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AMERICAN
r ASSOCIATION
FIFTH EDITION °J CRITICAL-CARE
NURSES
AACN
Essentials of
Progressive
Care Nursing
Sarah A. Delgado
Mc
Gra w
Hill
AACN Essentials of Progressive Care Nursing
Fifth Edition
Sarah A. Delgado, MSN, RN, ACNP

Clinical Practice Specialist
American Association of Critical-Care Nurses
Aliso Viejo, California
New York Chicago San Francisco Athens London Madrid Mexico City
Milan New Delhi Singapore Sydney Toronto
Delgado-PC_FM_pi-xviii.indd 1 10/08/23 1:58 PM

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Contents
Contributors...........................................................................................................................................................................................................................................................xiii
Peer Reviewers....................................................................................................................................................................................................................................................... xv
Preface................................................................................................................................................................................................................................................................ xvii
Section I. The Essentials........................................................................................................................................................................................................................................ 1

1. Assessment of Progressive Care Patients and Their Families........................................................................................................... 3
Lynn Orser
2. Planning Care for Progressive Care Patients and Their Families.................................................................................................. 19
Lynn Orser
3. Interpretation and Management of Basic Cardiac Rhythms.......................................................................................................... 37
Carol Jacobson
4. Hemodynamic Monitoring................................................................................................................................................................. 73
Yana Dilman
5. Airway and Ventilatory Management................................................................................................................................................ 99
Robert E. St. John and Maureen A. Seckel
6. Pain and Sedation Management....................................................................................................................................................... 141
Yvonne D’Arcy and Sara Knippa
7. Pharmacology..................................................................................................................................................................................... 163
Earnest Alexander
8. Ethical and Legal Considerations..................................................................................................................................................... 193
Laura Webster
Section II. Pathologic Conditions..................................................................................................................................................................................................................... 217

9. Cardiovascular System....................................................................................................................................................................... 219
Brook Powell and Barbara Leeper
10. Respiratory System............................................................................................................................................................................. 253
Kiersten N. Henry and Maureen A. Seckel
11. Multisystem Problems....................................................................................................................................................................... 287
Sonya M. Grigsby
12. Neurological System........................................................................................................................................................................... 311
Kathrina Siaron and DaiWai M. Olson
iii

iv CONTENTS
13. Hematologic and Immune Systems................................................................................................................................................. 337

Danya Garner
14. Gastrointestinal System..................................................................................................................................................................... 353
Anna M. Alder
15. Renal System....................................................................................................................................................................................... 385
Jie Chen
16. Endocrine System............................................................................................................................................................................... 403
Heather Roff
17. Trauma................................................................................................................................................................................................. 425
Alina Huneke and Jen Miller
Section III. Advanced Concepts........................................................................................................................................................................................................................ 443

18. Advanced ECG Concepts.................................................................................................................................................................. 445
Carol Jacobson
19. Advanced Cardiovascular Concepts................................................................................................................................................ 493
20. Advanced Neurologic Concepts....................................................................................................................................................... 521
Section IV. Key Reference Information............................................................................................................................................................................................................. 543

21. Normal Laboratory Reference Values.............................................................................................................................................. 545
Sarah A. Delgado
22. Implementing Crisis Standards of Care........................................................................................................................................... 549
Laura Webster
23. Cardiac Rhythms, ECG Characteristics, and Treatment Guide................................................................................................... 551
Carol Jacobson
Index ............................................................................................................................................................................................................... 559

Contents in Detail
Contributors..............................................................................................................................................................................................................................................................xiii
Peer Reviewers.......................................................................................................................................................................................................................................................... xv
Preface.................................................................................................................................................................................................................................................................... xvii
Section I. The Essentials........................................................................................................................................................................................................................................ 1

1. Assessment of Progressive Care Patients and Their Families........................................................................................................... 3
Lynn Orser
Assessment Framework 3
Prearrival Assessment 4 / Arrival Quick Check 4 / Comprehensive Initial Assessment 4 /
Ongoing Assessment 4 / Patient Safety Considerations in Admission Assessments 4
Prearrival Assessment: Before the Action Begins 5
Admission Quick Check Assessment 6
Airway and Breathing 7 / Circulation and Cerebral Perfusion 7 / Chief Complaint 7 /
Drugs and Diagnostic Tests 7 / Equipment 8
Comprehensive Initial Assessment 8
Past Medical History 9 / Social History 9 / Physical Assessment by Body System 9 /
Transition/Discharge Planning 15
Ongoing Assessment 16
Principles of Management 17
Selected Bibliography 17
Progressive Care Assessment 17 / Evidence-Based Practice 17
2. Planning Care for Progressive Care Patients and Their Families.................................................................................................. 19
Lynn Orser
Interprofessional Plan of Care 20
Planning Care through Staffing Considerations 20
Patient Safety Considerations in Planning Care 21
Prevention of Common Complications 22
Physiologic Instability 22 / Venous Thromboembolism 22 / Hospital-Acquired Infections 22 /
Pressure Injury 24 / Sleep Pattern Disturbance 24 / Falls 25 / Psychosocial Impact 25
Patient and Family Education 27
Assessment of Learning Readiness 27 / Strategies to Address Patient and Family Education 27 /
Outcome Measurement 28
Family-Centered Care 28
Family Visitation 29
Transporting the Progressive Care Patient 30
Assessment of Risk for Complications 30 / Level of Care Required during Transport 31 /
Preparation 32 / Transport 32 / Interfacility Transfers 34
Transitioning to the Next Stage of Care 34
Supporting Patients and Their Families during the Dying Process 34
v

vi CONTENTS IN DETAIL
Patient and Family Needs 34 / Infection Prevention and Control 35 / Patient and Family
Education 35 / Psychosocial Care 35 / Sleep Deprivation 35 / Transport of Critically Ill Patients 35 /
Evidence-Based Practice 35
3. Interpretation and Management of Basic Cardiac Rhythms.......................................................................................................... 37
Carol Jacobson
Basic Electrophysiology 37
Ecg Waveforms, Complexes, and Intervals 38
P Wave 39 / QRS Complex 39 / T Wave 39 / U Wave 39 / PR Interval 39 / ST Segment 39 /
QT Interval 39
Basic Electrocardiography 39
Cardiac Monitoring 40
Determination of the Heart Rate 41
Determination of Cardiac Rhythm 43
Common Dysrhythmias 43
Rhythms Originating in the Sinus Node 43
Normal Sinus Rhythm 43 / Sinus Bradycardia 43 / Sinus Tachycardia 44 / Sinus Dysrhythmia 44 /
Sinus Node Dysfunction 45 / Sinus Pause and Sinus Arrest (Failure of the Sinus Node to Fire) 45 /
Tachycardia-Bradycardia (Tachy-Brady) Syndrome 45
Dysrhythmias Originating in the Atria 46
Premature Atrial Complexes 46 / Wandering Atrial Pacemaker and Multifocal Atrial Tachycardia 47 /
Atrial Tachycardia 47 / Atrial Flutter 48 / Atrial Fibrillation 51 / Supraventricular Tachycardia 56
Dysrhythmias Originating in the Atrioventricular Junction 57
Premature Junctional Complexes 57 / Junctional Rhythm, Accelerated Junctional Rhythm, and
Junctional Tachycardia 58
Dysrhythmias Originating in the Ventricles 58
Premature Ventricular Complexes 58 / Idioventricular Rhythm and Accelerated Idioventricular
Rhythm 59 / Ventricular Tachycardia 60 / Ventricular Fibrillation 60 / Ventricular Asystole 62
Atrioventricular Blocks 62
First-Degree Atrioventricular Block 62 / Second-Degree Atrioventricular Block 63 / High-Grade
Atrioventricular Block 64 / Third-Degree Atrioventricular Block (Complete Block) 64
Temporary Pacing 65
Indications 65 / Transvenous Pacing 65 / Epicardial Pacing 65 / Components of a Pacing
System 66 / Basics of Pacemaker Operation 66 / Initiating Transvenous Ventricular Pacing 68 /
Initiating Epicardial Pacing 68 / External (Transcutaneous) Pacemakers 69
Defibrillation and Cardioversion 70
Defibrillation 70 / Automatic External Defibrillators 70 / Cardioversion 70
Evidence-Based Practice 71
4. Hemodynamic Monitoring................................................................................................................................................................. 73
Yana Dilman
Hemodynamic Parameters 74
Cardiac Output 74 / Components of Cardiac Output/Cardiac Index 76 / Stroke Volume and Stroke
Volume Index 77 / Ejection Fraction 77 / Factors Affecting Stroke Volume/Stroke Volume Index 77 /
Global End-Diastolic Volume as a More Reliable Preload Marker 81
Basic Components of Hemodynamic Monitoring Systems 82
Arterial Catheter 82 / Pressure Tubing 82 / Pressure Transducer 82 / Pressure Amplifier 82 /
Pressure Bag and Flush Device 82 / Alarms 84
Obtaining Accurate Cvp and Arterial Values 84
Zeroing the Transducer 84 / Leveling the Transducer to the Catheter Tip 84 / Ensuring Accurate
Waveform Transmission 84
Insertion and Removal of Catheters 87
Central Venous Catheters 87 / Arterial Catheters 87
Obtaining and Interpreting Hemodynamic Waveforms 88
Patient Positioning 88 / Interpretation 88 / Artifacts in Hemodynamic Waveforms:
Respiratory Influence 90

CONTENTS IN DETAIL vii
Tissue Perfusion Markers 91

Central Venous Oxygen (Scvo2) Monitoring 91 / Venoarterial Carbon Dioxide Gap 91 /
Lactate Monitoring 91 / Capillary Refill Time Monitoring 91
Minimally Invasive Hemodynamic Monitoring 91
Pulse Contour Measurement 91
Transpulmonary Thermodilution (PiCCO) 91 / LiDCO 92 / FloTrac/Vigileo 92 / Volume Clamp
Method 92 / Thoracic Bioimpedance/Bioreactance 92 / Esophageal Doppler 93 / Applanation
Tonometry 93 / Pleth Variability Index and End-Tidal Carbon Dioxide Pulse Pressure 93 /
Microcirculatory Targets 93 / Ambulatory Pulmonary Artery Pressure Monitoring 94
Hemodynamic Monitoring 95 / Minimally Invasive Hemodynamic Monitoring 96 /
Therapeutics 97 / Evidence-Based Practice Guidelines 98
5. Airway and Ventilatory Management................................................................................................................................................ 99
Robert E. St. John and Maureen A. Seckel
Diagnostic Tests, Monitoring Systems, and Respiratory Assessment Techniques 99
Arterial Blood Gas Monitoring 99 / Venous Blood Gas Monitoring 104 / Pulse Oximetry 104 /
Assessing Pulmonary Function 106
Airway Management 109
Oropharyngeal Airway 109 / Nasopharyngeal Airway 109 / Laryngeal Mask Airway 109 /
Artificial Airways 109 / Endotracheal or Tracheostomy Suctioning 112 / Extubation 114
Decannulation 114
Oxygen Therapy 115
Complications 115 / Oxygen Delivery 115
Basic Ventilatory Management 118
Indications 118 / General Principles 118 / Modes 121 / Complications of Mechanical
Ventilation 123 / Weaning From Short-Term Mechanical Ventilation 125 / Weaning From
Prolonged Mechanical Ventilation 128 / Respiratory Fatigue, Rest, and Conditioning 129 /
Wean Trial Protocols 130 / Other Protocols for Use 131 / Critical Pathways 131 / Systematic
Institutional Initiatives for the Management of the LTMV Patient Population 131 / Troubleshooting
Ventilators 131 / Oral Feedings 132 / Communication 132
Maximizing Oxygenation, Ventilation, and Patient-Ventilator Synchrony 136 / Maintain a Patent
Airway 136 / Monitor Oxygenation and Ventilation Status Frequently 136 / Physiotherapy and
Monitoring 137 / Maintain Oxygenation and Ventilatory Support at All Times 137 / Weaning from
Mechanical Ventilation 137 / Preventing Complications 137 / Maximizing Communication 137 /
Reducing Anxiety and Providing Psychosocial Support 137
General Progressive Care 137 / COVID-19 139 / Ventilator Management 139 /
Weaning from Mechanical Ventilation 139 / Communication 139 / Evidence-Based Resources 139
6. Pain and Sedation Management....................................................................................................................................................... 141
Yvonne D’Arcy and Sara Knippa
Physiologic Mechanisms of Pain 141
Peripheral Mechanisms 141 / Spinal Cord Integration 142 / Central Processing 142
Responses to Pain 143
Pain Assessment 144
A Multimodal Approach to Pain Management 144
Nonsteroidal Anti-Inflammatory Drugs 145
Side Effects 145
Opioids 146
Side Effects 146 / Intravenous Opioids 147 / Patient-Controlled Analgesia 147 /
Switching From IV to Oral Opioid Analgesia 148
Epidural Analgesia 148
Epidural Opioids 148 / Epidural Local Anesthetics 151
Non-Pharmacological Pain Management 151
Cutaneous stimulation 151 / Distraction 152 / Imagery 153 / Relaxation Techniques 153 /
Deep Breathing and Progressive Relaxation 153 / Presence 153

viii CONTENTS IN DETAIL
Special Considerations For Pain Management In Older Adults 153

