compensates for
(Acid) (Bicarbonate)
the buildup of carbon dioxide. In the older adult, the slowing
of body function creates an inability to compensate for the
Imbalance acid–base imbalance. In addition to these age groups, clients
Respiratory acidosis Metabolic acidosis who undergo surgery requiring general anesthesia and clients
taking narcotics that depress the central nervous system are
also at risk for respiratory acidosis.
The causes of respiratory acidosis are a decrease in the
rate and depth of respirations (Box 11-1). As the CO2 level
Excess Deficit rises above 45 mm Hg, the balance between carbonic acid or
H2CO3 HCO3– H2CO3 and bicarbonate or HCO32 is affected. Bicarbonate
(Acid) (Bicarbonate) is a carbonic acid anion in which only one of the H1 ions is
pH pH removed (Mosby’s Dictionary, 2009). To maintain homeosta-
PaCO2 HCO3
Serum CO2 sis between acid and base, the human body has a ratio of 1
part carbonic acid to 20 parts of bicarbonate. If this balance is
Respiratory alkalosis Metabolic alkalosis disrupted by the accumulation of CO2, the H2CO3 begins to
BOX 11-1
CAUSES OF RESPIRATORY ACIDOSIS
Deficit Excess
H2CO3 HCO3–
(Acid) (Bicarbonate) • Chronic obstructive pulmonary disease (COPD)
pH pH • Narcotic overdose
PaCO2 HCO3– • General anesthesia
Serum CO2
• Hypoventilation
• Acute airway obstruction
Figure 11-2 Acid–base balance and imbalance.
• Pulmonary emboli
• Atelectasis
• Diaphragmatic muscle weakness
Table 11-1 Laboratory Values
• Sleep apnea
in Acid–Base Imbalances • Pulmonary edema
SITUATION pH PCO2 HCO3 • Hypercapnia
• Hypoxia
Normal 7.35 to 35 to 22 to • Acute brain injuries
parameters 7.45 45 mm Hg 26 mEq/L • Pneumothorax
Respiratory
acidosis
Acute <7.35 >45 mm Hg Normal
Chronic <7.35 >45 mm Hg >26 mEq/L LIFE SPAn COnSIDERATIOnS
Respiratory >7.45 <35 mm Hg Normal
alkalosis Risk for Respiratory Acidosis
Metabolic <7.35 Normal <22 mEq/L Older adults are at greater risk for development
acidosis
of respiratory acidosis because of the increased
Metabolic >7.45 Normal >26 mEq/L incidence of chronic lung diseases such as COPD.
alkalosis As the population increases in age, the incidence
of complications related to chronic illnesses also
increases. Older adults are at risk for respiratory
bines with H2O creating carbonic acid or H2CO3, which is distress or respiratory failure because of the
a weak acid. increase in age-related or seasonal illnesses, such
Formula: CO2 1 H2O 5 H2CO3 as pneumonia or influenza. This increases their
chances of developing the complication of respira-
As more H2CO3 is created, the balance between the acid
tory acidosis.
and base is disrupted. The body begins to become acidic.
Consequently, the arterial blood has a pH level of less than 7.35.
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Table 11-2 Common Diagnostic

COLLABORATIVECARE Tests for Respiratory Acidosis
DIAGNOSTIC exPeCTeD
Respiratory Acidosis TeST ReSULTS PURPOSe OF TeST
Collaborative care is important to effectively treat ABGs pH <7.35 Provides data to
a client diagnosed with respiratory acidosis. The diagnose respiratory
PaCO2
physician and nurse must work closely together to >45 mm Hg acidosis.
ensure that the client receives appropriate care. It is
HCO3:
necessary for the physician and nurse to communicate
Acute:
effectively and exchange assessment data so that the
22–26 mEq/L
cause of the respiratory acidosis is quickly identified.
Chronic:
When the cause is clearly diagnosed, the appropriate
>26 mEq/L
treatment and interventions are implemented by the
PaO2 < or 5
health care team.
80–100%
Potassium >5 mEq/L A late sign and

level symptom is
increase. The imbalance between the carbonic acid and bicar- hyperkalemia due to
bonate ratio causes the pH to decrease. The decrease in pH be- potassium shifting to
low 7.35 is a direct result of the human body developing more the extracellular fluid.
carbonic acid than is needed to maintain acid–base balance.
Respiratory acidosis manifestations are generally the same Chest x-ray Infiltrates Pulmonary edema
for any age group. The most evident symptom is the change in inhibits the ability of
the rate (slowed) and depth (more shallow) of respirations, the lung to exhale
which leads to hypoventilation. As the hypoventilation pro- adequately; therefore,
gresses, hypoxia occurs causing cyanosis to appear around the

CO2 level increases.
lips, finger tips, nail beds, and mucous membranes. As hyper-
capnia becomes more apparent, the client begins to experience Tissue perfu- <95% Hypercapnia
acute disorientation and confusion. In addition, the client may sion (SpO2) prevents adequate
complain of a headache, asterixis, apprehension, restlessness, pulse oximetry tissue perfusion.
and visual disturbances. As this imbalance progresses, hypo-
tension, cardiac arrhythmias, hyperkalemia, and diaphoresis
may occur. Medical and nursing interventions are necessary to the blood pH is above normal, is increased (Ignatavicius &
prevent the complication of a coma. Workman, 2010).
Once the cause of the respiratory acidosis has been
determined, the physician orders specific diagnostic labora-
tory tests. Table 11-2 lists the common diagnostic tests used
Medical-Surgical
in respiratory acidosis. The physician orders ABG testing for Management
acid–base imbalances. ABGs provide the health care team Medical
with the client’s pH, PaCO2, HCO32, PaO2, and base excess
results. Box 11-2 explains the nurse’s role in assisting with the The physician bases medical treatments on the etiology, signs
collection of an ABG. and symptoms experienced by the client, and assessment data
Depending on the etiology of the respiratory acidosis, the collected. The priorities are to maintain a patent airway and
physician may order a potassium level. Potassium increases assess the respiratory status, cardiac function, and vital signs.
with respiratory acidosis due to the buffer system (see the If the client is experiencing difficulty with any of the prior-
discussion of buffer systems earlier in this chapter). A chest ity systems of function (airway, breathing, circulation), then
x-ray is ordered to determine if infiltrates and congestion are treatments such as artificial ventilation and hemodynamic
present in the lung fields, which can induce respiratory aci- monitoring are implemented to maintain adequate function
dosis. Knowing the SpO2 level assists the health care team in of the respiratory and cardiac systems.
determining early signs of hypoxia. The physician may order bilevel positive airway pressure
Respiratory acidosis can create a number of complica- (BiPap) to assist in eliminating excess carbon dioxide. BiPap
tions. One such complication is hyperkalemia. Hyperkale- assists in supporting inspiration and expiration by providing
mia can be the catalyst to cardiac arrhythmias. The most higher airway pressure along with oxygen which helps the cli-
severe complication can be respiratory failure, which can ent reduce the carbon dioxide level and increase the oxygen
be a precursor to death. While the client is being treated level (Lewis et al., 2011).
for respiratory acidosis, it is important for the nurse to
monitor for the increased risk of alkalosis. If the prescribed Diet
pharmacological orders and interventions are implemented Before the physician alters the client’s diet, results of the
and the acidosis, where the blood pH is below normal, is potassium level test are needed. Initially, the client experi-
overcorrected, then the client’s risk for alkalosis, where ences hyperkalemia; therefore, it is necessary for the nurse to
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BOX 11-2
nURSE’S ROLE In ASSISTInG WITH THE COLLECTIOn OF An ARTERIAL BLOOD GAS
nurse’s Role in Preparation for ABG Collection
1. Review orders, and if necessary contact the physician for an order.
2. Explain the procedure to the client.
3. Discontinue any supplemental oxygen at least 15 to 30 minutes prior to the collection of the specimen, unless
contraindicated such as when the client is on a ventilator.
4. Contact the department responsible for collecting the specimen (such as the phlebotomy lab or respiratory
department) and provide a brief report if requested.
5. Collect and organize supplies: alcohol pads, 2 3 2 sterile dressings, Quik ABG syringes or supplies that the
facility provides, tape (paper or plastic), Band-Aid, clean gloves.
nurse’s Role during the Collection of the Arterial Blood Gas

1. Identify the client using two client identifiers.
2. Perform hand hygiene and don clean gloves.
3. Monitor the client’s comfort level and provide calming measures as needed.
4. Provide assistance to the person collecting the specimen.
5. Maintain sterile technique.
nurse’s Role after Arterial Blood Gas Collection

1. Maintain sterile technique when opening the 2 3 2 sterile dressing.
2. Apply direct pressure to the puncture site for 10 to 15 minutes (or longer if client is on an anticoagulant
medication).
3. Monitor comfort and provide calming measures if needed.
4. Review results.
5. Call the physician with the results.
6. Obtain and write any orders received from the physician.
7. Implement orders.
8. Assess puncture site for bleeding, swelling, and bruising.
monitor the client’s dietary selections to ensure the ingestion

of potassium-rich foods is minimized. As respiratory acidosis SAFETY
is resolved, the client’s potassium level may decrease because
of the shift from the extracellular space to the intracellular Activity Precautions
space (Lewis et al., 2011). Consequently, the nurse and
physician need to monitor the potassium level throughout During an acute episode of respiratory acidosis, it
treatment and increase or reduce the dietary intake of potas- is recommended that the client remain in bed or
sium as needed. seated in a chair as a safety precaution because of
the fatigue and respiratory difficulty being expe-
Pharmacological rienced. After the acute phase has been resolved,
Intravenous bicarbonate may be prescribed to increase the the client increases activity level as tolerated while
pH level, thereby reducing the acidic level and improving the maintaining safety. Safety is a top priority during
balance between acid and base. Depending on the results of the acute and recovery phase.
potassium, the physician may order a potassium supplement
to help increase the potassium level; thus, reducing hydrogen
and increasing pH.
Activity
To maintain adequate ventilation, it may be necessary to place NURSING PROCESS
the client in a semi- to high-Fowler’s position. The client is
instructed to assume a position of comfort that promotes ad- The nursing process enables the nurse and the health care
equate respiratory function. team to implement interventions appropriate for the existing
problem(s). Once the data have been collected, the nurse
organizes and reviews it to determine appropriate nursing
Nursing Management diagnoses. The nurse works together with the health care
The management of the client’s respiratory acidosis by the team and client to establish an individual and realistic plan
nurse is important to the client’s recovery. of care.
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Data Collection
As the nurse begins the process of collecting assessment data,
the client’s medical record is researched and information is
collected from client interviews. It is through the collection
of this subjective and objective data that the nurse is able to
formulate a realistic and individualized plan of care.
Subjective Data
The nurse asks appropriate questions to ascertain subjective
data from the client. The nurse collects a history about the

signs and symptoms the client has been experiencing such
as headache, weakness or fatigue, and abnormal periods of
drowsiness. Information about recent illnesses and any cur-
rent or past respiratory illnesses assists the health care team to
develop an effective care plan. In addition, a current medica-
tion inventory provides essential data about other medical
conditions the client may not realize could cause respiratory Figure 11-3 The respiratory system is assessed for
acidosis. Questions that assist the nurse in collecting subjec- ventilatory changes.
tive data related to respiratory acidosis are listed in Box 11-3.
for CNS disturbances such as tremors, numbness, tingling,
Objective Data confusion, fatigue, and weakness. The respiratory system
The nurse collects objective data during the physical exami- is assessed for the presence of ventilatory changes such as
nation of the client. The physical examination centers on the hypoventilation, decrease in rate and depth of respirations,
respiratory system and any other system that may cause or be presence of crackles, and shortness of breath (Figure 11-3).
affected by the acidosis. Neurologically the client is assessed The cardiac system is assessed to ascertain data that are
contributing to the respiratory acidosis or could be a direct
result of the respiratory acidosis. Such assessment data include
cardiac arrhythmias, bradycardia, peripheral pulse irregulari-
BOX 11-3 ties, or hypotension. It is necessary to assess extremity strength
DATA COLLECTIOn: SUBJECTIVE and coordination because the extremities may be affected by
DATA AnD CLIEnT InTERVIEW neurological disturbances such as asterixis. Diagnostic labora-
FOR RESPIRATORY ACIDOSIS tory results are also important for the nurse to review. Some of
the important laboratory results are ABGs, electrolyte panels,
• Describe the difficulties you are experiencing hemoglobin and hematocrit levels, and osmolarity/osmolality
with your breathing. values. Objective data to collect are described in Box 11-4.
• What differences have you noticed in your
breathing pattern? BOX 11-4
• Does activity, like walking, aggravate your
DATA COLLECTIOn: OBJECTIVE DATA
breathing problems?
AnD CLIEnT ASSESSMEnT FOR
• Have you experienced these breathing prob-
RESPIRATORY ACIDOSIS
lems in the past?
• What have you done to help alleviate the • Assess alertness by determining state of arousal
breathing difficulties? • Assess orientation by asking name? Place?
• What types of respiratory illnesses have you Time/date?
experienced recently? • Respiratory rate and quality of the respiratory
• What medications or inhalers do you currently status
take that are prescribed by a physician? • Lung sounds
• What over-the-counter medications do you • Apical pulse rate and quality
take routinely and what are the reasons for • Pulse oximetry
taking the medications? • Peripheral pulse rate and quality
• Do you use illegal substances and, if so, what • Blood pressure
substances do you use and how often? • Capillary refill
• Have you or anyone else noticed a difference • Skin or mucous membrane color
in the odor of your breath? • Arm drift
• What types of surgeries have you had • Arm and leg strength and coordination
recently? • Pedal push and pull
• Have you experienced any visual disturbances • ABGs: pH, PaO2, PaCO2, HCO32, base excess
such as blurred vision? • Potassium levels
• Do you ever feel lightheaded or dizzy upon • Hemoglobin and hematocrit
standing? • Osmolarity/osmolality values
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Nursing diagnoses for a client in respiratory acidosis include the following:

NURSING PLANNING/ NURSING
DIAGNOSeS OUTCOmeS INTeRVeNTIONS RATIONALe
Ineffective Breathing Client will maintain a Assess respiratory rate and Ensures breathing pattern is
Pattern related to respiratory rate between depth every 4 hrs and prn. effective.
decreased chest 12 and 20 breaths/min. Auscultate lung sounds every Ensures lung fields are clear.
expansion 4 hrs and prn.
Administer appropriate Certain medications promote
medications as ordered by the respiratory effectiveness by
physician. dilating the bronchi and en-
hancing the effectiveness of
the respiratory system.
Elevate head of the bed to a Promotes lung expansion and
semi- or high-Fowler’s position. diaphragmatic excursion, en-
abling the client to restore an
effective breathing pattern.
Assess ability to perform activi- Provides essential data to
ties of daily living (ADLs) without determine if the client is able
shortness of breath. to function without assistance
and maintain an effective
breathing pattern during in-
creased activity.
Deficient Knowledge Client will demonstrate Assess understanding about Provides information about
related to cognitive an increase in under- respiratory acidosis. the client’s knowledge of the
limitation standing of the signs and medical diagnosis, which as-
symptoms of respiratory sists the nurse in teaching.
acidosis. Consult respiratory therapy to Involving other disciplines
assist with teaching about respi- from the health care team
ratory acidosis. promotes effective planning,
and provides assistance with
accurate teaching.
Teach signs and symptoms of Ensures that the client is
respiratory acidosis. equipped to recognize them
and respond appropriately.
Teach the client about the treat- Educating the client about the
ment regimen for respiratory specific details of the treat-
acidosis. ment regimen allows the cli-
ent to understand the plan to
ensure compliance.
Impaired Gas Exchange Client’s capillary refill will Assess respiratory rate and Ensure client’s breathing pat-
related to reduced be less than 3 sec. depth every 4 hrs and prn. tern is effective.
airflow Assess lung sounds every 4 hrs Ensures lung fields are clear.
and prn.
Assess skin color every 4 hrs Skin color is affected by the
and prn. ability of the respiratory sys-
tem to promote effective gas
exchange between CO2 and
O2. The lack of O2 results in
cyanosis.
Elevate the head of the bed a Ensures proper lung expan-
minimum of 35 to 45 degrees sion to promote the effective
during periods of respiratory exchange of gases.
difficulty.
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RESPIRATORY ALKALOSIS BOX 11-5

Respiratory alkalosis is the depletion of CO2 resulting in COMMOn CAUSES OF RESPIRATORY
the increase of pH above 7.45 (Smeltzer, Bare, Hinkle, & ALKALOSIS
Cheever, 2010). As the normal level of CO2 declines, the • Hyperventilation
amount of carbonic acid being synthesized is decreased. • Anxiety
Therefore, as the CO2 level drops, the body’s ability to main-
• Stress (fever, pain)
tain homeostasis between carbonic acid and bicarbonate
becomes more difficult. It is the decrease of CO2 from the • Phobias
malfunctioning respiratory system that causes the reduc- • Fear
tion of carbonic acid, thus altering the normal ratio of 1:20 • Salicylate (ASA) overdose
between carbonic acid and bicarbonate. • Mechanical ventilation
When there is an event that causes hyperventilation to • Oxygen toxicity
occur, the incidence of respiratory alkalosis increases. As life
events become stressful, the increased risk for a client to hy-
perventilate increases; thus reducing the amount of retained
CO2. Individuals with psychological disorders can also experi- as hypokalemia and hypocalcemia can occur as this condition
ence episodes of respiratory alkalosis especially during exacer- worsens. If respiratory alkalosis is left untreated, the client
bation of those disorders. Clients who receive supplemental becomes comatose or death occurs.
oxygen via respiratory masks or ventilators are also at risk of The physician orders ABGs that provide the health care
respiratory alkalosis. team with data to confirm the diagnosis of respiratory alka-
Hyperventilation is the major cause of respiratory alkalo- losis. Chest x-rays provide visual images of the lung fields to
sis. As the respiratory rate increases, the depletion of carbon determine if any respiratory conditions are inhibiting the re-
dioxide occurs causing a decrease in carbonic acid produc- covery from respiratory alkalosis. Potassium and calcium lev-
tion. Causes of hyperventilation include anxiety, stress, panic els need to be closely monitored. Respiratory alkalosis leads to
attacks, hysteria, and fear, which can also induce respiratory the decrease in potassium and calcium that can be a catalyst to
alkalosis. When clients receive mechanical ventilation, it is other signs and symptoms such as skeletal muscle weakness,
important to monitor the settings on the ventilator to ensure cardiac arrhythmias, twitching, tetany, and decreased bone
that oxygen toxicity (oxygen delivered continuously over density. Table 11-3 lists common diagnostic tests for respira-
a 24-hour period at levels greater than 50%) does not occur tory alkalosis.
(Ignatavicius & Workman, 2010). Oxygen toxicity is another
cause of respiratory alkalosis. Box 11-5 lists the common
causes of respiratory alkalosis.
Medical-Surgical
The client experiencing respiratory alkalosis initially Management
presents with rapid shallow respirations, air hunger, and
anxiety. The client has difficulty maintaining a normal breath- Medical
ing pattern resulting in light-headedness, dizziness, numbness, Medical interventions are implemented to ensure that the
and tingling. As the respiratory alkalosis progresses and client receives effective treatment for respiratory alkalosis.
the rapid shallow respirations continue, the client has diffi- Treatment of respiratory alkalosis is based on the cause and
culty concentrating, muscle twitching, and beginning tetany; the severity of the respiratory difficulties. It may be necessary
convulsions follow. In addition, electrolyte imbalances such to use mechanical ventilation to increase the effectiveness
of the client’s respiratory system (Figure 11-4). Rebreather
masks enable the client to reabsorb CO2 and gradually
decrease the pH.
CLIEnT TEAChIng
Respiratory Acidosis
Educate the client and the family about the signs
and symptoms, risks factors, treatment regimens,
and complications of respiratory acidosis. When
the client and family members are aware of the
important aspects of respiratory acidosis, they are
more compliant with treatment and seek treat-
ment more quickly to ensure a better outcome.
Proper identification of the etiologies that sur-

round respiratory acidosis assist the client in
preventing an exacerbation of the acid–base
imbalance, and possibly assist in the collection of
subjective and objective data to promote a more
effective medical and nursing care plan.
Figure 11-4 Mechanical ventilation may be necessary for
clients experiencing respiratory alkalosis.
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COnCEPT MAP 11-1 RESPIRATORY ACIDOSIS
SIGNS and SYMPTOMS

Hypotension
Heart block
Prolonged PR interval
Tachycardia
Weak thready pulse
Warm flushed skin
Rapid shallow respirations
Papilledema
Elevated ICP
Headache
Drowsiness
Altered mental status ABG VALUES
Seizures pH <7.35
PaCO2 >45 mm Hg
Coma
RESPIRATORY ACIDOSIS
NURSING DIAGNOSIS
Ineffective Airway Clearance
Ineffective Breathing Pattern
Impaired Gas Exchange
PHYSIOLOGICAL
ARDS
Asthma
Atelectasis
PHYSICAL
Bronchitis PHARMACOLOGICAL
Paralysis
COPD Overdose
PSYCHOLOGICAL Chest Trauma
Emphysema Barbituates
Anxiety Blunt force
Hemothorax Benzodiazepines
Fear Crush injury
Pulmonary emboli Sedatives
Penetrating wounds
Pneumonia
Severe cough
Pneumothorax
(Courtesy of leon Klopfenstein anD eriC mason: lima, ohio)
Diet the critical symptoms that can accompany hypokalemia and

hypocalcemia (Smeltzer et al., 2010).
Results from the electrolyte panel determine if any changes to
the current diet order are needed. With respiratory alkalosis,
hypokalemia and hypocalcemia can manifest. Depending on Pharmacological
the evaluation of the potassium and calcium levels by the Antianxiety medications are often prescribed for clients di-
physician, an order to increase dietary intake of these two agnosed with respiratory alkalosis to help them relax. Other
electrolytes may decrease respiratory alkalosis because of classifications of medications prescribed to reduce anxiety
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Table 11-3 Common Diagnostic MEnTAL HEALTH

Tests for Respiratory Alkalosis COnnECTIOns
DIAGNOSTIC exPeCTeD Anxiety
TeST ReSULTS PURPOSe OF TeST Respiratory alkalosis is complicated by an
increase in the client’s anxiety and stress level.
ABGs pH >7.45 Provides data to
It is important to teach inexperienced nurses
PaCO2 diagnose respiratory
alkalosis. that clients must be given the autonomy to
<35 mm Hg
choose the position of comfort. The nurse
HCO32 < or 5
should accommodate reasonable requests from
22–26 mEq/L
the c lient to enhance adequate ventilation.
PaO2 80–100%
Novice nurses need to be reminded that the
Chest x-ray Clear, no Determines if any position of comfort for each client may be
infiltrates other respiratory different depending on the severity of the
condition exists respiratory alkalosis. When a client finds a
that may inhibit position of comfort, it may help to decrease
recovery. the anxiety level the client is experiencing.
CT scan No lung, Provides data about
kidney, or bone the ability of the
abnormalities buffer systems to the client increases activity as tolerated. Because of the anxiety
assist in regulat- and hyperventilation experienced by the client, the positions
ing the acid–base of laying flat and semi-Fowler’s may not be tolerated (Smelt-
imbalance. Assists zer et al., 2010). The position of comfort for the client is the
in observing for rule the nurse should follow during the acute phase of this
bone density and condition (Ignatavicius & Workman, 2010). As treatments
abnormalities from are implemented and the pH level begins to decrease, the cli-
hypocalcemia. ent is more likely to tolerate supine or prone positions.
Some complications of respiratory alkalosis result from
Potassium <3.5 mEq/L To diagnose electrolyte imbalances. Common complications resulting
level hypokalemia from hypokalemia and hypocalcemia are cardiac arrhyth-
and treat any mias, decreased deep tendon reflexes, tetany, convulsions or
potential cardiac seizures, confusion, cardiac arrest, and lethargy. Therefore,
or musculoskeletal it is essential for the nurse to monitor and review laboratory
problems. results. Other complications may result from overcorrecting
the alkalosis and decreasing the pH below 7.35, resulting
Calcium Total Ca11 Provides data to

level assist in diagnosing
in respiratory acidosis. The nurse monitors for signs and
<8.5 mg/dL
hypocalcemia and
symptoms of acidosis throughout the treatment of respiratory
Ionized Ca11 alkalosis. If the nurse suspects acidosis, contact the physician
<4 mg/dL avoid tetany.
and report the data that support the conclusion.
Nursing Management
and stress are hypnotics, sedatives, and centrally acting skel- Monitoring the ABGs, electrolytes, and the respiratory status
etal muscle relaxants. Pharmacological agents help depress are priorities of care for a client diagnosed with respiratory
the respiratory rate to decrease the amount of carbon dioxide alkalosis. It is important for the nurse to monitor the client’s
being exhaled by the client, thus reducing respiratory alka- respiratory status and maintain support for the client’s airway
losis. Table 11-4 lists commonly prescribed medications for and breathing pattern. Any data collected that support the
respiratory alkalosis. diagnosis or indicate the condition is worsening is reported
The nurse needs to be prepared to administer medica- to the physician immediately. The nurse monitors the client
tions that supplement the loss of the potassium and calcium. for signs of recovery from respiratory alkalosis and provides
The physician prescribes potassium chloride either orally or a report to the health care team on the client’s progress. The
intravenously depending on the severity of the hypokalemia. nurse must be alert to and able to recognize signs and symp-
A calcium supplement may also be ordered to ensure that the toms of overcorrection of the condition resulting in respira-
client experiencing respiratory alkalosis does not experience tory acidosis.
complications related to hypocalcemia.
Activity NURSING PROCESS

During an acute episode of respiratory alkalosis, clients have When nurses care for clients diagnosed with respiratory alka-
difficulty ambulating and exerting energy for ADLs. As treat- losis, it is necessary for the plan of care to restore and monitor
ment is implemented and the respiratory alkalosis is resolved, acid–base balance.
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Table 11-4 Commonly Prescribed medications for Respiratory Alkalosis

CLASSIFICATION
GeNeRIC (TRADe) ACTION NURSING INTeRVeNTIONS
Antianxiety
lorazepam (Ativan) Depresses the CNS by acting on the Assess for drowsiness and sedation. Assist client if
alprazolam (Xanax) limbic, thalamic, and hypothalamic ambulating or transferring. Keep side rails up and
areas. call light in reach. Monitor for allergic reaction.
Benzodiazepines/Sedatives/Hypnotics
zolpidem tartrate (Ambien) Inhibits the neurotransmitter GABA Monitor for improvement in sleeping habits. Assess
temazepam (Restoril) by acting on the limbic, thalamic, for daytime CNS depression. Maintain safety pre-
triazolam (Halcion) and hypothalamic levels. cautions after administering.
estazolam (ProSom)
Centrally Acting Skeletal Muscle Relaxants

diazepam (Valium) Stimulates the GABA receptors, Provide safety precautions such as assistance with
baclofen (Lioresal) which decreases the alpha-motor ambulation, call light within reach, side rails up, bed
quinine sulfate neurons. in low position and wheels locked. Observe closely
for adverse reactions and side effects: confusion,
dantrolene (Dantrium)
hallucinations, and depression.

Electrolyte Supplements
calcium plus vitamin D Cations that help cardiac, Monitor electrolyte blood tests. Assess
potassium chloride musculoskeletal, and kidney apical pulse for irregularities. Monitor for bone frac-
(K-Dur) function. tions (pathological). Monitor bleeding times.
Data Collection BOX 11-6

Subjective data and objective data provide the nurse and DATA COLLECTIOn: SUBJECTIVE
other health care team members with information needed to DATA AnD CLIEnT InTERVIEW
develop a plan and implement interventions for the client in FOR RESPIRATORY ALKALOSIS
respiratory alkalosis.
• What is your chief complaint?
Subjective Data • What recent illnesses have you experienced?
• What medications are you currently taking?
The nurse collects a detailed health history to assess for infor-
mation related to respiratory alkalosis. The health history is uti- • Do you have any chronic illnesses that affect
lized by the health care team as the care plan is developed. The the way you breathe? If so, please describe
most common subjective data the nurse expects to collect from the illnesses?
the client are respiratory difficulties related to hyperventilation. • What over-the-counter medications are you
In addition to respiratory problems, the client often de- currently taking?
scribes feelings of anxiety, stress, fears, nervousness, and panic • Have you recently traveled outside of the
attacks. It is important to allow the client to explore personal continental United States? If so, where?
feelings and concerns because the nurse and the health care • What phobias do you have?
team may be able to identify possible causes of the respiratory • What type of work do you do regularly?
alkalosis. Box 11-6 lists sample questions to ask during the • What types of environmental allergies do you
health history.
have?
Objective Data
The physical assessment by the nurse is important to identify develop an appropriate and effective care plan and treatment
the severity of the respiratory alkalosis. The physical assess- regimen. Box 11-7 provides a list of observable data to collect
ment assists the nurse and other health care team members to from a client with respiratory alkalosis.
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Nursing diagnoses for a client in respiratory alkalosis include the following:

Ineffective Breathing Pat- The client will maintain Place client in a semi- to Ensures proper lung expan-
tern related to anxiety respiratory rate, rhythm, high-Fowler’s position. sion to promote the effective
and depth within normal exchange of gases.
limits. Assess the rate, rhythm, and Ensures that the client’s
depth of respirations every breathing pattern is effective.
4 hrs and prn.
Encourage slow, deep Slow deep breathing in-
breathing. creases CO2 and assists in
decreasing the pH.
Administer supplemental O2 as A rebreather mask de-
ordered (e.g., 10 liters through creases the amount of CO2
a rebreather mask). being exhaled.
Ineffective Peripheral The client will maintain Assess pulse oximetry every Adequate tissue perfusion
Tissue Perfusion related pulse oximetry reading 4 hrs and prn. provides evidence that O2
to increased cardiac between 95% and 100%. and CO2 are balanced.
workload Assess vital signs (apical pulse, Vital signs within normal
blood pressure, respiratory limits demonstrate the ef-
rate) every 4 hrs and prn. fectiveness of the respiratory
and cardiac systems.
Assess skin color every 4 hrs Skin color is affected by the
and prn. ability of the respiratory sys-
tem to promote effective gas
exchange between CO2 and
O2. The lack of O2 results in
cyanosis.
Acute Confusion related The client will be alert Assess the alertness and Being alert and oriented to
to fluctuation in level and oriented to person, orientation every 4 hrs and prn. all three spheres demon-
of consciousness and place, and time. strates adequate mental
cognition status.
Encourage communication Communicating fears
about fears. reduces the emotional
instability.
Reorient to name, place, and Reorienting to the three
time as needed. spheres encourages mental
stability.
BOX 11-7
AnD CLIEnT ASSESSMEnT FOR METABOLIC ACIDOSIS
RESPIRATORY ALKALOSIS metabolic acidosis is an acid–base imbalance that results in
the arterial pH decreasing below 7.35. This acid–base imbal-
• Respiratory rate and depth
ance is the result of either the bicarbonate reserves decreasing
• Ability to perform ADLs
below 22 mEq/L or the production of acid due to metabolism.
• Chvostek’s sign The decrease of bicarbonate creates an environment of acidosis.
• Trousseau’s sign When the liver increases the metabolism of stored fats, the fats
• Level of consciousness split into fatty acids and the arterial pH begins to decrease.
• Confusion or disorientation Clients with diabetes mellitus are at risk for metabolic
• Hyperreflexia acidosis because of their body’s inability to utilize glucose
• Cardiac arrhythmias appropriately. Instead the body produces ketones and a condi-
tion referred to as diabetic ketoacidosis (DKA) occurs. Clients
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COnCEPT MAP 11-2 RESPIRATORY ALKALOSIS
SIGNS and SYMPTOMS

Apprehension
Hyperventilation
Dizziness
Palpitations
Tetany-like symptoms
Hyperactive reflexes ABG VALUES
Positive Chvostek sign pH >7.45
Positive Trousseau sign PaCO2 <35 mm Hg
RESPIRATORY ALKALOSIS
NURSING DIAGNOSIS
Impaired Gas Exchange
Anxiety
Risk for Injury
PHYSIOLOGICAL
Fever
Pain
Severe infection
Brain tumor
PHYSICAL
Meningitis
PSYCHOLOGICAL PHARMACOLOGICAL Trauma: CNS
Encephalitis
Anxiety Aspirin toxicity Excess exercise
Hyperthyroidism
Fear Progesterone Rapid mechanical

Liver cirrhosis
Hysteria ventilation
Pulmonary embolus
Hypoxia in high
altitudes
with chronic renal failure also have an increased risk for meta- the increase in blood glucose; fatty acids are synthesized
bolic acidosis because of the inability of the kidneys to excrete creating ketones with the spillover of acetones in the urine
normal amounts of hydrogen ions. In addition, conditions that (Daniels and Nicoll, 2012).
cause intracellular O2 depletion such as cardiopulmonary defi- The chronic condition of renal disease is another cause
ciencies and septicemia increase the risk of metabolic acidosis. of metabolic acidosis. The kidneys excrete H1 ions to assist
Renal disease and diabetes are the most common cause of in the homeostasis of acid–base balance. When the kidneys
metabolic acidosis. Diabetes mellitus increases the acid pro- are unable to excrete H1 ions normally, metabolic acidosis
duction by producing ketones during periods of uncontrolled occurs and the arterial pH begins to decrease. As metabolic
blood glucose level. As the liver abnormally metabolizes acidosis occurs, the respiratory system is activated to com-
stored fats or the client takes in dietary carbohydrates, the pensate for the acid–base imbalance by increasing ventilation
pancreas is unable to produce the insulin necessary to reduce to decrease CO2.
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88021_ch11_ptg01_221_245.indd 235 12/29/11 1:30 PM

BESTPRACTICE Tests for metabolic Acidosis
Electrolyte Shift DIAGNOSTIC exPeCTeD PURPOSe
An electrolyte shift occurs in metabolic acidosis. TeST ReSULTS OF TeST
Hydrogen and sodium ions move into the cells,
ABGs pH <7.35 Provides data to
and potassium moves into the extracellular fluid.
PaCO2 < or 5 diagnose the
Hyperkalemia may cause ventricular fibrillation acid–base
35–45 mm Hg
and death. imbalance.
HCO32
<22 mEq/L
PaO2 80–100%
Potassium >5 mEq/L Provides data to

level diagnose hyperka-
CulTuRAl COnSIdERATIOnS lemia and treat the
excess potassium
to avoid cardiac
Renal Failure problems.
Metabolic acidosis is not particularly more prevalent Blood glucose >250 mg/dL Assists in diag-
in any one group. However, the incidence of renal nosing DKA.
failure is higher in the African American population
in the United States and in the Japanese culture, Urine ketones Large amounts Assists in diag-
which increases the risk of metabolic acidosis. nosing DKA.
Electrocar- Invisible P Assists in diag-

diogram wave nosing cardiac
Diarrhea is another cause of metabolic acidosis. As the (ECG) Tented T wave arrhythmias.

gastrointestinal tract eliminates HCO3 in greater amounts Monitor for
than normal, the ability for the bicarbonate reserve to main- Widened QRS
complex potential life-
tain a balance between acid and base is decreased. threatening car-
Other causes of metabolic acidosis are a result of condi- diac arrhythmias.
tions that increase acid production such as diabetes mellitus
or lactic acidosis. Lactic acidosis occurs during cardiopulmo-
nary deficiencies and septicemia; therefore, cardiac problems
or severe infections can also cause metabolic acidosis. During compensation efforts. As the pH level decreases, the chemical
these conditions, the intracellular environment is depleted of buffer is initiated to begin the exchange between potassium
O2 and changes the energy source from aerobic to anaerobic and hydrogen inside the cell (intracellular fluid [ICF]).
metabolic pathways producing the waste products of lactate Blood glucose level is ordered to determine if the client is
and H1 ions, which form lactic acid. experiencing DKA. Because the cardiac system is affected
Clients with metabolic acidosis can experience mul- during metabolic acidosis, monitoring the client’s heart is
tiple signs and symptoms. The early manifestations of this necessary. Table 11-5 lists common diagnostic tests ordered
acid–base imbalance include headache, drowsiness, weakness, for metabolic acidosis.
hyperventilation, and hypotension. If the metabolic acidosis The treatment of metabolic acidosis is to correct the
continues without treatment, the client experiences stupor, acid–base imbalance, hyperkalemia, hyperglycemia, and
air hunger, hyperkalemia, arrhythmias, and Kussmaul’s re- arrhythmias. Mechanical ventilation may be necessary to cor-
spiratory pattern. Kussmaul’s breathing is recognized by a rect the Kussmaul’s breathing pattern. If the client’s breathing
deep, rapid, and gasping respiratory pattern. It is an abnormal is inadequate, the ability of the respiratory system to compen-
breathing pattern that is suggestive of metabolic acidosis. sate or buffer for the metabolic acidosis will be ineffective.
If metabolic acidosis is left untreated, the client can become Dialysis may be required to maintain adequate renal function,
comatose and eventually death can occur. However, early which also assists in correcting the acidosis and electrolyte
interventions reduce the severity of the signs and symptoms imbalances. The client’s diet and pharmacological regimen are
experienced by the client. ordered by the physician to assist in correcting the imbalance.
Respiratory difficulties are a common complication of
metabolic acidosis, which results in lethargy, stupor, coma, and
Medical-Surgical even death. Other complications result from compensatory
Management mechanisms such as electrolyte imbalances like hyperkalemia.
If hyperkalemia persists, the client experiences life-threatening
Medical arrhythmias. In addition, metabolic alkalosis occurs if the
Arterial blood results determine the acid–base imbalance. acidosis is overcorrected. Constant monitoring by the nurse
Electrolytes are ordered, specifically the potassium level be- is necessary during treatment of metabolic acidosis to prevent
cause in metabolic acidosis potassium increases to assist with respiratory difficulties, cardiac arrhythmias, and alkalosis.
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Cr it iCa l t HiNKiNG and family about foods high in potassium such as bananas,
oranges, and baked potatoes (see Table 10-3 in Chapter 10
for a list of foods rich in potassium).
Foods Rich in Potassium
Pharmacological
What are various teaching methods and resources The physician will monitor electrolyte results and prescribe
that the nurse can use to teach a client about medications to reduce the client’s potassium level if needed.
Medications to help reduce the blood glucose level are or-
foods rich in potassium?
dered when clients are diagnosed with hyperglycemia or
DKA. Table 11-6 lists commonly prescribed medications for
metabolic acidosis.
Diet
Because hyperkalemia is common with metabolic acidosis, Activity
the physician may order a low-potassium diet. The nurse Activity is dependent on the client’s neurological abili-
must monitor the meal trays to ensure the client’s potassium ties. If the client is drowsy or weak, the activity level is re-
intake is kept to a minimum. The nurse educates the client stricted to prevent falls and maintain safety. If the client is
Table 11-6 Commonly Prescribed medications for metabolic Acidosis

CLASSIFICATION
GeNeRIC (TRADe) ACTION NURSING INTeRVeNTIONS
Alkylating Agent
Sodium bicarbonate Increases the base reserve by rapidly Store in an airtight container. Monitor
neutralizing gastric acid, thus labs for electrolyte imbalances. Assess
increasing the pH. for metabolic alkalosis or acidosis.
Monitor for use of alkaline antacids.
Cation Exchange
sodium polystyrene sulfonate Reduce the potassium level by Administer PO or as a retention enema.
(Kayexalate) exchanging sodium for potassium Use warm water if given as an enema.
in the lower GI system and then Monitor potassium and sodium levels
excreting it through the bowel. during treatment. Monitor acid–base
balance during treatment.
Antidiabetic Agent/Hormone/Short-Acting Insulin

Regular insulin (Humulin R, Reduces the blood glucose and Administer subcutaneously or via
Novolin R, Velosulin R) potassium level by increasing trans- direct IV. Monitor blood glucose level.
membrane passage of glucose If administered as a direct IV, monitor
across the cell membrane of muscles potassium level. Report to physician if
and fat tissues. acetone with or without sugar in
the urine.
Antiemetic
trimethobenzamide hydro- Reduce nausea and prevent vomiting Monitor blood pressure. Report and
chloride (Tigan) by acting on the chemoreceptor stop treatment immediately if sudden
hydroxyzine pamoate (Vistaril) trigger zone. febrile illness occurs. Monitor for
promethazine (Phenergan) adverse reactions and side effects
such as rash and difficulty breathing.
Antidiarrheal
loperamide hydrochloride Reduce episodes of diarrhea by Monitor stool consistency; Implement
(Imodium) decreasing GI peristaltic activity. a stool count; Monitor fluid and elec-
calcium polycarbophil Prolongs emptying of the GI contents trolyte levels; Discontinue if desired
(FiberCon) and increases stool consistency, thus results are not met within 48 hours.
decreasing fluid and electrolyte loss.
Adapted from Prentice Hall Nurse’s Drug Guide 2008, by B. A. Wilson, M. T. Shannon, K. M. Shields, and C. L. Stang, 2008, Upper Saddle River,
NJ: Pearson Prentice Hall.
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unconsciousness, then the nurse implements a turn schedule

every 2 hours to maintain skin and tissue integrity. It may
be necessary to maintain a high-Fowler’s position for clients
experiencing respiratory difficulties to promote adequate
ventilation.
Nursing Management

It is important for the nurse and client to work together
to develop a care plan that is individualized and realistic
for the client. The health care team is consulted so ap-
propriate interventions are implemented to ensure holistic
recovery. Figure 11-5 A health history is essential in collecting
subjective data about metabolic acidosis.
NURSING PROCESS
Data Collection BOX 11-8
Assessment is an important part of the care plan process. The DATA COLLECTIOn: SUBJECTIVE
nurse collects subjective and objective data to provide vital DATA AnD CLIEnT InTERVIEW
information for the nursing care plan and physician-directed FOR METABOLIC ACIDOSIS
interventions.
• What medical illnesses have you experienced
Subjective Data in the recent past?
• What surgeries have you had recently?
A health history is necessary for the nurse to elicit infor-
mation from the client by asking appropriate questions • What prescription medications do you
(Figure 11-5). Questions focus on past medical history, currently take?
current list of prescription medications, current over- • What over-the-counter medications do you
the-counter medications taken, and signs and symptoms take currently?
currently experienced by the client such as headache, • Have you experienced breathing difficulties?
fatigue, hyperventilation, dizziness, lethargy, and restless- • Do you feel dizzy or light-headed upon standing?
ness. Box 11-8 lists sample questions to ask the client when • Do you feel tired after completing normal
collecting subjective data. activities?
• How often do you experience headaches?
Objective Data • When was your last headache?
The nurse performs a physical assessment on the client focus- • Have you been diagnosed with diabetes?
ing on the respiratory and cardiac systems. Priority assess- If so, what are your last several blood glucose
ment includes vital signs, alertness and orientation, electrolyte readings?
levels, ABGs, blood urea nitrogen (BUN), creatinine, blood • Have you had any recent changes in your
glucose level, and urine ketones. Box 11-9 lists objective data kidney function?
to be collected.
Nursing diagnoses for a client in metabolic acidosis include the following:

Ineffective Breathing Pat- The client will maintain Place client in high-Fowler’s Promotes effective
tern related to decreased a regular and unlabored position. ventilation.
energy or fatigue respiratory pattern. Check respiratory rate every Provides data to evalu-
4 hrs prn. ate the respiratory buffer
system.
Assess the respiratory pattern Evaluates the effectiveness
every 4 hrs prn. of the pulmonary system.
Assess for adventitious breath- Evaluates lung sounds to en-
ing sounds every 2 to 4 hrs sure effective breathing and
prn. oxygenation.
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Ineffective Peripheral The client will maintain Auscultate apical pulse rate Provides evidence about the
Tissue Perfusion (car- an apical pulse rate be- and rhythm every 4 hrs prn. effectiveness of the pumping
diopulmonary) related to tween 60 and 100 beats/ action of the heart.
exchange problem min. Assess pulse oximetry every Provides evidence of the ef-
4 hrs prn. fectiveness of the cardiopul-
monary action (oxygenation).
Compare skin color and tem- Evaluates the function of the
perature of extremities every cardiopulmonary action to
4 hrs prn. maintain appropriate oxy-
genation and temperature
status.
Assess capillary refill every Provides evidence that tis-
4 hrs prn. sue is adequately perfused.
Auscultate lung sounds every Determines the effectiveness
4 hrs prn. of gas exchange.
Fatigue related to The client will perform Assess the client’s energy level Provides evidence that the
disease state ADLs without complaint before performance of ADLs. client is able to complete
of fatigue. ADLs without assistance.
Allow for periods of rest Rest provides for recupera-
between activities. tion, which refuels energy
levels.
Consult physical therapist and Provides a plan of action
occupational therapist for eval- and evaluation to increase
uation and plan of action. the client’s endurance level.
BOX 11-9
AnD CLIEnT ASSESSMEnT FOR Ketones
METABOLIC ACIDOSIS
• Respiratory rate and rhythm
What will the client’s breath smell like? Why? What
• Apical rate and rhythm
diagnostic findings indicate ketones? What are nursing
• Vital signs
interventions for the client with a high ketone level?
• Alertness
• Orientation
• Blood glucose
and excessive antacid ingestion. Hypokalemia is an indica-
• Potassium level tion of metabolic alkalosis. Gastrointestinal suctioning can
• Renal function tests (BUN and creatinine) induce metabolic alkalosis. The most common acid–base
• Urine ketones imbalance diagnosed in hospitalized clients is metabolic
• Muscle strength and coordination alkalosis.
Causes of metabolic alkalosis include loss of gastric acid
(e.g., gastrointestinal suctioning), electrolyte imbalances,
METABOLIC ALKALOSIS renal disease, excessive antacid ingestion, and the use of
diuretics. Gastrointestinal suctioning is implemented when
metabolic alkalosis occurs as a result of excessive accumu- the acidity of the gastrointestinal tract is disrupted and alters
lation of bicarbonate or the excessive loss of H1 ions. As a the acid–base balance. In addition, chloride and water are
result of the acid–base imbalance, the arterial pH increases as depleted, which increases the bicarbonate concentration. As
HCO3 increases or arterial CO2 decreases. Because the body the acid reserves decrease, the ratio between acid and base,
attempts to maintain homeostasis, the buffer systems are acti- 1:20, favors the base and the pH scale begins to tilt toward
vated to help decrease the pH. alkalosis.
The incidence of metabolic alkalosis is prevalent in cli- The buffer systems help compensate for metabolic alka-
ents who have gastrointestinal upset (nausea and vomiting) losis. Decreasing the respiratory rate and depth and activating
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COnCEPT MAP 11-3 METABOLIC ACIDOSIS
SIGNS and SYMPTOMS

Hyperventilation: Deep and rapid
respirations (Kussmaul
respirations)
Headache
Lethargy, confusion
Anorexia
Nausea
Vomiting
Diarrhea
Abdominal discomfort ABG VALUES
Coma pH 7.35
Dysrhythmias HCO3 24 mEq/L
METABOLIC ACIDOSIS
NURSING DIAGNOSIS
Fluid Volume Deficit
Confusion, Acute
PHYSIOLOGICAL
Kidney disease
Diabetes mellitus PHYSICAL
PSCYHOLOGICAL PHARMACOLOGICAL Excessive infusion of
Diarrhea
Anxiety Diuretics chloride containing IV
Cardiac arrest solutions
Fear Overdose salicylates
Trauma: Burns
Crushing injury
(Courtesy of Kami l. fox, ms, Cnp)
the renal system to increase the excretion of bicarbonate up the acid reserve; thus, reducing the pH. Consequently,
assists the buffer systems to regain acid–base balance. The the client diagnosed with metabolic alkalosis presents with
assistance of these two compensatory mechanisms helps to cyanosis due to the depletion of tissue oxygenation. Because
reestablish the 1:20 acid-to-base ratio. As hypoventilation oc- of the concurrent electrolyte imbalances, the client experi-
curs, the CO2 levels increase providing an increase in the fixed ences hypotension, cardiac arrhythmias, tachycardia, muscle
acid reserves. When the kidneys compensate for metabolic twitching, tetany, nausea, and vomiting. As metabolic alka-
alkalosis, H1 ions are conserved and HCO32 are excreted to losis persists, the client experiences signs and symptoms of
regain the acid–base balance. confusion, irritability, and nervousness. If metabolic alkalosis
As pH increases, the respiratory system begins to slow is severe, the manifestation of seizures and possibly coma
breathing causing the retention of CO2, which helps to build can occur.
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BESTPRACTICE Tests for metabolic Alkalosis
Metabolic Alkalosis DIAGNOSTIC exPeCTeD PURPOSe
The following clinical conditions can place clients TeST ReSULTS OF TeST
at risk for metabolic alkalosis:
ABGs pH >7.45 Provides data to
• Vomiting and nasogastric suctioning or lavage HCO32 diagnose metabolic
cause a loss of hydrochloric acid and chloride. >26 mEq/L alkalosis.
With the loss of the hydrogen and chloride ions, PaCO2 > or 5
bicarbonate ions are absorbed, unneutralized, 45 mm Hg
into the bloodstream, and the pH of the extra-
cellular fluid rises (alkalosis). Electrolyte K1 <3.5 mEq/L Provides baseline
• Diarrhea and steroid or diuretic therapy can panel Cl2 <95 mEq/L electrolyte levels so
treatment can be ini-
cause excessive loss of potassium, chloride, and Ca11 <8.5 mg/dL
tiated to correct the
other electrolytes. The potassium deficit causes
imbalance. Assists
the kidneys to exchange hydrogen ions (instead
in diagnosing
of potassium ions) for sodium ions, which pro- secondary problems
motes the loss of hydrogen, thereby increasing related to electrolyte
the bicarbonate level. imbalances such as
cardiac, musculo-
skeletal, and acid–
base problems.
Complications as a result of metabolic alkalosis include
respiratory depression, which leads to cardiac arrhythmia, Electrocardio- Rhythm rate Provides data to
seizures, coma, and eventually death. Metabolic alkalosis gram (ECG) 100 beats/min or diagnose cardiac
is life threatening if left untreated or treated inadequately. greater arrhythmias that

Because of the electrolyte imbalances that exist with meta- Short to flat T wave are caused by elec-
bolic alkalosis, clients may experience complications related T wave merges trolyte imbalances
to hypokalemia, hypocalcemia, and hypochloridemia. The into the P wave associated with
client may experience cardiac arrhythmias, skeletal muscle metabolic alkalosis.
weakness, increased bicarbonate levels, tremors, tetany,
and lethargy. Another complication that can result from
metabolic alkalosis is acidosis. If the client is overtreated and
not monitored closely enough, then the opposite acid–base
Medical-Surgical
imbalance of acidosis can occur. These complications can Management
be life threatening unless the electrolyte imbalances are
corrected. Medical
Metabolic alkalosis is diagnosed by ABG results. ABGs The physician guides treatment according to the diagnostic
provide information about pH and the bicarbonate level test results and the cause of metabolic alkalosis. If the physi-
along with O2, pCO2, and O2 saturation. Because elec- cian determines that the client is suffering from metabolic
trolyte levels have a direct relationship to maintaining alkalosis because of GI suctioning, it may be necessary for the
acid–base balance, an electrolyte panel, specifically potas- suctioning to be set to intermittent or held for intervals that
sium, chloride, and calcium is important for the nurse would promote acid–base balance. Depending on the results
to monitor. An electrocardiogram (ECG) is ordered to of the laboratory tests, the physician may alter the client’s diet
diagnose arrhythmias, tachycardia, flat T wave, and/or a and/or medication regimen.
U wave (Hogan, Gingrich, Overby, & Ricci, 2007).
Table 11-7 provides common diagnostic tests and possible Diet
results for metabolic alkalosis. Because the client with metabolic alkalosis may have hypokalemia
and hypocalcemia, the dietitian is consulted to provide client
education about selecting foods high in potassium such as baked
LIFE SPAn COnSIDERATIOnS potatoes, bananas, and oranges or orange juice. As calcium is
increased in the client’s diet, vitamin D needs to also be increased.
Antacids
Because the elderly are more prone to gastroin-
Pharmacological
testinal problems and taking antacids excessively, The treatment plan consists of medications such as elec-
they are at greater risk for developing metabolic trolyte supplements, histamine-2 antagonists, antiemetics,
alkalosis.
and/or normal saline-based IV fluids (Hogan et al., 2007).
Table 11-8 lists commonly administered medications for the
treatment of metabolic alkalosis.
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Table 11-8 Commonly Prescribed medications for metabolic Alkalosis

CLASSIFICATION GeNeRIC (TRADe) ACTION NURSING INTeRVeNTIONS
Electrolytic and Water Balance Agent
potassium chloride (K-Dur) Cations assist cardiac, musculo- Monitor electrolyte blood tests.
skeletal, and kidney function. Assess apical for irregularities.
Monitor for bone fractions
(pathological). Monitor bleeding times.
Fluid and Electrolytic Replacement Solution

Calcium chloride Provides chloride ions that Monitor ECG and blood pressure.
Calcium gluconate promote acidosis and temporary Client remains in bed for 15 to 30 min
diuresis due to sodium excretion. after administration. Monitor calcium
Restores calcium during level and pH level.
hypocalcemia.
Antiemetic
promethazine Reduces nausea and prevents Monitor blood pressure. Report and
hydrochloride (Phenergan) vomiting by acting on the stop treatment immediately if sudden
trimethobenzamide chemoreceptor trigger zone. febrile illness occurs. Monitor for
adverse reactions and side effects
hydrochloride (Tigan)
such as rash and difficulty breathing.
Stimulant Laxative/Stool Softener

senna (Senokot) Stimulates peristalsis by active Monitor acid–base balance,

docusate sodium (Colace) aglycone; allows fat and water especially the pH level. Monitor stool
to penetrate the colon, which consistency and count number of
softens the stool. stools. Withhold medication if diar-
rhea exists.
Activity Nursing Management

Assist the client with ambulating and repositioning. If meta- As subjective and objective data are collected, the nurse
bolic alkalosis symptoms worsen, the client is placed on bed uses a care plan to help the client with metabolic alkalosis.
rest with seizure precautions. Conduct frequent assessments The nursing process guides the nurse in a systematic way to
to ensure safety. Make sure that side rails are up, the bed is in develop an effective plan.
low position, wheels locked, and the call light is within reach.
MEMORY TRICK
ROME
A nurse can figure out if a client is in respiratory or metabolic acidosis/alkalosis depending on the ABG laboratory
results. An easy way to decide whether it is respiratory or metabolic is by using the ROME memory trick. If the pH
is opposite the PaCO2 (either high or low), then it is respiratory. If the pH is equal to the HCO32, it is metabolic.
R 5 Respiratory M 5 Metabolic
O 5 Opposite E 5 Equal
Examples of how to use the ROME memory trick:
1. A client’s ABGs are pH 7.31, PaCO2 54, HCO32 24, PaO2 62. Because the client’s pH is less than 7.35, the client
is in acidosis. Now use the ROME memory trick. Is the pH opposite of the PaCO2? Yes, it is. The pH is low, and
the PaCO2 is high. This client is in respiratory acidosis.
2. A client’s ABGs are pH 7.49, PaCO2 40, HCO3 42, PaO2 80. Because the client’s pH is greater than 7.45, the
c lient is in alkalosis. Now use the ROME memory trick. Is the pH equal to (following the same trend) the
HCO3? Yes, it is. The pH is high, and the HCO3 is high. This client is in metabolic alkalosis.
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COnCEPT MAP 11-4 METABOLIC ALKALOSIS
SIGNS and SYMPTOMS

Irritability
Confusion
Tetany-like symptoms
Hyperactive reflexes ABG VALUES
pH >7.45
Hypoventilation
HCO3 >28 mEq/L
Shallow breathing
METABOLIC ALKALOSIS
NURSING DIAGNOSIS
Deficit Fluid Volume
Risk for Injury
PHYSIOLOGICAL
Vomiting
Gastric suction
PHARMACOLOGICAL
Hypokalemia
Antacids (magnesium
Decreased renal PSYCHOLOGICAL hydroxide) PHYSICAL

perfusion Anxiety Bulimia
Loop or thiazide diuretics
Bartter syndrome Fear Self-harm
Calcium carbonate
Massive blood
transfusion Excess glucocorticoids
and objective data, the nurse is able to review the data and
NURSING PROCESS create a plan of care.
Data Collection Subjective Data
The five steps to the nursing process provide the nurse with The nurse performs a health history and collects data about
an outline for developing an efficient care plan. The nurse the client’s emotional state, physical endurance level, feelings
collects the client’s medical history and performs a physical of nausea, and irritability. Information is gathered about the cli-
assessment on the client. After the collection of the subjective ent’s current medical problem and medication list. Box 11-10
lists subjective data questions to ask during the health history.
Cr it iCa l t HiNKiNG Objective Data
The nurse conducts a physical examination of the client di-
Reviewing ABG Results agnosed with metabolic alkalosis. Vital signs and head-to-toe
assessment typically reveal hypotension, bradycardia, hypoven-
tilation, and an irregular heart rhythm (Figure 11-6). The client
complains of hypertonicity of muscles, hyperactive reflexes,
When reviewing ABG results, what should the
and seizures (Hogan et al., 2007). Objective data also includes
nurse look at first? Why? confusion, stuporous activity, coma, or death. Box 11-11 lists
objective data to collect during the physical examination.
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BOX 11-10
DATA COLLECTIOn: SUBJECTIVE
DATA AnD CLIEnT InTERVIEW
FOR METABOLIC ALKALOSIS
• What medical conditions do you have?
• Do you become short of breath? If yes, explain
how often you need to stop and rest between
activities of daily living.
• How do you feel when you wake up?
• Do you ever feel dizzy or light-headed when
you stand from a lying or sitting position?
• What prescription medications are you
currently taking? Please explain why you are
taking the medication.
• What over-the-counter medications do you
take? What is the purpose for taking this
medication?
• Have you experienced any changes in your
appetite recently? If yes, please explain.
• What types of foods do you eat on a regular
basis?
• What types of fruits do you eat regularly?
• Have you noticed any difference in the way

your heart feels?
• Describe your breathing pattern.
• Have you been experiencing any nausea, vomit-
ing, or diarrhea recently? If yes, please explain.
• Do you take antacids regularly? If yes, please
explain which antacid and how often you take
the antacid.
Figure 11-6 Vital signs for clients in metabolic alkalosis
may reveal hypotension, bradycardia, and an irregular heart
rhythm.
CASE STUDY
Acid–Base Imbalance
J.M. is a 71-year-old man diagnosed with type 2 diabetes 10 years ago with an average blood sugar of
220 mg/dL. In addition, J.M. was diagnosed with heart failure 15 years after his five vessel coronary artery
bypass grafts (CABGs). The cardiac history is a result of the untreated hypertension he suffered from for
12 years before his bypass surgery. Physical assessment data reveal oral temperature 98.4°F, respiratory
rate 10 breaths/min, apical pulse 128 beats/min, blood pressure 186/96 mm Hg, and pulse oximetry is
80%, and crackles scattered throughout all lung fields. J.M. complains of shortness of breath (SOB) with
activity, denies pain, is able to perform ADLs, states problems with swallowing thin liquids, and requests
to be placed in high-Fowler’s position. Respiratory pattern is irregular and shallow. J.M. is oriented to
person and place, and skin is cool, moist, and pale. Bowel sounds are active in all four quadrants, and the
abdomen is semihard and slightly distended. J.M. has (12) pitting edema to the lower extremities.
The following questions will guide your development of a nursing care plan for this case study.
1. List subjective and objective assessment data.
2. What acid–base imbalance does the nurse suspect?
3. Select three priority nursing diagnoses for J.M.’s acid–base imbalance.
4. Choose the priority nursing diagnosis and develop an appropriate client centered goal.
5. What nursing interventions should the nurse implement to assist J.M.?
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Nursing diagnoses for a client in metabolic alkalosis include the following:

Ineffective Breathing Pat- The client will maintain a Assess the respiratory rate and Provides evidence that
tern related to decreased regular respiratory rhythm. depth every 4 hrs prn. breathing rate is within
chest expansion normal limits.
Keep the head of bed at 45 de- Promotes lung expansion.
grees or more during periods of
dyspnea.
Auscultate lung sounds every Provides evidence that
4 hrs prn. the pulmonary system is
functioning effectively.
Decreased Cardiac Out- The client will maintain Auscultate rate of apical pulse Provides verification that the
put related to decreased blood pressure: systolic every 4 hrs prn. apical pulse is within normal
contractility pressure between 110 limits promoting effective
and 140 and diastolic cardiac output.
between 60 and 80. Palpate peripheral pulses every Provides evidence about
4 hrs prn. the function of the cardiac
system.
Monitor potassium and calcium Potassium and calcium af-
levels as frequently as ordered. fect the function and output
of the heart.
Nausea related to The client will have a Assess the client for what is Supplies information for
biochemical disorder decrease in nausea. causing the nausea immediately effective management of the
after becoming aware of its nausea and vomiting.
presence.
Assess for triggers that are To determine the nox-
causing the nausea after each ious stimuli that triggers
episode. chemoreceptor zone in the
medulla.
Administer antiemetics as To reduce the stimulation to
prescribed. the chemoreceptor trigger
zone.
Assess for pain every 4 hrs and Pain can cause feelings of
prn. GI upset.
BOX 11-11 CONCLUSION
DATA COLLECTIOn: OBJECTIVE The human body continuously makes subtle adjustments to
DATA AnD CLIEnT ASSESSMEnT maintain acid–base balance. Various conditions and illnesses
FOR METABOLIC ALKALOSIS affect the pH level, which varies only slightly within narrow
• Vital signs
ranges. The bicarbonate, phosphate, and protein buffering
systems work to regulate the pH. The four types of acid–
• Apical rate and rhythm
base imbalance are respiratory acidosis, respiratory alkalosis,
• Respiratory rate and depth metabolic acidosis, and metabolic alkalosis. The type of
• Ability to perform ADLs acid–base imbalance that the client is experiencing deter-
• Level of consciousness mines the depth of nursing assessment, the types of diagnostic
• Confusion or disorientation testing, the medical treatment, the nursing management, and
• Hyperreflexia the plan of care selected for the client.
• Cardiac arrhythmias
• Muscle strength and coordination
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CHAPTER 12
IV Therapy
KEY TERMS
butterfly catheters flow rate over-the-needle catheter
care bundle hypervolemia parenteral
drug incompatibilities implantable port phlebitis
electronic infusion device (EID) infiltration piggybacked
extravasation IV push (bolus) vesicant
LEARNING OBJECTIVES
2. Explain how to assemble and when to use the IV solution administration equipment.
3. Identify principles of safe intravenous (IV) infusion administration.
4. Describe nursing responsibilities for initiation, monitoring, removal, and documentation
of peripheral venous therapy.
5. Calculate the correct flow rate for an IV infusion.
6. Relate potential complications of peripheral venous therapy.
7. Discuss potential liabilities for the nurse administering intravenous infusion and
IV medications.
8. Explain assessments and preparation of the client receiving blood transfusions.
9. Relate safety measures prior to and during the administration of blood products.
10. Discuss symptoms of transfusion reactions.
246
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CHAPTER 12 IV Therapy 247
if fluid is infused without accompanying electrolytes and

INTRODUCTION beyond the client’s tolerance.
The LPN/LVN IV therapy role varies widely within states • Isotonic fluid. This solution increases only extracellular
and facilities. The rules and regulations of each state board fluid volume. Cardiac overload may result if fluid is infused
of nursing establish and regulate the LPN/LVN IV admin- beyond the client’s tolerance.
istration role and establish guidelines for LPN/LVN nursing • Hypertonic fluid. This solution increases osmotic pressure
programs to teach IV administration. Some state boards of and draws fluid from the cells and interstitial spaces.
nursing expect nursing programs to teach IV therapy within Cellular dehydration may result if fluid is infused beyond
the curriculum, while others allow LPN/LVNs very limited the client’s tolerance (Bulechek, Butcher, & McCloskey
access to IVs. Therefore, it is the responsibility of the LPN/ Dochterman, 2007).
LVN to know the standards of practice for the state in which
she is practicing. Common intravenous solutions are shown in Table 12-1.
The purpose of an IV is to correct fluid and electrolyte
imbalances, administer medications and blood products, and IV EQUIPMENT
provide nutritional supplements (Figure 12-1). This chapter
explains safe IV infusion and medication administration. Intravenous equipment is disposable, sterile, and prepackaged
IV therapy equipment includes a parenteral fluids (solutions) with user instructions. The user instructions, including a sche-
administration set, IV pole, filter, and regulators to control IV matic labeling the parts, are usually placed on the outside of
flow rate. An established venous route is also needed. the package, which allows the user to read the package before
opening it. When handling IV equipment, sterile technique
is essential when connecting tubings, spiking the IV bag, and
PARENTERAL FLUIDS attaching it to the client’s IV catheter because it is in direct
Read the physician’s order in the client’s medical record to contact with IV fluids that are infused into the bloodstream.
confirm the type and amount of IV solution. Intravenous solu- The administration (infusion) set includes an insertion
tions are sterile and usually packaged in plastic bags. Solutions spike with a protective cap, a drip chamber, tubing with a slide
incompatible with plastic are in glass containers. clamp and regulating (roller) clamp, an injection port, and a
Plastic IV solution bags collapse as gravity pulls the solu- protective cap over the needle adapter (Figure 12-2). Protec-
tion into the infusion set. Plastic solution bags are packaged tive caps keep both ends of the set sterile and are removed
with an outer plastic bag, which should remain intact until only when used. The insertion spike is inserted into the port
the solution is prepared for administration. If the outside of of the IV solution container.
the solution bag is wet when removed from its outer wrapper, There are two types of drip chambers: a macrodrip,
do not administer the solution. Moisture on the bag indicates which releases 10 to 20 drops per milliliter of solution, and
that the integrity of the bag has been compromised, and the a microdrip, which releases 60 drops per milliliter. The drop
solution cannot be considered sterile. Return the bag to the rate, which varies with the manufacturer, is indicated on the
department that issued the solution. Glass containers are dis- package.
cussed in the section on equipment. The roller clamp compresses the plastic tubing to control
Parenteral fluids are classified based on their relation- the flow rate. There is an adapter at the end of the IV tubing
ship to normal blood plasma. Solutions may be hypotonic, that connects to the client’s IV catheter. Extension tubing may
isotonic, or hypertonic. The solution prescribed is based on be used to lengthen the primary tubing or provide additional
the client’s diagnosis and the goal of therapy. Y-injection ports for administering additional solutions.
• Hypotonic fluid. The effect of this solution is to lower
osmotic pressure and make fluid move into and around the Intravenous Filters
cells from the venous system. Water intoxication may result Intravenous filters remove particulate matter that may cause
irritation and phlebitis (inflammation of a vein) from the
solution. Intravenous filters come in various sizes and some IV
tubing has an in-line filter. If the catheter has an in-line filter,
it is not necessary to add a filter to the tubing.
Needles and Catheters

Needles and catheters provide access to the venous system.
A variety of devices of different sizes are available to accom-
modate to the age of the client and the type and duration
of therapy (Figure 12-3). The needles and catheters vary in
gauge from small bore to large bore. The larger the number,
the smaller the lumen of the needle or catheter; a 20 is larger

than a 28. A 20- to 22-gauge flexible catheter is used for adults.
Butterfly (scalp vein or wing-tipped) catheters, or
Intimas, are short, over-the-needle catheters with plastic
wings attached to the shaft. The wings (which are flexible)
are held tightly together to facilitate catheter insertion and
Figure 12-1 A nurse adjusts the rate of a client’s IV. then are flattened against the skin and taped to prevent
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Table 12-1 Common Intravenous Solutions

TONICITY SOLUTION CONTENTS (MEQ/L) CLINICAL IMPLICATIONS
Hypotonic Sodium chloride 0.45% 77 Na1, 77 Cl2 Daily maintenance of body fluid and
establishment of renal function.
Isotonic Dextrose 2.5% in 0.45% 77 Na1, 77 Cl2 Promotes renal function and urine output.
saline
Dextrose 5% in 0.2% 77 Na1, 77 Cl2 Daily maintenance of body fluids when less
saline Na1 and Cl2 are required.
Dextrose 5% in water 38 Na1, 38 Cl2 Promotes rehydration and elimination;
(D5W) may cause urinary Na1 loss; good vehicle
for K1.
Ringer’s lactate 130 Na1, 4 K1, Ca21, Resembles the normal composition of
109 Cl2, 28 lactate blood serum and plasma; K1 level below
body’s daily requirement.
Normal saline (NS), 0.9% 154 Na1, 154 Cl2 Restores sodium chloride deficit and
extracellular fluid volume.
Dextran 40 10% in NS A colloidal solution used to increase plasma
(0.9%) or D5W volume of clients in early shock; it should
not be given to severely dehydrated clients
and clients with renal disease, thrombocy-
topenia, or active hemorrhaging.
Dextran 70% in NS A long-lived (20 hours) plasma volume
expander; used to treat shock or impend-
ing shock caused by hemorrhage, surgery,
or burns. It can prolong bleeding and coats
the RBCs (draw type and cross match
before administering).
Hypertonic Dextrose 5% in 0.45% 77 Na1, 77 Cl2 Daily maintenance of body fluid and
saline nutrition; treatment of fluid volume deficit
(FVD).
Dextrose 5% in saline 154 Na1, 154 Cl2 Fluid replacement of sodium, chloride, and
0.9% calories (170).
Dextrose 10% in saline 154 Na1, 154 Cl2 Fluid replacement of sodium, chloride, and
0.9% calories (340).
Dextrose 5% in lactated 130 Na1, 4 K1, 3 Ca21, Resembles the normal composition
Ringer’s 109 Cl2, 28 lactate of blood serum and plasma; K1 level
below body’s daily requirement; caloric
value 180.
Hyperosmolar saline 3% 856 Na1, 865 Cl2 Treatment of hyponatremia; raises the Na
and 5% NaCl osmolarity of the blood, and reduces intra-
cellular fluid excess.
Ionosol B with dextrose 57 Na1, 25 K1, 49 Cl2, Treatment of polyionic parenteral replace-
5% 25 lact., 5 Mg21, 7 PO42 ment caused by vomiting-induced alkalosis,
diabetic acidosis, fluid loss from burns, and
postoperative FVD.
From Fluids and Electrolytes with Clinical Applications: A Programmed Approach (7th ed.), by J. Kee, B. Paulanka, and C. Polek, 2009, Clifton Park,
NY: Delmar Cengage Learning.
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Insertion spike
Flange
Drop orifice
Drip chamber
Luer-lock
adapter
Close Open
Slide clamp
Regulating (roller) clamp Needleless cannula injection ports
Open
Close Open
Close
C D
Figure 12-2 A, Basic IV administration set; B, regulating roller clamp and slide clamp; C, macrodrip chamber;
D, microdrip chamber.
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dislodgment. These are generally used for short-term or inter- facilities to use needle-free IV systems or use all available
mittent therapy and for infants. safety precautions to increase employee safety (Figure 12-4).
Several types of catheters are used to access peripheral
veins. Some of these catheters are threaded over a needle,
and others are threaded inside a needle during insertion. An Vascular Access Devices
over-the-needle catheter (sometimes called an angiocath, Vascular access devices (VADs) are peripheral and central
for short) has a metal stylet to pierce the skin and vein. Then catheters inserted into the large veins of the vascular system
the plastic catheter is threaded into the vein and the metal rather than the regular IV that is inserted into the small veins
stylet removed. Many facilities use a safety-shield intravenous of the hand or arm. VADs include various cannulas, catheters,
catheter or retractable needle system for inserting peripheral and infusion ports that allow long-term IV therapy or repeated
IV lines. This safety equipment requires various methods to access to the central venous system. The client’s diagnosis
remove the metal stylet and requires training. and the type and length of treatment determine which VAD
is used.
Central venous catheters (CVCs) have the tip of the
Needle-Free System catheter placed in the distal one-third of the superior vena
Safety is a concern with IV therapy. Accidental needlestick cava. The catheter is tunneled under the skin close to the vein
injuries and puncture wounds with contaminated devices where it is inserted. Tunneling allows the catheter to remain
increase the employee’s risk for infectious diseases such as in the vein longer, and potential infections can be stopped
AIDS, hepatitis (B and C), and other viral, rickettsial, bacte- before reaching the tip of the catheter. Tunneled catheters
rial, fungal, and parasitic infections. The Occupational Safety include Hickman, Broviac, Groshong, and Hohn (Daniels &
and Health Administration (OSHA) requires all health care Nicoll, 2012).
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Figure 12-4 Needleless IV access devices. (Courtesy of BeCton, DiCkinson anD Company)
INFECtION CONtROL BestPractice

Central Line Bundle
Inserting a CVC
A care bundle is a grouping of individual best
When assisting with the insertion of a long-line
practices that improve the quality of care pro-
central catheter, observe the client for symptoms
vided for a specific disease process. When these
of a pneumothorax:
practices are grouped together as a “bundle,”
they significantly improve the quality of client • Sudden shortness of breath or sharp chest pain
care. The central line bundle is a group of • Increased anxiety
evidence-based interventions that improve the • A weak, rapid pulse
quality of care provided for clients with intra- • Hypotension
vascular central catheters. The best practices of • Pallor or cyanosis
the central line bundle are: These symptoms indicate accidental puncture of
• Hand hygiene. the pleural membrane.
• Maximal barrier precautions when the
catheter is inserted (sterile gloves, sterile
gown, cap, mask, and large sterile drape). Another type of CVC is a percutaneous catheter that is
• Chlorhexidine skin prep at insertion time. inserted directly into the jugular and subclavian veins. Usually
• Best catheter site selection (avoid femoral the port of entry for this catheter is near the antecubital fossa
vein for central venous access in adult clients). and then it is threaded to the superior vena cava. A peripher-
• Evaluate daily whether line is needed and ally inserted central catheter (PICC) is called a PICC line.
promptly remove if line is not needed. A PICC line is inserted when infusion therapy lasts longer
Note: LPN/LVNs do not insert or remove than 2 weeks and the medication is too caustic for peripheral
central catheters. vessels.
CVCs may have a single or multiple lumens, which allow
Institute for Healthcare Improvement (2011). infusion of incompatible solutions since they never mix in the
catheter (Daniels & Nicoll, 2012). The insertion of a CVC is a
specialized treatment performed by a physician or an infusion nurse.
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BOX 12-1
ChangIng the CentraL Venous DressIng
Preferably use a prepared, sterile kit to change a central venous dressing. If the facility does not provide dress-
ing change kits, the following equipment is needed:
• Povidone-iodine swabs, chlorhexidine gluconate (CHG), or agency-approved antiseptic solution
• Sterile gauze, tape, or moisture-transparent dressing
• Label with date and time of dressing change
• Latex-free clean gloves
• Mask
• Latex-free sterile gloves
• Catheter stabilizing device
steps to Follow When Changing a Central Venous Dressing
1. Perform hand hygiene and put on latex-free clean gloves.
2. Put on mask. Some agencies have clients wear a mask also.
3. Inspect the dressing and remove old dressing, being careful not to dislodge the central catheter.
4. Note drainage on dressing for color, odor, consistency, and amount. Remove soiled gloves.
5. Inspect skin at insertion site for redness, tenderness, or swelling.
6. Put on latex-free sterile gloves and palpate tunneled catheter for presence of Dacron cuff, using care not to
palpate close to the exit site.
7. Visually inspect catheter from hub to skin.
8. Remove gloves and apply a new pair of latex-free sterile gloves.
9. Clean exit site according to institution protocol. Chlorhexidine (ChloraPrep) is quickly becoming the agent of
choice and requires a brisk scrub using circular motions from clean area to dirty.
10. Stabilize the catheter using a catheter stabilization device.
11. Apply a transparent dressing over the area.
12. Label the dressing with date, time, and the initials of the nurse who changed the dressing.
13. Remove gloves and dispose of all used materials according to agency policy.
14. Perform hand hygiene.
Include these items when documenting the procedure:
• The date and time the dressing was changed
• The cleansing solution and dressing applied
• The condition of the skin at the site
• The presence of exudate or bleeding at the site
• The ease or difficulty experienced by client or caregiver during the dressing change
Document on an appropriate flow sheet or electronic medical record (EMR).
LPN/LVNs change CVC dressings in a few states. It is

the responsibility of the LPN/LVN to know the rules and regula- LIFe sPan ConsIDeratIons
tions of the state board of nursing in the state of clinical practice.
See Box 12-1 for the correct technique for changing a CVC selecting needle gauge
line dressing.
The implantable port (a device made of a radiopaque Consider the client’s age and body size and the
silicone catheter and a plastic or stainless steel injection port type of solution to be administered when selecting
with a self-sealing silicone-rubber septum) is another type of the gauge of the needle or catheter.
VAD. Only nurses who are specially trained are allowed to access • Teenagers and adults, 22 or 20 gauge
an implanted port because of the risk of infiltration into the tissue • Elderly, 24 or 22 gauge
if needle placement is incorrect.
PREPARING AN INTRAVENOUS
SOLUTION Initiating IV Therapy
Before preparing an IV solution, read the physician’s order Before starting IV therapy, consider the type of fluid to be
and the agency’s protocol, and then gather necessary equip- infused, calculate the flow rate, and assess for a venipuncture
ment. Because IV solutions and equipment are sterile, the site. The Infusion Nurses Society (INS) (2011) recommends
package expiration date is checked before use. The IV is pre- selecting the smallest size and shortest length catheter to
pared in the client’s room or in a nurses’ work area. accommodate the prescribed infusion therapy (20 to 22 gauge
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for maintenance fluids and routine antibiotics, 18 gauge for fluids can infiltrate (leak from the vein into the tissue at
rapid bolus infusions and blood products). the site of puncture). When IV therapy is discontinued for
infiltration, it can only be restarted proximally to the initial
Calculating Flow Rate puncture site. Generally, it is best to begin with the hand
and advance proximally up the arm if new sites are needed.
The physician prescribes the flow rate, the volume of fluid Figure 12-5 illustrates common peripheral sites for initiat-
to infuse over a set period, for example, 125 mL per hour or ing IV therapy.
1,000 mL over an 8-hour period. The hourly infusion rate is
calculated as follows:
Total volume
5 mL/ hour infusion rate
Number of hours to infuse
For example, if 1,000 mL is to be infused over 8 hours:
Cephalic vein
1, 000 Basilic vein
5 125 mL/hour Median
8 cubital vein
Calculate the actual infusion rate (drops per minute) as
follows:
Total fluid volume Accessory
Drop factor Drops per minute cephalic vein
Total time minutes ( ) Medial
antebrachial
For example, if 1,000 mL is to be infused over 8 hours with a vein
tubing drop factor of 10 drops per milliliter, then:
1, 000 mL 10, 000 drops 2 0.8 or 21
10 drops/mL
8 ( 6 0 ) min 48 0 min drops/min Radial vein
Another way to calculate the actual infusion rate is to use A

the hourly infusion rate (125 mL/hr from the first example):
125 mL 10 drops/mL
2 0.8 or 21 drops/min
6 0 min
Consider body size, age, skin condition, clinical status,
and impairments when assessing for a potential IV site. Veni- Cephalic vein
puncture site contraindications are as follows:
• Any signs of infection, infiltration, or thrombosis
• Affected arm of a postmastectomy client
• Arm with a functioning arteriovenous fistula (dialysis) Basilic vein
• A paralyzed arm B
Dorsal venous
• Arm with circulatory or neurological impairments. network
Because venous blood flows toward the heart, select a Dorsal

vein for an IV at its most distal end to maintain the integ- metacarpal veins
rity of the vein. When a vein is punctured with a needle,
BestPractice Great
saphenous
setting Volume to Be Infused vein
When setting the volume to be infused (e.g.,

Dorsal plexus
1,000 mL), set it slightly lower (e.g., 950 mL) so
that the alarm goes off before the fluids are
Dorsal arch
completely gone. This practice provides time
to get the next bag of fluids ready when all
1,000 mL have been infused. This is especially
helpful when having to warm refrigerated fluids. C
Report that the alarm is set early to the nurse on

the next shift.
Figure 12-5 Peripheral veins used in intravenous therapy:
A, forearm; B, dorsum of the hand; C, dorsal plexus of the foot.
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Figure 12-7 Insert the needle with the beveled side up.
Keep the angle low, 10 to 30 degrees.
Figure 12-6 Inspect the site for potential veins to use and

palpate to further locate a vein and test the firmness. of the nondominant hand beside the vein and pulling down,
making the skin taut (Figure 12-7). This technique also
makes the needle insertion less painful. Hold the needle at
a 10- to 30-degree angle, bevel up to puncture the skin, then
LIFe sPan ConsIDeratIons lessen the angle to prevent puncturing the back of the vein
(Berman et al., 2008; Jensen, 2008a). Secure the needle in
Locating a Vein place according to agency policy. Some methods of securing
the IV infusion site are shown in Figure 12-8. The 2011 INS
For clients who are elderly or have fragile veins, standards recommend using a manufactured catheter stabili-
eliminate the tourniquet or apply it very loosely if zation device because such devices decrease the risk of phle-
a vein can be palpated. bitis, infection, and catheter dislodgment (Figure 12-8B).
Catheter stabilization devices decrease the movement of the
catheter in and out of the insertion site resulting in less irrita-
tion of the vein.
LOCATING A VEIN
When the solution has been prepared and the rate calculated,
explain the procedure to the client. With the client’s arm
extended on a firm surface, place a tourniquet on the arm,
tight enough to impede venous flow yet loose enough that a
radial pulse can still be palpated. Next, the index and middle
fingers of the nondominant hand are used to palpate a vein
(Figure 12-6). It should feel soft and resilient and not have a
pulse. If no vein can be seen or felt, a warm, moist compress
may be applied for 10 to 20 minutes, the area may be massaged
toward the heart, or the client may be asked to open and close
the fist (Berman, Snyder, Kozier, & Erb, 2008; Jensen, 2008a). A
PLACING THE NEEDLE/

CATHETER
After hand hygiene and gloving have been completed, prepare
the selected site according to agency policy. Without touch-
ing the prepared site, stabilize the vein by placing the thumb
INFECtION CONtROL
Venipuncture
Standard Precautions are followed when per- B
forming a venipuncture to prevent exposure to
bloodborne pathogens. Figure 12-8 A, Transparent dressing to secure IV infusion
site; B, an example of a manufactured catheter stabilization
device. (a, Delmar Cengage learning, B, Courtesy of C.r. BarD, inC.)
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A B C
Figure 12-9 A, A nurse is adding a medication to an IV line as a piggyback. B, The tubing of the medication is piggybacked
to the primary tubing at the Y-port. C, A nurse can also administer the medication by setting the dose and rate with an electronic
infusion device.
ADMINISTERING IV THERAPY
IV administration may be continuous over a 24-hour period,
or intermittent, 1,000 mL once in a 24-hour period. Although
fluids may be continuous, the type of fluids can change over a
24-hour period. For example, a physician’s order to the phar-
macy might read Add 40 mEq of KCl to first bag of 1,000 mL
of normal saline.
Intravenous medications may be piggybacked, con-
nected to an existing IV to infuse concurrently (Figure 12-9A).
Connect piggyback tubing to primary tubing at the Y-port

(Figure 12-9B). Refrigerated solutions and medications
should be warmed to room temperature before administra-
tion (usually for 30 minutes) for client comfort.
Regulating IV Solution
Flow Rate Figure 12-10 Volume IV pump/controller.
The flow rate for IV solutions can be regulated by calculating
the drops per minute and adjusting the drip rate to that num-
ber or by the use of volume controllers and pumps.
IV Pumps and Volume-Control infOrmatics

Devices electronic Infusion Devices
The IV infusion rate is generally regulated by an infusion
pump, which is also known as an IV pump or electronic EIDs have smart technology in the form of
infusion device (EID), an electronic device used to control computerized programming guidelines specific
the flow of IV solutions or medications (Figure 12-10). Pumps to the client care units on which they are
maintain a preselected volume delivery by adding pressure used (Weinstein, 2007). These devices are
when needed. Resistance may develop from the use of a large programmed with specific drugs, dosage ranges,
catheter in a small vein, high venous pressure, infusing a vis-
and infusion rates for medications and IV solutions
cous solution, or a decrease in the height of the container from
the IV site. Resistance causing a decrease in the flow will sound frequently administered on a specific clinical unit
the controller alarm indicating that the pump has reached its (Figure 12-9C). Another desirable option for
maximum pressure limit. Pumps may be used when large vol- EIDs may be the ability to infuse two solutions
umes must be delivered in a short period and for viscous fluids. simultaneously. Pumps should be inspected
When a drug or solution is administered under high pressure, regularly by biomedical technicians.
clients have a greater risk for complications.
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Figure 12-11 Dial-a-Flo in-line device to regulate IV flow.

saFety
Marking an IV Bag
The ink from a felt-tip pen can leak through the Figure 12-12 Applying a time strip to the IV container.
plastic and contaminate the solution. Do not use
such a pen.
BestPractice
Volume controllers are devices that are dependent on IV-related sepsis
gravity to maintain a preselected flow, but they do not add If a client has chills and fever, check how long the
pressure to overcome resistance (e.g., Dial-a-Flo or Buretrol). IV solution has been hanging and the needle or
Volumetric controllers permit flow rates to be set in milliliters catheter in place. Assess the client’s vital signs and
per hour (Figure 12-11). for other symptoms of pyrogenic reactions, such as
Sometimes a time strip is applied to the IV solution bag
backache, malaise, headache, nausea, and vomit-
as a safety check for the infusion pump or to monitor that
the infusion rate is the rate prescribed by the physician if an ing. If IV-related sepsis occurs, the pulse rate in-
infusion pump is not used (Figure 12-12). Tag the IV tubing creases and the temperature is usually above
with the date and time to notify other nurses when the tubing 100°F (37.7°C). Stop the infusion, notify the physi-
needs replacing. The time strip and the IV tubing tag are initi- cian, and obtain blood specimens if ordered.
ated by the nurse when a new bag is hung.
INS Standard 43 recommends changing the primary and
secondary continuous infusion sets every 96 hours. The inter-
mittent primary infusion is changed every 24 hours because of Client care is coordinated with the maintenance of IV
increased risk of contamination each time it is connected and lines. If the facility does not have snaps or Velcro on its gown
disconnected. Many facilities also change IV tubing when the sleeves, changing the gown and IV tubing when doing site care
catheters are changed. decreases the number of times the access device is manipu-
lated. This client care action decreases the risk for infiltration
MANAGING IV THERAPY and phlebitis. According to the 2006 INS standards, peripher-
ally inserted devices are changed every 96 hours.
Intravenous therapy requires frequent client monitoring to
ensure an accurate flow rate. Other nursing actions are to
ensure client comfort and position; check the IV solution Hypervolemia
to ensure that the solution, amount, and timing are correct; Hypervolemia (increased circulating fluid volume) may
monitor expiration dates of the IV system (tubing, venipunc- result from rapid IV infusion of solutions, causing cardiac
ture site, dressing) and change as necessary; and be aware of overload, which can lead to pulmonary edema and cardiac
safety factors. failure. If the IV rate is not regulated by a pump, the infusion
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rate must be monitored hourly to prevent these complications.