Assessment 153 / Interventions 154 / Principles of Pain Management 154
Sedation 154
Analgosedation 154 / Reasons for Sedation 154 / Goals and Management of Sedation 156 /
Sedative Medications 158 / Sedation Considerations During Drug Shortages 158 / Issues Related to
Sedation 158 / Principles of Management for the Use of Sedatives 160
Pain Management 161 / Sedation 161 / Evidence-Based Practice Guidelines 161
7. Pharmacology..................................................................................................................................................................................... 163
Earnest Alexander
Medication Safety 163
Medication Administration Methods 164
Intravenous 164 / Intramuscular or Subcutaneous 164 / Oral 164 / Sublingual 165 / Intranasal 165 /
Transdermal 165
Central Nervous System Pharmacology 165
Sedatives 165 / Analgesics 169 / Anticonvulsants 170
Cardiovascular System Pharmacology 173
Parenteral Vasodilators 173 / Antiarrhythmics 176 / Vasodilators and Remodeling Agents 179 /
Soluble Guanylate Cyclase Stimulators 179 / Vasopressor Agents 179 / Inotropic Agents 180
Antibiotic Pharmacology 181
Vancomycin 181
Pulmonary Pharmacology 182
Albuterol 182 / Levalbuterol 182 / Ipratropium 182
Gastrointestinal Pharmacology 182
Stress Ulcer Prophylaxis 182 / Acute Peptic Ulcer Bleeding 183 / Variceal Hemorrhage 183
Renal Pharmacology 183
Diuretics 183
Hematologic Pharmacology 185
Anticoagulants 185 / Factor Xa Inhibitors 187 / Direct Thrombin Inhibitors 187 / Glycoprotein IIb/IIIa
Inhibitor 188 / Thrombolytic Agents 188
Immunosuppressive Agents 189
Cyclosporine 189 / Tacrolimus (FK506) 190 / Sirolimus (Rapamycin) 190
Special Dosing Considerations 190
Drug Disposition in Older adults 190 / Therapeutic Drug Monitoring 190
General 192 / Evidence-Based Practice Guidelines 192
8. Ethical and Legal Considerations..................................................................................................................................................... 193
Laura Webster
Foundational Terms: Defining Ethics and Morality 193
Types of Ethical Issues 193
The Foundations for Ethical Decision Making 195
Common Ethical Theories 195 / Professional Codes and Standards for Nurses 195 /
Rule-Based 196 / Institutional Policies 196 / Legal Standards 197 / Principles of Ethics 197 /
Relationship-Focused 198 / Ethic of Care 198 / Casuistry 198 / Outcome-Based 198
Surge Capacity and Crisis Standards of Care 198
Rights 200
Building an Ethical Environment 201
Healthy Work Environments 201
Common Ethical Issues 204
Fidelity 204 / Privacy and Confidentiality 204 / Veracity 205 / Informed Consent 205 / Shared
Decision Making 206 / Substitute Decision Making 206 / Respect for Persons 206 /
End-of-Life Care 207 / Informed Assent 208 / Evolving Technology 211 /
Electronic Health Record 212 / Social Media 212 / Patient Advocacy 212
The Process of Ethical Analysis 213
Professional Codes, Standards, and Position Statements 216 / Evidence-Based Guidelines 216 /
Online References of Interest: Related to Legal and Ethical Considerations 216

CONTENTS IN DETAIL ix
Section II. Pathologic Conditions..................................................................................................................................................................................................................... 217

9. Cardiovascular System....................................................................................................................................................................... 219
Special Assessment Techniques, Diagnostic Tests, and Monitoring Systems 219
Assessment of Chest Pain 219 / Coronary Angiography 219
Pathologic Conditions 221
Acute Coronary Syndromes 221 / Principles of Management of Acute Coronary Syndromes 227 /
Percutaneous Coronary Interventions 229 / Other Percutaneous Coronary Interventions 230 /
Surgical Management 231 / Indications 232 / Contraindications 232 / Postoperative Management
232 / Electrophysiology Studies 233
Heart Failure 234
Sympathetic nervous system activation 235 / Ventricular Remodeling 235 /
Neurohormonal Response 236 / The Progression of Heart Failure 237 / Principles of Management
for Heart Failure 240 / Shock 242 / Hypertension 247
General Cardiovascular 250 / Coronary Revascularization 250 / Acute Coronary Syndromes 250 /
Heart Failure 250 / Hypertension 251 / Evidence-Based Practice Guidelines 251
10. Respiratory System............................................................................................................................................................................. 253
Kiersten N. Henry and Maureen A. Seckel
Chest X-Rays 253 / Computed Tomography, Magnetic Resonance Imaging, and Bedside
Ultrasonography 258 / CTPA and V/Q Scans 259 / Chest Tubes 259
Thoracic Surgery and Procedures 261
Principles of Management for Thoracic Surgery and Procedures 261
Acute Respiratory Failure 262 / Acute Respiratory Distress Syndrome 266 / Acute Respiratory
Failure in the Patient with Chronic Obstructive Pulmonary Disease 267 / COVID-19
(SARS-CoV-2) 270 / Principles of Management for COVID-19 Infection 272 / Acute Respiratory
Failure in the Patient with Asthma 272 / Principles of Management for Asthma Exacerbations 274 /
Interstitial Lung Disease 274 / Pulmonary Arterial Hypertension 275 / Pneumonia 276 / Pulmonary
Embolism 279
Critical Care Management of Respiratory Problems 284 / Chest X-Ray Interpretation 285 /
COVID-19 (SARS-COV-2) 285 / Evidence-Based Practice Resources 285
11. Multisystem Problems....................................................................................................................................................................... 287
Sonya M. Grigsby
Sepsis and Septic Shock 287
Etiology, Risk Factors, and Pathogenesis 287 / Clinical Presentation 289 / Principles of Management
of Sepsis and Septic Shock 292
COVID-19 294
Substance Use Disorders 296
Etiology, Risk Factors, and Pathophysiology 296 / Principles of Management for Overdose 300
Pressure Injury 302
Pressure Injury Stages 302 / COVID-19 Related Pressure Injuries 304 / Principles of Management of
Pressure Injury 304
Healthcare-Associated Infections 305
CAUTI 305 / CLABSI 305 / Selected Infectious Diseases 306 / HAI Prevention 307
Sepsis and Septic shock 307 / Overdoses 308 / Pressure Injuries 308 / Healthcare-Associated
Infections 308 / Selected Infectious Diseases 309
12. Neurological System........................................................................................................................................................................... 311
Special Assessment Techniques and Diagnostic Tests 311
Level of Consciousness 311 / Glasgow Coma Scale (GCS) and the Full Outline of Unresponsiveness
(FOUR) Score 312 / Mental Status 313 / Delirium and Dementia 314 / Motor Assessment 315 /
Sensation 315 / Cranial Nerve Assessment and Assessment of Brain Stem Function 316 /
Vital Sign Alterations in Neurologic Dysfunction 318

x CONTENTS IN DETAIL
Diagnostic Testing 319

Computed Tomography 319 / Magnetic Resonance Imaging 319 / Lumbar Puncture 320 /
Cerebral (Catheter) Angiography 321 / Transcranial Doppler Ultrasound 321 /
Electroencephalography 322/ Electromyography/Nerve Conduction Studies 322
Intracranial Pressure 322
Causes of Increased Intracranial Pressure 323 / Cerebral Blood Flow 323 / Clinical Presentation 324
Principles of Management of Increased ICP 325
Acute Ischemic Stroke 325
Etiology, Risk Factors, and Pathophysiology 325 / Clinical Presentation 327 / Diagnostic Tests 328
Principles of Management of Acute Ischemic Stroke 328
Hemorrhagic Stroke 330
Etiology, Risk Factors, and Pathophysiology 330 / Clinical Presentation 330 / Diagnostic Tests 330 /
Principles of Management of Intracerebral Hemorrhage 330
Seizures 331
Etiology, Risk Factors, and Pathophysiology 331 / Clinical Presentation 331 / Diagnostic
Testing 332 / Principles of Management of Seizures 332
Infections of the Central Nervous System 333
Meningitis 333 / Encephalitis 333 / Intracranial Abscess 333
Neuromuscular Diseases 333
Myasthenia Gravis 333 / Multiple Sclerosis 334 / Guillain-Barré Syndrome 334 / Amyotrophic
Lateral Sclerosis 334
Acute Ischemic Stroke and Hemorrhagic Stroke 334 / Assessment and Diagnostic Testing 334 /
Evidence-Based Practice 334 / Infections of the Central Nervous System 335 / Intracranial
Pressure 335 / Neuromuscular Diseases 335 / Seizures 335 / Websites with More Information about
Neurological Disorders 335
13. Hematologic and Immune Systems................................................................................................................................................. 337
Danya Garner
Complete Blood Count 337 / Red Blood Cell Count 337 / Hemoglobin 338 / Hematocrit 338 /
Red Blood Cell Indices 338 / Total White Blood Cell Count 338 / White Blood Cell Differential 339 /
Platelet Count 339 / Coagulation Studies 339 / Additional Tests and Procedures 340
Anemia 340 / Immunocompromise 342 / Coagulopathies 345
Anemia 350 / Immunocompromised Patient 350 / Coagulopathy 351
14. Gastrointestinal System..................................................................................................................................................................... 353
Anna M. Alder
Acute Gastrointestinal Bleeding 353 / Liver Failure 362 / Acute Pancreatitis 367 / Intestinal Ischemia 370 /
Bowel Obstruction 372 / Bariatric Surgery and Weight Management 373 / Surgical Procedure 374
Nutritional Support for Acutely Ill Patients 376
Nutritional Requirements 376 / Nutritional Case: Special Populations 376 / Enteral Nutrition 377 /
Bowel Sounds in Enterally Fed Patients 380 / Complications of EN: Nausea, Vomiting, and Diarrhea 380
Acute Gastrointestinal Bleeding 381 / Liver Failure 382 / Acute Pancreatitis 382 /
Intestinal Ischemia/Bowel Obstruction 382 / Nutrition 383 / Online References of Interest 383 /
Bariatric Surgery and Weight Management 383
15. Renal System....................................................................................................................................................................................... 385
Jie Chen
Acute Kidney Injury 385
Etiology, Risk Factors, and Pathophysiology 385 / Clinical Phases 387 / Clinical Presentation 388 /
Principles of Management of Acute Kidney Injury 389
Electrolyte Imbalances 391
Sodium Imbalance: Hypernatremia and Hyperosmolar Disorders 391 / Sodium Imbalance:
Hypo-Osmolar Disorders 392 / Potassium Imbalance: Hyperkalemia 392 / Potassium Imbalance:
Hypokalemia 393 / Calcium Imbalance: Hypercalcemia 393 / Calcium Imbalance: Hypocalcemia 393 /

CONTENTS IN DETAIL xi
Magnesium Imbalance: Hypermagnesemia 394 / Magnesium Imbalance: Hypomagnesemia 394 /

Phosphate Imbalance: Hyperphosphatemia 394 / Phosphate Imbalance: Hypophosphatemia 395 /
Principles of Management for Electrolyte Imbalances 395
Renal Replacement Therapy 397
Access 397 / Dialyzer/Hemofilters/Dialysate 398 / Procedures 398 / Indications for and Efficacy of
Renal Replacement Therapy Modes 399 / General Renal Replacement Therapy Interventions 401 /
Summary: Principles of Management 401
General Renal and Electrolyte 401 / Acute Kidney Injury 402 / Renal Replacement Therapy 402
16. Endocrine System............................................................................................................................................................................... 403
Heather Roff
Hyperglycemic States 403
Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar 403 / Acute Hypoglycemia 413 /
Summary: Hyperglycemia and Hypoglycemia 414
Pituitary Gland Function and Associated Disorders 414
Syndrome of Inappropriate Antidiuretic Hormone Secretion 414 / Diabetes Insipidus 416 /
Summary: Pituitary Gland and DI/SIADH 418
Thyroid Gland Function and Associated Disorders 418
Hyperthyroidism and Thyroid Storm 419 / Hypothyroidism and Myxedema Coma 419 /
Summary: Hyperthyroidism and Thyroid Storm, Hypothyroidism and Myxedema Coma 420
Adrenal Gland Function and Associated Disorders 420
Cushing Syndrome 420 / Aldosteronism 420 / Addison Disease and Crisis 421 / Critical Illness-
Related Corticosteroid Insufficiency 421 / Pheochromocytoma and Catecholamine Crisis 421 /
Summary: Adrenal Gland Dysfunction 421
Blood Glucose Monitoring 422 / Hyperglycemia, DKA, EDKA, and HHS 422 / SIADH and Diabetes
Insipidus 422 / Hyperthyroidism and Thyroid Storm 422 / Hypothyroidism and Myxedema
Coma 422 / Adrenal Gland, Cushing Disease, and Pheochromocytoma 422 / Critical Illness-Related
Corticosteroid Insufficiency 422
17. Trauma................................................................................................................................................................................................. 425
Alina Huneke and Jen Miller
Specialized Assessment 425
Primary, Secondary, and Tertiary Trauma Surveys 426 / Diagnostic Studies 428 / Mechanism of
Injury 428
Common Injuries in the Trauma Patient 430
Thoracic Trauma 430 / Abdominal Trauma 433 / Musculoskeletal Trauma 435
Complications of Traumatic Injury in Severe Multisystem Trauma 436
General Concepts 436 / Infection, Sepsis/Septic Shock, and Multiple Organ Dysfunction 439 / Acute
Respiratory Distress Syndrome 439
Psychological Consequences of Trauma 440
General Trauma 440
Section III. Advanced Concepts........................................................................................................................................................................................................................ 443

18. Advanced ECG Concepts.................................................................................................................................................................. 445
Carol Jacobson
The 12-Lead Electrocardiogram 445
Axis Determination 449 / Bundle Branch Block 451 / Acute Coronary Syndrome 454 /
Effects of Electrolyte Imbalances on the ECG 461 / Hyperkalemia 463 / Hypokalemia 463 /
Hypercalcemia 463 / Hypocalcemia 465 / Preexcitation Syndromes 465
Advanced Dysrhythmia Interpretation 471
Supraventricular Tachycardias 471 / Polymorphic Ventricular Tachycardias 474 /
Differentiating Wide QRS Beats and Rhythms 475
St-Segment Monitoring 480
Measuring the ST Segment 480 / Choosing the Best Leads for ST-Segment Monitoring 481

xii CONTENTS IN DETAIL
Cardiac Pacemakers 482

Evaluating Pacemaker Function 483 / VVI Pacemaker Evaluation 484 / DDD Pacemaker
Evaluation 487
Electrocardiography 491 / Acute Coronary Syndrome 491 / Long QT Syndrome and Brugada
Syndrome 491 / Dysrhythmias 491 / Pacemakers 491 / Evidence-Based Practice 491
19. Advanced Cardiovascular Concepts................................................................................................................................................ 493
Cardiomyopathy 493 / Valvular Heart Disease 498 / Pericarditis 505 / Aortic Aneurysm 507 /
Cardiac Transplantation 510 / Ventricular Assist Devices 515
General Cardiovascular 518 / Cardiomyopathy 518 / Heart Transplantation 518 /
Valvular Disorders 518 / Pericarditis 519 / Thoraco-Abdominal Aneurysms 519 / Ventricular Assist
Devices 519 / Evidence-Based Practice/Guidelines 519
20. Advanced Neurologic Concepts....................................................................................................................................................... 521
Subarachnoid Hemorrhage 521
Principles of Management of Aneurysmal Subarachnoid Hemorrhage 523
Traumatic Brain Injury 526
Principles of Management of Traumatic Brain Injury 529
Traumatic Spinal Cord Injury 531
Principles of Management of Acute Spinal Cord Injury 533 / Future Spinal Cord
Injury Treatment 537
Brain Tumors 537
Principles of Management of Intracranial Tumors 538 / Special Considerations: Transsphenoidal
Resection of Pituitary Tumors 539
Special Procedures: Invasive Monitoring of Intracranial Pressure 540
Intracranial Pressure Waveforms 540
Special Procedures: Management of a Patient with a Lumbar Drain 541
Subarachnoid Hemorrhage 542 / Traumatic Brain Injury 542 / Spinal Cord Injury 542 /
Brain Tumors 542 / Intracranial Pressure Monitoring 542 / Evidence-Based Guidelines 542
Section IV. Key Reference Information............................................................................................................................................................................................................. 543

21. Normal Laboratory Reference Values.............................................................................................................................................. 545
Sarah A. Delgado
22. Implementing Crisis Standards of Care........................................................................................................................................... 549
Laura Webster
Examples of Conventional, Contingency and Crisis Standards of Care 549
23. Cardiac Rhythms, ECG Characteristics, and Treatment Guide................................................................................................... 551
Carol Jacobson
Index .................................................................................................................................................................................................................................................................... 559

Contributors
Anna M. Alder, MS, RN, PCCN, CCRN, NPD-BC Kiersten Henry, DNP, ACNP-BC, CCNS, CCRN-CMC
Clinical Instructor Chief Advanced Practice Provider
University of Utah College of Nursing MedStar Montgomery Medical Center
Salt Lake City, Utah Olney, Maryland
Chapter 14: Gastrointestinal System Chapter 10: Respiratory System
Earnest Alexander, PharmD, BCCCP, FCCM Alina M. Huneke, MSN, AGACNP-BC, CCRN, CRNP
Assistant Director, Clinical Pharmacy Services University of Maryland Medical Center
Tampa General Hospital R Adams Cowley Shock Trauma Center
Tampa, Florida Baltimore, Maryland
Chapter 7: Pharmacology Chapter 17: Trauma
Jie Chen, RN, CMSN, ACNP-BC Carol Jacobson, MN, RN
Harrisburg, Pennsylvania Partner, Cardiovascular Nursing Education Associates
Chapter 15: Renal System Cardiovascular Nursing Education Associates
Seattle, Washington
Yvonne D’Arcy, MS, APRN, CNS, FAANP
Chapter 3: Interpretation and Management of Basic Cardiac
Pain Management and Palliative Care Nurse Practitioner
Rhythms
Retired, Suburban Hospital Johns Hopkins Medicine
Chapter 18: Advanced ECG Concepts
Ponte Vedra Beach, Florida
Chapter 23: Cardiac Rhythms, ECG Characteristics, and
Chapter 6: Pain and Sedation Management
Treatment Guide
Yana Dilman, MSN, RN, AG-ACNP
Robert E. St. John, MSN, RN, RRT
Critical Care Nurse Practitioner
Senior Clinical Director – Patient Monitoring
UPMC Central PA
Medtronic
Mechanicsburg, Pennsylvania
St. Louis, Missouri
Chapter 4: Hemodynamic Monitoring
Chapter 5: Airway and Ventilatory Management
Danya Garner, PhD, RN, OCN, CCRN-K, NPD-BC
Sara Knippa, MS, RN, ACCNS-AG, CCRN, PCCN
Associate Director, Continuing Professional Education
Critical Care Clinical Nurse Specialist
The University of Texas MD Anderson Cancer Center
UCHealth
Houston, Texas
Aurora, Colorado
Chapter 13: Hematologic and Immune Systems
Chapter 6: Pain and Sedation Management
Sonya M. Grigsby, DNP, APRN, AGACNP-BC, FNP-BC,
Barbara Leeper, MN, APRN, CNS-MS, CCRN-K,
EMBA-HCM, CCRN
CV-BC, FAHA
Nurse Practitioner
Clinical Nurse Specialist
Christus Mother Frances Hospital
Cardiovascular and Critical Care
Tyler, Texas
Dallas, Texas
Chapter 11: Multisystem Problems
Chapter 9: Cardiovascular System
Chapter 19: Advanced Cardiovascular Concepts
xiii

xiv CONTRIBUTORS
Jennifer Miller, DNP, AGACNP-BC, ACCNS-AG Maureen A. Seckel, MSN, APRN, ACNS-BC, CCRN,
CRNP CCRN-K, FCCM, FCNS, FAAN
University of Maryland, R Adams Cowley Shock Critical Care Clinical Nurse Specialist and
Trauma Center Sepsis Coordinator
Baltimore, Maryland ChristianaCare
Chapter 17: Trauma Newark, Delaware
Chapter 5: Airway and Ventilatory Management
DaiWai M. Olson, PhD, RN, FNCS
Chapter 10: Respiratory System
Professor
University of Texas Southwestern Kathrina B. Siaron, BSN-RN, CCRN, SCRN
Dallas, Texas Staff Nurse, Neuro ICU & Rapid Response Team
Chapter 12: Neurological System UT Southwestern Medical Center Clements
Chapter 20: Advanced Neurologic Concepts University Hospital
Dallas, Texas
Lynn Orser, MSN, RN, CCRN, PCCN, NPD-BC
Chapter 12: Neurological System
Nurse Educator
Chapter 20: Advanced Neurologic Concepts
Hartford Healthcare St. Vincent’s Medical Center
Bridgeport, Connecticut Laura Webster, D.Be, RN, HEC-C, CEN
Chapter 1: Assessment of Progressive Care Patients and Pacific NW Division VP of Ethics–CommonSpirit Health
Their Families Affiliate Faculty–University of Washington School of
Chapter 2: Planning Care for Progressive Care Patients and Medicine, Department of Bioethics and Humanities
Their Families Seattle, Washington
Chapter 8: Ethical and Legal Considerations
Brook Powell, BSN, RN, CCRN
Chapter 22: Implementing Crisis Standards of Care
Clinical Program Manager Rapid Assessment Team
Parkland Health
Dallas, Texas
Chapter 9: Cardiovascular System
Chapter 19: Advanced Cardiovascular Concepts
Heather Roff, MS, AGACNP-BC, ACCNS-AG, CCRN
Critical Care Nurse Practitioner
University of California San Francisco
San Francisco, California
Chapter 16: Endocrine System