If the IV is regulated by a pump, check that the rate is flowing MeMOrY tricK
correctly on clients at risk for fluid volume overload.
When a solution infuses at a rate greater than prescribed, treating an Infiltration
decrease the rate to keep vein open (KVO) and immediately To remember the treatment for an infiltration, recall
notify the physician. Report the amount and type of solution the five s’s: site, skin, symptoms, sort, and sign.
that was infused over the exact time period and the client’s
response. Monitor infusion site.
Assess the client’s skin.
Infiltration Recognize symptoms.
Infiltration (accidental administration of a medication or sort out treatment.
solution not capable of causing injury into surrounding tissue)
may result from dislodging the device from the vein, inserting sign an adverse event report.
the wrong type of device, or using the wrong-gauge needle.
Adapted from Huber (2009).
Using a high-pressure pump may also cause infiltration or
vein irritation. The client usually expresses discomfort at the
IV site. Inspect the site by palpating for swelling and feeling
the temperature of the skin. Cool and blanching (pale) skin
is an indication of infiltration. Other symptoms of infiltration with permanent loss of function to the extremity. Extravasation
include skin tightness, decreased movement of extremity, is the inadvertent administration of a vesicant (medication
pain, and discomfort (Gorski, 2007). that causes blistering and tissue injury when it escapes from the
Follow the institution’s guidelines when there is a blood vessel) into surrounding tissue. This may cause signifi-
suspected infiltration, such as notifying an IV nurse or cant tissue loss with permanent disfigurement and loss of func-
charge nurse. If an infiltration occurs, remove the needle tion. INS Standard 48 for an extravasation includes immediate
or catheter from the vein and apply a sterile dressing to the discontinuation of the infusion, notification of physician, and
puncture site. immediate nursing interventions to decrease the effects of the
The puncture site may ooze or bleed after the IV is extravasation (INS, 2011).
removed (especially in clients receiving anticoagulants). If Nurses often think that an IV pump will alert them that
oozing or bleeding occurs, apply pressure until it stops and an IV is infiltrating. This is not always the case, since an infil-
reapply a sterile dressing. Accurately assess and document the tration or extravasation usually occurs below the alarm trigger
degree of edema according to the INS IV infiltration grading settings (Huber, 2009). Nursing interventions to prevent an
scale shown in Table 12-2. infiltration include frequent monitoring of the infusion site
Injury may occur from infiltration. If an IV site is grossly and client’s skin, recognizing symptoms and promptly treat-
infiltrated, the soft tissue edema may cause nerve compression ing, and notifying the biomedical technician of a possible
pump malfunction (Huber, 2009). See Memory Trick above
to recall nursing interventions for an infiltration.
Table 12-2 INS Standards
for Grading IV Infiltration Phlebitis
Phlebitis may result from either mechanical or chemical
INFILTrATION trauma or bacterial invasion of the site. Inserting a device with
GrADE CLINICAL SYMPTOMS too large a gauge, using a vein that is too small or fragile, or
leaving the device in place for too long may cause mechanical
0 No symptoms trauma. Chemical trauma may result from infusing too rapidly
1 Skin blanched, edema <1 inch, or from an acidic solution, hypertonic solution, or a solution
cool to touch, with or without pain containing electrolytes (especially potassium and magne-
2 Skin blanched, edema 1–6 inches, sium) or other medications.
cool to touch, with or without pain Phlebitis may be a precursor of sepsis. Client descriptions
3 Skin blanched/translucent, gross of tenderness are usually the first indication of an inflamma-
edema >6 inches, cold to touch, tion. The IV site must be inspected for changes in skin color
mild-moderate pain, possible and temperature. A reddened area or a pink or red stripe along
numbness the vein and warmth and swelling are indications of phlebitis.
If phlebitis is present, the vein might also feel rope-like to
4 Skin blanched/translucent, skin palpation.
tight/leaking/discolored, bruised, If phlebitis is present, the IV infusion must be discon-
swollen, gross edema >6 inches, tinued. Before removing and discarding the venous device,
deep pitting tissue edema, circula- check the facility’s protocol to see whether the tip of the
tory impairment, moderate-severe device is to be cultured. If so, it is sent to the laboratory for a
pain, infiltration of any amount of culture and sensitivity test. After removing the device, apply
blood product, irritant, or vesicant a sterile dressing to the site and wet, warm compresses to the
Adapted from Infusion Nurses Society (2011). affected area. Document the time, symptoms, and nursing
interventions.
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CASE STUDY
Client with an IV
O. H., a 56-year-old female, has a peripheral IV in her cephalic vein mid right forearm. It is a 20-gauge,
1-inch catheter. Her infusion is dextrose 5% with 0.45 normal saline with 20 mEq of potassium chloride
per liter at 125 mL/hr. The nurse assesses the IV site.
The following questions will guide your development of a nursing care plan for the case study.
1. What should the nurse include in her assessment of the peripheral IV?
The client reports discomfort at the IV site. She rates it a 4 on a 0–10 scale. When the nurse palpates the
site, she finds a 1-inch-diameter area of firm edema around the site. She also notices that O. H.’s right fore-
arm is larger in general than her left. O. H. denies her arms being asymmetrical in the past.
2. What is the most likely reason for the nurse’s findings?
3. What steps should the nurse take in relation to what she found at the IV site?
Intravenous Dressing Change bottle. Some hospitals have a policy of running 50 mL of the
insulin solution into the waste or sink so the tubing is coated
Standard Precautions and aseptic technique are followed for with insulin molecules, thereby providing the client with an
intravenous dressing changes. The frequency of care is deter- accurate dose.
mined by institutional protocol and the type of intravenous
access device and dressing. Persistent drainage at the IV site
may require more frequent dressing changes or may neces- Adding Drugs
sitate changing the IV site. to a Volume-Control
Administration Set
INTRAVENOUS DRUG THERAPY A volume-control set is used to administer small volumes
When a rapid drug effect is desired or a medication is irritat- of IV solution. They have various names, such as Soluset,
ing to tissue, the IV route is used. Intravenous administra- Metriset, Volutrol, or Buretrol. To use this method, do the
tion immediately releases medication into the bloodstream; following:
therefore, it can be dangerous. Intravenous medications are • Withdraw the prescribed amount of medication into a
administered by one of the following modes: syringe.
• Intravenous fluid container • Cleanse the injection port of a partially filled volume-
• Volume-control administration set control set with an alcohol swab.
• Intermittent infusion by piggyback or partial fill • Inject the prepared medication through the port of the
• Intravenous push (IVP or bolus) volume-control set.
• Gently mix the solution in the volume-control chamber.
Adding Drugs • Check the infusion rate and adjust as necessary.
to an Intravenous
Fluid Container Administering Medications
Before administering IV medications, assess the patency of by Intermittent Infusion
the infusion system and the condition of the injection site for A common method of administering IV medications is by
signs of infiltration and phlebitis. Some IV medications or using a secondary, or partial-fill additive bag, often called
solutions with high or low pH or high osmolarity are irritating an IV piggyback (IVPB). The secondary line is a complete
to veins and can cause phlebitis. Also note the client’s aller- IV set (fluid container and tubing with either a microdrip
gies, drug or solution incompatibilities, the amount and type or a macrodrip system) connected to a Y-port of a primary
of diluent needed to mix the medication, and the client’s line. The primary line maintains venous access. The IVPB is
general condition to establish a baseline before administering used for medication administration. When the IVPB medica-
medication. Drug incompatibilities are undesired chemical tion is incompatible with the primary IV solution, run the
or physical reactions between a drug and a solution, between medication as a primary solution, flushing with normal saline
a drug and the container or tubing, or between two drugs. For before and after the medication. Another method of infusing
example, diazepam (Valium) and chlordiazepoxide hydro- a medication that is incompatible with the primary line is to
chloride (Librium) are not compatible with a saline solution. disconnect the primary line from the IV catheter, flush the
Insulin sticks to the inside of the soft pliable solution bags catheter, connect the medication as a primary line to the IV
and IV tubing, so administer it in a rigid plastic bottle or glass catheter, and infuse the medication.
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BestPractice
heparin-Induced thrombocytopenia
Many facilities now use saline rather than hepa-
rin because of the potential for heparin-induced
thrombocytopenia (HIT). When a client is on
heparin therapy, including flushing of IV lines, an
autoimmune response can occur that causes clots
to form. The reaction occurs 5 to 14 days after
heparin therapy is initiated. HIT is diagnosed by a
A
decreased platelet count and a thrombosis. Com-
plications include pulmonary embolism, stroke,
myocardial infarction, and extremity ischemia.
(Baroletti & Goldhaber, 2006; Sisson, 2007)
Intermittent Infusion
Devices
When the client requires only IV medications without a quan-
tity of solution, an intermittent infusion device is attached to
a peripheral needle or catheter in the client’s vein. This device
B
is commonly referred to as a heparin or saline lock, depending
on the facility’s policy of heparin or saline maintenance. A lock
provides continuous venous access, eliminating the need for a
continuous IV and increasing the client’s mobility.
The device is used to infuse intermittent IVPB or IV
push (also called bolus) medications, or it can be converted
to a primary IV. An IV push (bolus) is the administration of
a large dose of medication in a relatively short time, usually
1 to 30 minutes. A saline lock device provides venous access in
case of an emergency and is routinely used with cardiac clients.

Administering IV Push
Medications C
An IV push medication can be injected into a saline or a hepa-
rin lock or through a continuous infusion line (Figure 12-13). Figure 12-13 Injecting an IV push (bolus) medication:
When giving an IV push medication into a continuous infusion A, into a peripheral saline lock; B, into a primary infusion line;
C, another type of needleless syringe and needleless IV access
device for administering intravenous medications.
MeMOrY tricK
sash line, stop the fluids in the primary line by placing the pump on
One way to remember the order of flushing when hold while injecting the drug.
administering medications IV is the acronym sas
for peripheral lines and sash for central lines if Documentation
adding heparin follows institutional policy. When IV therapy is begun, the date, time, venipuncture
s 5 Saline flush site, number of attempts made, amount and type of fluid,
and equipment used must be documented. Each time the
a 5 Administer medication insertion site, venipuncture device, or IV tubing is changed,
s 5 Saline flush the reason for the change must be documented (e.g., rou-
tine, infiltration). The condition of the insertion site and
h 5 Heparin flush; usually central lines only, not
the fluid type, amount, and flow rate are documented each
peripheral lines. Only use heparin if it follows shift and at intervals specified by agency policy. Any com-
institutional policy. plications are precisely documented along with the nurse’s
actions.
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LIFe sPan ConsIDeratIons
Incorrect Drug Initial assessment
If older clients with congestive heart failure or mal-
nutrition are at risk for circulatory overload, notify
You discover that a similar but incorrect drug
the blood bank to divide the 500-mL bag of blood
(not the drug ordered) is being given IV to a
into two 250-mL bags or discuss with the physician
client.
other alternatives, such as packed RBCs rather than
1. What is the first thing you should do?
whole blood.
2. What is your next course of action?
3. How do you feel about the nurse who made
the medication error and did not recognize it?
saFety
BLOOD TRANSFUSION Blood transfusion Incompatibilities
The LPN/LVN role when blood transfusions are adminis- Only 0.9% normal saline can be used with a blood
tered varies from state to state. It is the responsibility of the product. Blood transfusions are incompatible with
LPN/LVN to know the rules and regulations of the state dextrose and with Ringer’s solution.
board of nursing in the state of clinical practice.
A blood transfusion is given to replace blood loss (deficit)
with whole blood or blood components. Based on the client’s
unique needs, the physician determines the type of transfu-
sion, either whole blood or a component of whole blood.
BestPractice
Whole Blood
transfusion reaction
and Blood Products
Whole blood contains red blood cells (RBCs) and plasma The severity of a transfusion reaction is related to
components of blood. It is used when all the components of the time of onset. Severe reactions usually occur
blood are needed to restore blood volume and to restore the shortly after the blood begins to infuse. At the
oxygen-carrying capacity of the blood. first sign of a reaction, stop the blood infusion
When the physician prescribes whole blood or a blood immediately.
product, the client’s blood is typed and cross matched. If time
and the client’s condition permit, the family may arrange for
donors. The blood is stored in the blood bank after typing and
crossmatching.
to verify that the client’s name and blood type match the
Whole blood has a refrigerated shelf life of 35 days, but
name and blood type on the transfusion bag.
platelets must be administered within 3 days after extracted
from whole blood. If the RBCs and plasma are frozen, their • Assess the client’s age and state of nutrition.
shelf life is up to 3 years (Kee, Paulanka, & Polek, 2010). Infuse scheduled IV medications before blood admin-
istration to prevent a medication reaction while blood is
Initial Assessment infusing. If a reaction were to occur, it would not be known
whether the medication or the blood was causing the reaction.
and Preparation
Perform an initial assessment before administering blood:
Administering Whole Blood
• Verify that the client has signed a blood administration con-
sent form and that the consent matches what the physician
or a Blood Component
has prescribed. A facility’s blood protocol may require that a licensed person
sign a release for blood from the blood bank and that two
• Identify the gauge of needle or catheter if an IV is in place.
licensed personnel check blood products before infusion. The
A 20-gauge catheter is frequently used for blood adminis-
client’s name and identification number, ABO group and Rh
tration, especially if a rapid infusion is needed.
factor, donor number, type of product ordered, and expiration
• Ensure patency of the existing IV site. date must be on the blood bag label and verified for accuracy.
• Establish vital signs baseline data, especially temperature, To maintain RBC integrity and decrease the chance
and assess skin for eruptions or rashes. of infection, blood administration should begin within
• Verify label on the whole blood or blood component with 30 minutes after it is received from the bank. Whole blood
the client’s blood type before administration, to ensure should not be unrefrigerated for more than 4 hours. After
compatibility. Many facilities require two registered nurses 4 hours, the blood may become contaminated with bacteria.
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Safety Measures Table 12-3 Nursing Actions

Vital signs are taken before initiating the infusion, 15 min- for Blood reactions
utes after start, every hour while the blood is infusing, and at
the completion. When blood administration is first started, IMMEDIATE
closely observe the client for a transfusion reaction within the NUrSING ACTION OTHEr MEASUrES
initial 15 minutes.
The three basic types of transfusion reactions are allergic, • Stop transfusion. • Monitor client’s vital
febrile, and hemolytic and may be mild or severe, depend- • Keep vein open with signs every 15 min for
ing on the cause. Hemolytic reactions may be immediate or 0.9% normal saline. 4 hrs or until stable.
delayed up to 96 hours, depending on the cause of the reac- • Notify the physician. • Monitor I&O.
tion. Other complications include sepsis, hypervolemia, and • Send IV tubing and bag
hypothermia. The classic symptoms of a reaction and sepsis of blood back to the
are fever and chills. blood bank.
The nursing actions for all types of reactions and com- • Obtain a blood and urine
plications are given in Table 12-3. Table 12-4 gives details of specimen.
several transfusion reactions, etiologies, signs and symptoms,

• Label specimen “Blood
and treatments.
Transfusion Reaction.”
• Process a transfusion
reaction report.
transfusion reactions
How can a nurse determine the type of transfu-

sion reaction a client is experiencing?
Table 12-4 Transfusion reactions, Etiologies, Signs and Symptoms,

and Treatments
rEACTION ETIOLOGY SIGNS AND SYMPTOMS TrEATMENTS
Acute Reactions
Acute hemolytic Incompatible blood Fever, low back pain, Stop the transfusion immediately.
transfusion reac- product transfused be- pain at IV site, hypo- Keep the vein open with a 0.9%
tion (intravascular cause of errors during tension, tachycardia, normal saline IV. Contact physician
hemolysis) processing the blood abdominal pain, dys- stat. Support vital functions—may
products and the type pnea, nausea/vomiting, require hemodialysis. Complete
and crossmatch rash/hives, headache, lab tests necessary to determine
anxiety, renal failure if blood reaction occurred.
Nonhemolytic trans- Reaction to donor leu- Fever, anemia, increased Give premedications to reduce
fusion reaction kocytes in the blood bilirubin levels reaction: acetaminophen (Tylenol),
products diphenhydramine hydrochloride
(Benadryl), hydrocortisone
(Cortef).
Allergic reactions Recipient antibodies Itching to rashes to ana- Stop the transfusion, treat with
against donor antigens phylaxis and shock antihistamines; may resume slowly
(foreign proteins) or when symptoms resolved.
ingredients to keep blood
safe for infusion
Transfusion-related Anti-HLA antibodies and Acute respiratory insuf- Support respiratory function,
acute lung injury neutrophil antibodies ficiency, chills, fever, IV steroids.
(TRALI) cyanosis, hypotension
(Continues)
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Table 12-4 Transfusion reactions, Etiologies, Signs and Symptoms,

and Treatments (Continued)
rEACTION ETIOLOGY SIGNS AND SYMPTOMS TrEATMENTS
Bacterial con- Endotoxins from Fever, shock, dis- High-dose antibiotics, vital organ
tamination of blood gram-negative and seminated intravascular support, steroids.
product gram-positive bacteria coagulation (DIC), renal
failure
Circulatory overload Too rapid a flow rate for Dyspnea, cough, frothy Support respiratory system, adminis-
client’s cardiovascular sputum ter diuretic between units, use slower
system infusion rates for clients with known
cardiovascular compromise.
Citrate toxicity Hypocalcemia resulting Tetany Monitor for signs and symptoms.
from citrate binding with Monitor calcium level and transfuse
calcium in the recipient’s extra calcium, if warranted.
bloodstream
Delayed Reactions
Graft-versus-host Lymphocytes infused Fever, hepatitis, bone Pretransfusion radiation of blood
disease with blood product into marrow suppression, products containing lymphocytes
an immunosuppressed overwhelming infection, preventing replication of donor
recipient 90% to 100% mortality lymphocytes and the engrafting
rate process.
Disease transmitted Contamination during Depends on disease Careful aseptic technique through
with the blood prod- processing, preexisting transmitted all portions of donation and transfu-
uct: bacterial, syphi- donor infection, contami- sion, careful screening of donors
lis, protozoal, viral nation during donation and testing of blood products for
viruses.
Delayed hemolytic Reaction to donor None to fever, mild jaun- Conduct additional antibody
reaction antibodies dice, and anemia testing prior to additional blood
transfusions.

Iron overload Repeated blood Liver failure, cardiac Infuse chelation treatment
transfusions for chronic toxicities Desferal to bind to iron and remove
anemic conditions, such from system. Monitor iron level
as sickle cell anemia routinely.
SAMPLE NUrSING CArE PLAN
the Client with Dehydration

M.G., a 67-year-old male, was mowing his yard with a push mower when the temperature was 90°F (32.2°C). He
became faint, weak, and nauseated. Because he has a history of a myocardial infarction, his wife took him to the
emergency department. The physician ordered an ECG, which was normal. He is diagnosed with dehydration. An IV
is started and the nurse develops a plan of action with the client regarding IV therapy.
NUrsING DIAGNOsIs 1 Deficient Knowledge related to receiving peripheral IV therapy

Knowledge: IV Therapy Health Education
Risk Identification
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SAMPLE NUrSING CArE PLAN (Continued)

PLannIng/outCoMes nursIng InterVentIons ratIonaLe
M.G. verbalizes reason for IV therapy. Describe reason for IV therapy to Knowledge helps the client be an
client and explain the IV insertion active participant in his care.
procedure.
Review potential complications of The client can inform the nurse when
which the client informs the nurse: he observes complications.
redness, pain, edema.
Teach the importance of hydra- Sweating depletes the body of fluids,
tion especially when working in predisposing the client to dehydration.
high temperatures. Replace fluids with water or an elec-
trolyte drink.
evAlUAtION
M.G. verbalizes knowledge of purpose of peripheral IV therapy.
NUrsING DIAGNOsIs 2 Risk for Imbalanced Fluid Volume related to infusion of IV fluids
Fluid Balance Fluid Management
Hydration Intravenous (IV) Therapy
PLannIng/outCoMes nursIng InterVentIons ratIonaLe

M.G. shows no signs of fluid overload Weigh client daily at same time, An increase in weight may indicate
(increased weight, edema in extremi- on same scale, with same amount fluid overload.
ties, moist respirations, or decreased of clothing.
output).
Inspect extremities for edema ev- Edema may indicate increasing fluid
ery 8 hrs. volume.
Assess breath sounds every shift Adventitious breath sounds may indi-
and more often if respirations in- cate early fluid overload.
crease or become moist.
Monitor intake and output. Intake greater than output may indi-
cate fluid overload.
evAlUAtION
M.G. does not gain weight, has no edema, and breath sounds are normal.
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ConCePt Care MaP 12-1
NURSING DIAGNOSIS 3
Risk for Infection related to a site for organisms secondary to the presence of an invasive line
NOC: Immune Status; Risk Detection

NIC: Health Screening; Infection Control
CLIENT GOAL
M.G. remains free from signs or symptoms of infection during IV therapy.

1. Assess client’s history for presence of 1. Awareness of conditions predisposing the
diseases or conditions that predispose client to infections helps nurses to be more
client to increased risk for infection. vigilant for infections.
2. Maintain sterile dressing at insertion site. 2. Aseptic technique reduces risk for infections.
3. Inspect site every 2 hours. 3. Early detection of problems allows for
early treatment of infection.
4. Remove IV at first sign of infection – 4. Removal of IV reduces access of bacteria
culture site prior to removing catheter. to client. Culture determines presence of
causative organism.
5. Use proper hand hygiene before working 5. Correct hand hygiene reduces viable
with IV equipment. organisms.
6. Wear gloves due to risk of contact with 6. Standard Precautions protect nurse and
blood borne pathogens. client.

EVALUATION
M.G.’s IV site remains free of redness, warmth, and edema.
CONCLUSION calculated correctly. Careful, frequent IV site assessments

prevent significant complications. The rules and regulations
IV infusions and blood transfusions are procedures that can of state boards of nursing specifically state the LPN/LVN
have grave consequences if completed incorrectly. Sterile and RN role in IV therapy and blood administration. It is
technique is essential when handling IV equipment and the responsibility of the nurse to know and abide by these
administering IV medications. It is vital that flow rates are guidelines.
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UNit SUMMa r Y
• Homeostasis is the maintenance of the body’s internal • The bicarbonate buffer system works to regulate pH in
environment within a narrow range of normal values. It is both intracellular and extracellular fluids.
an ongoing process, with changes constantly occurring in • The phosphate buffer system works to regulate the pH
the body. of intracellular fluid and fluid in kidney tubules.
• Compounds that ionize in water are called electrolytes. • Protein buffers regulate pH inside cells, especially red
• Substances move in and out of cells by the passive trans- blood cells.
port methods of diffusion, osmosis, and filtration and by • Hospitalized clients, especially elderly clients, are at risk
active transport. for developing dehydration.
• The kidneys regulate fluid and electrolyte balance. • Clients receiving IV therapy require constant monitoring
• Sodium is the main electrolyte that promotes the reten- for complications.
tion of water. • Parenteral drugs are injected through intradermal (ID),
• The slightest decrease or increase in electrolyte levels subcutaneous, intramuscular (IM), or intravenous (IV)
can cause serious, adverse, or life-threatening effects on routes and are typically fast acting.
physiological functions. • Clients receiving intravenous therapy or blood transfu-
• The normal range of blood pH is 7.35 to 7.45. A decrease sions require constant monitoring for complications.
or increase beyond this range can cause severe or even
fatal physiological problems.
t HEOr Y t O Pr a Ct iCE
1. In the clinical setting, review the chart of a client who has had diagnostic blood work com-
pleted for electrolyte levels. Use Table 10-4 in Chapter 10 to review and compare with the
client’s electrolyte levels. Are the client’s electrolytes within normal range? If not, what action
should be taken?
2. Use the “ROME” memory trick from Chapter 11 to figure out if a client is in respiratory or
metabolic acidosis/alkalosis depending on the arterial blood gas (ABG) laboratory results.
A. A client’s ABGs are pH 7.33, PaCO2 56, HCO3 24, PaO2 62.
B. A client’s ABGs are pH 7.48, PaCO2 40, HCO3 44, PaO2 92.
C. A client’s ABGs are pH 7.47, PaCO2 32, HCO3 26, PaO2 80.
D. A client’s ABGs are pH 7.34, PaCO2 38, HCO3 22, PaO2 89.
3. An order reads 1,000 mL D5W with 20 mEq KCl over 8 hours. Drop factor is 10 gtts/mL.
A. Calculate the mL/hr.
B. Calculate the gtts/min.
4. An order reads 2,000 mL NS over 24 hours. Calculate the mL/hr.
5. Observe a nurse starting an IV and hanging an administration set, administering an IV push
medication, and a piggyback medication. Answer the following questions:
A. What teaching did the nurse give the client when she started the IV?
B. How quickly was the IV push medication given? How did the nurse determine how fast to
administer the medication?
C. What medication was given piggyback? How did the nurse determine the flow rate?
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NCl EX-St Yl E r EViEW QUESt iONS

1. A nurse is assessing a 77-year-old postoperative 6. Which client is at greatest risk for developing meta-
client using a morphine sulfate PCA pump for pain bolic acidosis?
control. The assessment data reveal a respiratory 1. A 29-year-old client with broken ribs
rate of 8 bpm and irregular. The client is lethargic 2. A 41-year-old client with hypertension
and confused. The nurse is updating the client’s 3. A 63-year-old client positive for ketones
care plan and selects which nursing diagnosis as 4. A 58-year-old client with hypokalemia
top priority?
7. The nurse is teaching a client with a serum potas-
1. Risk for Injury related to regulatory function sium level of 3.2 mEq/L about foods that are rich in
2. Impaired Gas Exchange related to inadequate potassium. The client correctly identifies all the fol-
ventilation lowing foods as potassium rich except:
3. Ineffective Airway Clearance related to viscosity 1. a dinner roll.
of secretions 2. raw carrots.
4. Rest and Sleep Disturbance related to ineffective 3. a baked potato.
breathing pattern
4. an apricot.
2. The nurse determines that which of the following
8. A client experiencing fever, pain, and rapid, shallow
clients is at greatest risk for developing a decrease
respirations is brought to the emergency department
in pH?
for treatment. Assessment findings include hyperac-
1. A 39-year-old client diagnosed with pneumonia tive reflexes, a positive Chvostek’s sign, and muscle
2. An 89-year-old client prescribed Vasotec 5 mg, tremors. The ABG results are pH 7.50 and PaCO2
IV push 28 mm Hg. This client is at risk for:
3. A 45-year-old client diagnosed with asthma 1. respiratory acidosis.
4. A 64-year-old client diagnosed with irritable 2. respiratory alkalosis.
bowel syndrome
3. metabolic acidosis.
3. A nurse is caring for a client receiving mechanical 4. metabolic alkalosis.
ventilation treatment for respiratory failure. The
9. Which of the following arterial blood gas values
nurse suspects that the ventilator rate is set too high,
would the nurse document as respiratory acidosis?
causing hyperventilation. What acid–base problem
1. pH 5 7.31; PaCO2 5 50; HCO3 5 30
could result from the ventilator rate being set too
high? 2. pH 5 7.32; PaCO2 5 39; HCO3 5 25
1. Metabolic acidosis 3. pH 5 7.42; PaCO2 5 29; HCO3 5 19
2. Respiratory acidosis 4. pH 5 7.50; PaCO2 5 35; HCO3 5 22
3. Metabolic alkalosis 10. When the intracellular fluid (ICF) compartment
4. Respiratory alkalosis develops an osmolality greater than the extracellular
fluid (ECF) compartment, water shifts from the
4. Acidosis and alkalosis are identified by changes in
ECF into the ICF compartment. This fluid shift is
the pH. Which of the following statements is true?
known as:
1. A pH above 7.45 is called acidosis.
1. active transport.
2. A pH above 7.45 is called alkalosis.
2. osmosis.
3. A pH increase caused by an increase of bicarbon-
3. diffusion.
ate in the blood is metabolic acidosis.
4. filtration.
4. A pH decrease caused by an accumulation of car-
bonic acid results in respiratory alkalosis. 11. A 72-year-old male client has COPD. He is cur-
rently hospitalized with an upper respiratory infec-
5. A nurse is taking a health history from a client
tion. ABG results are pH 5 7.33, PaCO2 5 60, and
who admits to using an excessive amount of base-
HCO3 5 24. Which objective assessment findings
containing antacids every day. The nurse’s best
can the nurse expect for this client?
response to client is:
1. Headache, nausea, and chest pain
1. “Antacids can decrease the risk of alkalosis.”
2. Hypotension, heart block, and tachycardia
2. “The more antacids you take, the greater your
risk for developing alkalosis.” 3. Prolonged PR interval, slow shallow respirations,
and bradycardia
3. “You should not take antacids.”
4. Warm flushed skin, weak thready pulse, and
4. “Acidosis is increased when an excessive amount
hypertension
of antacids is used.”
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12. Which of the following clients is at greatest risk for 3. Culture the IV site.
decreased oral fluid intake? 4. Elevate the extremity.
1. A 35-year-old NPO female client 17. A health care provider orders 2,000 mL D5W over
2. A 52-year-old male client with an IV running at 24 hours. Drop factor is 10 gtts/mL. The IV should
30 mL/hr run at how many gtt/min?
3. A mildly confused 80-year-old female client 1. 1.4 gtts/min
4. A lightly sedated client waiting for a Foley cath- 2. 14 gtts/min
eter to be inserted 3. 83 gtts/min
13. When teaching a hypocalcemic client about calcium 4. 833 gtts/min
supplements, it is important to educate the client 18. All of the following conditions were present in a
that which vitamin is required for absorption of client. Which one would prohibit inserting an IV in
calcium in the gastrointestinal tract? that particular arm?
1. Vitamin C 1. The vital sign machine’s blood pressure cuff is
2. Vitamin B12 wrapped on the arm.
3. Vitamin B6 2. A dialysis fistula is present.
4. Vitamin D 3. The arm or hand is the dominant one.
14. A client receiving a blood transfusion tells the nurse, 4. There was a previous IV site in the extremity.
who is taking the first set of 15-minute vital signs 19. The nurse is preparing to give the client an antibi-
that she is cold (chills) and her chest hurts. The otic. What actions will the nurse perform? (Select all
nurse’s first priority is to: that apply.)
1. stop the transfusion. 1. Educate the client about the medication and side
2. get a warm blanket for the client. effects.
3. call the blood bank to come and check the blood. 2. Assess for desired and unwanted effects.
4. stay with the client and talk quietly to her to help 3. Order the correct dose for individual clients.
her relax. 4. Know the proper administration route.
15. A 76-year-old client has a peripheral IV infusing in 5. Alter the dose to achieve maximum response.
her left arm. The nurse discovers all of the following 6. Understand the correct administration rate.
findings in her assessment. To what does the nurse 20. The nurse is caring for a client who experienced an
react and treat immediately? infusion-related infection. What nursing interven-
1. The IV site is bruised without edema. tion would be most important?
2. The client reports tingling in her hands and 1. Educate the client on good hand hygiene.
muscle cramping. 2. Monitor for dysrhythmias.
3. The client has a moist cough and distended neck 3. Monitor for signs and symptoms of sepsis.
veins.
4. Use full barrier precautions when initiating
4. The client’s urine output was 150 mL for the past IV therapy.
8 hours.
16. The client is complaining of pain at her IV site.
The nurse assesses the site and notes that there is a
hard cord along the vein, diffuse redness, and slight For additional content, activities, games, and
edema. The nurse opts to remove the IV and per- more, visit the White Premium Website at
form which nursing intervention? www.cengagebrain.com.
Use the access code printed in the front of
1. Cleanse the site carefully with chlorhexidine.
this book to log on to this free resource today!
2. Apply warm soaks.
r EFEr ENCES/SUGGESt ED r Ea DiNGS

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r ESOUr CES
American Association of Critical-Care Nurses National Coordinating Council for Medication Error
http://www.aacn.org reporting and Prevention
Infusion Nurses Society http://www.nccmerp.org
http://www.ins1.org National Council of State Boards of Nursing, Inc.
Institute for Safe Medication Practices https://www.ncsbn.org
http://www.ismp.org U.S. Pharmacopeia
http://www.usp.org
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88021_ch12_ptg01_246_270.indd 270 12/29/11 11:51 AM

Perioperative
UNIT 4
Nursing Care
13 Caring for Surgical Clients / 272
Clients are anxious when confronted with having surgery. These types
of questions may cross their minds: What will the surgeon find? Will
the growth be cancerous? Will the scar be ugly? How long will it take
me to recover? Will I be able to live a normal life afterwards? The nurse
fulfills a special role in alleviating the client’s fears and in teaching the
client what to expect from the surgical experience. Chapter 13, Car-
ing for Surgical Clients, explains the nurse’s role in the perioperative
setting. Specific assessment techniques are described for the preop-
erative and postoperative phases. Thorough postoperative nursing
care is discussed to prevent postoperative complications. However,
if the client experiences complications, appropriate nursing interven-
tions are presented so that the nurse can meet the client’s needs.
Detailed teaching guidelines assist the nurse in preparing the client for
discharge.
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ChApTER 13
Caring for Surgical Clients
KEy TERmS
KEy TERmS
Aldrete score aseptic technique perioperative
ambulatory surgery capnography postoperative phase
amnesia dehiscence preoperative phase
analgesia evisceration regional anesthesia
anesthesia general anesthesia sedation
anesthesiologist informed consent sterile conscience
anesthetist intraoperative phase surgery
asepsis orthostatic hypotension synergism
LEARNING OBJECTIVES
2. List risk factors in a preoperative nursing assessment.
3. List information in a general teaching plan for a preoperative client.
4. Identify common nursing care for the preoperative, intraoperative, and postoperative
phases.
5. Describe the principles of asepsis and their application to nursing practice.
6. Describe the difference between regional and general anesthesia.
7. Identify the purposes of sedation.
8. Describe the effects of sedation or general anesthesia on memory and cognitive function.
9. Discuss the types of monitoring necessary to ensure client safety during sedation.
10. Describe the signs and symptoms and risks of oversedation.
11. Discuss the dangers involved in aspiration of gastric contents and how gastric aspiration
is prevented during anesthesia.
272
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CHAPTER 13 Caring for Surgical Clients 273
12. List the medications that are typically given on the day of surgery.
13. List and describe the different types of regional anesthesia.
14. Describe the risks involved with regional and general anesthesia.
15. Discuss the residual effects of anesthesia on the client.
16. Discuss nursing interventions to prevent or treat postoperative complications.
17. List three methods of postoperative pain management and explain briefly how each
is administered.
18. Explain information needed by the postoperative client before discharge.
19. Discuss the physiological changes of aging that affect the older adult client’s response
to surgery.
20. plan care for a postoperative client.
The term perioperative encompasses the preopera-

INTRODUCTION tive (before surgery), intraoperative (during surgery), and
Surgery refers to the treatment of injury, disease, or defor- postoperative (after surgery) phases of surgery. Each phase
mity through invasive operative methods. Surgery is a unique refers to a particular time during the surgical experience, and
experience, with no two clients responding alike to similar each requires a wide range of specific nursing behaviors and
operations. Even the same client may respond differently functions. Perioperative nursing has one continuous goal: to
to two separate surgical situations or to the same surgery provide a standard of excellence in the care of the client be-
performed at a later time. To a client, there is no such thing fore, during, and after surgery. Nursing activities are geared to
as minor surgery; anxiety and fear are normal. Surgery, even meet the client’s immediate physical and psychosocial needs.
when planned well in advance, is a stressor that produces both Individuals face surgery with their own values. Each client
psychological (anxiety, fear) and physiological (neuroendo- has specific expectations of the surgical experience and dis-
crine) stress reactions. tinct hopes for the outcome of the surgery. The nurse takes an
Surgeries are classified as minor (presenting little risk active part in the entire perioperative process to ensure quality
to life) or major (possibly involving risk to life) and are per- and continuity of client care.
formed for a variety of reasons. Table 13-1 lists indications
for surgery.
PREOPERATIVE PHASE
The preoperative phase begins with the client’s decision
to have surgery and ends with the transfer of the client to the
operating table.
Table 13-1 Indications for Surgery The outcome of surgical treatment is tremendously
enhanced by accurate preoperative nursing assessment and
TYPE OF careful preoperative preparation. The client is assessed by the
SURGERY PURPOSE EXAMPLE nurse both physiologically and psychologically. Assessment
Diagnostic Detect or confirm Biopsy
of the client involves the integration of factors relating to the
cause of symptoms
client’s illness, physical condition, related medical conditions,
Exploratory and current surgical diagnosis. Regardless of how minor the
laparotomy surgical procedure, obtaining a thorough health history is
Curative Remove a diseased Cholecystectomy essential. The health history must be available to the periop-
body part or replace erative team throughout client’s surgical experience.
Total knee
a body part to re- The psychological well-being of the client has an impact
arthroplasty
store function on the surgical outcome. The surgical client is at risk for
anxiety related to the surgical experience and the outcome
Palliative Relieve symptoms Tumor resection of surgery. Fear and anxiety are normal responses to the
without curing associated with stress of surgery and affect the client’s ability to cope with the
disease cancer proposed plan of care. Because individuals differ in their per-
ceptions of the meaning of surgery, the degree of anxiety and
Restorative Strengthen a Herniorrhaphy fear experienced varies. If fear and anxiety become excessive,
weakened area however, these emotions interfere with recovery by magnify-

ing the normal physiological stress response. By assessing and
Cosmetic Improve appearance Face lift being aware of the fears and anxieties of the surgical client, the
Change shape Mammoplasty nurse can provide support and information so that stress does
not become overwhelming. The most common fears related
273
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274 UNIT 4 Perioperative Nursing Care
BOX 13-1 BOX 13-2

COMMON FEARS OF SURGERY COMMON PREOPERAtivE
LAbORAtORY tEStS
Fear of the unknown
Fear of pain and discomfort • Complete blood count (Some physicians only
Fear of mutilation and disfigurement order a hemoglobin and hematocrit [Hgb and
Hct] and white blood cell [WBC] count.)
Fear of anesthesia
• Blood typing and crossmatching (screening)
Fear of disruption of life patterns • Serum electrolytes
• Separation from family/significant others • Prothrombin time (PT), International Normal-
• Sexuality ized Ratio (INR), and partial thromboplastin
• Financial time (PTT)
• Permanent/temporary limitations • Bilirubin
Fear of death/not waking up • Liver enzymes: alanine aminotransferase (ALT)
Fear of not being in control and aspartate aminotransferase (AST)
• Urinalysis
• Blood urea nitrogen (BUN) and creatinine
• Pregnancy test for women of childbearing age
to surgery are listed in Box 13-1. Fear of the unknown is the and no history of hysterectomy
most prevalent fear before surgery and is the fear the nurse
can easily allay through client education and preoperative
teaching.
Preoperative Physiological computerized tomography scans provide useful information

about the nature of the disease process and its anatomic loca-
Assessment tion and extent. Any organ that is undergoing major surgery
Physiological assessment includes a physical examination and is adequately evaluated with these techniques before the
a review of the client’s laboratory values and diagnostic stud- operation.
ies. Laboratory and diagnostic studies are divided into those Electrocardiograms (ECGs) are routinely performed in
that are routine and those that are performed specifically to middle-age and older adult clients undergoing surgery be-
evaluate the client’s primary disease process or coexisting cause of the prevalence of ischemic heart disease in these age
condition. The common preoperative laboratory tests are groups. It is also of value to have a baseline study for compari-
listed in Box 13-2. son in case subsequent ECGs are needed.
When clients are admitted to the hospital, a chest x-ray Preoperative testing is completed several days before the
is often omitted for healthy adults younger than 40 years date of surgery. The type and amount of screening depends on
of age in whom the physical examination is normal and the age and condition of the client, the nature of the surgery,
there is no reason to suspect pulmonary or cardiac disease. and the surgeon’s preference. Surgeons (doctors who perform
Additional radiographic or fluoroscopic examinations, sono- surgery) are coming under increasing economic pressure to
grams, radioisotopic scans, magnetic resonance imaging, and minimize routine testing procedures. The current trend is
based on costs versus benefits, moving away from extensive
testing in the absence of indicative/warranting data from the
health history and physical examination. The nurse’s role in
Mental HealtH preoperative testing is to ensure that the ordered tests are per-
COnneCtiOns formed, that the results are placed in the client’s chart, and that
abnormal results are reported to the physician immediately.
Clients’ Psychological Condition The physiological nursing assessment is completed be-
fore surgery. Preoperative assessment takes place in the
The client “who fears dying while under an-
surgeon’s office, in the hospital during hospitalization, or in
esthesia runs a greater risk of cardiac arrest the hospital or ambulatory surgery unit on the day of surgery.
on the operating table than [do] clients with The nurse collects client health data by interviewing the cli-
known cardiac disease” (Phillips, 2007). The ent, the family, significant others, and health care providers.
psychological condition of the client can have a Data collection also is accomplished through review of the
stronger influence than does the physical condi- client’s records, assessment, consultation, or via phone prior
tion. Encourage clients to express their feelings to surgery. Assessment is essential to establishing nursing di-
and fears about receiving anesthetic and having agnoses and predicting outcomes. When performing the nurs-
surgery. Observe the client for nonverbal clues ing assessment, the nurse screens the client for risks that may
indicating anxiety. To reduce client anxiety, contribute to complications in the perioperative period. The
explain what happens throughout the surgical
nurse’s role in the preoperative phase ensures client safety,
understanding, and compliance with health care treatment.
experience.
The variables affecting surgical status are age, nutrition, fluid
and electrolytes, various body systems, and medications.
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Age pneumonia, and also leads to decreased wound healing and

an increased risk of thrombus formation. Often, obese clients
Surgery is performed on individuals of any age, although also have other chronic conditions, such as hypertension or
persons at both extremes of age (infants and elders) are at diabetes mellitus, that increase the likelihood of surgical com-
greater risk for complications. Older adult clients experience plications. In some surgical situations, such as joint replace-
many physiological changes associated with aging and are ment, surgery is delayed until nutritional status improves and
more likely to have degenerative disease in many organs. the client loses weight.
Older adults are more likely to become dehydrated and are
thus less able to adapt to fluid loss during surgery. The older
adult client is also more sensitive to central nervous system Fluid and Electrolyte Status
depressants used during the perioperative period; however, Dehydration and hypovolemia, with correlating electrolyte
even older adult clients favorably tolerate extensive surgery disturbances, predispose a client to complications during and
when carefully assessed and managed. after surgery. Both are caused by diarrhea, excessive nasogas-
tric suctioning, inadequate oral intake, vomiting, and bleed-
Nutritional Status ing. The complications of fluid and electrolyte imbalance are
Nutritional assessment includes evaluation of individual defi- numerous and varied. Changes in fluid and electrolyte balance
ciencies or excesses that place the client at greater risk for com- affect cellular metabolism, renal function, and oxygen concen-
plications during surgery. Surgery increases the body’s need for tration in the circulation. Nursing care focuses on administer-
nutrients necessary for tissue healing and resistance to infection. ing parenteral fluids or blood products as prescribed, keeping
Nutritional deficiencies place the client at greater risk a detailed intake and output record, and evaluating results of
for fluid and electrolyte imbalance, delayed wound healing, laboratory studies.
and wound infections. The malnourished individual has
diminished stores of carbohydrates and fats; in such instances, Respiratory Status
proteins are used for energy instead of tissue building and Respiratory assessment includes detection of acute and
restoration. In addition to carbohydrates and fats, vitamins B chronic problems. Because acute respiratory infections may
complex and C are also significant because these vitamins are lead to bronchospasms or laryngospasms, surgery for clients
essential to healing. Poor nutritional status also adversely af- with these conditions is delayed or contraindicated. Chronic
fects liver and kidney function, leaving the client with a poor respiratory problems, such as asthma and chronic obstructive
tolerance for anesthetic agents and a tendency for bleeding. pulmonary disease, impair the client’s gas exchange and in-
Nutritional excesses or obesity increase the risk for re- crease the risk associated with the use of inhalation anesthetic
spiratory, cardiovascular, and gastrointestinal complications. agents. Clients with chronic respiratory problems are more
Obesity makes access to the surgical site more difficult, which likely to develop atelectasis and pneumonia.
prolongs surgical time and increases the amount of anesthetic Respiratory assessment as performed by the nurse in-
agents required. Because inhalation anesthetics are absorbed cludes assessing breath sounds, color of the skin and
by and stored in adipose tissue and released postoperatively, mucous membranes, and for shortness of breath (dyspnea)
recovery time from anesthesia is slower in the overweight and coughing. All clients, and especially those who smoke and
client. Adipose tissue is less vascular and more difficult to have chronic lung disease, are taught deep breathing, use of
suture, which predisposes the client to wound infection, incentive spirometry (Figure 13-1), coughing, and the impor-
delayed wound healing, and increased incidence of wound tance of frequent turning postoperatively. When the client has
complications, including postoperative incisional hernias. had an abdominal incision, teach the client to clasp a folded
Failure to exercise and ambulate increases the chances of de- pillow against the abdomen and cough after an inspiration.
creased respiratory function, accompanied by atelectasis and This action supports the incision, decreases discomfort, and
clears the lungs (Figure 13-2).
LiFE SPAN CONSiDERAtiONS Cardiovascular Status

Cardiovascular assessment focuses on such diseases as angina,
Surgery in the Older Adult Client recent myocardial infarction or cardiac surgery, hemophilia,
hypertension, and congestive heart failure. Clients with a his-
The University of Virginia’s Department of Sur-
tory of cardiac disease are prone to developing complications
gery’s research study on 7,696 surgical procedures such as dysrhythmias, hypotension, myocardial infarction,
found that clients older than 80 years of age had a congestive heart failure, cardiac arrest, stroke, shock, deep
morbidity of 51% and a mortality of 7% compared vein thrombosis, thrombophlebitis, or pulmonary embolism.
to the total clients’ morbidity rate of 28% and a Also assess for anxiety; elevated blood pressure; slow,
mortality rate of 2.3% (Turrentine, Wang, Simpson, & rapid, or irregular pulse; chest pain; edema; coolness or
Jones, 2006). Older adult clients do not tolerate cyanosis/discoloration of extremities; weakness; and short-
emergency or long, complicated surgeries as well ness of breath (dyspnea). All clients are taught postoperative
as do younger clients because of a lesser ability to leg exercises. Compression stockings are frequently ordered
adapt to physical and psychological stress. Older postoperatively to prevent thrombophlebitis.
clients may also be less likely to express pain
The goal of nursing care is to improve the client’s
cardiovascular condition to the highest degree possible by
because of aphasia or an inability to do so.
promoting rest alternated with activity; encouraging a low-
sodium, low-fat, and low-cholesterol diet; administering heart
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A B
Figure 13-1 A, An incentive spirometer. B, The nurse teaches the postoperative client to use an incentive spirometer to expand the
lungs.
CLiENt teaChing
Postoperative Leg Exercises
activity Instructions
Leg lifts 1. While lying on back or in a
semi-sitting position, raise the
leg off the bed.
2. Hold for count of five.
3. Lower leg to the bed.
4. Repeat five times then proceed
to other leg.
Perform every hour.
Dorsiflexion 1. Flex ankles and raise toes
and hyper- toward head, stretching
extension of posterior calf.

ankles 2. Hold for a count of two.
3. Relax.
4. Repeat five times then proceed
to other foot.
Figure 13-2 The postoperative client supports an incision Perform every hour.
with a folded pillow when taking a deep breath and coughing. Foot circles 1. Point the toe and raise the leg
slightly off the bed.
2. Use the great toe to trace a
medications; and judiciously administering parenteral fluids
and recording intake and output. circle in the air, first to the
right and then to the left.
Renal and Hepatic Status 3. Repeat five times, then proceed
to the other foot.
Because many medications and anesthetic agents are detoxi-
Perform every hour.
fied by the liver and excreted by the kidneys, renal and hepatic
sufficiency constitutes a major concern. Renal disease affects
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Cr it iCa l t HiNKiNG level in the client with diabetes. Thus the morning dose of
insulin usually is adjusted.
Effects of Liver and Kidney When anesthetized during surgery, the client with
diabetes exhibits very few overt symptoms of glucose imbal-
Function on a Surgical Client ance. Serum glucose must therefore be checked frequently
during surgery, usually by the anesthesia provider. Stabil-
Recall the function of the liver and kidney. How ity is attained by the administration of insulin, glucose, or
does decreased liver and kidney function cause
both. Besides hyperglycemia and hypoglycemia, a client
with diabetes is more prone to fluid and electrolyte imbal-
a poor tolerance for anesthetic agents and a
ances, infection including respiratory and urinary tract
tendency for bleeding? infections, neurogenic bladder, impaired wound healing,
ketoacidosis, deep vein thrombosis, thrombophlebitis, and
pulmonary embolism.
Because the immunological system protects the client
from infections, the immunocompromised surgical client is
fluid and electrolyte balance and protein equilibrium. Liver prone to infection. Clients receiving steroids or chemotherapy
disease causes bleeding tendencies and carbohydrate, fat, and or who have systemic lupus erythematosus, Addison’s dis-
amino acid imbalances that impair wound healing and in- ease, or acquired immunodeficiency syndrome (AIDS) are
crease the risk of infection. Assess for symptoms of urinary fre- considered immunocompromised. The immune response in
quency, dysuria, and anuria and record the color and amount these clients is weakened or deficient, resulting in an increased
of the urine. Also assess for a history of bleeding tendencies, incidence of infection. Because surgery breaks the integrity
easy bruising, nosebleeds, and use of anticoagulants. The most of the skin and the normal inflammatory response is sup-
commonly ordered preoperative tests to assess renal function pressed, wound healing may be impaired. Strict adherence to
are urinalysis, blood urea nitrogen (BUN), and creatinine. aseptic technique (covered later in this chapter) is thus even
The most common liver tests are prothrombin time (PT), more imperative. Prevention of infection is crucial in these
activated partial thromboplastin time (APTT), bilirubin, clients. The role of the nurse is to communicate the presence
and the liver enzymes alanine aminotransferase (ALT) and of potential immunosuppression to other health care team
aspartate aminotransferase (AST). Nursing care focuses on members involved in the client’s care and to prevent infection
administering fluids and adequate nutrition, monitoring fluid by practicing aseptic technique.
intake and output, and reviewing results of laboratory tests.
Medications
Neurological, Musculoskeletal, Knowledge of the client’s use of drugs for recreational or
and Integumentary Status therapeutic purposes is essential to preoperative assessment.
Assess the client’s overall mental status, including level of The history of medication usage by the client should include
consciousness; orientation to person, place, and time; and type and frequency of use of over-the-counter, prescription,
the ability to understand and follow instructions. Note skin herbal and dietary supplements, alternate therapies, and street
condition, including turgor and any rashes, bruises, lesions, drugs. The use of certain drugs affects the client’s reaction
or previous incisions. Assess client mobility and sensation to anesthetic agents and surgery. Medications that increase
through observation of both range of motion and ability to surgical risks usually are temporarily discontinued before
ambulate and through client statements. Note any abnormali- surgery. Other medications, such as heart or hypoglycemic
ties, injuries, or previous surgeries and assess the risk for falls. medications, may still be given even though the client is to
The presence of internal or external prostheses or implants undergo surgery. The surgeon or anesthesia provider writes
such as pacemakers, heart valves, or joint prostheses is also specific orders in such instances. Dosages of medications are
noted, because the presence of these may necessitate preop- adjusted during the perioperative period.
erative antibiotics. Chronic alcohol use increases surgical risk because it is
Thin clients, clients undergoing long surgical procedures often accompanied by impaired nutrition and liver disease.
or vascular procedures, and older adult clients are the most Postoperatively, the client may exhibit delirium tremens or
vulnerable to neurological, musculoskeletal, or integumentary acute withdrawal syndrome. Furthermore, pain medication
injuries. Some underlying disease processes, such as edema, may be less effective.
infection, cancer, osteoporosis, arthritic joints, or neck or
back problems, also place a client at greater risk for injury.
Clients who are malnourished, anemic, obese, hypovolemic, Psychosocial Health
paralyzed, or diabetic are also prone to skin breakdown. Infor-
mation gathered about the neurological, musculoskeletal, and
Assessment
The psychosocial health status of the client is assessed. The
integumentary systems is used to prepare the surgical site, for nurse elicits the client’s perceptions of surgery and the ex-
surgical positioning, and as a comparative basis for postopera- pected outcome. The nurse also ascertains the client’s coping
tive assessments and complication screening. mechanisms and the client’s knowledge level and ability to
understand. The data collected are incorporated into the
Endocrine and Immunological Status nursing care throughout the perioperative experience.
Clients with diabetes are scheduled as early in the morning as Cultural beliefs can influence a client’s perception of sur-
possible, and a fasting glucose drawn immediately before surgery. For example, some cultures believe that surgery is a “final
gery. Surgery is a stressor, and stress raises the serum glucose effort” performed only when all other possible treatments
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BestPraCtiCe
Questions to Assess Cultural COnsIDeRatIOns
Psychosocial Status
impending Surgery
• Why are you having surgery?
• When did this problem start? • Some clients desire special religious rites before
• Is there something you think may have caused surgery.
this problem? • Some clients may not want to receive blood
• Has this caused any problems in your relation- transfusions or other treatments.
ships with others? • All client beliefs are respected.
• Has this problem prevented you from working?
• Are you able to take care of your own needs?
• Are you experiencing any discomfort or pain?
• What are you expecting from this surgery?
• Is there anything that you do not understand Preoperative Teaching
regarding your surgery? The client about to have surgery is at risk for knowledge defi-
• Are you worried about anything? cit related to preoperative procedures and protocols and post-
• Will someone be available to assist you when operative expectations. The potential benefits of preoperative
you return home? teaching include reduced anxiety and more rapid recovery
with fewer complications and shorter hospitalization. The
purposes of preoperative teaching are to (1) answer questions
and concerns about surgery, (2) ascertain the client’s knowl-
edge of the intended surgery, (3) ascertain the need or desire
for additional information, and (4) provide information in a
have been of no avail. Furthermore, surgeries that cause manner most conducive to learning.
changes in the appearance of the body can alter body image Teaching a client on an individual basis is the most per-
and self-esteem; the client may worry about being sexually sonal method of instruction, but try to include the family or
attractive or active after surgery. significant other when possible. The level of learning increases
The nurse provides an opportunity for the client to ex- when more than one teaching medium is used. For example,
press his spiritual values and beliefs. Many clients wish to see using materials such as videotapes, charts, tours, anatomic
a member of the clergy before having surgery. models, pictures, and brochures reinforces both visual and
auditory learning. Demonstration followed by return demon-
Surgical Consent stration is helpful. Written instructions serve as a reference for
An informed consent is a legal form signed by the client and later use. Make instructions simple, using terms the client can
witnessed by another person that grants the client’s physi- understand. Any unfamiliar words or concepts are thoroughly
cian permission to perform the procedure explained by the explained.
physician. An informed consent is needed whenever these Clients are often interested in any information that
situations occur: describes the sights, sounds, tastes, feelings, odors, and tem-
perature of what they are about to experience. For example,
• Anesthesia is used. the feeling of relaxation from preoperative medications; the
• The procedure is considered invasive. sounds of instruments or equipment in the operating room
• The procedure is nonsurgical but has more than a slight risk (OR); the pressure from the automatic blood pressure cuff;
of complications (such as with an arteriogram). the warmth or coolness of skin-preparation solutions; or the
• Radiation or cobalt therapy is used. brightness of the OR lights are all sensations the client may
experience. Analogies or stories of real or fictitious situations
Informed consent protects both the client (against un- of sensory experiences help the client understand. The teach-
authorized procedures) and the physician and the health ing methods used strongly influence the client’s learning and
care facility and its employees (against claims that an unau- retention of information.
thorized procedure was performed). Although the ultimate Preoperative teaching begins as soon as the client con-
responsibility for obtaining the informed consent lies with the sents to having surgery. Instructions given over the phone or
physician, the nurse often obtains and witnesses the client’s mailed to the client prior to surgery are beneficial. Just before
signature and ensures that the client signs the consent form surgery, a brief review of preop teaching is given with addi-
voluntarily and is alert and comprehending of the action. tional information tailored to the needs of the client. Give the
Most hospitals use a standard preprinted consent form. client an opportunity to ask questions.
The information written by the health care personnel is spe- Information always is targeted to the client’s needs and
cific to the individual client. The client’s signature on the form according to the client’s level of knowledge and anxiety. Mild
indicates the information has been read and is correct. The to moderate anxiety actually heightens a person’s alertness
client has the right to refuse treatment even after signing the and motivates learning. Mildly anxious clients receive the
consent. When this occurs, the nurse informs the physician most complete instructions. Moderately anxious clients re-
immediately of the client’s decision. ceive less information but more attention to specific areas of
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CLiENt teaChing
Preoperative teaching • Include significant others:
• Time to arrive at the hospital
• Introduce self:
• Location of the surgical waiting area
• Identify role in client’s care
• What to expect when the client returns to the unit
• Determine client’s knowledge level and need or
• Explain postanesthesia care unit (PACU):
desire for additional information.
• Location of recovery room
• Explain the routine for the day of surgery:
• Purpose of recovery room
• Restricted food or fluid intake
• Routine of postanesthesia care
• Intravenous fluids
• Identify anticipated dressings, drains, catheters,
• Premedication
casts, etc.
• Time of surgery
• Demonstrate and evaluate client’s proficiency with:
• Anticipated length of surgery
• Coughing and deep-breathing exercises
• Transportation to the OR
• Turning
• Special skin preparations
• Incentive spirometry
• Type of surgical incision (Figures 13-3
• Extremity exercises
and 13-4)
• Any special transfer procedures or aids required
• Familiarize client with the OR environment:
after surgery
• Operating room lights and table
• Describe pain management strategies appropriate
• Accessory equipment
for the specific surgical procedure.
• Monitoring equipment
• Inform client of what to expect after surgery.
• Anesthesia induction

Figure 13-3 Common traditional surgical incisions: Figure 13-4 A client having laparoscopic surgery has
A, sternal split; B, oblique subcostal; C, upper vertical midline; approximately three to four ½-inch incisions at the best
D, thoracoabdominal; E, McBurney; F, lower vertical midline; accessible points for instrument placement. For example, a
G, Pfannenstiel. laparoscopic gallbladder surgery may have insertion points
as indicated in this figure.
concern. Severely anxious clients receive only basic informa- statements, surgeon verification, and the signed surgical con-
tion but are encouraged to verbalize their concerns. Clients in sent form. Particular attention is given to differentiating between
a state of panic are unable to learn; in such cases, no instruc- right and left operative sites. Some physicians sign the exact
tion is given, and the surgeon is notified. surgical site with a black marker during the preoperative prep.
Special care is given to the preparation of the operative
site to lessen the chance of infection. The operative site is
Physical Preparation thoroughly cleansed with an antiseptic soap to reduce the
Extremely close attention is given to identifying the proper number of microorganisms on the skin. The Centers for
client both verbally and by reading the identification name Disease Control and Prevention (CDC) recommends cleans-
band (a minimum of two client identifiers) and to verifying ing the skin insertion site with a 2% chlorhexidine-based
the operative procedure. This is completed through client preparation prior to vascular catheterization. However, the
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evidenCe-Based
PraCtiCe
Surgical Skin Preparation
Source: Darouiche, R., Wall, M., Itani, K., & Otterson, M. (2010). Chlorhexidine-alcohol versus povidone-iodine for surgical-site antisepsis.
New England Journal of Medicine, 362 (1), 18–26.
DIsCussIOn to the initial incision. After surgery, the infections (4.2% versus 8.6%), fewer deep
Between April 2004 and May 2008, surgical site and vitals signs were assessed incisional infections (1% versus 3%),
a prospective randomized study was at least once during hospitalization, on and there was no difference between the
conducted on a total of 897 clients by discharge, at the follow-up evaluation, and groups as to organ-space infections.
six university-affiliated hospitals in the whenever a surgical site infection (SSI)
United States comparing two skin prepa- occurred. IMplICatIOns fOR pRaCtICe
rations: 2% chlorhexidine gluconate and Of the 897 clients initially in the The results of this study indicate clients
70% alcohol versus 10% povidone-iodine. study, 813 clients concluded the study receiving a skin prep with 2% chlorhexi-
Clients 18 years and older having a clean- with 391 in the chlorhexidine-alcohol dine gluconate and 70% alcohol prior
contaminated procedure (small intestine, group and 422 in the povidone-iodine to surgery have fewer SSIs than clients
colorectal, biliary, etc.) were randomly group. The group cleansed with 2% prepped with a 10% povidone-iodine
assigned to a group in which the skin was chlorhexidine gluconate and 70% alcohol solution. According to the results of this
prepped with the chlorhexidine-alcohol had a significantly lower rate of SSIs than study, nurses may consider cleansing a
or povidone-iodine. Each client was given the group cleansed with 10% povidone- client’s skin with a 2% chlorhexidine
a preoperative history and physical exam iodine (9.5% versus 16.1%). The group gluconate and 70% alcohol rather than a
and routine lab tests. All clients received cleansed with a chlorhexidine-alcohol 10% povidone-iodine solution if offered a
a systemic antibiotic within 1 hour prior preparation had fewer superficial incision choice between the two types of solution.
CDC has not made a recommendation for a specific antisep-

tic solution to cleanse the skin prior to surgery (Darouiche, SAFEtY
Wall, Itani, & Otterson, 2010). Typically, the operative site
is not shaved, but if shaving is to be performed, it is done in iodine and Latex Allergies
the OR immediately before surgery. An enema is ordered to
reduce the number of bacteria in the gastrointestinal tract for • Each client is asked about allergy to shellfish,
gastrointestinal, peritoneal, perianal, or pelvic surgery. Enemas iodine, and latex.
prevent contamination of the perineal area by fecal content • If a client is allergic to any of these items,
passed during surgery. The reduction in colon size related to document the allergy on the client’s record
the loss of bulk also helps prevent colon injury and increases and inform the surgeon and OR personnel
visualization of the operative site. Enemas are usually given the so that an iodine-free solution and latex-free
night before surgery. If the enema is done at home, give the cli- equipment are used.
ent detailed instructions. Many types of surgery require special
preparations. The specific protocol for each surgical procedure
is available from the health care facility or the physician.
Check the client’s vital signs, including blood pressure,
temperature, pulse, and respirations. Some changes in vital the client may experience side effects that are unpleasant. For
signs are normal as a result of anxiety. If marked differences example, many clients experience nausea when given morphine;
exist from the baseline data, however, the surgeon is notified. although unpleasant, this is not a drug allergy. A true allergy
Assist the client in putting on a hospital gown, hair cap, produces a skin reaction or anaphylactic reaction, in which
and, if ordered, antiembolic hose sized according to client size. the client experiences cardiorespiratory reactions that may be
Institutional policy usually requires the removal of all jewelry, life threatening, such as hypotension and pulmonary edema. A
including body jewelry. Hairpins, wigs, and prostheses also client with multiple food allergies is also prone to hypersensi-
are removed. The nurse is responsible for recording the dis- tivities to medications. When allergies are identified, the client’s
position of any personal items removed for surgery. If policy chart is marked accordingly, and an allergy wristband is placed
requires, nail polish (from at least one nail, if dark polish) is on the client. By being aware of and alerting other team members
removed to read oxygen saturation via pulse oximetry. Makeup to the client’s allergies, client safety and comfort are maintained.
is also removed so that skin color can be observed. Verify the NPO (nothing by mouth) status of the client
Allergies to medication, food, and chemicals (including for the time specified by the surgeon’s order. Restricting oral
contrast agents) are verified, as are previous blood reactions. intake reduces the possibility of aspiration. If surgery takes
The nurse differentiates between a medication intolerance and a place in the afternoon, the client has a clear liquid breakfast if
true allergic reaction. With an intolerance to certain medications, ordered by the surgeon. Careful client instruction is required
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BestPraCtiCe LiFE SPAN CONSiDERAtiONS

implementing NPO Status Preparation for Surgery
• Explain reasons for NPO status to the client. The older adult client may have:
• Remove any food and water from the client’s • Increased risk of complications including
overbed table and nightstand. infection
• Mark the client’s door and bed with an NPO • Increased incidence of coexisting conditions
sign. • Unpredictable response to medications and
• Mark the client’s Kardex, electronic medical anesthetics
records, and other nursing information sources. • Greater need for support from family and
• Notify the dietary department. significant other
• Increased skin and bone fragility
• Nutritional and financial deficiencies
• Impaired vision and hearing
• Impaired or slowed thought processes and
because surgery may need to be postponed if the client eats cognitive abilities
or drinks. • Fear of death, loss of independence, and change
In addition to the previously outlined preparations, re- in lifestyle
move dentures and bridgework to prevent loss, damage, and
possible dislodgement and airway obstruction during the
surgery. If the client has a bridge, metal bar, or other dental
work that cannot be removed, a teeth guard can be used dur-
ing surgery to protect the device. Ensure that the client has an
empty bladder by allowing time for the client to void before
transfer to surgery.
Identify any sensory deficits of the client and commu-
nicate this information to other health care team members.
Glasses, contact lenses, and hearing aids are usually removed
to prevent loss or damage; if policy allows, however, it is best
to leave these items in place so the client is better able to see

and hear. In such a situation, the nurse is responsible for com-
municating the presence of these aids to the surgical team
members.
The surgeon or anesthesiologist (a doctor trained in
providing anesthesia) may order preoperative medication.
The nurse gives the medication by the prescribed route
(intramuscular, intravenous, or oral) at the specified time Figure 13-5 A nurse prepares a client for anesthesia and
(typically 1 hour before surgery). Preoperative medications surgery.
may be ordered “on call,” which means that the nurse is noti-
fied by a member of the surgical team when the preoperative
medication is to be given. Before administering the medica- Cr it iCa l t HiNKiNG
tion, ask the client to void. After administering the preop-
erative medication, raise the top two side rails of the bed, put Physical Assessment
the bed in the lowest position, place the call light and other and Anesthesia
personal items within reach, and instruct the client not to get
up without assistance.
When the surgical team is ready, the client is transported Why is it important for a nurse to perform a
on a gurney by a member of the OR team, typically an orderly. physical assessment prior to a client being given
The client is always transported feet first and with the side anesthesia?
rails up to ensure safety and minimize the likelihood of diz-
ziness and nausea. The client may be taken to a preoperative
holding area first (Figure 13-5). The nurse instructs the family
or significant others where to wait.
The information collected as part of preoperative prepa- PREANESTHETIC PREPARATION
ration is documented in the client record, usually on a preop-
erative checklist. Figure 13-6 illustrates a typical preoperative Preparing a client for anesthesia and surgery is a cooperative
checklist. This checklist is completed before the client leaves effort involving the surgeon, the anesthesia provider, and
the clinical unit or upon the client’s admission to ambulatory the nursing staff who cares for the client before and after
surgery. The nurse also verbally communicates to other health surgery. The client may undergo general (total body) anes-
care members any necessary information collected. thesia, where the control of body functions is temporarily
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CK NURSE
( ) COMMENTS CK ( )
COMPLETE NIGHT BEFORE SURGERY
List allergies
Procedure scheduled
Surgical permit signed/witnessed
History/physical on chart and/or dictated
Preanesthetic evaluation done
Able to state type and purpose of surgical procedure
Demonstrates ability to perform: Deep breathing, turning and coughing exercises
Leg exercises
P.M. care with shower or bath given
Nail polish removed and makeup removed
Old chart requested and obtained
Type and crossmatch for ______ units of blood
Blood consent signed and witnessed
Laboratory work a. CBC ______ b. UA ______
Tonsillectomy and adenoidectomy patients: a. ___PTT b. ___PT c. ___Platelets
If ordered by MD: a. ECG ___ b. Chest X-ray ___
Add other lab work ordered (specify)
Notify surgeon of abnormal lab work
New progress note and physician order sheet on chart
Weight
NPO after midnight (if applicable)
Signature of Nurse _________________________________________ Date ______________

COMPLETE DAY OF SURGERY
Jewelry removed and secured with responsible party or placed in facility locker
Dental prosthesis and contact lenses removed
Voided on call to surgery
Indwelling catheter ordered and inserted
Tampon removed
Identiband and/or bloodband on/checked for accuracy
Time _______ Pulse _______ Resp _______ B/P _______ Temp. _______
Pre-op medicine given (state medication given) ___________________________________
Time medication given __________ AM PM
Siderails up and bed to lowest level
Patient instructed not to get out of bed without nursing assistance
Addressograph plate/MARs on chart
VS 30 minutes after pre-op (if remains on unit)
BP _______ P _______ R _______ T _______
Old chart sent to surgery per request
Surgical prep done and checked
To surgery Time _______ Via _______
Signature of Nurse _________________________________________ Date ______________

Holding Room Nurse Signature _________________________________________ Date ______________
Figure 13-6 Sample preoperative checklist.

282
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lost; regional anesthesia, where a region of the body is made before surgery. In other circumstances, they are taken right
insensible to pain; or local anesthesia, where only a small area up until surgery. Low-molecular-weight heparin or hepari-
of the body is numbed. noids may be given preoperatively to prevent postoperative
thromboembolism, but higher doses of heparin and any dose
Oral Intake of Coumadin is stopped before surgery to allow coagulation
times to return to within normal ranges. Coumadin is usually
General anesthesia removes a person’s ability to guard the stopped a week to 10 days before surgery and heparin within
airway by coughing or closing the vocal cords. Passive regur- a few hours of surgery. Health care providers may order labo-
gitation of stomach contents into the back of the throat can ratory work the morning of surgery if the client takes antico-
occur at any time during the delivery of general anesthesia. agulants to check the INR or PT for Coumadin and APTT or
Aspiration of gastric contents into the lungs can cause sig- PTT levels for heparin.
nificant illness or death. An important step in preventing Additional medications may be ordered to prepare the
aspiration of gastric contents is ensuring that the stomach is client for surgery or anesthesia. Surgeons often order pro-
as empty as possible. In the past, adults have been instructed phylactic antibiotics. The anesthesia provider may order a
not to eat or drink anything for at least 8 hours before surgery sedative to help the client sleep the night before surgery or
and usually nothing past midnight the night before surgery. to ease the client’s anxiety while waiting for surgery. Opioids
Recent information strongly indicates that adults need not like morphine also are used for pain relief or to ease the in-
go without clear liquids for 8 or more hours before surgery; duction of anesthesia. Atropine may be given to decrease oral
2 hours are sufficient (American Society of Anesthesiologists, secretions and prevent aspiration. Some anesthesia providers
2007; Mount Sinai Hospital, 2011). In fact, the amount of prefer to give preoperative medications in the operating room
liquid in a person’s stomach at the time of surgery may actually
be decreased if water is taken a couple of hours before surgery.
Some anesthesia providers still prefer that their clients not
have anything to eat or drink for at least 8 hours before sur-
gery; others may allow water up to 2 hours before surgery. BestPraCtiCe
Preoperative Medication Preanesthetic Care
Most scheduled medications that a person takes daily at home • Health care providers explain the risks and
or receives while in the hospital are continued until the time benefits of anesthesia and the surgical
of surgery. Give oral medications with just enough water to procedure and have the client sign consent
swallow them, even when a client is having surgery first thing forms before they administer any preoperative
in the morning. medications. The client must be alert to sign
Exceptions include administration of drugs such as insulin
consent forms.
and oral antihyperglycemics, nonsteroidal anti-inflammatory
drugs (NSAIDs) such as aspirin, and anticoagulants such as • Complete the preoperative checklist.
heparin or warfarin (Coumadin). Because food is withheld, • Make sure all preoperative orders are executed,
giving insulin or oral antihyperglycemic drugs is likely to especially those for blood tests, preoperative
result in a dangerously low blood sugar level. How insulin medications, and blood from the blood bank.
and glucose administration is handled depends on the sever- • Check, verify, and document the presence or
ity of the client’s disease and the preference of the physician absence of drug allergies for each client.
and anesthesia provider. Anticoagulants and NSAIDs affect • Administer regular daily oral medications with a
clotting. With some types of surgery, the bleeding caused by small sip of water as ordered.
aspirin-like drugs or low-dose heparin is more likely to occur. • Remind the client of the importance of
In some cases, no NSAIDs are allowed for 10 days to 2 weeks following instructions regarding any eating or
drinking restrictions.
• Administer preoperative medications at the
ordered time as timing can be crucial to
CLiENt teaChing achieving the desired effect.
• If the client responds abnormally to the
preoperative medication, notify the
Oral intake before Surgery anesthesiologist immediately.
• Clearly explain to clients those things that • Be sure the client’s chart is complete when it
they will or will not be allowed to eat or drink goes to the operating room with the client.
before surgery. Recent diagnostic test results are especially
• Emphasize the need to exactly follow the important to include; otherwise, surgery may be
instructions related to the time at which eating delayed while these results are sought.
or drinking must cease before surgery. • Make sure the client’s consent forms are in
• Discuss taking usual medications with doctor order and included in the chart when the client
before surgery. is transported to surgery.
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to precisely control the medication’s effect on the client. This caused by the acidity of the local anesthetic solution. Most cli-
is especially true for very sick clients. ents are uncomfortable knowing they are undergoing surgery
and prefer to be less alert during the procedure. Procedural
Consent sedation (also known as moderate sedation and conscious
sedation) decreases the client’s perception of these physical
Consent for anesthesia is usually obtained on the same form and mental discomforts.
as is surgical consent, or a separate anesthesia consent form During local anesthesia and sedation, the client must
may be used instead of or in addition to the combined con- remain conscious and in control of his own airway and breath-
sent. In either case, for informed consent to be obtained, the ing reflexes. Oversedation is likely to result in airway ob-
anesthetic must be discussed with the client by someone with struction and places the client at risk for aspiration of gastric
expert knowledge of anesthesia, usually an anesthesia provider contents. Because sedatives are CNS depressants and, thus,
or the surgeon. respiratory depressants, give supplemental oxygen to clients
during sedation. Monitoring during sedation is done through
observation by an individual knowledgeable and experienced
SEDATION in the assessment of respiratory volume and airway patency.
Sedation refers to a reduction of stress, excitement, or The Joint Commission (2009) standards for monitoring
irritability and involves some degree of central nervous system clients undergoing procedural sedation require that the blood
(CNS) depression. Sedation is used to decrease awareness of pressure be measured at frequent and regular intervals and
events, relieve anxiety, control the physiological changes that the heart rate and oxygenation be continually monitored by
often accompany anxiety, and ease the induction of general pulse oximetry. They also require the continual monitoring of
anesthesia. This is welcome news to many clients who fear respiratory rate and pulmonary ventilation. Cardiac rhythm
local or regional anesthesia because they do not want to be for clients with significant cardiovascular disease or predispo-
awake to see or hear anything during surgery or a diagnostic sition to dysrhythmias is monitored with an ECG.
procedure. One method of monitoring pulmonary ventilation is cap-
Different sedatives given in combination have a greater nography. Capnography is used to measure a client’s carbon
effect on the client than does any one of the sedatives given dioxide concentration. The capnogram displays the CO2 level
alone. This phenomenon is called synergism. The syner- as a waveform (Srinivasa & Kodali, 2008). The individual
gistic effect that occurs when different sedative drugs are monitoring the client’s breathing and vital signs is devoted to
administered together makes respiratory depression and un- that task to the exclusion of any other duties.
consciousness more likely. In general, benzodiazepines (di-
azepam [Valium] and midazolam hydrochloride [Versed])
are better sedatives than are opioids (morphine and fentanyl
Residual Effects of Sedation
citrate [Sublimaze]). If a client’s anxiety is caused by pain, an Sedation usually persists beyond the duration of the surgi-
opioid is a better choice of sedative because the opioid relieves cal procedure. The length of time it takes to recover from
the pain that caused the anxiety. sedation depends on the health of the client, the properties of
Sedative medications are administered based on the cli- the drugs used, other drugs the client may be taking, and the
ent’s physical condition, weight, mental state, and the proce- amount of sedative drugs administered.
dure being performed, with close observation of the effects of Amnesia (the inability to remember things) produced
the drugs on the client. by sedatives is commonly found even in clients who appear
The amount of sedation required by a client for comfort to be completely recovered. Such clients will probably not
is always balanced with the amount of stimulation experi- remember any instructions given to them during or soon after
enced as a result of pain or anxiety. Sedation and general the procedure. Given that minor procedures and surgery are
anesthesia both involve CNS depression; thus sedation commonly performed on an outpatient basis, some clients
and anesthesia exist on a continuum. As sedation becomes may be discharged before regaining the ability to remember
deeper and deeper, it eventually becomes general anesthesia. verbal instructions. All instructions should thus be given in
Sometimes, the line between sedation and general anesthe- writing and explained to the person responsible for taking the
sia is very difficult to distinguish. When sedation becomes client home. Some facilities put the discharge instructions on
general anesthesia, all of the risks of general anesthesia are a CD-ROM, DVD, or video for the client to take home and
present, including airway obstruction, respiratory arrest, and review.
aspiration of gastric contents. For this reason, all but the If heavy sedation was used or the procedure ends sud-
lightest sedation should be administered by an anesthetist denly, the client may remain significantly sedated after the
or another provider skilled and experienced in airway assess- procedure is completed because the CNS stimulation ended
ment, protection, and management, as well as assessment of while the CNS depressant effect of the sedative remains. The
oxygenation and ventilation. client is closely monitored until the effects of the sedative
medications wear off enough for the client to awaken and
become oriented.
Sedation and Monitoring
Sedation is often used to alleviate client anxiety and discom- INTRAOPERATIVE PHASE
fort during procedures performed under local anesthesia.
Properly administered, local anesthetic injection blocks the The intraoperative phase is the time during the surgical
painful stimulus of small incisions and minor surgical pro- experience that begins when the client is transferred to the OR
cedures; however, local anesthetic administration can cause table and ends when the client is admitted to the postanesthe-
significant discomfort because of edema and tissue irritation sia care unit (PACU).
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Physical Description of the A

Operating Room Environment
For the purposes of preventing wound infections, the surgical
suite is environmentally controlled. Personnel restriction and
geographic isolation from other areas of the hospital or clinic
are part of this control. Constant filtered airflow and posi-
tive air pressure in the OR also aid in environmental control.
Clean areas and contaminated areas are separated within the
suite. Equipment and supplies needed for each client are in
the surgical suite so members of the surgical team do not have
to leave the area.
ORs vary in size depending on the amount of equipment
needed for each particular type of operation. Supplies and
furniture are limited to prevent dust collection and are usually
made of stainless steel to withstand corrosive disinfectants.
Furniture and equipment are easily movable on wheels. In ad-
dition to general illumination from ceiling lights, the operative
site is illuminated by overhead operating lights. Figure 13-7
shows a typical OR. The temperature of the room can be
adjusted but usually is maintained at a cool 66° to 68°F (19°
to 20°C). This provides comfort for the surgical team (the
members of which wear gowns, gloves, and masks under hot
lights). This temperature also is an unfavorable environment
for bacterial incubation and growth.
The client entering the OR is confronted with an envi-
ronment that is most likely unfamiliar. The OR is cold. The
surgical team members dress in surgical scrubs and have
their hair covered by caps and their faces covered by surgi-
cal masks, making them appear impersonal and distant. The
sounds of equipment being prepared can be unfamiliar and B
alarming. The terminology used in conversations among OR
personnel may be foreign. These elements combined with the
sight of ominous overhead lights and the feel of the hard OR
table may increase the client’s fear, anxiety, and feelings of
powerlessness.
Minimally Invasive Surgery

Minimally invasive surgery (MIS) is replacing much of the
traditional types of surgery. The surgeon completes a MIS
with one to five small incisions in which a videoscope and
specialized instruments are inserted into the small incisions
to complete the surgery (Figure 13-8). The same traditional
Figure 13-8 Minimally invasive surgery (MIS): A, Surgeons,
using small incisions, introduce specialized instruments into the
body to perform surgery. B, Special instruments are manipulated
by the surgeons to perform surgery. (© 2009 intuitive surgiCal, inC.)
infOrmatiCs
Minimally invasive surgery has changed the way in
which surgeries are completed. Computers are
increasingly being used in these types of surgeries.
In some emerging MIS techniques, the surgeon
performs robotic surgery without ever touching
the client. Robotic technology makes it possible for
a surgeon in New York to operate on a client in
Figure 13-7 Typical operating room and proper surgical Asia (Ulmer, 2010).
attire. (Photo Courtesy of the u.s. army)
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Figure 13-9 Minimally invasive surgical suite: A, Typical layout of a MIS surgical suite. B, Surgeon at the Da Vinci Si console with
patient cart and surgical nurse at the vision cart. (© 2009 intuitive surgiCal, inC)
type of surgery would require a much longer incision through are performed by passing all instruments through a 1.5- to 2-cm
larger areas of tissue and muscle. The layout of the surgi- single-entry incision, usually at the naval. The advantages of
cal room for MIS is different than that for the usual surgery single-entry-port surgeries are decreased scarring and better cos-
suite. Figure 13-9 shows the layout of a MIS surgical room metic appearance than the traditional incision. NOTES allows
and surgical system of a console, patient cart, and vision cart. a surgeon to perform a transgastric cholecystectomy by making
Abdominal, thoracic, pelvic, and spine surgeries are per- an incision in the stomach to access the gallbladder, which is
formed using MIS. removed through the mouth (Ulmer, 2010). Surgeons require
MIS includes robotics, single-incision laparoscopic sur- advanced knowledge and skill to perform NOTES safely. The
gery (SILS), natural orifice transluminal endoscopic surgery VATS technique eliminates incising the sternum and spreading
(NOTES), and video-assisted thoracoscopic surgery (VATS). the rib cage to access the thoracic organs.
Table 13-2 lists the types of MIS and the procedures performed The advantages of MIS are smaller incisions (resulting
via this method. With the SILS technique, complex surgeries in less scarring externally and decreased adhesions internally),
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Table 13-2 Types of Minimally Invasive Surgery

PROCEdURE EXPLAnATIOn OF PROCEdURE PROCEdURES PERFORMEd
Robotics With the assistance of computer technology, Cardiac

a surgeon performs surgery with robotic arms Genitourinary
that “mimic the actions” of instruments used in Gynecological
traditional surgical procedures General surgery
(Ulmer, 2010, p. 565).
Single-incision laparoscopic surgery Complex surgeries are performed through a Adrenalectomy

(SILS) single entry port through which the surgeon Appendectomy
Other names for this type of proce- passes all instruments. Bariatric weight loss surgery
dure are single-port access (SPA) Cholecystectomy
and one-port umbilical surgery Gastrectomy
(OPUS) Hernia repair
Hysterectomy
Nephrectomy
Nissen fundoplication
Oophorectomy
Splenectomy
Natural orifice transluminal endo- Surgery is performed instrumentally through Appendectomy

scopic surgery (NOTES) a natural body orifice, such as the mouth or Gastrojejunostomy
vagina. Liver biopsy
Oophorectomy
Splenectomy
Tubal ligation
Video-assisted thoracoscopic sur- Thoracic surgery is performed with the assis- Pulmonary resection
gery (VATS) tance of a video camera and a thoracoscope. Esophageal resection
See Figure 13-8A. Thymectomy
Sympathectomy
Data adapted from Ulmer (2010).
less postoperative pain, shortened hospital stays, less risk of other nursing functions such as changing dressings, insert-
infection, prompt return to normal activities and work, and ing a Foley catheter, or preparing for an obstetrical delivery.
fewer overall postoperative complications (George Washington Thus, the practice of aseptic technique is not confined to
University Hospital, 2009; Ohio State University Medical Center, the OR, but applies to other clinical nursing units and other
2009; Ulmer, 2010). Specific MIS surgery is discussed throughout procedures as well.
the various system chapters. The practice of aseptic technique requires the develop-
ment of sterile conscience, an individual’s personal sense
of honesty and integrity with regard to adherence to the
Asepsis principles of aseptic technique. Aseptic technique must be
Prevention of infection is the responsibility of the entire strictly followed. Doing so requires constant assessment
surgical team. The environment of the surgical client con- and monitoring of self and others. It is sometimes easier or
tains both pathogenic (disease-producing) and nonpatho- less expensive to overlook an infraction of aseptic technique
genic microorganisms. When the skin, a prime barrier to rather than to correct that infraction. This must never be
infection, is broken, as occurs during surgery, susceptibility allowed. Compromising the principles of aseptic technique
to a bacterial invasion increases. Bacteria carried by dust may increase the likelihood of infection and, thus, harm to
or nose and throat droplets are easily transported by air the client.
currents.
Asepsis is the absence of pathogenic microorganisms.
Aseptic technique is a collection of principles used to Anesthesia
control and prevent the transfer of pathogenic microor- Anesthesia refers to the absence of normal sensation.
ganisms from sources within (endogenous) and outside Analgesia refers to pain relief without producing anesthe-
(exogenous) the client. For example, scrubbed persons sia. Anesthesia is a specialty of both nursing and medicine.
wear sterile gowns and gloves; sterile drapes are used to cre- An anesthesiologist is a licensed physician educated and
ate a sterile field; items used in a sterile field are sterilized; skilled in the delivery of anesthesia who also adds to the
and those working within a sterile field maintain the integ- knowledge of anesthesia through research or other schol-
rity of the sterile field. Aseptic technique is applicable to arly pursuits. An anesthetist is a qualified registered nurse
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Table 13-3 drugs Used for Sedation
and Anesthesia
Sterile Conscience
Local anesthetics chloroprocaine (Nesacaine)
procaine (Novocain)
How can you use a sterile conscience when tetracaine (Pontocaine)
bupivacaine (Marcaine)
providing nursing care?
dibucaine (Nupercaine,
Nupercainal)
lidocaine (Xylocaine)
(RN), dentist, or physician who administers anesthetics. prilocaine (Citanest)
Experienced RNs with a baccalaureate degree can become
General enflurane (Ethrane)
certified registered nurse anesthetists (CRNAs) after com-
anesthetics halothane (Fluothane)
pleting two or more years of graduate education in nurse
isoflurane (Forane)
anesthesia. Today there are more than 37,000 CRNAs who
administer more than 30 million anesthetics in the United Intravenous methohexital sodium (Brevital)
States each year and are the only anesthesia providers in anesthetics thiopental sodium (Pentothal)
two-thirds of all U.S. rural hospitals (American Association diazepam (Valium)
of Nurse Anesthetists, 2009). CRNAs often work in groups midazolam hydrochloride (Versed)
with anesthesiologists. fentanyl citrate (Sublimaze)
Before administering an anesthetic, the anesthesia pro-
vider assesses the client’s health status, discusses the risks and Adjuncts to succinylcholine chloride
benefits of anesthesia with the client, and plans an anesthetic anesthesia (Anectine, Quelicin, Sucostrin)
appropriate for the client and the surgical procedure. Surgical tubocurarine chloride
nurses prepare clients to talk with their anesthesia providers (Tubocurarine)
by encouraging them to ask any questions they have about
anesthesia and the care they will receive. Adapted from Pharmacology for Nurses: A Pathophysiologic Approach,
The use of anesthesia is essential to the health and well- by M. Adams, L. Holland, and P. Bostwick, 2008, Upper Saddle River,
being of clients undergoing surgery. Although anesthesia NJ: Pearson Prentice Hall.
prevents any sensation of pain, it also temporarily eliminates
or diminishes the client’s ability to control many essential
physiological functions such as respiration, heart rate, and amount of local anesthetic drug is injected either into the
temperature regulation. In addition to ensuring adequate skin and subcutaneous tissues around a cut or at the site of a
levels of anesthesia throughout a surgical procedure, the anes- needle puncture for a central line placement, it is called local
thesia provider monitors and, when necessary, controls physi- anesthesia. The anesthetic is not aimed at a specific nerve;
ological functions such as respiratory rate and blood pressure. rather it anesthetizes all small superficial nerves in the target
Before the end of the surgery, the anesthesia provider ad- area. Local anesthesia is most commonly performed using
ministers appropriate medications to ensure that the client is lidocaine (Xylocaine) and lasts approximately 1 hour. Seri-
comfortable when emerging from the anesthetic. Pain may be ous side effects of lidocaine (Xylocaine) are convulsions,
relieved with local anesthetic infiltration, opioid analgesics, or respiratory depression, and dysrhythmias leading to cardiac
nonopioid analgesics.
Regional Anesthesia
In regional anesthesia a region of the body is temporarily SAFEtY
rendered insensible to pain by injection of a local anesthetic.
Local anesthetics are a class of drugs that temporarily block Preventing Choking and Aspiration
the transmission of small electrical impulses through nerves To prevent choking and aspiration after the
(Table 13-3). The duration of anesthesia produced by a local use of an oral anesthetic solution (e.g., viscous
anesthetic depends on the drug used, the amount injected,
lidocaine) or spray, fluids and foods must be
and into which part of the body the drug is injected. The
amount of insulation surrounding a nerve fiber, the anatomic withheld until the gag reflex returns. To check if
location of the fiber, and the diameter of the fiber all influ- a client has a gag reflex, gently place a tongue
ence the ease with which nerve impulses are blocked by local blade to the lateral side of the posterior tongue
anesthetics. section. This should not provoke a gag reflex.
There are three types of regional anesthesia: local anes- Gently and slowly move the tongue blade
thesia, nerve blocks, and spinal and epidural blocks. toward the center of the tongue until the client
gags voluntarily. If the client does not gag, the
Local Anesthesia gag reflex is still under the influence of the local
Clinically, the use of local anesthetics to block nerves is anesthetic.
identified by different names depending on the amount of
local anesthetic used and where it is injected. When a small
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arrest. Lidocaine with preservatives or epinephrine is used as possible (Figure 13-11). Either position separates the
only for local anesthesia and never given for dysrhythmias vertebra, making insertion of the needle or catheter possible.
(Adams, Holland, & Bostwick, 2008). Occasionally, for Epidural blocks have an added advantage in that by varying
some types of plastic surgery, this type of anesthesia is used the way the anesthetic is used, the block can produce analgesia
over a large area of the body. In this case, longer acting local (pain relief without producing anesthesia), complete anesthe-
anesthetics are used. Because very small amounts of local sia, and even profound muscular relaxation (needed for some
anesthetics are generally used, the risk of local anesthetic types of surgery). This allows the use of epidural anesthesia
toxicity is also small. not only for surgical procedures, but also for analgesia during
Topical anesthesia, achieved with direct application of a labor and for postoperative pain relief.
local anesthetic to tissue, is desired in some situations (e.g.,
before insertion of an IV). The anesthetic takes the form of an
ointment, lotion, solution, or spray.
Nerve Blocks
When a local anesthetic is injected more deeply into the body
or is directed at a specific nerve or nerves, it is called a nerve
block. Nerve blocks are often called by the name of the specific
nerve or nerves they block. Examples include an ulnar nerve
block in the arm or a brachial plexus block of all of the nerves
in the arm. Nerve blocks are often performed using lido-
caine (Xylocaine), mepivacaine (Carbocaine), or bupivacaine
(Marcaine) and may last from 1 to 12 hours.
Spinal and Epidural Blocks
Blocks also are identified according to where the local anes-
thetic is injected. One example is an epidural block, for which
local anesthetic is injected into the epidural space near the Sacrum
spinal cord to anesthetize several spinal nerves at once. With
spinal blocks (also called subarachnoid blocks), the local an-

esthetic is injected into the cerebrospinal fluid (CSF), where
it can bathe uninsulated spinal nerves as they exit the spinal
cord to the periphery of the body (Figure 13-10).
Spinal and epidural blocks are generally used to anesthe- Pelvis Spinous Transverse Vertebra
tize a significant area of the body. They are capable of safely process process
producing anesthesia sufficient for surgery in the abdomen,
pelvis, perineum, or lower extremities. When an epidural Figure 13-11 The surgical nurse assists the client into the
block is performed, a catheter is usually inserted into the correct position so the physician can perform a spinal block or
epidural space, making it possible to inject additional doses insert an epidural catheter into the lumbar area. The assistance
of drug. The client must either be sitting in a bent-over posi- of trained personnel is crucial to the proper positioning, reassur-
tion or lying on the side with head and knees as close together ance, and safety of the client.
A B C
Anterior Spinous process
Dura mater Vertebral Spinal cord
Subdural space body Supraspinous
Arachnoid ligament
Subarachnoid Intervertebral Interspinous ligament
space foramen Ligamentum flavum
Ventral Epidural catheter
ramus in epidural space
Posterior Epidural space
Dura arachnoid
Transverse Pia Dorsal Subdural space
Spinal ramus
process mater ganglion Cerebrospinal
fluid space
Posterior Epidural space