Peer Reviewers
Janet Ahlstrom, MSN, APRN, ACNS-BC, NEA-BC Gail Markowski, DNP, ANP-C, ACNP-C, CCRN
Clinical Nurse Specialist Clinical Assistant Professor
University of Kansas Health System State University of New York at Buffalo
Kansas City, Kansas Buffalo, New York
Markie Baxter, BSN, RN Karen Marzlin, DNP, CCNS, ACNPC-AG, CCRN-CMC,
Nurse Professional Development Specialist CHFN
Virginia Mason Medical Center Acute Care Nurse Practitioner, Clinical Nurse Specialist,
Seattle, Washington Educator, Consultant
Kidney and HTN Consultants, Cardiovascular Nursing
Linda Bell, MSN, RN
Education Associates, Key Choice
Clinical Practice Specialist
Canton, Ohio
American Association of Critical-Care Nurses (AACN)
Tryon, North Carolina Georgina Morley, PhD, MSc, RN, HEC-C
Nurse Ethicist
Naomi Colón, MSN, RN, CCRN, PCCN, TNS
Cleveland Clinic
Clinical Nurse Educator
Cleveland, Ohio
Bethesda Butler Trihealth Hospital
Hamilton, Ohio Nancy Munro, RN, MN, CCRN, ACNP-BC, FAANP
Nurse Practitioner
Stephanie Gregory, FNP-C, BMTCN
Pulmonary Hypertension Service, NIH
Lead Nurse Practitioner
Bethesda, Maryland
Northside Hospital BMT unit
Atlanta, Georgia Heather Przybyl, DNP, RN, CCRN
RN Certified Specialist
Lindsey A. Hart, DNP, AGPCNP-BC
Banner University Medical Center Phoenix
Nurse Practitioner Coordinator- Structural Heart Program
Phoenix, Arizona
Maimonides Medical Center
Brooklyn, New York Brenda Pun, DNP, RN, FCCM
Director of Data Quality
Carrie Judd, MSN, APRN, FNP-C
Vanderbilt University Medical Center
Clinical Instructor
Nashville, Tennessee
The University of Texas at Tyler
Longview, Texas Gina Riggi, PharmD, BCCCP, BCPS
Clinical Coordinator, Trauma ICU Clinical Specialist
Mary Beth Flynn Makic, PhD, RN, CCNS, CCRN-K,
Jackson Memorial Hospital
FAAN, FNAP, FCNS
Miami, Florida
Professor
Adult-Gerontology Clinical Nurse Specialist Program Magally Rolen, MSN, RN, PCCN
Director Intensive Care Unit – Registered Nurse
University of Colorado Texas Health Resources
College of Nursing Fort Worth, Texas
Aurora, Colorado
xv

xvi PEER REVIEWERS
Kristin E. Sandau, PhD, RN, FAHA, FAAN Terri Townsend, MA, RN, CCRN-CMC
Professor of Nursing Clinical Educator, Ret.
Bethel University Community Hospital Anderson, Ret.
St. Paul, Minnesota Anderson, Indiana
Mary A. Stahl, MSN, RN, CCNS, CCRN-K Maxine Wanzer, MSN, AGACNP
Clinical Practice Specialist Critical Care APP & Fellowship Advisor
American Association of Critical-Care Nurses OhioHealth
Parkville, Missouri Columbus, Ohio
Daniel N. Storzer, DNP, ACNP, CCRN, EMT-P, FCCP, Catherine A. Wolkow, PhD, BSN, RN, CCRN
FCCM Critical Care Nurse
Intensivist UWMC-Northwest (University of Washington Medical
ThedaCare Center – Northwest)
Neenah, Wisconsin Seattle, Washington
Scott Carter Thigpen, DNP, RN, MSN, CCRN-K Susan Yeager, DNP, RN, CCRN, ACNP-BC, FNCS
Professor of Nursing Advanced Practice Provider Neurocritical Care Educator
South Georgia State College, School of Nursing The Ohio State University Wexner Medical Center
Douglas, Georgia Columbus, Ohio

Preface
This text provides the reader with evidence-informed con- • Part III: Advanced Concepts presents advanced pro-
tent about the care of acutely ill patients and their families. gressive care concepts or pathologic conditions that
Written by nursing experts, this book sets a standard for are more complex and represent expert level informa-
progressive care nursing education, supports preparation tion. Specific advanced chapter content includes ECG
for national certifications, and can be a resource to address concepts, cardiovascular concepts, and neurologic
uncertainty in patient care delivery. The organization of the concepts.
text recognizes the learner’s need to assimilate foundational • Part IV: Key Reference Information contains selected
knowledge before attempting to master more complex pro- reference information including laboratory and diag-
gressive care nursing concepts. In addition, the American nostic values that apply to the content cases in the
Association of Critical-Care Nurses affirms this book’s value text; and cardiac rhythms, ECG characteristics and
to the AACN community and especially to clinicians at the treatment guide. New in this edition is a table that
point of care. As the editor, I am grateful for the time and demonstrates how conventional, contingency and
effort that AACN’s team put forth in providing this valida- crisis standards of care are implemented. Content
tion. The title continues to carry AACN’s name, as it has in part IV is presented primarily in table format for
since the first edition. quick reference.
AACN Essentials of Progressive Care Nursing is divided
Each chapter in Parts I, II, and III, begins with “Knowledge
into four parts:
Competencies” that can be used to guide informal or for-
• Part I: The Essentials presents core information that mal teaching and to gauge the learner’s progress. In addi-
clinicians must understand to provide safe, compe- tion, each of the chapters provide “Essential Content cases”
tent nursing care to acutely ill patients who require that focus on key information presented in the chapters in
progressive care. This part includes content on assess- order to assist clinicians in understanding the chapter con-
ment, diagnosis, planning, and interventions com- tent and how to best assess and manage conditions and
mon to patients and their families in progressive care problems encountered in critical care. The case studies are
units, including interpretation and management of also designed to enhance the learners understanding of the
cardiac rhythms; hemodynamic monitoring; airway magnitude of the pathologic problems/conditions and their
and ventilatory management; pain, sedation, and impact on patients and families. Questions and answers are
neuromuscular blockade management; pharmacol- provided for each case so that learners may test their knowl-
ogy; and ethical and legal considerations. Chapters edge of the essential content.
in Part I provide the progressive care clinician with The design of this text demonstrates the expertise of
information to develop foundational competence. the first edition editors, Marianne Chuley and Suzanne M.
• Part II: Pathologic Conditions covers pathologic Burns. Both are outstanding leaders with boundless nursing
conditions and management strategies commonly expertise, and I am honored and humbled to contribute to
encountered in progressive care units, closely paral- their tradition. The world of progressive care nursing has
leling the blueprint for the PCCN certification exami- shifted dramatically since they published the first edition.
nation. Chapters in this part are organized by body The prevalence of e-learning programs, including AACN’s
systems and selected conditions, such as cardiovascu- Essentials of Critical Care Orientation, as well as webinars,
lar, respiratory, multisystem, neurologic, hematologic podcasts and other platforms offers nurses many ways to
and immune, gastrointestinal, renal, endocrine, and advance or confirm the knowledge that informs patient care.
trauma. Technology has also changed our interventions and the way
xvii

xviii PREFACE
we document them. New evidence has altered old prac- learning and translating that learning to optimal patient out-
tices and changed our interpretation of clinical data. The comes. This 5th edition, like its predecessors, meets nurses
COVID-19 pandemic has profoundly altered the delivery of in their journey to learn, supports their pursuit of validation
progressive care, and the lives of those who provide it. While through certification, and offers a resource for direct patient
the complexity of progressive care requires collaboration care. As the book’s editor, I hope it also serves to honor the
among team members who each bring unique expertise, it is profound contributions that nurses make every moment of
nurses who provide a continual and compassionate presence every day and every night in the lives of patients, families,
for patients. and their communities.
As progressive care continues to evolve, the skills and In gratitude for the profession of nursing,
knowledge that nurses leverage will also change. The con-
stant element will be nurses’ profound commitment to Sarah A. Delgado, MSN, RN, ACNP

The Essentials I
Delgado-PC_Ch01_p001-018.indd 1 11/08/23 10:15 AM

1
Assessment of
Progressive Care
Patients and
Their Families
Lynn Orser
KNOWLEDGE COMPETENCIES
1. Discuss the importance of a consistent and • Comprehensive initial assessment
systematic approach to assessment of progressive • Ongoing assessment
care patients and their families. 3. Describe how the assessment is altered based on
2. Identify the assessment priorities for different the patient’s clinical status.
stages of an acute illness:
• Prearrival assessment
• Arrival quick check
The assessment of acutely ill patients and their families is an Crucial to developing competence in assessing pro-
essential competency for progressive care nurses. Informa- gressive care patients and their families is a consistent and
tion obtained from an assessment identifies the immediate systematic approach. Without this approach, it would be
and future needs of the patient and family so a plan of care easy to miss subtle signs or details that may identify an
can be initiated to address or resolve these needs. actual or potential problem and also indicate a patient’s
Traditional approaches to patient assessment include changing status. Assessments focus first on the patient,
a complete evaluation of the patient’s history and a com- then on the technology. The patient is the focal point of
prehensive physical examination of all body systems. This the progressive care practitioner’s attention, with technol-
approach is ideal, though progressive care clinicians must ogy augmenting the information obtained from the direct
balance the need to gather data while simultaneously prior- assessment.
itizing and providing care to acutely ill patients. Traditional There are two standard approaches to assessing
approaches and techniques for assessment are modified in patients—the head-to-toe approach and the body systems
progressive care to balance the need for information, while approach. Most progressive care nurses use a combination—a
considering the acute nature of the patient and family’s systems approach applied in a top-to-bottom manner. The
situation. admission and ongoing assessment sections of this chapter
This chapter outlines an assessment approach that rec- are presented with this combined approach in mind.
ognizes the dynamic nature of an acute illness. This approach
emphasizes the collection of assessment data in a phased or
ASSESSMENT FRAMEWORK
staged manner consistent with patient care priorities. The
components of the assessment can be used as a generic tem- Assessing the progressive care patient and family begins
plate for assessing most progressive care patients and fami- from the moment the nurse is aware of the pending admis-
lies. The assessment can then be individualized based on the sion or transfer and continues until transitioning to the
patient’s diagnosis. These specific components of the assess- next phase of care. The assessment process can be viewed
ment are identified in subsequent chapters. as four distinct stages: (1) prearrival, (2) arrival quick check

4 CHAPTER 1. Assessment of Progressive Care Patients and Their Families
(“just the basics”), (3) comprehensive initial assessment, and body system. If the patient is being transferred to the pro-
(4) ongoing assessment. gressive care unit from another area in the hospital, the com-
prehensive assessment includes a review of the admission
Prearrival Assessment assessment data with comparison to the patient’s current
status. The comprehensive assessment is vital to successful
Patients admitted to a progressive care unit may be transi-
outcomes because it provides insight into which proactive
tioning from a critical care unit, as they become more stable
interventions are needed.
and improve in condition. Conversely, they may be trans-
ferred from a less acute level of care because their physiologic
status may be deteriorating. In either case, the progressive Ongoing Assessment
care patient has the potential to have a rapid change in status. After the baseline comprehensive assessment is completed,
A prearrival assessment begins the moment the infor- ongoing assessments—an abbreviated version of the com-
mation is received about the upcoming admission of the prehensive assessment—are performed at varying intervals.
patient to the progressive care unit. This notification comes The assessment parameters outlined in this section are usu-
from the initial healthcare team contact. The contact may be ally completed for all patients, in addition to other ongoing
a transfer from another facility or a transfer from other areas assessment requirements related to the patient’s specific con-
within the hospital such as the emergency department, oper- dition, treatments, and response to therapy.
ating room, the intensive care unit (ICU), or medical/surgical
nursing unit. The prearrival assessment paints the initial Patient Safety Considerations in Admission Assessments
picture of the patient and allows the progressive care nurse to Admission of an acutely ill patient can be a chaotic event with
begin anticipating the patient’s physiologic and psychologi- multiple disciplines involved in many activities. It is at this
cal needs. This assessment also allows the progressive care time, however, that healthcare providers are particularly cog-
nurse to determine the appropriate resources that are needed nizant of accurate assessments and data gathering to ensure
to care for the patient. The information received in the pre- the patient is cared for safely with appropriate interventions.
arrival phase is crucial because it allows the progressive care Obtaining inaccurate information on admission can lead to
nurse to adequately prepare the environment to meet the ongoing errors that may not be easily rectified or discovered
specialized needs of the patient and family. and lead to poor patient outcomes.
Obtaining information from an acutely ill patient may
Arrival Quick Check be challenging due to cognitive impairment or symptoms
An arrival quick check assessment is obtained immediately that affect communication. If the patient is unable to supply
upon arrival and is based on assessing the parameters repre- information, other sources are utilized such as family mem-
sented by the ABCDE acronym (Table 1-1). The arrival quick bers, electronic health records (EHRs), past medical records,
check assessment is a quick overview of the adequacy of ven- transport records, or information from the patient’s belong-
tilation and perfusion to ensure early intervention for any life- ings. Of particular importance at admission is obtaining
threatening situations. This assessment is a high-level view of accurate patient identification, as well as past medical his-
the patient but is essential because it validates that basic car- tory and any known allergies. Obtaining current medication
diac and respiratory function is sufficient, and it can be used regimens as soon as possible is essential to provide clues to
as a baseline for potential future changes in a condition. the patient’s medical conditions, identify any potential con-
tributing factors to the current condition, and ensure medi-
cation reconciliation to continue appropriate medications
Comprehensive Initial Assessment and avoid medication interactions.
A comprehensive assessment is performed as soon as pos- With the use of EHRs, there are opportunities for timely
sible, with the timing dictated by the degree of physiologic access to past and current medical history information
stability and emergent treatment needs of the patient. If the of patients. Healthcare providers may have access to both
patient is being admitted directly to the progressive care unit inpatient and outpatient records within the same health-
from outside the hospital, the comprehensive assessment care system, assisting them to quickly identify the patient’s
includes an in-depth assessment of the past medical and most recent medication regimen and to trend laboratory and
social history and a complete physical examination of each diagnostic results. In addition, healthcare systems within the
same geographic locations may offer intersystem access to
the medical records of patients treated at multiple healthcare
TABLE 1-1. ABCDE ACRONYM institutions. This is particularly beneficial when patients are
Airway unable to articulate essential medical information including
Breathing advance directives, allergies, and next of kin.
Circulation, Cerebral perfusion, and Chief complaint Careful physical assessment on admission to the pro-
Drugs and Diagnostic tests gressive care unit is pivotal for the prevention and/or early
Equipment
treatment for complications associated with the illness.

PREARRIVAL ASSESSMENT: BEFORE THE ACTION BEGINS 5
Of particular importance is the assessment of risk for pres- of the patient and information on the presence of invasive
sure injury, alteration in mental status, infection, and/or falls. tubes and lines, medications being administered, other
Risks associated with accurate patient identification never ongoing treatments, and pending or completed laboratory
lessen, particularly as these relate to interventions such as or diagnostic tests. This basic information may indicate a
performing invasive procedures, medication administra- need to consider whether the patient will need a specialty
tion, blood administration, and obtaining laboratory tests. bed such as a bariatric bed or a bed to optimize skin integrity.
Nurses need to be cognizant of safety issues as treatment Determining this in advance is helpful as it may take time to
begins as well; for example, identifying patients at risk for acquire a specialty bed.
falls and implementing mitigation strategies. It is imperative It is also important to consider the potential isolation
that nurses use all safety equipment available to them such as requirements for the patient, including neutropenic precau-
bar-coding technology to prevent medication errors. Health- tions, contact precautions, or special respiratory isolation.
care providers also ensure the safety of invasive procedures Being prepared for isolation needs prevents potentially seri-
that may be performed emergently. ous exposures to the patient, roommates, or the healthcare
providers. The prearrival information assists the clinician in
anticipating the patient’s physiologic and emotional needs
PREARRIVAL ASSESSMENT: BEFORE THE ACTION BEGINS prior to admission or transfer and in ensuring that the bed-
A prearrival assessment begins when information is received side environment is set up to provide all monitoring, supply,
about the pending arrival of the patient. The prearrival and equipment needs prior to the patient’s arrival.
report, although abbreviated, provides key information Many progressive care units have a standard room
about the chief complaint, diagnosis, or reason for admis- setup, guided by the major diagnosis-related groups of
sion, pertinent history details, and physiologic stability of patients each unit receives. The standard monitoring and
the patient (Table 1-2). It also contains the gender and age equipment list for each unit varies; however, there are certain
common requirements (Table 1-3). The standard room setup
is modified for each admission to accommodate patient-
TABLE 1-2. SUMMARY OF PREARRIVAL AND ARRIVAL QUICK CHECK specific needs (eg, additional equipment, intravenous [IV]
ASSESSMENTS
fluids, and medications). Proper functioning of all bedside
Prearrival Assessment equipment is verified prior to the patient’s arrival. If using a
• Abbreviated report on patient (age, gender, chief complaint, diagnosis, bed scale, zeroing to ensure accurate weight on admission is
allergies pertinent history, physiologic status, invasive devices, equipment,
an important step.
and status of laboratory/diagnostic tests)
• Complete room setup, including verification of proper equipment functioning It is also important to prepare the medical record forms,
• Do Not Resuscitate (DNR) status which usually consist of a computerized data entry system
• Isolation status or paper flow sheets to record vital signs, intake and out-
Admission Quick Check Assessment put, medication administration, patient care activities, and
• General appearance (consciousness)
patient assessment. The prearrival report may suggest pend-
• Airway:
Patency ing procedures, necessitating the organization of appropri-
Position of artificial airway (if present) such as tracheostomy ate supplies at the bedside. Having the room prepared and
• Breathing: all equipment available facilitates a rapid, smooth, and safe
Quantity and quality of respirations (rate, depth, pattern, symmetry, admission of the patient.
effort—use of accessory muscles)
Breath sounds
TABLE 1-3. EQUIPMENT FOR STANDARD ROOM SETUP
Presence of spontaneous breathing
• Circulation and Cerebral Perfusion: • Bedside ECG or telemetry monitoring and invasive pressure monitor with
Electrocardiogram (ECG) (rate, rhythm, and presence of ectopy) appropriate cables
Blood pressure • ECG electrodes
Peripheral pulses • Blood pressure cuff
Capillary refill • Pulse oximetry
Skin color, temperature, moisture • End-tidal CO2
Presence of bleeding • Thermometer
Level of consciousness, responsiveness • Suction gauges and canister setup
• Chief Complaint: • Suction catheters
Primary body system • Bag valve mask device
Associated symptoms • Oxygen flow meter, appropriate tubing, and appropriate oxygen delivery
• Drugs and Diagnostic Tests: device
Drugs prior to admission (prescribed, over-the-counter, illicit) • IV poles and infusion pumps
Current medications • Bedside supplies to include alcohol swabs, non-sterile gloves, syringes, bed
Review diagnostic test results pads, and dressing supplies
• Equipment: • Admission kit that usually contains bath basin and general hygiene
Patency of vascular and drainage systems supplies (if direct admission)
Appropriate functioning and labeling of all equipment connected to patient • Bedside computer and/or paper admission documentation forms

ADMISSION QUICK CHECK ASSESSMENT ordered. Simultaneously with the ABCDE assessment, the
patient’s nurse validates that the patient is appropriately
From the moment the patient arrives in the progressive
identified through a hospital wristband, personal identifi-
care unit setting, his or her general appearance is immedi-
cation documents, or family identification. Additional
ately observed and assessment of ABCDEs is quickly per-
wristbands, per institution policy, may include allergy
formed (see Table 1-1). The condition of the patient is
band, fall risk band, or limb restriction band. In addition,
determined so any urgent needs can be addressed first. The
the patient’s allergy status is verified, including the type of
patient is connected to the appropriate monitoring and
reaction that occurs and what, if any, treatment is used to
support equipment, medications being administered are
alleviate the allergic response.
verified, and essential laboratory and diagnostic tests are
ESSENTIAL CONTENT CASE
Prearrival Assessment
The charge nurse notifies Terry that they will be receiving a central venous pressure (CVP) setup and a left chest tube
26-year-old man from the ICU who was involved in a serious to water seal are in place. Terry questions the critical care
car accident 14 days ago. The ICU nurse caring for the patient nurse regarding the patient’s mental status including his
has called to give Terry a report following the hospital’s stan- level of consciousness (LOC), neuro deficits, and any agita-
dardized report format. tion. They also ask if a Foley catheter or nasogastric (NG)
tube is present, and whether the family has been notified of
Case Question 1: What basic information will Terry want the transfer to the progressive care unit.
to know from the prearrival communication with the ICU 2. Vital signs, neurologic status, the tracheostomy and oxygen
nurse? requirements of the patient, medications are appropriately
infusing, and whether the patient is agitated or experienc-
Case Question 2: What patient issues are likely to need
ing extensive pain.
immediate assessment and/or intervention on arrival to the
Terry goes to check the patient’s room prior to admis-
progressive care unit and determine appropriate equipment
sion and begins to do a check of what will be needed. “The
is set up in the room?
patient has a tracheostomy so I’ll connect the AMBU bag
Case Question 3: What information should be included in to the oxygen source, check for suction catheters, and make
the more formal handoff between the ICU nurse and Terry sure there are two suction systems available and working.
after the patient is settled in his room in the progressive care The pulse oximeter is ready to use. I’ll also ensure the telem-
unit? etry pack has fully charged batteries and have the ECG
electrodes ready to apply. The CVP line flush system and
Answers transducer are also ready to be connected. The IV infusion
1. Patient name/age, date of birth, pain level, pain location, devices are set up. Safety equipment to have on hand for the
last pain medication dose and response to pain medica- chest tube includes sterile water, sterile dressings including
tion or intervention, type and date of accident, extent of Vaseline gauze and waterproof tape. This patient has an
accident injuries, pertinent medical history, allergies, vital altered LOC, which means frequent neuro checks. I have
signs, placement of lines and tubes, other medications being my penlight handy. The computer in the room is on and
administered, significant laboratory results, anticipated plan ready for me to begin documentation. I think I’m ready.”
for care and discharge plan, presence of family, and any 3. Using an SBAR (Situation, Background, Assessment, and
other special instructions such as concerns about fall risk Recommendations) format, the ICU nurse can give more
and patient ability to transfer. detailed information about the injuries from the car acci-
The patient suffered a closed head injury and chest dent, the patient’s complete medical history as known, reit-
trauma with collapsed left lung. The patient was initially eration of known allergies, a system by system assessment
intubated and placed on a mechanical ventilator. During his review, significant diagnostic test results, confirmation of all
ICU stay, the patient had pneumonia and had a tracheos- invasive lines and equipment settings, the anticipated plan
tomy placed due to the duration of mechanical ventilation for ongoing assessments, interventions, and discharge plan-
and the need to manage copious secretions. He is now off ning, and any pertinent family information. Terry can also
the ventilator and requires 30% FiO2. A central line with a clarify any remaining questions.
There may be other healthcare professionals present attaching monitoring cables. Without a leader, care can be
to receive the patient and assist with arrival tasks. The pro- fragmented and vital assessment clues overlooked.
gressive care nurse, however, is the leader of the receiving The progressive care nurse rapidly assesses the ABCDEs
team. While assuming the primary responsibility for assess- in the sequence outlined in this section. If any aspect of this
ing the ABCDEs, the progressive care nurse may delegate preliminary assessment deviates from normal, interventions
other tasks, such as changing over to the unit equipment or are immediately initiated to address the problem before