Vertebral body
Anterior
Spinous process
Figure 13-10 A, Cross-sectional anatomy of the spine; B, side view of spinal anatomy with the tip of an epidural needle placed in
the epidural space; C, side view of spinal anatomy with the tip of an epidural catheter placed in the epidural space.
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Spinal blocks are most often performed using lidocaine As a regional block begins to wear off, motor function
(Xylocaine) or bupivacaine (Marcaine) and last from 1 to begins to return first, sensation begins to return next, and
3 hours. Epidural blocks are most commonly performed using sympathetic nervous function returns last. Motor function
bupivacaine (Marcaine), and the block can be continued as and sensation are easily detected by asking the client to move
long as local anesthetic is injected through the catheter into the blocked part or by touching the skin and asking the client
the epidural space. whether it feels normal. The return of sympathetic function
Opioids such as morphine and fentanyl citrate (Subli- is more difficult to detect. Orthostatic hypotension may oc-
maze) may be added to the local anesthetic in either of these cur even after motor and sensory functions have completely
blocks to intensify the analgesic or anesthetic effect, or to returned and the regional block appears to have worn off. To
provide postoperative pain relief after the block has worn off. prevent fainting, the nurse assists the client in getting out of
One type of complication is peculiar to spinal and epi- bed until she is able to do so without any dizziness or signifi-
dural regional anesthetics. When CSF leaks out through a cant decrease in blood pressure.
hole made in the dural membrane during performance of a
subarachnoid block or an accidental dural puncture during Residual Sensory Block
the attempted performance of an epidural block, a postdural Normal sensation may not have returned completely upon
puncture headache (PDPH) may result. The headache is client discharge from the recovery area. As the regional block
caused by the loss of CSF from around the brain. The head- wears off, sensation returns gradually. As sensation begins to
ache is relieved by lying down and returns when the individual return, the client experiences a “pins-and-needles” feeling in
sits up or stands. Pain commonly occurs in both the front and an arm or leg that has been blocked and may feel touch or
the back of the head and is sometimes accompanied by neck pressure before recovering complete sensation. Until com-
and shoulder stiffness. Photophobia or double vision may be plete recovery of normal sensation, any blocked areas are
present with severe headache. The onset of the headache is frequently checked and carefully protected, because the client
usually not immediate and may take 1 to 2 days to become may be unaware that a finger or hand, for example, is being
bothersome. Treatment involves adequate hydration to allow pinched or denied blood supply.
the normal production of CSF; analgesics; and bed rest in a
supine position. One treatment for significant or persistent Residual Sympathetic Block
PDPH is a procedure called an epidural blood patch, which The last nerve fibers to recover as a local anesthetic wears
involves injecting 15 to 20 mL of the client’s own blood into off are those responsible for carrying instructions to the
the epidural space. Once the blood clots, it plugs the hole in muscles that surround blood vessels. When these sympa-
the dural membrane. Another treatment involves connecting thetic nerves are blocked, veins and arteries dilate, lower-
an IV infusion to the epidural catheter to replace the lost CSF ing the blood pressure. The venous system has a large
and treat the headache. capacity, and venous dilation results in the pooling of
a large amount of blood. This decreases the amount of
Residual Effects of Regional Anesthesia blood that returns to the heart, and the blood pressure
falls. The amount of blood that pools is greatest in parts
All anesthetics wear off as the drug responsible for causing the
of the body that are farthest below the level of the heart.
anesthesia is removed, metabolized, and eliminated. Some ef-
Even in a client who has had a spinal or epidural block
fects wear off faster than others. The client may be wide awake
and is lying supine, a significant amount of venous pool-
and able to carry on a conversation but have residual effects
ing occurs, resulting in lower than normal blood pressure.
that are not detected by casual observation. Motor, sensory,
If the same client is allowed to sit up, even more venous pool-
and sympathetic residual block effects are common.
ing will occur, less blood will return to the heart, and blood
pressure will fall substantially. This phenomenon of a large
Residual Motor Block drop in blood pressure when sitting up or standing is called
A motor block is a temporary condition caused when local orthostatic hypotension. Orthostatic signifies that it in-
anesthetic blocks nerves that carry instructions to skeletal volves body position, and hypotension means low blood
muscles telling them to contract. Motor block results in the pressure. Clients who have had a spinal or epidural block are
inability to move a body part and is usually the last effect to more likely to have orthostatic hypotension the higher in the
develop and the first to wear off. It results only when the re- spinal column the level of their block.
gional block is very dense and complete.
A complete motor block results in a temporary paralysis,
with the client being incapable of moving the blocked part General Anesthesia
despite tremendous effort. With a complete motor block, General anesthesia involves unconsciousness, complete in-
there is usually no function in any other type of nerve in the sensibility to pain, amnesia, motionlessness, and muscle relax-
same area. A client with a complete motor block of any part of ation. With general anesthesia, the body also loses the ability
the body would not likely be released from the recovery area. to control many important functions, including the abilities to
Clients experiencing residual (incomplete) motor block may maintain an airway, control vital functions such as breathing
be released from recovery. A client who has had any type and heart rate, and regulate temperature. These functions are
of block involving the legs is not allowed to get out of bed controlled by the anesthesia provider during administration of
without assistance until she can demonstrate that a complete general anesthesia.
recovery of motor strength in the legs has been regained. Even General anesthesia involves four overlapping stages:
a small amount of residual motor block greatly increases the induction (going to sleep), maintenance, emergence (waking
possibility that a client will fall. up), and recovery.
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Stylet
Endotracheal tube Laryngoscope
Esophagus
Trachea
Nasopharynx

Figure 13-13 A typical anesthesia machine is a complex
equipment set. This machine has anesthetic vaporizers and
10 cm flowmeters to deliver oxygen, nitrous oxide, and air. It also
supports a ventilator and equipment to monitor ventilation,
oxygen content of inspired gas, client oxygen saturation, blood
Figure 13-12 Placing an endotracheal tube in the pressure, heart rate, and respiration. (Pictured above is the
trachea with direct visualization by laryngoscopy. Datex-Ohmeda Aestiva/5 anesthesia delivery system equipped
with a Cardiocap/5 monitor.) (rePrinteD with Permission of Datex-ohmeDa, inC)
Induction and Airway Management Emergence

The induction of general anesthesia is a short but critical
period during which the client is rendered unconscious, vital Emergence from general anesthesia occurs when anesthetic
functions are controlled, and enough anesthetic drug is intro- drugs are allowed to wear off. The anesthesia provider care-
duced into the body to keep the client asleep during surgery. fully controls the timing and amount of anesthetic drug
In adults, drugs are usually injected into an IV line to quickly given in order for the client to emerge from general anes-
produce unconsciousness, and additional anesthetic is then thesia at the desired time. The initial phase of emergence is
inhaled (Table 13-3). usually quite quick, allowing the client to awaken enough to
Immediately after the induction of general anesthesia, respond to verbal directions and maintain an airway. After
the anesthesia provider secures the airway using a cuffed this time, the client’s breathing tube usually is removed,
endotracheal tube (ETT) (Figure 13-12). An ETT provides and the client is taken to the PACU (recovery room). If,
a breathing passage from outside the client to within the cli- for some reason, the client is left on a ventilator and with
ent’s trachea. a breathing tube in place, the anesthesia provider takes the
client to an intensive care unit asleep instead of waking the
client up from the anesthetic.
Maintenance
General anesthesia is maintained with some combination of Recovery
IV and inhaled drugs. Figure 13-13 shows a client connected Recovery from general anesthesia is not complete simply
to an anesthesia machine by a breathing circuit. because the client has regained consciousness. The client may
not remember what has happened for minutes or even hours
Skeletal Muscle Relaxation after receiving an anesthetic. The ability to think clearly often
takes longer to return, with some residual thinking difficulty
Some types of surgery require complete relaxation of skeletal
persisting for several days or even weeks. Inhalation anesthet-
muscles. In these cases, the anesthesia provider administers
ics are eliminated from the body through the lungs, and very
a skeletal muscle relaxant such as pancuronium bromide
small amounts of anesthetic are still being exhaled for several
(Pavulon) or vecuronium bromide (Norcuron) to completely
weeks. Many anesthetic drugs are stored in body fat and re-
paralyze the client. These types of drugs prevent clients from
leased back into the bloodstream very slowly after anesthetic
breathing on their own, requiring the anesthesia provider to
administration has ended. The speed of this release depends
ventilate clients during surgery. Paralysis is eliminated before
on the amount of anesthetic given during the surgery, the
emergence from anesthesia so the client can breathe indepen-
length of the surgery, and how deeply the client is breathing.
dently again.
Inadequate reversal of paralysis presents as anything from
total skeletal muscle paralysis to the inability of the client to Oxygenation and Ventilation
cough and clear the airway. If the client is having difficulty Almost all anesthetics are respiratory depressants. Benzodi-
breathing, basic life support is provided until the arrival of an azepines, opioids, and inhalation anesthetic agents have sig-
anesthesia provider. nificant respiratory depressant effects. Any one of these drugs
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may be used in a dose that causes apnea (lack of respirations

for more than 10 seconds) during general anesthesia. When
used in combination their effect on respiration is at least
additive. When the rate or depth of respirations decreases, the
elimination of carbon dioxide is retarded, and carbon dioxide
builds up in the blood and in the lungs. Oxygen saturation is
monitored by pulse oximetry. Even small amounts of supple-
mental oxygen given to a client whose rate or depth of breath-
ing is decreased add significantly to the amount of oxygen in
the bloodstream. This is the most important reason that oxy-
gen is given to even healthy clients when they are recovering
from general anesthesia.
Heart Rate and Blood Pressure

Few direct effects on heart rate (HR) and blood pressure
(BP) regulation are seen during recovery from general an-
esthesia. Some anesthetic techniques that are heavily based
on opioids, such as fentanyl citrate (Sublimaze) or sufentanil
citrate (Sufenta), can cause a slow HR, but as long as BP is
maintained, no specific treatment is necessary. Although most
general anesthetics are myocardial depressants, the depressive
effects of current agents are mild, especially after anesthetic
administration has ended. Figure 13-14 A forced-air warming blanket may be applied
Most HR and BP changes seen during recovery result to the upper abdomen, chest, and arms or lower torso of a client
from factors related indirectly to the anesthetic. Both HR during surgery. The unit on the floor to the left of the anesthesia
and BP increase as a result of sympathetic stimulation. Pain, provider (foreground) is the heating unit, which contains a fan
hypoxia, and fear can all result in sympathetic stimulation that pushes warm air through the hose and into the blanket,
with an increase in HR and BP. Discovering and addressing much like a furnace pushes warm air through heating ducts and
the source of the client’s fear often reduces the anxiety. When into a house. Warm air exits hundreds of pinholes on the surface
the causes of sympathetic stimulation are addressed, HR and of the blanket and next to the client. (Courtesy of mallinCkroDt meDiCal, inC)
BP should normalize.
Temperature Regulation and Shivering
With general anesthesia, the body loses its natural ability to
regulate temperature. General anesthetic agents dilate the Client Monitoring
blood vessels close to the surface of the body, exposing the cli- after Anesthesia
ent’s warm blood to the cool exterior. During anesthetization,
the client is mostly uncovered in a cold operating room, and Why must clients be monitored very closely after
the body’s surgical area is cleaned with cold solutions. After
receiving an anesthetic?
this is done, the client’s insulating covering (skin and subcuta-
neous fat) is cut open to expose the warm interior of the body
and allow its heat to escape. Room temperature intravenous
(IV) fluids are infused into the veins, and the client breathes
cool gases. Surgical clients lose a great amount of heat at a time
when the body is least able to respond to warm the tissues. Fluid Balance
Hypothermia adds to the CNS depression resulting from any Surgical procedures and the injuries that necessitate them
residual anesthetics. Surface warming with a forced-air warm- have major effects on the body’s distribution of fluid.
ing blanket is an effective way to increase the temperature of Appropriate care during anesthesia sometimes necessitates
a client intraoperatively and when recovering from general the delivery of a large volume of IV fluid. This IV fluid
anesthesia; warm cloth blankets also maintain body warmth. does not stay in the vascular system long, moving out of
Figure 13-14 shows use of a forced-air warming blanket. the vascular space to replace losses from the interstitial and
All potent inhalation agents are associated with shivering intracellular spaces.
during emergence from general anesthesia when the blood Trauma, whether caused by an accidental injury or
level of the anesthetic agent is very low. The cause of the a surgical incision, results in fluid losses or shifts in three
shivering is not clear but does not appear to be related to the general areas: direct blood loss, evaporation through the
client’s body temperature. (Of course, postoperative clients surgical wound, and fluid shifts. Large volumes of fluid are
also shiver when they are cold.) The key to eliminating shiver- lost to the air through the surgical wound, especially during
ing postoperatively is to ensure client warmth and encourage abdominal procedures. A major abdominal procedure, for
deep breathing so that the anesthetic is eliminated as quickly example, can result in the loss of up to 10 mL/kg/hr of fluid
as possible. by evaporation.
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Intraoperative Nursing Care Upon the client’s arrival in the PACU, the anesthesia
provider verbally reviews the client’s anesthesia and operative
The success of nursing care in the OR is measured by cli- procedure with the postanesthesia nurse. The postanesthesia
ent outcomes. The Association of periOperative Registered nurse notes the client’s arrival time to the unit and immedi-
Nurses has established client outcome standards for evaluat- ately begins to assess the patency of the airway by placing a
ing perioperative clients on completion of surgery. These hand above the client’s nose and mouth to feel exhalation.
outcomes state that the client is to be free from infection The quality and quantity of respirations are then immediately
and injury related to positioning, foreign objects, or chemi- observed, as is the presence of an artificial airway. The client
cal, physical, and electrical hazards. In addition, skin integ- is attached to a pulse oximeter (Figure 13-16), and breath
rity and fluid and electrolyte balance are to be maintained. sounds are auscultated. The color and condition of the skin
Consequently, nursing care in the OR strives to provide these are noted as part of the respiratory assessment. The lips are
standards to all clients undergoing surgery. checked for circumoral pallor. Peripheral cyanosis may be an
indication of hypothermia rather than respiratory distress.
Refer to Box 13-3 for guidance in completing the postanesthe-
POSTOPERATIVE PHASE sia assessments.
The postoperative phase is the time during the surgical Because most clients admitted are unconscious and have
experience that begins with the end of the surgical procedure received muscle relaxants during surgery, respiratory exchange
and lasts until the client is discharged not just from the hospi- is often affected. Snoring, stridor, labored chest movement,
tal or institution, but from medical care by the surgeon. Upon sternal retractions, cyanosis, and apnea are all signs of respira-
transfer from the OR, the client usually goes to the PACU (Fig- tory distress. Respiratory distress is the gravest of all complica-
ure 13-15). All clients who receive general anesthesia, spinal tions because respiratory crisis and subsequent death occur in a
anesthesia, or regional anesthesia are admitted to the PACU. matter of minutes if distress is not observed and treated quickly.
Occasionally, clients who have undergone surgery with local In the event of any signs of respiratory distress, the postanesthe-
anesthesia or no anesthesia or who have received only IV seda- sia nurse must be alert to the possibility of respiratory arrest and
tion are placed in the PACU for a short period to be monitored be ready to initiate cardiopulmonary resuscitation.
closely until their condition stabilizes. The PACU is usually The Aldrete score, also known as the postanesthetic
located next to the OR. Typically, it is one large room with in- recovery score, is used in PACUs to objectively assess the
dividual units for clients along the perimeter of the room. Each physical status of clients recovering from anesthesia and
of these units has an oxygen delivery system, suction, various serves as a basis for discharge from the PACU. The Aldrete
other supplies, and cardiac, respiratory, and BP monitoring score was adapted to also assess the readiness of clients for
devices. Curtains are pulled to provide privacy if needed, but discharge from ambulatory surgery. The first five items listed
an open view allows continual assessment of all clients. in Table 13-4 are used for discharge from the PACU. Clients
are assessed at the time of admission to the PACU and every
15 minutes until discharge. The first five items include assess-
Postoperative Nursing Care ing activity, respiration, consciousness, circulation, and color
The postanesthesia care nurse is an RN specially trained (oxygen saturation). Each of the five items is scored from
in caring for immediate postoperative clients. The goal of 0 to 2, according to the degree of functional disturbance.
postanesthesia nursing care is to promote recovery from an- The score is expressed as a total score, with 10 being the
esthesia and the immediate effects of surgery. This specialized maximum. Typically, a minimum score of 8 is required for
nurse has knowledge and skill in recognizing and treating an- discharge from the PACU.
esthetic and surgical complications very quickly. The nurse is Fluid intake and output are assessed. The amounts
empathetic and is able to assess and manage pain for the client and types of IV solutions hanging are identified, as are any
who is not able to express himself. added medications. The IV fluids are infused according to
Figure 13-15 The nurse cares for the postop client in the Figure 13-16 The nurse applies a pulse oximeter sensor on
postanesthesia care unit (PACU). the client’s finger.
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BOX 13-3 Table 13-4 Aldrete Score/

QUEStiONS tO ASK Postanesthetic Recovery Score
AND ObSERvAtiONS tO MAKE
WHEN COLLECtiNG DAtA Activity • Able to move 4 extremities 2
voluntarily or on command
Subjective Data • Able to move 2 extremities 1
The client is usually unconscious, so subjective voluntarily or on command
data is not obtained until the client awakens. • Able to move 0 extremities 0
Then the client is assessed for alertness and pain. voluntarily or on command
Objective Data Respiration • Able to breathe deeply 2

Time of arrival in recovery room and cough freely
• Dyspnea or limited breathing 1
Patency of airway
• Apneic 0
Respirations
Presence of artificial airway devices Consciousness • Fully awake 2
• Oral airway • Arousable on calling 1
• Nasopharyngeal airway • Not responding 0
• Endotracheal airway Circulation • BP ± 20% of preanesthetic level 2
Oxygen saturation • BP ± 20% to 50% of 1
Need for supplemental oxygen preanesthetic level
• Mode of administration • BP ± 50% of preanesthetic level 0
• Flow rate Color • Normal 2
Breath sounds • Pale, dusky, blotchy, jaundiced, 1
Color of skin, nail beds, and lips other
• Cyanotic 0
Presence of cardiac dysrhythmias
Other vital signs Additional Assessments: Aldrete Score/Postanesthetic
• Blood pressure, pulse Recovery Score for Clients Having Anesthesia on an
Skin condition (moist or dry, warm or cool) and Ambulatory Basis
skin temperature
Dressing • Dry and clean 2
Initiate Aldrete score • Wet but stationary or marked 1
Intravenous infusion • Growing area of wetness 0
• Type of solution
Pain • Pain free 2
• Amount in bottle or bag
• Mild pain handled by oral 1
• Flow rate
medication
• Appearance and location of IV site • Severe pain requiring parenteral 0
Dressings medication
• Amount and character of drainage
Ambulation • Able to stand up and walk 2
Drains and tubes
straight
• Intactness and function • Vertigo when erect 1
• Connection to drainage and/or suction • Dizziness when supine 0
Level of consciousness Fasting/ • Able to drink fluids 2
feeding • Nauseated 1
Activity level
• Nausea and vomiting 0
Other assessments according to surgical
procedure Urine • Has voided 2
output • Unable to void but comfortable 1
Pain
• Unable to void and 0
uncomfortable
Used by permission of J. Antonio Aldrete, M.D., M.S., Defuniak Springs, FL.
the surgeon’s order and are run at a specified rate. The IV
site is assessed for patency, redness, and swelling. The client
is restrained as necessary to maintain patency of the IV site.
All other infusions and irrigations are also assessed. drainage tubes are then connected, and the type of drain and
Dressings and/or peripads are checked for any evidence the drainage amount are recorded according to physicians’
of bloody drainage and the amount noted so that any subse- orders. Table 13-5 outlines common types of drains placed
quent appearance of blood may be accurately evaluated. All during surgery. Urinary output is also monitored. Scanty
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Table 13-5 description, Uses, and nursing Care of Common drainage
devices Placed during Surgery
TYPE EXAMPLE dESCRIPTIOn USES nURSInG CARE
Passive Penrose A single-lumen, To remove drainage • Inspect dressing.
soft latex tube that when more than a • Check underneath client to ensure
works with gravity minimal amount of drainage has not leaked from the side of
directly from the drainage is expected the dressing.
surgical incision • Always keep a dressing over drain.
• Check safety pin through end of drain.
Active Hemovac Closed-wound Used after multiple types • Assess the drainage system as
Jackson-Pratt drainage system of procedures; provides appropriate to client’s condition for:
J-Vac with drain and continuous gentle suction 1. Continued drainage
Relia Vac reservoir having of the operative site to 2. Maintained decompression
Surgivac self-suction increase drainage of 3. Airtight tubings
when reservoir is serosanguineous fluid 4. Need for emptying
compressed and collapse tissue to • To reactivate suction, wash hands and
facilitate healing wear gloves and eye/face protection.
• Empty reservoirs every 8 hours, when
drainage nears the full line, or as
ordered by the physician.
Passive Davol Sump Large, multilumen To drain intra-abdominal • Use one of the smaller or sump ports for
or active Axiom Sump tube with a larger fluids from abscesses, continuous irrigation.
main port for cysts, or hematomas • Calculate intake and output carefully
drainage and/or with irrigations.
suction and with • Place impervious pads underneath
smaller side port(s) client.
for irrigation and/or • Change dressings frequently when
air venting to help saturated.
prevent tissue from • Attach to catheter drainage bag if not
being suctioned attached to suction; do not plug sump
against catheter ports.
and damaged
Chest tube Large single-lumen To drain fluid or air from • Assess breath sounds and respirations,
ThoraKlex drain attached to pleural cavity including depth, rate, symmetry of chest
Pleur-Evac closed water-seal expansion, color of mucous membranes,
drainage system and presence of crepitus with suction off
or tubing clamped.
• If present, assess amount and type of
suction.
• Ensure that connections are tight and
sealed with tape.
• Keep chest tube drainage reservoir
lower than client’s chest.
• Observe for air leaks in air leak indica-
tor or drainage chamber of drainage
reservoir.
• Place petroleum jelly gauze nearby for
quick access should the tube become
dislodged.
• Measure drainage at least every 8 hours
(more frequently if in a critical care unit
or client’s condition warrants it).
• Clamp or milk the chest tube only if or-
dered by surgeon.
• Notify surgeon if drainage is greater than

100 mL/hr.
• Change drainage system when
two-thirds full.
295
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urinary drainage (<50 mL/hr or as ordered) is reported to

the surgeon.
Surgical drains are placed so the wound can drain
freely of blood clots, body fluids, pus, and necrotic material
that otherwise would collect in the wound and provide a A B
rich medium for bacterial growth. Figure 13-17 illustrates
common drainage devices. All drains are inserted at the op-
erative site and exit through the incision or a separate stab
wound adjacent to the incision. The type of drain is chosen
according to the location of wound, size of wound, and
type of drainage anticipated. The use of drains decreases
pain and infection and aids wound healing; however, if the
wound is draining, the skin is not closed, and a pathway
exists for the entrance of microorganisms. Drain sites can
thus also be a source of infection. Potential complications
of drains include hemorrhage, sepsis, drain loss, and bowel
herniation. Nursing care for drains includes assessing the
color, character, and odor of drainage; ensuring the patency
of the drain (making sure there are no kinks in the tubing);
and ensuring that the drain does not accidentally become
dislodged. Table 13-6 lists additional nursing care accord-
ing to surgical procedure.
Part of the neurological assessment involves assessing
the activity level or the ability to move extremities voluntarily.
The ability to move extremities on command indicates volun-
tary movement. Hearing is the first sensation to return to the
client after having been anesthetized. Clients in the PACU
are asked to squeeze the postanesthesia nurse’s hands and to
plantarflex and dorsiflex the feet.
Continuing Nursing
Care in the PACU
After the client has been admitted and assessed in the PACU,

the postanesthesia nurse checks the surgeon’s and the anes-
thesia provider’s orders and initiates any therapy designated
for the PACU.
The postanesthesia nurse charts on a separate nursing C
record for the PACU. Anything unusual must be adequately
documented. If vital signs are in the normal range, the Figure 13-17 Common drainage devices: A, Penrose
drain; B, Hemovac; C, Jackson-Pratt.
Table 13-6 Additional nursing Care According to Classification or Type

of Surgical Procedure
CLASSIFICATIOn OR
TYPE OF SURGICAL
PROCEdURE nURSInG CARE
Orthopedic • Expose wet casts to the air.
• Check surgeon’s orders for positioning of client; operated extremities typically are
elevated.
• Check for digital warmth, color, mobility, circulation (pulses), and sensation in affected
extremity.
Urological • Attach all catheters to drainage.

• Closely monitor continuous irrigation to ensure that flow in and flow out are equal;
if obstructed, the bladder could rupture.
• Increase or decrease irrigation flow rate according to amount of bleeding.
• Assess for chills or elevated pulse, possibly indicative of hemolysis or bacterial infection.
• Assess abdomen for signs of distention and rigidity and report, especially if client
complains.
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Table 13-6 Additional nursing Care According to Classification or Type

of Surgical Procedure (Continued)
CLASSIFICATIOn OR
TYPE OF SURGICAL
PROCEdURE nURSInG CARE
Oral • Suction frequently and carefully around sutures.
• Observe breathing; ensure that drainage or packing does not obstruct airway.
• Apply ice bag, when ordered.
• Remove dental packs as ordered and assess every 15 minutes for further bleeding.
Eye, ears, nose, Eye surgery • Assess for facial paralysis.

and throat (EENT) • Minimize head movement, coughing, vomiting, and restlessness.
Ear surgery • Assess edema and tracheal patency (listening for stridor and observing
for restlessness).
Nose surgery • Maintain open airway; suction orally; and apply ice.
Tonsillectomy • Place on side to facilitate drainage: elevate head of bed; have suction
available. Observe closely for bleeding, vomiting, and obstruction.
Neurological • Assess level of consciousness; be alert to drowsiness, slurred speech, disorientation, or

irritability that differs from that exhibited in the preoperative state.
• Observe for pupil changes: inequality, constriction, and nonreactivity to light.
• Assess for respiratory changes such as snoring, retraction of cheeks and trachea,
shallowness, and slowed rate.
• Monitor blood pressure and pulse; an elevated blood pressure coupled with a lowered
pulse leads to shock.
• Observe extremity movement for weakness, paralysis, and rigidity; observe for unilateral
drooping of facial features.
• Use caution when medicating.
Laminectomy • Move only as ordered.
or discectomy • Assess sensation, circulation, and motion of extremities distal to
incision.
Craniotomy • Position as ordered.
• Complete a neurological check.
• Use Trendelenburg position only with permission of the surgeon.
Vascular (all grafts, • Assess color, sensation, warmth, and mobility of extremity.
carotid endarterectomy, • Observe presence and strength of pedal and post-tibial pulses.
femoral-popliteal bypass) • Complete a neurological check for carotid endarterectomy.
• Frequently check all dressings and the area directly beneath the client.
• Drainage can roll around a curved body part, leaving the dressing appearing dry.
However, check the area directly under curved body structures for bleeding.
Thoracic • Closely observe chest tube for patency, amount of bleeding, and air leaks. Tape all
connections. Mark drainage container upon client’s admission and discharge. Assess
fluctuation of drainage in tubing. Attach suction as ordered.
• Observe respirations closely with regard to color change, restlessness, apprehension,
dyspnea, or mediastinal shift.
• Elevate head of bed 30°, unless contraindicated.
• Encourage coughing and deep breathing.
• Use caution in administering narcotics, especially morphine sulfate, because client
cannot afford respiratory depression.
Pneumonectomy • Do not turn on nonoperative side. Alternately turn from back to
operated side.
Lobectomy • May turn client to either side.

and resection
Gynecological • Assess vaginal drainage.
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postanesthesia nurse checks them every 15 minutes. If vital

signs are unstable, they are checked every 5 minutes or as BOX 13-4
often as necessary until stable. If vital signs fail to stabilize, QUEStiONS tO ASK AND
the surgeon and anesthesia provider are notified. The surgi- ObSERvAtiONS tO MAKE WHEN
cal site is checked at least every 30 minutes. If any initial COLLECtiNG DAtA
bleeding has not subsided, the surgeon is notified. Routine
checks are continued until the client is discharged from the Subjective Data
PACU. Ascertain if the client is alert and oriented to
The postanesthesia nurse determines whether the cli- time, place, and person.
ent meets the criteria for discharge from the PACU. Typi- Ask the client to relate current pain location,
cally, the client’s vital signs are stable and within the client’s quality, and level of intensity on a scale of
normal limits. The Aldrete score is 8 to 10. If the score is 7 0–10 with 0 as no pain and 10 the most pain
or less, a surgeon’s or anesthesia provider’s order is required
felt.
for discharge. Also before client discharge, the dressing is
checked, changed, or reinforced according to orders. All other Objective Data
parameters are reassessed and charted. Institutional protocol Time of arrival in unit
dictates minimum stay in the PACU. Adults are typically kept
in the PACU for a minimum of 1 hour, except outpatients, Transfer from stretcher or gurney to bed
who go to the ambulatory surgery unit when they are awake • Place bed in lowest, locked position, with the
and when postmedication time is fulfilled. When criteria for top two side rails raised
discharge are met, the postanesthesia nurse calls the clinical • Place client in position of comfort, or as
unit or ambulatory surgery unit and reports the client’s name, ordered
vitals, surgery, and any other pertinent information. The client Vital signs including airway assessment and
is then transferred to the appropriate unit. breath sounds
Color of skin, nail beds, and lips
Later Postoperative Skin condition (moist or dry, warm or cool)
Nursing Care Activity level
Before the client’s arrival in the clinical unit, the nurse pre- Intravenous infusion
pares for the client. The linen is changed, the bed linen folded • Type of solution
down, and the room cleared of clutter. Any required special • Amount in bottle or bag
equipment, as directed by the postanesthesia nurse, is gath- • Flow rate
ered. An emesis basin and tissue are available. The nurse is
• Appearance and location of IV site
ready to assess the client in an organized manner, focusing on
the body system affected by surgery. Dressings
Upon the client’s arrival in the clinical unit, the nurse • Amount and character of drainage (In some
assists in transferring the client to the bed. Refer to Box 13-4 facilities, a nurse draws a line around the
for guidance in completing the nursing assessment and care drainage and writes the date, time, and
of the client upon admission to the clinical unit. A brief as- nurse’s initials inside the line, so one can see
sessment, including vital signs, is completed every 15 minutes if the drainage is increasing the next time the
for 1 hour; every 30 minutes for 2 hours; and every hour for dressing is assessed.)
4 hours, or as prescribed by the physician.
The possibilities of postanesthetic complications con- Drains and tubes
tinue, but as time passes, different postsurgical complications • Intactness and function
may develop; the nurse is responsible for managing these: • Connection to drainage and/or suction
1. The client is at risk for Ineffective Airway Clearance Urinary output
caused by atelectasis and hypostatic pneumonia. Respi- • Need to void or time of voiding
ratory complications can still occur with any anesthe- • Presence of patency and catheter; output/
tized client. As in the PACU, the postoperative client hour
is at risk for ineffective airway clearance, ineffective
breathing patterns, and aspiration. Now, however, nurs- Pain
ing measures are directed toward preventing ineffective • Last dose of analgesia
airway clearance caused by atelectasis and hypostatic • Current pain location, intensity, quality
pneumonia, both of which usually occur within the first Compare assessment with PACU report
48 hours postoperatively. In postoperative atelectasis, Call light within reach
the bronchioles of the lungs become plugged with mu-
• Reorient client to usage
cus so that air cannot reach the alveoli. The alveoli then
collapse. The client develops dyspnea, fever, tachypnea, Location of family or significant others
tachycardia, and cyanosis. In postoperative hypostatic Postoperative orders
pneumonia, stagnant mucus promotes the growth of
bacteria, and atelectasis then develops into a secondary
infection.
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To prevent these complications, actively encour- to adjust. Check the radial pulse frequently and ask the
age the client to cough, deep breathe (with and without client if he is dizzy or nauseated. If syncope occurs
incentive spirometry), and turn as instructed preop- during ambulation, ask for assistance in obtaining a
eratively. Encourage the client to sit up and ambulate wheelchair for the client, use a nearby chair, or lower
as soon and as often as ordered. Ensure adequate pain the client to the floor until the client recovers. Although
relief measures so that mobility is well tolerated. frightening for the client, syncope is not physiologically
2. The client is at risk for Peripheral Neurovascular Dysfunc- threatening unless the client is injured in a fall.
tion, Excess/Deficient Fluid Volume, and Activity Intoler- 3. The client may be at risk for Imbalanced Nutrition: Less
ance. The client continues to be at risk for decreased than Body Requirements related to nausea and vomiting,
cardiac output and fluid volume deficit. Implement hiccups, abdominal distention, constipation, and NPO
measures to prevent deep vein thrombosis, thrombo- status. Gastrointestinal complications become more
phlebitis, pulmonary embolism, complications of fluid prevalent after immediate postoperative recovery. The
overload, fluid deficit, hypokalemia, and syncope. client may also experience pain related to hiccups and
The stress response to surgery, inactivity, pressure slowed gastrointestinal function.
related to body position, obesity, and injury to pelvic Anesthetic agents, narcotics, hypotension, and the
veins during surgery contributes to the formation of manipulation of the bowel during surgery cause nausea
deep vein thrombosis, thrombophlebitis, or pulmonary and vomiting. Handling of the bowel during pelvic and
embolism. These complications may appear immedi- abdominal surgery causes peristalsis to stop or severely
ately after surgery or 1 to 2 weeks later. Routinely as- slow. Bowel function normally returns 2 to 5 days after
sess for a positive Homans’ sign and for warm, tender, surgery. If bowel inactivity persists, a paralytic ileus de-
reddened, hardened areas in the calves. To assess for velops. As bowel function resumes, continue to assess
Homans’ sign, ask the client to forcefully dorsiflex the the client for bowel sounds and, if a nasogastric tube is
foot. If pain is felt in the calf of the leg, it is considered present, a reduction in drainage. As peristalsis returns in
a positive Homans’ sign; if no pain is felt, it is con- a discontinuous fashion, the client experiences distention
sidered a negative finding. A positive Homans’ sign along with flatulence and gas pains. After bowel sounds
may indicate thrombophlebitis and is reported to the resume in all quadrants, the client is removed from NPO
surgeon. Deep vein thrombosis and thrombophlebitis status according to the surgeon’s orders. Provide good
may lead to a pulmonary embolus, although there is oral hygiene when the client is NPO and administer anti-
no warning of pulmonary embolism. The client experi- emetics as needed for nausea and vomiting.
ences dyspnea, chest pain, cyanosis, cough, hemoptysis, Hiccups are caused by irritation of the phrenic
tachycardia, and fever coupled with an elevated white nerve. Impulses then cause the diaphragm to contract
blood cell count when a pulmonary embolism occurs. If rhythmically and violently. Abdominal distention, gas-
the embolism is large enough, shock develops rapidly. tric distention, and the presence of a nasogastric tube
Pulmonary embolism may be fatal. are common causes, but electrolyte and acid–base dis-
To prevent the formation of deep vein thrombosis, turbances, intestinal obstruction, and intra-abdominal
thrombophlebitis, and pulmonary embolism, encour- bleeding also initiate hiccups. Notify the surgeon when
age ambulation to the extent the client is able. When hiccups are prolonged.
in bed, encourage the client to perform postoperative Gas pains and signs and symptoms of abdominal
leg exercises each hour. Antiembolism stockings may distention are minimized by early and frequent ambula-
be ordered, or a sequential compression device, which tion and resumption of oral intake. Frequently reposi-
is a boot applied to the legs to simulate walking by al- tioning the client encourages movement of air through
ternate inflation. Remove the boots and antiembolism the intestines, relieving gas pains. As air rises and peri-
stockings every day to cleanse the skin. Antiembolism stalsis moves from right to left, the client is moved from
stockings and the sequential compression device are lying on the left side (where air will rise on the right),
not substitutes for leg exercises. Encourage the client to to lying supine, to lying on the right side (where air will
perform leg exercises. rise on the left). If the client can tolerate it and there are
When ordered, low-molecular-weight heparin, no contraindications, lying prone with the head turned
enoxaparin (Lovenox), is administered to hemostati- to the side places pressure on the abdomen, forcing air
cally stable clients who have undergone pelvic, abdomi- to rise and move out through the rectum. Other nursing
nal, or thoracic surgery. It is given subcutaneously every care measures to relieve abdominal distention might
12 hours or daily as ordered until discharge. If preopera- include irrigation of the nasogastric tube, if present.
tive INR levels were within normal range, no laboratory Irrigating the nasogastric tube may also relieve hiccups.
test is necessary to determine the drug’s effect. The regi- Constipation is a major source of discomfort for
men is ordered at the surgeon’s discretion. the client. Analgesics combined with decreased activity
Measure intake and output and monitor laboratory and NPO status are very constipating. Oral fluids and
findings (e.g., electrolytes, hematocrit, hemoglobin, and activity are encouraged. If ordered, a medical regimen
serum osmolality) and signs and symptoms of hemor- of stool softeners and suppositories is indicated.
rhage by assessing vital signs, skin color and condition, 4. The client is at risk for developing Urinary Retention
dressings, drains, and tubes, as in the PACU. related to anesthesia, immobility, and pain. The cli-
Clients often experience syncope when changing ent is also at Risk for Infection related to Foley catheter
from a lying position to a sitting or standing position. placement. The quantity and quality of urine are more
Assist the client to change positions slowly, proceed in directly related to cardiac output and the perfusion of
steps, and allow time for the client’s internal equilibrium the kidneys than to anesthesia, immobility, and pain,
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although a stress response following surgery causes the when clients are groggy from being awakened. Often,
body to retain fluids for 24 to 48 hours after surgery. thoughts will clear if the client is given the opportunity
Urine output should be at least 30 mL/hr if a catheter to thoroughly awaken. Encouraging the presence of
is in place. The catheter is assessed for patency. If not loved ones, offering explanations, and listening to the
catheterized, the client should void at least 200 mL at the client decreases sensory perceptual alterations. Encour-
first postoperative voiding. Most clients void within 6 to aging previous sleep patterns, providing uninterrupted
8 hours after surgery; however, urinary retention occurs sleep, and alternating rest and activity also is beneficial.
frequently in the postoperative period, especially follow- Hypothermia is common in the first few hours fol-
ing abdominal or pelvic surgery. Anesthesia depresses lowing surgery. Offer blankets as needed. Because of the
the urge to void. Narcotics, vagolytic agents (anticho- normal inflammatory response, temperature may later
linergics), and spinal anesthesia also interfere with the elevate to a low-grade fever. If temperature rises higher
ability to initiate voiding. Facilitate voiding by encour- than 101°F (38°C), notify the surgeon. Atelectasis and
aging fluid intake and assisting the client to void in an dehydration cause elevated temperature (higher than
anatomically correct position depending on the client’s 101°F [38°C]) in the first 24 to 48 hours after surgery.
condition. Privacy, running water, indirect bladder pres- After 48 hours, temperature higher than 101°F (38°C)
sure (placing a firm hand over the bladder), and warm indicates a wound, respiratory, or urinary tract infec-
water over the perineum may also encourage voiding. tion; thrombophlebitis; or pulmonary embolism.
If the client has not voided, use a noninvasive The nurse’s primary role is to prevent infection
bladder ultrasound instrument to measure the bladder by using aseptic technique. Once a fever has occurred,
volume (Figure 13-18). If the facility does not have a follow orders to ascertain the cause of the elevation
bladder scanner, palpate, inspect, and percuss the blad- by taking urine, wound, blood, or sputum cultures.
der to check for distention. The surgeon will order a Administer antipyretics as ordered. Measures that may
Foley catheter to be inserted if the client has a distended increase comfort include providing light covers and
bladder or has not voided after 8 to 10 hours. clothing, performing frequent linen changes, offering
5. The client may become at risk for Disturbed Sensory cool washcloths, and ensuring a cool environment.
Perception related to anesthesia, narcotics, change of 6. The surgical client is at Risk for Impaired Skin Integrity
environment, fluid and electrolyte imbalances, sleep and Risk for Infection related to surgical incision. The
deprivation, hypoxia, and sensory deprivation or over- nurse generally does not remove the primary dressing
load. The client may also experience Hypothermia without an order to do so. Bleeding is monitored by
related to anesthesia and surgical environment and circling the drainage on the dressing and then reas-
Hyperthermia related to infection. Alterations in neu- sessing later to ascertain whether the drainage area has
rological function vary and manifest as pain, fever, increased in size. The dressing also is reinforced with
or delirium. Assessing the level of consciousness is a additional absorbent dressings as needed. In some insti-
priority. A change in level of consciousness may be the tutions, the dressing is changed as necessary after the
first indication of a stroke and/or increased intracranial first dressing change. Some surgeons prefer no dressing
pressure. Determining the level of consciousness is if there is no drainage or drains.
difficult, especially in the older adult client or at night, Drainage on dressings and in drains typically
changes from sanguineous to serosanguineous to se-
rous over several hours to several days, depending on
the type of surgery. The amount also decreases over the
same time period. Purulent, odorous drainage is a sign
of infection. A sudden increase in drainage is a sign of
impending wound separation. Always notify the sur-
geon of any excessive or abnormal drainage.
All wounds heal by primary, secondary, or tertiary
intention. In primary intention, the wound layers are
sutured together and have no gaping edges. The wound
generally heals in 8 to 10 days but may take up to
3 months. There is minimal scar formation. Most surgi-
cal wounds are of this type.
In secondary intention, the wound heals by filling
in with granulation tissue and by contracting where
the skin edges are not approximated. This method
is used for ulcers when there is not enough tissue to
approximate the edges or for infected wounds when
drainage is desirable. Wounds healing by secondary

intention are assessed according to the presence of
granulation tissue having a red, granular appearance.
Wound healing is slow, possibly taking many months
or years. Thus wound healing by primary intention is
preferable.
Figure 13-18 The nurse uses a noninvasive bladder In tertiary intention, the approximation of tissue
ultrasound to measure the client’s bladder volume. edges is delayed. This allows an infection to drain
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or an area of extensive tissue removal to begin heal- and are preceded by a sudden spillage of serosanguineous
ing. The edges of the wound are closed 4 to 6 days drainage. Dehiscence and evisceration are more likely to
later. Because areas of granulation tissue are brought occur in the older adult client, the malnourished client,
together at this time, the scar is usually much wider the client with an infection, or the client with abdominal
(Figure 13-19). distention who is straining severely. If evisceration occurs,
Wound dehiscence and evisceration are serious com- the viscera is immediately covered with sterile saline dress-
plications of wound healing. dehiscence occurs when ings and the surgeon notified of the wound disruption.
the wound edges separate (Figure 13-20A). Eviscera- When dressings are changed, the surgical incision
tion occurs when the wound separates completely and is cleansed to remove debris and bacteria from the inci-
the viscera protrude from the wound (Figure 13-20B). sion. The choice of cleansing agent depends on the phy-
Both are more likely to occur 7 to 10 days after surgery sician’s prescription as well as institutional protocol. It
is recommended that isotonic solutions such as normal
saline or lactated Ringer’s be used.
The major principles to keep in mind when cleans-
ing a surgical incision are:
• Use Standard Precautions at all times.
• Use a sterile swab or gauze and work from the clean area
out toward the dirtier area. Begin over the incision line
and swab downward from proximal to distal. Change
the swab and proceed again on either side of the inci-
sion, using a new swab each time (Figure 13-21).
The surface closures (staples or sutures) are re-
moved as the incision heals. Continuous sutures are
made with one thread and tied at the beginning and end
of the suture line. Intermittent sutures are each tied indi-
vidually. In blanket continuous sutures, the single thread
A
is grounded again in the last suture exit (Figure 13-22).
Some surgical wounds are closed with dissolvable sutures
and special tape strips and others with special adhesive
glue. Dissolvable sutures are not removed; instead, the
glue wears off by beginning to crack and then falling off
in 5 to 10 days. Usually no dressing is applied when the
wound is closed with glue. When a wound is glued, the
client may take a shower, but is not to get any soap or
lotion on the glue for 24 hours.
The incisional dressing keeps the incision clean and
protects it from physical trauma and bacterial invasion.
Generally, the same kind of dressing is put on as was
taken off. As the incision heals and drainage lessens, a
small, thinner dressing usually is applied. Bandages and
binders are applied over the incision dressing to secure,
immobilize, or support a body part; to hold the dressing
B in place; or to prevent or minimize swelling of a body
part. Bandages are long rolls of material, such as gauze,
webbing, or muslin, designed for wrapping around
body parts. Figure 13-23 illustrates several different
methods of bandaging. Binders are bandages made for
C
A B
Figure 13-19 Wound healing: A, primary intention;
B, secondary intention; C, tertiary intention. Figure 13-20 A, Dehiscence; B, evisceration.
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3
1
2 7 8
5 6
3 4
1 2
A B
1 2 3

C
Figure 13-21 Use a clean, sterile swab for each stroke when cleansing a surgical incision. A, Gently clean the incision, then each
side alternately. B, Gently wipe swab outward, away from the incision. C, Clean around a drain site in a circular motion.
A B (Delmar Cengage learning)
C D E
Figure 13-22 Skin closure methods: A, continuous; B, intermittent; C, blanket continuous; D, staples; E, glue.
specific body parts, usually the abdomen or arm (sling) During dressing changes and after the dressing
(Figure 13-24). Abdominal binders support the abdo- has been removed, the surgical wound is assessed for
men of an obese client following abdominal surgery. skin edge approximation, edema, and bleeding. The
A sling is a cloth support with adjustable straps that skin edges may be slightly reddened and swollen from
wrap around the back to provide support for an injured the normal inflammatory response. Possible signs of
arm; it maintains the arm in a set position. a wound infection include increased suture tension,
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3
5 2
4
B 6
8
Figure 13-23 Common bandaging methods: A, Circular turns are wrapped around a body part several times to anchor the
bandage or supply support. B, Spiral turns begin with a circular turn and then proceed up the body part, with each turn covering
two-thirds the width of the preceding turn. C, Spiral reverse turns begin with a circular turn. The bandage is then reversed or twisted,
once each turn, to accommodate a limb that gets larger as the bandaging progresses. D, Figure-eight turns crisscross in the shape of a
figure eight and are used on a joint that requires movement. E, Recurrent turns are anchored with circular turns, follow a back-and-forth
motion, and are completed with circular turns; they are used to cover a fingertip, head, or residual limb.
warmth, erythema, drainage, odor, pain, and induration style, financial strain, or a poor prognosis. Many clients
around the incision site. Wound healing is enhanced undergo a psychological adjustment to surgery. Tak-
by promoting nutrition, discouraging smoking, and ing time to listen to the client and also offering simple
performing proper wound cleansing. The practice of explanations and reassurances support the client’s needs
aseptic technique cannot be emphasized enough in to combat anxiety.
preventing nosocomial infections (hospital-acquired As the client recovers and is ready for discharge from
infection) in a surgical incision. the hospital, the client is at risk for Deficient Knowledge re-
7. Clients are at risk for Anxiety or Ineffective Coping lated to home care. Ideally, the client receives home care
related to disturbance in body image, change in life- instructions from the moment of admission. Adequate
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COMMUNitY/HOME HEALtH CARE

Dressing Wounds
• Because of early discharge, clients are often sent
home with incisions that need dressing changes.
• Ascertain the client’s support system, including
caregivers, the home environment, and avail-
able resources.
• Teach the client and/or home caregiver the cor-
rect method of changing the dressing.
• Have the client and/or home caregiver change
the dressing before the client is discharged.
A
• Provide a list of signs and symptoms of compli-
cations of wound healing.
• At times, a referral for home care nursing is
necessary.
COMMUNitY/HOME HEALtH CARE

Postoperative Care
To provide quality home care, the client and family
are given information about the following topics:
• Medication regimen
• Diet
• Activity restrictions
• Follow-up appointments
• Wound care
• Special instructions
B
The specifics for each topic will vary with each cli-
Figure 13-24 Protective devices: A, abdominal binder; ent and will depend on the surgical procedure and
B, arm sling. the client’s age and physical condition.
teaching about home care results in a quicker recovery, the client’s full participation in coughing, deep breath-
fewer complications, and greater independence. ing, turning, and ambulation.
The Institute for Healthcare Improvement’s Sur-
gical Care Improvement Project (SCIP) has a website
that encourages nationwide improvements in the qual- POSTOPERATIVE PAIN
ity of surgical care to decrease surgical complications.
Refer to this website for more information: www MANAGEMENT
.ihi.org. A web search for surgical core measures also Pain has many causes. Postoperative pain results from tissue
provides valuable information on providing quality injury, release of local and hormonal substances, inflamma-
surgical care. tion, mental outlook, and, perhaps, neural hyperexcitability
8. The client may also experience Acute Pain related to related to excessive noxious input. As such, baseline postop-
the surgical incision. Assess and record subjective data erative pain, pain from pressure placed on an incision, and
regarding pain location, intensity on a scale of 0 to 10, pain from client movement each respond best to different
quality, and duration as well as factors contributing to pain-relieving strategies.
pain. Objective data such as grimacing and crying are The amount of medication needed to relieve pain de-
also recorded. Analgesics are usually ordered for admin- pends on the intensity and type of pain, the size of the client,
istration via patient-controlled analgesia, epidural anal- and the client’s age. The opioid dose for an older adult client is
gesia, intravenously, intramuscularly, or orally, all on started at 25% to 50% of the usual adult dose and then slowly
a PRN (as-needed) basis. Encourage the client to ask increased by 25% to 50% increments until the client reports a
for medication before the pain becomes severe. Offer mild pain level (McDonald, 2006). The opioid of choice for
medication before activity or painful procedures such as older adults is morphine, with hydromorphone hydrochloride
wound irrigation. Attend to analgesic requests promptly (Dilaudid) as the second choice (McDonald, 2006). Monitor
and evaluate the effectiveness of the pain medication older adults closely for opioid toxicity on a pain scale that they
given per facility policy. Ensuring comfort encourages can understand.
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Patient-Controlled added to a spinal or epidural anesthetic provides hours of

postoperative pain relief, often enough so that no other pain
Analgesia medication is needed; it may even provide better pain relief
Patient-controlled analgesia (PCA) allows clients to self- than do IM injections or intravenous PCA. Opioids are added
administer pain medication by pushing a button when they to spinal or epidural anesthetics as a single dose or infused
experience pain. After an IV catheter is in place, a client- into the epidural space postoperatively. Although spinal and
controlled analgesia pump is connected “piggyback” to the epidural morphine provide excellent pain relief, they may
IV line. The pump is programmed to deliver a predeter- also produce significant respiratory depression. Fortunately,
mined dose of morphine, hydromorphone hydrochloride respiratory depression after spinal or epidural morphine ad-
(Dilaudid), or fentanyl citrate (Sublimaze) when the cli- ministration is rarely rapid in onset. Respiratory depression
ent pushes a button. It will not, however, deliver unlimited is very rare with properly dosed epidural or spinal fentanyl
amounts. A set time must pass between each successive citrate (Sublimaze). As a result of the client selection and dos-
dose, and when the total dose of opioid delivered in any hour ing protocols currently in use, life-threatening respiratory de-
reaches a preset limit, the pump will not deliver any more pression is a rare event. When it does occur, it can be detected
medicine until the next hour. This is referred to as lockout. long before it causes harm, by observing the client frequently,
Properly programmed, PCA allows the client a great deal noting respiratory rate and depth, and periodically measuring
of control over when pain medicine is received, which is likely oxygen saturation by pulse oximetry.
to help decrease anxiety. PCA also results in a shorter interval
between the need for pain medicine and its administration, AMBULATORY SURGERY
better pain relief than that obtained with intermittent IM injec-
tions, and a reduction in nursing time necessary for the deliv- Ambulatory surgery is defined as surgical care performed
ery of pain medicine. It does not, however, decrease the need under general, regional, or local anesthesia involving less
for client assessment of pain while the PCA machine is in use. than 24 hours of hospitalization. Other names for ambulatory
surgery include same-day, one-day, outpatient, in and out, or
Regional Analgesia short-stay surgery.
The trend in health care is to promote wellness. Clients
Regional analgesia and anesthesia have many applications in
the relief of postoperative pain. Regional anesthetics do not are encouraged to accept more personal responsibility for their
cease working when the surgery ends and provide pain relief state of health. In the past, the message sent to clients was that
for a variable period of time afterward. The duration of post- the client is sick, and the medical community will provide all
operative pain relief can be extended by continuing the infu- care. Today, ambulatory surgery clients are sent an entirely
sion of pain medication into the epidural space or by adding different message: that the postoperative client is not sick and,
opioids to either epidural or spinal anesthetics. except for a few minor limitations, can often resume normal
daily activities soon after undergoing anesthesia and surgery.
Ambulatory surgery provides the longest period of time
Local Anesthetics for the client to receive skilled postoperative care or monitor-
Local anesthetics, either alone or in combination with opi- ing without formal admission to the hospital. The practice of
oids, are administered into the epidural space at low concen- ambulatory surgery attempts to overcome the risk of prema-
trations that do not cause complete anesthesia. This type of ture dismissal while meeting fiscal requirements. The empha-
pain relief is most commonly used for women in labor who sis on cost containment coupled with government reductions
receive epidural analgesia. Local anesthetic in low concentra- in Medicare and Medicaid payments has further promoted
tions is a powerful analgesic. If local anesthetic is administered the concept of ambulatory surgery.
in a way to relieve pain in the lower extremities, clients are To further reduce health care costs, few clients are admit-
usually confined to bed, because even dilute concentrations of ted to the hospital before the day of surgery. Most surgical
local anesthetic may affect the strength of leg muscles enough clients are processed through the ambulatory surgery unit.
to increase the risk of falling. Clients receiving analgesia via an These clients are called “day of surgery” or “A.M. admit”
epidural block are watched carefully to ensure that they do not clients. Necessary laboratory work, radiology tests, or other
develop pressure necrosis in the blocked areas. examinations are completed on an outpatient basis before
the day of surgery. Even clients undergoing extensive surger-
Opioids ies such as open-heart surgery (a coronary artery bypass),
The spinal cord has receptors for opioids, and when opioids craniotomy, or total joint replacement are admitted the day
are added to a spinal or epidural anesthetic, they provide pain of surgery. Then, after discharge from the perioperative suite,
relief even after the anesthetic block has worn off. Morphine the client either is admitted to the hospital as an inpatient or
is sent home from the ambulatory surgery unit.
In addition to fiscal considerations, the growth of ambu-
latory surgery can also be traced to technological advances.
BestPraCtiCe Clients now require shorter recovery periods as a result of
new procedural technology, such as laparoscopic cholecys-
Patient-Controlled Analgesia (PCA) tectomy. The introduction of shorter acting anesthetic agents
• Only the client should push the button to ad- also decreases the immediate postoperative recovery time,
minister more analgesic. facilitating the client’s ability to function independently upon
• The client should not ask visitors to push the
discharge from the ambulatory surgery setting.
The benefits of ambulatory surgery are many. Ambula-
button.
tory surgery decreases costs to the client, institution, insurance
carriers, and governmental agencies. The risk of acquiring a
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BestPraCtiCe BestPraCtiCe
Postanesthetic Care Ambulatory Surgery
• Immediately report to the anesthesia provider • Precertification documents are approved before
or surgeon any client breathing difficulty or a the preadmission visit.
respiratory rate of 12 breaths per minute or less. • Preadmission diagnostic tests, preoperative
• Immediately report to the surgeon or the an- nursing assessment, and initial teaching are usu-
esthesia department a fall in the client’s BP or ally performed the day before the scheduled
increase in HR. surgery.
• Verify client’s ability to stand or walk with nor- • On the day of surgery, care is focused on the
mal motor strength and coordination and with- immediate needs of the client.
out any dizziness before allowing the client to
get up without assistance.
• Do not allow clients to rub their eyes. Clients
hospital-acquired infection is also decreased. The client experi-
who are still drowsy may try to rub out protec- ences less disruption to personal life and less psychological dis-
tive eye moisturizer and, in the process, cause tress related to hospitalization. With ambulatory surgery, the
painful corneal abrasions. client especially benefits from early postoperative ambulation.
• Observe clients immediately and hourly for Ambulatory surgery is performed in several different set-
bladder distention. Both regional and general tings. Hospital-based integrated facilities are formal ambula-
anesthesia can sometimes cause temporary uri- tory surgery programs incorporated into existing inpatient
nary retention. surgery programs. Clients are cared for preoperatively and
• If clients have an epidural catheter for post- postoperatively in the ambulatory surgery unit but are mixed
operative pain management, ensure that they with inpatients on the OR schedule. This type of facility
change positions from time to time to prevent
also allows preoperative processing of day-of-surgery clients.
Hospital-affiliated facilities consist of a separate department
pressure necrosis. Do not allow the lateral as-
with designated preoperative, intraoperative, and postopera-
pect of the leg to rest on the side rails. tive areas. Such a facility is located within the hospital, adjacent
• Report to the anesthesia department as soon as to the hospital, or at a satellite location. Freestanding facilities
possible any headache that gets worse when the are independently owned and operated and are not affiliated
client sits up or stands. with a hospital or medical center. In the past, physicians gener-
• Before giving discharge instructions, verify that ally owned such facilities, but today the trend is for health care
the client’s ability to remember instructions has corporations to own these facilities. Some doctors’ offices also
returned. Always share discharge instructions have facilities for performing minor ambulatory surgery.
with the individual responsible for taking the The Aldrete score has been modified for use with
client home and provide the client with a writ- clients having anesthesia on an ambulatory basis. Five assess-
ten copy of the instructions.
ments were added to the Aldrete score for this purpose (see
Table 13-4). Attainment of these criteria indicates that clients
can care for themselves at home and accomplish activities of
daily living independently and safely. The points are totaled
at regular intervals (usually every half hour), and clients are
discharged home when their total score is 18 or higher.
CASE STUDY
Postop Client
C.P. is in the recovery room after outpatient surgery. She received a general anesthetic and is now awake,
breathing deeply, and talking to the staff. She has received morphine sulfate intravenously and is quite
comfortable. Before being discharged home from the surgery center, C.P. rests in an easy chair in the tran-
sitional recovery area. The nurse taking care of her notices that she asks questions about things that have
already been discussed and has even asked one question three times.
The following case study questions will guide your critical thinking when caring for clients postoperatively.
1. After making these observations, what nursing diagnoses and goals might the nurse identify for C.P.?
2. List nursing interventions in caring for C.P.
3. Identify teaching approaches.
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OLDER ADULT CLIENTS blood flow, cardiac output, and conduction velocity of the
HAVING SURGERY nervous system all diminish. Table 13-7 lists the physiologi-
cal changes in the older adult client along with correlating
Older adult clients (older than 65 years of age) are at risk for nursing interventions for postoperative care. Aging affects all
developing complications from surgery or anesthesia. Un- body systems, and the nurse’s knowledge of these changes and
fortunately, because an increased incidence of disease cor- the interventions geared toward each assist in preventing and
relates with increasing age, more older adult clients require detecting complications of surgery.
surgery than does any other age group. As the percentage The older adult client has a lifetime of experiences that
of older adults in the whole population rises, the number of affects the response to surgery. A lifetime of watching family
surgeries on the aged is increasing. Because of the complex and friends experience surgery, illness, and death particularly
needs of the older adult client undergoing surgery, knowl- influences personal reactions to impending surgery. Because
edge in promoting health and rehabilitation in the older of the variation in such experiences, each client reacts dif-
client is necessary. ferently to similar situations. Simply talking with the client
Surgery is a stressor. Because of depleted energy sources, to provide information or listening to the client’s fears helps
the older adult client may not have sufficient resilience to react prepare the client for upcoming surgery.
defensively to this stressor. The risk of complications from Third-party reimbursement policies often require older
surgery further increases in older adult clients who have one adult clients to undergo surgical procedures on an outpa-
or more chronic diseases. In these clients, surgery then can be tient basis. Because many older adult clients have neuro-
the source of a downward spiraling effect toward debilitation logical deficits and other chronic disease processes, the
or possibly death. older outpatient poses a particular challenge. Additional
Older adult clients vary in their abilities to respond to the postoperative self-care deficits may result from the surgical
stress of surgery. Physiological changes related to the aging procedure and the effects of anesthesia. Older adult clients
process inhibit the older adult client from readily coping with often live alone and lack the support systems necessary
surgery. The number of physiological changes in the aged cli- for home care. To provide realistic discharge planning, the
ent (older than 80 years of age) is markedly greater than that nurse assesses the ability of the client, family, and friends to
in those in their sixties and seventies. Breathing capacity, renal provide care at home.
Table 13-7 Physiological Changes of Aging and Related Postoperative

nursing Interventions
BOdY SYSTEM CHAnGES nURSInG InTERVEnTIOnS
Cardiovascular • Decreased elasticity of the vascular • Closely monitor vital signs and peripheral pulses.
system • Encourage early ambulation.
• Decreased cardiac output • Use antiembolism stockings.
• Decreased peripheral circulation • Monitor intake and output, including blood loss.
• Monitor preoperative response to activity and compare
to postoperative response.
Respiratory • Decreased vital capacity • Closely monitor respirations.

• Decreased alveolar volume • Auscultate breath sounds frequently.
• Decreased movement of cilia • Encourage coughing and deep breathing.
• Turn frequently.
• Monitor oxygen saturation.
Urinary • Decreased glomerular filtration rate • Monitor intake and output every 1 to 2 hours.
• Decreased bladder muscle tone • Assist frequently with toileting.
• Weakened perineal muscles • Monitor fluid and electrolyte status.
Gastrointestinal • Decreased gastric and intestinal motility • Assess for obesity and malnutrition.
• Altered digestion and absorption • Encourage fluids and activity.
• Decreased food consumption • Encourage consumption of high-protein foods and
supplements.
• Assist with meals as needed.
• Provide companionship during mealtime.
Immunological • Decreased level of gamma globulin • Follow strict aseptic technique.

• Decreased plasma proteins • Monitor temperature.
• Assess incision site.
(Continues)
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Table 13-7 Physiological Changes of Aging and Related Postoperative

nursing Interventions (Continued)
BOdY SYSTEM CHAnGES nURSInG InTERVEnTIOnS
Neurological • Decreased conduction velocity • Allow use of glasses and hearing aids.
• Decreased visual acuity • Orient to environment.
• Loss of hearing • Provide for safe environment.
• Decreased sensation • Repeat information as needed.
• Use medications sparingly.
• Provide written instructions.
• Allow for extra education time.
Integumentary • Lack of elasticity • To prevent shearing forces on skin when positioning

• Loss of collagen client, lift rather than slide client.
• Decreased subcutaneous fat • Pad bony prominences.
• Use tape that is easy to remove.
• Use warm prepping solutions, irrigating solutions,
and IV solutions intraoperatively.

• Provide extra blankets.
• Ensure warm room temperature.
• Turn frequently.
• Encourage early ambulation.
CASE STUDY
Postop Care of an Older Adult Client
G.S., a 74-year-old retired school teacher who is married and the father of 4 and the grandfather of 16,
weighs 275 lbs. He has undergone a right hemicolectomy, wherein the right side of his colon was removed
because of cancer. He has a history of smoking but has no other health problems. The surgery was uncom-
plicated, and he is in the PACU. He has a midline incision with a Penrose drain and a stab wound with a
Jackson-Pratt drain adjacent to the incision. He also has a nasogastric tube attached to low intermittent suc-
tion. He is alert and oriented and moves all four extremities freely. His blood pressure is normal for him in
comparison to his preoperative levels. He is breathing regularly and easily at a rate of 16 breaths per minute,
and his skin color is pink. His oxygen saturation, however, is 86% with additional oxygen given via mask.
The following case study questions will develop your critical thinking for when you give postopera-
tive care to an older adult client.
1. What risk factors for developing postoperative complications can you identify for G.S.?
2. What is his Aldrete score at this point?
3. What nursing measures can you institute to promote oxygenation?
4. What type of drainage is expected from the incision and the drains during the first 1 to 2 days?
5. What nursing observations can be made and reported to indicate to the surgeon that the nasogastric
tube can be removed?
6. What nursing measures can be implemented to prevent deep vein thrombosis, thrombophlebitis,
and pulmonary embolism?
7. Write and prioritize three individualized nursing diagnoses and outcomes for G.S.
8. What information will G.S. need before discharge?
CONCLUSION intraoperative nurse constantly assesses the client’s status

and carefully monitors the surgical area that sterile tech-
The nurse assesses the physical and psychological status nique is maintained throughout the procedure. Postop-
of the surgical client. Teaching is a vital component of eratively the nurse initiates nursing interventions to prevent
the perioperative care and alleviates the client’s fear. The postop complications.
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UNit SUMMa r Y
• Surgery is a major stressor for all clients. Anxiety and fear sources within (endogenous) and outside (exogenous) the
are normal. Fear of the unknown is both the most preva- client. All clinical nursing units practice these principles.
lent fear before surgery and the fear easiest for the nurse to The sterile conscience governs personal behavior with re-
help the client overcome. gard to adherence to aseptic technique.
• The outcome of surgical treatment is significantly en- • In addition to ensuring an adequate level of anesthesia
hanced by accurate preoperative nursing assessment and throughout a surgical procedure, the anesthesia provider
careful preoperative preparation. Information gathered monitors and controls physiological functions.
through preoperative assessment and risk screening is later • Nursing care in the OR focuses on the safety and protec-
used to prepare the surgical site, for surgical positioning, tion of the client.
and as a comparative basis for postoperative assessments • A person is unlikely to remember what has happened
and complication screening. for minutes to hours after receiving sedation or a general
• The teaching methods that the nurse uses strongly influ- anesthetic.
ence the client’s degree of learning and the retention of • Intravenous patient-controlled analgesia (PCA) allows
information. clients to self-administer pain medication by pushing a
• Most scheduled medications that a client takes every day button on the PCA machine. Limits are programmed into
are continued up to and including the morning of surgery. the machine to prevent overdose.
• Some anesthesia providers prefer that clients not have • Local anesthetics, alone or in combination with opioids,
anything to eat or drink for at least 8 hours before surgery. can be injected into the epidural space at low concentra-
Others allow water up to 2 hours before surgery. tions to provide postoperative analgesia.
• Sedation depresses brain activity, which decreases aware- • Spinal and epidural morphine can produce dangerous
ness, reduces anxiety, and eases the induction of general respiratory depression. This can be detected by frequent
anesthesia. observations of the client’s respiratory rate and depth and
• Oversedation results in respiratory depression, which can by periodic measurement of oxygen saturation via pulse
cause airway obstruction, and places the client at risk for oximetry.
aspiration of gastric contents. • Postoperative nursing assessments are completed in an or-
• Regional anesthesia by the injection of a local anesthetic ganized manner, focusing first on the priorities of airway,
temporarily renders a “region” of the body insensible to breathing, and circulation, and then on the body system
pain. affected by surgery.
• General anesthesia produces unconsciousness, complete • The nurse prevents the formation of deep vein thrombo-
insensibility to pain, amnesia, motionlessness, and muscle sis, thrombophlebitis, and pulmonary embolism through
relaxation. encouraging early ambulation and postoperative leg
• The surgeon completes a MIS with one to five small inci- exercises and by providing antiembolism stockings or a
sions in which a videoscope and specialized instruments sequential compression device, if ordered.
are inserted into the small incisions to complete the • Ambulatory surgery is defined as surgical care performed
surgery. under general, regional, or local anesthesia and involving
• The advantages of MIS are smaller incisions (resulting fewer than 24 hours of hospitalization. Cost containment,
in less scarring externally and decreased adhesions inter- governmental health care regulation changes, and tech-
nally), less postoperative pain, decreased hospital stay, less nological advances promote the concept of ambulatory
risk of infection, prompt return to normal activities and surgery.
work, and fewer overall postoperative complications. • Because of the physiological changes and complex needs
• Aseptic technique is a collection of principles used to of the elderly client undergoing surgery, the nurse’s knowl-
control and prevent the transfer of microorganisms from edge assists in promoting health and rehabilitation in the
elderly surgical client.
t Heo r Y t o Pr a Ct iCe
Objectives of clinical and observational experience when caring for a surgical client:
1. Complete a preop nursing assessment on your assigned client scheduled for surgery.
2. Provide preop nursing care to your assigned surgical client.
3. Relate the action, side effects, and nursing considerations for all of the preop and postop
medications on your assigned surgical client.
4. Administer preoperative medications to your assigned surgical client.
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5. Follow your assigned client through the surgical holding unit, surgical suite, PACU, and
return to the clinical postop unit. Observe the care of your client in each of these units and
provide the nursing care determined by your college’s policies and nursing faculty guidelines.
6. Complete a postop assessment on your assigned surgical client.
7. Provide postop nursing care to your assigned surgical client.
Follow a surgical client through preoperative care, surgical holding area, surgical suite, PACU,
and postoperative care. This clinical and observational experience enhances sterile asepsis concepts,
assessment skills, and nursing care of a surgical client. Complete the following questions as you care
for and observe nurses and the surgical team caring for your assigned surgical client.
Preoperative Phase
1. Read the Preoperative Phase section in Chapter 13 of this text. Practice documenting a
preoperative nursing assessment on your assigned surgical client.
2. Relate the action, side effects, and nursing considerations for all of the preop medications on
your assigned surgical client. Administer preoperative medications to your assigned surgical
client.
3. Describe the preoperative teaching you did with your assigned surgical client.
4. Describe the client’s emotional status prior to surgery. Describe how you prepared your
client emotionally for surgery.
5. What teaching did the nurse provide the client in the surgical holding area?
6. What nursing care did the nurse provide for the client in preparation for surgery?
Intraoperative Phase
7. What safety measures did the surgical team use when transferring the client from the
stretcher/gurney to the surgical table?
8. How did the surgical team address the positioning and pressure points of the client while on
the surgical table?
9. Describe how the surgical team maintained sterility of the operative field and instrument
tables.
10. Explain the anatomy and physiology of the body structures of the surgical procedure.
11. What was the role of the surgical circulating nurse?
12. What medications did the client receive during surgery?
13. What IV solutions did the client receive during surgery? What was the purpose of the
solution(s)?
PACU Phase
14. Describe the physical stability of the surgical client in the PACU.
15. Describe the nursing care provided by you and the recovery nurse to the client.
16. How was the client’s airway maintained in the PACU?
Postoperative Clinical Unit
17. Collect subjective and objective data for your assigned postop client.
18. What type of drains did the client have and what nursing care did you provide related to
them?
19. Relate the action, side effects, and nursing considerations for all of the postop medications on
your assigned surgical client. Administer postoperative medications to your assigned surgical
client.
20. Did the client have any complications from surgery?
21. Prepare discharge teaching for the client.
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NCl eX-St Yl e r eVieW QUeSt io NS

1. Clients are at risk for aspiration of gastric contents 7. A client is given fentanyl citrate (Sublimaze) with a
into the lungs when receiving a general anesthetic spinal anesthetic for pain relief. To adequately assess
because: the client for respiratory depression, the nurse:
1. general anesthesia causes stomach distention. (Select all that apply.)
2. general anesthesia eliminates protective airway 1. notes respiratory rate and depth.
reflexes. 2. observes the color of the mucous membranes.
3. gastric peristalsis is reversed during general 3. measures oxygen saturation with a pulse oximeter
anesthesia. on a regular basis.
4. vomiting normally occurs during general 4. monitors the client’s ventilation by capnography.
anesthesia. 5. checks apical and peripheral pulses.
2. The most dangerous result of oversedation is: 6. observes symmetry of chest wall movements and
1. lack of response to verbal directions. use of accessory muscles.
2. longer recovery time and resultant delayed 8. A client had a regional anesthetic. During postopera-
discharge. tive care, the nurse assesses for residual effects of the
3. prolonged amnesia. anesthesia by: (Select all that apply.)
4. inability to breathe adequately. 1. asking the client questions and listening to his
3. What is one sign that a client has a postdural punc- responses.
ture headache following a spinal or epidural regional 2. asking the client to move an area blocked by the
block? anesthesia.
1. The headache subsides after intake of plenty of 3. touching the client’s legs and asking if the touch
liquids. feels normal.
2. The headache begins after the surgical procedure. 4. assisting the client to a sitting position and asking
3. The headache worsens when the client sits up or if she is dizzy.
stands. 5. assessing the client’s mental alertness.
4. The client is confused in addition to having a 6. assessing the motor strength in her legs.
headache. 9. A client has a nonunion fracture of the fifth pha-
4. After cessation of a general anesthetic, how long lange and is having a nerve block as the anesthesia.
might it be before a client can think as clearly as What client statement indicates to the nurse that
before the client received the anesthetic? more teaching is needed about the anesthesia and
1. Before being discharged from the recovery room scheduled procedure?
2. Within 2 hours 1. “I may be awake but sleepy throughout the
3. 6 hours surgery.”
4. Several days 2. “I will not be able to move my lower arm during
surgery.”
5. What effect might a spinal or epidural anesthetic 3. “I will not have any painful feeling in my lower
block still have after normal sensation and motor arm or hand during surgery.”
function have returned? 4. “I will be unconscious and put to sleep prior to
1. Decrease in pulse rate when the client is lying in and during the surgery.”
bed
2. Decrease in blood pressure when the client stands up 10. The main priority of the anesthesia provider during
a general anesthetic is monitoring the:
3. Inhibition of protective airway reflexes
1. blood pressure at frequent intervals.
4. Sore muscles
2. oxygenation by pulse oximetry.
6. A client who has returned from surgery has a PCA 3. respiratory rate and pulmonary ventilation.
for pain. The main purpose of the PCA is: 4. cardiac rhythm by an EKG.
1. to allow the client to control pain medication
administration. 11. Client education is:
2. so the nurse does not have to stop caring for 1. completed when time allows.
another client to administer medication to the 2. started when discharge is scheduled.
client in pain. 3. always more beneficial when completed in a
3. to provide better pain relief for the client than structured group setting.
intermittent IM injections. 4. directed toward the client’s family when the
4. to require less time to assess the client’s pain level. client is unable to learn.
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12. The role of the nurse in obtaining consent 17. The surgical client’s most common fear is of the
includes: unknown. The nurse can ease the client’s fears by:
1. judging the quality of the explanation and ascer- 1. listening to the client’s concerns about surgery.
taining the client’s understanding of the consent 2. taking time from the busy schedule and sitting
form. beside the client for a few minutes.
2. acting as a witness to the signature of the 3. asking the client’s family to stay with the client.
client. 4. teaching the client about the surgical process and
3. administering the preoperative medication answering questions.
before the client signs the consent. 18. A 73-year-old client is scheduled for prostate surgery.
4. ensuring that coercion was used to obtain the His vital signs are T 98.2, P 74, R 14, and BP 160/92.
client’s signature on the consent. He drinks heavily and smokes a pack of cigarettes
13. Upon the client’s admission to the PACU, the nurse a day. What are the client’s risk factors pending his
knows to first: upcoming surgery? (Select all that apply.)
1. take the client’s blood pressure. 1. Hepatic status
2. assess the airway. 2. Fluid and electrolyte status
3. assess the client’s level of consciousness. 3. Age
4. check the incision site. 4. Cardiovascular status
14. The nurse is making a preoperative assessment on a 5. Respiratory status
client. Of the following, the most important finding 6. Musculoskeletal system
to know for a client who is having general anesthesia 19. The PACU nurse asks a new surgical client if he has
is that the client is: the ability to wiggle his toes and move his feet. She
1. hearing impaired. is assessing his: (Select all that apply.)
2. a right-leg amputee. 1. hearing because that is the first sensation to
3. color-blind. return after anesthesia.
4. a smoker. 2. ability to pull his drain from the wound.
15. The nursing intervention that has the greatest 3. likeliness of becoming combative after surgery.
impact on reducing overall surgical risk is: 4. ability to voluntarily move his extremity.
1. encouraging activity and early ambulation. 5. Homans’ sign in both lower extremities.
2. assessing blood pressure. 6. circulation to the extremities.
3. ensuring adequate nutrition. 20. A client returns to the PACU following a craniotomy.
4. monitoring intake and output. After assessing the airway, the first priority of the
16. An elderly client is returning to the unit from nurse is to:
surgery. The nursing interventions specifically 1. attach all tubes to drainage.
geared toward elderly care are: (Select all that 2. place the client in Trendelenburg position.
apply.) 3. check abdomen for bowel sounds.
1. carefully monitoring vital signs and peripheral 4. assess level of consciousness and extremity
pulses. movement.
2. lifting the client rather than sliding client when
repositioning. For additional content, activities, games, and
3. encouraging early ambulation. more, visit the White Premium Website at
4. repeating information as needed. www.cengagebrain.com.
5. following strict aseptic technique.
6. using tape that is easily removed.
r eFer eNCeS/SUGGeSt eD r ea DiNGS

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United States—At a glance. Retrieved March nursing: Assessment and management of clinical problems (5th ed.).
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OBS_Standards_Sampler_2007_final.pdf
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r eSo Ur CeS
American Association of nurse Anesthetists Association of periOperative Registered nurses
http://www.aana.com (AORn)
American Society of Anesthesiologists http://www.aorn.org
http://www.asahq.org Foundation for Anesthesia Education and Research
American Society of PeriAnesthesia nurses http://www.faer.org
http://www.aspan.org Institute for Healthcare Improvement: Surgical Care
American Society of Regional Anesthesia and Pain Improvement Project (SCIP)
Medicine http://www.ihi.org
http://www.asra.com Intuitive Surgical, Inc.
Anesthesia Patient Safety Foundation http://www.intuitivesurgical.com
http://www.apsf.org Society for Education in Anesthesia
http://www.seahq.org
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Nursing Care of Clients
UNIT 5
with Respiratory Disorders
14 Assessment of the Respiratory System / 317
15 Caring for Clients with Upper Respiratory Tract

Disorders / 332
16 Caring for Clients with Lower Respiratory Tract

Disorders / 346
17 Caring for Clients with Acute Respiratory Disorders / 375
The respiratory system is about more than just breathing. It is an

amazing body system that fuels us with oxygen, a life-sustaining gas.
The primary function of the respiratory system is delivery of oxygen to
the lungs and removal of carbon dioxide from the lungs. A firm knowl-
edge base of the respiratory system is essential for the nurse to have
to promote and maintain the integrity of this crucial body system when
caring for clients.
The focus of this unit is to provide a comprehensive presentation
of concepts integral to upper respiratory tract, lower respiratory tract,
and acute respiratory disorders. The unit consists of the following
chapters.
Chapter 14, Assessment of the Respiratory System, provides an
anatomy and physiology review of the respiratory system, a discussion
of assessment and health history questions to ask and observations to
make when collecting subjective and objective data, and a listing and
discussion of common diagnostic tests for clients with symptoms of
respiratory disorders and infections.
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Chapter 15, Caring for Clients with Upper Respiratory Tract Dis-
orders, presents an overview of various infectious and inflammatory
disorders of the upper respiratory tract including disorders of the nose,
sinusitis, tonsillitis, laryngitis, pharyngitis, and laryngeal cancer. Influenza
is also explained. Medical-surgical and nursing management sections
discuss pharmacological, activity, diet, assessment, and subjective/
objective data collection for upper respiratory tract disorders.
Chapter 16, Caring for Clients with Lower Respiratory Tract Disor-
ders, provides the learner with detailed discussions of pneumonia, pul-
monary tuberculosis (TB), pleurisy/pleural effusion, and lung cancer. This
chapter also addresses asthma, chronic obstructive pulmonary disease
(COPD), chronic bronchitis, emphysema, and bronchiectasis. Medical-
surgical and nursing management sections present pharmacological,
activity, diet, assessment, and subjective/objective data collection for
lower respiratory tract disorders.
Chapter 17, Caring for Clients with Acute Respiratory Disorders,
presents an overview of atelectasis, pulmonary embolism (PE), acute
pulmonary edema, acute respiratory distress syndrome (ARDS), severe
acute respiratory syndrome (SARS), acute respiratory failure, pneumo-
thorax, and hemothorax. Medical-surgical and nursing management
sections address pharmacological, activity, diet, assessment, and
subjective/objective data collection for acute respiratory disorders.
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CHAPTER 14
Assessment of
the Respiratory System
KEy TERmS
adventitious breath sound fine crackle respiratory cycle
bronchial sound hemoptysis sibilant wheeze
bronchovesicular sound internal respiration sonorous wheeze
chemoreceptor lung stretch receptor stridor
clubbing oxygen saturation surfactant
coarse crackle perfusion ventilation
diffusion pleural friction rub vesicular sound
external respiration respiration
LEARNING OBJECTIVES
2. Identify the anatomy of the respiratory system.
3. Collect health history and assessment data for the respiratory system.
4. Describe the purpose, nursing responsibilities, and significance of expected results
for common respiratory diagnostic studies.
317
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318 UNIT 5 Nursing Care of Clients with Respiratory Disorders
INTRODUCTION Thoracic Cavity

The chest cage is a closed compartment bounded on the top by
Astute assessment skills have always been the hallmark quality the neck muscles and at the bottom by the diaphragm. The walls
of an expert nurse. As the learner gains in clinical judgment of the chest cage are formed by the ribs and intercostal muscles
skills, he will be able to assess each clinical situation from a laterally, the thoracic vertebrae posteriorly, and the sternum
perspective of increased complexity and move from novice to anteriorly. The inside of the chest cage is called the thoracic cavity.
expert. The intent of this chapter is to provide the framework Contained within the thoracic cavity are the lungs. The lungs
from which the novice nurse can begin to develop expertise in are cone-shaped, porous organs separated from the other chest
respiratory assessment. organs by the mediastinum. The lungs lie free, except for their
This chapter has three sections. The first section reviews attachment to the heart and trachea, and are encased in the
anatomy and physiology of the respiratory system in order pleura, a thin, transparent double-layered serous membrane lin-
to provide a framework for clinical assessment. The assessing the thoracic cavity. The layers of the pleura are the parietal
ment section begins with a focused history-taking in order pleura, which lie adjacent to the chest wall and produce pleural
to identify areas of concern, and follows with a discussion of fluid, and the visceral pleura, which adhere to the surface of the
the four data collection maneuvers of inspection, palpation, lungs and absorb pleural fluid. The area between the two pleura
percussion, and auscultation. These skills are presented in is known as the pleural space or pleural cavity.
that order to provide a comprehensive approach as well as to The pleural space contains 5 to 20 mL of fluid, which
guide the clinician in identifying specific issues. These issues allows the layers of the pleura to slide on each other yet hold
can be further addressed by specific diagnostic tests, which are together. The pressure within the pleural space is less than
covered in the third section of this chapter along with nursing that of outside air. This difference in pressure creates a suc-
implications of these tests. tion that prevents the lungs from collapsing on exhalation.
The right lung is larger than the left and is divided into three
ANATOMY AND PHYSIOLOGY sections, or lobes: upper, middle, and lower. The left lung is
REVIEW divided into two lobes: upper and lower (Figure 14-1). The
upper portion of the lung is referred to as the apex (plural,
The primary function of the respiratory system is gas apices). The lower portion is called the base. The lungs pos-
exchange, which is the delivery of oxygen to the lungs and sess a dual blood supply: bronchial circulation and pulmonary
removal of carbon dioxide from the lungs. circulation. Bronchial circulation begins with the bronchial
Nasopharynx
Oropharynx
Nasal cavity
Laryngopharynx Nose
Parietal pleura Rib
Esophagus
Visceral pleura Epiglottis

Pleural space Larynx
Intercostal
muscles Lung Trachea
Main
Mainstem bronchus
bronchus
Secondary
Right bronchus
upper lobe Tertiary
bronchus
Right
middle lobe Left
upper lobe
Right Left
lower lobe lower lobe
Terminal
bronchiole
Alveoli
Alveolar
duct
Diaphragm
Mediastinum
Respiratory
bronchiole
Alveolar sacs
Figure 14-1 Structures of the respiratory tract.
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CHAPTER 14 Assessment of the Respiratory System 319
composed of four structures: the uppermost thyroid cartilage

(Adam’s apple), the cricoid cartilage (which lies at the lower
Terminal
bronchiole
edge of the larynx), the epiglottis (a leaf-shaped structure that
covers the larynx during swallowing), and the glottis (the tri-
angular space between relaxed vocal cords).
The trachea, commonly known as the windpipe, is a tube
composed of connective tissue mucosa and smooth muscle
supported by C-shaped rings of cartilage that extends into
the bronchi. The trachea is 2.0 to 2.5 cm wide (approximately
Respiratory 1 inch) and 10 to 12 cm long (approximately 4 to 6 inches).
bronchiole
The trachea terminates by branching into two tubes: the right
Pulmonary and left primary bronchi. The bronchi are somewhat smaller
artery
in diameter than the trachea, and each passes into its respec-
Pulmonary
tive lung.
vein The right bronchus is wider and more vertically posi-
tioned than the left. This difference in positioning allows
foreign matter to enter the right bronchus more easily than
the left. Within the lungs, the bronchi branch off into increas-
ingly smaller diameter tubes until they become the terminal
bronchioles. These branch further, forming alveolar ducts

that end in numerous sac-like, thin-walled structures called
Alveoli the alveoli. Collectively, the alveoli and the alveolar ducts
resemble a cluster of grapes. The branching makes this por-
tion of the respiratory tract resemble an inverted tree, giving
Capillaries rise to the term bronchial tree (Figure 14-1).
Figure 14-2 Gas exchange occurs at the alveolar capillary Respiratory Tissues
membrane. The respiratory tissues perform the function of gas exchange.
The alveoli constitute the primary site of gas exchange. The
artery, which provides the passageways of the lungs with alveolar ducts are smooth, muscular tubes containing abundant
blood to meet nutritional needs and ends when the venous alveolar macrophages that remove foreign particles (e.g., bacte-
blood enters the pulmonary veins. Pulmonary circulation is ria). The alveoli, into which the alveolar ducts terminate, consist
the route by which blood is delivered to the alveoli for gas of interconnected spaces with thin walls, or septa, occupied by
exchange (Figure 14-2). a network of capillaries called the alveolar capillary membrane.
The alveoli contain two specialized types of cells. Type I
Conducting Airways alveolar cells are flat, squamous, epithelial cells across which gas
exchange occurs. Type II alveolar cells produce a phospholipid
The conducting airways are tube-like structures that provide a substance called surfactant. Surfactant coats the inner surfaces
passageway for air as it travels to the lungs. These are the nasal of the alveoli, reduces the surface tension of pulmonary fluids,
passages, mouth, pharynx, larynx, trachea, bronchi, and bron- allows gas exchange, and prevents the collapse of the airways.
chioles (Figure 14-1). The conducting airways are lined with Each lung contains approximately 300 million alveoli.
epithelial tissue containing serous glands, mucus-secreting
goblet cells, and hair-like projections called cilia. The mucus
of the goblet cells together with the cilia form a mucociliary
Accessory Muscles
blanket that protects the respiratory system from foreign of Respiration
particles. The constant upward motion of the cilia propels the There are several accessory muscles of breathing that only
mucociliary blanket toward the pharynx, where foreign matter get called into play with respiratory distress and are used to
is expectorated or swallowed. accommodate increased oxygen demand. Pathology, such as
The nasal passages are the preferred route for air to enter that in asthma, may lead to the use of accessory muscles. They
the respiratory tract. In addition to the function of filtering may also be used during exercise to accommodate a sudden
inspired air, the nasal passages are richly supplied with blood demand in oxygenation. Accessory muscles consist of the
vessels that warm and moisten the air. Because the mouth lacks scalene, sternocleidomastoid, trapezius, pectoralis, and the
cilia and abundant blood supply, breathing through the mouth abdominal muscles and do not normally participate in respira-
reduces the ability to filter, warm, and moisten inspired air. tion. However, in times of respiratory distress, these muscles
Connecting the nasal passages and mouth to the lower will contract to assist with breathing efforts.
parts of the respiratory tract is the pharynx. Located behind
the oral cavity, the pharynx serves as a passageway for both
inspired air into the larynx and ingested food passing into the
Respiratory Defense
digestive system. Mechanisms
At the distal portion of the pharynx is the larynx, also Several mechanisms are involved in protection of the respira-
known as the voice box. tory system. The bronchi trap foreign particles that are inhaled
The larynx contains the vocal cords and is the passage- from the environment, are swept up by the bronchial cilia, and
way for air entering and leaving the trachea. The larynx is trapped by mucus produced by the goblet cells that line the
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bronchus. In addition, the type II pneumocytes produce a Air blown out Air drawn in
substance called surfactant that reduces surface tension of the Airways of
alveoli. These alveoli have a natural tendency to collapse on respiratory
expiration and the surfactant helps to keep them open. Other tree
defense mechanisms to assist with expelling foreign particles (ventilation)
include sneezing, coughing, and swallowing.
Respiration
Respiration is a process of gas exchange. This process is Alveoli
necessary to supply cells with oxygen for metabolism and to
remove the waste by-product carbon dioxide. There are two
types of respiration: external respiration and internal respira-
O2
tion. External respiration is the exchange of gases between A
the inhaled air, now in the alveoli, and the blood in the pulmo- External respiration (gas exchange between air
nary capillaries. Internal respiration is the exchange of gases CO2 in alveoli and blood in pulmonary capillaries)
at the cellular level between tissue cells and blood in systemic Blood in
capillaries (Figure 14-3). These functions depend on the pulmonary capillaries
Blood flow CO2
adequacy of ventilation, perfusion, and diffusion. Ventilation
is the movement of gases into and out of the lung. Perfusion O2 B
is the flow of blood through the vessels of a specific organ or Internal
body part. Pertaining to the respiratory system, diffusion is Blood in respiration
the movement of gases across the alveolar capillary membrane systemic capillaries (gas

from areas of high concentration to areas of lower concentra- Blood flow exchange
between
tion. Factors that affect ventilation, perfusion, and diffusion tissue
affect respiration (Table 14-1). cells and
blood in
Neuromuscular Control systemic

capillaries)
of Respiration Figure 14-3 A, External respiration; B, internal respiration.

Unlike the heart muscle, the respiratory muscles must re-
ceive continuous neural stimuli to function. Regulation of
respiration is integrated by neurons located in the pons and carbon dioxide in the blood. With certain chronic pulmonary
medulla of the brain. The control of respiration is influenced disorders, such as emphysema, chemoreceptors become more
by involuntary (automatic) and voluntary components. In- responsive to a low level of oxygen. This becomes significant
voluntary components include chemoreceptors, lung stretch when administering oxygen to persons whose drive to breathe
receptors, and impulses from other sources. Chemorecep- depends on a low level of oxygen in the blood. Lung stretch
tors monitor the levels of carbon dioxide and oxygen and receptors monitor the pattern of breathing and prevent
the acidity/alkalinity (pH) of the blood. Normally, chemo- overexpansion of the tissues. Many other sources involun-
receptors initiate respiration in response to an increase of tarily send impulses to the respiratory center. For example,
if a person becomes frightened or angry, the respiratory rate
increases in response to stimuli from the autonomic nervous
Table 14-1 Factors Affecting system. Voluntary components of respiratory control inte-
Ventilation, Perfusion, and Diffusion grate breathing with acts such as talking and speaking.
The diaphragm acts as the primary muscle of respiration.
Ventilation Position: Dependent areas receive During inspiration, the diaphragm contracts and flattens out
majority of air. in response to stimuli from the respiratory center, increas-
ing the length of the thoracic cavity. At the same time, the
Lung volume: Low volume results in
intercostal muscles contract, elevating the ribs and increasing
shunting air to lung apices.
the diameter of the thoracic cavity. The total thoracic space
Disease: Bronchial constriction and airway increases, reducing the pressure within the thoracic cavity.
collapse decrease ventilation. The pressure within the thoracic cavity then becomes nega-
Perfusion Position: Dependent areas receive
tive in relation to that of atmospheric pressure, and air moves
majority of blood.
into the thoracic cavity. Upon expiration, the respiratory cen-
ter signals the diaphragm and intercostal muscles to relax. The
Hypoxia: Results in vasoconstriction and thoracic cavity returns to its original size. Aided by the elastic
decreased perfusion. recoil of the lungs, the decrease in size of the thoracic cavity
Blockage: Results in decreased or absent increases pressure, and air moves out of the lungs.
perfusion to distal areas.
Diffusion Alveolar capillary membrane: Alterations Gas Exchange

may occur in thickness and permeability Gas exchange occurs at the alveolar capillary membrane
of membrane. (Figure 14-2). Venous blood from the right ventricle is
pumped into the pulmonary arteries and travels to the alveolar
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capillary network, where it is exposed to the inhaled air. Be- Health History
cause of the higher concentration of oxygen in the alveoli,
oxygen diffuses into the blood within the alveolar capillary Nursing assessment begins with a complete history. The
network. The majority of oxygen binds to the iron atoms of client is questioned regarding allergies, occupation, lifestyle,
the hemoglobin molecule in the red blood cells. The clinical and health habits such as smoking or alcohol use (Box 14-1).
measure of oxygen attached to hemoglobin is the oxygen Ask about other health problems that affect the respiratory
saturation (SaO2, SpO2). Approximately 1% to 3% of oxygen system, such as pneumonia or cardiac problems. Symptoms
dissolves into the blood plasma. such as dyspnea, decreased exercise tolerance, and cough are
The exchange of carbon dioxide also occurs within the explored in depth.
alveoli. Within the alveolar capillary network, the carbon Ask the client if the cough is nonproductive or produc-
dioxide detaches from hemoglobin and diffuses into the alveo- tive and to describe the secretions produced. Terms used to
lar space. Carbon dioxide is removed from the alveolar space describe secretions expectorated are thick, thin, yellow, and
when exhalation occurs. The blood within the pulmonary green. Hemoptysis is a term used for coughing up blood or
capillary network is now oxygenated and travels to the heart blood-tinged sputum from the respiratory tract. This is an im-
via the pulmonary veins. Oxygenated blood is sent to the body portant assessment finding because it may indicate a serious
via the aorta and the arterial network (Figure 14-3). underlying lung disease (e.g., tuberculosis).
The client’s occupational or home environment may
affect breathing patterns; exposure to dust, chemicals, vapors,
tobacco, smoke, or paint fumes, and irritants such as asbes-
ASSESSMENT tos are noted. Ask about the client’s activities of daily living.
Is the client able to care for himself? Has he noticed a change
Data Collection in his level of physical ability, such as ability to do housework,
To understand the assessment of the respiratory system, the gardening, or walking from place to place? Has he noticed
student must be familiar with related terminology (Table 14-2). that he must stop and rest more frequently? Following a
Table 14-2 Respiratory Terms

TERM DEFINITION
Eupnea Normal breathing
Apnea Cessation of breathing, possibly temporary in nature
Dyspnea Labored or difficult breathing, possibly normal if associated with exercise
Bradypnea Abnormally slow breathing, respiratory rate <12 breaths/min
Tachypnea Abnormally rapid breathing, respiratory rate >20 breaths/min
Orthopnea Discomfort or difficulty with breathing in any but an upright sitting or standing position
Kussmaul’s respirations Abnormal respiratory pattern characterized by irregular periods of increased rate and depth of
respiration; most often seen with diabetic ketoacidosis
Biot’s respirations Abnormal respiratory pattern characterized by irregular periods of apnea alternating with short
periods of respiration of equal depth; most commonly seen with increased intracranial pressure
Cheyne-Stokes Abnormal respiratory pattern characterized by initially slow, shallow respirations that increase
respirations in rapidity and depth and then gradually decrease until respiration stops for 10 to 60 sec;
pattern then repeats itself in the same manner
Anoxia Without oxygen
Hypoxia Lack of adequate oxygen in inspired air such as occurs at high altitude
Hypoxemia Insufficient amount of oxygen in the blood possibly due to respiratory, cardiovascular, or
anemia-related disorders
Cyanosis Bluish, grayish, or purplish discoloration of the skin caused by abnormal amounts of reduced
(oxygen-poor) hemoglobin in the blood; not always a reliable indicator of hypoxia
Acrocyanosis Cyanosis of the fingertips and toes; often caused by vasomotor disturbances associated with
vasoconstriction
Circumoral cyanosis Bluish discoloration encircling the mouth
Oxygen saturation Amount of oxygen combined with hemoglobin
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BOX 14-1
QUESTIONS TO ASK AND OBSERVATIONS TO MAKE WHEN COLLECTING DATA
Subjective Data • If you smoke, how long have you smoked? What
• Do you have seasonal or environmental do you smoke? How much do you smoke each
allergies? day?
• Are you currently taking any prescription or • Does your chest feel tight when you breathe?
over-the-counter medication for your allergies? • Are you experiencing any chest pain or discom-
How long have you been taking the medica- fort when breathing?
tion? Does it effectively relieve your allergy • What type of work do you do?
symptoms? • Are you exposed to any type of chemicals, dust,
• Have you been coughing? If so, are you cough- or mold?
ing up any mucus or secretions? What does it • Have you traveled to a foreign country recently?
look like?
Objective Data
• Do you get frequent upper respiratory
• Check vital signs.
infections?
• Check pulse oximetry levels.
• Have you ever had pneumonia? If so, when and
• Observe respiratory effort.
how often?
• Observe use of accessory muscles.
• Have you had the pneumonia vaccine?
• Assess color of mucous membranes and nail beds.
• Do you get a flu shot annually?
• Assess for sputum production.
• Do you have any chronic lung conditions such
• Record the quality, color, and odor of the
as asthma or emphysema?
sputum.
• Are you experiencing any difficulty breathing?
• Observe client’s activity tolerance.
• Have you experienced any shortness of breath
• Assess supplemental oxygen requirements.
with exertion or activity?
• Auscultate lung sounds.
• Is your nose feeling stuffy and congested?
• Report chest x-ray results or other diagnostic test
• Does your throat hurt or feel sore?
results.
• Have you experienced changes in your voice?
• Record the quality, color, and odor of the
• Do you currently or have you ever smoked?
sputum.
• If you no longer smoke, when did you quit?
complete history, the nurse completes a physical assessment Taking the “head-to-toe” approach, first assess the nose for
of the client. patency by occluding first one nostril, then the other. Lift the
tip of the nose and inspect for color and patency of the muco-
Inspection sal membranes for color, drainage, and discharge. The septum
Physical assessment of the respiratory system starts with should be at the midline without perforation, lesions, or bleeding
inspection. Note the client’s color, level of consciousness, (Estes, 2010). A small amount of clear, watery discharge is an
and emotional state. Respirations are observed for their rate, expected finding. Observe the nares for signs of inspiratory flaring.
depth, quality, rhythm, and breathing pattern. The normal Inspection of the mouth and pharynx should reveal buc-
respiratory rate in a resting adult is 12 to 20 breaths per cal mucosa that is moist, smooth, and without lesions. Teeth
minute. Symmetry of chest wall movement is also noted. The should be firmly surrounded by gum tissue. Observe the mouth
nurse observes for use of accessory muscles to aid breathing. for cyanosis or pursed-lip breathing. With the client’s head tilted
The position the client assumes provides information on re- back and the mouth wide open, observe the throat. It is nor-
spiratory status because individuals having trouble breathing mally pink and vascular without swelling, exudates, or lesions.
often lean forward. The neck should be supple and without tenderness to palpation.
The client’s fingernails and toenails are inspected for nail
bed angle and curvature that may indicate chronic hypoxia.
Normal nail angle is 160 degrees. A nail bed angle greater
BestPractice than 160 degrees is considered abnormal. Clubbing is an
abnormal enlargement of the distal segments of the fingers
Paroxysmal Nocturnal Dyspnea and is often associated with advanced chronic pulmonary
Dyspnea that wakes up clients from sleep is called disease (Figure 14-4). It can occur as a result of chronic
paroxysmal nocturnal dyspnea. It is often seen hypoxia or lung cancer (Estes, 2010).
in clients with left ventricular failure or in COPD
because of pooling of secretions and positional
Palpation and Percussion
decrease in lung volume, or changes in airway
The next steps in the respiratory assessment are palpation and
percussion. These are normally done by the registered nurse
resistance during sleep.
or physician. Through the use of palpation and percussion,
areas of varying densities in the lung can be detected. The
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BestPractice
Respiratory Chest Pain versus Cardiac Chest Pain
If a client has chest pain, it is sometimes difficult to differentiate whether the pain is of a respiratory or a cardiac
origin. Generally speaking, respiratory muscular chest pain does not radiate, and there is often tenderness during
palpation. Myocardial ischemic type of pain is due to an imbalance in the supply and demand of oxygen in the heart
muscle. The pain typical of angina can be brought on by a heavy meal, exercise, or emotional stress. This pain is clas-
sically described as pressure or squeezing in the center of the chest, sometimes with radiation to the jaw, or one or
both arms. The chest pain of myocardial ischemia is often responsive to vasodilators such as nitroglycerin and rest.
Inflammation to the joints and muscles of the thoracic cage can also be a cause of chest pain. This can be
associated with tenderness to touch over the affected area. The following questions help to distinguish the pain.
1. Describe the pain. Rate the pain from 0–10.

2. Ask client to show where the pain is located. Pain that is localized on one side can be the result of pleurisy, or
inflammation of the pleural surface.
3. Is the pain constant or intermittent?
4. Does it hurt to touch your chest? Does it hurt to take a deep breath? Pain that increases with a deep breath
or with a change in body position can be due to pleurisy.
5. What brings on the pain? Pain after heavy meals, emotional upsets, or exercise can be due to angina.
6. Have you injured your chest recently?
If there is any doubt about the origin of the pain, rule out a cardiac cause first.
180°
BestPractice
Respiratory Cycle
A respiratory cycle consists of one inhaled and one
exhaled breath. Count the respiratory cycles the
client has for one full minute. Observe respirations
without informing the client because the
client may change the respirations if aware that
the chest is being observed (Estes, 2010).
density of lung tissues changes with disease states such as

pneumonia, pneumothorax, and pleural effusion.
Palpation
Palpation is performed to detect the density of lung tissue,
to determine chest movement and expansion, and to assess
for tracheal deviation, lesions, masses, and tenderness of
the chest.
The nurse begins by palpating the neck to ensure that the
trachea is midline. Tracheal deviation is caused by changes in
intrapleural pressure. The trachea can be pulled toward the
affected side in the case of massive atelectasis, unilateral pul-
monary fibrosis, or pneumonectomy; or pushed away from the
affected side in the case of tension pneumothorax or massive
hemothorax. The trachea can also be pulled toward the unaf-
fected side in neck tumors, thyroid enlargement, mediastinal
mass, or massive pleural effusion (Pierre & Jablons, 2007).
Thoracic expansion is assessed by placing hands on opposite
sides of the client’s posterior thorax with your thumbs pointing
to each other approximately 5 cm (2 inches) apart at the 10th
Figure 14-4 Clubbing. (Courtesy of robert A. silvermAn, mD, CliniCAl AssoCiAte Pro- spinal vertebra or “bra line.” Next, ask the client to take a deep
fessor, DePArtment of PeDiAtriCs, GeorGetown university) breath and watch the movement of your thumbs as the client
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inhales and exhales. The thumbs should move equally away The quality and pitch of the percussion note elicited can
from each other, then back toward each other. provide important information about the condition of the client.
Fremitus is the feeling of vibration on the chest wall. The The five percussion notes reflecting differences in density are:
ulnar side (outer aspect) of the palm is the most sensitive • Resonant. Healthy lung tissue
area to vibrations. The client is asked to say “99” while the
nurse places the ulnar side of the hand, moving side to side, • Hyperresonant. Reflects more air-filled lung as found in
along the client’s posterior thorax. The vibrations are com- COPD or a small pneumothorax (Note: This is a normal
pared from one side to the other. Fremitus may be increased finding in children and very lean adults.)
or decreased, depending on the underlying condition. One • Tympanic. A higher pitched musical note that is heard over
principle to remember is that the presence of liquid or solid a gastric air bubble (Can be mimicked by inflating your
transmits sound more effectively than air-filled spaces. There- cheek with air and percussing over it.)
fore, vocal fremitus is increased in conditions where the alve- • Dull. A muffled or “thud-like” sound that is heard over
oli have been replaced by fluid or consolidation of lung tissue. dense tissue such as muscle, the diaphragm, or a pleural
effusion
Percussion • Flat. A high-pitched, very short duration sound that is not
Percussion is an assessment technique used to help to deter- really a note at all. Indicates solid tissue such as the liver or
mine whether the underlying tissue is filled with air, fluid, or bone
solid. The middle finger of the nondominant hand is pressed
firmly and flatly over the intercostal space. The tip of the Auscultation
middle finger of the dominant hand is used to tap firmly and Auscultation is the act of listening through a stethoscope in
sharply against that finger, aiming squarely between the joints order to assess airflow through the tracheobronchial tree,
of the finger placed on the chest. detect the presence of mucus, fluid, or obstruction in the air
1 2
1 2
3 4
3 4
5 6 5 6
7 8 7 8
9 10 9 10
11 12
A B
1 1
2 2
3
4 4
C D
Figure 14-5 Stethoscope locations for each auscultation: A, anterior thorax; B, posterior thorax; C, right lateral thorax;
D, left lateral thorax.
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passages, and assess the condition of the surrounding lungs compression. Bronchovesicular sounds are heard over
and pleural space. The client should breathe slowly through the anterior one-third of the chest near the sternum and also
the mouth while the listener assesses breath sounds at each around the scapula posteriorly (Figure 14-6). Bronchovesicu-
location for the length of a complete inspiration and expira- lar sounds are relatively loud and have a medium pitch and
tion. Breath sounds are assessed for duration, pitch, and intensity with inspiration and expiration being equal in dura-
intensity. Figure 14-5 illustrates the recommended stetho- tion. They may be heard in the periphery of the lung when
scope location for each auscultation. consolidation and fluid are present.
Vesicular sounds are heard over the majority of the
Stethoscopes lungs (Figure 14-6). These soft, low-pitched sounds are best
One of the most valuable tools of a nurse is the stetho- heard during inspiration and may be inaudible during expira-
scope. To maximize the quality of sound, it is important to tion. They are light and “breezy” in quality, and are the sound
use the stethoscope correctly. Eartips should point toward of alveoli opening and closing as air passes in and out.
the nose, fitting the normal direction of the auditory canal.
The stethoscope must have both a diaphragm and a bell. Adventitious Breath Sounds
The diaphragm, primarily used for respiratory assessment, Abnormal breath sounds are called adventitious breath
is the larger, flat piece and is used with firm pressure against sounds and include fine crackles, coarse crackles,
the chest to detect high-pitched sounds. Although not typically sonorous wheezes (rhonchi), sibilant wheezes, pleural
used to assess the lungs, the bell is a smaller and concave piece friction rub, and stridor. Table 14-3 describes the general
used with very light pressure against the chest to detect low- characteristics of these adventitious breath sounds.
pitched heart sounds and murmurs.
When auscultating breath sounds, the nurse should place Voice Sounds
the stethoscope between the ribs, in the intercostal spaces. Because sound is transmitted better through fluid or solid
It is easier to hear breath sounds through tissue than bone. than through normal lung tissue, we can use voice sounds
Care should be taken to avoid placing the stethoscope over to further assess the presence of consolidation. When lungs
the scapula or vertebral column when auscultating breath become consolidated they fill up with fluid or debris, and the
sounds posteriorly. It is important to remember that the right alveoli collapse. Because sound is transmitted better through
side of the chest has three lung lobes and the left side has two. liquid or solid than it is through normal lung tissue, breath
All five lung lobes need to be auscultated and assessed. sounds and voice sounds will be louder than normal in areas
It is important to clean a stethoscope before and after each of consolidated lung tissue.
client assessment to prevent the spread of microorganisms and Voice sounds are assessed by asking the client to speak
infection. Eartips should also be routinely cleaned. while the nurse applies the stethoscope to the chest and listens
from side to side. Bronchophony is the presence of distinct,
Normal Breath Sounds clear, and relatively loud sounds heard over areas of the lung
Under normal circumstances, bronchial sounds are heard in which the normal alveoli are filled with fluid or replaced
over the sternum (Figure 14-6). These loud, high-pitched by solid tissue. They are obtained by asking the client to say,
tubular, hollow-like sounds last longer during expiration than “One, two, three.” Whispered pectoriloquy is similar to bron-
during inspiration. When heard in areas other than the ster- chophony, except the vocal cords are bypassed when the client
num, bronchial sounds indicate fluid, exudate, or lung tissue whispers, “One, two, three.” Egophony is the presence of loud,
Vesicular
Bronchovesicular
Bronchial
Anterior thorax Posterior thorax
Figure 14-6 Location of breath sounds.
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326
Table 14-3 Characteristics of Adventitious Breath Sounds
RESPIRATORY CLEAR WITH
BREATH SOUND PHASE TIMING DESCRIPTION COUGH ETIOLOGY CONDITIONS
88021_ch14_ptg01_315_331.indd 326
Fine crackle Predominantly Discontinuous Dry, high-pitched No Air passing through COPD, congestive
inspiration crackling, popping, moisture in small heart failure (CHF),
short duration; roll hair airways that suddenly pneumonia,
near ears between reinflate pulmonary fibrosis,
your fingers to atelectasis
simulate this sound
Coarse crackle Predominantly Discontinuous Moist, low-pitched Possibly Air passing through Pneumonia,
inspiration crackling, gurgling; moisture in large pulmonary edema,
long duration airways that suddenly bronchitis,
reinflate atelectasis
Sonorous wheeze Predominantly Continuous Low pitched; snoring Possibly Narrowing of large Asthma, bronchitis,
(rhonchi) expiration airways or obstruction airway edema, tumor,
Z Z Z Z
Z Z Z Z Z Z Z Z of bronchus bronchiolar spasm,
Z Z Z Z
Z Z Z Z
Z Z Z Z foreign body
Z Z Z Z
Z Z Z Z
obstruction
Sibilant wheeze Predominantly Continuous High pitched; musical Possibly Narrowing of large Asthma, chronic
expiration airways or obstruction bronchitis,
of bronchus emphysema, tumor,
foreign body
obstruction
Pleural Inspiration and Continuous Creaking, grating No Inflamed parietal and Pleurisy,
friction rub expiration visceral pleura; can tuberculosis,
occasionally be felt pulmonary infarction,
on thoracic wall as two pneumonia,
pieces of dry leather lung abscess
rubbing against each
other
Stridor Predominantly Continuous Crowing No Partial obstruction of Croup, foreign body

Z Z Z Z
Z Z Z Z
Z
Z
Z Z Z inspiration the larynx, trachea obstruction, large
Z Z Z
Z Z Z Z
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Z Z Z Z airway tumor
Z
12/29/11 1:37 PM
nasal, and “bleating” sounds, often heard just above a pleural COMMON DIAGNOSTIC TESTS
effusion. They are assessed by asking the client to say “Eeee.”
Normally, the examiner will hear the same sound through the Commonly used diagnostic tests for clients with respiratory
stethoscope. However, in the presence of consolidation, the disorders are listed in Tables 14-4, 14-5, and 14-6. Table 14-7
examiner will hear a nasal and bleating “Aayy” sound. lists normal values for arterial blood gases.
Table 14-4 Common Diagnostic Tests for Respiratory Disorders

SIGNIFICANCE OF
TEST RELATING TO
LABORATORY EXPLANATION/ THE RESPIRATORY NURSING
TESTS NORMAL VALUES SYSTEM RESPONSIBILITIES
Hemoglobin Measures the oxygen-carrying compound Reveals hypoxemia The client is not required to
(Hgb) in RBCs. fast for the test.
Normal: Sample may be drawn from a
Male: 14–18 g/dL finger of a child or the heel
Female: 12–16 g/dL of an infant.
Critical value: <5 g/dL
Pulmonary A group of studies used to evaluate Asthma: reveals an Explain the procedure to the
function tests ventilatory function. Measurements abnormal flow rate client. PFTs should not be
(PFTs) are obtained directly via spirometer or and lung volume done within 1–2 hrs after a
calculated from the results of spirometer Emphysema: reveals a meal.
measurements. Bronchodilators may be decrease in expiratory After the test, monitor
used during the study. Measurements volume respiratory status. Advise
included are: the client to avoid activity
Tidal volume: The amount of air inhaled and and to rest following the test,
exhaled in one breath: 500 mL at rest. because fatigue may result.
Inspiratory reserve volume: The amount
of air inspired at the end of a normal
inspiration.
Expiratory reserve volume: The amount of
air expired following a normal expiration.
Residual volume: The amount of air left in
lungs after maximal expiration.
Vital capacity: The total volume of air that
can be expired after maximal inspiration.
Total lung capacity: The total volume of air
in the lungs when maximally inflated.
Inspiratory capacity: The maximum amount
of air that can be inspired after normal
expiration.
Forced vital capacity: The capacity of air
exhaled forcefully and rapidly following
maximal inspiration.
Minute volume: The amount of air breathed
per minute.
(Continues)
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Table 14-4 Common Diagnostic Tests for Respiratory Disorders (Continued)

SIGNIFICANCE OF
TEST RELATING TO
LABORATORY EXPLANATION/ THE RESPIRATORY NURSING
TESTS NORMAL VALUES SYSTEM RESPONSIBILITIES
Sputum Sputum samples are examined for the Tuberculosis: Explain the procedure and its
analysis presence of bacteria, fungi, molds, yeasts, presence of active purpose to the client.
and malignant cells. Appropriate antibiotic acid-fast bacilli (AFB) Obtain specimens early
therapy is determined via C&S studies. in the morning to prevent
contamination via ingested
food or fluids.
Instruct the client to breathe
deeply and cough, so as
to facilitate collection of a
specimen originating from
the lower respiratory tract.
If necessary, pulmonary
suctioning may be used to
induce such a specimen.
Instruct the client to

expectorate sputum into the
appropriate container. Deliver
specimens to the laboratory as
soon as possible.
Table 14-5 Common Radiological Studies for Respiratory

Disorders
SIGNIFICANCE
RADIOLOGICAL EXPLANATION/ OF TEST RELATING TO NURSING
STUDIES NORMAL VALUES THE RESPIRATORY SYSTEM RESPONSIBILITIES
Chest x-ray Provides a two- Pneumonia: Reveals Explain the test to the client. If
dimensional image of consolidation in affected areas. appropriate, inquire whether the
the lungs without using Tuberculosis: Reveals the client may be pregnant, to prevent
contrast media. Used to presence of primary tubercles, exposure of the fetus to x-rays.
detect the presence of calcified lesions, and cavitation The client is generally required
fluid within the interstitial in the lung. to stand for various views; if
lung tissue or the alveoli; Pleurisy/pleural effusion: Will the client is unable to stand,
tumors or foreign bodies; show pleural effusions of 250 mL views may be obtained with the
and the presence and size of fluid or more. client in a sitting position, or a
of a pneumothorax. The portable x-ray may be obtained.
Atelectasis: Shows area of
size of the heart can also Instruct the client to inspire deeply
collapse.
be determined by chest and hold the breath.
x-ray. Acute respiratory distress
syndrome: Shows widely Instruct the client to remove all
scattered infiltrates, often metal objects from the chest and
referred to as a “white-out.” neck area and to don a hospital
Asthma: Shows hyperinflation of gown that does not have snap
the lungs. closures.
Chronic obstructive pulmonary
disease: Shows hyperexpansion
of the lungs.
Emphysema: Reveals
hyperinflated lung tissue and a
flattened diaphragm, which has
been displaced by distended
lung tissues.
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Table 14-5 Common Radiological Studies for Respiratory

Disorders (Continued)
SIGNIFICANCE
RADIOLOGICAL EXPLANATION/ OF TEST RELATING TO NURSING
STUDIES NORMAL VALUES THE RESPIRATORY SYSTEM RESPONSIBILITIES
Ventilation/ Assesses ventilation and Same as Explanation column. Assess for allergy to iodine.
perfusion scan perfusion of the lungs. Explain the procedure to the client:
(V/Q scan) Most often used to detect that a radioactive contrast media
the presence of pulmonary will be introduced via an IV access
emboli. and inhalation of radioactive gas
and that the client will be required
to hold the breath for short periods
as images are obtained.
Computed Provides a three- Same as Explanation column. Explain the procedure to the client.
tomography dimensional cross- Obtain informed consent.
(CT) scan sectional view of tissues. Remove wigs and hairpins and
Computer-constructed clips for head CT. Initiate NPO
picture interprets densities status 8 hrs prior to scan. Assess
of various tissues. Most for iodine allergy.
useful for viewing tumors Observe for signs of anaphylaxis,
in the chest, abdominal if dye is used. Check for
cavity, and brain. There claustrophobia.
are several different types
Inform the client that the test will
of CT scans depending on
take approximately 45 min to 1 hr.
what is being assessed
The client must lie still on a hard,
(e.g., brain, cardiac,
flat table and will be put through a
thoracic, bone, abdomen,
large machine.
pelvic scans). Angiography
or myelography can also Because barium will interfere with
be performed via CT the test, schedule tests using
scanning. barium either after or 4 or more
days before the scan.
Pulmonary Assesses the arterial Same as Explanation column. Explain the procedure to the client.
angiography circulation of the lungs. Obtain informed consent per
Most often used to detect facility policy.
pulmonary emboli. Assess for allergy to iodine or
shellfish. Inform the client that
an arterial puncture is required,
usually of the femoral artery, and
that injection of the dye may cause
a flushing or warm sensation due
to vasodilation.
After the study, assess the arterial
puncture site frequently for
evidence of bleeding. Assess vital
signs and respiratory status.

The client may be required to lie
flat for up to 6 hours if the femoral
artery is used for access.
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Table 14-6 Other Diagnostic Tests for Respiratory Disorders

SIGNIFICANCE OF TEST
DIAGNOSTIC EXPLANATION/ RELATING TO THE NURSING
TESTS NORMAL VALUES RESPIRATORY SYSTEM RESPONSIBILITIES
Pulse oximetry A noninvasive proce- Reveals hypoxemia Explain the procedure to the client. Assess
dure. A transdermal clip peripheral circulation, because this may alter
is placed on a finger results.
or earlobe to detect Place the sensor on the earlobe, fingertip, or
the arterial oxygen pinna of the ear. Keep the sensor intact until
saturation (SaO2). a consistent reading is obtained. Observe
Normal: >95% (at sea and record readings. Report to the physician
level) measurements below 95%.
Bronchoscopy Direct visual Atelectasis: Visualizes the Obtain written informed consent per facility
examination of the area of obstruction and policy.
bronchi through a can obtain specimen for Explain the procedure to the client: that the
fiber-optic scope. diagnostic purposes client must be NPO for at least 6 hrs prior to the
Used to remove foreign Lung cancer: used to test; that, if ordered, preprocedure sedation is
bodies, for aggressive confirm diagnosis administered; that an IV access will be obtained
pulmonary cleansing, and sedation given during the procedure via this
and to obtain sputum route.
and tissue specimens. Following the procedure, frequently assess vital
signs and respiratory status. Assess the client for
unusual amounts of bleeding. Inform the client
that sputum may be blood tinged initially following
the procedure. Maintain the client in a side-lying
position until the gag reflex returns. Withhold all
food and fluids until the client is fully awake and
has a gag reflex.
Thoracentesis Removal of fluid for Pleural effusion/pleurisy/ Explain the procedure to the client. Obtain
diagnostic purposes. atelectasis: Removal of written informed consent.
May also obtain biopsy, trapped air or fluid Position the client in an upright sitting position,
instill medications, and leaning forward.
remove fluid for client Have client rest the arms on an overbed table to
comfort and safety. facilitate this position.
Explain to the client that the area will be
anesthetized prior to the procedure. Instruct
the client to hold as still as possible during the
insertion of the thoracentesis needle. Assist
the physician during the procedure. Deliver the
specimen to the laboratory as soon as possible.
Observe the thoracentesis site for bleeding
following the procedure. Assess breath sounds
before and after the procedure. Report absent
breath sounds immediately.
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Table 14-6 Other Diagnostic Tests for Respiratory Disorders (Continued)

SIGNIFICANCE OF TEST
DIAGNOSTIC EXPLANATION/ RELATING TO THE NURSING
TESTS NORMAL VALUES RESPIRATORY SYSTEM RESPONSIBILITIES
Magnetic Uses magnetic field Pleurisy/Pleural Effusion: Assess the client for the presence of metal
resonance and radio waves Reveals pleural effusion, objects within the body (i.e., shrapnel, cochlear
imaging (MRI) to detect edema, particularly small ones implants, pacemakers).
hemorrhage, blood Obtain informed written consent, per facility
flow, infarcts, tumors, policy. Explain the procedure to the client:
infections, aneurysms, the client will be required to lie still for up to
demyelinating disease, 20 min at a time; the client will be placed within
muscular disease, a scanning tunnel; sedation may be required
skeletal abnormalities, if the client has claustrophobic tendencies;
intervertebral disk the magnet will make a loud thumping noise
problems, and as images are obtained (provide earplugs as
causes of spinal cord necessary).
compression. Can be Because the test may require up to 2 hrs to
used in conjunction with perform, have the client void prior to entering
an angiogram (MRA). the scanning tunnel.
Provides greater tissue
discrimination than a
chest x-ray or a CT

scan. Performed by
qualified technologist.
Takes approximately
1 hour.
Table 14-7 Arterial Blood Gases:

Normal
BestPractice
MEASUREMENT Arterial Blood Gases
IN BLOOD NORMAL VALUE To ensure an accurate determination of the client’s
Acidity or alkalinity (pH) 7.35–7.45 actual blood gases, ABGs should not be drawn
within 30 minutes after any respiratory treatment.
Partial pressure of 80–100 mm Hg
oxygen (PaO2)
Partial pressure of carbon 35–45 mm Hg

dioxide (PaCO2)
CONCLUSION
Bicarbonate ion (HCO3) 24–28 mm Hg

The nurse must be knowledgeable about the client’s respira-
Arterial oxygen saturation 95%–100% tory anatomy and physiology, assessment techniques and
(SaO2) use of appropriate questions to ask to gather pertinent health
history and physical data, and the current laboratory and
diagnostics tests that are used to diagnose respiratory disor-
ders and infections. By being knowledgeable and utilizing the
information presented in this chapter, a nurse should be able
to gather essential respiratory system assessment data pertain-
ing to her client.
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CHAPTER 15
Caring for Clients with Upper
Respiratory Tract Disorders
KEY TERMS
adenoidectomy influenza sleep apnea
allergen rhinoplasty tonsillectomy
deviated septum rhinorrhea
epistaxis septoplasty
LEARNING OBJECTIVES
2. Discuss medical and surgical management for clients with upper respiratory tract
disorders.
3. Describe nursing interventions in caring for clients with upper respiratory tract disorders.
4. Assist in developing a nursing care plan for a client with an upper respiratory tract
disorder.
332
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CHAPTER 15 Caring for Clients with Upper Respiratory Tract Disorders 333
INTRODUCTION
This chapter presents an overview of disorders of the nose; InformatIcs
various infectious and inflammatory disorders of the upper re-
spiratory tract; obstruction of the nose, paranasal sinuses, and Computer Imaging
pharynx; trachea and larynx conditions; and laryngeal cancer. for Rhinoplasty
Computer imaging is a valuable tool being used
by physicians to display potential results of
STRUCTURAL/TRAUMATIC rhinoplasty to a client during consultation and
DISORDERS OF THE NOSE planning (Mühlbauer & Holm, 2005).
S tructural and traumatic disorders of the nose include devi-

ated septum and epistaxis.
improve airflow. This surgical procedure is performed entirely
through the client’s nostrils. As a result, little or no bruising
■ DEVIATED SEPTUM or external visible signs of surgery are evident. Septoplasty
may be combined with a rhinoplasty. Rhinoplasty is surgery
A n ideal nasal septum is exactly midline, and separates the

right and left sides of the nose into equal sized airways.
It is estimated that 80% of nasal septums are off-center, but
to reshape the nose in which case the external appearance of
the nose is altered and swelling/bruising of the face is evident.
Septoplasty may also be combined with sinus surgery depend-
not usually noticeable. A deviated septum is when the ing on the deviation and obstruction.
cartilage that separates the nostrils is misaligned, resulting in The reconstructive operation averages about 1 to 1.5 hours
partial airway obstruction. According to the American Society depending on the deviation and is usually done on an outpa-
of Plastic Surgeons (2007), one of the most common causes tient basis. After surgery, nasal packing is inserted to control
of breathing impairment is a deviated septum. postoperative bleeding and a splint is placed inside the nose.
A client with a mildly deviated septum may only have A dressing is placed on the outside of the nose and cold com-
symptoms of breathing impairment when infected with presses are applied as directed. It usually takes several months
an upper respiratory infection such as the common cold. for the nasal swelling to disappear and up to a year for the com-
An infection of the upper respiratory tract (e.g., common plete goal of the surgery to be evident.
cold) causes inflammation of the nasal passageways that may
restrict airflow related to the deviated septum. When the client Pharmacological
recovers from the infection, the nasal inflammation decreases Analgesics to assist in pain control and anti-inflammatory
and the symptoms associated with the deviated septum often drugs for the treatment of swelling will be ordered.
disappear and resolve. Symptoms are usually worse on one
side, with the deviated septum interfering with sinus drainage,
which often results in repeated sinus infections.
Activity
According to the American Academy of Otolaryngology Keep head of bed elevated at all times until swelling has sub-
Head and Neck Surgery (2011) a deviated septum may cause sided. Light to normal activity usually resumes within a few
one or more of the following: days of surgery.
• Blockage of one or both nostrils

• Nasal congestion, sometimes one sided
Nursing Management
Assess for pain, shortness of breath, dyspnea, cyanosis, anxi-
• Frequent sinus infections
ety, and level of consciousness. Monitor vital signs, pulse
• At times, facial pain, headaches, postnasal drip oximetry, and breath sounds. Apply cold compresses as or-
• Noisy breathing during sleep (in infants and young dered. Observe dressing for drainage noting the color and
children) amount. Provide client with written and verbal discharge
• Frequent nosebleeds instructions regarding pain management, dressing changes,
signs and symptoms of infection, and follow-up appointments.
Medical-Surgical
Management NURSING PROCESS
Medical Data Collection
The client is assessed by a health care provider or specialist for The priority is to maintain an open patent airway. Frequent
previous nasal trauma or surgery. An examination of the gen- and close monitoring of the client’s respiratory status is vital.
eral appearance of the nose and the position of the nasal sep- Assessment for swelling that impairs the client’s breathing is
tum is performed by using a bright light and a nasal speculum. important and frequently performed. Pain management is es-
sential to promote healing and a positive client outcome.
Surgical
Surgery may be necessary if the deviated septum is causing
serious obstruction, recurrent sinus infections, or nosebleeds. Subjective Data
Septoplasty is a surgical treatment to correct the alignment The nurse assesses the client for headache, facial pain, discom-
of the septum and to reduce projections inside the nose to fort, nausea, and nasal congestion.
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Objective Data
Observe for color, amount, and consistency of nasal drain- INFECtION CONtROL
age when removing and inserting nasal packing. Monitor for
respiratory distress, swelling, and bruising. Assess for signs of Epistaxis
infection such as fever or purulent drainage.
Wear gloves, goggles or a face mask, and a
gown when caring for a client with epistaxis.
■ EPISTAXIS A cough or sneeze can splatter blood.
T he most common disorder of the nose is epistaxis,

or a nosebleed. Epistaxis is bleeding of the nares or
nostrils. It is either unilateral, which is most common, or
bilateral. Epistaxis may be primary in nature, stemming
from drying of the nasal mucosa, local irritation, or trauma, Nursing Management
or may occur secondary to uncontrolled hypertension or Evaluate overt blood flow and visually examine the poste-
coagulopathies (e.g., thrombocytopenia, anticoagulant rior oropharynx for hidden bleeding. Monitor vital signs.
therapy). The diffuse vascularity and proximity of blood ves- Have client sit up with head bent slightly forward, breathe
sels to the surface of the nasal mucosa make the nares a sus- through the mouth, and allow blood to run freely from the
ceptible avenue for hemorrhage. Blood loss can be minimal to nose into a container. Avoid tipping the head back because
severe. With significant blood loss, hypovolemic shock occurs. blood will flow down the esophagus, causing nausea and
vomiting. Then, wearing gloves, compress the nares for
5 minutes. Suction through the mouth to prevent aspira-
Medical-Surgical tion. Monitor for nausea and vomiting caused by swallowed
Management blood.
Medical
The client with epistaxis usually arrives at an urgent care facility NURSING PROCESS
or emergency department after unsuccessful attempts to stop
the bleeding. Signs of airway obstruction or aspiration require Data Collection
immediate attention. The goals of treatment are to maintain
airway, stop bleeding, identify the cause, and prevent recur- Subjective Data
rence. Nosebleeds are usually responsive to compression of the Ask about the onset, precipitating events, duration, and fre-
nares. Maintain firm pressure for 5 minutes. If bleeding persists, quency of epistaxis, as well as associated symptoms such as
the client should blow the nose and clear the nasal passages. nausea, vomiting, headache, and light-headedness. The client
Resume pressure for a full 10 minutes. Epistaxis that continues with occult bleeding in the back of the throat may complain of
following these measures requires more aggressive treatment. needing to swallow frequently.
Bleeding sites that cannot be visualized require a sterile
nasal packing inserted after application of a local anesthetic. Objective Data
In severe cases, a Nasostat is inserted. This device resembles
a Foley catheter and provides direct compression to the site Evaluate blood flow for amount, consistency, color, and rate
of bleeding via a balloon. Clients with severe nosebleeds may (or severity). Overt bleeding from the nose may be present.
require fluid and blood replacement to prevent hypovolemic This bleeding can vary in flow, from a continuous drip to a
shock. Persistent or recurrent epistaxis may require surgical pulsating stream of blood. Visually examine the posterior oro-
ligation of the artery supplying the area. pharynx of the client with an occult epistaxis to assess blood
flow. Vomiting may be present. Lowered blood pressure and
rapid heart rate are signs of hypovolemic shock. Prothrombin
Pharmacological time (PT), Activated Partial Thromboplastin (APTT), Inter-
Sites of bleeding that can be visualized are cauterized by national Normalized Ratio (INR), and other clotting studies
the physician using silver nitrate sticks. Hemostasis also is will be abnormal with underlying coagulopathies. Decreased
accomplished by packing the affected nostril with epinephrine red blood cell count, hemoglobin, and hematocrit are evi-
1:1000 on cotton packing. dence of significant bleeding.
Nursing diagnoses for a client with epistaxis include the following:

NURSiNg PlaNNiNg/ NURSiNg
DiagNoSES oUTComES iNTERvENTioNS RaTioNalE
Impaired Gas Exchange The client’s respiratory Place client in a high-Fowler’s Aids in preventing aspiration
related to airway rate, color, and blood position, with the head bent of blood. Avoid tipping the
obstruction gases will be within slightly forward. head back as blood will flow
normal limits. down the esophagus, caus-
ing nausea and vomiting.
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Instruct client to breathe Aids in preventing obstruc-
through the mouth and allow the tion of the airway and swal-
blood to escape freely from the lowing of blood.
nose and into a container.
Monitor client for signs and A patent airway is a priority.
symptoms of airway obstruction.
Assess client’s color, respira- Promotes early identification
tory rate and effort, and breath of changes in respiratory
sounds. function.
Monitor pulse oximetry and lab Promotes adequate
reports of ABGs and admin- oxygenation.
ister supplemental oxygen as
indicated.
Risk for Aspiration re- The client will develop no Place client in the position pre- Aids in preventing aspiration
lated to epistaxis complications related to viously described. of blood.
aspiration. Assess client for signs of Monitors client for compli-
aspiration, such as choking, cations related to aspiration.
coarse crackles on auscultation,
or elevated temperature.
Suction the respiratory tract Prevents aspiration of blood
through the mouth to remove and promotes an open
secretions and blood. airway.
Deficient Fluid Volume The client will maintain With a gloved hand, compress Compression helps to con-
related to blood loss adequate fluid volume. the nares for 5 minutes. If bleed- trol and/or cease bleeding.
ing persists, have client blow
nose to clear passages, then
compress nares for 10 minutes.
If bleeding continues following Cautery and nasal packing
compression attempts, prepare control are procedures to
to assist the physician with stop nasal bleeding.
procedures such as cautery or
insertion of nasal packing.
Administer medications to con- Epistaxis may occur sec-
trol blood pressure, as ordered. ondary to uncontrolled hy-
pertension. Controlling blood
pressure aids in decreasing
incidence of epistaxis.
After hemostasis has been If clots are removed this
established, the clots formed will lead to recurrence of
should not be removed or bleeding.
dislodged.
Every 30 minutes, evaluate the Monitors for signs of hypo-
blood pressure and pulse of the volemic shock.
client who shows signs of vol-
ume depletion.
Assess for orthostatic hypoten- A decrease in systolic
sion as a means of measuring blood pressure of greater
volume depletion. than 10 mm Hg when the
position is changed from
lying to sitting or standing
indicates hypovolemia.
Administer intravenous fluids, as To replenish fluid volume loss
ordered. and correct fluid imbalance.
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INFECTIOUS/INFLAMMATORY
DISORDERS OF THE UPPER
RESPIRATORY TRACT
I nfectious and inflammatory disorders of the upper respira-

tory tract are common and usually self-limiting. Among the
causal factors of infectious and inflammatory disorders are
various viruses (rhino viruses, influenza viruses) and bacteria
(streptococci and pneumococci). Group A beta-hemolytic
streptococci infections of the upper respiratory system are
associated with serious sequelae such as rheumatic fever.
Allergic reactions frequently play a role in the development of
sinusitis and pharyngitis. Laryngitis is associated with factors
such as pollution, smoking, and excessive use of the voice.
Breathing cold air decreases local immune responses of the Figure 15-1 Giving a pet a bath helps decrease the animal
dander that causes allergic rhinitis. (Courtesy of CDC/Dawn arlotta; photo by CaDe
respiratory tract. This fact coupled with closer and prolonged
Martin, 2009)
contact with others indoors during the colder months leads to
an increased incidence of acute upper respiratory tract inflam-
matory disorders. times of the year. Uncontrolled allergic rhinitis can reduce
The signs and symptoms that occur with acute upper a person’s quality of life and impair work and school perfor-
respiratory tract infection or inflammation are a result of the mance and social functioning (Hayden, 2010). Learning what
inflammatory process. Early signs and symptoms include allergens trigger the allergic response and finding the right
general malaise, low-grade fever, localized redness, and edema treatment is essential.
of affected tissues. Joint pain is common with viral disorders. Risk factors for developing allergic rhinitis include having
The client may complain of nasal or sinus congestion and asthma or other allergies, being male, having a family member
headache. Drying of the mucous membranes coupled with with asthma or allergies, exposure to cigarette smoke during
edema causes local discomfort such as sore throat. Cough and the first year of life, and being in an environment with con-
nasal or sinus discharge may occur. Nasal secretions that are stant exposure to allergens. Poor quality of sleep, sinusitis, ear
thick and purulent indicate bacterial infection. infections, and worsening asthma symptoms are often associ-
Most clients with acute upper respiratory tract infections ated with allergic rhinitis.
or inflammatory disorders are treated in a clinic or office Testing for allergens involves a skin prick test or a RAST
setting. Unless the disorder becomes chronic or bacterial (radioallergosorbent) blood test. During skin testing, the arm
infection occurs, treatment is symptomatic. When infection is or upper back skin is pricked with small amounts of allergy-
suspected, specimens for culture and sensitivity are obtained, inducing material. If the client is allergic, a hive will develop
and appropriate antibiotic therapy is initiated. Disorders that at the site. The RAST blood test measures the amount of
develop into chronic conditions (e.g., tonsillitis and sinusitis) immunoglobulin E (IgE) allergy causing antibodies in the
may require surgical intervention to remove or drain affected
tissues.
CLIENT teachIng
■ ALLERGIC RHINITIS Allergic Rhinitis Triggers
A llergic rhinitis, also known as hay fever or pollinosis, is a

common allergy in our society caused by airborne aller-
gens such as pollen, mold, animal dander, dust, and ragweed
Teach the client that allergens that trigger allergic
rhinitis are either seasonal or year-round. Seasonal
triggers include:
(Figure 15-1). Symptoms include nasal congestion; thin, clear,
• Tree pollen (spring)
watery discharge; sneezing and coughing; itching eyes, nose,
throat; decreased sense of smell or taste; sinus pressure and • Grass pollen (late spring and summer)
facial pain; swollen, blue-colored skin under the eyes (allergic • Weed pollen (fall)
shiners); and redness of the eyes. Headaches and ear infec- • Spores (fungi and molds)
tions may also develop. Hay fever symptoms usually start im- Year-round triggers include:
mediately after exposure to a specific allergy-causing substance • Dust mites
(allergen). Approximately 13.1 million ambulatory care visits • Cockroaches
to health care providers each year are for allergic rhinitis • Dander (pets)
(Centers for Disease Control and Prevention [CDC], 2011c). • Spores (fungi and molds)
Unlike a common cold, allergic rhinitis isn’t caused by a Teach the client with allergic rhinitis to stay
virus. It is caused by an allergic response to airborne allergens. indoors when airborne allergens are present in
Figure 15-2 outlines the differences between a cold and an
great numbers.
airborne allergy. Some clients have symptoms year-round,
whereas others have symptoms that get worse at certain
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Is It a Cold or an Allergy?
Symptoms Cold Airborne Allergy
Cough Common Sometimes
General Aches, Pains Slight Never
Fatique, Weakness Sometimes Sometimes
Itchy Eyes Rare or Never Common
Sneezing Usual Usual
Sore Throat Common Sometimes
Runny Nose Common Common
Stuffy Nose Common Common
Fever Rare Never
Duration 3 to 14 days Weeks (for example, 6 weeks for
ragweed or grass pollen seasons)
Treatment Antihistamines Antihistamines

Decongestants Nasal steroids
Nonsteroidal anti- Decongestants
inflammatory medicines
Prevention Wash your hands often Avoid those things that

with soap and water you are allergic to such
Avoid close contact as pollen, house dust
with anyone with a cold mites, mold, pet dander,
cockroaches
Complications Sinus infection Sinus infection

Middle ear infection Asthma
Asthma
Figure 15-2 Differences between a cold and an airborne allergy. (aDapteD froM national institute of allergy anD infeCtious Diseases, 2008)
blood. This allergy blood test can measure a client’s immune corticosteroids (prednisone), and nasal ipratropium (Atro-
response to a specific allergen. vent). Immunotherapy (allergy shots) may be given over a
The best treatment is to avoid allergens and prevent period of 3 to 5 years to help desensitize the client to aller-
exposure to substances that trigger rhinitis. Sometimes this gens that are causing the symptoms. Rinsing the sinuses with
is not possible and the client needs additional treatments a saline nasal irrigation is another effective way to relieve
or medication to manage the symptoms. Over-the-counter nasal congestion.
medications for mild allergic rhinitis include antihistamines
such as diphenhydramine (Benadryl), loratadine (Clari-
tin, Alavert), and cetirizine (Zyrtec); oral decongestants ■ ACUTE VIRAL RHINITIS
such as Sudafed, Actifed, and Drixoral; and nasal sprays
such as phenylephrine (Neo-Synephrine), oxymetazoline
(Afrin), and cromolyn sodium (NasalCrom). Prescription
medications may be necessary to treat allergic rhinitis and
A cute viral rhinitis (common cold) is a viral upper re-
spiratory infection that is highly contagious. Although
currently more than 200 viruses can cause a common cold,
include nasal corticosteroids (Flonase, Nasonex), antihis- the rhinovirus is the most common culprit. Symptoms are
tamines (Allegra), a leukotriene modifier (Singulair), oral rhinorrhea (runny nose), sore throat and cough, watery
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eyes, sneezing, congestion, body aches, low-grade fever, and

sometimes a mild headache. A cold is usually harmless and
Nursing Management
most people recover in about 1 to 2 weeks. There is no cure or Hand hygiene and avoiding close contact with individuals
vaccine for the common cold, therefore treatment is symptom who have upper respiratory infections or colds are vital in
management. preventing the spread of infection. The client should cover
Certain factors can increase a person’s risk of getting a cold. cough to prevent spread and be encouraged to cough up all
Infants and preschool children are at greatest risk of colds be- secretions and dispose of them in a tissue.
cause of immature immune systems and frequent contact with
other children. Individuals with weakened immune systems NURSING PROCESS
are also at an increased risk. The fall and winter seasons tend
to be the time of the year when both children and adults are
more susceptible to colds.
Data Collection
Otitis media (ear infection) is a frequent complication of Subjective Data
common colds in young children when a bacterial infection Subjective data include information about present signs and
occurs in the fluid behind the eardrum. Infection and inflam- symptoms, onset of symptoms, and exposure to infected
mation can also lead to sinusitis. individuals. Common symptoms include sore throat, nasal
congestion, body aches, mild fatigue, and headache.
Medical-Surgical
Management Objective Data
Objective data include low-grade fever, inflammation, red-
Pharmacological ness, edema, and drying of the mucous membranes of the
Nonprescription antipyretic, analgesic, anti-inflammatory oropharynx. Symptoms appear 1 to 3 days after exposure and
medications are used to reduce discomfort, fever, and inflam- include sneezing, rhinorrhea, cough, and watery eyes. Secre-
mation. Antitussives are used to suppress cough and allow for tions are evaluated for their color, viscosity, amount, and odor.
rest. To aid in removal of secretions, expectorants are used.
If a bacterial infection is also present, it is treated with vari-
ous antibiotics according to culture and sensitivity studies.
■ INFLUENZA
Comfort measures such as saline gargles may be useful.
Diet I nfluenza (the flu) is a common contagious respiratory ill-
ness affecting the nose, throat, bronchial tubes, and lungs
and is caused by influenza viruses that lead to mild to severe
Fluids are advocated to liquefy secretions and hydrate dry illness and, at times, death. Influenza viruses are spread from
mucous membranes. Nausea may occur if secretions are person to person in respiratory droplets of coughs and sneezes
swallowed as opposed to expectorated. With severe cough- (Figure 15-3). In 2009, the H1N1 influenza virus caused
ing, emesis may occur. Avoid alcohol and caffeine, which can the first influenza pandemic in more then 40 years (CDC,
cause dehydration. The client is encouraged to rest before 2011b). Annual outbreaks of the seasonal flu usually occur
meals and may require an antitussive to reduce coughing. during the late fall through early spring.
Activity
Normally, activity does not need to be restricted, but energy Medical-Surgical
level may decrease. The client who is infectious is encouraged Management
to avoid contact with others. Strenuous activity should be
avoided to reduce oxygen requirements and coughing. Medical
The best way to prevent the flu is to get a flu vaccination
each year. Two types of influenza vaccines are available: the
“flu shot” and the nasal-spray flu vaccine (Figure 15-4). The
SAFETy
Cold Medications
• Never give aspirin to children. It has been asso- Influenza
ciated with Reye’s syndrome (a rare but poten-
Certain age groups such as older adults (over
tially fatal illness).
65 years of age), young children, pregnant women,
• Be careful to read all cold medication labels.
and individuals with certain health conditions are
Do not give a client two medicines with the
at high risk for complications. Approximately 90%
same active ingredient, such as an antihista-
of influenza-associated deaths occur in adults age
mine, decongestant, or pain reliever.
65 years or older (CDC, 2010a).
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88021_ch15_ptg01_332_345.indd 338 12/29/11 12:02 AM
Complications of influenza include bacterial pneumonia,

ear infections, sinus infections, dehydration, and worsening
of chronic medical conditions, such as heart failure, asthma,
or diabetes.
Pharmacological
Two antiviral medications are currently recommended for
the treatment of influenza in the United States. Oseltamivir
(Tamiflu) and zanamivir (Relenza) are recommended by the
CDC due to the emerging influenza A resistance to amanta-
dine (Symmetrel) (CDC, 2011a).
Antiviral drugs are prescription medicines (pills, liquid,
or an inhaled powder) that stop flu viruses from reproducing
in your body. If you get sick, antiviral drugs can make your
Figure 15-3 Sneezing spreads influenza viruses via illness milder and make you feel better faster. They may also
respiratory droplets. (Courtesy of CDC/brian JuDD; photo by JaMes gathany, 2009) prevent serious flu complications. It is very important that
antiviral drugs be used early to treat flu in people who are very
seasonal flu vaccine protects against the three influenza vi- sick with flu (for example, people who are in the hospital)
ruses that research suggests will be most common. and people who are sick with flu and have a greater chance
For more information on influenza, visit http://www of getting serious flu-related complications, including cancer
.cdc.gov or http://www.niaid.nih.gov. patients and survivors.
A number of flu tests are available to detect influenza
viruses. The most common are called rapid influenza diagnostic Diet
tests. These tests can provide results in 30 minutes or less. Un- Fluids are encouraged to hydrate dry mucous membranes
fortunately, the ability of these tests to detect the flu can vary and liquefy secretions. Avoid alcohol and caffeine, which
greatly. Therefore, you could still have the flu, even though your can cause dehydration. The client is encouraged to rest
rapid test result was negative. In addition to rapid tests, several before meals and may require an antitussive to reduce
more accurate and sensitive flu tests are available that must be coughing.
performed in specialized laboratories, such as those found in
hospitals or state public health laboratories. All of these tests
require that a health care provider swipe the inside of your nose Activity
or the back of your throat with a swab and then send the swab Activity does not need to be restricted, but the client will be
for testing. These tests do not require a blood sample. fatigued with decreased energy levels. The client who is infec-
tious is encouraged to avoid contact with others. Strenuous
activity should be avoided to reduce oxygen requirements
and coughing.
Nursing Management
Hand hygiene and avoiding close contact with individuals
who have influenza are vital in preventing the spread of
infection. Teach the client to cover mouth with tissue or
elbow during coughing and to not cough into hands. The
client should cover cough to prevent spread and be encour-
aged to cough up all secretions and dispose of them in a
tissue.
NURSING PROCESS
Data Collection
The flu and the common cold are both respiratory illnesses
but are caused by different viruses. Because these two con-
ditions have similar symptoms, it can be difficult to tell the
difference between them. Assessment of the client with in-
fluenza reveals more intense symptoms such as fever, body
aches, extreme tiredness, and a dry cough. Colds are usually
milder than the flu and generally do not result in serious
Figure 15-4 The nurse is administering a nasal-spray flu health problems, such as pneumonia, bacterial infections, or
vaccine. (Courtesy of CDC/Dr. bill atkinson; photo by JaMes gathany, 2009) hospitalizations.
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Subjective Data Encourage intake of cool or cold clear liquids when client is
fully awake. Administer analgesic as ordered. Educate client
Symptoms of influenza usually include a combination of and caregivers to avoid red or brown liquids, using straws, or
chills, sore throat, fatigue, headache, and body aches. The cli- coughing or blowing the nose to decrease the risk of spontane-
ent may state that the symptoms came on suddenly and feel ous hemorrhage.
worse than a cold.
Objective Data NURSING PROCESS

Objective data to assess is a cough, weakness, fever over 100°F
(38°C), sweats/chills, and a runny nose. Data Collection
A thorough assessment is necessary to collect data on which
■ TONSILLITIS to make an accurate nursing diagnosis.
T onsillitis, a common illness among children but one that

can also occur in adults, is an inflammation of the tonsils
(two masses of lymphoid tissue located in the back of the
Subjective Data
Be sensitive to the client’s level of anxiety regarding removal
of the tonsils and offer opportunities for expression of con-
mouth), resulting from pharyngitis. Tonsils filter and protect cerns. The client with tonsillitis may verbalize chills, persistent
the respiratory and alimentary tracts from infection. They pain in the throat, pain radiating to the ear on swallowing,
normally enlarge progressively between 2 and 10 years of headache, thick speech, malaise, and swelling and tenderness
age and reduce during preadolescence. If the tonsils become of neck glands (lymph nodes).
enlarged from infection, they can interfere with breathing
and swallowing and cause partial deafness. Clinical manifes-
tations of tonsillitis include recurrent sore throat; enlarged, Objective Data
bright-red tonsils; mouth breathing; halitosis; nasal speech; Presurgical assessments such as complete blood count (CBC),
fever; difficulty swallowing; and snoring. The most common clotting time, and urinalysis are usually done on an outpatient
bacterium causing tonsillitis is Streptococcus pyogenes or group basis.
A streptococcus, which causes strep throat. Upon admission on the day of surgery, review vital signs
and laboratory results for abnormalities, and assess the client for
Medical-Surgical signs of infection (fever, elevated white blood cell count [WBC],
and redness and exudate of the throat). Observe the client’s
Management mouth for loose teeth that could be aspirated during anesthesia.
Postoperatively monitor vital signs and observe for hemor-
Surgical rhage, ability to swallow, and dehydration. The most obvious
Tonsillectomy (removal of the tonsils) may be warranted in signs of bleeding from the surgical site are restlessness or anxi-
cases of abscesses, upper airway obstruction, and obstructive ety, frequent swallowing, and rapid pulse. Each time vital signs
sleep apnea. adenoidectomy (removal of lymphoid tissue are taken, use a flashlight to observe the pharynx for bleeding.
in the nasal pharynx) is performed in cases of recurrent otitis
media with eustachian tube obstruction or for persistent nasal
or airway obstruction. ■ LARYNGITIS
Pharmacological
Medical treatment includes analgesics for pain, antipyretics
L aryngitis is an inflammation or swelling of the larynx
(voice box). The voice of someone with laryngitis will
often sound hoarse or raspy. Causes include excessive use
for fever, and antibiotics for streptococcal infections. of the voice, bacterial or viral infections, or irritation to the
vocal cords (cigarette smoke, stomach acid). Laryngitis is
Nursing Management often associated with an upper respiratory infection. Because
Postoperatively monitor vital signs, intake and output (I&O), laryngitis is most commonly viral, antibiotics may not help.
and blood loss. Maintain client in prone or side-lying position. Resting the voice to decrease inflammation of the vocal folds,
administering analgesics to provide pain relief, and using a
humidifier are common treatments.
BestPractIce
■ PHARYNGITIS
Throat Culture
The only reliable means of determining whether
pharyngitis is viral or bacterial is with a throat cul-
A sore throat is the primary symptom of pharyngitis, in-
flammation of the pharynx. In addition to a sore throat,
the client exhibits erythema and inflammation of the pharynx
ture. The nurse is most often the person who per- and tonsils; fever; and enlarged tender cervical lymph nodes.
forms a throat smear for culture, which requires a Pharyngitis is typically viral (80%) with a gradual onset of
physician’s order. The applicator is swabbed across hoarseness, cough, rhinitis, and malaise. It can also be bacte-
the tonsils, the posterior edge of the soft palate,
rial (20%) with symptoms of abdominal pain, vomiting, and
headache. Management is rest, fluids, nonsalicylate antipyret-
and the uvula.
ics or ibuprofen, warm salt-water gargles, cool liquids, and
antibiotics for streptococcal infections.
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CONCEPT CARE MAP 15-1 PhARyNgITIS: INEFFECTIvE BREAThINg PATTERN
NURSING DIAGNOSIS:
Ineffective Breathing Pattern related to airway obstruction as evidenced by dyspnea, tachypnea, low oxygen
saturation, and inability to swallow.
NOC: Respiratory Status Ventilation; Respiratory Status Airway Patency

NIC: Airway Management, Ventilation Assistance
CLIENT GOAL
Client will have effective ventilation.

1. Frequently monitor respiratory rate, 1. Provides information regarding
effort, color, and vital signs for distress. pulmonary status changes that indicate
improvement or deterioration.
2. Monitor the need for airway insertion. 2. Protects the client’s safety. Inability
to maintain adequate oxygenation can
lead to respiratory failure or death.
3. Administer oxygen, corticosteroids, or 3. Assists in preventing hypoxia,
antibiotics as ordered. edema, and treats infection if present.
4. Assist client to reduce anxiety level. 4. Anxiety will increase the cardiac and
respiratory workload.
EVALUATION
Goal met: Client’s respirations stabilized to within normal range, no signs of hypoxia
or respiratory distress. Edema decreased, thus allowing for adequate oxygenation and
swallowing.
(Courtesy of Christine higbie, rn, Msn, arChbolD, ohio)
Nursing diagnoses for a client with an upper respiratory infection or inflammatory

disorder include the following:
Deficient Knowledge The client will be able to Educate client regarding signs Promotes early identification
related to signs and state the signs and symp- and symptoms indicating a and treatment of infection.
symptoms of respira- toms of bacterial infection. respiratory bacterial infection,
tory bacterial infection, such as purulent or green secre-
potential allergens, and tions, fever.
antibiotic therapy The client will be able to Assist physician in allergy Nurses often assist physi-
identify individual potential testing. cians during procedures
allergens. within the scope of practice.
(Continues)
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The client will complete Teach client to avoid those Prevents an allergic
entire course of antibiotic things that precipitate an allergic response.
therapy. response.
Instruct client to complete the Necessary to decrease bac-
entire course of antibiotics. terial count and to prevent
drug resistance.
Ineffective Airway Clear- The client will verbalize a Encourage client to blow the Facilitates removal of
ance related to nasal decrease or absence of nose and not “snuffle” secre- secretions.
secretions nasal congestion. tions back up into nose.
through the nose. Corticosteroids, steroid nasal sprays, and

OBSTRUCTION OF THE antibiotics may be ordered.
NOSE/PARANASAL SINUSES/
PHARYNX ■ FOREIGN BODIES
O bstructions of the nose, paranasal sinuses, and pharynx

include polyps, foreign bodies, and sleep apnea. A nasal foreign body is an object that is lodged in the nose.
If the object is not removed, it can lead to a bacterial in-
fection. Symptoms include nasal and facial congestion, swell-
ing, tenderness/pain, nasal drainage, nosebleeds, and fever.
■ POLYPS Nasal foreign bodies are most common in children. Common
nasal foreign bodies include food, marbles, seeds, beads, eras-
N asal polyps are sac-like noncancerous polypoidal growths

of inflamed tissue lining the nasal mucosa or sinuses.
A polyp may become large enough to obstruct the client’s
ers, vitamins, and candy. Treatment includes removal of the
foreign object, topical nasal anesthetic, and decongestant
nasal spray.
sinuses or nasal airway. Clients with nasal polyps commonly
complain about having a cold that lasts for months. Symptoms
include mouth breathing, runny nose, decreased ability to ■ SLEEP APNEA
or loss of smell, and stuffy or obstructed nasal passageways.
Grayish round masses in the nasal cavity are visible upon
inspection. Surgical removal usually makes it easier to breathe A pnea is a Greek word meaning “without breath.” Sleep
apnea is a period, during sleep, of not breathing
evIdence-based
PractIce
Effects of Continuous Positive Airway Pressure on Obstructive Sleep Apnea
Source: Tomfohr, L. M., Ancoli-Israel, S., Loredo, J. S., & Dimsdale, J. E. (2011). Effects of continuous positive airway pressure on fatigue and
sleepiness in patients with obstructive sleep apnea: Data from a randomized controlled trial. Sleep, 34(1), 121–126.
DIScuSSIon to therapeutic or placebo CPAP for a and sleepiness from OSA. Sleep is essen-
Clients with obstructive sleep apnea 3-week intervention period. The results of tial to promoting and restoring health.
(OSA) frequently complain of daytime the study revealed that 3 weeks of thera- Nurses need to educate clients with OSA
fatigue and sleepiness. The objective of a peutic CPAP significantly reduced fatigue about the benefits of therapeutic CPAP.
research study by Tomfohr and colleagues and increased energy in clients with OSA. Clients with OSA should discuss using
(2011) was to evaluate the impact of con- CPAP with their health care provider.
tinuous positive airway pressure (CPAP) IMPLIcATIonS FoR PRAcTIcE
on fatigue. The study included 59 men This research has important significance
and women who were randomly assigned for clients experiencing daytime fatigue
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BestPractIce ■ TRACHEOSTOMY
Sleep Apnea
A number of factors increase a person’s risk for
A tracheostomy is a surgical procedure to create an open-
ing through the neck into the trachea (windpipe).
A tracheostomy tube (trach tube) is usually placed through this
sleep apnea. These risk factors include having a hole to provide an airway and to remove secretions from the
small upper airway (or large tongue, tonsils, or lungs via suctioning if necessary (Figure 15-5). Tracheostomy
uvula); being overweight; having a recessed chin,
tubes are usually temporary, but can be permanent depending
on the client’s health condition and reason for having this pro-
a small jaw, or a large overbite; having a large
cedure done. A tracheostomy may be done if the client has an
neck size (17 inches or greater in a man or object blocking the airway, has severe mouth or neck injuries,
16 inches or larger in a woman); smoking and cannot breathe on her own, sustained paralysis affecting swal-
alcohol use; being age 40 or older; and ethnicity lowing ability, or has an inherited abnormality or cancerous
(African Americans, Pacific Islanders, and Hispanics) condition of the larynx or trachea.
(NSF, 2011). It can take up to 2 weeks for a tracheostomy to heal or
mature. During this time the client may be provided nutri-
tion through intravenous or feeding tubes. Communication
becomes a challenge since it is impossible for the client to talk
following a period of loud snoring. People with untreated or make sounds. With training, practice, or use of a speaking
sleep apnea may stop breathing hundreds of times for up to valve, most clients learn to talk with a trach tube.
60 seconds or more. Sleep apnea affects 18 million people in
the United States (National Sleep Foundation [NSF], 2011).
There are three types of apnea: obstructive, caused by
relaxation of muscles in the back of the throat that block the SAFETy
airway; central, caused by a failure of the brain to signal the
muscles to breathe; and mixed, a combination of the two Tracheostomy Care
(American Sleep Apnea Association, 2011). Clients must be taught safety precautions
The unaware sleeper stops breathing repeatedly during regarding:
sleep and as frequently as 100 times per hour, often for a min-
• Exposure to water, aerosols, and powder
ute or longer. Usually, those with sleep apnea have no idea that
they are not breathing or that they are continually waking up • How to clean, suction, and change the inner
(American Academy of Sleep Medicine, 2008). cannula of the trach tube
Sleep apnea results in REM-sleep deprivation, manifest-
ing as excessive daytime sleepiness. Sleep apnea can cause
hypertension and an increased risk of heart attack or stroke.
A nasal continuous positive airway pressure (CPAP) device,
which maintains airflow with a small compressor, may give COMMuNITy/hOME hEALTh CARE
relief. Dental appliances that reposition the tongue may also
help. With some individuals, surgical intervention is required
to correct the cause of the apnea. Tracheostomy Care
Home health care services provide tracheostomy
clients with equipment, teaching, routine care,
TRACHEA AND LARYNX suctioning, and medication administration to allow
clients with special needs to stay in their homes.
CONDITIONS
T rachea and larynx conditions include airway obstruction

and tracheostomy.
■ AIRWAY OBSTRUCTION
F ood or small objects can cause an airway obstruction if

(DelMar Cengage learning)
they become lodged in the throat or airway. This is a life-

threatening emergency that requires using a technique called
the Heimlich maneuver and possibly also cardiopulmonary
resuscitation (CPR). Common foods that can cause an airway
obstruction include hot dogs, peanuts, grapes, and popcorn.
Other conditions that can lead to swelling and possible airway
obstruction include allergic reactions (bee sting, peanuts), Figure 15-5 Suctioning a tracheostomy to remove
croup, laryngitis, and tracheitis. secretions.
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the submandibular gland, the sternocleidomastoid muscle,

NEOPLASMS OF THE the jugular vein, and the spinal accessory nerve (Georgetown
University Hospital, 2011). A modified radical neck dissec-
RESPIRATORY TRACT tion removes all the lymph nodes in one or both sides of the
N eoplasms discussed in this section include laryngeal

cancer.
neck without removing neck muscles. Radiation may be used
as an adjunct to surgery or as primary treatment if the tumor
is detected in the early stages. Following surgery, a permanent
tracheostomy is necessary to allow air to enter the respiratory
tract. A small incision is made into the trachea and below the
■ LARYNGEAL CANCER Adam’s apple, and a plastic tracheostomy tube is inserted.
T he American Cancer Society (2011) estimated that in

2010 approximately 12,720 Americans would be diag-
nosed with laryngeal cancer, and about 3,600 persons would
Nursing Management
Monitor respiratory status. Suction secretions and provide
die from it. Risk factors for cancer of the larynx include smok- tracheostomy care. Teach client stoma protection. Keep
ing, chronic alcohol abuse, chronic laryngitis, and overuse of head of bed elevated and provide extra humidity. Refer client
the voice. Laryngeal cancer is relatively asymptomatic. The to the American Cancer Society for support at http://www
client may experience hoarseness or difficulty speaking above .cancer.org.
a whisper. If either persists for more than 2 weeks, medical
care should be sought. Difficulty swallowing is sometimes
present. Laryngeal pain radiating to the ear or a lump in the NURSING PROCESS
throat are often signs of metastasis.
Data Collection
Medical-Surgical Subjective Data
Management Obtain a history of the onset, duration, and severity of
symptoms, such as hoarseness or laryngitis and alcohol and
Treatment is determined by the extent of tumor growth.
tobacco use. The client may describe ear pain and difficulty
breathing and swallowing.
Surgical
Surgical removal of the larynx, a laryngectomy, is used to
treat laryngeal cancer. A radical or modified radical neck Objective Data
dissection may be performed if the cancer has spread to sur- Evaluate the client’s respiratory status for other respiratory
rounding tissues and lymph nodes. Radical neck dissection problems that may accompany laryngeal cancer, such as
operations have been performed for almost 100 years and chronic obstructive pulmonary disease (COPD). Examine
include the removal of lateral neck lymph nodes and tissues, sputum for the presence of blood.
Nursing diagnoses for a client with laryngeal cancer include the following:
Ineffective Airway Clear- The client’s respiratory Suction frequently following Removes static secretions
ance related to tracheos- rate and color will be surgery and provide routine and promotes a patent
tomy tube within desired ranges, tracheostomy care. airway.
and the client will have Provide small, frequent feedings To prevent choking.
clear breath sounds to of liquid or pureed food.
auscultation.
Assist client to turn, cough, and Promotes lung expansion
deep breathe two to four times and prevents stasis of lung
an hour. secretions.
Teach client stoma protection. For safety to prevent aspira-
tion or airway obstruction.
Assess respirations two to four Monitors for adequate respi-
times an hour, if secretions are ratory oxygenation.
copious.
Auscultate lung sounds. Monitors for complications
and infection.
Keep head of bed elevated. Facilitates lung expansion
and ease of breathing.
Provide extra humidity. To ease breathing and
prevent drying of mucous
membranes.
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Impaired Verbal Com- The client will be able Before surgery, establish a Communication is vital for
munication related to to communicate needs. means of communication to be safety and adequate as-
removal of the larynx used afterward. sessment of client’s condi-
tion and pain control. If
available, a manual or com-
puter word/picture board
works well.
Keep call light by client’s bed. Provides client with a means
of communicating the staff.
Avoid mouthing This is frustrating to the cli-
communications. ent and is time consuming.
As possible, ask questions that To prevent client frustration.
require only a “yes” or “no”
answer.
Refer client to the local support Support groups provide a
group (Lost Chord Club) or the positive environment for the
American Cancer Society. client to ask questions and
share feelings and concerns.
Provide written information and Provides the client with
materials. information to refer back
to at a later time. Also pro-
vides another means of
communication.
Deficient Knowledge The client will verbalize Teach client and family how to Teaches the client the cor-
related to tracheostomy precautions and safety suction the respiratory tract, rect technique to prevent
care measures for a trache- care for the tracheostomy, and complications and infection.
ostomy; how to use use respiratory equipment.
equipment; how to suction Instruct client and family about Prepares the client for com-
the respiratory tract; how what to do in case of an emer- plications and promotes
to change the inner can- gency, such as secretions clog- safety.
nula of the tracheostomy ging the tracheostomy tube.
tube; and actions to take
Advise client not to swim and Prevents aspiration of water
in an emergency.
to avoid aspirating water when that can cause choking or
showering or bathing. drowning.
Advise client to avoid extremely Cold air can be irritating to
cold temperatures. the lungs.
Cover tracheostomy site for Prevents aspirating threads
warming or cosmetic purposes or materials into the lungs.
with a porous material without
frayed or loose threads.
CONClUSION
Upper respiratory tract conditions such as influenza, epistaxis,
and cancer can be serious and life threatening. Prompt nurs-
ing interventions may be necessary to maintain and promote
the client’s respiratory function. The nurse needs to be know-
ledgeable about upper respiratory tract disorders and proper
treatment to provide safe and effective client care.
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CHAPTER 16
Caring for Clients with Lower
Respiratory Tract Disorders
KEY TERMS
asthma emphysema pneumonia
bronchiectasis empyema primary tubercle
caseation pleural effusion status asthmaticus
cavitation pleurisy
LEARNING OBJECTIVES
2. Describe the signs and symptoms of acute respiratory system disorders.
3. Discuss medical and surgical management for clients with lower respiratory tract
disorders.
4. Describe nursing interventions in caring for clients with lower respiratory tract disorders.
5. Assist in developing a nursing care plan for a client with a lower respiratory tract disorder.
346
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CHAPTER 16 Caring for Clients with Lower Respiratory Tract Disorders 347
chemical pneumonia is the aspiration of gastric contents. Inhala-

INTRODUCTION tion of irritating substances can also result in a chemical pneumo-
This chapter provides the learner with detailed discussions of nia. Pneumonia is now classified according to the causative factor
pneumonia, pulmonary tuberculosis (TB), pleurisy/pleural rather than the area of the lung affected (e.g., aspiration pneumo-
effusion, and lung cancer. Also addressed are asthma, chronic nia). The right middle and lower lobes are affected by pneumonia
obstructive pulmonary disease (COPD), chronic bronchitis, more frequently than the right upper and left lobes because of the
emphysema, and bronchiectasis. anatomy of the right bronchus and the effects of gravity.
A high fever of sudden onset is often the presenting
complaint of the client. The elderly client, however, may be
■ PNEUMONIA seriously ill and have only a low-grade fever. A productive
cough yielding abnormally thick and discolored sputum may
P neumonia is inflammation of the bronchioles and alveoli
accompanied by consolidation, or solidification of exudate,
in the lungs. It can result from bacteria, viruses, mycoplasms,
be present. Associated respiratory symptoms include dyspnea,
coarse crackles, and diminished breath sounds. Most clients
complain of pleuritic chest pain, which is stabbing in nature
fungi, chemical exposures, or parasite invasions. Pneumonia and increases on inspiration. Pain occurs as a result of irrita-
can also be caused by aspiration, oversedation, or inadequate tion of the pleura lying adjacent to the affected alveoli.
ventilation. Pneumonia remains a common cause of hospitaliza- In the case of bacterial pneumonia, white blood cell count
tion and is often a cause of death, particularly among the elderly. increases and may go as high as 40,000/mm3. Pneumonia
Under normal circumstances, the alveolar macrophages are able caused by viruses or mycoplasms may produce a normal or a
to remove foreign matter. When confronted with overwhelming lowered white blood cell count. Chest x-ray reveals consolida-
numbers of virulent microorganisms, however, this protective tion in the affected areas. Bacterial pneumonia is likely to pro-
mechanism fails. The invading organism irritates the walls of the duce isolated areas of consolidation on a chest x-ray, whereas
alveoli. In response to this irritation, the alveolar walls secrete exu- viral and chemical pneumonia appear as more diffuse areas
date (an accumulation of fluid in the pulmonary passageways). of consolidation. Arterial blood gases (ABGs) may reveal a
Eventually, the alveoli fill with the exudate, resulting in consolida- decrease in PaO2 or oxygen saturation caused by interference
tion. The exudate within the alveoli interferes with gas exchange. with gas exchange. Pulmonary function tests (PFTs) are usu-
Risk factors for the development of pneumonia include im- ally within normal limits unless the client has an underlying
mobility, depressed cough reflex (caused by anesthesia or cere- pulmonary disorder such as emphysema.
brovascular accident [CVA]), alterations in respiratory function
(e.g., COPD), advanced age, and numerous other chronic debili-
tating conditions (e.g., heart failure, diabetes mellitus). Common
Medical-Surgical
bacterial causes of pneumonia are Streptococcus pneumoniae, Management
Pneumococcus, Staphylococcus aureus, Klebsiella pneumoniae, and
Pseudomonas aeruginosa. A common, serious viral source of pneu- Medical
monia is the cytomegalovirus, which affects clients with compro- Clearing the airways of exudate and maintaining adequate oxy-
mised immune status, such as those taking immunosuppressant genation are the goals of treatment for clients with pneumonia.
medications or those infected with human immunodeficiency Postural drainage and percussion may be ordered to aid the cli-
virus (HIV). Pneumocystis jiroveci (formerly called Pneumocystis ent in mobilizing secretions. Aerosol or nebulization treatments
carinii) pneumonia can also occur in the immunosuppressed cli- may also be utilized, often with added medications. The client
ent. The invading organism associated with P. jiroveci pneumonia is encouraged to cough and deep breathe, particularly following
causes a fungal infection of the lungs. respiratory treatments. Incentive spirometry, which measures
Chemical pneumonia is caused by entry of irritating sub- the amount of air inspired in one inhalation, is ordered to aid the
stances into the pulmonary passageways. A common source of client when coughing and deep breathing are inadequate (e.g.,
after surgery) (Figure 16-1). If the client is unable to mobilize
secretions, suctioning of the respiratory tract is indicated.
CLIENT TEACHING When secretions are overwhelming, the physician may
perform a bronchoscopy in order to remove them. Intravenous
Pneumonia
• Discuss pertinent information about medications
being taken.
• Instruct in measures to prevent spread of infection
(e.g., covering the mouth and nose with a tissue
when coughing or sneezing).
• Encourage disposal of tissues in a closed paper sack.
• Outline individual’s specific risk factors (e.g., age,
chronic respiratory condition, cardiac condition).

• Instruct in methods to prevent future infection
(e.g., avoiding crowds and obtaining vaccine).
• Encourage increase in oral fluid intake, if
appropriate for client.
Figure 16-1 An incentive spirometer.
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COLLABORATIVECARE Respiratory Status in the Older Client
Postural Drainage and Medications • Respiratory effort increases because muscles
atrophy, the diaphragm flattens out,
Respiratory therapists work together with nurses
costochondral cartilage calcifies, ligaments and
to provide postural drainage for clients with pneu-
joints stiffen, and intervertebral disks degenerate.
monia or other respiratory problems when exudate
• Alveolar gas exchange diminishes because of
drainage from the lungs is desired. They also col-
a decrease in the lung’s elastic recoil, which
laborate on administering aerosol or nebulized
causes air to be trapped, especially in the lower
medications.
lobes, for a portion of the respiratory cycle.
• The medulla becomes less sensitive to changes
in carbon dioxide and oxygen levels, thereby
fluids are utilized to maintain adequate hydration, especially in rendering the respiration triggering mechanism
the presence of fever. Adequate hydration promotes liquefaction less active.
of respiratory secretions and thus aids in their removal. Pulse • Ciliary activity diminishes, thereby increasing
oximetry or ABGs are done to assess the level of oxygenation. susceptibility to infection.
Supplemental oxygen is used when oxygenation is inadequate. • Cough reflex decreases.
• Aspiration risk increases because of the decrease
Pharmacological in the cough reflex.
The treatment of choice for bacterial pneumonia is specific
based on a sputum specimen for culture and sensitivity (C&S).
It should be obtained before initiating antibiotic therapy. After
a specimen has been obtained, the physician may start therapy
with a broad-spectrum antibiotic. If laboratory data indicate BESTPRACTICE
resistant microorganisms, a specific antibiotic will be started.
Antiviral agents, such as acyclovir sodium (Zovirax), are utilized Assessment and Respiratory
for clients with chronic respiratory problems related to viral Assistive Devices
pneumonia. Prophylactic antibiotic therapy is often utilized for
viral pneumonia to prevent a secondary bacterial infection. To When caring for clients with respiratory assistive
promote opening and clearing of the airways, bronchodilators devices in place, assess the following:
and mucolytic agents are administered via aerosol or nebuliza- • Oxygen
tion by the respiratory therapist or nurse. Expectorants may be • Mode of delivery (e.g., nasal cannula, face mask)
given orally. Cough suppressants and pain relievers, especially • Percentage of oxygen that is being delivered
those containing narcotics such as codeine sulfate, are adminis- (e.g., 25%, 40%)
tered only with discretion, because they may further inhibit the • Flow rate of the oxygen (e.g., 2 L/min, 4 L/min)
client’s ability to clear the airways. • Humidification provided and oxygen warmed
• Incentive spirometer
Diet • Frequency of use
The client with pneumonia is encouraged to drink fluids to aid • Volume achieved
in the liquefaction of respiratory secretions. Small, frequent, • Number of times client reaches goal with
nutritionally balanced meals are preferred. Respiratory treat- each use
ments that promote coughing should be avoided immediately
before and after meals to prevent nausea and vomiting associ-
ated with vigorous coughing.
sickle cell disease, HIV infection or AIDS, cancer, leukemia,
Activity lymphoma, multiple myeloma, nephrotic syndrome, organ or
Bed rest or limited activity promotes optimal tissue oxygen- bone transplant, or are taking medication that lowers immunity
ation; however, range-of-motion exercises and progressive (chemotherapy, long-term steroids). When a second dose is
ambulation prevent immobility complications. given, it should be given 5 years after the first dose. Medicare
pays for this vaccine (American Lung Association [ALA], 2011).
Health Promotion
Pneumococcal vaccine (Pneumovax 23), a vaccine that prevents Nursing Management
infection caused by Streptococcus pneumonia, should be given Auscultation of lungs for breath sounds, assessment of vital
to clients at risk of developing pneumonia, such as those with signs, and monitoring pulse oximetry and ABGs are nursing
chronic respiratory or cardiac conditions and the older adult. responsibilities. Encourage deep breathing, use of incentive
Usually only one dose of vaccine is needed, but under certain spirometer, and the intake of fluids. Reposition clients who are
circumstances a second dose may be given. A second dose is rec- on bed rest at least every 2 hours. Assist with range-of-motion
ommended for clients who have a damaged or removed spleen, exercises and ambulation when able.
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NURSING PROCESS
Pneumonia Data Collection
Subjective Data
Your client, a 78-year-old woman with pneumo- Data gathered in the history include the onset, duration, and
nia, asks you what she should expect in terms of severity of cough; the color, amount, and odor of sputum if
her recovery after a recent bout of pneumonia. present; the onset and duration of elevated temperature; and
She admits that she is weakened and a little the presence or absence of night sweats.
fearful of being alone. Although she has family
nearby, they work and she is anxious to preserve Objective Data
her independence. The client’s level of consciousness should be noted. Evi-
1. What information will you share in your dence of dyspnea, orthopnea, tachypnea, and cyanosis may
client teaching? be present. On auscultation of the lung fields, moist crackles
2. What concerns do you have about the likeli-
or diminished breath sounds may be heard. In the event of
hood of her experiencing problems at home?
obstruction of the airways, sibilant wheezes occur. All vital
signs are taken before and after drug therapy to provide infor-
3. What are some reliable strategies to prevent
mation regarding the severity of the illness and the efficacy of
a recurrence of pneumonia? treatment. The color, amount, viscosity, and odor of sputum
4. What referrals will be helpful in identifying are noted.
supports that will promote her independence?
Nursing diagnoses for a client with pneumonia include the following:

NuRsiNg PLaNNiNg / NuRsiNg
DiagNoses ouTComes iNTeRveNTioNs RaTioNaLe
Ineffective Airway Clear- The client will have clear Encourage client to breathe Promotes expansion of
ance related to inability to breath sounds upon deeply and cough a minimum of the lungs and clearing of
remove airway secretions auscultation. every 2 hrs. secretions.
Teach use of the incentive Promotes lung expansion.
spirometer to encourage lung
expansion.
Administer aerosol and nebulizer Promotes bronchodilation to
treatments as ordered. facilitate ventilation and gas
exchange.
Assess breath sounds and re- Evaluates effectiveness of
spiratory rate prior to and fol- the respiratory procedure/
lowing respiratory procedures/ treatment.
treatments.
Encourage fluids to liquefy thick- Decreases the viscosity of
ened secretions. secretions.
For clients who are able, assist Facilitates drainage, prevents
in sitting up or ambulating three pooling of secretions, and
to four times daily; those on bed promotes lung expansion.
rest, turn every 2 hrs.
Impaired Gas Exchange The client will have an Monitor pulse oximetry and/or Promotes early identification
related to inflammatory oxygen saturation level ABGs. of impaired oxygenation.
changes in alveolar capil- of 95% or greater. Administer supplemental oxygen To maintain oxygen
lary membrane as ordered. saturation at greater than
95% or as ordered.
Activity Intolerance re- The client will be able to Encourage client to complete Promotes independence and
lated to hypoxia second- complete activities of daily ADLs according to ability and daily physical activity accord-
ary to pneumonia living (ADLs) and activity the physician’s orders. ing to the client’s abilities.
as ordered and without Alternate periods of activity and Prevents client fatigue.
complaints of fatigue. care with periods of rest.
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CONCEPT CARE MAP 16-1 PNEuMONIA: ImpaIred Gas exchanGe
NURSING DIAGNOSIS:
Impaired Gas Exchange related to an alveolar-capillary membrane changes.
NOC: Respiratory Status: Gas Exchange. Tissue Perfusion: Pulmonary

NIC: Respiratory Monitoring, Oxygen Therapy, Airway Management
CLIENT GOAL
Client will have improved oxygenation
and symptoms of respiratory distress.