ADMISSION QUICK CHECK ASSESSMENT 7
continuing with the arrival quick check assessment. Addi- oriented, aware of their surroundings, or whether a verbal
tionally, regardless of whether the patient appears to be con- or painful stimulus is required to obtain a response, or if
scious or not, it is important to provide verbal reassurance the patient is unresponsive. Observing the response of the
throughout the admission process so the patient knows what patient during movement from the stretcher to the progres-
to expect with each interaction and intervention. sive care unit bed can supply additional information about
the LOC. Note whether the patient’s eyes are open and obser-
Airway and Breathing vant, and what the response is to simple commands such as
“Place your hands on your chest” or “Slide your hips over.” If
Patency of the patient’s airway is verified by having the
the patient is unable to talk because of trauma or the pres-
patient speak, watching the patient’s chest rise or fall, or
ence of an artificial airway, note whether they nod appropri-
both. If the airway is compromised, verify that the head has
ately to questions.
been positioned properly to prevent the tongue from occlud-
ing the airway. Inspect the upper airway for the presence of
blood, vomitus, and foreign objects before inserting an oral Chief Complaint
airway if indicated. If the patient already has an artificial air- Optimally, the description of the chief complaint is obtained
way, such as a cricothyrotomy or tracheostomy, ensure that from the patient, but this may not be realistic. The patient
the airway is secured properly. Note the position of the tra- may be unable to respond or may face a language barrier. Data
cheostomy and size of the airway. Suctioning of the upper may need to be gathered from family, friends, or bystand-
airway, either through the oral cavity or artificial airway, may ers, or from the completed admission database if the patient
be required to ensure that the airway is free from secretions. has been transferred from another area in the hospital. For
Note the amount, color, and consistency of secretions that patients who face a language barrier, an approved hospital
are removed. translator or phone translating service can assist with the
Assessment of the patient’s breathing also includes interview and subsequent evaluations and communication.
observation of the rate, depth, pattern, and symmetry of Avoid asking family and friends to translate for the patient to
breathing; the work of breathing; the use of accessory mus- protect the patient’s privacy, to prevent errors in translating
cles; and, if mechanically ventilated, whether breathing is in medical terminology, and to eliminate well-intentioned but
synchrony with the ventilator. Do not overlook nonverbal potential bias in translating for the patient. In the absence of
signs of respiratory distress including restlessness, anxiety, or a history source, practitioners need to depend on the physi-
change in mental status. Auscultate the chest for presence of cal findings (eg, presence of medication patches, permanent
bilateral breath sounds, quality of breath sounds, and bilat- pacemaker, or old surgery scars), knowledge of pathophysi-
eral chest expansion. Optimally, both anterior and posterior ology, access to electronic medical records, and transport
breath sounds are auscultated, but during this arrival quick records.
check assessment, time generally dictates that just the ante- Assessment of the chief complaint focuses on determin-
rior chest is assessed. If noninvasive oxygen saturation moni- ing the body systems involved and the extent of associated
toring is available, observe and quickly analyze the values. symptoms. Additional questions explore the time of onset,
If chest tubes are present, note whether they are pleural precipitating factors, and severity. Although the arrival quick
or mediastinal chest tubes. Ensure that they are connected check phase is focused on obtaining a quick overview of the
to suction, if appropriate, and are not clamped or kinked. key life-sustaining systems, a more in-depth assessment of a
In addition, assess whether the chest tubes are functioning particular system may need to be done at this time; for exam-
properly (eg, air leak, fluid fluctuation with respirations) and ple, in the prearrival case study scenario presented, comple-
the amount and character of the drainage. tion of the ABCDEs is followed quickly by more extensive
assessment of both the nervous and respiratory systems.
Circulation and Cerebral Perfusion
The arrival quick check assessment of circulation includes Drugs and Diagnostic Tests
quickly palpating a pulse and viewing the ECG monitor Information about infusing medications and diagnostic tests
for the heart rate, rhythm, and presence of ectopy if ECG is integrated into the priority of the arrival quick check. If
monitoring is ordered. Obtain blood pressure and tempera- IV access is not already present, it is immediately obtained
ture. Assess peripheral perfusion by evaluating the color, and intake and output records started. If IV medications are
temperature, and moisture of the skin along with capillary infusing, check the medication and verify the concentration
refill. Based on the prearrival report and reason for admis- and correct infusion of the desired dosage and rate.
sion, there may be a need to inspect the body for any signs Determine the latest results of any diagnostic
of blood loss and determine if active bleeding is occurring. tests already performed. Augment basic screening tests
Evaluating cerebral perfusion in the arrival quick check (Table 1-4) with additional tests appropriate to the under-
assessment is focused on determining the functional integ- lying diagnosis, chief complaint, transfer status, and recent
rity of the brain as a whole, which is done by rapidly evaluat- procedures. Review available laboratory or diagnostic data
ing the gross LOC. Assess whether the patient is alert and for abnormalities or indications of potential problems that

TABLE 1-4. COMMON DIAGNOSTIC TESTS OBTAINED DURING ARRIVAL QUICK TABLE 1-5. EVIDENCE-BASED PRACTICE: FAMILY NEEDS ASSESSMENT
CHECK ASSESSMENT
Quick Assessment
Serum electrolytes • Offer realistic hope
Glucose • Give honest answers and information
Complete blood count with platelets • Give reassurance
Coagulation studies Comprehensive Assessment
Chest x-ray • Use open-ended communication and assess their communication style
ECG • Assess family members’ level of anxiety
• Assess perceptions of the situation (knowledge, comprehension,
expectations of staff, expected outcome)
• Assess family roles and dynamics (cultural and religious practices, values,
may develop. The abnormal laboratory and diagnostic data spokesperson)
for specific pathologic conditions will be covered in subse- • Assess coping mechanisms and resources (what do they use, social
quent chapters. network, and support)
• Assess knowledge and capacity for providing support after discharge
Equipment
The last phase of the arrival quick check is an assessment of
the equipment in use. Quickly evaluate all vascular, feeding, review of the plan of care, and confirmation of the intent to
and drainage tubes for location and patency and connect give the patient the best care possible (Table 1-5). If feasible,
them to appropriate monitoring or suction devices. Note allow the family to stay with the patient in the room dur-
the amount, color, consistency, and odor of drainage secre- ing the arrival process. If this is not possible, give them an
tions. Verify the appropriate functioning of all equipment approximate time frame when they can expect to receive an
attached to the patient and label as required. While con- update on the patient’s condition. Another member of the
necting the patient to monitoring equipment, it is important healthcare team can assist by escorting them to the appropri-
for the nurse to continue assessing the patient’s respiratory ate waiting area.
and cardiovascular status until all equipment is function-
ing appropriately and can be relied on to transmit accurate
COMPREHENSIVE INITIAL ASSESSMENT
patient data.
The arrival quick check assessment is accomplished in Comprehensive assessments determine the physiologic and
a matter of a few minutes. After completion of the ABCDE psychosocial baseline to which future changes are com-
assessment, the comprehensive assessment begins. If at any pared to determine whether the patient’s status is improv-
phase during the arrival quick check, a component of the ing or deteriorating. The comprehensive assessment also
ABCDEs has not been stabilized or is in question, the prior- defines the patient’s pre-event health status, determining
ity is to resolve that concern before proceeding to the com- problems or limitations that may impact patient status
prehensive admission assessment. during this admission as well as potential issues for future
After the arrival quick check assessment is complete, transitioning of care. The content presented in this sec-
and if the patient requires no urgent intervention, there may tion is a template to screen for abnormalities or determine
now be time for a more thorough report from the health- the extent of injury or disease. Any abnormal findings or
care providers transferring the patient to the progressive changes from baseline warrant a more in-depth evaluation
care unit. Handoffs with transitions of care are intervals of the pertinent system.
when safety gaps may occur. Omission of pertinent infor- The comprehensive assessment includes the patient’s
mation or miscommunication at this critical juncture can medical and social history, and physical examination of each
result in patient care errors. Use of a standardized handoff body system. The comprehensive assessment of the pro-
format—such as the “SBAR” format, which includes com- gressive care patient is similar to admission assessments for
munication of the Situation, Background, Assessment, medical-surgical patients. This section describes only those
and Recommendations—can minimize the potential for aspects of the assessment that are unique to progressive
miscommunication. Use the handoff as an opportunity to care patients or require more extensive information than is
confirm observations such as dosage of infusing medica- obtained from a medical-surgical patient. The entire assess-
tions, abnormalities found on the quick check assessment, ment process is summarized in Tables 1-6 and 1-7.
and any potential inconsistencies noted between the arrival An increasing proportion of patients in progressive
quick check assessment and the prearrival report. It is easier care units are older adults, requiring assessments that incor-
to clarify questions while the transporters are still present, porate the effects of aging. Although the assessment of the
if possible. aging adult does not differ significantly from the younger
This may also be an opportunity for introductory inter- adult, understanding how aging alters the physiologic and
actions with the patient’s family members or friends, if pres- psychological status of the patient is important. Key physi-
ent. The relationship between the family and the healthcare ologic changes pertinent to the progressive care older adult
team begins with a professional introduction, reassurance, are summarized in Table 1-8.