1. Frequently monitor respiratory status and 1. Provides information regarding pulmonary
oxygenation saturation levels. status changes indicating improvement or
deterioration.
2. Assist client to high Fowler's position in 2. Allows for greater lung expansion and ease
bed. of respiration.
3. Encourage coughing and deep breathing 3. Facilitates expansion of alveoli and lung tissue.
exercises.
4. Assess client's color, respiratory effort, 4. Provides information on effectiveness of
and lung sounds frequently. treatments and oxygenation status.
5. Provide oxygen and medications as 5. Promotes adequate oxygenation and facilitates
ordered. healing.
EVALUATION
Was the goal met or not met? Did the client demonstrate improved oxygenation and have
no signs of respiratory distress? How did the client's color and lung sounds improve?
(Courtesy of Christine higbie, rn, msn, arChbolD, ohio)
■ TUBERCULOSIS Once inhaled in sufficient numbers, the tubercle bacilli

cause an inflammatory response within the alveoli of the
P ulmonary tuberculosis (TB) is an infection of the lung tis-

sue by Mycobacterium tuberculosis. Infection by tubercle ba-
cilli can occur in other parts of the body, but with less frequency.
lung. A small nodule called a primary tubercle, containing
tubercle bacilli, forms in the lung tissue. In an attempt to
isolate the primary tubercles, the body forms a fibrous outer
In pulmonary tuberculosis, the tubercle bacilli are inhaled into coating around each tubercle. This fibrous surface interferes
the lungs. Whether infection occurs depends on the host’s sus- with the blood and nutritional supplies to the tubercle. In
ceptibility, the virulence of the tubercle bacilli, and the number time, the interior of the tubercle becomes soft and cheese-
of bacilli inhaled. Tuberculosis is not as highly contagious as like as a result of decreased perfusion, a process known as
once thought. Prolonged exposure to the bacilli is required to caseation. Then the tubercle may become calcified and is
produce infection. In addition, persons with uncompromised called a Ghon’s tubercle.
immune systems are able to combat the bacilli and do not de- Liquefaction necrosis, where the tissue dies and changes
velop the disease. Those at risk for tuberculosis include persons to a liquid or semi-liquid state, may occur; this fluid may
suffering from malnutrition, those living in crowded conditions, then be coughed up. A cavity is formed at the site where
persons with compromised immune status, and health care the primary tubercle liquefied and ruptured. This is called
workers providing care to high-risk individuals. cavitation.
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Following the advent of antitubercular medications in the TB infection. The client receives the results from this test in
1950s, the incidence of TB decreased dramatically until 1985. less than 24 hours (ALA, 2008a).
From 1985 to 1992, TB cases increased 20%, but from 1992 The bacteria can remain alive but inactive in the body,
have decreased 39%. In 2008, the total number of cases of TB often for a lifetime, so a client is given prophylactic treat-
(12,904 persons) in the United States was the lowest it has ment, usually isoniazid (INH), for 6 to 12 months. Other
been since the study started in 1953 (ALA, 2010b). medications used against tuberculosis are outlined in
New forms of TB that are resistant to conventional Table 16-2. If INH has not been given and the person later
drug therapy have surfaced. Some of the factors that may in life is under physical or emotional stress, which weakens
be responsible for the increase in TB cases are increased the immune system, the bacteria may become active and
numbers of persons with compromised immune systems cause TB disease.
(e.g., many AIDS clients also have TB); increased mobility of A negative reaction does not rule out the possibility
the world’s population (persons from areas of high TB inci- of TB exposure. Individuals at high risk, such as those who
dence moving to areas of low incidence); widespread IV drug are infected with HIV or who have compromised immune
abuse; increased numbers of those with poor access to health status, may have a negative reaction because they are unable
care; and increased numbers of those living in impoverished to develop antibodies. Immediately following exposure to
conditions. Worldwide direct health care costs for TB in 2009 TB, a skin test may reveal a false-negative result because it
were estimated at $2.5 billion (ALA, 2010b). can take up to 10 weeks for an infected individual to develop
Symptoms of TB develop gradually following infection the antibodies. An additional skin test may be done in 10 to
and include the following: low-grade fever that recurs in a 12 weeks. If the second TB test is positive, the client’s history
specific pattern, persistent cough, hemoptysis, hoarseness, is reviewed for the presence of symptoms suggesting TB, and
dyspnea on exertion, night sweats, fatigue, weight loss, and further evaluation is indicated.
enlarged lymph nodes. Chest x-ray and sputum specimens are utilized to confirm
The Mantoux skin test is the preferred screening method a diagnosis of TB. Inpatient clients are placed in airborne
for TB. Purified protein derivative (PPD) of killed tubercle respiratory isolation until cultures are completed with results.
bacilli 0.1 mL is injected intradermally in the inner forearm. Sputum is tested for the presence of acid-fast bacilli (AFB).
The test is evaluated by measuring the area of induration The sputum specimen is collected when the client arises in the
(palpable swelling) that occurs 48 and 72 hours follow- morning to prevent specimen contamination with ingested
ing injection. A reddened area with no induration is not food and liquids. In most instances, three specimens collected
considered positive. A positive skin test, however, indicates on consecutive days and testing positive for AFB indicate a
only that the client has been infected with and developed positive diagnosis of TB. The TB diagnosis is confirmed if
antibodies against the tubercle bacillus (Table 16-1). It is im- the TB bacilli grow in a culture. Individuals who are unable
portant for clients to know that the test will thereafter always to produce sputum, including children and older adults, may
be positive throughout the individual’s lifetime. The Food have stomach contents aspirated for AFB testing. Chest x-ray
and Drug Administration approved a TB blood test called may reveal the presence of primary tubercles, calcified lesions,
QuantiFERON-TB that is used for detecting TB and latent and cavitation in the lung.
Table 16-1 Classification of the Tuberculin Reaction

CLassiFieD as PosiTive PoPuLaTioN
Induration of 5 mm or more • HIV-positive persons

• Recent contacts of TB case
• Persons with chest x-rays consistent with old, healed TB
• Clients with organ transplants or other immunosuppressed persons
Induration of 10 mm or more • Injection drug users

• Recent arrivals (<5 years) from high-prevalence countries
• Residents and employees of high-risk congregate settings (prisons, nursing homes,
mental institutions, residential facilities for people with AIDS, and homeless shelters)
• Persons with medical conditions that have been shown to increase the risk of TB,
such as silicosis; persons who are 10% or more below ideal body weight; and
persons with some hematological disorders (leukemias and lymphomas) and other
malignancies
• Mycobacteriology laboratory personnel
• Children <4 years of age, or children and adolescents exposed to adults in high-risk

categories
Induration of 15 mm or more Persons with no risk factors for TB
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Table 16-2 Tuberculosis medications

DRug meDiCaTioN PReCauTioNs aND iNFoRmaTioN
First-Line Drugs
ethambutol hydrochloride Monthly vision checks are important for acuity and distinction of red and green colors.
(Myambutol) Take medication with food.
isoniazid (INH) (Laniazid) Alcohol ingestion interferes with metabolism and may cause hepatitis. Check baseline
and monthly hepatic enzymes. Report signs of neuropathy and hepatitis. Have client
take pyridoxine (vitamin B6) to decrease side effects.
pyrazinamide (PMS Take medication with food and drink 2 liters of liquids daily. Check baseline and monthly
Pyrazinamide) uric acid and liver enzymes.
Rifamate A combination of isoniazid and rifampin.
rifampin (Rifadin) Body secretions (urine, sweat, tears) turn orange while taking the medication.
rifapentine (Priftin) As effective as rifampin but taken less frequently. Body secretions (urine, sweat, tears)
turn orange. Drug must be given with at least one other tuberculosis drug.
Rifater A combination of isoniazid, rifampin, and pyrazinamide.
streptomycin sulfate Have monthly audiograms to check auditory function. Check baseline and monthly
renal function.
Second-Line Drugs
cycloserine (Seromycin) Observe for mental alertness. While taking the medication, monitor renal and liver
function, drink 2 to 3 liters of fluid daily, and avoid alcohol.
ethionamide (Trecator-SC) Given with other antitubercular drugs to prevent resistant organisms from
developing.

kanamycin sulfate (Kantrex) Drug may cause steatorrhea and electrolyte imbalance.
para-amino-salicylate Must be taken with other antitubercular drugs; taken with meals.
(Sodium P.A.S.)
EVIDENCE-BASED
PRACTICE
Rapid Molecular Screening for Multidrug-Resistant Tuberculosis
Source: Barnard, M., Albert, H., Coetzee, G., O’Brien, R., & Bosman, M. (2008). Rapid molecular screening for multidrug-resistant
tuberculosis in a high-volume public health laboratory in South Africa. American Journal of Respiratory and Critical Care Medicine,
177, 787–792.
DiSCuSSiOn conducted a study to assess the perfor- interpretable results within 1 to 2 days.
Current conventional methods to test mance and feasibility of using a com- The study concluded that the molecular
for tuberculosis drug resistance can take mercially available molecular screening assay is a highly accurate screening tool
weeks to months to get results. In South assay for rapid detection of isoniazid and for multidrug-resistant TB.
Africa, the challenge to tuberculosis rifampicin resistance. The research study iMpliCAtiOnS fOR pRACtiCe
control of HIV and multidrug resistance performed the rapid molecular screen- The rapid molecular assay screen has
is serious. Rapid molecular screening ing on 536 sputum specimens from cli- the potential to revolutionize multidrug-
is available, but has not been imple- ents at risk for multidrug-resistant TB. resistant TB diagnosis by providing high
mented in areas of “high TB burden.” In The results of the research study found accuracy with faster results.
Cape Town, South Africa, researchers that overall, 97% of the specimens gave
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Medical-Surgical MEMORY TRICK

Management MASK
Medical
A memory trick for the nurse to use to remember
Most clients are treated briefly in the hospital, with long-term
treatment continuing at home. In the hospital, follow Air- how to correctly wear and use an N95 particulate
borne Precautions in addition to Standard Precautions. The respirator mask when providing care for a TB client
precautions include placing the client in an isolation room is the term MASK:
with negative air pressure. (Air inflow is controlled through M = Make sure you are using the correct size mask.
one vent and air outflow is exhausted through another vent
directly to the outside and is not recirculated to other rooms.) A = Always wear an N95 particulate respirator
The doors and windows of the client’s room must be kept mask (NOT a surgical mask).
closed to maintain control of airflow. Caregivers should wear S = Seal between face and respirator must be
N95 particulate respirator masks because standard isolation tightly fitted and intact.
masks do not prevent Mycobacterium tuberculosis from pass-
ing through (Figure 16-2). The Centers for Disease Control K = Keep N95 particulate respirator mask on
and Prevention recommends periodic TB skin testing for until after you leave the client’s room.
health care personnel. The Directly Observed Treatment
Short-Course (DOTS) is an internationally recommended
approach for diagnosing and treating TB. The DOTS proto-
col requires the TB client to be supervised by an independent
observer to make sure that the client takes the medication and InFectIOn cOntrOL
treatment throughout the prescribed period of time (usually
6 months). use of a Particulate Respirator
Surgical • Follow facility’s procedure for fit-testing.

• Use the correct size mask.
In the past, surgical intervention involving the removal of
• Put on respirator before entering client’s
affected lung tissues was common. With the advent of effec-
tive chemotherapy (treatment with drugs), however, surgical room and remove after leaving client’s room.
intervention is now rarely utilized. • Ensure that the respirator is free of holes.
• Check that the seal between face and
respirator is intact.
• Discard soiled or damaged respirators.
• Have client wear N95 respirator when leaving
the room.
Pharmacological
Multidrug-resistant TB (MDR TB) can develop when a cli-
ent does not complete the full therapy or is inadequately
treated. A new strain of TB called extensively drug-resistant
tuberculosis (XDR TB) is a strain with extensive resistance to
second-line drugs. XDR TB is a public threat worldwide and
is raising concerns of a future epidemic of TB that is virtually
untreatable (ALA, 2010a).
Active TB is treated with a combination of medications.
Three medications—isoniazid (Laniazid, which is most ef-
fective), rifampin (Rifadin), and pyrazinamide (PMS Pyra-
zinamide)—are given for several months. This is followed
by a regimen of rifampin and isoniazid for an additional time.
The combination of three drugs is given initially to rapidly de-
crease the number of active bacilli in the body and to prevent
the development of MDR TB. Long-term therapy is required
because TB bacilli have long periods of metabolic inactivity.
Those clients with bone and joint infections, meningitis, or
resistant forms of TB are treated for longer periods. Clients
who are HIV positive require a longer regimen of isoniazid
Figure 16-2 A particulate respirator fits tightly around the and pyrazinamide; prophylactic treatment with isoniazid is
nose and face. (Photo Courtesy of molDex metriC inC., httP://www.molDex.smugmug.Com) indicated from then on.
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Ethambutol hydrochloride (Myambutol) and streptomy- Taking multiple drugs can be confusing and lead to non-
cin sulfate are added to the treatment regimen if the infecting compliance. The development of two new drugs has been
organism is resistant to one of the three normally used medi- valuable. These drugs are Rifater, a combination of isoniazid,
cations. Infection with MDR TB requires the use of kanamy- rifampin, and pyrazinamide, and Rifamate, a combination of
cin sulfate (Kantrex), capreomycin sulfate (Capastat Sulfate), isoniazid and rifampin.
and cycloserine (Seromycin). The client is considered non-
infectious following three negative AFB sputum specimens. Diet
At that point, the client may return to work and other normal The client with TB often has nutritional deficits. Correcting
activities. Prophylactic treatment of high-risk individuals is these deficits assists the client in overcoming the disease pro-
recommended to reduce their chances of developing the dis- cess. Dietary management is based on the type of deficiency
ease following their exposure. present. A well-balanced diet is encouraged for all clients with
TB. Fluids are encouraged to aid in the liquefaction of respira-
tory secretions.
SAFETy
Activity
Caregivers in Health Care Institutions Activity is restricted based on the client’s tolerance. The client
• Be aware of risks when caring for a client who is severely compromised from a respiratory standpoint
with TB. may be placed on bed rest. If the client’s condition allows,
• Follow Standard Precautions and Airborne
activity is encouraged because it promotes lung expansion and
aids in the removal of static secretions. The client in isolation
Precautions.
whose condition permits it may ambulate in the hallways, as
• Use face and/or eye shield in addition to partic- long as a particulate respirator mask is worn by the client while
ulate mask when performing sputum-induction outside of the room.
procedure.
• Plan care to limit prolonged exposure to client.
• Perform hand hygiene frequently and
thoroughly.
COMMuNITy/HOME HEALTH CARE
The Client with Tuberculosis
Advise the client of the following:
• Keep all clinic appointments.
InFectIOn cOntrOL • Take all medications exactly as directed for
duration of treatment.
Tuberculosis • Until tested and noninfectious:
• Put used tissues in a closed paper sack and
• Instruct client to cover mouth and nose throw away.
when coughing or sneezing. • Avoid close contact with anyone; wear a
• Double-bag secretions and dispose of them mask.
as infectious waste. • Sleep alone in bedroom.
• Use disposable items for care when possible. • Air out bedroom often, using a fan in the
• Thoroughly clean and disinfect nondispos- window to blow air outside.
able items. • Thoroughly clean articles such as eating
• Client must wear an N95 mask when being utensils.
transported from one area of a facility to
another area.
Tuberculosis Precautions
CLIENT TEACHING
A nurse is working in a medical clinic when a
Side Effects of Rifampin
client comes to the desk and informs her that
• Urine, saliva, or tears may turn orange. one of his friends has TB, and that he was told
• May permanently discolor contact lenses. to come to the clinic to get checked. The client is
• Birth control pills and implants become less coughing continuously. The nurse knows that it
effective. Use alternative methods of birth will be 45 minutes before she can get him in to
control. see the physician. What should the nurse do?
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Health Promotion NURSING PROCESS

Prevention of TB is preferred to treatment. In areas where the
disease remains endemic (seldom in the United States), a vac-
cine containing attenuated tubercle bacilli, bacillus Calmette-
Data Collection
Guérin (BCG) may be given. Individuals receiving it will test Subjective Data
positive to the tuberculin skin test. The history includes questions about the presence of signs
Any person who has had close contact with a client and symptoms of TB, such as night sweats, dyspnea on exer-
with TB without practicing appropriate protective measures tion or at rest in late disease, anorexia, loss of muscle strength,
should be tested. Other measures that decrease the likelihood and fatigue. Pleuritic pain occurs when the pleura is involved.
of TB include adequate nutrition and housing, health care ac-
cess, and treatment of individuals who have or are at risk for Objective Data
developing TB.
Objective data include weight loss; persistent, low-grade
fever; and persistent cough. The cough may be nonproduc-
tive early in the disease. Later, the cough is productive and
Nursing Management yields thick, purulent sputum. Eventually, hemoptysis (blood
Assess client for low-grade fever, night sweats, and persistent spitting) occurs. Auscultation of breath sounds reveals coarse
cough. Teach client and family about the disease process and crackles. In the presence of cavitary disease, breath sounds are
stress the importance of absolute compliance with the treat- diminished or absent in the affected areas. Sputum is observed
ment plan. as to amount, color, odor, and consistency.
Nursing diagnoses for a client with TB include the following:

NuRsiNg PLaNNiNg/ NuRsiNg
Ineffective Breathing The client will have color Assess client’s color, respiratory Evaluates respiratory status
Pattern related to and respiratory rate within rate, and respiratory effort and and provides a baseline for
pulmonary infectious normal limits and will not auscultate the breath sounds. detecting changes.
process complain of dyspnea. Plan care activities to allow cli- Prevents client fatigue.
ent uninterrupted periods of rest.
Assist client in assuming Promotes lung expansion
the position that most aids and gas exchange.
respiratory effort.
Administer medications as Treats infection and/or
ordered. promotes bronchodilation.
Encourage fluids if not otherwise Decreases the viscosity of
contraindicated. secretions.
Deficient Knowledge The client will verbalize Teach client and family about Facilitates early recognition,
related to disease pro- an understanding of the the basic pathophysiology of TB, treatment, and prevention
cess and its treatment disease process and its how the infection is contracted, of TB.
treatment. who is at risk of developing an
infection, the signs and symp-
toms of TB infection, and com-
plications that may arise.
Present information regarding Prepares the client for side
the actions, side effects, and effects and knowledge of
untoward effects of the drugs what to expect.
being administered.
Teach client signs and symp- Facilitates prompt treatment.
toms of adverse drug reactions
to report to the physician.
Emphasize the necessity of Symptoms decrease and are
long-term therapy to cure TB. often gone long before the
organism is eliminated from
the body.
(Continues)
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Ineffective Family Thera- The client will continue Include client and family in Promotes self-care and
peutic Regimen Manage- medication regimen for making decisions about care, family support of care
ment related to client value the prescribed length of when appropriate. given.
system time. Allow client to be an active par- Increases personal responsi-
ticipant in care decisions. bility and accountability.
Visits from public health or home Monitors compliance with
care nurses may be necessary treatment.
to monitor client for compliance.
Explore reasons for noncompli- Identifies reasons for
ance with client and family, and noncompliance and pro-
identify strategies to increase motes the implementation of
compliance. effective strategies.
Refer client who is unable to Assists the client to obtain
afford the cost of medica- necessary treatment.
tions to agencies such as the
local health department for
assistance.
Begin directly observed therapy Ensures that the client
if the client continues to be is taking medication and
noncompliant. Directly observed following treatment regimen.
therapy involves sending the
nurse or another health care
worker to the client to administer
the medications and verify that
they are taken.
samPLe NuRsiNg CaRe PLaN
The Client with TB

R.D. is an 87-year-old man who is admitted to the hospital with a chief complaint of productive cough and fatigue.
Four months ago, R.D. was placed in a long-term care facility because of his inability to care for himself at home
after his wife’s death 1 year previously. Since admission to the long-term care facility, R.D. has lost 15 pounds. The
nurses at the facility report that R.D. has experienced progressive fatigue, dyspnea on exertion, cough, night sweats,
and anorexia. Initially, his cough was nonproductive, but it is now productive of moderate amounts of thick, puru-
lent sputum that is occasionally streaked with blood. Vital signs are as follows: temperature 99.8°F, pulse 108 beats/
min, respirations 26 breaths/min, and blood pressure 138/86 mm Hg. A TB skin test done at the long-term care facil-
ity 1 week ago was evaluated as negative at 6 mm. Sputum specimens for AFB reveal the presence of active tubercle
bacilli, and chest x-ray is positive for TB. Auscultation of breath sounds reveals crackles in the right lower half of the
lung. R.D. says, “I don’t understand why I can’t breathe good and what all this fuss is about.”
NuRSINg DIAgNOSIS 1 Ineffective Breathing Pattern related to infectious pulmonary process as evidenced by
dyspnea on exertion and productive cough

Respiratory Status: Airway Patency Airway Management
Respiratory Status: Ventilation Respiratory Monitoring
Energy Conservation Ventilation Assistance
Energy Management
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samPLe NuRsiNg CaRe PLaN (Continued)

PLANNINg/OuTCOMES NuRSINg INTERvENTIONS RATIONALE
R.D. will have respiratory rate, Initially and periodically assess Provides a database from which the
oxygen saturation, and color within R.D.’s respiratory status, including plan of care can be formulated and
desired ranges and will not complain color, respiratory rate, respiratory against which the effectiveness of
of dyspnea. effort, oxygen saturation, breath treatment is evaluated. Subsequent
sounds, level of consciousness, assessments evaluate the effectiveness
cough, and sputum. of interventions and may modify the
care plan.
Assist R.D. in assuming a position Allows for greater ease of respiration
that most aids respiratory effort. and lung expansion.
Alternate care activities with Allows R.D. to compensate for the
periods of rest. increased oxygen demand required
by activity.
Encourage activity within R.D.’s Promotes expansion of the lungs.
tolerance.
Encourage fluids. Promotes liquefaction of respiratory
secretions.
Administer medications for Persistent fever leads to dehydration,
fever as ordered. which hinders the removal of respira-
tory secretions.
Administer oxygen as ordered to Necessary for optimal cellular
maintain an SaO2 of 95% or greater. function.
Administer antitubercular drugs Decreases the number of viable tu-
as ordered. bercle bacilli.
EVALuATION
R.D. verbalizes a decrease in dyspnea and cough. R.D.’s color, respiratory rate, and oxygen saturation are within
normal limits.
NuRSINg DIAgNOSIS 2 Risk for Infection spread related to viable bacilli in secretions as evidenced by AFB in
sputum

Knowledge: Infection Control Health Education

R.D. will verbalize both those situa- Place R.D. in a negative air pressure, Prevents transmission of the tubercle
tions that allow for the transmission of private room; keep door closed at all bacilli in air that has been circulated
the tubercle bacilli and the means to times. On the door, place Airborne into and out of R.D.’s room. Prevents
prevent their transmission. Precaution signs indicating that R.D. inadvertent contact and exposure.
has an infectious process and asking The nature of the infection is not
visitors to see nursing personnel be- revealed publicly to maintain client
fore visiting. Instruct visitors to wear confidentiality. Visitors are informed
N95 respirators when in of precautions to take to prevent
exposure.
R.D.’s room, to limit the length of
their visits, to avoid intimate contact,
and to wash their hands when leav-
ing the room.
(Continues)
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samPLe NuRsiNg CaRe PLaN (Continued)

Instruct R.D. to cover his mouth and Aids in the containment of
nose when coughing and sneezing. the tubercle bacilli.
Instruct R.D. to cough up secretions in Aids in preventing the spread of the
tissues and to place the tissues in a plas- tubercle bacilli.
tic bag. Dispose of contained secretions
as infectious waste.
Inform the long-term care facility and Known exposure to active tubercle
family/significant others of the posi- bacilli necessitates testing to identify
tive results of the AFB studies. Instruct individuals who may have become
those persons who have been exposed infected.
to R.D. to have a TB skin test.
Observe Standard Precautions and Decreases the likelihood of transmitting
Airborne Precautions. the tubercle bacilli (and other infectious
diseases) to staff and other clients.
Wear a fitted N95 respirator when in Prevents the inhalation of tubercle ba-
R.D.’s room. cilli, which are able to pass through a
simple surgical mask.
EVALuATION
Persons exposed to R.D. have been tested for TB. Those with TB are being treated.
NuRSINg DIAgNOSIS 3 Deficient Knowledge related to disease process and its treatment as evidenced by client
statement: “I don’t understand why I can’t breathe good and what all this fuss is about.”

Knowledge: Disease Process Teaching: Disease Process
Knowledge: Treatment Regimen Teaching: Individual

R.D. will verbalize an understanding Assess R.D.’s present level of knowl- Provides a database regarding R.D.’s
of the disease process and the re- edge regarding TB and its treatment. present level of knowledge regarding
quired medication regimen. TB and its treatment. Client educa-
tion can then be individualized to
build and expand on that knowledge
base. Misinformation can also be
corrected.
Provide information in small amounts Increases the likelihood of learning
and use a variety of approaches (e.g., and stimulates the various senses.
verbal, written, video).
Encourage and allow time for R.D. to Provides a means to clarify informa-
ask questions. tion and for the nurse to evaluate
learning and correct misconceptions.
Have R.D. verbalize signs and Provides a means to clarify informa-
symptoms of adverse medication tion and for the nurse to evaluate
effects to report to the staff. learning and correct misconceptions.
EVALuATION
R.D. verbalizes individual treatment regimen and its purpose. R.D. reports adverse effects of medication to health care
personnel to allow for early intervention.
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■ PLEURISY/PLEURAL EFFUSION BESTPRACTICE

P leurisy is a painful condition that arises from inflam-
mation of the pleura, or sac that encases the lung. This
pleuritic pain is sharp and stabbing in nature. Pain increases
Assessment of Client with a Chest Tube
• Obtain vital signs as ordered.
on inspiration as the irritated pleura rub over each other. In- • Be alert for dyspnea.
flammation of the pleura occurs with many disorders, such as • Record and describe amount of drainage.
viral infections, cancer of the lung, trauma, tuberculosis, heart • Look for loops of tubing containing drainage.
failure, and pulmonary embolism. The inflamed pleura secrete
• Monitor water level in the water seal.
increased amounts of pleural fluid into the pleural cavity, creat-
ing a pleural effusion. As fluid accumulates within the pleural Fluctuation (called tidaling) should occur
space (cavity), it compresses the lung tissue (Figure 16-3). with respirations and will stop when lung is
Collapse, or atelectasis, results if the effusion is left untreated. reexpanded, tubing is kinked, connections are
Those areas of collapsed lung tissue are unable to take part in not tight, or chest tube becomes dislodged.
gas exchange, thereby decreasing oxygenation. empyema is • Keep chest drainage system below the level of
the term used to describe infected pleural exudate. the client’s chest.
The primary manifestation of pleurisy is pain on inspira- • Every 2 hours, monitor client’s response to
tion. Signs and symptoms of pleural effusion depend on the coughing and deep breathing.
amount of lung tissue compressed and the source of the ef- • If the chest tube is accidentally dislodged, cover
fusion. With large pleural effusions, the mediastinum (heart, opening with petrolatum gauze and tape only
great vessels, and trachea) shifts toward the unaffected side;
three sides of the dressing to create a one-way
this can be detected by inspection, and heart sounds will move
toward the unaffected side. Magnetic resonance imaging valve in which air can exit the pleural space on
(MRI) or computerized tomography (CT) studies are useful exhalation to prevent a tension pneumothorax
in detecting pleural effusions, particularly small ones. A chest from occurring (O’Connor & Adamski, 2010;
x-ray will show pleural effusions of 250 mL of fluid or more. If Daniels & Nicoll, 2012).
empyema is suspected, C&S studies will identify the presence • Assess for pain and discomfort.
and type of infection. The client with empyema will also have • Auscultate breath sounds in each lung lobe.
an elevated temperature and white blood cell count. • Assess chest tube insertion site for signs of infection.
• Assess and palpate skin at chest tube insertion
Medical-Surgical site for puffiness and crepitus (crackling).
Management •
•
Observe for signs of subcutaneous emphysema.
Inspect occlusive dressing at insertion site for
Medical drainage.
Treatment is aimed at eliminating the underlying cause, main-
taining adequate oxygenation to the tissues, and preventing
complications such as atelectasis and pneumonia. Oxygen-
ation is evaluated by ABGs or pulse oximetry. Supplemental needle is placed into the pleural space. Fluid is removed (no
oxygen is given to maintain an oxygen saturation of 95% or more than 1,500 mL) and may be sent to the laboratory for
greater. Respiratory treatments to aid lung expansion such as diagnostic purposes (e.g., culture, cytology). If fluid accumu-
incentive spirometry are used. lation continues, a thoracotomy tube is placed into the pleural
space to drain fluid continuously. Following administration
Surgical of local anesthetics, the physician places a large-bore cath-
Larger pleural effusions require that a thoracentesis be per- eter into the pleural space. This catheter is attached to an
formed by the physician to remove accumulated fluid. After underwater seal chest tube drainage device (Figure 16-4). It
the overlying tissues have been anesthetized, a large-bore prevents the negative pressure within the pleural space from
Contralateral mediastinal shift
pulling air into the pleural space, and allows for the drainage of
accumulated fluid or air. Most chest tube devices have a cham-
Pleural ber to which suction may be applied to assist in the removal
effusion of fluid or air from the pleural space. It can also be sealed with
and
thickening a Heimlich (one-way) valve. A chest x-ray is done to evaluate
the chest tube’s placement and effectiveness.
Pharmacological
Fluid in
pleural
If a pleural effusion is small and does not interfere greatly with
No breath space respiratory function, diuretics are used to promote removal
sounds
of fluid from the pleural space. Furosemide (Lasix) and bu-
metanide (Bumex) may be given for this purpose. If empyema is
present, specific therapy is used once the causative agent is iden-
tified. Pain relief is a high priority. Analgesia that also decreases
Figure 16-3 Pleural effusion. inflammation is preferred. Ketorolac tromethamine (Toradol)
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From air vent

From
client
Nursing Management
Suction Assess the client’s color, respiratory rate and effort, and level of
consciousness. Monitor vital signs and breath sounds. If a chest
tube is in place, watch that all tubes are in place and the drain-
age device is working properly. A variety of closed-drainage
chest tube systems are available. Encourage the client to use the
incentive spirometer.
NURSING PROCESS
Data Collection
Water
Subjective Data
seal A nursing history is obtained from the client regarding onset,

duration, and severity of symptoms. The client usually de-
scribes both chest pain that increases with each inspiration
Drainage Chest and difficulty breathing.
Suction
control collection drainage
chambers Objective Data
The client’s color, respiratory rate, and effort are evaluated
Figure 16-4 Underwater seal chest drainage device.
along with the level of consciousness. Abnormalities in vital
signs are noted. Breath sounds over the areas of involvement
or other nonsteroidal anti-inflammatory drugs are often used. are diminished or absent. A pleural friction rub may be au-
Severe pain may require narcotics. For extensive inflammation, dible. Dyspnea, cyanosis, and hypoxia occur in proportion
corticosteroids may be utilized. to the severity of the condition. If a chest tube is in place, the
amount and color of drainage are assessed.
Activity
The client’s activity is limited to prevent fatigue. High-Fowler’s
position assists with chest expansion.
Nursing diagnoses for a client with a pleural effusion include the following:
Acute Pain related to Using a scale of 0 to 10, Administer pain medications as Promotes pain relief and
inflammation of the the client will verbalize a ordered. comfort. Analgesia that also
pleura decrease in the level of decreases inflammation is
pain. preferred.
Assist the client in attaining the Promotes comfort and al-
position that allows for greatest lows for greater ease of res-
comfort. piration and lung expansion.
Elevate the head of the bed. High-Fowler’s position as-
sists with respirations.
Impaired Gas Exchange The client will maintain Monitor vital signs and pulse Monitors for changes in re-
related to compressed an oxygen saturation of oximetry. spiratory status and oxygen
lung 95% or greater and a saturation level.
respiratory rate of 14 to Provide supplemental oxygen as To maintain oxygen satura-
22 breaths/min and will ordered. tion at greater than 95% or
have clear breath sounds. as ordered.
Encourage client to breathe Promotes lung expansion.
deeply or use the incentive spi-
rometer as ordered.
Administer diuretics and anti- Diuretics are used to pro-
inflammatory medications as mote removal of fluid from
ordered. the pleural space.
Collect specimen for C&S and To identify the presence and
other studies as ordered. type of infection.
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Risk for Activity Intoler- The client will increase ac- Stagger periods of activity with To prevent fatigue, plan ac-
ance related to hypoxia tivity without complaining periods of rest. tivities around therapies.
secondary to pleural of fatigue.
effusion
Hygiene/Bathing Self- The client will increase Assist client with hygiene and To prevent client fatigue.
Care Deficit related to self-care activities as mo- self-care needs, but encourage
mobility restriction bility increases. participation in self-care activi-
ties within the limits of the physi-
cian’s orders.
bronchoscopy, needle biopsy, or mediastinoscopy. Lung

NEOPLASMS OF THE scans are occasionally useful for diagnosis. Before initiating
treatment, the client is evaluated for metastatic disease us-
RESPIRATORY TRACT ing bone and total body scans.
N
Family members and significant others often need assis-
eoplasms discussed in this section include benign neo-
tance in coping with their feelings. Provide emotional support
plasms and lung cancer.
and written information about support groups and local com-
munity resources.
■ BENIGN NEOPLASMS
A benign tumor or cyst in the lung has sharply defined

edges, as revealed on an x-ray. Peripheral tumors usually
have no symptoms. Bronchial tumors may cause obstruction,
infection, or atelectasis.
■ LUNG CANCER A B
M alignant tumors (carcinomas) of the lung may origi-

nate within the lung or may result from metastasis
from other tumor sites (e.g., breast, colon, or kidney). Men,
especially those older than 40 years of age, are more likely to
have lung cancer than are women. The number of deaths is
still rising among women, but has reached a plateau for men
(ALA, 2009b). Cigarette smoking is the most important risk
factor for lung cancer. Air pollution and exposure to carcino-
gens such as asbestos are also risk factors, especially among
smokers, for developing lung cancer. Exposure to radiation or
radon is also known to cause lung cancer. Prognosis depends
on the size of the tumor when diagnosed and the specific cell
type (Figure 16-5).
Symptoms develop late in the course of lung cancers.
Peripheral lesions generally have few symptoms. Initially, C D
the client may complain of a chronic cough or wheez-
ing. Central lesions cause obstruction and erosion of the
bronchi. As the tumor grows and occludes the air passages,
the client may experience shortness of breath, dyspnea,

and blood-tinged sputum. Pain occurs relatively late in
the course of the disease and indicates that the tumor has
grown to a significant size to put pressure on adjacent
nerves and other structures. Although some tumors can
be seen on chest x-ray, many cannot. Low-dose helical
CT scans and MRI scans are more reliable studies when Figure 16-5 Lung cancers: A, small-cell carcinoma;
assessing soft-tissue structures. To confirm a diagnosis, B, epidermoid (squamous-cell) carcinoma; C, adenocarcinoma;
cytology studies are performed on specimens collected via D, large-cell (undifferentiated) carcinoma.
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Medical-Surgical Pharmacological
Management The specific type of chemotherapy used depends on the cell
type and the extent of tumor growth.
Medical
Treatment of lung cancer depends on the type and stage of Health Promotion
the cancer.
The foremost method of preventing lung cancer is to avoid smok-
ing or to cease smoking. Avoid the secondhand smoke of others.
Surgical
Surgical intervention involves the removal of the tumor and
adjacent lung tissue. Pneumonectomy is the removal of an Nursing Management
entire lung. Lobectomy is the removal of a lobe of a lung. Review client’s history and gather information about onset
Segmental resection is the removal of a segment of a lung. and severity of symptoms. Assess for pain. Monitor breath
The client will have a thoracotomy tube on the operative sounds, vital signs, and drainage from chest tube. Assist to
side. A laryngeal stoma is a surgically created opening and semi-Fowler’s position or lying on the affected side. Monitor
may be performed if needed. Radiation and chemotherapy ABGs and provide oxygen as indicated. When pain medica-
are often used in conjunction with surgery. The incidence tion is given, monitor for respiratory depression. Aid client
of lung tumor recurrence following surgery is high. Surgery and family to express feelings of grief about diagnosis.
is often indicated for early non–small-cell carcinomas.
NURSING PROCESS
COMMuNITy/HOME HEALTH CARE
Data Collection
Client with Laryngeal Stoma Subjective Data
• Humidify home, especially in winter. Review the client’s history for smoking, exposure to carcino-
• The client and family must know how to suction gens, and other risk factors. Gather information regarding the
the respiratory tract and care for the respiratory onset, duration, and severity of symptoms. The client may re-
port hoarseness, chronic cough, pain, and shortness of breath.
equipment.
Assess pain for location, character, duration, and severity.
• Use warm water to clean around the stoma.
• Do not use tissues, linty cotton, or soap for
cleansing.
Objective Data
• Wear a bib or dressing over the stoma to filter Note the color, amount, consistency, and odor of sputum. Be-
fore surgery, wheezing or decreased breath sounds may be heard
and warm incoming air.
on the affected side. Following surgery, breath sounds are dimin-
• Do not swim or splash water in the stoma when
ished or absent on the affected side. Monitor the amount and
showering or bathing. color of drainage from the thoracotomy tube. Assess the wound
• Notify the physician if any signs of respiratory for hemorrhage and infection. Respiratory rate and effort may
infection develop, such as fever, cough, be increased. Pulse rate may be elevated as a result of a variety
yellow or green mucus, or redness around of factors including decreased oxygenation, hemorrhage, and
the stoma. infection. Hypotension occurs with significant blood loss. High
• Keep follow-up appointments with physician. blood pressure may indicate pain, anxiety, or other underlying
pathology such as essential hypertension.
Nursing diagnoses for a client with lung cancer include the following:
Ineffective Breathing Pat- The client’s respiratory rate Frequently monitor client’s level Detects decreased oxy-
tern related to disease and color will be within of consciousness, vital signs, genation, hemorrhage, and
process normal limits. color, respiratory effort, and infection.
breath sounds.
Assess oxygenation and pro- Necessary for optimal cel-
vide supplemental oxygen as lular function.
indicated.
Stagger activities with periods Prevents overtaxing client’s
of rest. energy reserves.
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Assist client in assuming the Promotes lung expansion
position that maximizes respira- and gas exchange.
tory effort by positioning client in
semi-Fowler’s position or lying
on the affected side.
Monitor lab reports for blood gas Detects changes in pH level
levels. (acidosis/alkalosis) and oxy-
genation status.
Chronic Pain related to The client will state pain is Administer pain medication Provides pain relief. A side
lung cancer decreased on a scale of 0 and monitor for respiratory effect of several narcotics is
to 10. depression. decreased respiratory rate.
Assist client in assuming a posi- Promotes comfort for the
tion of comfort. client.
Anticipatory Grieving The client will be able Aid the client in expressing Assists client through the
related to prognosis and to express to significant feelings of grief related to the stages of grieving and pro-
perceived separation others and staff feelings diagnosis. motes a trusting helping
from significant others related to diagnosis and relationship.
prognosis. Hope should not be eliminated, Establishes a caring relation-
but false hope should not be en- ship with the client that is
couraged. open and honest to facilitate
trust and mutual respect.
Allow the client and family time Demonstrates caring and
to express their feelings. concern for the client.
The hallmark of an asthma attack is sudden onset of sibi-

CHRONIC RESPIRATORY lant wheezing, increasing dyspnea, and chest tightness. Mild
asthma usually is controlled by routine medication. Severe
TRACT DISORDERS asthma attacks usually occur at night and require extra medi-
A sthma, chronic obstructive pulmonary disease (COPD),

chronic bronchitis, emphysema, and bronchiectasis are
discussed in the following sections.
cation. With severe attacks, wheezing may be audible to the
unaided ear. Expiratory wheezes are common as air attempts

■ ASTHMA
Asthma and Age
A sthma is a condition characterized by intermittent
airway obstruction in response to a variety of stimuli.
The epithelial lining of the airways responds by becoming in-
In children:
• Asthma attacks often become less severe and
flamed and edematous. Bronchospasm occurs in the smooth less frequent as the child ages.
muscles of the bronchi and bronchioles. Secretions increase in • Asthma attacks are usually associated with defi-
viscosity. Elastic recoil decreases. All of these changes result in nite allergens.
a reduction of the diameter of the airways, making breathing • Oral bronchodilators should be taken 30 to
more difficult. Some clients who develop asthma in childhood
60 minutes before exercise, inhaled bronchodi-
experience spontaneous recovery.
lators 15 to 20 minutes before exercise.
Asthma is classified as extrinsic or intrinsic. Extrinsic
asthma is caused by substances outside the body that precipi- In adults:
tate the asthma response, such as pollen, house dust, or food • Asthma attacks usually become more severe and
additives. Intrinsic asthma is diagnosed when no extrinsic more frequent as the individual ages.
factor can be identified and the asthma is the result of inter- • Asthma attacks are usually not associated with
nal factors such as emotional stress, exercise, or fatigue. An definite allergens.
asthma attack that does not respond to treatment and persists
is known as status asthmaticus.
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SAFETy MEMORY TRICK

Asthma Asthma
To remember medications used in the treatment
Absence of wheezing during an asthma attack
of asthma, the nurse can use the memory trick
could indicate complete closure of the airway.
ASTHMA.
A = Aminophylline
S = Steroids
to escape through the narrowed airways. Both inspiratory and
expiratory wheezes may be heard. Absence of wheezing could T = Theophylline
indicate complete closure of the airway. The respiratory rate rises H = Histamine
initially, but as the client tires, the rate may decrease. Nasal
flaring and costal and sternal retractions may be present, par- M = Mucolytics
ticularly in the young client. The client uses accessory muscles A = Anticholinergics
to assist respiratory effort. Cough occurs as the respiratory
secretions become thick and block the airways. Cyanosis and
a decrease in oxygen saturation occur. Heart rate elevates, as
may blood pressure. The client becomes anxious and may ipratropium bromide (Atrovent). Corticosteroids such as
complain of a sense of impending doom. These responses are prednisone (Deltasone) are utilized to decrease inflamma-
thought to be caused by a release of catecholamines. Values of tion. Mucolytic agents such as acetylcysteine (Mucomyst) aid
ABGs indicate hypoxia and respiratory acidosis. Chest x-ray in liquefying secretions. Supplemental oxygen is given when
shows hyperinflation of the lungs. Pulmonary function tests indicated.
reveal an abnormal flow rate and lung volume. With a severe
asthma attack, apnea and sudden death can occur in minutes.
Diet
Adequate fluid intake is maintained to promote liquefaction of
Medical-Surgical secretions. Foods, such as dairy products, which contribute to
Management mucous production, should be avoided during or immediately
following an asthma attack. A recent review was conducted
Medical to examine the role of vitamin D in asthma pathogenesis and
The client with allergies should avoid specific antigens that the consequences of vitamin D deficiency. The authors of the
might bring on an attack. Some clients with asthma are aided review hypothesize that vitamin D supplementation may lead
by controlling psychological stressors. Routine physical ex- to improved asthma control (Sandhu & Casale, 2010).
ercise is beneficial in treating exercise-induced asthma. The
client with asthma should avoid other respiratory irritants Activity
such as cigarette smoke and air pollution. Clients who develop Incorporate several rest periods for the client. Use relaxation
asthma later in life show more symptoms as they age. techniques to manage anxiety. The client should not overexert
to the point of dyspnea, wheezing, or fatigue. If overexertion
Pharmacological occurs, the client should sit down and sip warm water. This
The primary treatment for an acute asthma attack is phar- promotes slower, regular breathing and bronchodilation and
macological. A combination of medications is used to open also loosens secretions.
the narrowed airways. Medications used to dilate the bronchi
include bronchodilators such as aminophylline (Aminophyl-
lin) and terbutaline sulfate (Brethine, Bricanyl), beta agonists Nursing Management
such as epinephrine (Primatene Mist) and albuterol sulfate Obtain history about previous asthma attacks. Evaluate
(Ventolin), and anticholinergics such as atropine sulfate and wheezes for location, duration, and phase of respiration when
they occur. Monitor pulse oximetry and ABGs for oxygen-
ation and acid–base balance.
COLLABORATIVECARE COMMuNITy/HOME HEALTH CARE

Assessment and Teaching for Asthma Asthma
Respiratory therapists and nurses work together
• Prohibit smoking in the home, especially if a
in assessing breath sounds and respiratory effort.
child has asthma.
Teaching the client how to use a nebulizer or in-
• Use a humidifier, especially in the bedroom of
halers and aerosol treatment is a collaborative ef-
the person with asthma.
fort of nurses and respiratory therapists.
• Use fans to circulate air.
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NURSING PROCESS Objective Data

Note the effectiveness of ventilation. Wheezes are evaluated as
Data Collection to their duration, location, and the phase of respiration during
which they occur (e.g., inspiration). Wheezes heard without
Subjective Data the aid of a stethoscope are called audible wheezes. Respiratory
A detailed history is taken regarding exposure to triggering rate, depth, rhythm, and effort; position assumed; and client
stimuli before past asthma attacks. Also, the onset, duration, color are evaluated. Monitor pulse oximetry or lab reports of
and severity of symptoms such as dyspnea are noted. ABG values to determine oxygenation and acid–base balance. If
sputum is produced, note its color, amount, viscosity, and odor.
Nursing diagnoses for a client with asthma include the following:

Ineffective Breathing The client will have respi- Assist client in assuming a posi- Promotes lung expansion
Pattern related to nar- ratory rate and color within tion that facilitates ventilation. and gas exchange.
rowed airways normal limits, clear breath Administer medication as or- Promotes bronchodilation
sounds on auscultation, dered. Assist client in the use of and gas exchange.
and ABG or pulse oximetry inhalers and aerosol treatments.
values within normal limits.
Assess oxygenation by ABG or Observes for changes in pH
pulse oximetry values and ad- level and oxygenation status.
minister supplemental oxygen, Necessary for optimal cel-
as ordered. lular function.
Frequently assess respiratory Provides a database from
rate and effort as well as color which the plan of care can
as client’s condition dictates be formulated and against
and auscultate the lung fields for which the effectiveness
presence of wheezes. of treatment is evaluated.
Subsequent assessments
evaluate the effectiveness
of interventions and may
modify the care plan.
If sputum is produced, note its Yellow or green secretions
color, amount, viscosity, and indicate infection. Thick se-
odor. cretions are more difficult to
cough up and may increase
hypoxia.
Frequently assess vital signs as Monitors for changes in cli-
client’s condition dictates. ent’s condition and respira-
tory status.
Unless otherwise contraindi- Promotes liquefaction of re-
cated, encourage fluid intake. spiratory secretions.
Deficient Knowledge The client will verbalize an Teach client and family about Facilitates early recognition
related to asthma, understanding of both the the disease process; the pur- and treatment of asthma.
asthma treatment, and pathophysiology and treat- pose, effect, adverse effects, Prepares the client for side
individual triggers for ment of asthma, including side effects, and use of all pre- effects and knowledge of
asthma attacks the medications taken and scribed medications, especially what to expect. Facilitates
their purposes and side inhalers and respiratory aerosol prompt treatment.
effects. The client will also equipment.
identify individual triggers Assist client in establishing a Facilitates regular and timely
and means of avoiding medication schedule. taking of medications.
these triggers.
Instruct client to use the inhaler Aids in breathing while
prior to meals. eating.
If client is taking steroids, teach Prevents fungal infection from
to rinse mouth after using the occurring in the client’s mouth
inhaler. as a result of taking steroids
by inhaler route.
(Continues)
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Encourage exercise as Exercise increases respira-
tolerated. tory reserve and improves
overall physical condition.
Assist client in identifying trig- To prevent an asthma attack
gering stimuli and ways to avoid from occurring.
them.
Teach client and family signs Facilitates prompt
and symptoms of asthma at- treatment.
tacks and respiratory tract
infections.
Teach client to avoid crowded To prevent contracting a re-
areas and close contact with spiratory infection.
persons with infections.
Anxiety related to per- The client will verbalize a Provide client with explanations Knowledge and understand-
ceived threat of dying decrease in anxiety. for all care. ing of care being provided
may decrease client’s
anxiety.
Provide care in a calm, unhurried Demonstrates caring, aids
manner. in decreasing anxiety, and
gives client time to ask
questions.
Plan care to allow client uninter- To avoid overwhelming the
rupted periods of rest. client with stimuli and re-
lieves fatigue.
Allow client to make decisions Promotes client’s involve-
regarding care, if possible. ment and self-control over
own care.
Provide client with opportuni- Facilitates open communica-
ties to discuss anxiety with staff, tion and a therapeutic help-
family, or significant others. ing relationship. Provides
client an opportunity to iden-
tify causes of anxiety and
determine effective coping
strategies.
■ CHRONIC OBSTRUCTIVE ■ CHRONIC BRONCHITIS

PULMONARY DISEASE
C hronic obstructive pulmonary disease (COPD), also

called chronic obstructive lung disease (COLD), is a
B ronchitis is an inflammation of the bronchial tree accom-
panied by hypersecretion of mucus. The condition be-
comes chronic if cough and sputum are present on most days
term used for two closely related respiratory diseases: chronic for 3 months a year for 2 consecutive years or for 6 months
bronchitis and emphysema. These two diseases often occur in 1 year (ALA, 2010b). Constant irritation of the bronchi
together. Most clients have a long history of heavy cigarette results in hypertrophy of the mucous-secreting glands. The
smoking (National Heart Lung and Blood Institute, 2009a). bronchioles fill with exudate, and subsequent infections are
First signs are chronic cough, sputum production, or short- common. There may be narrowing of large and small airways.
ness of breath. It gradually gets worse over time. There is no Environmental factors, especially cigarette smoke, play an im-
known cure. In the United States, about 12 million adults portant role in the development of chronic bronchitis.
have COPD. It is the fourth leading cause of death. In 2010, The client usually has a history of recurrent respiratory
the national cost for COPD was approximately $49.9 billion infections, dyspnea, cyanosis, and chronic or recurrent cough
(ALA, 2010b). yielding copious amounts of sputum. Often, the sputum is
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88021_ch16_ptg01_346_374.indd 366 12/29/11 1:38 PM
purulent or green in color. Over the course of time, the chest required on a long-term basis, they may be given by inhala-
wall configuration becomes slightly distended. Coarse crackles tion to prevent some adverse systemic effects. Mucolytic
are present throughout the lung fields. Breath sounds may medications such as acetylcysteine (Mucomyst) are given to
be diminished or absent over the periphery of the lung fields. reduce the viscosity of purulent and nonpurulent pulmonary
Elevation of pulmonary artery pressure results in increased secretions. Guaifenesin (Robitussin, Naldecon Senior EX,
workload for the right ventricle and in signs and symptoms Mucinex) are expectorants given to loosen phlegm and thin
of right-sided heart failure (HF), such as peripheral edema bronchial secretions. If infection occurs, broad-spectrum anti-
and fatigue. Arterial blood gases reveal increased PaCO2 and biotics are given. Immunization against influenza viruses and
decreased PaO2. The red blood cell count elevates, as do Streptococcus pneumoniae is recommended.
hemoglobin and hematocrit. The increases in the amounts of The client with chronic bronchitis who also has HF will
red blood cells and hemoglobin represent an attempt by the receive medications to aid the function of the weakened heart.
body to compensate for the lower oxygen level. Chest x-ray Digoxin (Lanoxin) strengthens the force of the contraction of
shows hyperexpansion of the lungs. When HF occurs, the the heart muscle. Diuretics such as furosemide (Lasix) are given
chest x-ray also shows an enlarged heart. to remove fluid by increasing urinary output. Supplemental po-
tassium chloride (K-Dur, Kay-Ciel elixir) is given if the client’s
Medical-Surgical potassium level decreases from effect of the diuretic.
Management Diet
Medical Encourage the client to eat a well-balanced diet. If the client
The goals of medical treatment are to decrease symptoms also has HF, sodium intake is restricted. Unless contraindi-
of airway irritation, decrease airway obstruction related to cated, fluids are encouraged. Offer small, frequent meals to
secretions and inflammation, prevent infection, maintain clients experiencing shortness of breath.
oxygenation, and increase the client’s exercise tolerance. Re-
spiratory therapy includes the use of updraft (nebulizer) and Activity
aerosol treatments, along with percussion and postural drain-
age. Humidification of inspired air helps liquefy secretions. Activity is restricted to decrease the workload on the heart and
Supplemental oxygen is administered based on ABG or pulse lungs. With acute exacerbations, the client is placed on bed
oximetry values. The neurological stimulus to breathe be- rest. The level of activity is then slowly increased based on the
comes altered in some clients with chronic bronchitis so that client’s tolerance.
breathing is initiated when the blood level of oxygen falls in- Programs of breathing exercises and graded (easy to
stead of when the level of carbon dioxide rises. Consequently, difficult) exercise regimens assist the client to achieve the
when the level of oxygen in the blood is relatively high in maximum level of activity tolerance. Breath-retaining exer-
relation to the level of carbon dioxide, the stimulus to breathe cises such as coughing techniques, pursed-lip breathing, and
is reduced and further depresses the central nervous system diaphragmatic or abdominal breathing are taught. The client
(CNS). When supplemental oxygen (e.g., venturi mask) is is monitored from a respiratory standpoint while exercising.
necessary, it is maintained at the lowest possible flow rate to The goal is to increase the client’s capacity for all ADLs.
maintain oxygenation and prevent depression of the client’s
respiratory drive. Evaluate the client with chronic bronchitis Nursing Management
and HF for signs of fluid overload. Daily weight, intake, and Obtain history of onset, duration, and severity of symptoms.
output are monitored. Note changes in level of consciousness, mental status, respi-
ratory rate and effort, color, and use of accessory muscles.
Pharmacological Obtain sputum specimen for C&S. Monitor vital signs. Assess
Current medications used include beta-adrenergic agonists, for signs of right-sided heart failure including weight gain,
cholinergic antagonists, methylxanthines, corticosteroids, peripheral edema, and neck vein distention.
cromolyn sodium/nedocromil, and leukotriene modifiers.
Bronchodilators such as theophylline (Theo-Dur) given
orally, and ipratropium bromide (Atrovent) given as an in- NURSING PROCESS
halation aerosol (metered-dose inhaler [MDI]) or inhalation
solution (nebulizer), are used to open airways. Tiotropium Data Collection
bromide (Spiriva) is a once-daily inhalation powder adminis- Subjective Data
tered using a HandiHaler device. Salmeterol (Serevent), given
by a dry powder inhaler (DPI), is a long-acting beta2-selective A thorough past medical history is obtained, including infor-
agonist used for chronic maintenance therapy. Inhalation mation about the onset, duration, and severity of symptoms.
aerosol (MDI) or inhalation solution (nebulizer) treatments The client may describe fatigue and difficult breathing.
with bronchodilators such as albuterol (Proventil, Ventolin)
or metaproterenol sulfate (Alupent) are often used in con- Objective Data
junction with oral medications. Note changes in level of consciousness or mental status, color,
Prednisone (Meticorten), a corticosteroid, is given as respiratory rate and effort, the position the client assumes
short-term therapy for acute exacerbations. If steroids are to aid respiratory effort, and the use of accessory muscles.
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Review ABGs or pulse oximetry values. Auscultate lung signs. The pulse may be elevated and irregular. Blood pressure
fields for crackles and diminished breath sounds. Note color, may be elevated or low. An elevated temperature may indicate
amount, viscosity, and odor of sputum. Obtain specimens for infection. Assess for peripheral edema, neck vein distention,
culture and sensitivity, if indicated. Frequently measure vital and rapid weight gain.
Nursing diagnoses for a client with chronic bronchitis include the following:
Ineffective Airway Clear- The client’s color, respira- Frequently assess level of con- Establishes baseline and
ance related to thicker tory rate, and ABG values sciousness, mental status, vital monitors client for changes
and increased amounts will be within normal limits. signs, respiratory effort, and color, in health status.
of respiratory secretions and auscultate breath sounds at
least every 4 hours.
Obtain sputum specimens as Yellow or green secretions
ordered, and assess sputum for indicate infection. Thick se-
amount, viscosity, color, and cretions are more difficult to
odor. cough up and may increase
hypoxia.
Assist client in assuming the Promotes lung expansion.
position that most aids respira-
tory effort, usually an upright
position.
Administer oxygen and respira- To maintain oxygen satura-
tory treatments as ordered and tion at greater than 95% or
assess their effectiveness. as ordered. Necessary for
optimal cellular function.
Evaluate results of diagnostic Evaluates oxygenation and
and laboratory tests (ABGs) acid–base balance.
and notify the physician of
abnormalities.
Alternate care with periods of Reduces the workload on
uninterrupted rest. the heart and lungs and pre-
vents client fatigue.
Administer antibiotics and Facilitates bronchodilation,
bronchodilators as ordered and treats infection, and pro-
evaluate their effectiveness. motes client comfort.
Provide client with a well-bal- Provides necessary nutrition
anced diet and, unless otherwise for metabolic needs, main-
contraindicated, encourage tains optimal fluid balance,
fluids. and decreases the viscosity
of secretions.
Assess client for signs and Promotes early identification
symptoms of HF (i.e., fine crack- and prompt treatment.
les heard on auscultation, pe-
ripheral edema, weight gain, and
fatigue).
Report any signs and symptoms Promotes prompt treatment
of HF to the physician. of this serious condition.
Deficient Knowledge re- The client will verbalize Teach client to avoid respiratory Use of these health promo-
lated to chronic bronchi- signs and symptoms to infections, maintain adequate tion strategies helps prevent
tis and its treatment and report to the physician, nutrition, increase fluid intake, respiratory infections and
prevention safety precautions to and obtain adequate rest; the promote necessary care and
take with medication and purpose, expected effects, and treatment of chronic bron-
equipment, medication side effects of medications; and chitis.
and respiratory treatment to administer respiratory treat-
regimen, and techniques ments and medications prior to
for facilitating breathing. eating to aid in breathing.
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Instruct client to rinse mouth fol- Prevents fungal infection
lowing use of inhaler. from developing in client’s
mouth.
Teach client to self-administer Facilitates correct adminis-
oxygen. tration of oxygen.
Provide information regard- Promotes correct and safe
ing both the use of equipment use of equipment.
and safety measures for the
equipment.
Refer client to an established re- Provides client informa-
spiratory rehabilitation program. tion to make an informed
If such a program is not avail- decision regarding their
able, instruct client in breathing care. Promotes respiratory
techniques. rehabilitation.
Encourage regular exercise Exercise increases respira-
within the client’s limitations. tory reserve and improves
overall physical condition.
Encourage client to obtain im- Use of this health preven-
munization against influenza tion strategy helps decrease
viruses and Streptococcus client’s risk of respiratory
pneumoniae. infections.
The extra effort required to breathe increases metabolic

■ EMPHYSEMA need, resulting in weight loss. Chest x-ray reveals hyperin-
flated lung tissue and a flattened diaphragm, which has been
E mphysema is a complex and destructive lung disease wherein
air accumulates in the tissues of the lungs. The airways lose
their elasticity and the walls thicken, resulting in narrower lumens.
displaced by distended lung tissues. Pulmonary function stud-
ies reveal a decrease in expiratory volume. Polycythemia and
elevation of hemoglobin and hematocrit occur in response to
Airflow is impeded as it leaves the lungs (i.e., during expiration). prolonged hypoxia.
The alveoli distal to these airways become overdistended with
trapped air (Figure 16-6). Rupture of the alveolar wall may occur. Increased Trachea
The alveolar capillary membrane is destroyed, resulting in a loss thoracic midline Prolonged
of available area for gas exchange. Cigarette smoking is the most volume
breath
common cause of emphysema. Deficiency in alpha1-antitrypsin is sounds
a familial disorder that leads to the development of emphysema.
Trapped
Alpha1-antitrypsin is an enzyme that inhibits the activity of the air
enzyme elastase, which breaks down lung tissue.
Emphysema develops slowly over a period of years. The
earliest symptom is a daily morning cough with clear sputum.
Later, the client notes increasing dyspnea in response to ac-
tivity. The degree of dyspnea corresponds to the degree of
hypoxia, which is usually mild at rest but becomes increasingly
severe in response to activity. In advanced stages of the dis-
ease, hypoxia is evident even at rest. With infection, a cough
yielding purulent sputum occurs. The client’s complexion
appears ruddy, or reddish in color. The chest becomes barrel
shaped (Figure 16-7) as the chest cage enlarges to accommo-
date distended lung tissues. The respiratory rate elevates. The
expiratory phase of respiration becomes increasingly difficult.

Accessory muscles are used to aid respiratory effort. Because Flattened
of destruction of the alveoli, bronchial breath sounds are diaphragm Normal
heard in the periphery of the lungs. As the disease progresses, placement of
breath sounds diminish and eventually disappear over the pe- diaphragm
riphery of the lungs. Arterial blood gases reveal the degree of
hypoxia depending on the severity of the disease. Figure 16-6 Emphysema.
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A B
Skin Color/Cyanosis

x
• For a client with highly pigmented skin, estab-
x
lish a baseline skin color.
2x x • Observe skin surfaces that have the least
amount of pigmentation, such as the palms, the
1:2 ratio 1:1 ratio
soles of the feet, the abdomen, mucous mem-
Figure 16-7 Changes in chest configuration and posture: branes, or the inner aspect of forearms.
A, The normal ratio of the anterior posterior diameter to the
lateral diameter is 1:2. B, With a barrel chest, the ratio between
the diameters is 1:1.
Activity
Medical-Surgical Level of activity is increased based on the client’s oxygenation.
Management Oxygen saturation is evaluated periodically as the activity level
is increased to determine the effect of activity on oxygenation.
Medical
The goals of treatment are to prevent further damage to the Health Promotion
lung tissues, maintain adequate oxygenation, prevent infec-
tion, and improve the client’s activity tolerance. The client The client with emphysema benefits from a respiratory reha-
who smokes should stop or, at least, decrease the number bilitation program. The client is taught breathing exercises
of cigarettes smoked daily. Supplemental oxygen is given to similar to those taught to the client with chronic bronchitis.
maintain oxygenation. The client with advanced emphysema A graded exercise program is also used for the client with em-
and severe, chronic hypoxia may be maintained at PaO2 of physema. Group programs that aid in smoking cessation are
55 to 59 mm Hg or oxygen saturation of 90% or greater. As useful for the client who smokes.
with chronic bronchitis, the client with emphysema is given
supplemental oxygen at the lowest possible flow rate, usually Nursing Management
1 to 2 L/min, to prevent respiratory and CNS depression. Review factors that increase client’s dyspnea and those that
relieve dyspnea. Evaluate client’s nutritional status, vital signs,
Pharmacological ABGs, pulse oximetry, color, and level of consciousness. Assist
The client with emphysema receives many of the same medi- with ADLs. Plan for uninterrupted periods of rest.
cations used to treat chronic bronchitis. To open airways that
have become fibrotic, theophylline and similar preparations NURSING PROCESS
are used. Steroids may be required for exacerbations. The
client with emphysema usually does not need mucolytic
agents, unless infection is present. Antibiotics are used to treat
Data Collection
and prevent respiratory tract infections. The client should Subjective Data
receive immunizations against influenza and Streptococcus Included in the history is information regarding the timing of
pneumoniae. The client who smokes may use nicotine gum or dyspnea, those factors that exacerbate dyspnea, and those fac-
transdermal patches to aid in smoking cessation. tors that relieve dyspnea.
Diet Objective Data

The client with emphysema requires a proper combination Assess sputum for color, amount, viscosity, odor, and vital
of nutrients to supply the energy necessary for breathing. signs. An elevated pulse may indicate hypoxia or infection.
Because the client uses muscle tissue to provide energy, a diet Auscultation of the lungs will reveal the presence of adventi-
high in protein is ordered. According to Grodner, Long, and tious, diminished, or absent breath sounds. Note the client’s
Walkingshaw (2007), adequate, but not excessive, amounts of position to aid respiratory effort, color, respiratory rate and
protein stimulate the respiratory drive. Dietary supplements effort, and use of accessory muscles to aid breathing. Evaluate
such as Ensure may be needed to supply the necessary calo- the client’s nutritional status by weighing the client and mea-
ries and nutrients. Unless contraindicated, fluids and small suring nutrient and caloric intake. Review results of laboratory
frequent meals are encouraged. and diagnostic tests.
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88021_ch16_ptg01_346_374.indd 370 12/29/11 1:38 PM
Nursing diagnoses for a client with emphysema include the following:

Impaired Gas Exchange The client’s respiratory Assess the client’s level of con- Monitors for oxygenation
related to destruction of rate, color, and ABG val- sciousness and mental status. changes that affect mental
the alveoli ues will be within normal status.
limits. Frequently evaluate client’s Establishes baseline and
respiratory rate, respiratory ef- monitors client for changes
fort, color, and oxygenation with in health status. Evaluates
ABGs or pulse oximetry. oxygenation and acid–base
balance.
Assess the effect of activity on Activity promotes lung ex-
oxygenation, particularly when pansion and increases oxy-
activity is being increased and gen demands.
provide supplemental oxygen as
ordered.
Auscultate the lungs and report Adventitious breath sounds
abnormalities to the physician. may indicate infection.
Assess client’s vital signs. Heart rate and temperature
elevations may indicate in-
fection, an elevated pulse
may indicate hypoxia.
Review results of diagnostic Evaluates oxygenation and
and laboratory tests and report acid–base balance.
abnormalities.
Administer medications and re- Facilitates bronchodilation,
spiratory treatments as ordered. treats infection, and pro-
motes client comfort.
Assist client in assuming the Promotes lung expansion.
position that offers the most
comfort and most aids respira-
tory effort.
Instruct client in breathing Breathing techniques con-
techniques, such as pursed-lip trol shortness of breath by
breathing. keeping airways open longer
and decreasing the work of
breathing.
Risk for Activity Intoler- The client will complete Assist client with ADL and hy- Prevents overtaxing client’s
ance related to hypoxia activity without experienc- giene needs. energy reserves.
ing fatigue or dyspnea. Plan care and treatments to allow Reduces the workload on
client uninterrupted periods of the heart and lungs and pre-
rest. Allow rest before and after vents client fatigue.
meals. As activity increases, as-
sess the effects on oxygenation.
Imbalanced Nutrition: The client will achieve or Assess client’s weight and Evaluates if client’s weight
Less than Body Re- maintain a weight within evaluate in relation to the client’s and height are within normal
quirements related to normal limits for height. height and age. parameters for age. Estab-
increased energy relishes a baseline.
quirements to maintain Evaluate client’s diet for nutri- Assesses client’s prefer-
respiration tional adequacy and review cli- ences to promote dietary
ent’s food likes and dislikes. intake.
(Continues)
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Provide a well-balanced diet Promotes nutritional ad-
based on client’s likes and dis- equacy to provide energy
likes. requirements to maintain
respiration.
Provide nutritional supplements To meet nutritional
as ordered. requirements.
Avoid activities or procedures Certain procedures prior to
prior to meals that might reduce meals can reduce appetite
appetite (e.g., enemas). and decrease food intake.
Administer medications and Aids in breathing.
respiratory treatments prior to
meals.
HF, cardiomegaly. Respiratory flow rate decreases, and lung

■ BRONCHIECTASIS volume increases, as demonstrated by pulmonary function
studies. Table 16-3 compares asthma, chronic bronchitis, em-
B ronchiectasis is chronic dilation of the bronchi. The
main causes of this disorder are pulmonary TB infection,
physema, and bronchiectasis.
chronic upper respiratory tract infections, and complications
of other respiratory disorders of childhood, particularly cys- Medical-Surgical
tic fibrosis. The bronchi become distended and eventually Management
lose their elastic recoil property. The mucociliary blanket’s
function is impaired, and secretions thicken. Secretions ac- Medical
cumulate in the bronchi, resulting in a medium for infection. Medical treatment is aimed at removing respiratory secre-
Airflow is hindered, reducing gas exchange. tions, preventing or eliminating infection, and maintaining
The client with bronchiectasis describes a frequent or adequate oxygenation. Percussion and postural drainage are
chronic productive cough, dyspnea, weight loss, and fatigue. used to aid in the removal of secretions. Aerosol and updraft
Sputum is thick and sometimes purulent when infection is respiratory treatments may be ordered before percussion
present. Crackles, which clear on coughing, are heard scat- and drainage. If the client is unable to expectorate secre-
tered throughout the lungs and are more prominent early in tions, bronchial suctioning is performed. The physician per-
the morning. Accessory muscles are used to aid respiration. forms a bronchoscopy to remove especially tenacious and
Over a period of time, right-sided HF and peripheral edema copious secretions. Arterial blood gases or pulse oximetry
develop. ABGs reveal elevated PaCO2 , decreased PaO2 , values are evaluated to assess the need for supplemental
and respiratory acidosis. Polycythemia and elevated hemo- oxygen. Daily weight and I&O are performed to detect signs
globin and hematocrit levels are present. Chest x-ray shows of HF. Pulmonary function studies evaluate the severity of
slight hyperinflation of lung tissue and, in the presence of lung damage.
BESTPRACTICE
Cystic Fibrosis
Cystic fibrosis (CF) is an inherited life-threatening disorder that causes severe lung damage and nutritional defi-
ciencies. Improvements in the treatment of CF have increased the life expectancy of a client with CF from 10 years
of age in 1962 to 37 years of age in 2009 (National Institutes of Health, 2009a). Treatment for CF is aimed at re-
lieving symptoms and complications. New antibiotics such as inhaled tobramycin sulfate (TOBI) are more effective
in treating infections, and other drugs, such as dornase alfa recombinant (Pulmozyme) and azithromycin (Zithro-
max, Zmax), slow the progression of the lung disease. Mechanical chest physical therapy devices used daily, such
as electric chest clappers and inflatable vibrating vests, help loosen and remove thick mucus from the lungs. Lung
transplantation may be an option for clients with severe lung damage. Respiratory failure is the most danger-
ous consequence of CF (Mayo Clinic, 2009). For more information about CF visit the Cystic Fibrosis Foundation at
http://www.cff.org.
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Table 16-3 signs and symptoms of asthma, Chronic Bronchitis,

emphysema, and Bronchiectasis
CHRoNiC
asTHma BRoNCHiTis emPHYsema BRoNCHieCTasis
History Intermittent attacks Recurrent respiratory Insidious onset, dyspnea Cystic fibrosis,
of dyspnea and infections, chronic on exertion to dyspnea recurrent respiratory
wheezing cough at rest infections, TB
Cough Present during attack Chronic or recurrent Present with infections Frequent or chronic
productive cough productive cough
Sputum Thick Copious, Clear, scanty mucoid, Thick, tenacious,
mucopurulent, green unless infection present sometimes purulent
secretions
Weight No weight loss Slight or no weight loss Weight loss common Commonly, weight
loss or failure to gain
Appearance Flushed then Commonly cyanosis Ruddy complexion Clubbing of fingernails
cyanotic (“blue bloater”) (“pink puffer”)
Chest Slight overdistention Slight overdistention Overdistention Slight overdistention
Configuration prominent (“barrel
chest”)
Breath Sounds Audible wheezing Coarse crackles Bronchial breath sounds Crackles
Prolonged expiration in peripheral lung fields
Diminished or absent
breath sounds in late
disease
Edema Infrequent Peripheral edema Infrequent Peripheral edema in
common, especially in late disease
ankles
Right-sided HF Infrequent Frequent Infrequent Frequent late in
(Cor Pulmonale) disease
CO Retention Sometimes Common Unlikely Common in late
(Hypercapnia) disease
Hypoxemia Depends on severity Possibly severe Usually mild, especially Possibly severe in
of attack at rest late disease and with
infection
Dyspnea Increases during Progressive Dyspnea on exertion to With respiratory
attack dyspnea at rest infection and late
disease
Accessory Yes Yes Yes Yes
Muscles Used
for Respiration
Polycythemia Uncommon Late in disease Yes In late disease

Respiratory Possible Common Possible Common
Failure
Pharmacological such as prednisone (Meticorten) or by inhalation with beclo-

Mucolytic agents are given to promote liquefaction of respira- methasone dipropionate (Beclovent). The client with cystic
tory secretions. Antibiotics are ordered to treat and prevent fibrosis is required to take pancreatic enzymes, pancrelipase
infection. The client is immunized against influenza and (Pancrease capsules, Cotazym capsules), to replace those
against Streptococcus pneumoniae with a pneumococcal vac- that are missing with this disorder. If HF occurs, the client
cine (Pneumovax 23). Bronchodilators are indicated to open is treated with digoxin (Lanoxin), furosemide (Lasix), and
the fibrotic airways. Inflammation is treated with oral steroids potassium supplements, as indicated.
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88021_ch16_ptg01_346_374.indd 373 12/29/11 1:38 PM
CaSE STUDy
COPD
P.W. is a 77-year-old woman with a history of smoking two to three packs of cigarettes per day for the past
60 years. P.W. has been diagnosed with COPD for the past 4 years. She has required supplemental oxygen
at 2 L/min for the past 18 months. Three days ago, P.W. was admitted with chief complaints of increasing
dyspnea on exertion and a productive cough yielding thick, green-yellow sputum. She states that she does
“not know why she is coughing up this awful stuff.”
Physical examination of P.W. this morning revealed vital signs of T = 101.5°F, P = 124 beats/min,
R = 38 breaths/min, BP = 168/74 mm Hg, and sonorous and sibilant wheezes on expiration and in the
posterior lung fields, with superimposed coarse crackles heard in the right posterior lower lung field. She is
unable to ambulate to the bathroom or complete other ADLs because of the dyspnea. Chest x-ray showed
a large area of consolidation in the right lower lobe. Sputum culture is still pending.
The following questions will guide your development of a nursing care plan for the case study.
1. List the clinical manifestations that indicate P.W. is experiencing an infection concomitant with her
COPD.
2. Explain why COPD predisposes a client to respiratory infection.
3. Explain why the physician will increase P.W.’s oxygen flow to 3 to 4 L/min.
4. List the subjective and objective data the nurse should obtain during the nursing assessment.
5. Identify three nursing diagnoses and client goals that would be pertinent to P.W.’s care.
6. List the above diagnoses in order of priority, with number one being the highest.
7. Describe client outcomes indicating that P.W.’s treatment and nursing care regimen have been
successful.
Cr it iCa l t HiNKiNG Activity is progressively increased depending on the client’s

tolerance. Respiratory rehabilitation and graded exercise pro-
grams are useful in the treatment of bronchiectasis. Regular
COPD Disorders exercise is encouraged, particularly for the pediatric client
with cystic fibrosis.
What are the differences and the similarities

among the two disorders classified as COPD? Nursing Management
Review client’s history for recent and past respiratory infections,
TB, and cystic fibrosis. Monitor vital signs. An increased heart
rate may indicate hypoxia or infection, and an elevated tem-
perature may indicate infection. Note weight loss and muscle
Diet wasting. Monitor breath sounds and suction mucus as necessary.
To provide energy for breathing, the diet should be high in
carbohydrates and calories. Protein is supplemented if nec-
essary. Dietary supplements such as Ensure may be needed. CONCLUSION
Fluids are encouraged, unless otherwise contraindicated. So- Lower respiratory tract conditions such as pneumonia, tuber-
dium is restricted in the diet of the client with HF to prevent culosis, pleurisy, cancer, and asthma can be serious and life
fluid retention. The diet for the client with cystic fibrosis is threatening. Prompt nursing interventions may be necessary
restricted in fats because fats are not properly absorbed. to maintain and promote the client’s respiratory function.
Chronic respiratory disorders such as COPD, bronchitis, em-
Activity physema, and bronchiectasis require the nurse to be knowl-
During acute exacerbations or in the presence of serious edgeable about the condition and proper treatment to provide
infection, activity is limited. The client is placed on bed rest. safe and effective client care.
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88021_ch16_ptg01_346_374.indd 374 12/29/11 1:38 PM
CHAPTer 17
Caring for Clients with Acute
Respiratory Disorders
Key Terms
anticoagulation cyanosis orthopnea
atelectasis
LeArNING OBJeCTIVes
2. Describe the signs and symptoms of acute respiratory system disorders.
3. Discuss medical and surgical management for clients with acute respiratory disorders.
4. Describe nursing interventions in caring for clients with acute respiratory disorders.
5. Assist in developing a nursing care plan for a client with an acute respiratory disorder.
375
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88021_ch17_ptg01_375_392.indd 375 12/28/11 11:23 PM
collapsed areas. Chest wall movement may decrease on the

INTRODUCTION affected side. Oxygenation decreases as shown by ABGs or
Acute respiratory conditions can be serious and life threaten- pulse oximetry. Pulse and respiratory rate increase as the
ing. Prompt nursing interventions may be necessary to main- heart and lungs work harder to meet the body’s oxygen needs.
tain and promote the client’s respiratory function. Nurses Trapped secretions are a growth medium for microorgan-
need to be knowledgeable about acute respiratory disorders isms. An elevated temperature indicates secondary infection
and proper treatment to provide safe and effective client care. (pneumonia). Chest x-ray shows the areas of collapse. Bron-
choscopy (insertion of a bronchoscope into the trachea) is
used to directly visualize the area of obstruction, remove the
ACUTE RESPIRATORY obstruction if possible, or obtain a specimen for diagnostic
purposes.
TRACT DISORDERS
A cute respiratory tract disorders include atelectasis, pul-

monary embolism (PE), acute pulmonary edema, acute
respiratory distress syndrome (ARDS), severe acute respira-
Medical-Surgical
Management
tory syndrome (SARS), and acute respiratory failure. Medical
The physician orders incentive spirometry and deep-breathing
■ ATELECTASIS and coughing exercises to promote expansion of the lungs.
A
Postural drainage and percussion aid in the removal of any
telectasis refers to the collapse of a lung or a portion of static secretions. If the client is unable to cough up secretions,
a lung. The most common cause of atelectasis is airway suctioning of the respiratory tract is performed. Bronchoscopy
obstruction. A bronchiole becomes blocked with secretions, may be done to remove secretions and obtain specimens. Ar-
and the alveoli distal to it collapse (Figure 17-1). Airway terial blood gases and pulse oximetry are utilized to evaluate
obstruction of this nature is common after surgery and with the need for supplemental oxygen. Oxygen is administered to
immobility problems. Anesthesia, pain, narcotics, and immo- maintain an oxygen saturation of 95% or greater.
bility can cause hypoventilation and retention of secretions.
Hypoventilation can cause atelectasis, which increases hy-
poventilation. Atelectasis can occur with compression of lung Surgical
tissue, as in pleural effusion or pneumothorax. Insufficient Clients with pneumothorax or pleural effusion as the underly-
surfactant results in increased recoil properties of the lungs, ing cause of atelectasis require removal of trapped air or fluid
leading to atelectasis. via thoracentesis or placement of a thoracotomy tube (refer
Signs of respiratory distress are proportional to the to the sections on pleural effusion and pneumothorax). Atel-
amount of lung tissue involved. When large areas of the lung ectasis resulting from the growth of a tumor requires removal
are involved, orthopnea (difficulty breathing when lying of the tumor.
down) or cyanosis (bluish discoloration of the skin and
mucous membranes observed in lips, nail beds, and earlobes) Pharmacological
may develop. Breath sounds are diminished or absent over
Adequate pain control aids the client, particularly the surgical
client, to breathe deeply and cough. Client-controlled analge-
Ipsilateral sia or a routine schedule of pain medication may be used to
mediastinal shift
Obstruction provide effective pain management. Bronchodilators may be
(secretions or tumor) used to open the airways. Mucolytic agents are used to liquefy
Lung not secretions. Bronchodilators, such as albuterol sulfate (Vento-
totally lin), and mucolytics, such as acetylcysteine (Mucomyst), may
inflated also be administered via updraft or nebulizer treatments. The
Breath client with an infection requires treatment with an appropriate
sounds antibiotic.
decreased
Diet
Unless otherwise contraindicated, fluids are encouraged to
promote liquefaction of trapped respiratory secretions.
Activity
Activity promotes lung expansion. Immobile clients are

turned a minimum of every 2 hours and assisted to do range-
of-motion exercises. Surgical clients may do leg exercises as
well as deep breathing and coughing. Ambulation is recom-
mended if the client’s condition allows. If the client is unable
to walk, sitting up in a chair is encouraged. To prevent fatigue,
Figure 17-1 Atelectasis (collapsed lung). rest periods are planned between activities.
DESIGN SERVICES OF
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CHAPTER 17 Caring for Clients with Acute Respiratory Disorders 377
Nursing Management The client is asked about the onset, duration, and severity of
symptoms such as pain, cough, and dyspnea. The client may
Monitor for pain, shortness of breath, fatigue, dyspnea, cya- verbalize or show signs of air hunger, shortness of breath,
nosis, anxiety, and level of consciousness. Assess for Homans’ fatigue, and anxiety.
sign. Teach client how to cough, deep breathe, and use the
incentive spirometer. Encourage ambulation as the client’s Objective Data
condition allows. Turn immobile clients at least every 2 hours.
Assess the client for changes in level of consciousness, an
early sign of decreased oxygenation. Periodically evaluate for
dyspnea, tachypnea, cyanosis, and restlessness. Measure vital
NURSING PROCESS signs frequently, with particular attention to respiratory rate
and effort. Auscultation reveals diminished or absent breath
Data Collection sounds over the areas of atelectasis. Crackles or sonorous
wheezes may be heard if pneumonia develops. Note objective
Subjective Data indicators of pain such as facial grimacing, and validate by
Clients who smoke, those who are immunocompromised, subjective questioning. Assess the effectiveness of the client’s
and those who have known chronic respiratory or cardiovas- cough. A productive cough is evaluated for amount, color,
cular diseases are at increased risk of developing atelectasis. consistency, and odor of secretions.
Nursing diagnoses for a client with atelectasis include the following:

NuRsiNg PlANNiNg/ NuRsiNg
DiAgNoses outComes iNteRveNtioNs RAtioNAle
Impaired Gas Exchange The client will have an oxy- Establish a schedule for cough- Promotes expansion of the
related to decreased gen saturation of 95% or ing and deep breathing. lungs.
alveolar-capillary surface greater, a respiratory rate Encourage client to ambulate Activity promotes lung
of 14 to 22 breaths/min, and/or sit up in a chair three to expansion.
and clear breath sounds. four times daily.
Turn the immobile client every Facilitates drainage, prevents
2 hrs or more frequently. pooling of secretions, and
promotes lung expansion.
Assess client’s vital signs and Establishes baseline and
breath sounds every 4 hrs or monitors client for changes
more frequently as situation in health status.
warrants.
Encourage fluids if client’s con- Maintains optimal fluid bal-
dition allows. ance and decreases the vis-
cosity of secretions.
Administer respiratory treat- Facilitates bronchodilation,
ments and medications as treats infection, and pro-
ordered. motes client comfort.
Assess secretions (sputum) for Yellow or green secretions
color, amount, consistency, and indicate infection. Thick se-
odor. cretions are more difficult to
cough up and may increase
hypoxia.
Risk for Activity Intoler- The client will complete Encourage some activity, such Promotes lung expansion
ance related to hypoxia activity without complaints as walking, and alternate with and avoids client fatigue.
secondary to atelectasis of shortness of breath, periods of rest.
dyspnea, or fatigue. Provide assistance with ADLs as To decrease the work of
client’s condition requires. breathing and avoid client
fatigue.
Place client in a high- or semi- To aid lung expansion.
Fowler’s position.
Position client on the unaffected Facilitates drainage of secre-
side. tions to prevent infection
and complications.
(Continues)
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88021_ch17_ptg01_375_392.indd 377 12/28/11 11:23 PM

Deficient Knowledge The client will verbalize the Teach all preoperative and im- Promotes lung expansion
related to the complica- purpose of deep breath- mobile clients to cough and and ensures that learning
tions of surgery and/or ing, coughing, and activity breathe deeply at least ev- has occurred.
immobility following surgery, and will ery 2 hrs and have the client
demonstrate deep breath- demonstrate.
ing and coughing. Teach the surgical client to Minimizes discomfort that
splint the surgical incision when might occur with coughing
coughing and deep breathing. and deep breathing.
Instruct clients in the use of in- Decreases risk for develop-
centive spirometry. ing atelectasis in surgical or
immobile client. Promotes
lung expansion.
Emphasize the importance of Promotes lung expansion.
early ambulation and activity.
■ PULMONARY EMBOLISM Medical-Surgical

Management
P ulmonary embolism (PE) develops when a bloodborne
substance lodges in a branch of a pulmonary artery and
obstructs flow. A common source of PE is deep vein thrombo-
Medical
Preventive measures are instituted for the client at risk of
sis (DVT). Other sources are air from intravenous infusions, developing DVT. Following surgery, antiembolism stock-
fat from long-bone fractures, and amniotic fluid. The size and ings, sequential compression devices (SCDs), intermittent
location of the emboli determine the severity and outcome of pneumatic compression devices (e.g., PlexiPulse), and early
the condition. ambulation are indicated. When hypoxia occurs, supplemen-
Pulmonary emboli rarely develop before adulthood. As tal oxygen is given to increase oxygenation. The underlying
age increases, the risk for pulmonary embolism becomes cause of the PE is treated when identified.
greater because of the development of arteriosclerosis and
other vascular changes associated with aging. Other factors Surgical
increasing the risk for PE are heredity, smoking, peripheral
In severe cases, the physician may remove the clot via an em-
vascular disease, diabetes mellitus, and oral contraceptive use.
bolectomy. This procedure is usually done at the time of an-
Emboli interfere with gas exchange to the pulmonary
giography. Clients who experience successive episodes of PE
circulation distal to the emboli, resulting in hypoxemia. The
may require a vena caval plication or filter. This surgical pro-
client describes breathlessness and dyspnea. Pulse oximetry
cedure involves placing a sieve-like device in the inferior vena
or ABGs will show the degree to which oxygenation has
cava to catch emboli before they enter pulmonary circulation
been affected. Obstruction of a main branch of a pulmonary
(National Heart Lung and Blood Institute [NHLBI], 2009b).
artery can result in lung infarction, necrosis, and may even
lead to death.
All clients at risk for PE are observed for signs and symp- Pharmacological
toms of DVT, such as localized calf tenderness or swelling. The client at risk of developing DVT or PE may be treated
Measures to prevent thrombus formation are taken for these with enoxaparin (Lovenox). Lovenox is often used in the
individuals. Any signs of thrombophlebitis are immediately postoperative client to prevent clot formation. After PE has
reported to the physician. developed, anticoagulation (the prevention of coagulation
Signs and symptoms of PE are abrupt in onset. The cli- by use of medication) is ordered to prevent the formation
ent becomes anxious and restless. Sudden, sharp chest pains of further clots. Heparin sodium is initially used to establish
or back pain of a pleuritic nature (worse on inspiration) anticoagulation and is administered parenterally by either
develops. Dyspnea and cough, along with hemoptysis, oc- the intravenous or subcutaneous route. After adequate anti-
cur. Venous return is diminished, resulting in jugular venous coagulation has been established, warfarin sodium (Couma-
distention. The client becomes diaphoretic. A low-grade fever din) therapy is initiated and may be given concurrently with
develops in response to inflammation. A high temperature heparin while the client is hospitalized until Coumadin level
indicates lung infarction. Diagnosis of PE is often done by is therapeutic. Coumadin alone is given orally when the client
a ventilation/perfusion lung scan, but the gold standard is is discharged. If the clot is large or lies in a branch of a main
pulmonary angiography. Arterial blood gases show hypoxia pulmonary artery, fibrinolytic therapy may be used. Fibrino-
and respiratory alkalosis. A spiral CT scan of the lungs may be lytics lyse, or dissolve, the clot versus inhibiting the formation
ordered, and can be performed within a few seconds. of new clots. Examples of fibrinolytic agents are alteplase
DESIGN SERVICES OF
88021_ch17_ptg01_375_392.indd 378 12/28/11 11:23 PM
CLIENTTEaChINg
CLIENT TEACHING 17-1
Activity
To prevent the formation of clots, activity is encouraged. After
Anticoagulant Therapy (Coumadin) a clot has formed, however, the client’s activity is restricted
to prevent the clot from moving and becoming an embolus.
Stress the importance of: Activities such as sitting, crossing the knees, or prolonged
• Follow-up laboratory testing bending at the hips are to be avoided because they promote
• Using a soft toothbrush to prevent trauma to venous stasis.
the gums (bleeding)
• Inspecting the skin for bruises or petechiae
• Using an electric razor to avoid scratching skin
Nursing Management
• Reporting nosebleeds, tarry stool, hematuria, or
Assess the abrupt onset of pleuritic chest pain for location,
duration, severity, and character. Assess lung sounds, monitor
hematemesis to the physician
pulse oximetry, vital signs, jugular veins for distention, periph-
• Eating a consistent amount of green, leafy veg- eral pulses, and capillary refill. Encourage deep breathing and
etables daily (differing amounts alter anticoagu- provide supplemental oxygen as ordered. Monitor results of
lant effects) activated partial thromboplastin time (APTT), International
• Avoiding other medications including aspirin (it Normalized Ratio (INR), prothrombin time (PT), hemoglo-
has an anticoagulant effect) without approval bin, and hematocrit. Do not massage site if DVT has occurred.
from physician
• In the female client, monitor menstrual flow for
excessive amount NURSING PROCESS
Data Collection
LIFE SPAN CONSIDERATIONS Subjective Data
The client’s history is obtained to identify potential risk fac-
tors for the development of PE. Ask the client about the on-
Older Adults at Risk set, duration, and severity of symptoms. Shortness of breath,
for Pulmonary Embolism dyspnea, and severe pleuritic chest pain are abrupt in onset.
The risk of developing a pulmonary embolism in- Pain is evaluated as to onset, location, duration, severity, and
creases with age. For each 10 years after age 60, character.
the risk of developing a pulmonary embolism dou-
bles (NHLBI, 2009c). Objective Data
Pulse oximetry measurements are monitored. The client’s res-
pirations may become rapid and shallow. Pallor progressing to
cyanosis develops as oxygenation decreases. The client may
recombinant (Activase) and streptokinase (Streptase). These become diaphoretic. Increased anxiety or a change in level
agents may be administered intra-arterially at the site of the of consciousness may be the first indication of PE. The pulse
clot or intravenously to achieve a systemic effect. Narcotic increases in response to anxiety and in an attempt to supply
analgesics such as morphine are used to control pain. oxygen to the body’s cells. Blood pressure may increase or de-
crease in response to hypoxia, anxiety, and pain. Temperature
Diet may elevate in response to inflammation and tissue necrosis.
Unless contraindicated, fluids are encouraged to prevent he- On auscultation, breath sounds may or may not be decreased.
moconcentration leading to clot formation. The jugular veins may be distended.
Nursing diagnoses for a client with pulmonary embolism include the following:
Impaired Gas Exchange The client will maintain Assess client for indications of Promotes early identification
related to alteration in an oxygen saturation of decreasing oxygenation. and treatment.
pulmonary circulation 95% or greater, have a Auscultate breath sounds every Adventitious breath sounds
respiratory rate of 14 to 4 hrs or more often as condition may indicate infection.
22 breaths/min, and have warrants.
color within normal limits.
Assess peripheral pulses and Promotes early identification
capillary refill. of impaired oxygenation.
(Continues)
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88021_ch17_ptg01_375_392.indd 379 12/28/11 11:23 PM