COMPREHENSIVE INITIAL ASSESSMENT 9
TABLE 1-6. SUMMARY OF COMPREHENSIVE INITIAL ASSESSMENT REQUIREMENTS and surgical conditions, hospitalizations, medications, and
Past Medical History symptoms besides the primary event that brought the patient
• Medical conditions, surgical procedures to the hospital (see Table 1-7). A thorough review of medica-
• Psychiatric/emotional problems tions includes the use of over-the-counter medication as well
• Hospitalizations as any herbal or alternative supplements.
• Medications (prescription, over-the-counter, illicit drugs) and time of last
medication dose
For every positive symptom response, additional ques-
• Allergies tions should be asked to explore the characteristics of that
• Review of body systems (see Table 1-7) symptom (Table 1-9). If the patient is transferred from
Social History another area in the hospital, review the admission assess-
• Age, gender, self-identified gender ment information gathered in prior assessments and clarify
• Ethnic origin
• Height, weight
as needed with the patient and family. Be aware of oppor-
• Highest educational level completed tunities for health teaching and identify transition planning
• Preferred language needs for discharge to home or to a rehabilitation facility.
• Occupation
• Marital status
• Primary family members/significant others/decision-makers
Social History
• Religious affiliation The social history includes asking about the use of caffeine,
• Advance Directive and Durable Power of Attorney for Health Care, Medical alcohol, tobacco, and other substances such as illicit drugs
Orders for Life-Sustaining Treatment (MOLST)
or prescription medications. Because the use of these agents
• Substance use/abuse (alcohol, illicit drugs or prescription medications,
caffeine, tobacco) can have major implications for the progressive care patient,
• Domestic abuse or vulnerable adult screen questions are aimed at determining the frequency, amount,
• Dependence on others—family members or paid caregivers—for and duration of use. Honest information regarding alcohol
assistance with activities of daily living and substance use, however, may not be always forthcoming.
Psychosocial Assessment
Alcohol use is common in all age groups. Phrasing questions
• General communication
• Coping styles about alcohol use by acknowledging this fact may be help-
• Anxiety and stressa ful in obtaining an accurate answer (eg, “How much alcohol
• Expectations of progressive care unit do you drink?” vs “Do you drink alcohol and how much?”).
• Current stresses Family or friends might provide additional information that
• Family needs
could assist in assessing these parameters. The information
Spirituality
• Faith/spiritual preference revealed during the social history can often be verified dur-
• Healing practices ing the physical assessment through the presence of signs
Physical Assessment such as needle track marks, nicotine stains on teeth and fin-
• Nervous system gers, or the smell of alcohol on the breath.
• Cardiovascular system
Patients are also asked about physical and emotional
• Respiratory system
• Renal system safety in their home environment in order to uncover poten-
• Gastrointestinal system tial abuse or exploitation. It is best if patients can be assessed
• Endocrine, hematologic, and immune systems for vulnerability when they are alone to prevent placing
• Integumentary system them in a position of answering in front of family members
a
Pain may need to be assessed in each body system rather than as a stand-alone assessment— or friends who may be abusive. Questions such as “Is anyone
see Table 1-9.
hurting you?” or “Do you feel safe at home?” are included in
a non-threatening manner. Any suspicion of abuse or vul-
Additional emphasis is also placed on the past medi- nerability warrants a consultation with social work to deter-
cal history because the older adult frequently has multiple mine additional assessments.
coexisting chronic illnesses and is taking several prescriptive
and over-the-counter medications. Social history addresses Physical Assessment by Body System
issues related to home environment, support systems, and
The physical assessment section is presented in the sequence
self-care abilities including the use of assistive devices such
in which the combined system, head-to-toe approach, is fol-
as wheelchairs, walkers, or bedside commodes. The interpre-
lowed. Although content is presented as separate compo-
tation of clinical findings in the older adult also takes into
nents, generally the history questions are integrated into the
consideration the coexistence of several disease processes
physical assessment. The physical assessment section uses
and the diminished reserves that can result in more rapid
the techniques of inspection, auscultation, and palpation.
physiologic deterioration than in younger adults.
Although percussion is a common technique in physical
examinations, it is less frequently used.
Past Medical History Pain assessment is generally linked to each body sys-
If the patient is being directly admitted to the progres- tem rather than considered as a separate system category;
sive care unit, it is important to determine prior medical for example, if the patient has chest pain, assessment and

TABLE 1-7. SUGGESTED QUESTIONS FOR REVIEW OF PAST HISTORY CATEGORIZED BY BODY SYSTEM
Body System History Questions

Nervous • Have you ever had a seizure?
• Have you ever had a stroke?
• Have you ever fainted, blacked out, or had delirium tremens (DTs)?
• Do you ever have numbness, tingling, or weakness in any part of your body?
• Do you have any difficulty with your hearing, vision, or speech?
• Has your daily activity level changed due to your present condition?
• Do you require any assistive devices such as canes?
• Have you fallen in the past 6 months?
Cardiovascular • Have you experienced any heart problems or disease such as heart attacks or heart failure?
• Do you have any problems with extreme fatigue?
• Do you have an irregular heart rhythm?
• Do you have high blood pressure?
• Do you have a pacemaker or an implanted defibrillator?
Respiratory • Do you ever experience shortness of breath?
• Do you have any pain associated with breathing?
• Do you have a persistent cough? Is it productive?
• Have you had any exposure to environmental agents that might affect the lungs?
• Do you have sleep apnea?
Renal • Have you had any change in frequency of urination?
• Do you have any burning, pain, discharge, or difficulty when you urinate?
• Have you had blood in your urine?
Gastrointestinal • Has there been any recent weight loss or gain?
• Have you had any change in appetite?
• Do you have any problems with nausea or vomiting?
• Do you have any difficulty swallowing?
• How often do you have a bowel movement and has there been a change in the normal pattern? Do you have blood in your stools?
• Do you have dentures?
• Do you have any food allergies?
Integumentary • Do you have any problems with your skin?
Endocrine • Do you have any problems with bleeding?
Hematologic • Do you have problems with chronic infections?
Immunologic • Have you recently been exposed to a contagious illness?
• Have you recently traveled outside the country?
Psychosocial • Do you have any physical conditions, which make communication difficult (hearing loss, visual disturbances, language barriers, etc)?
• How do you best learn? Do you need information repeated several times and/or require information in advance of teaching sessions?
• What are the ways you cope with stress, crises, or pain?
• Who are the important people in your family or network?
• Who do you want to make decisions with you, or for you?
• Have you had any previous experiences with acute illness?
• Have you every been hurt or verbally threatened with physical harm?
• Do you feel safe at home?
• Have you ever been abused?
• Have you ever experienced trouble with anxiety, irritability, being confused, mood swings, or suicidal thoughts or attempts?
• What are the cultural practices, religious influences, and values that are important to you or your family?
• What are family members’ perceptions and expectations of the progressive care staff and the setting?
Spiritual • What is your faith or spiritual preference?
• What practices help you heal or deal with stress?
• Would you like to see a chaplain, priest, or other spiritual guide?
documentation of that pain is incorporated into the cardio- and emotional reactions to the pain. The qualities and char-
vascular assessment. Rather than have general pain assess- acteristics of pain are listed in Table 1-9. Pain is a subjective
ment questions repeated under each system assessment, they assessment, and progressive care practitioners sometimes
are presented here. struggle with applying their own values when attempting to
Pain and discomfort are clues that alert both the patient evaluate the patient’s pain. To resolve this dilemma, use the
and the progressive care nurse that something is wrong and patient’s own words and descriptions of the pain whenever
needs prompt attention. Pain assessment includes differen- possible and use valid reliable pain scale (see Chapter 6, Pain
tiating acute and chronic pain, determining related physi- and Sedation Management) to evaluate pain levels objec-
ologic symptoms, and investigating the patient’s perceptions tively and consistently.

TABLE 1-8. PHYSIOLOGIC EFFECTS OF AGING
Body System Effects

Nervous Diminished hearing and vision, short-term memory loss, altered motor coordination, decreased muscle tone and strength, slower
response to verbal and motor stimuli, decreased ability to synthesize new information, increased sensitivity to altered temperature
states, increased sensitivity to sedation (confusion or agitation), decreased alertness levels
Cardiovascular Increased effects of atherosclerosis of vessels and heart valves, decreased stroke volume with resulting decreased cardiac output,
decreased myocardial compliance, increased workload of heart, diminished peripheral pulses
Respiratory Decreased compliance and elasticity, decreased vital capacity, increased residual volume, less effective cough, decreased response to
hypercapnia
Renal Decreased glomerular filtration rate, increased risk of fluid and electrolyte imbalances
Gastrointestinal Increased presence of dentition problems, decreased intestinal mobility, decreased hepatic metabolism, increased risk of altered
nutritional states
Endocrine, hematologic, Increased incidence of diabetes, thyroid disorders, and anemia; decreased antibody response and cellular immunity
and immunologic
Integumentary Decreased skin turgor, increased capillary fragility and bruising, decreased elasticity
Miscellaneous Altered pharmacokinetics and pharmacodynamics, decreased range of motion of joints and extremities
Psychosocial Difficulty falling asleep and fragmented sleep patterns, increased incidence of depression and anxiety, cognitive impairment disorders,
difficulty with change
Neurological System baseline, a later check of pupils during an acute event could
The neurological system is the master computer of all sys- inappropriately attribute pupil abnormalities to a pathophys-
tems and is divided into the central and peripheral nervous iologic event.
systems. Except for the peripheral nervous system’s cranial LOC and pupil assessment are followed by motor func-
nerves, the central nervous system (CNS) is the focus of the tion assessment of the upper and lower extremities for sym-
neurological evaluation. The physiologic and psychologi- metry and quality of strength. Traditional motor strength
cal impact of an acute illness, in addition to pharmacologic exercises include having the patient squeeze the nurse’s
interventions, may alter CNS functioning. The single most hands and plantar flexing and dorsiflexing of the patient’s
important indicator of cerebral functioning is the LOC. feet. If the patient cannot follow commands, an estimate
The LOC is usually assessed using a standardized scale (see of strength and quality of movements can be inferred by
Chapter 12, Neurologic System) observing activities such as pulling on side rails or thrash-
Additional neurological assessment includes evaluating ing around. If the patient has no voluntary movement or is
the patient’s pupils for size, shape, symmetry, and reactivity unresponsive, check the gag reflex.
to direct light. Certain medications such as atropine, mor- If head trauma is involved or suspected, check for evi-
phine, or illicit drugs may affect pupil size. Baseline pupil dence of fluid leakage around the nose or ears, differentiat-
assessment is important even in patients without a neuro- ing between cerebral spinal fluid and blood (see Chapter 12,
logic diagnosis because some individuals have unequal or Neurological System). Complete cranial nerve assessment
unreactive pupils normally. If pupils are not checked as a is rarely warranted, with specific cranial nerve evaluation
based on the injury or diagnosis; for example, extraocular
movements are routinely assessed in patients with facial
TABLE 1-9. IDENTIFICATION OF SYMPTOM CHARACTERISTICS trauma. Sensory testing is a baseline standard for spinal cord
Characteristic Sample Questions injuries, extremity trauma, and epidural analgesia.
Onset How and under what circumstances did it begin?
If the patient is responsive, assessment of mental sta-
Was the onset sudden or gradual? Did it progress? tus is a key element. Assess orientation to person, place, and
Location Where is it? Does it stay in the same place or does it time. Ask the patient to state their understanding of what is
radiate or move around? happening. As they answer questions, observe for eye con-
Frequency How often does it occur? tact, pressured or muted speech, and rate of speech. Rate of
Quality Is it dull, sharp, burning, throbbing, and so on? speech is usually consistent with the patient’s psychomotor
Intensity Rank pain on a scale (numeric, word description, status. Underlying cognitive impairments such as dementia
FACES, FLACC) and developmental delays are typically exacerbated during
Quantity How long does it last? an acute illness due to physiologic changes, medications, and
Setting What are you doing when it happens? environmental changes. Many hospitals routinely perform
Associated findings Are there other signs and symptoms that occur baseline and ongoing assessments for delirium in patients
when this happens? by using tools such as the Confusion Assessment Method
Aggravating and What things make it worse? What things make it (CAM). The family may be able to provide information
alleviating factors better?
about the patient’s baseline level of functioning.