Encourage deep breathing and Facilitates expansion of the
coughing. lungs.
Provide supplemental oxygen as To maintain oxygen satura-
ordered. tion at greater than 95% or
as ordered.
Administer anticoagulants To prevent clot formation.
(Heparin, Lovenox, Coumadin)
as ordered.
Encourage fluids, unless To prevent
contraindicated. hemoconcentration.
Acute Pain related to de- Using a scale of 0 to 10, Administer pain medication as To control pain and promote
creased perfusion of lung the client will indicate de- ordered and monitor for relief. client comfort.
tissue creased pain. Assist client in assuming a posi- Promotes client comfort.
tion of comfort.
If possible, place client in a high- To aid respiratory effort.
Fowler’s position.
Risk for Injury related The client will be free of Assess for evidence of bleeding. Indicates bleeding or hemor-
to anticoagulation/ abnormal bleeding and rhage resulting from antico-
fibrinolytic therapy maintain hemoglobin and agulant therapy.
hematocrit within normal Monitor lab reports for APTT, Evaluates the effectiveness
limits. INR, PT, decrease in platelet of anticoagulant/fibrinolytic
count, and hemoglobin and he- therapy.
matocrit levels.
Evaluate blood pressure and Rapid pulse and low blood
pulse for signs of bleeding. pressure can be signs of
bleeding.
Check stool for occult blood. As- Monitors for bleeding that
sess gums for bleeding. may occur secondary to an-
ticoagulant therapy.
fluid overload, inhalation of noxious gases, opiate overdose,

■ PULMONARY EDEMA aspiration, sepsis, or radiation injury.
The hallmark of acute pulmonary edema is a cough
A cute pulmonary edema is a life-threatening condition
characterized by a rapid shift of fluid from plasma into
the pulmonary interstitial tissue and the alveoli (Figure 17-2).
producing a copious amount of frothy, blood-tinged sputum
(hemoptysis), often appearing pinkish. The client rapidly
becomes dyspneic, orthopneic, and cyanotic. Anxiety ranging
As a result, gas exchange is markedly impaired. Pulmonary from restlessness to panic occurs. Heart and respiratory rate
edema generally has a cardiac cause such as left ventricular increase. Progressive crackles are heard in the lung fields on
failure or myocardial infarction, or a noncardiac cause such as auscultation. Initially, fine crackles are present in the poste-
rior bases of the lung. As pulmonary edema progresses, the
Extravascular crackles become increasingly coarser, louder, and more dif-
accumulation
of fluid in the
fuse. Wheezes are heard in the presence of significant airway
pulmonary obstruction by fluid. Left untreated, the client deteriorates
tissues and rapidly as oxygenation decreases. The client’s history is crucial
air spaces
to identify the cause. Noncardiogenic pulmonary edema can
quickly become respiratory failure.
Medical-Surgical
Management
Medical
The goals of medical management are to remove fluid from
Figure 17-2 Pulmonary edema. the alveoli and pulmonary interstitial space, prevent further
DESIGN SERVICES OF
88021_ch17_ptg01_375_392.indd 380 12/28/11 11:23 PM
influx of fluid, improve oxygenation, and decrease workload to the physician’s orders and the client’s ability to tolerate
of the left ventricle. Arterial blood gases and pulse oximetry activity.
values are used to assess oxygenation. Oxygen is administered
per physician’s order when hypoxia is present. Noncardio-
genic pulmonary edema often requires ventilation support
Nursing Management
and treatment of the cause. Monitor ABGs and pulse oximetry and administer oxygen as
ordered. Assess breath sounds, vital signs, and level of con-
sciousness. Keep client in high-Fowler’s position. Keep an
Pharmacological accurate intake and output record. Monitor client’s weight
A diuretic such as furosemide (Lasix) is administered for daily.
cardiogenic pulmonary edema. When the pumping force of
the left ventricle is impaired, a digitalis preparation is given
to improve the contractile force of the myocardium. To pre- NURSING PROCESS
vent further influx of fluid into the lungs, venous pooling is
enhanced. This also decreases the workload on the heart by Data Collection
limiting venous return. Nitroprusside (Nipride) is commonly Subjective Data
ordered to treat pulmonary edema. Morphine is used to pro-
mote vasodilation and, thus, increase venous pooling and to The nurse must be aware of the conditions that predispose the
relieve anxiety. Bronchodilators are administered to dilate client to pulmonary edema. The client may describe feeling
airways obstructed with fluid. anxious, breathless, and fatigued.
Diet Objective Data

Auscultate breath sounds for the presence of crackles. Report
A sodium-restricted diet may be ordered to prevent fluid
increasingly coarse and diffuse crackles to the physician. As-
retention. Intake and output as well as daily weight are mea-
sess the client’s level of consciousness, respiratory rate and
sured to monitor fluid balance.
effort, and color. Dyspnea, tachypnea, cyanosis, and/or pal-
lor may be present. Assess oxygenation via pulse oximetry or
Activity ABGs. A productive cough may be present, as may symptoms
Bed rest reduces the workload on the heart and lungs. of HF, such as rapid weight gain and peripheral edema. Pulse
High-Fowler’s position enhances chest expansion to aid may be rapid and weak. Blood pressure may increase in re-
respiratory effort. Activities are increased slowly according sponse to anxiety and decreased oxygenation.
Nursing diagnoses for a client with pulmonary edema include the following:
Impaired Gas Exchange The client will have an Provide adequate oxygenation To maintain necessary oxy-
related to pulmonary cap- oxygen saturation of 95% and ventilation as ordered. gen saturation levels for gas
illary membrane damage or greater, ABGs within exchange.
normal limits, and respira- Monitor ABGs and pulse oxim- Evaluates oxygenation and
tory rate and effort within etry results. acid–base balance.
normal limits.
Assess the client’s respiratory Monitors for changes in re-
rate and effort and auscultate spiratory function.
the lungs frequently.
Suction the respiratory tract as Removes excess secretions
necessary and provide oral care and promotes oral hygiene.
frequently.
Anxiety related to dif- The client, if able, will ver- Describe care and purposes to Knowledge and understand-
ficulty breathing and me- balize a decrease in anxiety the client. ing of care being provided
chanical ventilation or will exhibit fewer objec- may decrease client’s
tive signs of anxiety, such anxiety.
as restlessness and facial Allow rest periods between peri- To avoid overwhelming the
grimacing. ods of activity. client with stimuli. To prevent
fatigue and promote balance
between activity and rest.
Plan care to allow for uninter- Minimizes overstimulating
rupted rest. the client and provides rest.
(Continues)
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88021_ch17_ptg01_375_392.indd 381 12/28/11 11:23 PM

Allow family and significant oth- Support persons may facili-
ers to visit and participate in tate a calm relaxing environ-
care, as appropriate. ment for the client.
Assess client for signs of sen- Promotes early intervention
sory overload/deprivation. to decrease anxiety.
CONCEPT MAP 17-1 PROGRESSION OF PULMONARY EDEMA

Second Third
Restlessness Course crackles
Anxiety Wheeze
Panic Airway obstructed O F
st
Fir Heart rate ↑ by fluid Re xyge inal
Respiratory rate ↑ s
Lif pi a n
ic e r t
ne ic th ator ion
y sp pne tum Fine crackles re ↓
D tho ic s pu at y fa
r t en ilu
O ano with ing re
Cy ugh y
Co roth sh ged
F ki tin
Pin od–
Blo

and sonorous wheezes. The client may have a productive cough
■ ACUTE RESPIRATORY yielding blood-tinged sputum. Chest x-ray shows widely scat-
DISTRESS SYNDROME tered infiltrates, often referred to as a “white-out.”
A cute respiratory distress syndrome (ARDS; formerly

called adult respiratory distress syndrome) is a life-
threatening condition characterized by severe dyspnea,
Medical-Surgical
Management
hypoxemia, and diffuse pulmonary edema. The condition Medical
usually follows a major assault on multiple body systems or
severe lung trauma. Underlying causes include trauma, sepsis, The client with ARDS is cared for in the intensive care unit. The
coronary artery bypass surgery, major thoracic or vascular underlying cause of ARDS is ascertained and treated; until that
surgery, renal failure, severe pulmonary infections, inhalation time, supportive care is given. Mechanical ventilatory support
lung injuries, and acute drug poisoning. ARDS is a noncar- is necessary, with multiple other systems often also being sup-
diogenic pulmonary edema, caused by damage to the alveolar ported. A mechanical ventilator allows the oxygen percentage,
capillary membrane that allows fluid to leak into the lungs pulmonary pressure, and lung volume to be controlled. Oxygen-
under normal pressure. ation is monitored with ABGs and pulse oximetry. Respiratory
Gas exchange is severely impaired by the damage to the secretions are removed by frequent bronchial suctioning.
pulmonary capillary membrane and the presence of fluid in
the alveoli. The surfactant is rendered inactive, resulting in Pharmacological
the collapse of the alveoli, further reducing gas exchange. Hy- Pharmacological therapy includes high doses of corticoste-
poxemia, resistant to conventional oxygen therapy, develops. roids such as hydrocortisone sodium succinate (Solu-Cortef)
The client with ARDS is critically ill, as reflected by severe or methylprednisolone sodium succinate (Solu-Medrol). Fu-
dyspnea, tachypnea, and cyanosis. Arterial blood gases will rosemide (Lasix) and other diuretics are given to remove
show PaO2 <70 mm Hg, PaCO2 >35 mm Hg, bicarbonate ion fluids and increase urinary output. Aminophylline (Amino-
<22 mEq/L, and initially elevated then steadily decreasing pH. phyllin) is administered to open the bronchi. While the client
The ABGs and pulse oximetry reveal severe hypoxemia and is on the mechanical ventilator, pancuronium bromide (Pa-
progressive respiratory and metabolic acidosis. On ausculta- vulon) is given to suppress the client’s own respiratory effort.
tion, the lung fields may be filled with diffuse coarse crackles Blood pressure can fall dangerously low, and vasopressors
DESIGN SERVICES OF
88021_ch17_ptg01_375_392.indd 382 12/28/11 11:23 PM
such as dopamine hydrochloride (Intropin) may be required

to maintain the blood pressure within an acceptable range. NURSING PROCESS
Diet Data Collection
Total parenteral nutrition (TPN) may be given to the client, Subjective Data
especially during the acute phase of the illness. When possible, The client history is typically gathered from family members
enteral feedings are preferred. or significant others because the client is usually too ill to
communicate.
Activity
The client with ARDS will be on bed rest. Special beds that Objective Data
provide movement and pressure adjustment prevent the The client’s level of consciousness and response to stimuli
complications associated with immobility. According to the are assessed, and the client is observed for restlessness and
ARDS Support Center (2009a), prone positioning improves anxiety. Vital signs are measured every 15 minutes or more
oxygenation and may prevent further lung damage. often. Heart rate is increased, and arrhythmias may be pres-
ent. Blood pressure is usually low. Respiratory rate, rhythm,
and effort are assessed for signs of dyspnea, nasal flaring,
Nursing Management cyanosis, tachypnea, and other indications of respiratory
Monitor client’s level of consciousness, response to stimuli, distress. Arterial blood gases and pulse oximetry values are
vital signs, ABGs, pulse oximetry, and breath sounds. Suction assessed to evaluate oxygenation and acid–base balance. Dif-
excess secretions. Provide frequent oral care. Plan for uninter- fuse, coarse crackles and wheezes are heard throughout the
rupted rest periods. Assess for restlessness and anxiety. lung fields.
Nursing diagnoses for a client with ARDs include the following:

Impaired Gas Exchange The client will maintain an Place client in high-Fowler’s or Promotes lung expansion to
related to fluid in the lung oxygen saturation of 95% orthopneic position (sitting up- ease breathing.
tissue or greater and will have right leaning forward).
respiratory rate, color, and Continually assess oxygenation Monitors for adequate levels
blood gases within normal with ABG or pulse oximetry of oxygenation.
limits and clear breath measurements and provide
sounds. supplemental oxygen to maintain
an oxygen saturation of 95% or
greater or per physician’s order.
Frequently assess respiratory Monitors for changes in re-
rate, breath sounds, apical heart spiratory function.
rate, and blood pressure.
Administer respiratory treat- Promotes bronchodilation to
ments as ordered. improve ventilation.
Assist client with activities and Reduces the workload on
alternate periods of activity with the heart and lungs and pre-
periods of rest. vents client fatigue.
Excess Fluid Volume The client’s weight will re- Weigh client daily. One of the main indicators of
related to altered tissue turn to normal. fluid and electrolyte balance
permeability is an increase or decrease in
weight.
Monitor I&O. Monitors the client’s fluid
status.
Frequently assess the client for Edema is a main symptom
peripheral edema. of fluid volume excess.
Provide client with a low-sodium Sodium is the main electro-
diet as ordered. lyte that promotes the reten-
tion of water.
Administer diuretics per order The use of diuretics can place
and evaluate their effectiveness. the client at risk for hypokale-
mia and metabolic alkalosis.
(Continues)
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Monitor lab reports for electro- The slightest decrease or
lyte values. increase in electrolyte levels
can cause serious, adverse,
or life-threatening effects on
physiological functions.
Monitor the rate at which intra- Clients receiving IV therapy
venous fluids are given. require constant monitoring
for complications.
Teach client and family symp- Facilitates early recognition,
toms of fluid excess, medica- treatment, and prevention of
tion information, and dietary excess fluid volume.
modifications.
with preexisting pulmonary conditions coupled with acute

■ SEVERE ACUTE RESPIRATORY respiratory tract infections are at risk for developing acute
SYNDROME respiratory failure.
S evere acute respiratory syndrome (SARS) is a viral respi-

ratory illness with flu-like symptoms that is caused by the CHEST TRAUMA
P
SARS associated coronavirus (SARS-CoV). It was identified
in China in late 2002, and first reported in Asia in February neumothorax/hemothorax is discussed following.
2003 (Centers for Disease Control and Prevention [CDC],
2008). A total of 8,098 people became sick with SARS, and
773 died worldwide during the outbreak (CDC, 2005a). ■ PNEUMOTHORAX/
SARS spread worldwide over several months before the out-
break ended (National Institutes of Health, 2009c).
HEMOTHORAX
It appears that SARS spreads by close personal contact or
contact with infectious material (respiratory secretions). This
happens when a client with SARS coughs or sneezes droplets
N ormally, the pleural space between the visceral and pa-
rietal pleura contains pleural fluid and is held together
by surface tension. The pleural space is a closed compart-
onto themselves, others, or nearby surfaces. ment with a negative pressure compared to the lungs or the
The incubation period is generally 2 to 7 days. Then an atmosphere. When the integrity of the pleura is interrupted,
elevated temperature of >100.4°F (38°C) occurs and may be air from the atmosphere or from the lungs moves between the
associated with chills, headache, malaise, body aches, respi- pleura, creating a space. This air in the pleural space is known
ratory symptoms, pneumonia, and even respiratory failure. as a pneumothorax (Figure 17-3). The lung tissue underlying
After 2 to 7 days, clients may develop a dry, nonproductive the pneumothorax is compressed and unable to fully expand.
cough and dyspnea. If the pneumothorax is large enough, the entire lung may col-
There is no specific treatment for SARS. Support treat- lapse from the compression.
ment is provided based on the symptoms. A pneumothorax may be referred to as traumatic (closed
or open), spontaneous, tension, or a hemopneumothorax. A
Nursing Management closed pneumothorax occurs when there is no communica-
tion between the pleura and the external environment. An
Follow Standard Precautions (hand hygiene and eye protec- example of a closed pneumothorax is when blunt trauma to
tion), Contact Precautions (gown and gloves), and Airborne the chest causes a broken rib that pierces the pleura and lung,
Precautions (isolation room with negative pressure and allowing air to enter between the pleura. An open pneumo-
use of N-95 respirators). Monitor client’s vital signs. Assess thorax exists when there is direct communication between
breath sounds. Provide routine care with uninterrupted rest the external environment and the pleural space as in a gun-
periods. shot wound. A spontaneous pneumothorax occurs without
an obvious underlying cause. A tension pneumothorax is a
■ ACUTE RESPIRATORY FAILURE life-threatening condition wherein air enters the pleural space
on inspiration but is unable to exit on expiration. The air thus
A cute respiratory failure is not a disease entity in and

of itself; rather, the term is used to refer to conditions
wherein there is a failure of the respiratory system as a whole.
continues to accumulate in the pleural space, compressing the
underlying structures. If left untreated, a tension pneumotho-
rax collapses the lung and encroaches on the structures on
This condition occurs as a result of the client literally becom- the opposite side. The structures of the mediastinum shift to
ing too tired to continue the “work” of breathing. Mechanical the unaffected side as more and more air accumulates in the
ventilatory support is required during the acute phase. Clients pleural space. Without intervention, tension pneumothorax
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Contralateral Cr it iCa l t HiNKiNG

mediastinal shift
No breath
sounds Chest Tubes
1. Describe the difference between pressure
B
within healthy lungs and the environment.
2. Based on your description, what would the
client experience if there were an open
connection between the lungs and the
A environment?
3. What behaviors would your client present
Air
with?
4. What treatments would you likely see

initiated?
(Courtesy Patti Altman, RN, MSN, Archbold, Ohio, 2011)
Figure 17-3 Pneumothorax: A, penetrating wound; line and the fourth intercostal space. The thoracotomy tube
B, ruptured bleb on the lung. is connected to an underwater seal drainage device. The
underlying cause of the hemopneumothorax then must be
treated.
will result in cardiopulmonary arrest. Tension pneumothorax A recurrent spontaneous pneumothorax may require
is often associated with mechanical ventilation. The pressure a pleural decortication to prevent further episodes. This
exerted by the ventilator on compromised lung tissue inter- involves roughing the adjacent surfaces of the visceral and
rupts the integrity of the pleura. Air continues to enter the parietal pleura so the resulting scar tissue will improve adhe-
pleural space but is unable to exit as mechanical ventilation sion between the two surfaces. Emergency treatment for a
continues. In the case of a pneumothorax associated with tension pneumothorax that is severely compromising the
trauma or surgery, bleeding of adjacent vessels into the pleural function of the heart and lungs involves placing a large-bore
cavity often occurs. Blood within the pleural space is referred needle into the anterior chest at the fourth intercostal space.
to as a hemothorax. When accompanied by air, the condition A thoracotomy tube is then inserted until the lung(s) are fully
is called a hemopneumothorax. reexpanded and to prevent a recurrence.
The severity of injury and the amount of lung tissue af-
fected determine the signs and symptoms the client exhibits.
The client with a small pneumothorax may be asymptomatic Pharmacological
or may complain of minor dyspnea, whereas the client with a To control pleuritic pain, narcotic analgesics such as mor-
significant pneumothorax may exhibit signs of severe respira- phine sulfate or meperidine (Demerol) are prescribed. Anal-
tory distress. Dyspnea, tachypnea, orthopnea, and cyanosis gesics may be given orally or parenterally depending on the
may be present. Oxygenation is impaired. Pleuritic pain is severity of the pain. Before insertion of a thoracotomy tube,
common. Breath sounds are absent in the area of the pneumo- intravenous narcotics may be given prophylactically. Tissues
thorax. The client with an accompanying hemothorax exhibits adjacent to the area of the pneumothorax are injected with lo-
signs and symptoms of shock associated with blood loss. cal anesthetics before insertion of a thoracotomy tube.
Diet
Medical-Surgical A well-balanced diet with sufficient amounts of protein is
Management encouraged for healing. The client with other injuries and
conditions may require total parenteral nutrition or enteral
Medical feedings.
For the affected lung to reexpand, the air and/or blood must
be removed from the pleural space. When the blood loss Activity
associated with a hemothorax is significant, fluid and blood
replacement may be necessary. If hypoxia is present, activity restrictions are necessary. The pres-
ence of other injuries or conditions may also necessitate activity
restrictions. After the client is adequately oxygenated and stable,
Surgical activity is encouraged to promote expansion of the lungs.
A thoracotomy tube, or chest tube, is inserted by the physi-
cian into the pleural space to drain fluid and air and allow the
lung to reexpand. The tube is placed in the midaxillary line at Nursing Management
approximately the fifth intercostal space. To drain air alone, Gather information about recent chest injuries or falls. Assess
the tube is placed in the anterior chest at the midclavicular level of consciousness, mental status, color, respiratory effort,
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and chest wall movement. Monitor vital signs. Auscultate for Objective Data
breath sounds. When a chest tube is in place, assess function,
patency, and amount and character of drainage. Assess the client’s level of consciousness and mental sta-
tus and the client’s color, respiratory effort, and chest wall
movement. Chest wall movement is decreased on the af-
fected side. When a large pneumothorax is present, the
NURSING PROCESS trachea shifts toward the unaffected side. Dyspnea and
cyanosis may occur. The cough is forceful and nonproduc-
Data Collection tive. Respiratory rate and heart rate are elevated. Blood pres-
sure may be elevated because of the presence of pain and
Subjective Data anxiety or may be low because of blood loss. Breath sounds
Gather information about the source of the pneumothorax. are diminished or absent over the affected areas. Note the
Ask the client about previous pneumothoraces, recent chest location, duration, and severity of pain. When a chest tube
injury, falls, and severe coughing. The client often describes is inserted, assess for function, patency, and amount and
being very anxious. character of drainage.
Nursing diagnoses for a client with a pneumothorax include the following:

Ineffective Breathing Pat- The client’s respiratory rate Monitor the amount and char- To assess and monitor blood
tern related to decreased and color will be within acter of drainage from the chest loss.
lung expansion normal limits, and the cli- tube and note chest tube drain-
ent will have clear breath age as output.
sounds in affected area. Observe fluctuations (tidaling) in Indicates that the tube is in
the water seal chamber. the pleural space.
Investigate the absence of This may indicate that the
tidaling. lung is fully reexpanded or
that the tube is occluded or
kinked.
Observe for bubbling in the wa- Bubbling in the water seal
ter seal chamber. chamber indicates an air
leak.
Assess the connections and To determine if leaks are
chest tube. present.
Encourage client to cough and Prevents further respiratory
deep breathe. complications such as atel-
ectasis and infection.
Acute Pain related to The client will verbalize Assist client in assuming the po- Most clients find this to be
pleural space irritation a decrease in pain on a sition that most aids respiration. the orthopneic position.
scale of 0 to 10. Assess vital signs and respira- Pulse and blood pressure
tory status. may increase when a client
is experiencing pain.
Administer pain medications as To provide pain relief and
ordered. Remember that respira- promote comfort.
tory depression is possible with
narcotic medications.
CONCLUSION respiratory distress syndrome (ARDS), severe acute respira-

Acute respiratory disorders can be serious and life threat- tory syndrome (SARS), acute respiratory failure, pneumo-
ening. This chapter presented an overview of atelectasis, thorax, and hemothorax. Acute respiratory conditions require
pulmonary embolism (PE), acute pulmonary edema, acute prompt nursing interventions.
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u Nit Su MMa r Y
• The primary function of the respiratory system is delivery • Acute viral rhinitis (common cold) is a viral upper respira-
of oxygen to the lungs and removal of carbon dioxide from tory infection that is highly contagious.
the lungs. • Influenza (the flu) is a common contagious respiratory
• The function of the upper respiratory system is to warm or illness that spreads from person to person in respiratory
cool, filter, and humidify outside air. droplets of coughs and sneezes.
• The function of the lower respiratory system is to transmit • Clinical manifestations of tonsillitis include recurrent sore
air, resulting in exchange of oxygen and carbon dioxide at throat; enlarged, bright-red tonsils; mouth breathing;
the alveolar level. halitosis; nasal speech; fever; difficulty swallowing; and
• History taking is an important part of physical assessment snoring.
and should include client and family history. • Obstructions of the nose, paranasal sinuses, and pharynx
• The nurse inspects the client for skeletal abnormalities, include polyps and foreign bodies.
rate and rhythm of breathing, and clubbing. • Pneumonia is a lung infection wherein infectious secre-
• Palpation includes assessment for tracheal deviation, respi- tions accumulate in the air passages and interfere with gas
ratory excursion, and fremitus. exchange. Clients with chronic pulmonary disorders or
• Percussion is performed to assess the density of the under- problems of immobility are at increased risk of developing
lying tissue. pneumonia.
• Auscultation is the act of listening through a stethoscope • Pulmonary TB is an infection of the lung tissue caused by
in order to assess breath sounds, adventitious sounds, and Mycobacterium tuberculosis. Treatment of TB requires the
voice sounds. long-term administration of pharmacological agents.
• Laboratory tests of the respiratory system include blood • Chronic obstructive pulmonary disease is a collective term
gas sampling and sputum studies. used to refer to chronic bronchitis and emphysema, which
often occur together.
• Diagnostic tests for the respiratory system include labora-
tory, radiologic, angiographic, thorascopic, bronchoscopic, • A common respiratory tract disorder associated with im-
computerized tomography, nuclear imaging scans, and mobility and the administration of anesthetic agents is
pulmonary function testing. atelectasis. Clients at risk are encouraged to cough and
breathe deeply to aid in preventing atelectasis.
• A deviated septum is when the cartilage that separates
the nostrils is misaligned, resulting in partial airway • Obstruction of a pulmonary artery by a bloodborne
obstruction. substance is known as pulmonary embolism. Deep vein
thrombosis is a common cause of pulmonary emboli.
• The most common disorder of the nose is epistaxis
(nosebleed). • Traumatic disorders of the respiratory tract include pneu-
mothorax and hemothorax, wherein the underlying lung
• Laryngitis is associated with factors such as pollution, tissue is compressed and eventually collapses.
smoking, and excessive use of the voice.
• Cigarette smoking is indicated as a major causative factor
• Allergic rhinitis is a common allergy in our society caused in the development of respiratory disorders, such as lung
by airborne allergens such as pollen, mold, animal dander, cancer, cancer of the larynx, emphysema, and chronic
dust, and ragweed. bronchitis.
t Heo r Y t o Pr a Ct iCe
Read the following unfolding case study and answer the questions.
Chest Injury
J.C., a 19-year-old male, is transported to the emergency department following a
motorcycle–car accident. He was wearing a helmet and a cervical collar is in place.
He is having difficulty breathing, complains of chest pain, and is drowsy. Initial orders
include the following: stat CXR and draw ABGs, CBC, and electrolytes and apply
oxygen. The first set of vital signs you obtain are BP 146/82, AP 120, and R 36.
1. What other assessments need to be completed at this time?
2. What is the priority intervention focus?
Chest x-ray reveals multiple rib fractures and a tension pneumothorax on the left side.
ABG results: pH 7.31, PaCO2 54, HCO3– 24, PaO2 66. Lab results; Hgb 13, Hct 39,
WBC 15,000, and K+ 3.8.
3. What behaviors would you expect to find with rib fractures? What concerns are associated
with multiple rib fractures?
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4. What behaviors would you expect to find with a tension pneumothorax?

5. What changes might you see in his vital signs?
He has a chest tube placed. You are to attach the chest tube to a water seal drainage
system.
6. What are your responsibilities as a nurse with chest tube insertion?
7. What is the purpose of suction with chest tubes?
8. What does bubbling in the water seal compartment indicate when J.C. coughs?
9. Should the nurse strip the chest tube? Explain your answer.
10. What would you do if the chest tube were accidentally pulled out while you are at the
bedside?
11. If a client who has an 80% pneumothorax has a chest tube inserted, would you expect to see
his lung expand immediately?
The next morning, J.C. develops hemoptysis, crackles, and wheezing.
12. Discuss what may be happening to J.C.
13. What would contribute to this condition?
14. What diagnostic tests are used to establish the diagnosis of acute respiratory distress
syndrome?
15. What treatment recommendations would be made for a client with ARDS?
A diagnosis of ARDS is confirmed. A pulmonary artery catheter is inserted and J.C. is
intubated and placed on a mechanical ventilator.
ABGs are repeated 30 minutes after being placed on the ventilator:
pH 7.33, PaCO2 60, PaO2 56, HCO3– 27.
16. What do you anticipate the treatment plan will include?
17. What are the expected nursing interventions in the care of a client who is on a ventilator,
based on evidenced-based practice?
(Courtesy of Patti Altman, RN, MSN, Archbold, OH, 2011.)
NCl eX-St Yl e r ev iew Qu eSt io NS

1. The physician orders 2 to 3 L/min of oxygen to be 3. The nurse is teaching a client about lung cancer.
delivered to the client with COPD because: Which statement best demonstrates the client
1. no client ever requires more than 2 to 3 L/min of correctly understands the risk factors for lung
oxygen. cancer?
2. the client requests it. 1. “I work with asbestos every day and it is safe
3. a higher flow rate may suppress the client’s drive now.”
to breathe. 2. “Having asthma does not make me more at risk
4. 2 to 3 L/min is the maximum flow that a nasal for getting lung cancer.”
cannula can effectively deliver. 3. “I should stop chewing tobacco and drinking
2. A particulate respirator mask is used by the nurse alcohol.”
caring for a client with TB because: 4. “My wife smokes and I do not, so I do not have to
1. regular masks allow the tubercle bacilli to pass worry.”
through. 4. A client with severe epistaxis arrives at an urgent
2. this mask is more comfortable for long-term use. care clinic. When assessing this client, the nurse’s
3. this type of mask allows the nurse to be in close initial action should be to:
contact with the client for prolonged periods of 1. identify the cause of the bleeding.
time. 2. stop the bleeding.
4. there is no need for this type of mask when caring 3. assess for a patent airway.
for clients with TB. 4. teach the client how to prevent recurrence.
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5. The nurse’s assessment of a client with pulmonary 10. A client informs the nurse that she is not sure how
edema indicates the following: thick frothy sputum, to use her incentive spirometer. The most appropri-
cough, and dyspnea. On the basis of these findings, ate response from the nurse would be:
the most appropriate nursing diagnosis is: 1. “The incentive spirometer measures the amount
1. Ineffective Airway Clearance. of air inspired in one inhalation.”
2. Activity Intolerance. 2. “The incentive spirometer is a device that a client
3. Altered Tissue Perfusion. will use after surgery.”
4. Acute Pain. 3. “Would this be a good time for me to teach you
6. A client needs to be tested for tuberculosis when and demonstrate?”
the nurse takes a medical history that includes com- 4. “Did someone from the respiratory department
plaints of: teach you?”
1. cough, night sweats, hemoptysis. 11. A client’s wife informs the nurse that her husband
2. weight gain, diarrhea, vomiting. will sometimes stop breathing for up to 30 seconds
3. fever >102°F, fatigue, dry mouth. in his sleep and then begins snoring so loudly that
4. weight loss, stridor, chills. she cannot sleep. This is an example of:
1. hypersomnia.
7. The health care provider has prescribed furosemide
(Lasix) for a client with a pleural effusion as part of 2. bruxism.
the treatment plan. Which of the following state- 3. cataplexy.
ments made by the client regarding furosemide 4. apnea.
(Lasix) indicates that further teaching is needed by 12. Adventitious breath sounds that do not clear with
the nurse? coughing and reflect fluid deep within the alveoli are:
1. “I will probably need to urinate more frequently.” 1. pleural friction rubs.
2. “This medication will help remove fluid from my 2. crackles.
pleural space.” 3. rhonchi.
3. “The nurse will monitor my intake and output 4. wheezes.
each shift.” 13. For a client on supplemental oxygen, the best
4. “I should take this medication at bedtime.” method of assessing oxygenation status is:
8. Parents of a 14-year-old client with newly diagnosed 1. pulse oximeter.
asthma ask the nurse what medications will be pre- 2. co-oximeter.
scribed for their child. The nurse informs the par- 3. PaO2.
ents that common medications for asthma include: 4. capnography.
(Select all that apply.)
14. A barrel chest can be seen in: (Select all that apply.)
1. bronchodilators.
1. chronic obstructive lung disease.
2. antibiotics.
2. normal aging.
3. corticosteroids.
3. tension pneumothorax.
4. diuretics.
4. short-term oxygen therapy.
5. mucolytic agents.
5. congenital heart disease.
6. beta agonists.
6. Marfan’s syndrome.
9. A client with a pneumothorax is brought to the
15. Vesicular breathing occurs most frequently in which
emergency department. Which of the following as-
of the following conditions?
sessments will the nurse be able to make?
1. Pneumonia
1. Decreased respirations, low blood pressure, con-
stricted pupils 2. Chronic airflow limitation from bronchitis
2. Cyanosis, dyspnea, tracheal shift, and tachycardia 3. Usual and normal breathing
3. Clammy skin, dilated pupils, slow pulse, and low 4. Apnea
blood pressure 16. Percussion is a technique of physical examination
4. Dyspnea, agitation, visual hallucinations, and el- that is used primarily for which purpose?
evated blood pressure 1. To identify areas of localized tenderness, espe-
cially over the rib cage
2. To identify the margins of the trachea
3. To determine if both sides of the chest move
symmetrically
4. To detect the resonance or hollowness of the
chest
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17. Clubbing is a term that refers most closely to which 19. B.G. is diagnosed with pneumonia. His admission
of the following? assessment reveals generalized weakness, dyspnea,
1. Shortening of the costophrenic angle diaphoresis, lung congestion, and a history of smok-
2. Increase in the soft tissue of the nail bed ing a pack of cigarettes a day. Which of the following
3. Occupational asthma and use of inhaled medicines is the most appropriate nursing diagnosis for this
4. Chronic hypoxia client?
5. Fissures in the nail bed 1. Pneumonia related to smoking as manifested by
6. Separation of the nail from the nail bed lung congestion
2. Ineffective Breathing Pattern related to pneumonia
18. C.B. is an 88-year-old male client with impaired cough
as manifested by dyspnea and lung congestion
reflex and swallowing mechanism. He has just returned
3. Potential Ineffective Airway Clearance related to
from surgery with a decreased level of consciousness.
accumulation of lung secretions
The priority nursing action at this time is to:
4. Deficient Increased Fluids related to potential
1. maintain the head of the bed elevated at
ineffective airway clearance as manifested by
15 degrees.
diaphoresis
2. have suction available at all times.
3. contact speech pathology to evaluate the client’s
swallowing ability. For additional content, activities, games, and
4. provide thin liquids to drink when the client fully more, visit the White Premium Website at
awakens. www.cengagebrain.com.
r ef er eNCeS/Su GGeSt ed r ea d iNGS

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Estes, M. E. Z. (2010). Health assessment & physical examination Serafini, D. (2009). Caring for lower respiratory disorders. Manuscript
(4th ed.). Clifton Park, NY: Delmar Cengage Learning. submitted for publication. Denver, CO.
Georgetown University Hospital. (2011). Neck dissection patient Spratto, G., & Woods, A. (2011). 2011 Delmar nurse’s drug handbook.
information. Retrieved January 9, 2011, from http://www Clifton Park, NY: Delmar Cengage Learning.
.georgetownuniversityhospital.org/body.cfm?id=1016#3 Tomfohr, L. M., Ancoli-Israel, S., Loredo, J. S., & Dimsdale, J. E.
Grodner, M., Long, S., & Walkingshaw, B.C. (2007). Foundations and (2011). Effects of continuous positive airway pressure on fatigue
clinical applications of nutrition a nursing approach (4th ed.). and sleepiness in patients with obstructive sleep apnea: data from a
St. Louis, MO: Mosby/Elsevier. randomized controlled trial. Sleep, 34(1), 121–126.
Hayden, M. (2010). Allergic rhinitis: Diagnosis, treatment, and its ef- World Health Organization (WHO). (2009). Severe acute respiratory
fect on asthma. Journal of Asthma & Allergy Educators, 1, 8–11. syndrome. Retrieved April 11, 2009, from www.who.int/csr/sars/
Higby, C. (2011). Concept care maps: Pneumonia and pharyngitis. travel/en/index.html
Archbold, OH: Northwest State Community College. Yeh, M., Chen, H., Liao, Y., & Liao, W. (2004). Testing the functional
Mayo Clinic. (2009). Cystic fibrosis. Retrieved July 20, 2009, from status model in clients with chronic obstructive pulmonary disease.
http://www.mayoclinic.com/health/cystic-fibrosis/DS00287 Journal of Advanced Nursing, 48(4), 342–350.
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r eSo u r CeS
American Academy of otolaryngology–Head and Centers for Disease Control and Prevention
Neck surgery http://www.cdc.gov
http://www.entnet.org Cystic Fibrosis Foundation
American Cancer society http://www.cff.org
http://www.cancer.org international Association of laryngectomees
American lung Association http://www.theial.com/ial
http://www.lungusa.org National Heart, lung, and Blood institute, informa-
American society of Plastic surgeons tion on lung disease
http://www.plasticsurgery.org http://www.nhlbi.nih.gov/health/public/lung/
American thoracic society index.htm
http://www.thoracic.org
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Nursing Care of Clients
Unit 6 with Cardiovascular and
Hematologic Disorders
18 Assessment of the Cardiovascular System / 395
19 Caring for Clients with Dysrhythmias / 414
20 Caring for Clients with inflammatory/infectious Cardiac

Disorders / 423
21 Caring for Clients with Occlusive Disorders and

Heart Failure / 431
22 Caring for Clients with Peripheral Vascular Disorders / 452
23 Caring for Clients with Hypertension / 464
24 Assessment of the Hematologic System / 474
25 Caring for Clients with Hematologic Disorders / 482
The cardiovascular system has an underlying effect on many body

systems. Therefore, learning to thoroughly assess the cardiovascular
system is a key to determining the health status of other body sys-
tems. Chapter 18, Assessment of the Cardiovascular System, begins
with a comprehensive anatomy and physiology review. Students can
use this content to refresh their knowledge of the cardiovascular sys-
tem and to prepare themselves for the expanded content in other
chapters within this unit. Essential content is presented to teach stu-
dents to complete thorough cardiovascular assessments. A detailed
explanation of diagnostic tests is given at the beginning of the unit to
prepare students for relating the content to different cardiovascular
disease conditions.
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A healthy heart beats in a regular, rhythmic pattern when exercising
or at rest. However, when heart tissue is damaged, it develops irregular
beats. These abnormal rhythms are detailed in Chapter 19, Caring for
Clients with Dysrhythmias, with ECG examples. Health care providers
are taught to provide adequate care to clients with dysrhythmias. Chap-
ter 19 describes the medical management and nursing interventions
needed in these situations.
Heart tissue is susceptible to inflammatory and infectious conditions
when other infections within the body are not appropriately treated.
Chapter 20, Caring for Clients with Inflammatory/Infectious Cardiac Dis-
orders, addresses the etiology, pathophysiology, symptoms, diagnostic
tests, medical-surgical management, and nursing interventions used
when caring for clients with inflammatory/infectious cardiac conditions.
Heart failure is one of the leading causes of death in the United
States. Many heart conditions eventually develop into heart failure. In
Chapter 21, Caring for Clients with Occlusive Disorders and Heart Fail-
ure, occlusive coronary diseases are systematically traced to heart fail-
ure. The nursing care of clients with heart failure is described.
Peripheral vascular diseases decrease the blood supply to body tis-
sues. Complications from these diseases can occur quickly with poten-
tial loss of a limb. Chapter 22, Caring for Clients with Peripheral Vascular
Disorders, provides teaching tips to prevent and treat these diseases
and nursing interventions for clients with peripheral vascular disease.
Many individuals have hypertension without even being aware of
the symptoms. Many serious diseases occur when hypertension is not
treated effectively. Risk factors and treatment plans are explained in
Chapter 23, Caring for Clients with Hypertension.
An assessment guide of subjective and objective data is provided in
Chapter 24, Assessment of the Hematologic System, so the nursing stu-
dent can thoroughly assess clients with hematologic diseases. A quick
review of the anatomy and physiology of the blood system helps recall
previously learned information.
Clients with some of the hematologic disorders are facing terminal
illnesses. In these situations, clients need competent, caring, and com-
passionate nurses. Content in Chapter 25, Caring for Clients with Hema-
tologic Disorders, provides information and nursing interventions for the
nursing student to use when providing skilled care.
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Chapter 18
Assessment of the
Cardiovascular System
Key terms
afterload dyspnea preload
ascites heart sounds repolarization
cardiac cycle Homans’ sign stasis dermatitis
cardiac output (CO) orthopnea stroke volume (SV)
contractility palpitations vasoconstrict
depolarization paroxysmal nocturnal dyspnea vasodilate
Learning ObjeCtives
2. explain the anatomy and physiology of the cardiovascular system.
3. explain subjective and objective cardiovascular assessment techniques.
4. explain the cardiovascular diagnostic tests as they relate to the cardiovascular system.
395
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396 Unit 6 Nursing Care of Clients with Cardiovascular and Hematologic Disorders
The heart is a hollow muscular organ containing four

INTRODUCTION chambers that empty and fill with blood with each contraction
Since 1900, heart disease has been the leading cause of death (depolarization) and recovery phase (repolarization) of
in the United States every year except in 1918 during the the cardiac muscle. The upper chambers are the atria and the
flu epidemic (American Heart Association [AHA], 2007a). lower chambers are the ventricles (Figure 18-1). When the
In 2003, the number of deaths attributed to cardiovascular atria contract, blood is forced into the ventricles. Contraction
disease (CVD) was 911,163, compared to 869,724 deaths of the right ventricle pumps blood into the pulmonary arteries
in 2007 (AHA, 2007a). The death rate for CVD is declining and on to the lungs (pulmonary circulatory system). Contrac-
because of public education in modifying and decreasing risk tion of the left ventricle pumps blood into the aorta and out
factors such as smoking, high-fat diets, and minimal exercise. to the entire body (systemic circulatory system). The myo-
This chapter reviews the anatomy and physiology of the cardium of the left ventricle is thicker than the right ventricle
cardiovascular system. Refined assessment skills are essen- because more force is needed to pump blood throughout the
tial as the nurse cares for a cardiac client, therefore, detailed body.
subjective and objective assessment techniques are presented The heart has four valves: tricuspid, bicuspid (mitral),
with an emphasis on decreasing cardiac risk factors and im- pulmonic, and aortic. One end of fibrous cords called chordae
proving clients’ lifestyles. Diagnostic tests are discussed in tendineae is attached to the cusps of the tricuspid and mitral
detail so the student can make accurate nursing decisions after valves, and the other end is attached to papillary muscles on
reviewing the test values. the ventricular walls. The chordae tendineae keep the valves
from inverting when the ventricles contract, thus prevent-
ing blood from flowing back into the atrium. The pulmonic
ANATOMY AND PHYSIOLOGY and aortic valves prevent blood from flowing back into
the ventricles from the pulmonary artery and aorta during
REVIEW repolarization.
The cardiovascular system consists of the heart and its vascu-
lature and the peripheral vascular system. The heart is located
in the lower anterior area of the mediastinum with the apex
Circulation of Blood
near the diaphragm. The heart apex tips forward and to the Blood enters the heart through veins and leaves the heart
left of the client’s chest cavity. In an average lifetime, the heart through arteries. With the contraction of the right ventricle,
will pump 80 million gallons of blood. blood is forced through the pulmonic valve into the pulmo-
The peripheral vascular system consists of arteries, arteri- nary artery. Blood circulates through the pulmonary circula-
oles, capillaries, venules, and veins. The arteries carry oxygen- tory system, where carbon dioxide is exchanged for oxygen in
ated blood away from the left side of the heart to the body the lungs. The blood then returns to the left atrium through
tissues, and the veins carry deoxygenated blood back to the the pulmonary veins, providing oxygenated blood for systemic
right side of the heart. The capillaries connect the arterioles to circulation. With the contraction of the left ventricle, blood is
the venules. The venules and veins contain 60% to 70% of the forced through the aortic valve into the aorta, beginning sys-
body’s total blood volume. temic circulation. Blood is then distributed throughout the
The cardiovascular system provides oxygen, nutrients, body and returned to the right atrium of the heart through the
and hormones to the cells and removes carbon dioxide inferior and superior vena cava.
and waste products of cellular metabolism from body cells.
Body temperature is maintained by the distribution of heat
throughout the body produced by the metabolic activity of
Stroke Volume
muscles and other body organs. and Cardiac Output
Heart rate (HR) is the number of ventricular contractions per
Structure of the Heart minute as determined by auscultation of the heart or palpa-
tion of a pulse. Each time the heart beats, the ventricle pumps
The heart is encapsulated by a protective sac called the pericar- 60 to 80 mL of blood. The volume of blood ejected from the
dium and consists of three layers: endocardium, myocardium, left ventricle with each contraction or systole is known as
and epicardium. The endocardium is made of endothelium the stroke volume (SV). Normal stroke volume is approxi-
cells that line the inside of the heart, the four heart valves, mately 70 mL. The amount of blood ejected in 1 minute is
and is continuous with the endothelial lining of the arteries, known as the cardiac output (CO). Therefore, CO is deter-
capillaries, and veins, making the circulatory system a closed mined by multiplying HR for 1 minute by the stroke volume
system. Therefore, if a person has a systemic blood infection, (CO 5 HR 3 SV) (Bender, 2008). Normal cardiac output is
the heart lining and valves are also affected. The myocardium 4 to 6 L/min. If the heart has a strong ventricular contraction,
consists of striated muscle and varies in thickness depending more blood is pumped by the heart into the systemic circula-
on the heart chamber. The left ventricle pumps blood to the tory system. Therefore, CO has a direct effect on the circulat-
body and is, therefore, the thickest chamber. The outside of ing volume of arterial blood.
the heart is surrounded by the epicardium. The pericardium
consists of two layers: the parietal pericardium and visceral
pericardium. The parietal layer (outer layer) is a fibrous loose Coronary Arteries
sac that surrounds the heart and the visceral layer lines the Coronary arteries supply nutrients and oxygen to the muscle
great vessels and is also called the epicardium when it lines the tissue of the heart. The two coronary arteries, which branch
heart. The pericardial space is between the two pericardium off the aorta, are the right coronary artery and the left coro-
layers and is filled with fluid (Figure 18-1). nary artery (Figure 18-2). The right coronary artery divides
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CHAPtER 18 Assessment of the Cardiovascular System 397
Superior vena
cava Aorta
Right Left pulmonary
pulmonary artery
artery
Left
Right pulmonary
pulmonary veins
veins Left atrium
Pulmonic Aortic
(semilunar) (semilunar)
valve valve
Endocardium
Right atrium Pericardium
Parietal
Tricuspid valve pericardium
Bicuspid (mitral)
Right ventricle valve
Myocardium
Epicardium
Inferior vena Left ventricle
Endocardium Septum
cava
Pericardial
Space
Unoxygenated blood Endocardium

Oxygenated blood Pericardial

space
Parietal
pericardium
Epicardium
Myocardium
Figure 18-1 Internal view of the heart with aorta, vena cava, and pulmonary arteries and veins.
right ventricle, the atrioventricular (AV) node, and the poste-

rior section of the interventricular septum. The left coronary
artery divides into the anterior descending artery and the
circumflex artery. The left anterior descending (LAD) artery
Left supplies blood to the anterior section of the interventricular
coronary septum, anterior area of the left ventricle, and the lateral as-
artery pect of the left ventricle. The circumflex artery nourishes the
Right left atrium and ventricle.
coronary
artery Circumflex
artery Conduction System
The specialized cardiac muscle cells are capable of conducting
electrical impulses from one part of the heart to another. For
the heart to beat regularly in a rhythmic sequence, electrical
Posterior Anterior impulses follow a set pattern through the conduction system
descending descending of the heart. The conduction system, consisting of the sino-
artery or artery atrial (SA) node, AV node, bundle of His, bundle branches,
interventricular
and Purkinje fibers, controls the heartbeat (Figure 18-3).
artery
The SA node located in the superior aspect of the right
atrium initiates electrical impulses that cause the heart to
Marginal artery
beat. It is called the pacemaker of the heart. Electrical im-
pulses from the SA node pass through the muscle fibers of
Figure 18-2 Coronary arteries that supply blood to the the right and left atria, causing the atria to contract almost
heart tissue.
simultaneously. Atrial impulses are transmitted to the AV
node located in the lower part of the right atrium. There is a
into the posterior descending artery (interventricular artery) short delay in the impulse at the AV node that allows the atria
and the marginal artery and supplies blood to the anterior to complete their contraction and empty the blood into the
area of the right and left ventricles, the posterior area of the ventricles. The electrical impulse is transmitted from the AV
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S-A node
LA Left bundle branch
RA Posteroinferior fascicle
of left bundle branch
A-V node
LV
Anterosuperior fascicle
A-V bundle of His of left bundle branch
RV Septum
Right bundle branch

Purkinje fibers
Figure 18-3 Conduction system of the heart.
node into a group of specialized conduction fibers called the of cardiac contraction. Systolic pressure is the force exerted
AV bundle or the bundle of His. Once the impulse leaves the against arterial walls during ventricular contraction. Diastolic
AV node, it travels down the fibers of the bundle of His into pressure is the force exerted against arterial walls during
the interventricular septum. The fibers separate into right ventricular relaxation. Blood pressure is expressed as systolic
and left bundle branches dividing into smaller and smaller pressure/diastolic pressure (e.g., 120/80). A systolic blood
branches, called Purkinje fibers. These terminate in the ven- pressure reading of at least 80 mm Hg is needed to palpate a
tricular muscle, causing the ventricles to contract. When an radial pulse (Bender, 2008).
impulse has completely gone through the conduction system
of the heart and the ventricles have contracted, a cardiac
cycle is completed. Heart Sounds
The end-diastolic volume (EDV) is the amount of blood The cardiac landmarks are five locations where heart sounds
in the ventricles after the ventricular rest and filling phase are best heard (Figure 18-4):
of the cardiac cycle. In the healthy heart, the EDV is usu-
ally around 120 mL. The end-systolic volume (ESV) is the 1. Aortic area. Located at the second intercostal space
amount of blood in the ventricles after the ventricular con- (ICS) to the right of the angle of Louis (Figure 18-4A).
traction and ejection phase of the cardiac cycle. In the healthy 2. Pulmonic area. Located at the second ICS to the left of
heart, the ESV is usually around 50 mL. the sternum.
Ejection fraction (EF) is an indicator of ventricle func- 3. Midprecordial area, Erb’s point. Located in the third ICS
tioning and is reduced in clients with myocardial infarc- to the left of the sternum.
tion and diagnostic for heart failure (HF). To determine 4. Tricuspid area. The right ventricular area or septal area;
the EF, stroke volume is divided by end-diastolic volume located at the fifth ICS to the left of the sternum.
(EF 5 SV/EDV). In healthy hearts, the EF is between
5. Mitral area. The left ventricular area or apical area;
50% and 70% of the EDV. The EF is determined through
located at the fifth ICS at the midclavicular line.
echocardiography.
Four factors influence stroke volume and CO: preload, The mitral area is the apex of the heart and the aortic and
afterload, contractility, and HR. Preload refers to the amount pulmonic areas are located at the base of the heart. The apex
of pressure within the ventricles. This is determined by the or mitral area is also known as the apical impulse, sometimes
amount of stretch or tension derived from the ventricular called the point of maximal impulse (PMI). To systematically
filling and the pressure exerted by fluid volume on the myo- assess the heart, listen to the heart sounds from the aortic area
cardium at the end of diastole (ventricular end-diastolic pres- to the mitral area or from the mitral area to the aortic area
sure), or just before contraction. Afterload is the force that (Estes, 2010).
resists ejection of blood from the ventricles, or the force that Two normal heart sounds are heard on auscultation,
is needed to open the semilunar valve and eject blood during S1 and S2 (Figure 18-5). They yield a sound like “lub-dub.”
systole. This resistance arises from the pulmonary circula- S1, or the “lub,” is the sound of the mitral and tricuspid valves
tion for the right ventricle, and from the systemic circulation closing simultaneously. The S1 sound is heard best on the left
for the left ventricle. Contractility refers to the strength fifth intercostal space. S2 , or the “dub,” is the simultaneous
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Aorta
angle of
Louis Right Left pulmonary
pulmonary artery
A P artery
Left
E Right pulmonary
pulmonary veins
T veins
M Aortic
Pulmonic S2
(semilunar) (semilunar)
S2 S1
valve valve
S1

A Tricuspid valve
Bicuspid (mitral)
valve
A P
Figure 18-5 Anatomical location of S1 and S2 heart sounds.
E

T
M
Arterioles and Arteries
The arteries are thick-walled tubes consisting of three layers or
tunics (Figure 18-6). The inner layer is called the tunica intima
B and consists of a single layer of smooth endothelial cells. The
middle layer is the tunica media and is composed of smooth
Figure 18-4 A, Cardiac landmarks related to ribs and inter- muscle cells. The smooth muscle layer of the artery receives
costal spaces: A, aortic area; P, pulmonic area; E, Erb’s point; nerve stimulation from the sympathetic nervous system. The
T, tricuspid area; M, mitral area. The mitral area is located at suppleness of the smooth muscle allows the vessel to vasocon-
the apex of the heart and is also called the apical impulse (still strict (decrease in diameter) and vasodilate (increase in diam-
called PMI by some practitioners). It is located along the fourth
eter). The outer layer, the tunica adventitia or tunica externa,
intercostal space left of the sternal border and to the fifth inter-
costal space on the midclavicular line. The angle of Louis is very
consists of a connective tissue sheath with some of its collagen
useful in locating cardiac landmarks. B, Cardiac landmarks on fibers fusing with those of the surrounding tissue to hold the
chest. vessels in place. The elastic connective tissue allows the artery
to expand and recoil with each contraction of the ventricle as an
increased volume of blood is pumped through the vessel. The ar-
teries have thick walls, so they can withstand the increased pres-
sure from the left ventricle pumping blood through the body.
BestPractice The arteries divide and branch into smaller vessels called
arterioles. The same three layers are present in the walls, but
Point of Maximal Impulse as the arterioles approach the capillaries their walls become
versus Apical Impulse thinner. The outer layer is reduced to a very thin layer of con-
nective tissue.
The term point of maximal impulse (PMI) is not
used as frequently as it used to be because a car-
Endothelial
diac abnormality can cause a stronger impulse in cells
a different area. Therefore, the mitral landmark is Valve
now called the apical impulse (Bickley & Szilagyi,
Tunica
2008; Estes, 2010; Venkatesan, 2008; Weber, Kelley, intima
& Sprengel 2009).
Tunica
media
closing of the pulmonic and aortic valves and is heard best on

the right second intercostal space. There is a slight pause after Tunica
the “lub-dub” is heard. Clients with heart failure (HF) may adventitia
have a third sound known as S3. The low-pitched sound oc-
curs after the S2 sound, or the “dub,” making the heart sound
like the word “Kentucky” (“lub-dub-by”). The S3 sound also Artery Vein Capillary
is described as a gallop because of the similarity in sound to
a horse’s gallop. Figure 18-6 Tunic layers of each type of vessel.
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To heart To heart To heart
BestPractice
Blood
flow
Symptoms of Cardiovascular Disease
Contracted
skeletal Six common symptoms of cardiovascular disease
muscles Back
are dyspnea, chest pain, fatigue, edema, syncope,

flow
Relaxed and palpitations.
skeletal
muscles
A B C
mellitus. An individual’s response to stress may be a con-
Figure 18-7 Valves in the veins hold the blood at a certain tributing factor. Additional contributing factors for women
level in the vein. A, Contracted skeletal muscles apply pressure include menopause, use of birth control pills, and high
to veins and assist with the circulation of blood. B, Valves pre- triglyceride level.
vent the backflow of blood. C, Incompetent valves allow a back- Advancing age, male gender, diabetes, heredity, and cli-
flow of blood. ent or family history of chest pain or myocardial infarctions
are risk factors that cannot be altered. Alterable risk factors are
physical inactivity, smoking, contraceptive method, dyslipid-
Capillaries emia, overweight, obesity, and triglyceride level. A change in
Capillaries are very tiny, thin vessels that connect the smallest diet may alter the last four factors.
arterioles with the smallest venules. They have only one layer There are two objectives in assisting the client toward a
of endothelial cells whose cell membranes are the semiperme- healthier lifestyle: (1) to educate the client about the risk fac-
able membrane that allows the exchange of oxygen, nutrients, tors and (2) to determine what risk factors the client would
carbon dioxide, and waste products between the tissues of the like to modify. Once this is determined, assist the client to
body and the blood. establish goals and determine actions to achieve the goals.
Venules and Veins ASSESSMENT

Venules are small vessels that emerge from the capillaries and
gradually increase in size to eventually form veins. Veins have Data Collection
three layers or tunics like the arteries, but the middle layer of a Data collection includes clients’ self-report of symptoms as
vein is thinner with less smooth muscle and elastic tissue. The well as physical findings and confirming lab data.
elasticity of the smooth muscles allows the walls of the veins
to dilate more easily. Endothelial flaps, called valves, are on Subjective Data
the inside lining of veins. The valves open and close with each The typical concerns expressed by a client with a cardiac dis-
contraction of the surrounding skeletal muscles. The valves order are chest pain, dyspnea (difficulty breathing), edema,
assist the blood in returning to the heart. Blood is held by fainting, palpitations, diaphoresis, and fatigue. When a client
the valves until skeletal muscle contractions move the blood talks about having chest pain, ascertain the time of onset, situ-
toward the heart against gravity (Figure 18-7). ation occurring at the onset of pain, location and radiation of
pain, severity of chest pain, duration, past episodes of chest
HEALTH HISTORY pain, and methods used to alleviate pain. An ideal way for a
nurse to assess a client’s pain is to use the PQRST pain as-
The nurse has three goals when obtaining a health history sessment. This method is described in Memory Trick. Women
from a client: (1) Identify present and potential health prob- are more likely to experience shortness of breath, fatigue,
lems, (2) identify possible familial and lifestyle risk factors, back or jaw pain, and atypical discomfort such as a feeling of
and (3) involve the client in planning long-term health care. indigestion or nausea and vomiting (AHA, 2007b; Nagle &
The client’s past history of illnesses and surgeries, such as Nee, 2002).
previous myocardial infarctions, open heart surgery, or stent The client may be experiencing several types of dyspnea.
placement, gives information about the client’s heart health. Exertional dyspnea occurs when a person participates in
Ascertain the onset of the symptoms, the predisposing moderate activity and becomes short of breath. This occurs in
factors that cause the symptoms, and the client’s treatment of the early stages of HF and indicates that the heart is not able
the symptoms. Ask about the client’s activity level or limita- to meet the demands of the body during moderate activity.
tions in activity. Determine if appetite has increased or de- Orthopnea is when a client has difficulty breathing while ly-
creased. Evaluate the client’s ability to sleep, the need for the ing down and must sit upright or stand to relieve the dyspnea.
trunk of the body to be supported with pillows when sleeping, This occurs in a more advanced stage of HF. Paroxysmal
or the need to sleep in a chair. nocturnal dyspnea usually occurs 2 to 5 hours after an indi-
Major risk factors associated with cardiovascular dis- vidual falls asleep. The person suddenly awakens, is sweating,
eases are age, gender, heredity (including race), smoking, and has difficulty breathing.
dyslipidemia (presence of increased total serum cholesterol A client has fainting spells for various physical and psy-
and low-density lipoprotein [LDL]), high blood pres- chological reasons. Cardiac clients faint because of decreased
sure, physical inactivity, overweight, obesity, and diabetes CO causing decreased blood flow to the brain.
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MeMORY tricK BestPractice

Pain Assessment: PQRST
Taking a Jugular Venous Pressure
P 5 Provoker of pain (aggravating factors) and (JVP) Reading
palliative measures (alleviating factors)
1. Elevate the head of the bed 30 to 45 degrees.
Q 5 Quality of pain (gnawing, pounding, The neck veins are most visible at this angle.
burning, stabbing, pinching, aching, 2. Vertically measure in centimeters from the
throbbing, and crushing) sternal notch to the top of the distended neck
R 5 Region (location) and radiation to other vein. This measurement is the JVP.
body sites 3. A normal JVP measurement is ,4 cm. Jugular
vein distention usually is 1 to 2 cm when the
s 5 severity (quantity of pain on 0–10 scale,
head is elevated 45 degrees. There should be
0 5 no pain and 10 5 worst pain experi-
no distention when the head of the bed is el-
enced) and setting (what causes the pain)
evated 90 degrees.
t 5 timing (onset, duration, and frequency)
(Adapted from Estes, 2010)
Objective Data
In a head-to-toe assessment on a cardiac client, the skin, neck
A client may describe a “fluttering” or “pounding” sen- veins, respirations, heart sounds, abdomen, and extremities
sation in the chest. This is known as palpitations. If these are carefully assessed. Observe the skin for cyanosis in the
sensations occur during exercise, it is a sign that the heart has earlobes, lips, mucous membranes, and finger- and toenails.
to work harder to meet the demands of the body. Palpitations Assessment of skin turgor may indicate hydration status. If the
are also caused by anxiety, ingestion of a large meal, lack of skin is dry and has poor turgor, the client may be dehydrated
adequate rest, or a large intake of caffeine. from diuretics. If a client has distended internal and external
A cardiac client will usually experience fatigue increasing jugular veins when the head of the bed is gradually elevated to
throughout the day because the heart is not able to keep up a 45-degree angle, there may be right-sided HF (Figure 18-8).
with the demands of the body. Frequent rest periods will help Assess the quality of respirations for rate and ease of breath-
alleviate some of the fatigue. ing, signs of dyspnea, and coughing.
The typical concerns expressed by the client with a pe- Heart sounds are assessed for the normal S1 and S2
ripheral vascular disorder are pain, paresthesia (decreased sounds. If the typical lub-dub is heard, the valves are closing
sensation in an area), and/or paralysis in the hands, thigh, properly. While listening to the heart, palpate the radial pulse
calf, ankles, foot, abdomen, or lower back. The quality of pain to account for every heartbeat. The heart has decreased CO to
(aching, cramping, sharp, or throbbing) and any numbness or the extremities if a heartbeat is heard through the stethoscope
tingling are noted. but pulsation is not felt in the radial pulse. If the abdomen is
Highest level
of pulsation
Venous pressure
Sternal angle
External
jugular vein
Internal
jugular vein
°
Common
–45
carotid artery
30°
Figure 18-8 Client position when assessing jugular vein distention.
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BestPractice Table 18-1 Pulse Points

PULSE POINT USE
Locate Apex of the Heart
Temporal: over tem- For use when radial
• Raise client’s gown to expose sternum and left poral bone, lateral is inaccessible
side of chest. and superior to eye
• With client lying supine, palpate and locate su-
prasternal notch.
Carotid: under lower For use during shock
• Then, move to the left of the angle of Louis and
jaw in neck along or cardiac arrest
palpate for the second intercostal space. medial edge of ster- when other periph-
• Place index finger in intercostal space, count- nocleidomastoid eral pulses are too
ing downward until the fifth intercostal space is muscle weak to palpate; also
located. to assess cranial
• To palpate the apical impulse, move index fin- circulation
ger along fourth intercostal space left of the Apical: left midcla- To auscultate heart
sternal border and down to the fifth intercostal vicular line at fourth sounds and assess
space on the midclavicular line. to fifth intercostal apical-radial deficit.
• Keep index finger of nondominant hand on the space Take the apical pulse
for 1 full minute not-
apical impulse.
ing rate, rhythm, and
• Tell the client you are going to listen to her quality when adminis-
heart and ask her to remain silent. tering certain cardiac
• Place diaphragm of stethoscope over the apical medications, such as
impulse and auscultate the heart sounds. Move- cardiac glycosides,
ment of blood through the heart valves creates antianginals, and
S1 and S2 sounds. antidysrhythmics.
• Listen for a regular rhythm (heartbeats are Brachial: between To assess lower
evenly spaced) before counting. Start to count groove of biceps arm circulation and
and triceps muscles to auscultate blood
while looking at second hand or digital display
at antecubital fossa pressure
of watch. Count lub-dub sound as one beat.
Establishment of a rhythmic pattern deter- Radial: inner aspect To routinely assess
mines length of time to count the heartbeats of forearm on thumb pulse
to ensure accurate measurement. For a regular side of wrist
rhythm, count rate for 30 seconds and multiply
by 2. For an irregular rhythm, count rate for a Ulnar: outer aspect To assess circulation
full minute, noting number of irregular beats. of forearm on finger to ulnar side of hand
• Compare client’s pulse with baseline rate, ampli- side of wrist
tude (volume, strength), and rhythm (regularity)
to detect any changes.
Femoral: in groin, To assess circulation
• If pulse is irregular or abnormal, ask another below inguinal to legs and during
nurse to check the pulse and then report to ligament (midpoint cardiac arrest
health care provider. between symphysis
• Record by site the rate, rhythm, and, if appli- pubis and anterosu-
cable, number of irregular beats. Record rate perior iliac spine)
and characteristics at bedside to ensure accurate Popliteal: behind To assess circula-
documentation. knee, at center in tion to legs and to
popliteal fossa auscultate leg blood
pressure
Posterior tibial: in- To assess circulation

distended, the client may have ascites, which is excess fluid ner aspect of ankle to feet
in the abdomen. between Achilles
After assessing the heart and lung sounds, check the tendon and tibia
peripheral pulses (Table 18-1). Pulses on both sides of the
Dorsalis pedis: over To assess circulation
body should be checked at the same time to determine ade-
instep, midway to feet

quate bilateral perfusion. However, the right and left carotid
between extension
pulses are checked one at a time to decrease the possibility tendons of great and
of altering the blood supply to the brain. It is important to second toe
check pedal pulses in both feet to determine blood flow to
each foot. Pulse volume or amplitude can be measured on a
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Table 18-2 Three-Point and Four-

Point Scales for Measuring Pulse Volume
THREE-POINT SCALE FOUR-POINT SCALE
dESCRIPTION dESCRIPTION
SCALE OF PULSE SCALE OF PULSE
0 Absent 0 Absent
11 Thready/weak 11 Thready/weak

21 Normal 21 Normal
31 Bounding 31 Increased
1+ = disappears rapidly 2+ = lasts 10 to 15 seconds
41 Bounding
three- or four-point volume scale depending on institutional

policy (Table 18-2).
If the hands and feet are cold or have mottling, this may
indicate decreased CO. A normal capillary refill is less than
3 seconds in the fingers and toes. To assess blood perfusion of
peripheral vessels and skin, note changes in skin temperature,
color, and moisture; sensation; and changes in the pulses. Feel
the toes for warmth and color. Because the position of the

extremities can affect the skin temperature and appearance,
assess extremities at heart level and at a comfortable room
temperature. Evaluate pulse site as required by client’s condi- 3+ = lasts more than 4+ = lasts 2 to 5 minutes
tion; compare peripheral pulses bilaterally and note changes 1 minute
in strength and quality. For example, compare both pedal/
dorsal or both posterior tibial pulses when assessing clients Figure 18-9 Edema rating scale: Press down for 5 seconds,
with poor peripheral circulation in the lower extremities. The then time how long indentation remains.
nurse checks the degree to which the tissues are perfused by
measuring the SaO2 with a pulse oximeter. The normal range
is 95% to 100% saturation. and then vesicles form and start oozing. The skin becomes
Note if the feet, ankles, or legs are edematous (Figure 18-9). crusted, thickened, and brown.
A client may gain 10 pounds before edema is detected. Weigh A positive Homans’ sign is present in some cases of
cardiac clients with edema daily. For an accurate weight, weigh deep vein thrombosis (DVT). To test for Homans’ sign, dor-
the client on the same scale, at the same time of day, with the siflex the client’s foot (Figure 18-10). If there is pain in the
client wearing the same amount of clothing. calf of the leg or behind the knee, Homans’ sign is positive
Decreased circulation to an area results in coolness in the
ischemic area, pallor, paresthesia, and paralysis. Paresthesia
and paralysis result from a lack of oxygenated blood and nour-
ishment to the nerves. Symptoms of paresthesia are numbness
and tingling.
If an artery in the leg is occluded, the foot and/or leg
become reddish in color when the leg is in a dependent posi-
tion, and pale when elevated. As the ischemia progresses, the
leg and/or foot skin becomes mottled, smooth, and shiny. If
the veins are occluded, the foot and/or leg becomes cyanotic
when in a dependent position and has a normal coloration
when elevated. The anterior area of the lower leg and ankle
has a brown pigmentation with venous involvement.
Clients with decreased circulation to the extremities have
hardened and brittle nails and less hair distribution. The leg
is cool if there is an arterial circulatory problem but warm if
there is a venous circulatory problem. Skin ulcerations may be
found around the ankles and toes.
Check the client’s ankles for stasis dermatitis, an in-
flammation of the skin caused by decreased circulation. Waste
products that normally are carried away by the circulatory Figure 18-10 Homans’ sign assessment. Discomfort expe-
system remain in the tissues, causing pruritus and irritation of rienced in the calf when the foot is sharply dorsiflexed is consid-
the skin. At first, the ankle area is reddened and edematous, ered positive and may indicate thrombophlebitis.
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and may indicate the presence of a venous clot. If Homans’ AST and LD (LDH) are not specific for heart damage
sign is positive, do not palpate or rub the area or repeat the and are not recommended for clients suspected of having
Homan’s sign test. Do not do a Homans’ sign assessment if ACS (American Association for Clinical Chemistry, 2008).
there is a diagnosis of a thrombus, because the clot may be Troponins are replacing CK and CK-MB in some settings
dislodged with the procedure. Report a positive Homan’s sign because they are more specific for heart injury (versus skel-
to the physician. etal muscle injury) and are elevated for a longer period of
The focus of the subjective assessment includes personal time. Troponins elevate within 3 to 4 hours after injury and
habits contributing to or preventing cardiovascular disease, may remain elevated for 10 to 14 days (see Table 18-4 for
while the objective assessment centers on the symptoms the elevation times of biomarkers). The greater the tissue dam-
client displays indicating cardiovascular problems. Refer to age, the greater the elevation. Muscular injection, strenu-
Box 18-1, Questions to Ask and Observations to Make When ous exercise, and drugs that affect muscles do not elevate
Collecting Data, for guidance in completing client cardiac troponin levels as they do with CK (Bender, 2008). Other
assessments. general tests ordered with cardiac biomarkers are ABGs,
comprehensive metabolic panel, basic metabolic panel,
electrolytes, and CBC.
COMMON DIAGNOSTIC TESTS A newer cardiac biomarker test used with troponin and
an ECG to identify clients at a greater risk of an MI is ischemia
Commonly used diagnostic tests for clients with symptoms modified albumin (IMA). If IMA is not present in a client who
of cardiovascular system disorders are listed in Tables 18-3, has experienced chest pain for a few minutes to a few hours, it
18-4, 18-5, and 18-6. is not likely that the client has ischemia. IMA is not as valuable
Cardiac biomarkers that diagnose, evaluate, and moni- with a client who has experienced chest pain for several hours
tor clients with possible acute coronary syndrome (ACS) because the IMA level may have risen and returned to normal
are troponin I, troponin T, CK, CK-MB, and myoglobin. within that time frame.
Box 18-1
QueSTIonS To ASk AnD obSeRVATIonS To MAke WHen CoLLeCTIng DATA
Subjective Data objective Data
• Have you experienced chest pain? Radiating • Take vital signs: temperature, pulse, respirations,
pain? Nausea? Indigestion? Fatigue? blood pressure, and pulse oximetry.
• What activities cause chest pain? • Weigh client.
• Have you felt a “fluttering” or “pounding” • Check pupils.
sensation in the chest? Does your heart ever feel • Assess for jugular vein distention.
like it is skipping a beat? • Check capillary refill.
• Do you ever feel dizzy or light-headed? • Check the skin, lips, fingers, and feet for cyanosis.
• Tell me about your memory. Do you have trouble • Auscultate heart sound at the five cardiac
remembering events or facts? landmarks.
• On how many pillows do you sleep? • Listen to the apical pulse and palpate the radial
• Do you awaken short of breath? pulse at the same time.
• List prescription and over-the-counter • Listen to breath sounds in all lobes on anterior and
medications you are taking. posterior aspects of chest.
• Do you use any herbal supplements? • Listen to bowel sounds.
• Describe your daily exercise habits. • Palpate abdomen for ascites (accumulation of fluid
• Are you on any specific type of diet? in the abdomen), edema, or tautness.
• Do you weigh yourself at regular intervals? Have • Examine legs, ankles, and feet for swelling.
you noticed a weight gain of 5 pounds or more • Examine legs for hair distribution.
from one day to the next? • Check for areas of decreased sensation.
• How often do you urinate during the daytime? • Check peripheral pulses noting the quality, rhythm,
During the night? and amplitude.
• Are you sexually active? Have there been any • Check extremities for areas of brownish discolor-
changes in the last year? ation, ulcerations, and bruising.
• Do you experience swelling in your feet or ankles? • Complete a Homans’ sign assessment.
• Can you climb a flight of stairs without becoming
short of breath?
• Can you walk a block without feeling cramps in
your legs?
• How do you cope with stress?
• How do you relax?
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Table 18-3 Common Laboratory diagnostic Tests for Cardiovascular

System disorders
SIgNIFICANCE OF TEST
RELATINg TO THE
LAbORATORy ExPLANATION/ CARdIOVASCULAR
TESTS NORMAL VALUES SySTEMS NURSINg RESPONSIbILITIES
Arterial Blood Gases

The test measures the The test evaluates This test is done by a physician, lab
dissolved oxygen, carbon cardiopulmonary technicians, respiratory therapists,
dioxide, and pH levels in dysfunctions, acid–base or specialty nurses.
arterial blood. imbalances, and the Air bubbles are expelled from the sy-
pH 5 7.35–7.45 effectiveness of tissue ringe and the blood sample is immedi-
PCO2 5 35–45 mm Hg perfusion. ately placed on ice and sent to the lab.
HCO3 5 21–28 mEq/L Label the specimen with the time
PO2 5 80–100 mm Hg the sample was taken, the client’s
temperature, and if the client was
O2 saturation 5
breathing room air or using oxygen or
95%–100%
a ventilator.
Apply pressure to the arterial site for
3–5 min or 15 min if client is on an an-
ticoagulant. Assess site for bleeding
every 5–10 min for 30 minutes.
Complete Blood Count (CBC)

Indicates oxygen-carrying Client is not fasting or NPO.
capacity of blood and
presence of infection.
White blood cells 5,000–10,000 mm3 Elevated in myocardial
(WBCs) infarction and bacterial
infections.
Red blood cells 4.2–5.4/mm3 Elevation indicates
(RBCs) compensation for hypoxemia.
Hemoglobin (Hgb) 13.5–17.5 g/dL Elevated in HF.
Males 12–16 g/dL If less than 5 g/dL, may lead
Females to heart failure.
Hematocrit (Hct)
Males 40%–54%
Females 37%–47%
Culture and Sensitivity (C&S)

Determines presence Assists in diagnosis of Blood sample is done before
of microorganism and bacterial endocarditis. administration of antibiotics.
determines antibiotic that
will kill or inhibit growth of
microorganism.
Normal value is negative
for microorganism growth.
Cardiac Biomarkers
Creatine kinase (CK) Enzyme in the heart This enzyme elevates after If test is ordered on a client with
muscle, skeletal muscle, a myocardial infarction chest pain, ask about the onset
and brain. (MI), with myopathy due of pain, duration, severity, and
Male: 55–170 units/L to alcoholism, and after a predisposing and alleviating
Female: 30–135 units/L cardioversion, defibrillation, factors.
or cardiac catheterization.
(Continues)
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System disorders (Continued)
RELATINg TO THE
CK-MB (CK2) An isoenzyme released Level increases 4–6 hrs A ratio of CK-MB to CK that is
specifically from the following an MI and remains more than 2.5–3 is indicative of
cardiac muscle. elevated after injury for heart damage.
,7.1 units/L or CK-MB 48–72 hrs.
ratio to CK 0%
Troponin is a more specific If the level normalizes and
test for cardiac damage then increases a second
and is replacing CK-MB. time, it can indicate early
re-infarction.
High-sensitivity Test that is helpful in predict- Clients with higher levels Check if the client has a chronic
C-reactive protein ing a healthy person’s risk of have 1.5–4 times the risk of inflammatory disease, such as
(hs-CRP) cardiovascular disease, heart having a myocardial infarction rheumatoid arthritis.
attacks, and strokes. than those with lower levels. Client may need to be fasting if the
Also helpful in diagnosing Risk of an MI is increased test is done with a lipid profile.
inflammatory processes. when there is also elevated
Low risk: ,1.0 mg/L cholesterol, LDL-C,
Average risk: 1.0–3.0 mg/L triglycerides, and glucose.
High risk: .3.0 mg/L
B-type natriuretic Secreted from the Assists doctors to make the Explain to client that a blood
peptide (BNP, ventricles of the heart in correct diagnosis of heart sample is needed.
brain natriuretic response to changes in failure. The test takes about 15 min.
peptide, proBNP, pressure when heart failure
N-terminal pro BNP, develops and worsens.
NT-pro-BNP) No heart failure:
,100 pg/mL
Suggests heart failure is
present: 100–300 pg/mL
Mild heart failure:
.300 pg/mL
Moderate heart failure:
.600 pg/mL
Severe heart failure:
.900 pg/mL
Myoglobin Oxygen-binding protein The protein is released into Explain the procedure and the test
found in skeletal muscles the circulation when the heart purpose to the client.
and myocardium. or muscles are damaged. If a urine specimen is contaminated
Blood: ,70 ng/mL Myoglobin is filtered from with feces, discard the specimen
Urine: 0–2 mg/mL the blood in the kidneys. and obtain another.
High levels of myoglobin can
occlude the kidneys, leading
to kidney failure.
Ischemiamodified Indicator of ischemia If IMA is not present in a client Explain the purpose of the test.
albumin (IMA) and occurs when serum who has experienced chest
albumin comes in contact pain for a few minutes to a few
with ischemic heart tissue hours, it is not likely that the
(Schreiber, 2011). client has cardiac ischemia.
A newer cardiac biomarker IMA is not as reliable with a
test used with troponin and client who has experienced
an ECG to help rule out chest pain for several hours
cardiac ischemia in clients because the IMA level may
with chest pain. have risen and returned to
normal within that time frame.
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RELATINg TO THE
Troponin I and T Cardiac specific test. Used to diagnose an MI, to Explain to client that a blood
(TnI, TnT, cTnI, Troponin I 5 ,1.5 ng/mL detect and evaluate mild sample is needed.
cTnT) Troponin T 5 ,0.6 ng/mL to severe cardiac injury, and Test is very expensive.
to distinguish angina that Often used in the ED.
may be due to other causes.
Troponin I elevated level in
4–6 hrs.
Troponin T elevated level in
4–6 hrs.
Electrolytes
Test determines blood Na and K are necessary for Client is not fasting or NPO.
electrolyte levels. cardiac electrical conduction.
Sodium (Na) 136–145 mEq/L Acid-base imbalances can
cause cardiac dysrhythmias.
Potassium (K) 3.5–5 mEq/L Decreased and increased
Chloride (Cl) 100–110 mEq/L levels of potassium can
Carbon dioxide (CO2) 22–30 mEq/L cause dysrhythmias;
decreased in HF.
Magnesium (Mg) 1.6–2.6 mEq/L
Erythrocyte Sedimentation Rate (ESR, sed rate test)

Nonspecific test indicating An elevated level indicates MI The test should be performed
presence of inflammation. and bacterial endocarditis. within 3 hrs after blood is drawn.
Male: 0–13 mm/hr A decreased level indicates
HF and angina.
Female: 0–20 mm/hr Menstruation or pregnancy
may increase level.
Ethambutol, quinine, aspirin,
cortisone, and prednisone
may alter results.
International Normalized Ratio (INR)

The INR provides a Clients on anticoagulant drugs The INR is drawn before the daily
uniform standard within should have an INR of 2–3 warfarin (Coumadin) dose is given.
the United States and (2.5–3.5 for the client with a me-
internationally to monitor chanical prosthetic heart valve).
the effectiveness of The INR is more accurate
anticoagulants such as than prothrombin time
warfarin (Coumadin). in monitoring warfarin
Normal: 0.9–1.1 (Coumadin) therapy.
Platelet Count
Measures the number of Increased levels are seen Instruct the client that strenuous
platelets per cubic milliliter with thrombocytopenia exercise and oral contraceptives
of blood. purpura, chronic heart increase platelet level.
Normal: 150,000–450,000/ disease, chronic leukemia, Instruct the client that aspirin,
mm3 and polycythemia vera. acetaminophen, and sulfonamides
Critical level: ,50,000 and Decreased levels are present decrease platelet level.
.1 million/mm3 with anemias (aplastic and If the client has a low platelet
pernicious), bone marrow count, maintain digital pressure to
malignancies, and chronic the puncture site.
cor pulmonale.
(Continues)
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RELATINg TO THE
Prothrombin Time (PT, protime)
Measures the effectiveness In the presence of Ensure that the blood specimen
of several blood-clotting anticoagulant therapy, the is drawn before the daily dose of
factors. values should be 1½–2 times warfarin (Coumadin) is administered.
Normal: 10–13.4 sec the normal value. Instruct the client that alcohol
INR: 2.0–3.0 Critical value: .20 sec. intake may increase PT and that a
In the presence of diet high in fat may decrease PT.
anticoagulant therapy, the Medications that may increase PT
critical value should be levels are salicylates, sulfonamides,
.3 times the normal critical and methyldopa (Aldomet).
value. Digitalis and oral contraceptives
decrease the PT level.
Instruct the client not to take any
medication without notifying the
physician, because the drug may
affect the PT level.
Partial Thromboplastin Time (PTT), also called activated partial thromboplastin time (APTT)
Normal: PTT: 60–70 sec In the presence of If the client is receiving intermittent
APTT: 21–35 sec anticoagulant therapy, the heparin doses, schedule the APTT
Critical value: normal value is 1.5–2.5 times to be drawn 30–60 min before the
the control value. next heparin dose.
PTT: .100 sec
If heparin is given continuously, the
APTT: .70 se
blood specimen can be drawn at
any time.
If PTT is greater than 100 sec, the
client is at risk for bleeding, and the
physician is notified.
The antidote for heparin is
protamine sulfate.
Note whether the client is taking
antihistamines, vitamin C, or
salicylates, because these prolong
PTT time.
Serum Lipids (lipid profile)

Cholesterol Lipid necessary for steroid, Elevated in An accurate serum lipid test requires
bile, and cell membrane hypercholesterolemia. the client to fast for 9–12 hrs.
production. If elevated, increases risk of Have client fast 12–14 hrs prior to
Normal: ,200 mg/dL (total) CAD, hypertension, and MI. test.
No alcohol 24 hrs prior to test. Diet
intake 2 weeks prior to test will
affect results.
Steroids, phenytoin, and diuretics
may elevate level.
MAO inhibitors, some antibiotics,
and lovastatin may decrease level.
High-density Normal: 30–70 mg/dL Determines risk of developing Explain test to client.
lipoprotein (HDL) heart disease. The higher Teach that exercise increases HDL
the HDL level, the more levels.
the risk of heart disease is
decreased.
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RELATINg TO THE
Low-density Normal: 60–160 mg/dL The most important Explain test to client and suggest
lipoprotein (LDL) cholesterol form to determine diet changes as indicated.
a client’s risk of developing
heart disease.
Very low-density Normal: 25%–50% Determines risk of developing Explain test to client.
lipoprotein (VLDL) heart disease. Teach low-fat diet and exercise as
Contains the most circulating needed.
triglycerides.
Triglycerides Normal: 40–150 mg/dL Elevated level in CAD; level Explain test to client and suggest
increases when LDL level diet changes as indicated.
increases. If client is started on medication,
explain purpose and side effects.
Sources: American Association for Clinical Chemistry, 2011; Daniels, 2010.
Table 18-4 Cardiac biomarker Elevation Times

CARdIAC ONSET OF ELEVATION PEAk OF dURATION OF ELEVATION
bIOMARkER AFTER MI ELEVATION AFTER INjURy
Troponin I 3–12 hrs 18–24 hrs Up to 10 days
Troponin T 3–12 hrs 18–24 hrs Up to 10 days
Creatine kinase-MB 3–12 hrs 18–24 hrs 36–48 hrs

(CK-MB)
Myoglobin 1–4 hrs (Myoglobin is not 6–7 hrs Begins to return to normal after 12 hrs
specific to the heart. However, it but may be elevated up to 24 hrs.
is the first biomarker to elevate.)
Ischemia modified Few minutes to a few hours IMA is not as valuable with a client who
albumin (IMA) has experienced chest pain for several
hours because the IMA level may have
risen and returned to normal within
that time frame.
Source: Hartman, 2010.
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Table 18-5 Common Radiological and diagnostic Procedures

for Cardiovascular disorders
RELATINg TO THE
ExPLANATION/ CARdIOVASCULAR NURSINg
TEST NORMAL VALUES SySTEMS RESPONSIbILITIES
Angiography A contrast medium is injected Identifies coronary vessel Explain the procedure to the
(cardiac angiogram) into a vein through a catheter occlusion or abnormality. client.
so the vein can be visualized Obtain baseline vital signs.
by an x-ray. Assess for potential allergies
Normal: normal vessel to contrast medium.
Arteriography A contrast medium is injected Assesses for pathology Explain the procedure to the
(arteriogram) into an artery through a such as narrowing from client.
catheter so the artery can be atherosclerosis. Assess for potential allergies
visualized by an x-ray. to contrast medium.
Normal: normal vessels
Chest x-ray Provides a two-dimensional Detects size, as to Instruct the client to remove
image of the lungs without enlargement or hypertrophy, all metal objects from the
using contrast media. and displacement of the heart chest and neck area and wear
Normal: no cardiac within the chest. a hospital gown that does not
enlargement and no lung Lung congestion may indicate have snap closures.
congestion heart function. If chest x-ray shows lung
congestion, elevate the
head of the bed to improve
breathing.
Cardiac positron Radioactive tracers are Identifies cardiac tissue with Instruct the client not to
emission tomography injected intravenously prior adequate perfusion and smoke or consume caffeine or
(PET) scan to the test. Nuclear imaging tissue that is impaired due to alcohol for 24 hrs prior to the
is used to confirm tissue that decreased blood supply. test. Initiate NPO status from
has adequate blood supply 10 p.m. the evening before the
and tissue that has become test, except for medications
impaired due to a lack of and water. Obtain informed
blood. written consent.
Encourage the client to drink
fluids after the procedure to
facilitate faster excretion of
the radioactive material.
Radionuclide angi- A radioisotope is injected to The ejection fraction (a com- A signed consent is usually
ography (multigated evaluate the function of the parison of the volume of blood needed.
radioisotope scan, left ventricle. pumped by the left ventricle to
multigated acquisition the total volume of blood left
scanning, MUGA) in the ventricle) is measured.
Technetium A tracer or radioisotope, Important in diagnosing acute Instruct the client not to smoke
pyrophosphate which is injected MIs, with the best accuracy or consume caffeine or alcohol
scanning intravenously, accumulates obtained at 48 hrs after the for 3 hrs before the test.
in the damaged or infarcted client experiences symptoms Inform the client that the test
tissue areas, called hot spots. suggestive of an infarct. will take 45–60 min.
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Table 18-5 Common Radiological and diagnostic Procedures

for Cardiovascular disorders (Continued)
RELATINg TO THE
Thallium test A radioactive tracer (thal- Accumulation is lessened in Instruct the client to refrain
(myocardial perfusion lium-201) is injected and areas of myocardial tissue that from eating and drinking for
scan) accumulates in myocardial tis- are not well perfused, areas 3 hrs prior to the test.
sue that is well perfused. called cold spots.
The client may be asked to

perform exercise, such as rid-
ing a bike, during the test to
evaluate the perfusion of myo-
cardial tissue during exercise.
Table 18-6 Other diagnostic Tests

RELATINg TO THE
Cardiac biopsy Sample of cardiac tissue The tissue sample is taken Preparation is the same as
is taken during a cardiac from the apex or septum to for cardiac catheterization.
catheterization. determine toxicity related After the procedure, observe
to drugs, inflammation, or the client for symptoms
rejection of a transplanted of a perforation, such as
heart. chest pain, decreased blood
pressure, or dyspnea.
Cardiac A catheter is passed into the Determines oxygen level, Assess the client for allergy to
catheterization right and/or left side of the cardiac output, and pressure iodine or shellfish. The client is
(cardiac angiogram, heart. within the heart chambers. to fast for 6 hrs prior to the test,
coronary arteriogram) but medications can be taken
with sips of water. Inform the
client of the possibility of feeling
warm or flushed during the test.
After the procedure, assess
the peripheral pulses every
15 min for 2–4 hrs, or accord-
ing to physician’s orders. As-
sess color, temperature, and
pulse in the extremity below
the catheter insertion site.
Instruct the client to keep the
involved extremity straight for
6–8 hrs.
Echocardiogram An ultrasound of the heart Very helpful in diagnosing valve Explain the procedure to the
to determine hypertrophies, abnormalities and pericardial client and assure the client that
cardiomyopathies, or effusion. The Doppler there is no discomfort during
congenital defects. technique assesses coronary the procedure, although some
blood flow and evaluates pressure may be felt on the
cardiac valvular disease. chest wall from the transducer.
(Continues)
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Table 18-6 Other diagnostic Tests (Continued)

RELATINg TO THE
Electrocardiogram Electrodes are placed on the Detects myocardial damage, Explain the procedure to the
(ECG) skin to record wave patterns rhythmic disturbances, and client. Inform the client that
of the electrical conduction of hyperkalemia. the test is painless.
the heart.
Holter monitor A portable EKG monitors Relates cardiac dysrhythmias Instruct the client to engage
and records the electrical to client symptoms. Evaluates in normal daily activities and
conduction of the heart for pacemaker function and effect to keep a journal of symptoms
a period of 24 hrs. The heart of antiarrhythmic medications. experienced when performing
rhythm is compared to client these activities.
activities.
Pericardiocentesis Fluid is aspirated from the Analyzes fluid that is removed Obtain written informed
pericardial sac with a needle. from the pericardial sac. consent.
Relieves pressure of excess Position the client in the semi-
fluid in cardiac tamponade. Fowler’s position during the
procedure and attach to an
EKG monitor.
Postprocedure, take vital
signs every 15 min and
monitor EKG rhythm.
Pulse oximetry A noninvasive procedure. A Normal: .95% (at sea level) Explain the procedure to
transdermal clip is placed on Determines arterial blood the client. Assess peripheral
a finger or earlobe to detect oxygen saturation. circulation, because this may
the arterial oxygen saturation alter results. Place the sensor
(SaO2). on the earlobe, fingertip, or
pinna of the ear. Keep the
sensor intact until a consistent
reading is obtained. Observe
and record readings.
Report to the physician
measurements below 95%.
Stress test An ECG is taken as the client Evaluates the effects of Explain the procedure to the
exercises. Often the client is exercise on the heart. client.
asked to walk on a treadmill in The test is frequently used Encourage the client to wear
which the incline is elevated at with clients who have CAD. good walking shoes during
various times throughout the the test.
test.
Transesophageal An endoscopic ultrasound in Useful in diagnosing A postprocedural sore throat

echocardiography which a transducer is placed vegetations and abscesses on is expected, but assess client
(TEE) directly behind the heart to cardiac valves, especially the thoroughly for complications if
visualize the heart’s valves mitral valve, aortic dissection, he experiences a severe sore
and chambers. coronary artery disease, and throat.
Subcutaneous tissue, ribs, cardiac-originated arterial Monitor client for hemorrhage,
and lungs are avoided that emboli (Mosby’s Dictionary, dyspnea, and abdominal
may interfere with an external 2006). distention.
ultrasound.
Complications of the
procedure include esophageal
laceration or perforation,
peritonitis, pneumothorax, and
hemothorax (Fink, 2006).
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Table 18-6 Other diagnostic Tests (Continued)

RELATINg TO THE
Arterial This test can be done Determines arteriosclerotic Explain to the client that the
plethysmography on an artery (arterial disease in the upper test is painless.
(pulse volume plethysmography) or a vein extremities and occlusive Instruct the client to lie still
recorder or cuff (venous plethysmography). disease in the lower during the test.
pressure test) Three blood pressure cuffs are extremities. Instruct the client not to
applied to an extremity and A decrease of 20 mm Hg of smoke for 30 min prior to the
connected to a pulse volume pressure indicates arterial test.
recorder that records the occlusion with an arterial Instruct the client to remove
amplitude of each pulse wave. plethysmography. clothing from the extremity on
If there is a decrease in the Venous plethysmography which the test is to be done.
amplitude of the pulse wave, assesses venous blood flow in
an occlusion is in the vessel lower extremity.
proximal to the cuff.
The test is not as reliable as

angiography but also does not
have the risks associated with
an angiogram.
Normal arterial
plethysmography: normal
arterial pulse waves
Normal venous
plethysmography: Normal
venous pulse waves
Venous duplex Doppler exam of venous Diagnostic tool for deep Explain procedure to client.
ultrasonography blood flow. vein thrombosis and valve
function.
(Adapted from Pagana & Pagana, 2009)
CONCLUSION
A thorough knowledge of the anatomy and physiology of
the heart and circulatory system is essential to assessing the
cardiovascular system and understanding cardiovascular con-
ditions. When the learner comprehends this chapter content,
they should be able to competently assess clients with cardiac
disorders by relating physiological concepts to the disease
process and explain the relationship of laboratory results to
client conditions.
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Chapter 19
Caring for Clients
with Dysrhythmias
KeY terMs
cardiac ablations dysrhythmia pharmacological cardioversion
cardioversion implantable cardioverter-
defibrillation defibrillator (ICD)
Learning ObjeCtives
Upon completion of the chapter, you should be able to:
2. Differentiate basic eCg tracings of heart dysrhythmias.
3. explain the pathophysiology and causes of dysrhythmias.
4. Describe nursing interventions for clients with dysrhythmias.
5. assist with the formulation of nursing care plans for clients with dysrhythmias.
414
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CHAPTER 19 Caring for Clients with Dysrhythmias 415
electrical impulse continues from the right and the left bundle
IntroDuctIon branches to the Purkinje fibers that transmit the electrical
When a client has angina or palpitations, the health care pro- impulse to the myocardial cells, resulting in depolarization or
vider auscultates the apical pulse and reviews the ECG moni- contraction of the ventricles. On an ECG the QRS complex
tor for abnormal tracings. Therefore, it is vital for the nurse represents the electrical impulse as it travels through the AV
to have an understanding of normal sinus rhythm and basic node, AV bundle, bundle branches, Purkinje fibers, and myo-
dysrhythmias. This chapter discusses the electrical conduc- cardial cells, ending with the ventricles contracting. The Q
tion system of the heart as it relates to the ECG tracings. The wave is not always present on the ECG strip.
definition of, causes, and treatment for several dysrhythmias The pause after the QRS complex is called the ST segment.
are explained. This represents the period between the contraction and the be-
ginning of the recovery or repolarization of the ventricular mus-
cles. The T wave represents the repolarization of the ventricles.
cArDIAc rHYtHM/ After the repolarization of the ventricles, the entire cycle
DYSrHYtHMIA begins again at the SA node. In this way the P wave, QRS
complex, and T waves are repeated with each heartbeat (see
An understanding of the normal sinus rhythm is a basis for Figure 19-2).
understanding cardiac dysrhythmias.
Dysrhythmias
normal Sinus rhythm A dysrhythmia is an irregularity in the rate, rhythm, or con-
The electrical conduction of the heart begins with the SA duction of the electrical system of the heart. Dysrhythmia can
node located in the superior section of the right atrium. occur in the atria, ventricles, or any part of the conduction
From the SA node, the electrical impulse spreads in wave system. Specialized cells in the heart muscle have the ability to
fashion through the atria similar to the ripples from a pebble generate an electrical impulse. Under certain conditions these
dropped in water. The firing of the SA node and the electri- cells start sending impulses to other cells in the heart, causing
cal impulse spreading across both atria yield a P wave on the irregular beats called ectopic beats. The most common causes
ECG (Figure 19-1). The P wave represents the electrical of dysrhythmias are coronary artery disease (CAD), HF, and
activity causing the contraction of both atria. myocardial infarction (MI). Other causes of dysrhythmias are
After the atria contract, the electrical impulse reaches the electrolyte imbalances and drug toxicity.
AV node, where it pauses for approximately one-tenth of a Symptoms of a client experiencing a dysrhythmia vary
second, allowing blood to enter both ventricles. The electrical from asymptomatic to cardiac arrest. The client experiences
impulse then starts down the AV bundle that divides into right fainting, seizures, fatigue, decreased energy level, exertional
and left bundle branches in the interventricular septum. The dyspnea, chest pain, and palpitations.
R
Atrial Ventricle Cycle
Sinoatrial
depolarization repolarization begins
(SA) node
(contraction systole) (relaxation diastole) again
P wave
PR T
Voltage
P U P
segment
Atrioventricular T
(AV) node P
Q U-wave
(AV) Bundle S occurs in
some patients
Bundle Ventricle
QRS
of HIS depolarization
complex
(contraction systole)
Right and left Time

bundle branches
P wave is a positive wave representing atrial depolarization.

Purkinje fibers
PR segment represents the electrical impulse as it moves through
the AV node, AV bundle, Bundle of HIS, bundle branches, and
Purkinje fibers prior to ventricular contraction.
Q wave is negative deflection or wave.
R wave is a positive deflection or wave.

S wave is a negative wave.
QRS complex represents ventricular depolarization.
T wave is a positive wave and represents ventricular repolarization.
U wave (occasionally seen in some patients) is a positive deflection
and associated with repolarization.
Figure 19-1 Relationship of the conduction system to an ECG strip.
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416 UNIT 6 Nursing Care of Clients with Cardiovascular and Hematologic Disorders
Premature Atrial Contractions

A premature atrial contraction (PAC) is an ectopic impulse

R R
P T P T not originating in the sinoatrial node, but in the atrial tis-
QS Q
S
sue. This causes an atrial depolarization to occur earlier
in the cycle than expected, thus the term premature atrial
contraction.
PACs do not cause stressful physical symptoms depend-
Figure 19-2 An ECG strip showing a normal sinus rhythm ing on how often they occur. Generally they are benign and
with the P wave, QRS complex, and T wave identified. occur several times a day in healthy individuals. If their oc-
currence causes an increase or decrease in the pulse rate, they
should be evaluated. PACs can be a symptom of myocardial
ischemia, developing HF, digitalis toxicity, hypokalemia, or
an inflammatory condition. Stress, caffeine, and smoking also

cause PACs. PACs can be the first indication that more seri-
ous atrial dysrhythmias could occur if not treated properly.
Atrial Tachycardia
Atrial tachycardia is an ectopic impulse that causes the atria
to contract at the rate of 140 to 250 beats per minute. This
Figure 19-3 Sinus bradycardia. is sometimes referred to as a supraventricular dysrhythmia,
meaning the impulse causing the dysrhythmia is occurring
above the ventricles. This dysrhythmia occurs as a continu-
Bradycardia ous rhythm or as short, sudden eruptions that start and end
Sinus bradycardia is a HR of 60 beats per minute or less spontaneously.
(Figure 19-3). Causes of sinus bradycardia are myocardial Atrial tachycardia occurs with hypokalemia, digitalis
ischemia, electrolyte imbalances, vagal stimulation, beta toxicity, and ischemia. Potassium supplements are given for
blockers, heart block, drug toxicity, intracranial tumors, sleep, hypokalemia. If an increased level of serum digitalis is the
and vomiting. The treatment for bradycardia is the adminis- cause, digitalis is withheld until the level returns to normal.
tration of atropine. Some clients with bradycardia may require An artificial pacemaker may be surgically inserted to regulate
a permanent pacemaker. Asymptomatic bradycardia related the atrial tachycardia.
to physical fitness is usually not treated.
Paroxysmal Supraventricular
Tachycardia Tachycardia
Tachycardia is a sinus rhythm with a HR ranging from 100 to Paroxysmal supraventricular tachycardia (PSVT) was previ-
150 beats per minute (Figure 19-4). Causes of tachycardia are ously called paroxysmal atrial tachycardia (PAT). PSVT is
exercise, emotional stress, fever, medications, pain, anemia, a rapid atrial beat accompanied by an abnormal conduction
thyrotoxicosis, pericarditis, HF, excessive caffeine intake, and in the AV node. The dysrhythmia occurs suddenly (paroxys-
tobacco use. When the heart is beating at this rate, there is mally) and is usually initiated by a premature beat. PSVT can
limited time for the ventricles to fill with blood, and less blood stop as abruptly as it begins. It can be caused by myocarditis,
is pumped to the coronary arteries and throughout the body. caffeine, alcohol ingestion, smoking, and stress. PSVT may
The client may experience anginal pain. The treatment for also be present in clients with coronary artery disease, mitral
sinus tachycardia depends on the cause. valve prolapse, and acute pericarditis. The physician performs
vagal stimulation procedures such as the Valsalva maneuver
Atrial Dysrhythmias and carotid sinus pressure or massage, which usually stops the
dysrhythmia. If these measures do not stop PSVT, adenosine,
Atrial dysrhythmias occur from electrical conduction distur- calcium channel blockers, such as verapamil hydrochloride
bances in the atria, resulting in premature beats or abnormal (Calan) or diltiazem hydrochloride (Cardizem), or beta
atrial rhythms. Common causes for atrial dysrhythmias are blockers, such as metoprolol (Lopressor) or esmolol hydro-
myocardial infarction, HF, electrolyte imbalances, emotional chloride (Brevibloc), are effective in treating dysrhythmias.
stress, and drugs. Electrical cardioversion may also be used.
Atrial Flutter
Atrial flutter, a rapid contraction of the atria, yields a HR
of 250 to 350 beats per minute. The ECG displays a saw-
tooth wave pattern (Figure 19-5). The AV node attempts to

block some of the atrial impulses, but usually the ventricles
are also contracting at a rate of 300 beats per minute. This
causes a decreased blood supply to the body because the
atria and ventricles are unable to fill with blood when they
are contracting at such a fast rate. This requires immediate
Figure 19-4 Sinus tachycardia. intervention.
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AF Symptoms
AF symptoms include palpitations, dyspnea,

dizziness, chest pain, and syncope. Relate the
Figure 19-5 Atrial flutter. physiological rationale for each of the symptoms
experienced by a client with AF.
Atrial Fibrillation
Atrial fibrillation (AF) is an erratic electrical activity of pharmacological cardioversion (correction of dysrhyth-
the atria, resulting in a rate of 350 to 600 beats per minute mia with medication) of AF. Digoxin and beta-adrenergic
(Figure 19-6). Atrial depolarization is so uncoordinated dur- blockers, such as atenolol (Tenormin), metoprolol (Toprol),
ing the dysrhythmia that the atria quiver rather than contract. and esmolol (Brevibloc), may also slow conduction to the
The AV node is bombarded with impulses and randomly ventricles. Medications that decrease the rapid response of the
transmits the impulses to the ventricles, causing varied irregu- ventricles include calcium channel blockers, such as verapamil
lar contractions of the ventricles with a ventricular rate of 100 (Calan, Isoptin), and diltiazem (Cardizem). Other antiar-
to 180 beats per minute. rhythmic medications prescribed for AF include amiodarone
An individual may experience the symptoms of palpita- (Cordarone), propafenone (Rythmol), flecainide (Tambo-
tions, dyspnea, dizziness, chest pain, and syncope with AF. cor), sotalol (Betapace), procainamide (Pronestyl), ibutilide
In most individuals, AF initially occurs paroxysmally with (Covert), and dofetilide (Tikosyn).
the symptoms lasting a few minutes to hours and then self- An electrical cardioversion is used for clients who do not
correcting. AF can be persistent or chronic, resulting in a respond to medication. The client is sedated for the proce-
continuous abnormal rhythm. Rapid electrical impulses in dure and does not feel the electrical shock. Antiarrhythmic
the atrial chamber will diminish atrial contraction, causing medications are administered after the cardioversion to pre-
an approximate 30% decrease in emptying of atria blood vol- vent future incidents of AF.
ume into the ventricles. This decreased volume also affects Two types of cardiac ablations (destruction of tis-
the volume of blood ejected from the ventricles, resulting in sue causing dysrhythmias) may be used to correct AF if
impaired cardiac output. Because the atria are not contracting pharmacological or electrical cardioversions do not stop
properly, blood pools in the atria, predisposing the person to the dysrhythmias. The first is an AV node ablation in which
thrombi forming on the walls of the atria. The thrombi can radio-frequency energy is applied to the conduction pathway
dislodge and travel to the brain (resulting in embolic strokes), through a long, thin catheter to destroy the small areas of
lungs, and other parts of the body. Individuals with AF are five tissue that are causing the AF. The newer form of ablation
times more likely to have a stroke than those who do not have is a procedure called radio-frequency catheter ablation with
AF (Lloyd-Jones et al., 2010). Because of the risk of stroke, pulmonary vein isolation. Multiple catheters (mapping, abla-
most clients are on anticoagulant therapy such as warfarin tion, and defibrillation) are inserted in the blood vessels in
sodium (Coumadin), clopidogrel bisulfate (Plavix), or a low the groin and threaded to the right atrium through a trans-
dose (81 mg) of aspirin daily to prevent clot formation. septal puncture. The mapping catheter is used to detect the
The aging population is at risk for developing AF as multiple impulses originating in the pulmonary vein and
a result of CAD, heart failure, and hypertension. Both of other cardiac areas. The ablation catheter burns the area
these cardiac conditions create stretching and impairment causing the fibrillation, resulting in a scar that ideally stops
of myocardial muscle and conduction fibers, also found in the fibrillation (Johnson, Jadick, & Knippers, 2011). Ablation
cardiomyopathy and pericarditis. Secondary causes of AF procedures are not always successful and the client may have
include thyrotoxicosis, caffeine intake, alcohol intoxication, recurring fibrillation. According to a study conducted by
stress, electrolyte imbalances, and cardiac surgery. Once the Dr. Douglas Packer, director of the Section of Electrophysi-
underlying condition is treated, AF may stop. ology at the Mayo Clinic, ablation successfully prevented
The use of digoxin, beta-adrenergic blockers, and cal- recurring fibrillation in 75% of clients with paroxysmal AF
cium channel blockers has been found to be effective for (Mayo Clinic, 2011a).

Antidysrhythmic Medications
Antidysrhythmic medication doses are reduced
in older adults if they have hepatic or renal
impairment.
Figure 19-6 Atrial fibrillation.
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Nursing care after the ablation procedures includes moni- If PVCs occur without the presence of other cardiac con-
toring of vital signs and inspecting the insertion sites for hema- ditions, there is no treatment other than removing the precipi-
toma formation or active bleeding. Anticoagulants (enoxaparin tating cause, such as stress or caffeine. Potassium supplements
sodium [Lovenox], a low-molecular-weight heparin, and war- are given for hypokalemia-induced PVCs. Administering
farin) are given to decrease the possibility of clot formation. oxygen may increase the oxygen perfusion to the myocardial
The client is walked after 4 to 6 hours and is encouraged to tissue and decrease the frequency of premature beats.
use an incentive spirometer. At discharge, the nurse teaches
the client to avoid heavy lifting and not to climb stairs for 24 to Ventricular Tachycardia
48 hours after the procedure (Johnson et al., 2011). Ventricular tachycardia (VT) is the occurrence of three or
more consecutive PVCs. The ventricular rate may go as high
Ventricular Dysrhythmias as 140 to 240 beats per minute. Underlying conditions in
Ventricular dysrhythmias originate in the ventricles. They which VT occurs are cardiomyopathy, hypoxemia, digitalis
are more life threatening than atrial dysrhythmias because toxicity, and electrolyte imbalance.
the ventricles supply blood to the lungs and body. These dys- During VT, the client has a low blood pressure, weak or
rhythmias must be treated promptly. absent peripheral pulses, body weakness, and may become un-
conscious. The ventricle is beating so rapidly that it is unable
to fill with blood or eject blood properly. This causes blood to
Premature Ventricular Contractions back up in the pulmonary circulation, leading to pulmonary
Premature ventricular contractions (PVCs) arise from ecto- congestion.
pic beats in the ventricles and are the most common ectopic Ventricular tachycardia must be treated promptly be-
beats (Figure 19-7). PVCs can easily be identified on the ECG cause a VT rhythm may lead into ventricular fibrillation, a
because of the wide, bizarre QRS complexes. No P waves pre- life-threatening dysrhythmia. The client is given oxygen, and
cede the QRS complex. an intravenous line is inserted if one is not already in place.
Coronary artery disease is the most common cause of The drug of choice is amiodarone (Cordarone) given intra-
PVCs. Other causes of PVCs are myocardial ischemia, HF, venously. Lidocaine hydrochloride (Xylocaine HCL), sotalol
electrolyte imbalances, digitalis toxicity, anxiety, exercise, hy- (Betapace), and magnesium sulfate (Magnesium) may also be
poxia, caffeine, and excessive alcohol consumption. given. If the VT is not controlled with medications, the client
is cardioverted if peripheral pulses are present, or defibrillated
if peripheral pulses are absent.
Cardioversion
Cardioversion is the delivery of a synchronized electrical

shock to change a dysrhythmia to a rhythm that circulates
more blood to the body tissues and improves oxygenation of
the tissues. The electrical shock is delivered on the R wave
because a shock during ventricular depolarization may cause
ventricular fibrillation. Cardioversion is done as an elective
Figure 19-7 Premature ventricular contraction. or emergency treatment. Electrodes are placed to the right of
EvidEncE-BasEd
PracticE
Recovery PVCs Connected to Heart Disease
Sources: Dewey, F., Kapoor, J., Williams, R., Lipinski, M., Ashley, E., Hadley, D., et al. (2008). Ventricular arrhythmias during clinical treadmill
testing and prognosis. Archives of Internal Medicine, 168(2), 225–234.
Lundberg, G. (2008). The Medscape medical minute: Recovery PVCs during treadmill testing tied to heart disease. Medscape Journal of Medicine,
10(4), 93. Retrieved January 16, 2009, from http://www.medscape.com/viewarticle/571891_print
DisCussion study conclusion was that clients experi- mortality rate and show more risk factors
Eight individuals from Stanford reported encing PVCs in the recovery or rest period for coronary artery heart disease. These
a 7-year study on 1,847 heart failure– after exercise had an almost “doubled facts indicate that health care providers
free clients in the Archives of Internal propensity-adjusted mortality rate” caring for clients experiencing PVCs after
Medicine in 2008. Forty-six percent of the (Lundberg, 2008, p. 93). exercise should monitor these clients more
clients developed PVCs during exercise carefully and provide client teaching to
and 34% developed PVCs while recover- iMPLiCATions FoR PRACTiCE reduce risk factors for heart disease.
ing from the exercise period. Nine percent Clients who experience PVCs as they are
of these clients died within 5 years. The recovering from exercise have an increased
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the sternum below the clavicle and at the apex of the heart.
The electrodes are lubricated with a special gel or placed on
gel pads or defibrillator pads. The electrical current delivered
through the electrodes depolarizes the myocardium and allows
the heart’s pacemaker to reestablish a sinus rhythm.
The client is NPO for 8 hours before an elective cardio-
version. Diuretics and digitalis preparations are withheld 24 to
72 hours before the cardioversion because they make myocar-
dium cells less responsive to conversion to a normal rhythm Dual-chamber
or may cause a serious dysrhythmia after the cardioversion. ICD device
Anticoagulants and oral antidysrhythmics are still given be-
fore cardioversion. Anticoagulants are given so a thrombus
is not released into the system. A sedative such as diazepam
(Valium) or midazolam hydrochloride (Versed) is given in-
travenously before the procedure. Monitor the client’s vital
signs and ECG strip closely for the first hour afterward and
then as ordered by the physician.

Defibrillation
Defibrillation is the delivery of an unsynchronized, high-
energy electrical shock during an emergency situation, such as
a cardiac arrest or pulseless VT, to convert the life-threatening
dysrhythmia or arrhythmia to a sinus rhythm. Defibrillation is
done by a physician or a nurse who has had special education Figure 19-8 An implantable cardioverter-defibrillator:
to handle emergency situations. Paddles are lubricated with a A dual-chamber ICD device with a pulse generator is implanted
special gel, or gel pads or defibrillator pads are applied to the below the collarbone, and endocardial leads are positioned in
skin where the paddles will be placed. The paddles are placed the heart through a vein.
to the right of the sternum below the clavicle and at the apex of
the heart. When the electrical shock is delivered to the client,
everyone stands clear of the bed to prevent them from also electrical shock is sent from the pulse generator. The ICD is
receiving the electrical shock. More than one electrical shock capable of delivering three more shocks to the heart muscle if
may be delivered in an attempt to convert the rhythm. the heart does not return to normal sinus rhythm (NSR). Usu-
If conservative measures do not control the VT and ally, clients are converted to NSR with the first shock. Some
the client has periodic episodes of VT, an implantable ICDs also deliver cardiac resynchronization therapy (CRT)
cardioverter-defibrillator (ICD) is implanted in the cli- for clients with advanced HF. These devices have three leads;
ent (Figure 19-8). This device senses the dysrhythmia and one lead is placed in the right atrium and one lead is placed in
automatically sends an electrical shock directly to the heart to each of the ventricles. When this device functions as an ICD,
defibrillate it. it senses abnormal heartbeats and delivers a shock to the heart
Most ICDs have one to three endocardial leads that are to initiate a normal rhythm. When functioning as a CRT, it co-
guided through a vein into the right side of the heart where ordinates the beating of the ventricles so they effectively work
they become embedded into the heart tissue. The pulse gen- together and pump blood throughout the body (Stamper,
erator is placed under the skin below the collarbone. The ICD 2011). Some ICDs also function as a pacemaker and an ICD,
detects VT and ventricular fibrillation (VF) through the leads delivering shocks as needed to correct abnormal rhythms
attached to the heart muscle. Once VT or VF is detected, an but also initiating heartbeats when the heartbeat is too slow.
Another ICD, called an antitachycardia pacing (ATP) device,
sends a fast impulse to correct the rhythm after an ICD shock
and detects and treats rapid atrial heartbeats (FDA, 2002;
BESTPracticE Stanford Hospital and Clinics, 2009). ICDs store the client’s
dysrhythmic activity and allow the health care practitioner to
Placement of Defibrillator test the electrophysiological activity noninvasively (American
Pads on Client Heart Association, 2007c).
When a pacemaker or ICD is located where a pad Complications after the insertion of an ICD are atelecta-
would normally be placed, the pad is placed at sis, pneumonia, pneumothorax, thrombus, and a seroma at the
least an inch from the device.
generator site (a swelling from serum collecting around the
device that initiates the shock). According to Shaffer (2002),
Remove all transdermal medication patches
anger and depression are common, expected side effects.
and wipe the area before placing a defibrillator
pad because the medication patch may block the
electrical shock or cause burns on the chest (Ameri-
Ventricular Fibrillation
can Heart Association).
The most common cause of VF is CAD. VF is a disorganized,
chaotic quivering of the ventricles. The ventricles are un-
able to contract, and no blood is ejected into the circulatory
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Third-Degree AV Block
Third-degree heart block is when no impulses are able to pass
from the atria through the AV node to the ventricles. The atria

and ventricles beat independently of each other. The causes
of third-degree block are myocardial ischemia, drug toxicity,
and electrolyte imbalances. Atropine sulfate may be given
to improve conduction through the AV node. A permanent
pacemaker is usually required to control the dysrhythmia.
Figure 19-9 Ventricular fibrillation (VF). A pacemaker is an electronic device that stimulates the
heart to beat when the heartbeat is slow or drops below a set
HR. It consists of one or two lead wires that are attached to
the endocardium of the right atrium, right ventricle, or both,
and a pulse generator that is “the ‘brain’ of the pacemaker”
(Stanford Hospital and Clinics, 2009). The electrodes sense
the heart’s electrical activity and relay the information to the

pulse generator. The purpose of the pacemaker is to regu-
late the HR and increase CO. When the heart beats slower
than the programmed rate, an electrical impulse is sent to
the lead that causes the heart to beat faster. Pacemakers are
used for bradycardia, tachycardia, myocardial infarction, and
Figure 19-10 Ventricular asystole. heart block.
Some pacemakers have leads in the atrium, ventricle, or
both to sense electrical activity and set the beating pace of
system. The ECG reading is a series of jagged, unidentifiable one or both chambers. Sometimes in HF the ventricles do not
waves (Figure 19-9). The client will not have a pulse, blood pump effectively together, decreasing the amount of blood
pressure, or respirations. This dysrhythmia is serious. Aggres- pumped throughout the body. A biventricular pacemaker
sive measures must be taken to initiate CPR and defibrillate paces the ventricles together, increasing the pumping effec-
the client immediately. tiveness of the ventricles. The pacing of a biventricular pace-
maker is called cardiac resynchronization therapy because it
Ventricular Asystole puts the ventricles back in synch.
A pacemaker is used either temporarily or permanently.
Ventricular asystole is represented by a P wave or a straight A temporary pacemaker is utilized until a client’s condition
line on the ECG (Figure 19-10). The ventricles are not con- improves or until a permanent pacemaker is inserted. With
tracting, and the client is in cardiac arrest. The client loses a temporary pacemaker, the pulse generator remains out-
consciousness and has no pulse or respirations. Aggressive side of the body. The permanent pacemaker has a lead wire
treatment should be initiated within 1 minute to prevent threaded through a vein to the heart and the pulse generator
chemical changes within the body that jeopardize recovery. is implanted subcutaneously under the collarbone. An ECG
CPR is started, and the client is defibrillated. Atropine sulfate
and epinephrine are given intravenously.
Atrioventricular Blocks SAFETy

In atrioventricular blocks, the electrical conduction is inter-
rupted to some degree between the atria and ventricles at Pacemaker and ICD
the AV node. The extent of interruption is classified as first Encourage the client to carry an ID card and wear
degree, second degree, or third degree. a medical identification tag indicating the pres-
ence of a pacemaker or ICD.
First-Degree AV Block
In first-degree block, the impulse is delayed in traveling
through the AV node. The impulse eventually reaches the
ventricles but is delayed. There are no physical symptoms or
treatment for first-degree block.
CLIENT tEaching
CLIENT TEAChINg
Second-Degree AV Block
In second-degree block, some of the impulses pass through Pacemaker
the AV node to the ventricles and others are blocked. • High-tension wires, high-voltage electrical
Symptoms include irregular pulse, vertigo, and weakness. A generators, or MRIs may cause pacemaker
temporary pacemaker is inserted until the conduction pat- malfunction.
tern is stabilized. If the dysrhythmia persists, a permanent
• Avoid contact sports.
pacemaker is implanted. When the impulse is blocked, the
ECG reveals an extended PR interval that is not followed by • Pacemakers may activate airport security alarms.
a QRS complex.
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of a client with a pacemaker shows the impulse from the pulse

generator by a pacemaker spike, a vertical line before each
nursing Management
QRS on the ECG strip. Monitor vital signs including apical pulse. Provide rest periods
Before discharge, teach clients to take accurate apical and throughout the day. Explain all procedures and treatments.
radial pulses. Inform clients to report dizziness, fainting, or Encourage client to verbalize concerns about condition and
fever. Clients are taught to have regular pacemaker checks or potential complications. Teach relaxation methods.
transtelephonic monitoring in which an ECG strip is sent by
phone to a designated hospital or physician’s office.
nurSInG ProcESS
Medical-Surgical Data collection
Management Subjective Data
Pharmacological Inquire if the client has experienced palpitations, light-
Dysrhythmias originating in the atria are treated with amio- headedness, nausea, dyspnea, anxiety, fatigue, or chest
darone (Cordarone), diltiazem hydrochloride (Cardizem, discomfort.
Dilacor, Tiazac), and digoxin (Lanoxin). Dysrhythmias
originating in the ventricles are treated with amiodarone Objective Data
(Cordarone), lidocaine hydrochloride (Xylocaine HCl), and Check the HR, blood pressure, and respirations if a client is ex-
magnesium sulfate. periencing dysrhythmias. While listening to the apical pulse and
respirations, note abnormal heart sounds, and monitor breath
Diet sounds for crackles. Crackles indicate the lungs are filling with
The client is usually placed on a low-fat, low-cholesterol diet. fluid. Observe the skin for pallor and cyanosis, especially during
Caffeine consumption is restricted. and after activity/exercise. Urine output may decrease.
Nursing diagnoses for a client with dysrhythmias include the following:

NursINg PlaNNINg/ NursINg
DIagNoses outComes INterveNtIoNs ratIoNale
Decreased Cardiac Out- The client will have in- Apply electrodes for telemetry Provides continuous moni-
put related to inadequate creased CO as evidenced monitoring. toring of cardiac rhythms.
electrical conduction by stable vital signs, clear Balance activity with rest peri- To meet the demands of
breath sounds, no dizzi- ods, and monitor vital signs dur- daily activities with cardiac
ness, and urine output of ing activity and at rest. reserve. Monitoring vital
at least 1500 mL/24 hrs. signs gives the nurse an
indication of how client is
tolerating activity.
Listen to the apical pulse, espe- Nurse monitors the apical
cially noting rate and rhythm. pulse for dysrhythmias.
Elevate the extremities so they Blood pools in dependent
are not in a dependent position. extremities.
Anxiety related to fear of The client will relate Care for the client in a calm, Client feels confident and re-
potential diagnosis, treat- fears of potential cardiac confident, and efficient manner. laxed in a calm environment.
ment regimen, and death problems. Remain with the client and ex- Clients have less anxiety
plain procedures and treatments. when they understand pro-
cedures and treatments.
Encourage client input regarding Allowing input into care
the care. gives the client a sense of
control.
Encourage the client to verbal- Decreases client’s anxiety
ize concerns about the dys- and provides nurse with
rhythmia and potential future insight into client’s under-
complications. standing of condition.
Teach the client relaxation Provides client activities to
activities. decrease anxiety.
(Continues)
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NursINg PlaNNINg/ NursINg

DIagNoses outComes INterveNtIoNs ratIoNale
Deficient Knowledge The client will describe Explain medication administra- Explanation increases un-
related to electrical con- electrical disorder and tion times, action, side effects, derstanding of medication
duction of the heart and treatment methods. and symptoms that need report- purpose and compliance.
treatment methods ing. Provide written instructions Written instructions provide
to the client and family. printed reference for client to
review.
Explain symptoms of dysrhyth- Knowledge of symptoms al-
mias such as fatigue, edema, lows client to take necessary
palpitations, light-headedness, actions to treat or report
nausea, dyspnea, and anxiety. dysrhythmia to health care
provider.
If a pacemaker is needed, ex- Client understands reason
plain to client and family the pur- for pacemaker and is pre-
pose, insertion procedures, and pared to provide appropriate
home care. care after discharge.
concluSIon
When the electrical conduction of the heart follows a regular
pattern or cycle, the heart is in normal sinus rhythm. Any
alteration in the cycle produces a dysrhythmia. To correct
a dysrhythmia, the physician may order medications, car-
diac ablation, cardioversion, or defibrillation. The competent
nurse explains the different dysrhythmias, their causes, and
nursing interventions needed in the treatment.
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Chapter 20
Caring for Clients with
Inflammatory/Infectious
Cardiac Disorders
Key terms
annulus pericardial effusion pericarditis
cardiac tamponade pericardial friction rub transesophageal echocardiography
mitral valve prolapse pericardiectomy (TEE)
myocarditis pericardiocentesis vegetations
Learning ObjeCtives
2. Discuss pathophysiology of inflammatory/infectious cardiac disorders.
3. assess clients with inflammatory/infectious cardiac disorders.
4. Discuss diagnostic results of clients with inflammatory/infectious cardiac disorders.
5. recognize symptoms of clients with inflammatory/infectious cardiac disorders.
6. apply nursing interventions when caring for clients with inflammatory/infectious cardiac
disorders.
7. teach clients prophylactic care, medication administration and side effects, and
appropriate health care.
423
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88021_ch20_ptg01_423_430.indd 423 12/28/11 11:32 PM
IntroductIon
Inflammatory and infectious cardiac conditions often origi-
nate from a bacteria, virus, fungus, or parasite. Our immune TEE versus Echocardiogram
systems work hard to keep us safe from these pathogens.
However, when a pathogen enters the bloodstream, it can
invade not only the endocardium but other layers of the heart Describe the advantage of a TEE over an echocar-
and cardiac structures that lead to serious complications, such diogram when confirming the diagnosis of endo-
as valve disorders and congestive heart failure. carditis or valvular heart disease.
Cardiac inflammatory disorders include rheumatic heart dis-
ease, infective endocarditis, myocarditis, pericarditis, and valvular
heart disease. This chapter discusses the etiology and pathology,
diagnostic tests, signs and symptoms, medical and surgical treat- individuals who use IV drugs, are immunosuppressed, have den-
ment, and nursing interventions of these conditions. tal caries and abscesses, and a history of valvular heart disease.
Goldrick (2003) reported that endocarditis is associated with
body piercing. The American Heart Association recommends
■ RHEUMATIC HEART DISEASE that clients at risk for endocarditis avoid body piercing (Mayo
Clinic, 2009; Wilson, Taubert, Gewitz, et al., 2007).
R heumatic heart disease is a complication of rheumatic

fever and is also linked to group A streptococcus after
an upper respiratory infection. Rheumatic fever is a systemic
The two forms of endocarditis are acute and subacute.
Symptoms of acute endocarditis are tachycardia, pallor, dia-
phoresis, and symptoms of a systemic infection, such as tem-
inflammatory disease that occurs 2 to 3 weeks after an inade- perature of 103°F (39.4°C) and shaking chills. Clients with
quately treated pharyngitis caused by group A beta-hemolytic subacute endocarditis have low-grade fever, malaise, weight
streptococcus. Symptoms of rheumatic fever are a mild fever, loss, and anemia. Clients with both types may have murmurs
polyarthritis, carditis, chorea, and a rash. The endocardium, and symptoms of HF, such as dyspnea, peripheral edema, and
myocardium, and epicardium can become inflamed, with pulmonary congestion.
most of the damage occurring to the mitral valve. The mitral Endocarditis is diagnosed by the client’s history and
valve becomes incompetent because of thickening and steno- symptoms. Transesophageal echocardiography (TEE)
sis of the valve leaflets. Mitral valve prolapse (valve leaflets can confirm the diagnosis by ultrasonic imaging of the cardiac
flip back into the left atrium during systole) may result. structures through the esophagus. The erythrocyte sedimen-
A person who has had rheumatic fever is more likely to tation rate (ESR) and WBC are elevated. A blood culture and
have a recurrence. It is treated with intravenous antibiotics, sensitivity is done to determine the causative organism and
anti-inflammatory agents, corticosteroids, and strict bed rest. the most effective antibiotic.
The main goal is to treat the inflammation, prevent cardiac
complications, and prevent the recurrence of the disease. Medical-Surgical
According to the 2007 AHA guidelines (2010b), clients
with a history of rheumatic fever are no longer given a pro- Management
phylactic antibiotic prior to dental procedures unless they Surgical
have a history of endocarditis, a prosthetic cardiac valve, or Surgical repair or replacement of a valve is done in severe
certain forms of congenital heart disease. The AHA (2010b) cases. Surgical intervention for damaged valves is discussed in
also no longer recommends antibiotic prophylaxis for previ- more detail later in this chapter.
ous rheumatic fever clients undergoing a gastrointestinal or
genitourinary tract procedure. Pharmacological
Clients are treated with antimicrobial drugs and intravenous
■ InfECTIvE EnDoCARDITIS antibiotics. The antibiotics are usually continued for 2 to 6
weeks. Broad-spectrum antibiotics are given if there is a delay
I nfective endocarditis is an inflammation or infection of the

inside lining of the heart, particularly the heart valves. The eti-
ology of inflammatory endocarditis is a collagen-vascular disease
in obtaining blood culture results, and then changed to treat
the specific pathogen. The most commonly used antibiotics
are penicillin V potassium (V-Cillin K), vancomycin hydro-
or rheumatic fever. Clients with a prosthetic valve are among chloride (Vancocin), gentamicin sulfate (Garamycin), am-
those at highest risk for endocarditis (Fink, 2006). Infective picillin (Principen), amoxicillin (Amoxil), and ciprofloxacin
endocarditis is caused by bacteria, fungi, or virus. As the microor- (Cipro). Oxacillin-resistant strains of Staphylococcus aureus
ganisms invade the valves, they form fibrinous substances called are treated with vancomycin and rifampin (Rifadin) for at
vegetations. The vegetations cause scar tissue on the valves, re- least 6 weeks and gentamicin for the first 2 weeks. Nafcillin
sulting in hard, brittle valves that do not close properly and allow (Nafcil) is used for non-oxacillin-resistant S. aureus. Ampho-
blood to flow back into the previous chamber. The valve is said tericin B (Amphocin) alone or with fluconazole (Diflucan) is
to be insufficient. Sometimes the vegetations cause the valve flaps given for at least 6 weeks for a fungal infection (Fink, 2006).
to grow together, resulting in a narrowing of the opening. This
is called a valvular stenosis. The mitral valve is more frequently Diet
affected than any other valve and is termed mitral insufficiency Provide the client with a well-balanced nutritious diet, with
or mitral stenosis. Historically, rheumatic fever was the com- between-meal snacks. An adequate intake of protein, zinc,
mon cause of endocarditis. Clients at risk for endocarditis are iron, phosphate, and vitamins A, B, C, D, and E is important
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CHAPTER 20 Caring for Clients with Inflammatory/Infectious Cardiac Disorders 425
Table 20-1 AHA Antibiotic Recommendations Prior to Dental Procedures

for Clients with Prosthetic Cardiac Valve, Previous Endocarditis,
Congenital Heart Disease, and Cardiac Transplantation Recipients
with Cardiac Valvular Disease
DEnTAl PRoCEDuREs REquIRIng DEnTAl PRoCEDuREs noT REquIRIng
AnTIbIoTIC PRoPHylAxIs AnTIbIoTIC PRoPHylAxIs
• Procedures that involve manipulating or puncturing • Anesthetic injection through noninfected tissue
gingival tissue • Dental x-rays
• Procedures that involve manipulating or puncturing • Removal, placement, or adjustment of prosthodontic or
tooth root orthodontic appliances or brackets
• Procedures that involve manipulating or puncturing oral • Shedding of deciduous teeth
mucosa • Bleeding from lip or oral mucosa injuries
(Adapted from Wilson, 2009)
for the immune system and wound healing (Fink, 2006). be an autoimmune reaction such as with rheumatic fever or
Vitamin K intake is kept at a consistent level if the client is on lupus erythematosus. Usually the cause is a virus. Myocarditis
warfarin (Coumadin) (Fink, 2006). is more prevalent in clients with AIDS.
Acute myocarditis presents with flu-like symptoms of fever,
Activity pharyngitis, myalgias, and gastrointestinal complications. The
The client is on bed rest to decrease the workload of the heart. client will also have chest pain and should be monitored for signs
Provide a calm, quiet environment. of HF. Other common symptoms include dysrhythmias, dys-
pnea at rest or with exercise, edema of legs, ankles, and feet, and
Health Promotion fatigue. A pericardial friction rub is often heard if the pericar-
Clients who previously had endocarditis or have a mitral valve dium becomes involved. The friction rub is a “squeaky” sound
prolapse are more prone to develop endocarditis. Due to a heard through the stethoscope when the two inflamed pericar-
lack of hard scientific evidence the AHA (2010a) no longer dial surfaces rub together with the contraction of the heart.
recommends that clients at risk for bacterial endocarditis take Myocarditis diagnostic symptoms are nonspecific. They
antibiotics prophylactically prior to gastrointestinal or geni- include ECG, chest x-ray, MRI, echocardiogram, CK-MB,
tourinary procedures if there is no evidence of an infection myoglobin, troponin I and T, and culture and sensitivity. The
(Tong & Rothwell, 2000; Mayo Clinic, 2009c; Wilson, 2009). diagnosis of myocarditis can be confirmed with an endomyo-
See Table 20-1 for current AHA recommendations for anti- cardial biopsy.
biotic therapy prior to dental procedures only for clients with
a prosthetic cardiac valve, previous endocarditis, congenital Medical-Surgical
heart disease, or cardiac transplantation recipients with car- Management
diac valvular disease. If prophylactic antibiotics are needed,
amoxicillin trihydrate (Amoxil) or azithromycin (Zithromax) Pharmacological
is usually ordered 30 to 60 minutes before the procedure. Broad-spectrum antibiotics are given to treat the infection.
Anti-inflammatory agents (corticosteroids) may be given to re-
nursing Management duce the inflammation. Angiotensin-converting enzyme (ACE)
Administer oxygen as needed, and measure blood pressure and inhibitors, such as enalapril (Vasotec), captopril (Capoten),
pulse before and after activity to monitor tolerance. Note apical lisinopril (Zestril), and angiotensin II receptor blockers, losar-
pulse rate and rhythm and assess breath sounds for adventi- tan (Cozaar) and valsartan (Diovan), vasodilate cardiac vessels
tious sounds. Balance activity with rest periods. Monitor BUN and increase the blood flow. Beta blockers, such as metoprolol
and creatinine levels if a client is on vancomycin hydrochloride (Toprol-XL) and carvedilol (Coreg), slow the heart rate and de-
(Vancocin) or gentamicin sulfate (Garamycin) because both of crease dysrhythmias. Furosemide (Lasix), a diuretic, decreases
these drugs are nephrotoxic. Garamycin is also ototoxic, so the edema. Oxygen is administered as needed.
nurse observes if the client seems to have more difficulty hearing.
Activity
The client is placed on bed rest to decrease the workload of
■ MyoCARDITIS the heart.
nursing Management
M yocarditis is an inflammation of the myocardium of
the heart. Lymphocytes and leukocytes invade the
muscle fibers of the heart, causing the chambers to enlarge
Monitor the client for symptoms of HF or pericarditis. Place
the client in a semi-Fowler’s position to assist with breathing.
and the muscle to weaken. This can lead to HF. Myocarditis Provide a quiet environment and frequent rest periods. Apply
is caused by bacteria, viruses, fungi, or parasites. It can also a pulse oximeter to monitor arterial oxygen saturation level.
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88021_ch20_ptg01_423_430.indd 425 12/28/11 11:32 PM
BestPracTice CliEnT Teaching

TEaChing
Types of Pulse Oximetry Sensors avoid infections
Reusable Finger sensor Teach the client with myocarditis to avoid poten-
• The finger is the most common site to apply a tial infections by avoiding people with flu-like
sensor. symptoms, regularly washing hands, reducing ex-
• Assess that the sensor does not constrict blood posure to ticks, and maintaining immunizations,
flow. especially for rubella and influenza, which cause
• Move the reusable sensor to a new site every myocarditis (Mayo Clinic, 2010).
4 hours or according to manufacturer’s
guidelines.
single-Use Finger sensor
• Apply the detector to the padded part of the
■ PERICARDITIS
finger.
• Then place the emitter over the fingernail.
• Check the single-use finger sensor every 8 hours
W hen the pericardial membranous sac surrounding the
heart becomes inflamed, the condition is called peri-
carditis. Causative organisms are viral, bacterial, fungal, or
for skin integrity and correct positioning. parasitic. Inflammation can also occur from rheumatic or
collagen-vascular conditions such as systemic lupus erythema-
Forehead sensor
tosus. The most common cause of pericarditis is idiopathic,
• Clean the sensor site above an eyebrow with meaning no known cause. Symptoms of pericarditis are severe
alcohol to remove skin oils and to assist with precordial pain (pain on the anterior surface of the chest over
adhesion of the sensor pad. Let the site air-dry the heart) and pericardial friction rubs. The pain may radiate to
before application. the neck, back, or abdomen and become worse when the client
• The sensor is centered above an eyebrow. coughs or lies on the left side. If the client sits erect and leans
• Firmly press the sensor to the skin for 10 sec- forward, the pain is relieved. Pericardial effusion (excess fluid
onds to ensure adherence. in the pericardial space) may develop (Figure 20-1). Cardiac
• Check the forehead sensor every 12 hours for tamponade will result if the fluid rapidly increases and hinders
skin integrity and adhesion. the functioning of the ventricle. The S1 and S2 sounds are often
muffled and hard to hear because of fluid accumulation.
single-Use Nasal sensor With inflammation, scar tissue develops in the pericardial
• Cleanse the side and bridge of the nose with an sac. Heart movement is limited by the scar tissue and cardiac
alcohol pad to remove skin oils and let it air-dry. failure results.
• Place the apex of the sensor pad evenly over the
bridge of the nose with the sensor’s bases cen- Medical-Surgical
tered above each nare.
• Assess the site regularly for skin integrity and
Management
correct positioning. Medical
Reusable ear Clip sensor
The physician performs a pericardiocentesis to aspirate
the excess fluid from the pericardial sac. A needle is inserted
• Clip the sensor to the earlobe.
through the chest wall into the pericardial space.
• Change the site after 4 hours.
• Assess the site regularly for skin integrity and Surgical
correct positioning.
If fibrotic scar tissue in the pericardium hinders heart per-
Guidelines with Any type of Pulse Oximetry formance, the physician may perform a pericardiectomy or
sensor pericardial window. A pericardiectomy is the removal of the
• Attach the sensor to the monitor and set the pericardium. A pericardial window is performed by cutting a
alarm limits according to the facility’s policy. section of the parietal pericardium and tacking it back onto
• Document the SpO2 reading, pulse, and site itself, allowing fluid to escape from the pericardial sac.
assessment.
Pharmacological
(Monitoring your adult patient with bedside pulse oximetry. [2008].
Nursing2008, 9, 42–44.) Clients are given antipyretics, analgesics, and anti-inflammatory
agents. The infection is combated with antibiotics. A digitalis
preparation and diuretic improve the pumping action of the
heart and decrease fluid retention.
Reusable finger sensors and single-use sensors may not be ac-
curate if the client has decreased circulation, thickened nails, nursing Management
or is wearing nail polish. Use forehead sensors and nasal sen- Assess the client’s apical pulse and blood pressure and moni-
sors in these situations. tor the ECG for dysrhythmias. Assess for signs of cardiac
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A B
Figure 20-1 Pericardial effusion: A, normal pericardial sac; B, pericardial sac with excess fluid possibly causing cardiac tamponade.
tamponade such as decreased pulse and blood pressure, palpitations and fatigue caused by decreased CO. They also
muffled heart sounds, increased respirations, restlessness, may experience angina, dizziness, and syncope. Some clients
and oliguria. Administer oxygen as needed, and assist the cli- have panic attacks. Often a click or murmur is heard.
ent to a position of comfort. Administer analgesics, antibiot-
ics, and anti-inflammatory agents as ordered and monitor the
client’s responses. Encourage the client to verbalize concerns Medical-Surgical
and fears. Management
Medical
■ vALvULAR HEART DISEASE Clients with valvular heart disease take antibiotics prophy-
lactically before dental procedures as recommended by the
V alvular heart disease occurs when the valves do not open

and close properly. When the valve does not close com-
pletely, blood leaks back into the chamber from which it was
AHA. According to the AHA, prophylactic antibiotics are
not recommended prior to genitourinary or gastrointestinal
invasive procedures.
pumped. This is called regurgitation. The client with valvular
heart disease often has a history of rheumatic fever. Surgical
When the activities of a client with valvular heart disease be-
StEnoSIS And InSuFFIcIEncY come curtailed because of decreased CO and the symptoms
can no longer be controlled by medical means, surgery is
Table 20-2 presents the definitions, symptoms, diagnostic performed. The type of surgery performed will depend on the
findings, medical-surgical management, and nursing interven- client’s overall condition and on the involved valve.
tions for mitral and aortic valve conditions. For the mitral valve, surgery alleviates the symptoms,
but it does not cure the condition. Surgeries frequently
MItrAL VALVE ProLAPSE have to be repeated. A commissurotomy is done for mitral
stenosis, which surgically separates the valve leaflets. For
Mitral insufficiency can lead to mitral valve prolapse in which mitral regurgitation or insufficiency, a valvuloplasty is the
the valve leaflets, chordae tendineae, and papillary muscle be- treatment of choice. A percutaneous mitral valvuloplasty is
come damaged. The valve leaflets flip back into the left atrium a repair of perforated cusps or torn chordae tendineae. The
when the left ventricle contracts. This condition affects more risk of a thrombus is less with valvuloplasty than with grafts
women than men. Often the client remains asymptomatic. The or prosthetic valves. An annuloplasty, a repair of an annulus
symptoms that a client may experience depend on how seri- or valvular ring, can also be done (see Figure 20-2A). The
ously the mitral valve is affected. Sometimes clients experience annulus is tightened with a purse-string suture or an annular
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Table 20-2 Mitral and Aortic Valve stenosis and Insufficiency

MEDICAl-
VAlVE DIAgnosTIC suRgICAl nuRsIng
ConDITIon DEFInITIon syMPToMs FInDIngs MAnAgEMEnT InTERVEnTIons
Mitral stenosis The diseased Gradual onset of Chest x-ray: Medical manage- Encourage rest
valve becomes symptoms: exer- hypertrophy and ment: diuret- periods, administer
narrowed and tional dyspnea, enlargement of ics, digitalis, oxygen, elevate
the leaflets thick- fatigue, orthop- left atrium and anticoagulants, head of bed, reposi-
ened, preventing nea, paroxysmal right ventricle. antidysrhythmics, tion frequently to
blood from freely nocturnal dys- ECG: atrial prophylactic anti- decrease pressure
flowing from the pnea, murmur. fibrillation. biotics for invasive points, elevate legs,
left atrium into Later symp- Echocardiogram procedures, low- low-sodium diet,
the left ventricle. toms: peripheral and TEE: fusion sodium diet, semi- monitor for signs of
edema, atrial of valve leaf- Fowler’s position, right- and left-sided
fibrillation, jugular lets, enlarged activity restrictions HF, teach stress re-
venous disten- left atrium, de- as needed. duction techniques,
tion, hepatomeg- creased blood Surgical man- daily weight.
aly, abdominal flow through agement: com-
distention, hypo- valve. missurotomy,
tension, throm- percutaneous
bus from blood balloon mitral
pooling in the left valvuloplasty,
atrium. mitral valve
replacement.
Mitral The valve leaflets Gradual onset Chest x-ray: Medical manage- Same as mitral
insufficiency become hard of symptoms: hypertrophy and ment: same as stenosis, teach
and do not close exertional dys- enlargement of mitral stenosis. exercise
completely. Blood pnea, palpita- left atrium and Surgical modification.
backs up in both tions, fatigue, left ventricle. management:
the left atria and atrial fibrillation, ECG: atrial valvuloplasty,
ventricle, causing loud murmur and fibrillation. mitral valve
both chambers to gallop. TEE: adequacy of replacement.
hypertrophy. valve function.
Aortic stenosis The valve cusps Syncope, exer- Chest x-ray: en- Medical manage- Same as mitral
become hard and tional dyspnea, largement of left ment: Same as stenosis.
calcify due to dysrhythmias, an- ventricle, calci- mitral stenosis.
rheumatic fever, gina, murmur, and fication of aortic Surgical manage-
syphilis, a con- gallop; sudden valve. ment: percutane-
genital anomaly, death may occur. ECG: hypertrophy ous balloon aortic
or the aging Later symptoms of left ventricle valvuloplasty,
process. as the disease inverted T wave. aortic valve
progresses: par- Echocardiogram replacement.
oxysmal atrial and TEE: fusion
tachycardia, of valve leaflets,
orthopnea. regurgitation.
Aortic The valve cusps Palpitations, Chest x-ray: hy- Medical manage- Same as mitral ste-
insufficiency become so hard- chest pain, exer- pertrophy and ment: same as nosis, teach exer-
ened they do not tional dyspnea, enlargement of mitral stenosis. cise modification.
close completely. nocturnal angina, left ventricle. Surgical manage-
The blood no lon- dizziness, fatigue, TEE: adequacy ment: aortic valve
ger flows through decreased activ- of aortic valve replacement.
the aorta but ity, intolerance, function.
backs up into the paroxysmal noc-
left ventricle. turnal dyspnea,
visible pulsation
of the neck veins,
murmur, lung
congestion.
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B
A B
Figure 20-3 Percutaneous transluminal balloon valvulo-

plasty: A, A catheter with a balloon on the tip is advanced to the
affected valve. B, A balloon is inflated in the stenosed valve to
expand the narrowed valvular space, leaving a wider opening.
valves. The biologic valves come from calves, pigs, or humans.

Figure 20-2 A, Annuloplasty; B, Carpentier-Edwards The disadvantages of the biologic valves are tissue degen-
Perimount mitral pericardial bioprosthesis. (a, Courtesy of Delmar Cengage eration and calcification of the valve. Carpentier-Edwards
learning; B, Courtesy of eDwarDs lifesCienCe.)
produced the first biomechanical valve that consists of a me-
chanical device and natural tissue (Figure 20-2B).
ring. The mitral valve is replaced when other repair measures
are not feasible.
The aortic valve is not repaired, only replaced, if the nursing Management
symptoms cannot be controlled by medical means. The Assess for dyspnea, fatigue, palpitations, light-headedness,
preferred treatment for a client with an aortic stenosis cough, and numbness and tingling in the extremities. Pro-
is percutaneous transluminal balloon aortic valvuloplasty. vide rest periods during the day. Encourage smokers to stop
This treatment is often used in elderly or high-risk surgical smoking. Refer client and family to dietitian for information
clients. A catheter is advanced to the affected valve and a bal- on low-sodium diets. Encourage client’s input regarding care
loon is inflated in the stenosed valve. The narrowed valvular decisions.
space is expanded by the balloon, leaving a wider opening
(Figure 20-3). Later, large balloons may be used to expand
the opening as needed. nurSInG ProcESS
Mitral and tricuspid valves are now repaired or replaced
with robotically assisted closed-chest heart surgery. Cardiac data collection
surgeons perform these minimally invasive valve surgeries Subjective Data
with a robot. Some valves are still repaired and replaced with
the open chest method, but robotically assisted surgery has Review past medical history for conditions such as rheumatic
several advantages. They require smaller incisions with mini- fever or streptococcal infections. Document if the client has
mal scarring. The client experiences less trauma, pain, and experienced any dyspnea, palpitations, fatigue, cough, light-
bleeding. Clients have a decreased need for pain medication headedness, or numbness and tingling in the extremities.
and a decreased risk of infection. The hospital stay is shorter
than that for open heart surgery and the recovery is quicker, Objective Data
with a prompt return to daily activities. Take the vital signs and listen to the apical pulse for rate,
The two types of replacement valves are mechanical and rhythm, murmurs, and S3 sound. Auscultate breath sounds for
biologic. The mechanical valve is the caged-ball valve. There adventitious sounds. Note edema, jugular distention, cyano-
is a greater risk of a thromboembolism with a caged-ball valve. sis, and equality of peripheral pulses. Test for Homans’ sign
Clients remain on anticoagulant therapy with both types of because dysrhythmias may produce thrombi.
nursing diagnoses for a client with cardiac valvular disorders include the following:
nuRsIng PlAnnIng/ nuRsIng
DIAgnosEs ouTCoMEs InTERVEnTIons RATIonAlE
Decreased Cardiac The client will have in- Administer oxygen as needed. Provides more oxygen for
Output related to struc- creased CO. the body tissues that cannot
tural changes in valves be provided because of de-
creased CO.
(Continues)
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nuRsIng PlAnnIng/ nuRsIng

DIAgnosEs ouTCoMEs InTERVEnTIons RATIonAlE
Help the client balance activi- Allows the heart to rest and
ties with rest periods. The pulse compensate for decreased
should return to baseline within tissue oxygenation from the
10 min of activity; if not, activity activity.
has been excessive.
Discourage smoking and refer cli- Tobacco toxins cause the
ents to support groups to assist heart to beat faster; vessels
them to stop smoking. to constrict, requiring more
effort from the heart to pump
blood through the vessels;
plaque to build up in vessels;
HDL levels to decrease; and
thrombosis to become an in-
creased risk (Parmet, 2008).
Excess Fluid Volume The client will have a de- Administer diuretics as needed. Diuretics rid the body of ex-
related to decreased CO crease in edema. cess fluids.
Support extremities so they are Blood and excess fluid pools
not in a dependent position. in dependent extremities.
Encourage the client to maintain Sodium causes fluid reten-
a low-sodium diet. tion in the body tissues and
prevents fluid excretion in the
urine.
Anxiety related to threat to The client will list ways to Calmly explain the procedures Knowing what to expect
or change in health status cope with stressors. before doing them. calms the client and improves
compliance.
Encourage the client’s input Involving the client in core
about decisions regarding care. decisions provides autonomy
and improves compliance.
Assist the client and the client’s Encourages the client and
family in identifying ways to cope his family to identify and
with stressors. cope with stressors of the
condition.
Teach relaxation techniques. The client has the opportu-
nity to use the techniques to
relax.
Deficient Knowledge re- The client will relate the dis- Explain the valvular disease pro- Increases client’s knowledge
lated to disease process ease process and needed cess, medication actions, dosage of his condition and medica-
and treatment self-care management. times, and medication side ef- tions.
fects to report.
Refer the client and family mem- Increases the client’s and
bers to a dietitian for low-sodium family members’ compliance
diet instructions. in following a low-sodium
diet.
Encourage the client to begin an An appropriate exercise
appropriate exercise program. program decreases cardiac
workload.
concLuSIon
A nurse’s assessment skills are vital in identifying symptoms nurse can detect rather easily. If the symptoms are not found
of endocarditis and myocarditis since the symptoms can be quickly, pericardial effusion and cardiac tamponade can oc-
subtle but lead to serious valvular conditions and heart fail- cur. Understanding and applying the content of this chapter
ure if undetected. Pericarditis has distinct symptoms that a may save a client’s life.
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CHAPTER 21
Caring for Clients
with Occlusive Disorders
and Heart Failure
KEY TERMS
angina pectoris foam cells myocardial infarction
arteriosclerosis hypertrophy stent
atherosclerosis
LEARNING OBJECTIVES
2. Explain the pathophysiology of each type of arteriosclerosis.
3. Explain the pathophysiology of coronary artery disease, acute coronary syndrome,
myocardial infarction, and heart failure.
4. Differentiate between right-sided and left-sided heart failure symptoms.
5. Contrast the medical treatment and nursing interventions for coronary artery disease,
acute coronary syndrome, myocardial infarction, and heart failure.
6. Explain the pathophysiology, symptoms, and medical and nursing care of a client with
cor pulmonale.
7. Explain the rationale for immunosuppressant medication for cardiac transplantation
clients.
431
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INTRODUCTION Table 21-1 Predisposing Risk Factor

In 2006, 26% of deaths in the United States were due to heart for CAD and Myocardial Infarction
disease (Centers for Disease Control and Prevention [CDC], NONMODIFIAble MODIFIAble
2010). We often associate heart disease with men, but half of
these deaths were women. • Family history of • Hypertension
The heart conditions presented in this chapter originate heart disease • Tobacco smoking
from pathology of the coronary arteries that lead to angina,
• Age (risk increases • Elevated serum triglyceride,
acute coronary syndrome, myocardial infarction, and heart
with age) total cholesterol, and low-
failure. This chapter discusses the cause, diagnostic methods,
medical management, and nursing interventions when caring • Gender (most density lipoprotein (LDL) levels
for clients with heart disease. common in men • Lower levels of HDL
and postmeno- • Elevated homocysteine levels
pausal women)
• Type 2 diabetes mellitus
■ CORONARY ARTERY DISEASE • Race
• Obesity
C oronary artery disease (CAD), also called coronary

heart disease (CHD) and arteriosclerotic heart disease
• Excessive dietary intake of
saturated fats, carbohydrates,
or sodium

(ASHD), is the leading cause of death in the United States.
Every 25 seconds one man or woman in the United States • Sedentary lifestyle
has a coronary artery disease–related incident (Overbaugh, • Stress
2009). Coronary artery disease is any disorder, such as athero- • Drug use (especially cocaine)
sclerosis, that causes a narrowing or occlusion in a coronary
artery, such that the heart tissue is not perfused. Many of
these cases are preventable in individuals who make lifestyle
changes to avoid the cardiac risk factors (see Table 21-1; also
refer to Client Teaching for tips on decreasing cardiac risk
CLIENT TEACHING
CLIENT TEACHING
Teaching Guide for CAD Risk Factor Modification
Risk Factor and Goal Teaching Tips
Smoking Counsel patient and family to quit smoking and to avoid secondhand smoke
Goal: Complete cessation Provide contact information for local smoking cessation programs
Explore pharmacological aids including nicotine replacement and bupropion (Zyban)
Enlist family and friends to support efforts
Identify daily routines that trigger the urge to smoke and develop a plan to change
routines by substituting other activities for smoking, e.g., exercise, meditation
Substitute sugarless hard candy, gum, and vegetable sticks for the act of smoking
Avoid people who smoke and common smoking places
Hypertension Check blood pressure regularly and keep a log to bring to health care provider
Goal: BP less than or appointments
equal to 140/90 Take medications as prescribed
Limit salt intake to 2400 mg/day
Do not add salt when cooking, keep salt shaker off the table, season with fresh
herbs and spices
Avoid processed, canned, pickled, and fast food
Stop smoking
Decrease alcohol intake
Control or reduce weight
After approval by the health care provider, exercise regularly
Hyperlipidemia (nutrition) Have lipid panel checked regularly
Goal: LDL less than or Take medications as prescribed
equal to 100 mg/dL TLC diet: Total fat 25–30%, saturated fats to less than or equal to 7%, complex
(optional less than or carbohydrates 50–60%, protein 15% of total daily calories, total cholesterol less than
equal to 70 with CAD or equal to 200 mg/day, fiber 25 g/day
equivalent)
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CHAPTER 21 Caring for Clients with Occlusive Disorders and Heart Failure 433
CLIENT TEACHING
CLIENT TEACHING
HDL greater than or Steam, bake, broil, grill, or stir fry foods
equal to 40 mg/dL Avoid high fat foods such as meat, avocados, olives, nuts, butter, salad dressing,
Triglyceride less than or organ meats and shrimp, egg yolks, palm and coconut oils, high fat dairy products,
equal to 150 mg/dL fried foods
Choose fresh fruits and vegetables, egg substitutes or egg whites, lean meats, fish,
vegetable oils, low fat dairy products
Buy a heart-healthy cookbook
Achieve and maintain a healthy weight
Physical inactivity After approval by the health care provider begin a regular exercise program
Goal: Minimum 30 minutes Count pulse before, during, and after exercise; stop and rest if pulse increases to
three to four times/week more than 20 beats above resting pulse
Warm up and cool down
Walk for 5 to 10 minutes at a moderate pace; increase by 1 to 2 minutes per session
to reach the goal of 30 to 45 minutes
Maintain pace that does not increase heart rate above 20 beats from baseline and
ability to talk
General guidelines:
• Carry nitroglycerin at all times
• Walk on level ground
• Avoid walking in temperatures hotter than 85°F (29°C), more than 75% humidity,
cooler than 40°F (4°C)
• Wait one hour before or after meals
• Wear comfortable walking shoes and loose-fitting clothing
• Bring along a water bottle and drink plenty of water
• Stop if heart rate more than 20 beats above baseline, angina, palpitations, short
of breath, dizziness; notify health care provider if symptoms do not resolve after
15 minutes
Obesity Follow calorie-restricted diet: Avoid fad and crash diets
Goal: BMI less than or Provide community contact information for weight reduction programs
equal to 25 kg/m2 After approval by the health care provider, exercise regularly
Waist circumference less
than or equal to 40 inches
for males, less than 35 inches
for females
Diabetes mellitus Follow calorie-restricted diet
Goal: HbA1c less than or Monitor glucose levels regularly and keep a log to bring to health care provider
equal to 7% appointments
Take medications as prescribed
Control or reduce weight
Stress Identify items that cause stress in life
Goal: Identifies stressors in Brainstorm ways to decrease the stress
life and takes steps to Go to a professional counselor for assistance in handling stressful situation(s)
alleviate feelings of stress. Take needed steps to decrease stress
States feelings of stress Get a pet
are decreased. Seek the assistance of a support group
Exercise on a regular basis
Adapted from a table originally adapted by Daniels & Nicols (2012) from Brunner E., et. al. (2007). Dietary advice for reducing cardiovascular risk. Cochrane
Database of Systematic Reviews, Issue 4. Art. No.: CD002128. DOI: 10.1002/14651858.CD002128.pub3; Daniels, R., Grendell, R., & Wilkins, F. (2010). Nurs-
ing fundamentals: caring and clinical decision making (2nd ed.). New York: Delmar Cengage Learning; Roth, R., & Townsend, C. (2007). Nutrition and diet
therapy (9th ed.). New York: Delmar Cengage Learning.
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factors). Coronary artery disease includes arteriosclerosis and of cells) develop the atheroma plaques in the tunica media.
angina pectoris. The disease process is presented in the fol- The plaque accumulation narrows the diameter of the vessel
lowing discussion of these disorders. wall. When the fibrous cap on the plaque breaks, platelets
adhere to the damaged tissue and form clots. Sometimes the
thrombi dissolve, but at other times they grow to partially or
ARTERIOSCLEROSIS completely occlude the vessel.
Arteriosclerosis is a narrowing and hardening of arteries. A In calcific sclerosis, calcium deposits form on the middle
buildup of lipids, collagen, and smooth muscle cells narrows layer of the wall of the arteries. Hypertension damages the ar-
the lumen of the vessel. Decreased blood flow through the terioles by exerting excess force, which causes the walls of the
vessel causes decreased perfusion to cells beyond the nar- arterioles to expand and thicken, a condition called arteriolar
rowed or hardened area. sclerosis. With these conditions, vessels lose their elasticity,
The three types of arteriosclerosis are atherosclerosis, resulting in various conditions, such as arteriosclerotic heart
calcific sclerosis, and arteriolar sclerosis. Atherosclerosis disease, angina, myocardial infarction, stroke, and peripheral
is fatty deposits on the inner lining of vessel walls. The fat vascular disease.
deposit is called plaque and forms early in life as fatty streaks
accumulate on the arterial vessel walls. As a person ages, the ANGINA PECTORIS
fat cells, or LDL, accumulate in the vessel and injure the vessel
walls (Figure 21-1). The injury allows the LDLs to move into When coronary arteries lose elasticity or become narrow as
the vessel’s tunica layers. Macrophages engulf the LDLs and a result of plaque collection, the heart muscle receives less
form foam cells that contain large amounts of lipid. Foam blood and oxygen. Physical exertion, emotional stress, smok-
cells along with smooth muscle cell proliferation (multiplying ing, exposure to extreme cold or heavy meals, or an arterial
Primary injury Adventitia Fibrous cap (collagen fibers)

Damaged endothelium
Media
A Endothelium Cholesterol
D
Macrophage Fibrous cap rupture
LDL
Fat droplets
E
B
Blood clot formation
Smooth muscle cells

Macrophage
Foam cell
C F
Figure 21-1 Formation of atheroma to the development of a thrombi: A, tunica layer injured in vessel wall; B, LDLs move into the
vessel’s tunica layers; C, macrophages, foam cells, and smooth muscle cell proliferation cause plaque to form; D, atheroma with fibrous
cap; E, the fibrous cap ruptures; F, platelets adhere to the damaged tissue and form clots.
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spasm may cause a temporary inadequate blood and oxygen

supply to the heart. Myocardial ischemia and angina pectoris MEMORY TRICK
result. Myocardial ischemia is a temporary inadequate blood
and oxygen supply to the myocardial tissues. The person ex- MONA for Anginal Pain
periences chest pain or angina pectoris when this temporary M 5 Morphine sulfate 2 to 4 mg IV push
condition occurs. This type of angina is called stable angina
as compared to unstable angina, which is part of a condition O 5 Oxygen 2 to 4 L/min per nasal cannula to
known as acute coronary syndrome. This condition is dis- maintain SaO2 above 90%
cussed later in the chapter. N 5 Nitroglycerin tablets 0.3 to 0.4 mg sublin-
Stable angina occurs during exertion and lessens with gually every 5 minutes up to 3 doses
rest. At first, the person may experience a squeezing pain un-
der the sternum, which radiates to the left shoulder. For some, A 5 Aspirin 162 to 325 mg by mouth (crushed or
the pain may radiate to the right shoulder, jaw, or ear. The to be chewed)
discomfort may vary from mild discomfort to immobilizing (Overbaugh, 2009)
pain. Anginal attacks usually increase in frequency and sever-
ity over time. The severity of the condition depends on the
development of collateral circulation.
Collateral circulation improves as larger vessels gradu-
control. The nurse should closely monitor the BP, respirations,
ally narrow or harden. Blood that normally passes through
and SaO2 because the side effects of morphine are hypotension
the larger vessels is shunted into surrounding smaller vessels.
and respiratory depression. A side effect of nitroglycerin is also
These collateral vessels enlarge in an attempt to supply blood
hypotension. A mnemonic to recall the treatment of angina is
to the affected area. Collateral circulation increases the blood
MONA (see Memory Trick). Even though the letters are not in
supply to tissues that have an inadequate blood supply.
the order of administration, it helps the nurse recall the treat-
Many people experiencing ischemic attacks do not experi-
ment for angina (Overbaugh, 2009).
ence angina. This is called silent myocardial infarct or ischemia.
Silent ischemia is treated in the same way symptomatic
Symptoms are chest pressure or heaviness, restlessness, short-
ischemia is treated. The client needs to be educated about car-
ness of breath with increased respiratory rate, a sensation of
diac risk factors, the importance of following the prescribed
epigastric fullness with noisy belching, numbness or tingling in
medical regimen, and maintaining regular physical checkups.
either arms or shoulders, physical or mental fatigue, and dizzi-
ness. The person may also experience a change in sleep patterns
and mental alertness. The person may state that he or she “feels Surgical
funny.” Clients who are more likely to experience a silent myo- A percutaneous transluminal coronary angioplasty (PTCA)
cardial infarction are women, older adults, and individuals with may be done if only one coronary artery is involved and if
diabetes or a history of HF (Overbaugh, 2009). the atherosclerotic material is small and has not hardened. A
Two other types of angina are unstable angina and PTCA procedure presses atherosclerotic matter against the
Prinzmetal’s angina. Unstable angina is discussed in the Acute walls of the coronary vessels to improve circulation to myo-
Coronary Syndrome section. Prinzmetal’s angina is caused by a cardial tissue supplied by that coronary artery (Figure 21-2).
coronary artery spasm and occurs at rest. A guidewire is inserted to the stenosed area, and a special
Clients with hypertension and diabetes mellitus have a balloon-tipped catheter is placed in the narrowed sclerotic
high incidence of angina pectoris. The diagnosis of angina is area. When the balloon is inflated, the atherosclerotic mate-
made after reviewing the client’s history, lifestyle, laboratory rial is pressed against the wall of the vessel. The vessel, now
tests, and stress test. A lipid profile (cholesterol, HDL, LDL, open, allows more blood to flow to the myocardial tissue.
and triglycerides), hs-CRP, and lipoprotein A (Lp[a]) are During this procedure, a piece of the atherosclerotic material
evaluated. Angina pectoris is diagnosed by a stress test, thal- may break off and occlude the vessel. If this occurs, the client
lium scan, or a coronary arteriogram. would have to undergo immediate coronary artery bypass
graft (CABG) surgery. Other complications of the procedure
Medical-Surgical are occlusion of the vessel because of a vascular spasm.
An intracoronary stent may be implanted into a stenosed
Management vessel to prevent the vessel from collapsing and to keep the
atherosclerotic plaque pressed against the vessel wall. A stent
Medical is a tiny metal tube with holes in it (Figure 21-3). The proce-
Treatment for angina includes measures to increase the blood dure is sometimes done when a vessel collapses after a PTCA
supply to the affected area. Clients are administered an oral dose or in place of a PTCA. The stent is tightly wrapped around
of 162 to 325 mg of crushed aspirin or an aspirin to be chewed a balloon catheter. When the balloon catheter is threaded
because it prevents platelet aggregation and vasoconstriction. through a vessel to the stenosed area, the balloon is inflated
Oxygen is given at 2 to 4 L/min per nasal cannula to maintain and the stent expands and presses the plaque against the ves-
the SaO2 above 90%. Nitroglycerin tablets 0.3 to 0.4 mg are sel wall. The stent remains in the vessel and the catheter is
given sublingually every 5 minutes up to three doses because withdrawn.
nitroglycerin is a vasodilator and increases the oxygen supply to If a CABG is performed, the internal mammary artery,
the myocardium. If pain is not relieved with the nitroglycerin, the saphenous vein, or an accordion type of synthetic graft
morphine sulfate 2 to 4 mg IV push is administered because material is used. The vein or synthetic material is grafted to
morphine is a vasodilator and analgesic. The morphine dose the aorta and passed beyond the obstruction in the coronary
can be repeated every 5 to 15 minutes until the pain is under vessel (Figure 21-4). The graft provides an increased blood
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Catheter threaded
into aorta

Balloon in position in
right coronary artery
Figure 21-2 Demonstration of the function of a balloon-tipped catheter during a PTCA procedure.
Atherosclerotic material Balloon catheter with machine and only small incisions (2 to 3 inches) are needed
(plaque) expandable stent for the procedure. Risk of infection is decreased and the client
experiences less bleeding and pain. The average recovery time is
Artery wall 2 to 4 weeks compared with 6 to 8 weeks with traditional heart
surgery.
Inflated Another recent advance in CABG surgery is Cardica’s
balloon C-Port Flex-A system, which completes the vessel anasto-
mosis by arranging tiny, stainless steel staples that attach the
bypass vessel to the coronary artery. (To view the Cardica
C-Port Flex-A system used in a robotic CABG or an anima-
Expanded tion of the system, go to http://www.cardica.com.) The
stent presses anastomosis is completed with robotic arms in a minimally in-
plaque against
artery wall
vasive surgery while the heart is still beating. There is no need
for a heart bypass machine or a sternotomy. This surgery has
all the advantages of a minimally invasive surgery (Broadcast
Newsroom, 2009).
Plaque Pharmacological
Vasodilators, such as nitroglycerin tablets, cause blood vessels
to dilate, providing an increased blood supply to tissues. The
vasodilation action of nitroglycerin causes a sudden drop in
A BP, therefore, the client should be sitting or lying down when
the medication is taken.
Stent is left B The client may not need as much analgesic medication
in place and if beta blockers are given. Beta-adrenergic blockers and cal-
balloon catheter cium channel blockers slow the HR and decrease the oxygen
is deflated
and removed
demand of the heart. Calcium channel blockers also dilate
vessels and decrease spasms of the coronary vessels. All of
Figure 21-3 Placement of a stent in a coronary artery: these measures provide an increased blood supply to the myo-
A, Palmaz-Schatz stent; B, Gianturco-Roubin Ex-Stent. cardium. See Table 21-2 for a description of the medications
used to treat angina and CAD.
supply to the affected myocardium. The client then has less
angina and an increased tolerance for activities. Diet
A minimally invasive direct coronary artery bypass graft The client is placed on a low-fat, low-cholesterol, sodium-
(MID CABG) surgery is now an option for clients whose sur- restricted diet. Sodium restriction may vary from no salt to
geons use a left internal mammary artery to bypass an occlusion 4 grams daily depending on the ability of the client’s kidneys
in the left anterior descending artery (see Figure 21-4B). With to excrete excess sodium. An increase of fruits and vegetables
a MID CABG the client is not connected to a heart bypass in the diet is recommended.
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Left internal
thoracic artery
Saphenous
vein graft
Right internal
thoracic artery
A
Figure 21-4 A, Coronary artery bypass graft (CABG) with the saphenous vein and internal mammary vein; B, robotic-assisted sur-
gery completing a CABG. (a, Courtesy of Delmar Cengage learning; B, Courtesy of intuitive surgiCal, inC. ©2005.)
Activity of an elevator improve circulation and help decrease choles-

terol levels. Activities such as gardening or housework are
Activity should be slower and for shorter periods of time with also good.
more rest periods.
Health Promotion Nursing Management

To prevent CAD from resulting in angina, it is recom- Assess pain and medicate client as ordered. Monitor vital
mended that a person limit fat intake to 30 grams or less per signs. Emphasize taking rest periods. Encourage client to
day and exercise five times per week for at least 30 minutes. always carry nitroglycerin and to exercise regularly as recom-
Simple activities such as parking a car farther from an en- mended by the physician. Answer questions about the pre-
trance to increase walking distance and taking stairs instead scribed low-fat, low-cholesterol, sodium-restricted diet.
NURSING PROCESS
Data Collection
39-1 Subjective Data
Ask the client to describe the pain regarding type, radiation,
African Americans and CAD onset, duration, and precipitating factors.
African American men and women ages 45 to 74
have a higher rate of CAD deaths than men and Objective Data
women of other races who are in the same age Observe and document the client’s actions during the anginal
group (CDC, 2011). attack. Take vital signs and attach the client to an ECG moni-
tor and observe for any dysrhythmias.
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Table 21-2 Medications to Treat Angina and CAD

DRUG ACTION NURSING CONSIDeRATIONS
Nitrates Vasodilation of coronary Have client sit or lie down when taking sublingual form
Nitroglycerin arteries Monitor for hypotension
Nitroglycerin (sublingual, oral, Venodilation: decreases Monitor for headaches
spray, patch, intravenous) preload Allow 8–12 hours drug free interval for oral/topical routes
Isosorbide dinitrate (Isordil) Arterial dilation: decrease to prevent tolerance (usually while sleeping)
Isosorbide mononitrate (Imdur) afterload Intravenous dose is titrated to effect and replaced with
oral/topical usually if symptom free for 24 hours
Topical nitrate application sites should be visible ar-
eas, hairless, and rotated; clean excess from skin when
patch removed; wear gloves when contact with drug is
anticipated
Instruct client to avoid use of phosphodiesterase in-
hibitors (sildenafil citrate (Viagra), tadalafil (Cialis)) within
24 hours of nitrate use due to severe hypotension reaction
Teach client to always carry nitroglycerin in a tightly
closed dark colored container
Teach client to keep the medication in the originally dis-
pensed container so it is marked with medication name
and dose
Teach client not to use nitroglycerin after the expiration
date as it is not potent. Always make sure the medica-
tion is current
Beta blockers Decrease inotropy and Titrated to target HR 50–60

Nonselective blocker ß1 and ß2 chronotropy Monitor for symptomatic bradycardia, hypotension,
Atenolol (Tenormin) Decrease afterload prolonged PR interval, high-degree heart blocks, heart
Selective blocker ß1 Increased diastolic time failure
Metoprolol (Lopressor, increases coronary Monitor for shortness of breath and wheezing
perfusion Assess for noncompliance related to fatigue and sexual
Toprol XL)
dysfunction
Calcium-channel blockers Decrease inotropy and Monitor for symptomatic bradycardia, hypotension, pro-
Nondihydropyridines chronotropy longed PR interval, high-degree heart blocks
Verapamil hydrochloride Decrease preload and Monitor for edema
(Calan, Isoptin) afterload Implement constipation prevention strategies (e.g., fiber,
Diltiazem hydrochloride Coronary artery dilation stool softeners)
(Cardizem) Prevent vasospasm
Dihydropyridines
Amlodipine (Norvasc)
Nifedipine (Procardia)
Nicardipine (Cardene)
Antiplatelet agents Inhibits thromboxane stim- Prevent gastric irritation: use enteric-coated or buffered
ASA (aspirin) 75–325 mg/day ulated platelet aggregation preparations, give with food, monitor for Gl bleeding
Anti-inflammatory Take for life
Angiotensin I converting Block the enzyme that Monitor for hypotension, hyperkalemia, and renal failure
enzyme inhibitors (ACEI) converts angiotensin I to Cough is a common side effect
Captopril (Capoten) angiotensin II
Benazepril (Lotensin) Decrease preload and
Enalapril (Vasotec) afterload
Fosinopril (Monopril) Promote endothelial vaso-
dilatory and antithrombotic
Lisinopril (Prinivil, Zestril)
actions
Ramipril (Altace)
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Table 21-2 Medications to Treat Angina and CAD (Continued)

DRUG ACTION NURSING CONSIDeRATIONS
Antianginal agent Decreases myocardial Carefully monitor for prolongation of QT interval

Ranolazine (Ranexa) oxygen requirement; In- Do not administer with grapefruit products
creases coronary blood
supply, decreasing fre-
quency of angina
Lipid-altering agents Improve endothelial func- Monitor liver function studies, eye exams for opacities,
HMG CoA reductase tion and stabilize plaque and evaluate for myopathy
inhibitors (Statins) Block liver synthesis of Take at bedtime when cholesterol is synthesized by liver
Atorvastatin (Lipitor) cholesterol
Fluvastatin (Lescol) Decrease LDL 18–55%
Lovastatin (Mevacor) Increase HDL 5–15%
Pravastatin (Pravachol) Decrease TG 7–30%
Rosuvastatin (Crestor)
Simvastatin (Zocor)
Bile acid sequestrants Bind bile acids in intes- Gritty taste
Cholestyramine (Questran) tines: removal of lipids in Gl disturbances common (nausea, dyspepsia, flatulence,
Colestipol (Colestid) feces constipation)
Colesevelam (Welchol) Decrease LDL 15–30% Take 30 minutes before meals
Increase HDL 3–5% Interfere with absorption of other drugs; take other drugs
one hour before or four hours after
Niacin Inhibits liver secretion of Hot flashes and pruritus: take aspirin 30 minutes to one
Nicotinic acid (Niacin, Niaspan, lipoproteins and decrease hour before drug and after food
Slo-niacin) synthesis by decreasing Gl disturbances (nausea, vomiting, diarrhea): take with
release of free fatty acids food
from adipose tissue Monitor for gout, hyperglycemia, liver dysfunction
Decreases LDL 5–25% Take at bedtime
Increases HDL 15–35%
Decreases TG 20–50%
Fibric acid derivatives Decrease liver synthesis Mild Gl disturbances (nausea, diarrhea)
Clofibrate (Atromid) and secretion of VLDL Monitor for gallstones, myopathy (especially if com-
Fenofibrate (Tricor) Decrease LDL 5–20% bined with statins)
Gemfibrozil (Lopid) Increase HDL 10–35% Increase effects of anticoagulants and hypoglycemics
Decrease TG 20–50%
Cholesterol absorption inhibitor Inhibits intestinal absorp- Monitor for fatigue, headache, abdominal pain, and
Ezetimibe (Zetia) tion of cholesterol diarrhea
Decreases LDL 15–20% Monitor for liver dysfunction especially if combined with
Increases HDL 4–9% statins
Decreases TG 8%
Adapted by Daniels & Nicols (2012) from Broyles, B.E., Reiss, B.S., & Evans, M.E. (2007). Pharmacological aspects of nursing care (7th ed.). New York:
Delmar Cengage Learning.
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Nursing diagnoses for a client with angina include the following:

NURSING PlANNING/ NURSING
DIAGNOSeS OUTCOMeS INTeRveNTIONS RATIONAle
Acute Pain related to de- The client will experience Administer nitroglycerin tablets Nitroglycerin dilates blood
creased oxygen supply to decreased episodes of sublingually. The pain should be vessels and increases blood
the myocardium angina. relieved within 1 to 2 min. If the supply to the tissues. A
pain has not stopped after three sudden drop in blood pres-
doses 5 min apart, notify emer- sure may cause the client
gency personnel. to become dizzy or faint. If
the pain is not relieved af-
ter three doses, immediate
emergency measures are
needed.
Administer other medication Beta blockers and calcium
such as beta blockers or calcium channel blockers slow the
channel blockers as ordered and HR and decrease the oxygen
monitor client’s response. demand of the heart.
Anxiety related to per- The client will relate con- Assist the client in learning to Decreases anxiety and al-
ceived threat of death or cerns and practice stress decrease personal expectations lows the heart to meet
change in lifestyle reduction techniques. and to live within personal activ- oxygen demands of body
ity limitations. tissues.
Emphasize the importance Allows the heart to rest dur-
of getting adequate rest and ing activities and to attempt
stopping before becoming too to compensate for the oxy-
exhausted. gen needs of the body
Deficient Knowledge re- The client will explain the Explain the cause of angina. With the new knowledge, the
lated to disease process, disease process; medica- Teach the client to avoid stress- client can take action to de-
medications, and treat- tion actions, dosage times, ful situations that may produce crease episodes of angina.
ment regimen and side effects; and self- angina. Other ways to prevent
care practices. angina are to sleep in a warm
room, eat smaller proportions at
mealtimes, and not exercise out-
side in cold weather.
Inform the client to always carry Nitroglycerin becomes
nitroglycerin in a tightly closed ineffective if exposed to
dark-colored container. Teach light. Keeping the medication
the client to keep the medica- in the originally dispensed
tion in the originally dispensed container avoids confusion
container so it is marked with as to correct medication and
medication name and dose. dose.
Nitroglycerin may cause ortho- Nitroglycerin dilates the
static hypotension, so inform the blood vessels providing
client to sit after taking it and to more oxygen to tissues, thus
change position slowly after tak- preventing or decreasing the
ing the medication. effects of angina.
Encourage the client to start and Exercise improves circulation
maintain a regular exercise pro- and helps decrease choles-
gram as recommended by the terol levels.
physician.
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The degree of vessel occlusion can be diagnosed by

ACUTE CORONARY SYNDROME cardiac biomarkers and ECG recordings. Cardiac-specific
CAD can lead to acute coronary syndrome (ACS), which is biomarkers (troponin T and troponin I) are released when
the all-encompassing term for all signs and symptoms of sud- the myocardium is damaged. The biomarker levels may
den myocardial ischemia: unstable angina, non–ST-segment indicate the severity of the thrombus formation and cardiac
elevation myocardial infarction (NSTEMI), and ST-segment damage. Cardiac troponins are the preferred diagnostic test,
elevation myocardial infarction (STEMI). A partially occluded but CK-MB is also used. Myoglobin is the first biomarker to
coronary artery causes unstable angina and NSTEMI, whereas rise with myocardial damage.
a completely occluded coronary artery causes STEMI. In 2010, When a client has unstable angina or NSTEMI, the ECG
the AHA and the American College of Cardiology (ACC) reveals an ST-segment depression and inverted T waves
updated guidelines for the diagnosis and treatment of ACS. (Figure 21-5). When the ischemia pain resolves, the ST depres-
These guidelines are designed to enable all health care person- sion disappears but the inverted T waves continue, indicating
nel to provide standardized care to clients with ACS. the client has had myocardial ischemia. If a client has STEMI,
ACS starts when platelets aggregate (clump together) the ST segment is elevated in two different lead readings on the
and thrombi form on a ruptured arteriosclerotic plaque. If ECG (Figure 21-5C). The T wave may be inverted with STEMI
the clot occludes the vessel for more than 20 minutes, the but disappears within hours of a myocardial infarction (MI). If
myocardial tissue becomes necrosed and unrepairable. The an MI has occurred, an abnormal Q wave may appear and will
myocardium may not be able to contract properly, thus permanently appear on future ECGs (Figure 21-5D). Therefore,
diminishing cardiac output to vital organs and body tissues. an abnormal Q wave indicates a current MI and an old MI.
The decreased blood supply to the body tissues may cause
the body to go into shock. (Cardiogenic shock is covered in Medical-Surgical
Chapter 6.) Management
Unstable angina occurs at rest or with minimal exertion.
The client is more susceptible to myocardial infarction and Medical
sudden death. The chest pain in NSTEMI lasts longer and is Medication intervention for acute coronary syndrome includes
more severe than the pain of unstable angina. The pain in un- aspirin, oxygen, nitroglycerin, and morphine sulfate (MONA).
stable angina and NSTEMI may last longer than 15 minutes if The medical treatment and nursing interventions for ACS are
it is not treated with rest and/or nitroglycerin. The pain may the same as previously described for angina pectoris.
or may not radiate to the arm, neck, back, or epigastric area.
The client may also experience dyspnea, diaphoresis, nausea, MYOCARDIAL INFARCTION
and dizziness. The client may have tachycardia, tachypnea,
hypertension or hypotension, decreased SaO2, and cardiac Every year approximately 785,000 Americans experience a first
dysrhythmias. Women with ACS may experience indigestion, heart attack and, of those who have had one or more heart at-
palpitations, nausea, numbness in the hands, and fatigue, tacks, 470,000 will have another attack (CDC, 2010). The most
rather than chest pain (Overbaugh, 2009). common cause for myocardial infarction is atherosclerosis.
Normal sinus rhythm

Left
coronary
artery B
Right
coronary
artery Circumflex Ischemia
artery Plaque buildup Inverted wave
Posterior Injury
Anterior
descending ST segment elevation
descending
artery or artery
interventricular
artery D
Marginal artery
Infarcted tissue Clot formation Infarction
Abnormal Q wave
Figure 21-5 CAD conditions of a narrowed vessel from plaque or a blood clot may lead to ACS symptoms. ECG changes with ACS
symptoms: A, normal sinus rhythm; B, inverted T wave indicating myocardial ischemia; C, ST elevation with STEMI indicating myocar-
dial injury; D, abnormal Q wave indicating an MI.
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CONCEPT MAP 21-1 ACuTE CORONARy SyNDROME
CAD process can lead to Acute Coronary Syndrome
Diagnostic Tests Cardiac biomarkers
EKG
Unstable angina Negative Positive
Myocardial infarction
NSTEMI STEMI
ST - segment depression ST - segment elevated

(ST - segment disappears when (T wave inverted but disappears
ischemia resolves) within hours of MI)
Inverted T wave Abnormal Q wave appears

Myocardial ischemia Myocardial infarction
A myocardial infarction is caused by an obstruction in A myocardial infarction is diagnosed by client symptoms,

a coronary artery, resulting in necrosis (death) to the tissues ECG tracings, cardiac biomarker values, and a radioactive iso-
supplied by the artery. The obstruction is usually caused by tope scan; however, the ECG stress test has less diagnostic value
atherosclerotic plaque, a thrombus, or an embolism. The area with women than with men. An exercise echocardiography is
most commonly affected is the left ventricle. more reliable for women (Women’s Heart Foundation, 2007).
Obstruction of a large coronary artery damages the myo- When an MI is evolving in men, the ECG has an elevated ST seg-
cardial tissue and affects the pumping efficiency of the heart. A ment, which eventually changes into an inverted T wave.
client’s prognosis is better if a small coronary artery or arteriole is A CK-MB fraction that measures an isoenzyme specific
obstructed and there is good collateral circulation to the heart. If to the cardiac muscle increases within 3 to 12 hours of the
a large vessel is obstructed and the client does not have sufficient onset of a myocardial infarct, peaks in 18 to 24 hours, and
collateral circulation, the client may die immediately. returns to normal in 72 hours. CK studies are performed as
The typical symptoms of men experiencing an MI are soon as the client is admitted and then every 8 hours until
feelings of chest heaviness or tightness that progresses to a four samples have been obtained. A CK-MB fraction >5%
severe gripping pain in the lower sternal area. Pain also occurs indicates myocardial damage.
in the arm, neck, back, or epigastric area and may or may not Two other important lab values for diagnosing an MI are
radiate to these areas. The pain is not relieved by rest or nitro- cardiac troponin I and myoglobin. Cardiac troponin I is a pro-
glycerin, and the client becomes short of breath (dyspneic), tein found in cardiac cells. When cardiac cells are damaged,
diaphoretic, and anxious. The client frequently becomes the protein is released, resulting in an elevated level (normal
nauseated and vomits. The pulse may be irregular, rapid, and level is <0.6 ng/mL) for up to 10 days. Within an hour of an
weak, and the blood pressure is low. The skin is pale and then MI, the myoglobin blood level increases, peaks in 6 to 7 hours,
turns cyanotic. Even though a person may not experience the and returns to normal in 24 hours. If an MI is suspected, the
typical MI symptoms, the condition can still be serious or lab value must be obtained quickly.
fatal. Complications such as HF and stroke may also occur. During the first 3 days after the infarction, the client may
Women experiencing an MI present with atypical symp- have a low-grade fever and an increased white cell count. The
toms that often delay an accurate diagnosis. Women are more infarcted heart tissue is soft and necrotic and incapable of re-
likely to have upper abdominal pain, heartburn, nausea, dys- sponding to electrical stimuli. Life-threatening dysrhythmias
pnea, fatigue, lethargy, dull pain, anxiety, as well as chest pain are most likely to occur at this time. Four to seven days after the
(Joy, 2006). Women have pain in the back or left side of the infarction, the infarcted tissue is the softest and weakest. An an-
chest rather than substernally and report the symptoms as a eurysm, or ballooning effect, can occur in the infarcted area with
numb, tingling, burning, or stabbing sensation (Overbaugh, the potential of rupturing. There is a possibility of the ventricle
2009). rupturing from the time of the infarct to 2 weeks after the infarct.
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Collateral circulation begins forming around the edges of the

infarct, but it will be 2 to 3 weeks before the collateral circulation BESTPRACTICE
functions effectively. Two to three months will pass before the
heart muscle regains maximum strength. MI Clients and IM Injections
Medical-Surgical Giving medications IM increases CK blood levels.

Therefore, IM medications are usually not given to
Management clients with angina, ACS, or an MI.
Medical
Medical-surgical management focuses on reducing oxygen
demands, increasing oxygen supply to the myocardium, re- in lower extremities), or cerebrum (headache, vomiting, and
lieving pain, improving tissue perfusion, and preventing com- confusion). Heparin therapy inhibits further clotting. Aspirin
plications and further tissue damage. Immediately after an MI, and/or clopidogrel (Plavix) is given to prevent vasoconstric-
a client is admitted into a coronary care unit. The client’s heart tion and platelet aggregation.
is constantly monitored for dysrhythmias, and vital signs are
monitored for any changes. Diet
Three dysrhythmias that may occur after an MI are ven-
tricular fibrillation, bradycardias, and tachycardias. Ventricular Until the client is stabilized, a diet is withheld in case a PTCA
fibrillation is treated by defibrillation. Atropine is given and, if or CABG procedure is required. Fluids may be offered during
needed, a temporary pacer is inserted for bradycardias. Two the acute stage. A liquid diet is progressed to a regular low-fat,
tachycardias that may occur are atrial fibrillation and ventricular low-cholesterol, low-sodium diet. The client tolerates small
tachycardia. Atrial fibrillation is treated with digoxin (Lanoxin), frequent feedings better than three large meals. Avoid caffeine
diltiazem hydrochloride (Cardizem), or amiodarone hydro- and extremely hot and cold foods.
chloride (Cordarone). Ventricular tachycardia is treated with
Cordarone, lidocaine hydrochloride (Xylocaine HCl), or car- Activity
dioversion. If dysrhythmias continue, magnesium may be given. It is vital that the client receive physical, mental, and emo-
Medical complications that can occur following an MI tional rest. Less stimuli places less demand on the heart. Ex-
are acute left ventricular failure, cardiogenic shock, pericar- plain procedures so the client understands the care provided.
ditis, embolism and/or thrombosis, and cardiac rupture. The The client is usually limited to bed rest during the first
health care team must closely monitor the client for signs of 24 hours and progressed to sitting in a chair by the second
these complications. Women have a worse prognosis and die day. If pain returns or other complications occur, the client is
more often than men after a heart attack or bypass surgery placed on bed rest. Early ambulation is encouraged to prevent
(Bellasi, Paolo, Merz, & Shaw, 2007). thrombosis. During and after each activity, assess the client’s
tolerance by monitoring the HR for an increase of 20 beats per
Surgical minute, checking for a decrease in systolic blood pressure, and
Primary treatment may be PTCA instead of thrombolytic observing for dyspnea and dysrhythmias. Document verbal
therapy. Along with balloon compression, a stent(s) may be and nonverbal statements of fatigue and chest pain.
inserted. Clients with multiple vessels occluded, or for whom Before discharge, low-intensity tests are performed to de-
thrombolytic therapy and PTCA have not been effective, have termine the types of activities in which the client may engage
the CABG procedure performed. at home. When the client is able to climb two flights of stairs,
sexual activity is resumed.
Pharmacological Health Promotion
Oxygen is given by a Venturi mask or nasal cannula. Morphine A diet of less than 30 grams of fat per day reduces the progres-
sulfate is given intravenously for pain. Nitrates are given IV sion of atherosclerosis, but there is no documented evidence
or sublingually to relieve pain and dilate coronary arteries. that diet will prevent the disease in clients with hereditary hy-
Sublingual (SL) nitroglycerin is easy to administer and may perlipidemia. Regular exercise, 30 minutes at least 5 days per
provide immediate relief. One tablet of SL nitroglycerin is week, and smoking cessation help prevent an MI.
given every 5 minutes, up to three doses. If the client’s pain is
not relieved within 15 minutes, the physician may order nitro-
glycerin IV. Intravenous nitroglycerin is given until the client’s CRITICAL THINKING
symptoms stabilize. Then it is replaced with oral or topical
nitroglycerin. Sedatives are administered to calm and relax the
client, and a stool softener is given to prevent rectal straining. Lifestyle Changes for MI
Thrombolytic therapy is sometimes used within 3 to
6 hours of the myocardial infarction to dissolve a clot blocking
an artery and reperfuse the area. Medications such as strepto- 1. What would you teach a client to assist him
kinase (Streptase), anistreplase (Eminase), and alteplase re-
in decreasing risk factors for CAD and an MI?
combinant (Activase) are used. A possible complication from
2. What lifestyle changes could you take to de-
thrombolytic therapy is bleeding. Be alert for symptoms of
hemorrhaging in the gastrointestinal tract (hematemesis and crease the risk factors for CAD and an MI?
tarry stools), retroperitoneum (low back pain and numbness
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Participation in a cardiac rehabilitation program provides medications. Assess pain regarding onset, duration, intensity,
the client with monitored exercise sessions as well as educa- location, radiation, and precipitating factors; ask the client to
tion and counseling about reducing the risk of future heart describe the symptoms. Not all persons having angina or an
problems and coping with a new lifestyle. Because women MI will experience or state having pain. Some may describe
have a worse prognosis than men, it is critical for women to feelings of chest heaviness, indigestion, or “something not
participate in a cardiac rehabilitation program. right.” Explore these statements with the client so the client
can explain them in more detail. Dizziness, weakness, and
Nursing Management shortness of breath may be expressed. Ask how the client tried
Assess for pain. Observe for verbal and nonverbal signs of to relieve pain.
pain. Have client describe symptoms. Monitor vital signs,
breath sounds, pedal pulses, and ECG strips. Maintain cli- Objective Data
ent on bed rest with call light and other items within reach.
Accurately record I&O. Provide a quiet, calm environment. Assess vital signs, skin changes, breath sounds, and ECG
Balance activity with rest periods. rhythm strips. Monitor vital signs for an irregular or increased
pulse, hypotension, or slight temperature elevation. The client
may have pallor, cyanosis, diaphoresis, vomiting, cool clammy
NURSING PROCESS skin, or confusion. Assess breath sounds for lung congestion,
and monitor the ECG for dysrhythmias. Note any client
Data Collection clenching of hands or clutching at the chest.
Subjective Data
Note the medications the client has taken, including over-the-
counter medications, herbs, anticoagulants, and thrombolytic
Nursing diagnoses for a client with myocardial infarction include the following:
Decreased Cardiac The client will have in- Maintain bed rest with head of Bed rest reduces the de-
Output related to creased CO. bed elevated 30 degrees until mands on the heart and
damaged heart tissue the condition is stabilized. the client’s need for oxy-
gen. When a client sits at
30 degrees, the diaphragm
expands more fully with less
pressure from the GI organs.
Auscultate breath sounds and Monitor for congestion, an
palpate pedal pulses every 4 hrs. indication of HF, and ad-
equate peripheral circulation.
Administer oxygen per mask or Provides more oxygen to the
nasal cannula at 2 to 4 L/min. body tissues.
Start an IV so medications such An IV provides an avenue for
as morphine and antidysrhyth- prompt medication adminis-
mics can be administered. tration if needed.
If beta blockers are adminis- Beta blockers slow the HR
tered, monitor closely for a drop and cause blood vessels to
in HR and blood pressure. dilate decreasing the blood
pressure.
Constantly monitor the client for A complication of an MI is
dysrhythmias. Place a rhythm dysrhythmias.
strip on the chart at least once
per shift.
Monitor I&O. A sufficient output indicates
adequate blood flow to the
kidneys.
Administer medications as pre- Prescribed medications
scribed by the physician. cause the heart to pump
efficiently; therefore, medi-
cations are administered as
ordered.
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Acute Pain related to The client will verbalize Maintain client on bed rest and Bed rest reduces the de-
decreased oxygenation decrease in frequency and observe for verbal and nonverbal mands on the heart. Some
of myocardial tissue intensity of chest pain. signs of pain such as grimacing, clients are reluctant to ex-
diaphoresis, or increased HR. press pain but exhibit non-
verbal expression.
Ask the client to rate the pain Level of pain is easier to
on a scale of 0 to 10, 0 being no monitor with an objective
pain and 10 extreme pain. pain scale.
Administer analgesic, usu- Analgesic relieves pain. Oxy-
ally morphine, and oxygen, as gen administration increases
ordered. SaO2 level.
Risk for Activity The client will increase Place objects within reach of the Decreases workload on
Intolerance related to activities with decreased client. heart if client can easily
decreased circulation symptoms of angina, reach needed items.
to body tissues dyspnea, cyanosis, and Balance activity with rest Allows cardiac rest periods
dysrhythmia. periods. between activities.
Assist the client and partner to Client and partner may fear
discuss their fears and feelings angina or an MI with sexual
candidly about resuming sexual activity. Candid discussion
activity. expresses concerns and al-
leviates fears.
Death Anxiety related to The client will verbalize Encourage the client and family Verbalization of feelings
change in health status situations that are causing members to verbalize their allows client and health
and threat of death stress. feelings. care personnel to address
concerns.
Provide a quiet, calm environ- Excess stimuli produce anxi-
ment to relax the client and ety and places more stress
family. on the heart.
Administer sedatives to help the Sedatives calm the client’s
client relax and provide periods emotions.
of uninterrupted rest.
Since the myocardial client may Denial is common in cardiac
be in denial, be aware of denial clients because of their “A-
symptoms such as attempt- type” personalities. The cli-
ing to conduct business over ent does not come to terms
the phone while hospitalized or with the reality of his condi-
statements that the pain is really tion by participating in denial
nothing. activities.
two types of HF: right-sided HF and left-sided HF. Some of

■ HEART FAILURE the causes of right-sided failure are untreated left ventricular
failure, right ventricular myocardial infarction, chronic ob-
H eart Failure (HF) is often the final stage of many

other heart conditions. A weakened muscle wall from
a myocardial infarction or a heart that has been stressed over
structive coronary disease, cor pulmonale, and pulmonic valve
stenosis. HF usually begins on the left side and is caused by
left ventricular myocardial infarction, aortic valve stenosis,
a period of time to meet the metabolic needs of the body prolapsed valve complications, and hypertension. Notice
causes HF. HF develops when the heart is no longer capable that right- and left-sided failure is caused by a defect of the
of meeting the oxygen needs of the body. The muscles of the ventricle or an increased resistance in the path of the blood
left ventricle hypertrophy (increase in muscle mass) and pumped by the ventricles. This causes an increased workload
often the ventricular chamber enlarges in an attempt to meet for the involved ventricle.
the oxygen needs of the body. When left-sided HF occurs, the left ventricle is not able
Both the right and left ventricles act as pumps for the to completely empty of blood or effectively pump blood
heart. Each of these pumps can fail separately, resulting in out through the aorta to the body systems. Usually the right
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CASE STUDY
Myocardial Infarction
L.J., a 55-year-old truck driver, is admitted to the emergency room with a feeling of heavy squeezing
pressure in his sternal area. The pain is radiating to his left shoulder. He is diaphoretic, short of breath,
and nauseated. He states the sternal pain came on suddenly while watching a football game. He had
been mowing his yard and decided to rest. The emergency physician gives L.J. a nitroglycerin tablet
and attaches ECG leads to monitor his heart. Cardiac biomarkers (CK-MB, troponin T, troponin I, and
myoglobin) with an IMA and a chest x-ray are requested stat. Morphine sulfate 2 mg is given intrave-
nously. Oxygen is given by mask at 4 L/min. L.J.’s apical pulse is 102 beats/min and his blood pressure
is 130/88 mm Hg. A cardiac catheterization with fluoroscopy is ordered to determine the patency of the
coronary blood vessels and functioning of the heart muscle.
Three hours after admission, crackles are heard in the lungs.
The following questions will develop your critical thinking skills in preparation for caring for a client
diagnosed with an MI.
1. List symptoms/clinical manifestations, other than L.J.’s, that a client may experience when having a
myocardial infarction.
2. List two reasons morphine sulfate was given to L.J.
3. List two other diagnostic tests that may have been ordered for L.J.
4. List subjective and objective data a nurse would want to obtain about L.J.
5. Write three individualized nursing diagnoses and goals for L.J.
L.J. is moved from the critical care unit.
6. List pertinent nursing actions a nurse would do in caring for L.J. related to:
Oxygenation Activity
Cardiac output Medications
Comfort/rest Teaching
7. List teaching that L.J. will need before his discharge.
8. List at least three successful client outcomes for L.J.
9. How might the MI symptoms for a woman differ from L.J.’s symptoms?
ventricle continues to pump adequate quantities of blood. In the early stages of HF, the client experiences fatigue,
This causes blood to collect in the left ventricle, left atrium, dyspnea with slight exertion, pedal edema, and a slight cough
and pulmonary veins. The lungs become congested with fluid with a small amount of expectoration. The client may also
as fluid leaks through the capillaries and fills air spaces in the have paroxysmal nocturnal dyspnea.
lungs. The client becomes cyanotic, dyspneic, restless, and
coughs up blood-tinged sputum. Breath sounds have moist
crackles. Often the client has tachycardia with low blood pres- Medical-Surgical
sure because the heart is not able to pump sufficient blood Management
to meet the body’s demands. The client may have decreased
urinary output because enough blood is not pumped through Medical
the kidneys. As the blood oxygen level decreases, the client Goals for treating HF are to improve circulation to the coro-
becomes confused. nary arteries and decrease the workload of the left ventricle.
As the right side of the heart fails, blood collects in the To meet these goals, cardiac efficiency is increased with
inferior vena cava, causing edema first in the extremities and medication; oxygen requirements of the body are decreased
then in the trunk of the body. As the condition progresses, the by bed rest with the head elevated 45 degrees; edema and
client experiences edema of the ankles, lower legs, thighs, and pulmonary congestion are treated with medications, diet,
finally in the abdomen. The excess abdominal fluid causes and restricted fluid intake; and fluid retention is monitored
the client to be anorectic. Hepatomegaly (enlargement of the by weighing the client daily. A chest x-ray directly visual-
liver) and splenomegaly (enlargement of the spleen) develop. izes the ventricles for muscle hypertrophy and ventricular
The jugular veins in the neck become distended when the enlargement and the lungs for congestion. An ECG is com-
client is sitting or standing, and pitting edema occurs in the pleted and arterial blood gases are evaluated. The client’s
lower extremities (Figure 21-6). Oliguria occurs as decreased oxygen saturation level is monitored by pulse oximetry.
amounts of blood are pumped through the kidneys. Depending on the seriousness of the client’s condition, a
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Cardiac Early cardiac Late cardiac

systole diastole diastole
Figure 21-6 A, Jugular neck vein distention; B, pitting

edema in right-sided heart failure. (Delmar Cengage learning)
Balloon Balloon Balloon fully

pulmonary artery catheter (Swan-Ganz catheter) may be collapsed inflating inflated
inserted to determine left ventricular function.
In right-sided failure, the symptoms of edema, hepato-
megaly, and neck vein distention are significant diagnostic B
evidence.
Figure 21-7 An intra-aortic balloon pump increases circu-
lation to the coronary arteries and decreases the workload of the
Surgical left ventricle. A: Correct placement of the intra-aortic balloon
Two mechanical devices are available: an intra-aortic balloon pump; B: These three photos illustrate the function of the intra-
pump and a ventricular assist device. An intra-aortic balloon is aortic balloon pump.
threaded through the femoral artery to the descending aorta
(Figure 21-7). The pump is synchronized with the contractions flow to the coronary arteries, thus increasing oxygenation of the
of the left ventricle so the balloon inflates during diastole and de- myocardium. Deflation of the balloon allows the left ventricle to
flates during systole. Inflation of the balloon increases the blood pump blood to the body tissues with less peripheral resistance.
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Potential complications are bleeding, blood clots, respiratory

failure, renal failure, infection, stroke, and device failure.
Pharmacological
Medications to reduce the heart’s workload in moderate HF
are angiotensin-converting enzyme (ACE) inhibitors, angio-
tensin receptor blockers, vasodilators, nitrates, beta block-
ers, diuretics, digitalis, and aspirin (Table 21-3). The client
with HF will receive diuretics such as furosemide (Lasix) to
decrease fluid retention. ACE inhibitors, such as captopril
(Capoten) or enalapril (Vasotec), are given to reduce blood
pressure and peripheral arterial resistance and improve CO.
Beta blockers carvedilol (Coreg) and metoprolol succinate
(Toprol XL), the only beta blockers approved for HF in the
United States, are then added (Ammon, 2001). A digitalis
preparation may be required to increase the strength and
contractility of the heart muscle. Vasodilators such as nitro-
glycerin (Cardabid) are given to dilate the veins so the blood
will stay in the peripheral vessels and decrease blood return to
the right side of the heart, thereby decreasing the workload on
the heart. Clients in severe HF who are already taking an ACE
inhibitor may be given spironolactone (Aldactone) (Ahmed,
2008). Morphine sulfate is given in the acute phase to control
pain and decrease anxiety.
BESTPRACTICE
Figure 21-8 The cannula of the VAD takes blood from the
left atrium to the aorta, bypassing the ineffective left ventricle. Digoxin in Older Adults
(reprinteD with permission from thorateC Corporation.)
HF is the leading cause of hospitalization in adults
65 years of age and older. New data indicate that
The ventricular assist device (VAD) does not replace the a low dose (0.125 mg/day or lower) of digoxin
heart, but it assists a weakened heart to pump sufficient blood decreases hospitalization due to HF and may also
throughout the body. It is referred to as “a bridge to transplant” reduce mortality. Lower doses also decrease the risk
because a client uses the VAD while waiting for a heart transplant. of digoxin toxicity and the need for frequent serum
Some clients who are not transplant candidates may use the VAD digoxin levels. Digoxin in low doses is recommended
until death. A left VAD takes blood from the left ventricle and
for older adults with chronic HF (Ahmed, 2008).
delivers it to the aorta (see Figure 21-8); a right VAD takes blood
from the right ventricle and delivers it to the pulmonary artery.
Table 21-3 Recommended and Contraindicated Medications in Heart Failure

ReCOMMeNDeD MeDICATIONS CONTRAINDICATeD MeDICATIONS
FOR HeART FAIlURe THeRAPY FOR HeART FAIlURe ClIeNTS
• Loop diuretics for volume overload •

Alcohol
• ACE inhibitors (titrate upward to optimal dose) •
Cocaine
• Beta blockers (titrate upward to optimal dose with sup- •
Antiarrhythmic agents except amiodarone
port and monitoring) •
Calcium channel blockers except amlodipine besylate
• Digitalis (Norvasc)
• Spironolactone for advanced heart failure (with optimal • NSAIDs (associated with development of CHF and inter-
doses of ACE inhibitors and beta blockers. Monitor for act with ACE inhibitors)
complications such as hyperkalemia.) • Thiazolidinediones (may cause fluid retention)
• Angiotensin II receptor blockers (ARBs) if ACE inhibitors • Metformin hydrochloride (Glucophage)
are not tolerated
From “State of the Science for Care of Older Adults with Heart Disease,” by C. Deaton, J. Bennett, & B. Riegel (2004), in Nursing Clinics of North America,
39(3), 495–528; “Polypharmacy and Comorbidity in Heart Failure,” by F. Masoudi & H. Krumholz (2003), in British Journal of Medicine, 327(7414), 513–514.
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Diet signs. Keep bed in semi-Fowler’s position. Maintain accurate

intake and output. Provide frequent rest periods and minimal
A daily weight and strict intake and output are necessary to interruptions at night. Teach about disease process, medica-
assess fluid retention. Sometimes fluid intake is limited. The tions, and diet.
client is generally on a low-sodium diet.
Activity NURSING PROCESS

Activity orders will depend on the client’s activity tolerance.
The client’s activity may vary from strict bed rest to ambula- Data Collection
tion depending on the severity of the condition. When in bed, Subjective Data
the head of the bed is elevated 45 degrees. Visitation privileges
are monitored to provide rest periods. Ask the client about dyspnea, orthopnea, fatigue, anxiety,
weight gain, edema, pain, or difficulty in performing activities
of daily living.
Health Promotion
The most common cause of HF is left ventricular failure after Objective Data
a myocardial infarction. To prevent HF following CAD, a
diet low in fat, high in fiber, and balanced in caloric intake to Assess the client’s level of consciousness to determine cir-
maintain optimum weight is recommended. Stress reduction culation of blood to the brain. Check skin color for pallor or
and a regular exercise program will also decrease the risk of cyanosis. Assess skin turgor to help determine the level of
developing HF. Clients with congenital heart defects may not hydration. Jugular distention indicates right ventricle func-
be able to prevent HF, but following the prescribed medical tioning. Assess breath sounds for adventitious sounds and
regimen may prevent the early development of HF. heart sounds for gallop or murmurs. Bowel sounds may be
hypoactive depending on the amount of fluid retention in the
abdomen. Check peripheral pulses and capillary refill to assess
Nursing Management the level of circulation to the extremities. Assess edema in the
Monitor client’s level of consciousness, skin color and tur- extremities and abdomen according to the edema rating scale.
gor, and jugular veins for distention. Assess breath, heart, Monitor the client’s weight daily for possible increase from
and bowel sounds. Check capillary refill and peripheral and fluid retention. The physician should be notified if there is
abdominal edema. Weigh client daily at same time, on same a gain of more than 2 pounds in one day. Monitor I&O and
scale, in same type of clothes. Monitor electrolytes and vital assess for oliguria.
Nursing diagnoses for a client with HF include the following:

Decreased Cardiac Output The client’s vital signs will Take an apical pulse on all car- The nurse promptly deter-
related to mechanical fail- remain stable. diac clients, especially checking mines dysrhythmias by listen-
ure of heart muscle the rate and rhythm. ing to the apical pulse.
The client will have de- Monitor the client’s HR and ECG displays dysrhythmias.
creased adventitious rhythm by telemetry.
breath sounds. Auscultate breath sounds every Promptly determine changes
4 hrs. in lung congestion.
Administer diuretics, digitalis, and These medications control
vasodilators as prescribed. the symptoms of HF.
Closely monitor the electrolytes, Electrolyte levels affect
especially the potassium level, HF condition (e.g., sodium
because diuretics can deplete the causes fluid retention).
potassium level. Administer po- Hyper- and hypokalemia
tassium supplements as ordered. cause dysrhythmias.
Take the apical pulse before giv- The HR must be above 60
ing a digitalis preparation. If the to administer digitalis or 50
HR is below 60, withhold the if client is taking digitalis and
medication and notify the physi- a calcium channel blocker or
cian. In some institutions the HR beta blocker.
can drop to 50 before the physi-
cian is notified if the client is tak-
ing a calcium channel blocker or
beta blocker along with digitalis.
(Continues)
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Impaired Gas Exchange The client will have in- Provide oxygen by mask or nasal Administering oxygen in-
related to decreased CO creased gas exchange. cannula at 2 to 6 L/min. Apply a creases oxygen to the body
and pulmonary edema pulse oximeter and monitor the tissues.
oxygenation status. If the pulse
oximeter is ≤90%, notify the
physician.
Elevate the head of the bed to a When a client sits at a 30- to
semi-Fowler’s or Fowler’s posi- 45-degree angle, the dia-
tion to relieve pressure on the phragm expands more fully
diaphragm. with less pressure from the GI
organs.
Excess Fluid Volume re- The client will have less Encourage elevation of the cli- Excess fluid pools in body
lated to decreased cardiac edema of the extremities. ent’s legs, not letting them hang part placed in dependent
output and decreased re- in a dependent position. position.
nal output Maintain an accurate intake and Monitors fluids taken in and
output record. excreted from body in effort
to control edema.
Weigh daily at the same time Monitors fluid retention in a
each day, on the same scales, stable, controlled manner.
and with the client wearing the
same type of clothing.
If the client is on a fluid-restricted Sucking on a hard candy in-
diet, offer hard candies to quench creases saliva in the mouth
the thirst. so client does not feel as
thirsty.
Risk for Activity Intoler- The client will have an Schedule nursing care so the Rest periods decrease the
ance related to edema, increased tolerance for client is given frequent rest peri- heart’s workload.
dyspnea, and fatigue activity. ods with minimal interruptions at
night.
Teach the client to take frequent Allows the client to work
rest periods and to stop activities within his energy threshold.
before becoming tired.
Monitor the client’s vital signs for Determines activity demand
an increase or decrease in HR or on the client’s heart and as-
blood pressure, especially after sists in determining heart’s
periods of activity. recovery time after exercise.
Have an occupational therapist Teaching saves the client’s
assist the client to learn energy- energy reserves.
saving methods, such as placing
frequently used objects close to
chair so client does not have to
get up to obtain the item.
Instruct the client to call the phy- These are symptoms that
sician if there is more dyspnea, client’s HF is worsening and
fatigue, less activity tolerance, physician is able to make
or weight gain or loss when at changes in medication, diet,
home. or other medical care.
Cor Pulmonale causing pulmonary hypertension. The right ventricle is forced to

In this condition, the heart is affected because of a lung condition pump against increased pulmonary pressure. The right ventricle
that interferes with the exchange of carbon dioxide and oxygen in enlarges and finally weakens in the attempt to pump blood into
the alveoli. The carbon dioxide level increases in the blood. For the lungs. The symptoms the client experiences and medical and
some unknown reason, the pulmonary arteries vasoconstrict, nursing care are the same as for right-sided HF.
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CARDIAC TRANSPLANTATION CONCLUSION

Cardiac transplantations are done for cardiomyopathy, end- Factors of age, family genetics and history, gender, and race
stage CAD, and valvular disease. Recipients are evaluated for predispose a person to CAD. However, the risk for CAD can
emotional stability, minimal disease involvement, and a good be decreased by adhering to lifestyle choices of healthy nutri-
support system. The heart donor and the recipient’s tissues tion, regular exercise, elimination of smoking and drugs, and
are matched. stress reduction. Advanced CAD may cause stable angina or
The transplant is performed by removing the recipient’s lead to ACS of unstable angina, NSTEMI, and STEMI. A
heart except for posterior sections of the atria. The posterior myocardial infarction can lead to HF. By following the guide-
sections of the atria are removed from the donor’s heart, and lines set forth by the AHA and ACC, health care providers
then the heart is sutured to the recipient’s posterior atria. can provide quality care to these clients. One of the nurse’s
The recipient must remain on an immunosuppressant responsibilities is to teach the client preventive care, correct
medication for the remainder of life so the immune system administration of medications, and a balance of exercise and
does not reject the donor heart as a foreign object. Some im- rest within his cardiac output limitations.
munosuppressant medications are azathioprine (Imuran),
cyclosporine (Sandimmune), antithymocytic globulin, ATG
(Atgam), antilymphocytic globulin (ALG), rapamycin, and
FK 506 (Prograf).
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CHAPTER 22
Caring for Clients with
Peripheral Vascular Disorders
KEY TERMS
aneurysm phlebothrombosis thrombus
embolus sclerotherapy varicosity
hemolysis thrombectomy vein ligation
necrosis thrombophlebitis vein stripping
phlebitis thrombosis Virchow’s triad
LEARNING OBJECTIVES
2. Explain the pathophysiology of an aneurysm.
3. Discuss the medical care and nursing interventions for a client with an aneurysm.
4. Describe the symptoms of a client with a venous thrombosis or thrombophlebitis.
5. Explain the medical care and nursing interventions for a client with a venous thrombosis
or thrombophlebitis.
6. Explain the pathophysiology of a varicose vein.
7. Compare the symptoms, medical and surgical care, and nursing interventions of an
aneurysm and varicose vein.
8. Compare the pathophysiology of Buerger’s disease and Raynaud’s disease/
phenomenon.
9. Describe the nursing interventions for Buerger’s disease and Raynaud’s disease/
phenomenon.
452
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CHAPTER 22 Caring for Clients with Peripheral Vascular Disorders 453
INTRODUCTION EVIDENCE-BASED
Peripheral vascular disease is an umbrella for several diseases PRACTICE
that cause an insufficient blood supply to the legs, arms, stom-
ach, and kidneys. The etiology of peripheral vascular disease
Abdominal Aortic Aneurysm Screening
is a vasospasm or atherosclerosis (AHA, 2010c). Clients are at Source: Brearley, s. (2008). should we screen for abdominal aortic
risk for thrombi or emboli that occlude the vessel resulting in a aneurysm? Yes. British Medical Journal, 336(4), 862.
lack of perfusion to body tissue distal to the clot. This chapter
discusses symptoms, diagnosis, medical treatment, and nurs- Discussion
ing interventions for several peripheral vascular diseases. Approximately 5% of men ages 65 to 74 have abdominal aortic
aneurysms (AAAs) below the renal arteries that are at least 3 cm
■ PERIPHERAL VASCULAR in size. Aneurysms enlarge without symptoms until they rupture.
When an aneurysm ruptures, nearly half of the clients die before
DISORDERS arriving at the hospital and 40% to 60% die before discharge.
P eripheral vascular disorders include aneurysm, venous

thrombosis/thrombophlebitis, varicose veins, Buerger’s
disease, and Raynaud’s disease.
Overall, the mortality rate for ruptured aneurysms is 80%. If the
aneurysm is diagnosed with ultrasound prior to rupture, it can be
repaired with the traditional graft replacement or endovascular
repair, thus decreasing the mortality rate for AAAs.
In 2008, five pilot screening programs for AAAs in men
ANEURYSM 65 years of age were conducted in England. The Cochrane
An aneurysm is a localized dilation occurring in a weakened review (Cosford & Leng, 2007) of the screening program re-
section of an artery’s medial layer. A major cause of aneurysms ported a highly significant reduction in aneurysm-related mor-
is atherosclerosis (Mayo Clinic, 2011c). Some aneurysms tality and the Chichester study (Ashton, Buxton, Day, Kim,
occur because of genetic disturbances such as Marfan’s syn- Marteau, Scott, Thompson, & Walker, 2002) reported a sig-
drome or because of infection, inflammation, or trauma to nificant reduction in rate of aneurysm ruptures. The English
the vessel wall. Two other possible causes of an aneurysm study concluded that a national screening program had the
are increased turbulence in a section of the vessel and slower potential of preventing up to 2,000 aneurysm-related deaths
production of smooth muscle cells. Clients have a higher ten-
in England and Wales with a cost equal to or below other
dency to develop an aneurysm if they smoke cigarettes and
comparable screening programs. The U.S. Preventive Services
have hypertension.
Aneurysms can occur in any artery but occur most often Task Force (2005) has reached similar conclusions about the
in the abdominal aorta. The Agency for Healthcare Research English aneurysm screening program. England’s Department
and Quality (AHRQ) (2009) recommends that men between of Health decided to provide screening programs for all men
the ages of 65 and 75 who have smoked be screened for an 65 years of age within the next 10 years.
abdominal aortic aneurysm (see the Evidence-Based Practice implications for practice
box). Other involved vessels are the ascending, transverse,
Similar screening programs within the United States could
and descending aorta, thoracic aorta, popliteal arteries, and
femoral arteries. significantly reduce deaths from ruptured aneurysms in a cost-
Deposits of atherosclerotic plaque on the tunica intima effective manner as recommended by the AHRQ. Lives could
cause a hardening of the vessel, and the media layer of the ves- be saved if nurses teach men between the ages of 65 and 75 the
sel loses elasticity. Atherosclerosis and a lack of elastin in the importance of having a screening test for abdominal aneurysms.
vessel wall predispose the vessel to a weakened area, which
develops into an aneurysm.
The three types of aneurysms are fusiform, saccular, and
dissecting (Figure 22-1). A fusiform aneurysm is a uniform Symptoms of an aneurysm depend on its location. An-
dilation of the circumference of a vessel. In a saccular aneu- eurysms are often asymptomatic until they start leaking or
rysm, one side or section of the vessel balloons out and forms pressing on other structures. A thoracic aneurysm may press
a saclike outpouching on the side of the vessel. A dissecting on surrounding structures, causing dull upper back pain or
aneurysm occurs when blood enters a tear between the intima deep, scattered chest pain. Pressure on the trachea and bron-
and the media of a vessel wall. More blood is forced between chus may cause dyspnea, coughing, wheezing, and hoarseness.
the vessel layers by the high blood pressure in the vessel. A dis- Pressure on the esophagus causes dysphagia.
secting aneurysm does not circumvent (surround) the vessel The most common location of an abdominal aortic an-
but involves only a section of the vessel wall. eurysm is between the renal and iliac arteries. There may be
Dissecting aneurysms occur more frequently in the elderly no symptoms, but as it enlarges and presses on other vessels,
hypertensive client. A complication of a dissecting aneurysm is organs, and nerves, the client may experience abdominal,
that blood that has entered the torn layers may cause the tear to back, or flank pain. The client may feel a pulse in the abdo-
extend and eventually rupture the arterial wall. The rupture is a men when in a supine position. A tender pulsating mass may
surgical emergency. Symptoms of a ruptured aneurysm include be palpated slightly left of the umbilicus. Popliteal and femoral
intense back or abdominal pain, pallor, cool and clammy skin, aneurysms may cause decreased pedal pulses. Rupture of an
hypotension, diaphoresis, oliguria, loss of consciousness, and aneurysm is an emergency situation. Signs of rupture may
mottling of the abdomen and lower extremities. include hypotension, tachycardia, pallor, cool and clammy
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entitia
Media

Intima
Saccular Fusiform
A B
Figure 22-2 A, Aortoiliac aneurysm; B, bifurcated synthetic

graft.
After surgery, the client may be in the ICU with mechanical

ventilator assistance in breathing.
Pharmacological
Clients with aortic aneurysms may be given propranolol hy-
drochloride (Inderal) to decrease the pressure of the blood
Dissecting coming from the heart. Clients with hypertension are given
antihypertensive medications and diuretics. Analgesics are
Figure 22-1 Three types of aneurysms. given to control pain. Stool softeners are provided to prevent
straining during a bowel movement.
skin, and intense abdominal, back, or groin pain. An aneurysm Activity

is usually diagnosed when a client has an x-ray or ultrasound Any activity that increases blood pressure, especially exercise
done for other conditions/symptoms. and lifting, can increase pressure in the arteries and should be
avoided.
Medical-Surgical
Management Health Promotion
Clients are encouraged not to smoke. Education for hyper-
Medical tensive clients includes the importance of closely monitoring
If the client has hypertension, control of the hypertension is the blood pressure and taking antihypertensive medication as
the focus of care. Aneurysms are monitored for enlargement. prescribed.
Thrombi formation and ischemia may also result.
Surgical Nursing Management

Preoperatively, monitor vital signs and peripheral pulses. As-
Before elective surgery, the status of the client’s carotid arteries sess capillary refill, feet for mottling, and for edema. Postop-
and peripheral vessels is checked with a Doppler ultrasound. eratively, add frequent checking of the operative site. Check
Cardiac status is usually evaluated by a stress test or cardiac function and drainage of NG tube. Measure abdomen for in-
catheterization before surgery is scheduled. The surgeon often creasing size indicating internal hemorrhage. Measure output
orders an angiogram, ultrasound, or CT scan of the affected hourly for at least 30 mL of urine.
vessel before surgery to assess the blood supply to the area sur-
rounding the aneurysm. Before surgery, 4 to 8 units of blood
are placed on hold because hemorrhage is a possibility. The NURSING PROCESS
surgeon clamps the aorta, removes the section of the vessel
involving the aneurysm, and replaces it with a section of the Data Collection
client’s saphenous vein or a synthetic graft (Figure 22-2). Com-
plications that can occur from clamping the aorta are myocar- Subjective Data
dial infarctions, strokes, and renal damage. Vessels below the Preoperatively, the client may be concerned about an abdomi-
repaired aneurysm may become occluded because of decreased nal pulsation when reclining. The client may have chest, back,
blood flow during surgery or from plaque that has broken off abdominal, or flank pain depending on the aneurysm location.
from the wall of the vessel. A nasogastric tube may be inserted Postoperatively, listen for statements of pain and assess the level
to decrease pressure on the aneurysm repair site and incision. of pain according to a scale of 1 to 10 or the facility-approved scale.
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Objective Data
Palpate the abdomen for a pulsating mass, and check vital pulses before surgery. Pulses can then be compared preopera-
signs. Immediate intervention is needed if symptoms of tively and postoperatively. Postoperatively, assess the extremi-
bleeding or a rupturing aneurysm occur. Check the peripheral ties for color, warmth, peripheral pulses, and sensation.
Nursing diagnoses for a client with an aneurysm include the following:

NursiNg PlaNNiNg/ NursiNg
DiagNoses outComes iNterVeNtioNs ratioNale
Ineffective Tissue Perfu- The client will have well- Monitor for symptoms of an oc- A clot may be occluding a
sion (Peripheral) related oxygenated tissues as cluded vessel (pain, paleness, vessel, leading to ischemia
to decreased arterial manifested by strong cyanosis, and coldness). and necrosis in tissue distal
blood flow pulses and the skin re- to the clot.
maining the baseline color Monitor the temperature, color, The preoperative pulses serve
and warm. and fullness of the peripheral as baseline pulses postopera-
pulses in both extremities and tively. A clot or hemorrhage
compare them to the preopera- may cause a decrease in
tive pulses. pulse volume.
Assess capillary refill and client’s Capillary refill determines
feet for mottling and darkened quality of blood supply to an
areas on the toes and soles of area.
the feet.
Notify health care provider im- Health care provider can take
mediately if any of these symp- prompt action to correct a
toms occur. circulatory problem.
Risk for Deficient Fluid The client will have ad- Monitor vital signs closely for Regular monitoring of vital
Volume related to equate fluid volume. signs of hemorrhage. signs alerts the health care
hemorrhage provider if problems occur.
Check the operative site fre- The dressing is frequently
quently to make sure the dress- assessed for hemorrhaging.
ing is dry. Turn the client to Blood may seep over body
make sure blood is not pooling contours and pool under the
under the client’s body. Monitor client without appearing on
for other signs of hemorrhaging. the dressing. Other symp-
toms of hemorrhage are light-
headedness, dizziness, and
tachycardia.
Measure the abdomen for in- An increasing abdominal girth
creasing abdominal girth. indicates internal bleeding.
Monitor client for low back pain. Low back pain may indicate
hemorrhaging in the retroperi-
toneal space.
Check for adequate functioning A functioning NG tube de-
and drainage of the NG tube. creases pressure on the
aneurysm repair site and
incision.
Ineffective Tissue Perfu- The client will have a urine Measure hourly output to make An output of 30 mL/hr indi-
sion (Renal) related to output of at least 30 mL/ sure the client has at least cates minimal functioning of
interruption of blood flow hr. 30 mL of urine per hour. the kidneys.
during surgery Assess for edema. Edema could indicate
fluid overload or a vessel
occlusion.
Provide fluids as ordered. Providing adequate fluids en-
sures proper hydration.
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VENOUS THROMBOSIS/ CLIENT TEACHING

CLIENT TEACHING
THROMBOPHLEBITIS
Thrombophlebitis
The terms phlebitis, thrombosis, phlebothrombosis, and throm-
bophlebitis are often used interchangeably even though each • Drink 2 to 3 quarts of water per day.
word has a separate meaning and etiology. Phlebitis is an • Do not sit with legs crossed.
inflammation in the wall of a vein without clot formation. The • Elevate both legs when sitting.
formation of a clot in a vessel is a thrombosis, and a formed • Avoid sitting or standing for extended periods.
clot that remains at the site where it formed is a thrombus. If • Wear support hose.
the thrombus moves, it becomes an embolus, a mass such as
• When standing, shift weight frequently and oc-
a blood clot or an air bubble that circulates in the bloodstream.
Phlebothrombosis is the formation of a clot because of casionally stand on tiptoes to stimulate the calf
blood pooling in the vessel, trauma to the vessel’s endothelial muscle to pump blood.
lining, or a coagulation problem with little or no inflammation • Notify the physician immediately if leg pain,
in the vessel. thrombophlebitis is the formation of a clot tenderness or swelling, difficulty breathing, or
caused by an inflammation in the wall of the vessel. chest pain is experienced.
In 1846, Virchow listed three factors leading to the
formation of a clot: pooling of blood, vessel trauma, and a
coagulation problem. These are known as Virchow’s triad.
Risk factors for thrombi formation are prolonged bed rest, recommend the application of elastic support hose. If a DVT
leg trauma, oral contraceptives, obesity, varicose veins, hip is diagnosed, the client is placed on bed rest. Once the client
fractures, and total hip and knee replacement. improves and becomes ambulatory, below-the-knee compres-
The two types of thrombi are a superficial thrombus and a sion stockings are recommended.
deep vein thrombus (DVT). A superficial vein thrombus forms
in a superficial vein such as the saphenous vein in the leg. A DVT Surgical
forms in the deep veins of the arms, pelvic area, or legs, but the
legs are the most common site. Leg veins in which clots form are If a clot has formed in a large vein and all conservative meth-
the femoral, popliteal, iliac, and deep veins of the calf. ods have failed, the clot may be removed surgically. This
Phlebitis can either form spontaneously or as a result of procedure is called a thrombectomy and is performed only
IV catheters or cannulas, IV medications such as potassium or if the tissue in the area becomes ischemic or gangrenous or if
antibiotics, or direct trauma to a vein. A clot may then form as the client has a history of thromboemboli.
red blood cells pass over the damaged area, rupture, and start Another surgical procedure is a vena cava interruption
the clotting process. surgery (vena cavas plication) in which a Greenfield vena
Phlebitis manifests as a reddened streak over a vein. If a cava filter or umbrella filter is placed in the inferior vena cava
clot is in a superficial vein, the site becomes reddened, warm, to prevent thromboemboli from traveling from the lower ex-
tender, and swollen. A hardening is palpated in a section of tremities to the lungs, heart, or brain. Figure 22-3 shows these
the vein. Typically, there are no symptoms with a deep vein filters and their placement in the vena cava. The procedure is
thrombus. However, there may be warmth and tenderness at done on clients with a history of pulmonary emboli.
the site, unilateral edema of the affected extremity, positive
Homans’ sign, dilation of superficial veins, and cyanosis of Pharmacological
the foot. The client may say the leg feels “tight” or “heavy.” If If a client is at risk for a thrombus or phlebitis, anticoagulant
the clot is in the calf of the leg, the calf may feel tender. If the therapy is initiated. A prophylactic heparin dose is given.
swelling restricts the arterial blood flow, the leg may be cool Enoxaparin injection (Lovenox), a low-molecular-weight
and pale. If there are obvious clinical signs of a thrombosis, heparin, is used prophylactically after hip replacement
Homans’ sign should not be assessed because the clot may be surgery. It should be used cautiously with clients on oral
dislodged and become an embolus. Also, the calf or throm- anticoagulants.
botic area should not be rubbed. If a clot forms, the client is immediately started on hepa-
A complication of a DVT is a pulmonary embolus that rin as an IV bolus and then followed with a continuous IV drip
may result in death. Symptoms of a pulmonary embolus are of heparin. Before heparin is started, a partial thromboplastin
sudden and severe chest pain, dyspnea, and tachypnea. Em- time (PTT) or activated partial thromboplastin time (APTT)
boli may travel and block other vessels in the heart, brain, or and a platelet count are drawn by the laboratory to establish
peripheral vessels. a baseline level. The heparin dose is regulated by the PTT or
the APTT. For effective heparin therapy, the client’s PTT or
APTT level should be 2.5 times the baseline. A baseline level
Medical-Surgical is a value at a particular time that serves as a reference point
Management for future value levels.
Clients are usually discharged on Coumadin. Because
Medical of rapid hospital discharges, clients are often started on Cou-
A superficial phlebitis or thrombus may need no treatment, or madin the next day after heparin has been initiated. Once the
warm soaks may be applied to the affected area. Acetamino- Coumadin dose has been regulated, heparin is stopped.
phen or an NSAID is given for pain. Elevating the extremity After the initial Coumadin dose, the daily Coumadin dose
decreases swelling and improves venous return. Some doctors is regulated by the prothrombin time (PT) or the International
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cm Renal
Veins
1
Filter
2
A 3
Vena
Cava
4

Figure 22-3 Filter in the vena cava prevents an embolus Figure 22-4 An alternating pneumatic compression device
from traveling to the heart, lungs, or brain: A, Greenfield filter in squeezes the leg tissues causing blood to move toward the heart.
place; B, umbrella filter. This keeps blood circulating and prevents thrombi formation.
Normalized Ratio (INR). The client generally remains on CRITICAL THINKING

Coumadin for 3 to 6 months.
Thrombolytic drugs, urokinase (Abbokinase), strep- Alternating Pneumatic
tokinase (Streptase), and tissue plasminogen activator
Compression Device
(t-PA; Alteplase), are used locally and systemically if there
is a massive DVT. Streptokinase is only used on the same
client once every 6 months. If the client has had a recent 1. How does an alternating pneumatic compres-
streptococcal infection, streptokinase may not be effective sion device mimic the physiological action of
(Spratto & Woods, 2010). The main complication in a cli- muscles?
ent receiving thrombolytic drugs is bleeding. Heparin and 2. What are some other situations/conditions
Coumadin are given after the thrombolytic drugs to prevent
where a compression device may be used?
thrombi formation.
Diet
Adequate hydration is important for clients at risk for thrombi.
This is accomplished orally or intravenously. devices (Figure 22-4), prophylactic anticoagulants, elevation
of legs, leg exercises, and deep-breathing exercises all contrib-
ute to the prevention of thrombi.
Activity
During the acute stage, the client is placed on bed rest to pre-
vent the clot from dislodging and embolizing. Later, the leg is
Nursing Management
elevated periodically to improve venous return and decrease Monitor vital signs for changes and IV sites for redness and
swelling. The client’s leg should never be massaged because a warmth. Do not test for a Homans’ sign if a thrombus has
clot could be dislodged and become an embolus. been diagnosed. Measure the circumference of the affected
leg. Assess peripheral pulses and capillary refill. If the client
is on anticoagulant drugs, assess for signs of bleeding. When
Health Promotion on bed rest, elevate the entire affected leg. Remove elastic
Prevention is the best way to treat a DVT. Early ambula- support or pneumatic compression stockings daily to perform
tion, adequate hydration, alternating pneumatic compression hygiene tasks.
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NURSING PROCESS Objective Data

Check IV sites at least once per shift to see if a phlebitis or
Data Collection reddened area is developing at the insertion site. If a positive
Homans’ sign is detected during an assessment, notify the physi-
Subjective Data cian and do not perform another Homans’ sign until a clot has
Ask the client if there was any recent injury to the extremity, been ruled out. Assess the skin for redness, tenderness, hardness,
if the affected area is tender to the touch, or if there have been or warmth, and measure both legs to determine baseline mea-
clots previously. Note any chest pain, dyspnea, tachycardia, or surements. Measure the circumference of the affected leg every
hemoptysis. shift to determine an increase or decrease in swelling. Assess
peripheral pulses every 4 hours and more frequently if the cli-
ent experiences increased pain in the leg, cyanosis of the foot or
extremity, or increased swelling. These are signs of an occlusion.
Nursing diagnoses for a client with a venous thrombosis include the following:
Ineffective Tissue Perfu- The client will have ad- Elevate the client’s entire af- Gravity causes the blood in
sion (Peripheral) related equate tissue perfusion. fected leg when on bed rest to an elevated leg to flow to-
to decreased venous improve venous return. When ward the heart.
blood flow and/or clot elevated, the leg should be
formation slightly flexed at the knee with a
pillow under the thigh and calf.
Apply elastic support or inter- Elastic support hose or
mittent pneumatic compression an intermittent pneumatic
stockings on the client. Use in- compression stocking ap-
termittent pneumatic compres- plies pressure to the leg and
sion stockings only if a clot is causes blood to circulate to-
not present. ward the heart.
If the client has received throm- Anticoagulants prevent clot-
bolytic or anticoagulant drugs, ting and may cause bleeding.
assess for signs of bleeding,
which include hematuria, bruis-
ing, bleeding from the gums,
and blood in the stool.
Monitor pedal pulses and capil- These assessment measures
lary refill and measure thigh or ensure no clot has formed
calf circumference daily. and that the circulation is ad-
equate in the extremity.
Acute Pain related to in- The client will state ab- If the client has phlebitis, apply Warm moist soaks draw rich,
flammatory process sence of pain. warm moist soaks to the af- nutrient blood to the affected
fected area as ordered. area for healing and the re-
moval of pathogens.
Administer acetaminophen or a Analgesics, such as acet-
nonsteroidal anti-inflammatory aminophen or NSAIDs, relieve
as ordered for discomfort. pain.
Anxiety related to pos- The client will express Encourage client to discuss the Sharing concerns about the
sibility of the clot becom- anxiety about possible possibility of embolus formation. formation of an embolus with
ing an embolus embolus. a health care provider relieves
client anxiety.
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VARICOSE VEINS CLIENT TEACHING

Varicose veins, also called varicosities, are visibly prominent,
dilated, and twisted veins, usually in the lower extremities Varicose Veins
(Figure 22-5), but the veins in the esophagus (esophageal Apply support hose after the legs have been el-
varices) and anus (hemorrhoids) can also be affected. Usually,
evated for an extended time, 10 to 15 minutes, so
the saphenous vein is affected in the leg. Women are more
prone to varicose veins than men. Risk factors for developing the venous blood drains from the legs. Application
varicose veins are a familial tendency, congenital abnormali- before the client gets out of bed in the morning is
ties, pregnancy, obesity, constrictive clothing, and occupa- ideal. Do not fold or roll hose down from the top
tions that require prolonged standing. Pregnancy and obesity because this would act like a tourniquet, causing
cause more pressure in the veins of the legs. pooling of blood. Smooth the hose on the legs be-
The causes of varicose veins are incompetent valves and cause wrinkles or creases may cause extra pressure,
veins that have lost their elasticity. The wall of the vessel is leading to stasis or pooling of blood or pressure
weakened from a lack of elastin or collagen and is unable to ulcers. Remove hose daily so the leg can be washed
support the normal pressure of the blood in the vessel. The and dried before reapplication.
vein dilates as the blood in it flows backward. As the walls of
the vein dilate, the valves become incapable of holding the
blood and allow blood to leak backward through the space
between the valves. (Refer to Figure 18-7C in Chapter 18.)
The client has pain in the feet and ankles, swelling, and ulcers Medical-Surgical
on the skin. Trendelenburg’s test diagnoses the ability of the
venous valves to hold blood at a certain level in the vein and
Management
not allow the blood to retrograde or reflux (flow backward to Medical
the previous location). The test is performed by having the cli- Varicose veins are usually treated conservatively with elastic
ent lie supine and elevate one leg 90 degrees for 30 seconds. A support hose, elevation of the legs when sitting, not crossing
tourniquet is placed snugly above the knee, but not so tightly legs, and ankle and leg exercises.
that an arterial pulse cannot be felt. The client then stands and sclerotherapy involves injecting sodium tetradecyl sulfate
after 20 to 30 seconds, the tourniquet is released. The veins (Sotradecol) or polidocanol (Asclera) into the vein, causing the
should fill from distal to proximal. If the veins promptly fill vein to become sclerosed (hardened) so blood no longer flows
from proximal to distal, the venous valves are not able to hold through it. A compression bandage or elastic stocking is applied
the blood at the proper level in the vein. to the extremity for 4 to 5 days. The client wears support hose
for 5 more weeks. Complications of the procedure are necrosis
(tissue death) at the injection site, vasospasm, allergic responses,
and hemolysis (destruction of red blood cells).
Surgical
In more severe cases, varicose veins can be ligated (tied off)
or stripped. Vein stripping involves introducing a wire into
a vein. The wire has collapsible claws on the end. As the wire
is withdrawn, the claws expand and strip the walls of the vein.
This measure is used when there is a threat of thrombus or leg
ulcers. Vein ligation is tying off an involved section of a vein
with suture.
Endovenous laser ablation is another method of treating
varicose veins. After applying a local anesthetic, a nick the size
of a pencil tip is made in the vein. Then, with ultrasound guid-
ance, a small catheter is inserted into the vein and the vein is
closed with an application of laser energy. Blood is redirected
to other normal veins for tissue perfusion (Society of Inter-
ventional Radiology, 2005).
Pharmacological
Analgesics are given for leg discomfort. Anticoagulants may
be given to prevent clot formation.
(© auDie/ShutterStoCk)
Activity
The client is encouraged to exercise regularly. Walking is a
very good exercise to improve circulation because the blood
circulates faster in response to an increased heartbeat. Mus-
Figure 22-5 Varicose veins. cles in the legs apply pressure to the veins, forcing the blood
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Circular motion

Figure 22-6 Exercises to improve circulation to the lower extremities.
toward the heart. Ankle exercises such as rotating the ankle in after the surgery. Administer pain medication 30 minutes
circular motions also improve circulation (Figure 22-6). before the client ambulates until walking is tolerated without
discomfort. Encourage walking and leg exercises.
After endovenous laser ablation, there is minor soreness
Nursing Management and bruising that is treated with over-the-counter analgesics.
Assist the client in elevating the legs above the heart when in Since the incision is only a nick, there is no scarring.
bed or elevating the feet 6 to 10 inches on a pillow or stool
when sitting in a chair. BUERGER’S DISEASE
After sclerotherapy, the affected area may be tender and
discolored. Most discoloration will disappear in a few weeks, (THROMBOANGIITIS
but a darkened pigmentation may last for 6 to 8 months. Re- OBLITERANS)
peated sclerotherapy may be needed. Encourage the client to
maintain a walking exercise program to improve circulation Buerger’s disease is an inflammatory disease of small and
to the legs. medium arteries and veins that leads to vascular obstruc-
After vein stripping, the client is on bed rest for the first tion. Inflammation occurs in the tunica adventitia and tunica
24 hours. Elastic hose are worn continuously for 5 days to media layers of the vessels and may affect only a portion of
compress the blood into the deeper veins and for 5 weeks the vessel or the entire vessel. Hands and feet are mainly
involved, but the wrists and lower extremities may also be
affected. The distal tips of the hands and feet are pale, but as
the disease progresses, the hands and feet become reddened
CLIENT TEACHING when held in a dependent position. At first, pain in the palm
of the hand and arch of the foot is the main symptom. Pain
becomes more severe with disease progression, and as isch-
Health Promotion for Varicose Veins emia affects the nerves, the client may experience numbness,
Encourage clients with a familial tendency for burning, pain when at rest, and decreased sensation in the
varicose veins to elevate their legs 6 to 10 inches hands and lower extremities. The dorsalis pedis, posterior
on a small stool when sitting in a chair. Frequent tibia, and ulnar and radial pulses are weak or absent. Skin
position changes and not standing in one spot for
color changes, cold sensitivity, ulcers, and gangrene occur in
the later stages.
extended times also improve circulation.
Buerger’s disease occurs primarily in men between
the ages of 20 and 40 of Israeli, Indian, and Asian descent.
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There is a correlation between smoking and Buerger’s dis-

ease. Tests for diagnosis include arteriography and Doppler
ultrasound.
Medical-Surgical
Management
Medical
The client is encouraged to stop smoking and is referred to
a smoking clinic or seminar. Buerger-Allen exercises are rec-

ommended and explained. Buerger-Allen exercises consist
of elevating the legs until they blanch and supporting them
at that angle for 2 to 3 minutes. The legs are then lowered to
a dependent position until they become red and supported
at that level for 5 to 10 minutes. The legs are then placed flat
on the bed with the client in a supine position for 10 minutes. Figure 22-7 Raynaud’s disease.
The exercises are repeated as tolerated by the client.
an autoimmune disease, is necessary for a diagnosis of Rayn-
Surgical aud’s disease.
A sympathectomy (excision of a nerve, plexus, or ganglion of Raynaud’s is more prevalent in cold climates. Women are
the sympathetic portion of the autonomic nervous system) nine times more likely to be affected than men (Raynaud’s
is done to relieve pain and prevent vasospasm in the affected Association, 2008). Primary Raynaud’s begins between the
area. Digits and toes are amputated if gangrene occurs. ages of 15 and 25 (National Institute of Arthritis and Mus-
culoskeletal and Skin Diseases [NIAMS], 2006). Secondary
Raynaud’s begins later in life, between the ages of 35 and 40
Pharmacological (NIAMS, 2006). Persons who use vibrating hand tools such
Analgesics are given to control pain. Vasodilators are given to as air hammers or grinding wheels or who perform repetitive
increase circulation to the affected area. movements such as typing or playing the piano are at risk.
Diagnostic examinations include a complete blood count,
Nursing Management digital blood pressure measurement, digital plethysmography
Nursing diagnoses and interventions are the same as for other waveforms, and a cold-challenge test. A digital blood pressure
obstructive vascular conditions and are described in the fol- of 30 mm Hg below the brachial pressure indicates a digital ar-
lowing section about Raynaud’s disease. tery obstruction. A sedimentation rate, antinuclear antibody,
and rheumatoid factor determine the presence of autoim-
mune diseases. During a cold-challenge test, thermistors are
RAYNAUD’S DISEASE/ placed on the fingers and a baseline temperature is taken. The
PHENOMENON hands are submerged into ice water for 20 seconds and then
removed. The temperature of the hands is then taken every
Raynaud’s disease or primary Raynaud’s is an intermittent 5 minutes until it returns to the baseline level. Hand x-rays
spasm of the digital arteries and arterioles resulting in de- determine the presence of subcutaneous calcium deposits
creased circulation to the fingers and toes. Sometimes the and narrowing of bone in the digits. The diagnostic tests
tip of the nose and ears are also affected. The cause of the distinguish between Raynaud’s phenomenon and Raynaud’s
condition is unknown but seems to be related to vasospastic disease. If a client has unilateral or single-digit Raynaud’s, an
disorders, a disturbance with the innervation of the sympa- obstruction or embolus is suspected.
thetic nervous system, and angiography complications. Dur-
ing a spasm that lasts approximately 15 minutes, the fingers
become pale and then cyanotic. As the circulation returns to
the fingers, the fingertips become reddened and the person
MEMORY TRICK
experiences a tingling or throbbing pain in the fingers. Some Peripheral Vascular Disorders
people experience only pallor and cyanosis. The episode may Assessment
last 1 to 2 hours. Symptoms usually occur when the person is The nurse remembers 5 P’s when assessing clients
exposed to cold or experiences emotional stress. Gangrene is
with peripheral vascular disorders:
not common but can occur in the fingertips. Ulcerations can
also occur and are difficult to heal because of decreased circu- P 5 Pain
lation in the fingers (Figure 22-7). P 5 Pulse
When associated with a connective tissue or collagen
vascular disease, medications, or occupational trauma, the P 5 Pallor
condition is called Raynaud’s phenomenon or secondary P 5 Paresthesia
Raynaud’s. Raynaud symptoms may occur 10 years before
the related disease is diagnosed. A 2-year history of signs and P 5 Paralysis
symptoms with no evidence of underlying disease, especially
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Medical-Surgical Health Promotion

Management Encourage the client to avoid decongestants, caffeine, expo-
sure to cold, repetitive hand movements, and stressful situ-
Medical ations. Also encourage the client to quit smoking and avoid
Raynaud’s phenomenon is treated conservatively. The client secondary smoke because nicotine is a potent vasoconstrictor.
is assessed regularly for symptoms of autoimmune diseases. If Stress management techniques (e.g., biofeedback and t’ai chi)
the symptoms of Raynaud’s are caused by a vasospastic disease, may assist in alleviating some distress from the condition.
relief is best achieved with medications. Alternative therapies Wearing mittens in cold weather or when handling cold foods
such as relaxation techniques and biofeedback may be beneficial. keeps fingers warmer than wearing gloves. Keeping the entire
body warm is helpful.
Surgical
A sympathectomy is sometimes done to alleviate the client’s
Nursing Management
symptoms; however, it usually provides temporary relief and Assess digits for pallor, blanching, cyanosis, rubor, coldness,
is not a routine treatment. and texture. Encourage client to keep indoor temperature at
a comfortable level. Teach relaxation exercises to enhance
Pharmacological circulation. Encourage the use of mitts when pushing shop-
ping carts and the wearing of mittens and socks to bed. Apply
Calcium channel blockers, such as nifedipine (Adalat, Pro- lotion regularly to prevent dry, chapped skin.
cardia), amlodipine (Norvasc), and diltiazem hydrochloride
(Cardizem), improve symptoms in severe Raynaud’s phe-
nomenon by vasodilating small vessels in the hands and feet
and decreasing the frequency and intensity of attacks (Mayo NURSING PROCESS
Clinic, 2008). Clients may be given nifedipine (Adalat, Pro-
cardia) at night for severe cases of Raynaud’s phenomenon. Data Collection
Clients may also take the medication 1 to 2 hours before Subjective Data
engaging in an outdoor activity during cold weather. They
may not need to take the medication during warmer months. Ask the client how frequently the vasospastic episodes occur,
Alpha blockers, such as prazosin hydrochloride (Minipress) what symptoms are experienced, what triggers the episodes,
and doxazosin mesylate (Cardura), interfere with the ef- which digits are affected during an episode, and how long the
fects of norepinephrine, a hormone causing vasoconstriction. incident lasts. Inquire about daily activities the client finds dif-
Some clients benefit from topical nitroglycerin. Other drugs ficult, such as tying shoes, washing dishes, or handling frozen
in Raynaud’s research trials are losartan potassium (Cozaar), foods. Obtain a history of occupational activities.
sildenafil citrate (Viagra), fluoxetine hydrochloride (Prozac),
and prostaglandins (Mayo Clinic, 2008). Objective Data
Beta blockers, birth control pills, cold medications, and Assess the digits for pallor, blanching, cyanosis, rubor, cold-
diet pills cause some clients to have Raynaud’s phenomenon. ness, and texture. If the disease is long standing, the digits may
Chemotherapy drugs such as bleomycin sulfate (Blenoxane) be tapered and the skin shiny in appearance. There may be
and cisplatin (CDDP; Platinol) also cause secondary Raynaud’s. ulcerated or gangrenous areas on the fingertips.
Nursing diagnoses for a client with raynaud’s disease include the following:
Ineffective Tissue Perfu- The client will have fewer Encourage the client to use cau- Healing may be impaired
sion (Peripheral) related vasospastic episodes and tion when engaging in activities because of decreased
to vasospasm of periph- increased circulation in that may cause a cut or scratch. circulation.
eral arteries digits. If a client has ulcers, wash the Cleansing areas removes
areas with soap and water and pathogens. Antibiotics, cipro-
administer prescribed medica- floxacin, and iloprost, prevent
tions such as ciprofloxacin infection.
(Cipro) and intravenous iloprost.
Acute Pain related to The client will experience Teach client to keep the indoor Ischemic attacks occur in
decreased circulation in decreased pain as vaso- temperature at a comfortable colder temperatures.
digits spasms are controlled. level to avoid ischemic attacks.
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Encourage client to avoid dra- Cold temperatures stimulate
matic changes in environmental ischemic attacks.
temperatures (e.g., entering
a cold air-conditioned room
during hot summer months).
Encourage the client to wear
woolen or wind-proof gloves
or mittens and layered clothes
when exposed to colder tem-
peratures. Mittens may be bet-
ter than gloves so the fingers
can obtain warmth from each
other. Chemical warming de-
vices may be used inside gloves
and shoes.
Encourage the client to stop Smoking causes vasocon-
smoking and make a referral to striction leading to an isch-
a smoking cessation clinic. emic attack.
Teach the client relaxation ex- Stressful situations stimulate
ercises that may decrease the ischemic attacks. Appropri-
number of ischemic attacks. ate handling of stress may
decrease the number of isch-
emic attacks.
Situational Low Self- The client will learn ways Encourage client to use mitts Contact with other fingers
Esteem related to inabil- to handle activities of daily or potholders when removing provides warmth when mitts
ity of hands to perform living. items from the freezer or han- rather than gloves are worn.
activities of daily living dling cold food to decrease the
risk of a Raynaud’s episode. Cli-
ents can wear mittens or socks
to bed.
Use insulated mugs, foam These items insulate the fin-
rubber holders, or stemware gers from cold glass.
glasses to reduce ischemic
attacks.
Instruct client to wash vegeta- Tepid water does not cause
bles under tepid water instead vasoconstriction. Application
of cold, to bathe in lukewarm of lotion prevents dry and
water, and to apply lotion chapped skin.
regularly.
Encourage client to use gloves Decreases the cold sensation
when pushing shopping carts and softens the vibration.
or operating some vibrating
machines.
CONCLUSION
The client can choose healthy lifestyle changes to reduce the PVD, it is essential for the nurse to monitor closely the client’s
risks and complications of PVD. The nurse’s role is to teach perfusion because an acute situation can quickly develop if a
the client healthy life choices. When caring for a client with thrombus or embolus occurs.
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CHAPTER 23
Caring for Clients
with Hypertension
KEY TERMS
peripheral resistance primary hypertension secondary hypertension
LEARNING OBJECTIVES
2. Explain the pathophysiology of hypertension.
3. Describe the signs and symptoms of hypertension.
4. Discuss medical management of hypertension.
5. Explain nursing interventions for a client with hypertension.
6. Review client’s lifestyle habits and hypertension assessment to assist in the development
of an individualized teaching plan.
464
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CHAPTER 23 Caring for Clients with Hypertension 465
When the cause of hypertension is unknown, it is called

INTRODUCTION primary hypertension or essential hypertension. Eighty to
One in three adults in the United States have hypertension and ninety-five percent of clients with an elevated BP have pri-
it is the precursor of HF in 91% of cases (National Institutes of mary hypertension (Klabunde, 2007). In 5% to 10% of
Health [NIH], 2002; AHA, 2009). Of those who have hyperten- cases, the cause of hypertension is another condition within
sion, 80.6% are unaware they have it and only 48.4% of those the body such as renal artery stenosis, chronic renal dis-
who know of their diagnosis are controlling it (Reinberg, 2010). ease, primary hyperaldosteronism, sleep apnea, hyper- or
Incidents of stroke, myocardial infarction, and heart failure could hypothyroidism, pheochromocytoma, preeclampsia, or aortic
be reduced if hypertension were controlled (Phillips-Edwards et coarctation (Klabunde, 2007); this is known as secondary
al., 2007). This chapter discusses the pathophysiology, medical hypertension. Arteriosclerosis, atherosclerosis, hypernatre-
treatment, and nursing interventions for treating hypertension. mia (increased sodium in the blood), or prolonged stress may
also cause hypertension.
Malignant hypertension is a rapidly progressing, severe
HYPERTENSION elevation of BP (diastolic 120 mm Hg). It damages small
arterioles in the major organs. Arteriole inflammation in the
Blood pressure is the pressure exerted on the walls of blood eyes is the primary distinguishing finding. It is most common
vessels because of cardiac output and volume of circulat- in black males younger than 40 years of age.
ing blood. Hypertension (HTN), also known as high blood Another cause of hypertension is renal diseases that inter-
pressure, is defined as an elevated arterial blood pressure. A fere with blood flow to the kidneys causing them to release an
systolic blood pressure at or above 140 or a diastolic blood enzyme called renin. The released renin interacts with plasma
pressure at or above 90 indicates hypertension.
Unalterable risk factors for hypertension include African
American race, male gender, aging, postmenopausal women, EVIDENCE-BaSED
and family history of hypertension. Modifiable risk factors
include smoking, lack of exercise, obesity, stress, low socio- PraCtICE
economic status, diet high in sodium and fat, alcohol intake,
and oral contraceptives (see Figure 23-1). African Americans and Hypertension
Source: artinian, n., flack, J., nordstrom, c., Hockman, e.,
ble factors Washington, o., Jen, K., & fathy, m. (2007). effects of nurse-
Altera
managed telemonitoring on blood pressure at 12-month follow-
Diet high in Na
up among urban african americans. Nursing Research, 56(5),
Diet high in fat 312–322.
Alcohol intake
Obesity
able fac Discussion
ter t
al Smoking African Americans develop hypertension at an earlier age and
African-
or
Un
American
s
Stress
because of hypertension have higher rates of illness and death
Aging Male
than Caucasians. A 1-year research study from Wayne State
Postmenopausal
woman University involved 387 African Americans who took their BP
Family history
Oral
of HTN
three times a week on a home BP monitor and transmitted
Lack of exercise
contraceptives the readings by phone (telemonitoring) to the research center.
The participants were divided into two groups. One group

(n 5 193) visited a primary care provider, received low-cost
Low socioeconomic
status
medieations, and a hypertension brochure. The other group
(n 5 194) received phone calls from nurses who reviewed
their BP readings and provided support and needed informa-
tion to control their hypertension. At the end of the study,
Figure 23-1 Alterable and unalterable risk factors for
both groups had lowered their BP, but the group that received
hypertension.
the regular phone calls had a reduction of 13 mm Hg systolic
pressure more than those who were referred to a primary care
provider.
implications for practice
Cultural
Hypertension CONSIDERATIONS Telemonitoring technology provides a quality-based method
of reviewing clients’ BP. Perhaps clients would have better
Hypertension quality care and outcomes if nurses provided close review of
telemonitoring BP readings, support, and taught quality life-
African American clients develop hypertension ear- style changes. The results of this study may prompt nurses,
lier in life, and it is more severe (increased elevation especially those working in physicians’ offices, to use telemon-
of BP, more illness, and deaths) at any decade of itoring technology, provide quality client support, and teach
life than in other ethnic groups (Kennedy, 2008; Na- hypertensive lifestyle changes.
tional Heart Lung and Blood Institute (NHLBI), 2011).
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Medical-Surgical
Renal disease
Management
Decreased blood flow to kidneys
Medical
Release of renin The main goal for a client with HTN is keeping the blood
pressure within normal limits. The regimen is referred to as
Renin interacts with plasma protein a stepped-care approach. The first step is to encourage the
client to try some diet and lifestyle changes, including los-
Angiotensin formed ing weight if >15% over optimum weight; limiting sodium,
saturated fat, cholesterol, and alcohol intake; exercising on a
Vasoconstriction regular basis; stopping the use of nicotine; and maintaining
an adequate intake of calcium, magnesium, and potassium.

Increased peripheral resistance This step is tried for 3 to 6 months, and if the BP then is
<140/90 mm Hg, these steps are continued. If the BP still
Increased blood pressure remains high, the second step is the addition of a diuretic or
a beta blocker to the client’s care regimen. The client is again
evaluated for a period of time, usually 2 months. If the BP still
Figure 23-2 Pathophysiology of renal diseases and is not <140/90 mm Hg, the third step of increasing the drug
hypertension. dosage, trying another drug, or adding a second antihyperten-
sive drug from another class of drugs is implemented. If the BP
proteins, forming a vasopressor called angiotensin. Vasocon- is maintained at <140/90 mm Hg, the regimen is continued.
striction caused by angiotensin increases blood pressure when If the BP is still high, the last step is implemented by adding a
more force is required to push the blood through the vessel. second or third antihypertensive drug.
Vasodilation decreases vascular or peripheral resistance
(pressure within a vessel that resists the flow of blood such as
plaque buildup or vasoconstriction). Figure 23-2 depicts how
renal disease causes hypertension.
Arteriosclerosis causes the vessel walls to have less elas- INFOrMatICS
ticity, decreasing their ability to expand and recoil. Because
the vessel is not able to expand, more pressure is needed to Monitoring Blood Pressure
force the blood through the vessel. The plaque buildup causes The client who has an elevated BP only when it is
resistance to blood flow through the vessel, and more pressure
taken in a physician’s office has white-coat hyper-
is needed to get the blood through the vessel. Hypernatremia
tension. This situation may be indicative of hyper-
(increased blood sodium) causes vasocongestion, and the
heart must pump with more force, increasing the pressure in tension, but sometimes it is not. Technology has
the arteries, thus causing HTN. made it possible to monitor the BP on these clients
Stress stimulates the sympathetic nervous system, which over a 24-hour period. One such way is for the
supplies nerves to the smooth muscles of the arteries, arterioles, client to wear an ambulatory monitor with a stan-
veins, and venules. Stimulation of these smooth muscles causes dard BP cuff that inflates at preset times, usually
the vessels to constrict, leading to elevated blood pressure. every 15 to 30 minutes during awake hours and
Some complications of HTN are cerebrovascular ac- every 30 to 60 minutes when sleeping. The read-
cident (stroke), myocardial infarction, HF, vision problems, ings are retained in the unit and then transferred
and renal failure. Table 23-1 lists the recognized classification to the manufacturer’s computers. The physician
of blood pressure. receives a printed sheet of waking and sleeping
BP readings, pulse pressure, heart rate, and a per-
Table 23-1 Classification of Blood centage of readings above a predetermined level.
Pressure Treatment is prescribed according to the client’s
24-hour data collection. Ambulatory monitoring is
SYSTOLIC DIASTOLIC supported by the Joint National Committee on Pre-
CATEGORY (mm Hg) (mm Hg) vention, Evaluation, and Treatment of High Blood
Pressure (JNC) and the World Health Organization–
Normal <120 and <80 International Society of Hypertension.
prehypertension 120–139 or 80–89 Another method is telemonitoring BP readings.
Hypertension The client monitors the blood pressure and then
Stage 1 140–159 or 90–99 transmits the reading to an Internet-based telemoni-
Stage 2 ≥160 or ≥100 toring service. Research indicates these methods
may provide better client blood pressure monitoring
From The Seventh Report of the Joint National Committee on Preven-
tion, Detection, Evaluation, and Treatment of High Blood Pressure, 2003, rather than having the client return to the physi-
Bethesda, MD: National Institutes of Health. cian’s office for a BP check (Artinian, 2004).
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CHAPTER 23 Caring for Clients with Hypertension 467
A new class of antihypertensives is renin inhibitors that

Pharmacological effectively treat mild to moderate hypertension. The first drug
Diuretics are usually the first pharmacological step in treating in this classification is aliskiren (Tekturna). The new antihyper-
HTN. Diuretics increase the renal excretion of sodium and tensives inhibit the production of renin, thereby, lowering the
water from the body, decreasing the total fluid volume. When client’s blood pressure (see Figure 23-2). The main side effect
less fluid is in the body, less pressure or force is needed to of aliskiren is diarrhea. The client may also have a cough as in
pump the blood through the body. clients taking ACE inhibitors. A rare side effect is angioedema
Beta-adrenergic blocking agents are given to block the of the head and neck with the potential of causing respiratory
epinephrine and norepinephrine receptor sites. With these distress. This drug, like other renin-angiotensin-aldosterone
receptor sites blocked, the vessels do not constrict and the altering antihypertensives, is less effective in African Americans
blood has less resistance flowing through the vessel. Diuretics than in Caucasians and Asians (Aschenbrenner, 2007). See
and antihypertensive medications may cause impotence. Table 23-2 for other antihypertensive medications.
Table 23-2 Medications Used to Manage Hypertension

DRUG ACTION NURSING INTERVENTIONS
Diuretics
Thiazides Inhibits reabsorption of Na and Cl in May cause hyperuricemia and hyper-
chlorthalidone (Hygroton) proximal distal tubes. glycemia; therefore, closely monitor
hydrochlorothiazide (Esidrix, HCTZ) clients with gout and diabetes mellitus.
metolazone (Zaroxolyn) Encourage eating potassium-rich foods.
Give early in day to prevent nocturia.
Loop Inhibits reabsorption of Na and Cl in Teach client to rise slowly from sitting
bumetanide (Bumex) proximal distal tubes and the loop of or lying position because of orthostatic
ethacrynic acid (Edecrin) Henle. hypotension.
furosemide (Lasix)
torsemide (Demadex)
Potassium-sparing Inhibits aldosterone in distal tubules. May cause hyperkalemia; therefore,
amiloride (Midamor) Increases excretion of Na and H2O. monitor K blood level.
spironolactone (Aldactone) Decreases excretion of K1. May cause hypotension.
triamterene (Dyrenium)
Aldosterone receptor blockers Blocks the actions of ADH in the distal

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Brief CONTeNTS 37 Caring for Clients with Exocrine Pancreatic

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Gena Duncan, MSEd, MSN, RN

Wendy Baumle, MSN, RN, CNE

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Cengage Learning is a leading provider of customized learning solutions with

Cengage Learning products are represented in Canada by Nelson Education,

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Printed in the United States of America

Contributors / xxix Roles of the Medical-Surgical Nurse . . . . . . . . . . . . . . . . 11

Family Roles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Prodromal Stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Types of Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110

Ascites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200

Respiratory Alkalosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230 UNIT 4

BRONCHIECTASIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 372 Anatomy and Physiology Review . . . . . . . . . . . . . . . . . . . 396

CHAPTER 21: CARING FOR Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 462

Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 493 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 530

RENAL FAILURE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 555 Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 597

Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 620 Common Diagnostic Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . 660

HIATAL HERNIA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 697 Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 721

CHOLECYSTITIS AND CHOLELITHIASIS . . . . . . . . . . . . . . . 748 UNIT 10

CHAPTER 41: CARING FOR Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 853

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 839 CHAPTER 44: ASSESSING AND

INFECTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 876 OTITIS MEDIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 900

Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 942 Medical-Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . 964

CHAPTER 50: CARING FOR CHAPTER 52: CARING

Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1002 Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1017

UNIT 13 Eczema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1081

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1116 Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1143

CHAPTER 62: CARING Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1188

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1220 Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1243

CENTRAL NERVOUS SYSTEM Potential for Addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1274

Pathophysiology of Stress and Depression . . . . 1284 Reproductive System: Female . . . . . . . . . . . . . . . . . . . . . . . . . 1336

NEUROLOGICAL/NEUROSURGICAL MULTIPLE-SYSTEM TRAUMA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 1385

Patti Altman, MSN, RN Marty Downey, PhD, RN, AHN-BC, HTPA

Christine Higbie, MSN, RN Rhoda Owens, MSN, RN

Barbara Overman, MSN, RN

Nicole Adler, MSN, BSN, RN, CFNP Kim D. Cooper, MSN, RN

Margaret P. Bennett, MEd, BSN, RN Laura R. Durbin, BSN, RN, CHPN

Lisa W. Blackburn, BSN, RN Penni Ellis, MSN, BSN, RN

Terri B. Blevins, MSEd, BSN, RN Gwendolyn Gaston, MSN, RN

Priscilla S. Burks, MSN, BSN, RN Edith L. Gerdes, MSN, RN, BHCA

Dotty Cales, RN Margaret Gingrich, MSN, RN

Sherri Comfort Evelyn Grigsby, MSN, RN

Janis E. Grimland, BSN, RN Charlotte Prewitt, MSN, RN

M edical-Surgical Nursing: An Integrated Approach, Third

Medical-Surgical Nursing, Third Edition,

W e would like to thank the contributors for the time

L ois Elain Wacker White earned a diploma in nursing from

KEY TERMS KEY TERMS

Assessing Pain CRITICAL THINKING

This new feature presents examples of current Computer Imaging

COMMUNITY/HOME HEALTH CARE COMMUNITY/HOME HEALTH CARE

Use the mnemonic devices provided in the new of shock is CHANS.

working with clients. N  Neurogenic

CASE STUDY CASE STUDIES

Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)

PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE

Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)

PLANNING/OUTCOMES NURSING INTERVENTIONS RATIONALE

This new feature provides additional learning experi-

working with clients. N Neurogenic