It is also important to assess patients for the risk of a TABLE 1-10. PERIPHERAL PULSE RATING SCALE
fall. Progressive care patients often have increased mobility • 0 Absent pulse
as a goal so it is imperative that the nurse understand the • +1 Palpable but thready; easily obliterated with light pressure
fall risk for each individual patient and implement interven- • +2 Normal; cannot obliterate with light pressure
tions to minimize the potential for a fall. The patient’s physi- • +3 Full
• +4 Full and bounding
cal strength, memory, and ability to follow instructions to
wait for assistance before getting up all contribute to the risk
for falling. Verify and document settings for any electronic for subsequent assessments, mark the location of the pulse
devices (eg, bed or chair alarms, other fall prevention mea- with an indelible pen. It is also helpful to compare quality of
sures) that are being used to prevent falls. the pulses to the ECG to evaluate the perfusion of heartbeats.
Laboratory data pertinent to the neurological system Electrolyte levels, complete blood counts (CBCs), coag-
include serum electrolytes and urine electrolytes, osmolarity, ulation studies, and lipid profiles are common laboratory tests
and specific gravity. Drug toxicology and alcohol levels may evaluated for abnormalities of the cardiovascular system. Car-
be evaluated to rule out potential sources of altered LOC. diac biomarkers (troponin, creatine kinase MB, β-natriuretic
peptide) are obtained for any complaint of chest pain, sus-
Cardiovascular System pected chest trauma, or a concern for heart failure. Drug lev-
The cardiovascular system assessment is directed at evaluat- els of commonly used cardiovascular medications, such as
ing central and peripheral perfusion. Revalidate your admis- digoxin, may be warranted for certain types of arrhythmias.
sion quick check assessment of the blood pressure, heart rate, A 12-lead ECG may be evaluated, either due to the chief rea-
and rhythm. Assess the patient’s weight to establish a base- son for admission (eg, with complaints of chest pain, irregular
line, particularly in patients with heart failure. If the patient rhythms, or suspected myocardial bruising from trauma) or
is being monitored, assess the electrocardiogram (ECG) for as a baseline for future comparison if needed.
T-wave abnormalities and ST-segment changes and deter- Note the type, size, and location of IV catheters and
mine the PR, QRS, and QT intervals and the QTc measure- verify their patency. If continuous infusions of medications
ments. Note any abnormalities or indications of myocardial such as antiarrhythmics are being administered, ensure that
damage, electrical conduction problems, and electrolyte they are being infused into an appropriately sized vessel and
imbalances. Note the pulse pressure. If treatment decisions are compatible with any piggybacked IV solution.
will be based on the cuff pressure, blood pressure is taken in Verify that all monitoring system alarm parameters are
both arms to determine if they are the same. If different read- active with appropriate limits set. Note the size and loca-
ings are obtained, document and ensure consistency about tion of invasive monitoring lines such as arterial and central
the reading that will be followed for treatment decisions. If venous catheters. Confirm that the appropriate flush solution
an arterial pressure line is in place, use a fast flush test to is hanging with the correct amount of pressure applied. Level
assess the dynamic response and accuracy. Determine which the invasive line to the appropriate anatomic landmark and
pressure will be followed for future treatment decisions. zero the monitor as needed. Interpret hemodynamic pres-
Switching between methods may lead the healthcare team sure readings against normal value ranges with respect to
to inappropriately attribute fluctuations in blood pressure to the patient’s underlying pathophysiology. Assess waveforms
physiologic changes rather than anatomic differences. to determine the quality of the waveform (eg, dampened or
Note the color and temperature of the skin, with particu- hyperresonant) and whether the waveform appropriately
lar emphasis on lips, mucous membranes, and distal extremi- matches the expected characteristics for the anatomic place-
ties. Also evaluate nail color and capillary refill. Inspect for the ment of the invasive catheter (see Chapter 4, Hemodynamic
presence of edema, particularly in the dependent parts of the Monitoring); for example, a right ventricular waveform for a
body such as feet, ankles, and sacrum. Measurement scales CVP line indicates a problem with the position of the central
to quantify the severity of peripheral edema vary between venous line that needs to be corrected. Evaluate all cardio-
sources and institutions. Nurses are encouraged to follow vascular devices that are in place as feasible, such as a pace-
institutional policy, as appropriate, to ensure consistency. maker, or any ventricular assist device. Verify and document
Auscultation of heart sounds includes assessment of S1 equipment settings, appropriate function of the device, and
and S2 quality, intensity, and pitch, and for the presence of the patient response to that device function.
extra heart sounds, murmurs, clicks, or rubs. Listen to one
sound at a time, consistently progressing through the key Respiratory System
anatomic landmarks of the heart each time. Note whether Oxygenation and ventilation are the focus of respiratory
there are any changes with respiration or patient position. assessment parameters. Reassess the rate and rhythm of
Palpate the peripheral pulses for amplitude and quality, respirations and the symmetry of chest wall movement.
using the 0 to +4 scale (Table 1-10). Check bilateral pulses If the patient has a productive cough or secretions are suc-
simultaneously, except the carotid, comparing each pulse to tioned from an artificial airway, note the color, consistency,
its partner. If the pulse is difficult to palpate, an ultrasound and amount of secretions. Evaluate whether the trachea is
(Doppler) device is used. To facilitate finding a weak pulse midline or shifted. Inspect the thoracic cavity for shape,

anterior-posterior diameter, and structural deformities (eg, for continuation of urinary catheter use and consider switch-
kyphosis or scoliosis). Palpate for equal chest excursion, pres- ing to a less invasive method of measuring output.
ence of crepitus, and any areas of tenderness or fractures. If In addition to the urinalysis, urine electrolytes, serum
the patient is receiving supplemental oxygen, verify the mode electrolyte levels, BUN, creatinine, and urinary and serum
of delivery and percentage of oxygen against provider orders. osmolarity are common diagnostic tests used to evaluate
Auscultate all lobes anteriorly and posteriorly for bilat- kidney function.
eral breath sounds to determine the presence of air movement
and the presence of adventitious sounds such as crackles or Gastrointestinal System
wheezes. Note the quality and depth of respirations, and the The key factors when reviewing the gastrointestinal system
length and pitch of the inspiratory and expiratory phases. Ask are the nutritional and fluid status. Inspect the abdomen for
the patient to report their level of comfort with breathing. overall symmetry, noting whether the contour is flat, round,
Arterial blood gases (ABGs) may be used to assess oxy- protuberant, or distended. Note the presence of discolor-
genation and ventilation, and acid-base balance. Hemoglo- ation or striae. Nutritional status is evaluated by looking at
bin and hematocrit values are interpreted for their impact the patient’s weight and muscle tone, the condition of the
on oxygenation and fluid balance. If the patient’s condition oral mucosa, and laboratory values such as serum albumin
warrants, the oxygen saturation values may be continuously and transferrin. If there are any indications of swallowing
monitored or periodically assessed via a noninvasive oxygen difficulty, either patient reported or observed, follow hospi-
saturation monitor (pulse oximeter). tal protocol to perform a swallow screen and/or request a
If the patient is connected to a mechanical ventila- formal swallow evaluation by speech pathology.
tor, verify the mode, tidal volume, respiratory rate, positive Auscultation of bowel sounds is performed in all four
end expiratory pressure, and percentage of oxygen against quadrants in a clockwise order, noting the frequency and
prescribed settings. Observe whether the patient has spon- presence or absence of sounds. Bowel sounds are usually
taneous breaths, noting both the rate and the average tidal rated as absent, hypoactive, normal, or hyperactive. Before
volume of each breath. Note the amount of pressure required noting absent bowel sounds, listen for at least 60 to 90 sec-
to ventilate the patient for later comparisons to determine onds in each quadrant. Characteristics and frequency of the
changes in pulmonary compliance. If the patient has a tra- sounds are noted. After listening for the presence of normal
cheostomy, note the size and type of tube in place and the sounds, determine whether any adventitious bowel sounds
location to assist future comparisons for proper placement. such as friction rubs, bruits, or hums are present.
If the patient is on biphasic positive airway pressure (BiPAP), Light palpation of the abdomen identifies areas of fluid,
note and verify the pressure settings against ordered param- rigidity, tenderness, pain, and guarding or rebound ten-
eters. Also assess the patient’s tolerance to the full face or derness. Remember to auscultate before palpating because
nasal mask. Patients frequently exhibit anxiety with BiPAP palpation may change the frequency and character of the
and have difficulty tolerating the feeling of the mask. patient’s peristaltic sounds.
If chest tubes are present, palpate the area around the Assess the location and function of any drainage tubes,
insertion site for crepitus. Note the amount and color of and note the characteristics of any drainage. Validate the
drainage and whether an air leak is present. Verify whether proper placement and patency of NG tube or percutaneously
the chest tube drainage system is a water seal or is connected placed gastric tubes. Check placement and assess for any
to suction. drainage or leaking around the tubes. Check emesis and stool
for occult blood as appropriate. Evaluate ostomies for location,
Renal System color of the stoma, and color and consistency of their output.
Urine characteristics, electrolyte status, blood urea nitro-
gen (BUN), and creatinine are the major parameters used to Endocrine, Hematologic, and Immune Systems
evaluate the kidney function. In conjunction with the cardio- The endocrine, hematologic, and immune systems often are
vascular system, the renal system’s impact on fluid volume overlooked when assessing progressive care patients. The
status is also assessed. assessment parameters used to evaluate these systems are
Some progressive care patients have an indwelling uri- included under other system assessments, but consciously
nary catheter or a urinary collection device in place to evalu- considering these systems when reviewing these param-
ate urine output. Note the amount, clarity, and color of the eters is essential. Assessing the endocrine, hematologic, and
urine and, if warranted, obtain a sample to assess for the immune systems is based on a thorough understanding of
abnormal presence of glucose, protein, and blood. Inspect the primary function of each of the hormones, blood cells, or
the external genitalia for inflammation, swelling, ulcers, and immune components of each of the respective systems.
drainage. If suprapubic tubes or a ureterostomy are present, Assessment of the endocrine system is challenging
note the position as well as the amount and characteristics because symptoms of changes in hormone secretion are
of the drainage. Observe whether any drainage is leaking the same as symptoms that occur due to disorders in the
around the drainage tube or device. For those with indwell- other systems. The patient’s history may help differentiate
ing catheters, evaluate whether the patient meets the criteria the source, but any abnormal assessment findings detected

with regard to fluid balance, metabolic rate, altered LOC, Psychosocial Assessment
color and temperature of the skin, electrolytes, glucose, and The rapid physiologic and psychological changes associated
acid-base balance require the progressive care nurse to con- with acute illnesses, coupled with pharmacologic and biolog-
sider the potential involvement of the endocrine system. For ical treatments, can profoundly affect behavior. Patients may
example, are the signs and symptoms of hypervolemia related suffer from illnesses that lead to predictable psychological
to cardiac insufficiency or excessive amounts of antidiuretic responses, and, if untreated, may threaten recovery or life. To
hormone? Serum blood tests for specific hormone levels may avoid making assumptions about how a patient feels about
be required to rule out involvement of the endocrine system. his or her care, there is no substitute for asking the patient
Assessment parameters specific to the hematologic directly or asking a collateral informant, such as the family
system include laboratory evaluation of the red blood cells or significant other. Include a Suicide Risk Assessment in the
(RBCs) and coagulation studies. Diminished RBCs may psychosocial assessment of newly admitted patients, as indi-
affect the oxygen-carrying capacity of the blood which is evi- cated by institution policy.
denced by pallor, cyanosis, light-headedness, tachypnea, and
tachycardia. Check the patient for bruising, oozing of blood General Communication
from puncture sites or mucous membranes, or overt bleed- Factors that affect communication include trust, culture,
ing, which may indicate low platelet count or deficiency in developmental stage, physical condition, stress, perception,
clotting factors. See Chapter 13 (Hematologic and Immune neurocognitive deficits, emotional state, and language skills.
Systems) for additional discussion of the hematologic and The nature of an acute illness coupled with pharmacologic
immunologic assessment. and airway technologies can interfere with patients’ usual
The immune system’s primary function of fighting methods of communication. It is essential to determine pre-
infection is assessed by evaluating the CBC including white illness communication abilities and identify methods and
cell and differential counts, the C-reactive protein, eryth- styles to ensure optimal communication with the progressive
rocyte sedimentation rate, blood cultures and assessing care patient and family. For instance, if the patient uses hear-
puncture sites and mucous membranes for drainage, inflam- ing aids, ask the family to provide them. Offer strategies for
mation, and redness. Spiking or persistent low-grade tem- written communication such as paper and pen or tablets or
peratures often are indicative of underlying infections. The cellphones with a keyboard.
absence of these symptoms, however, may not indicate the The inability of some progressive care patients to com-
absence of infection. Many progressive care patients have municate verbally necessitates that progressive care prac-
impaired immune systems and the normal response to infec- titioners become expert at assessing nonverbal clues to
tion, such as white pus around an insertion site or elevated determine important information and needs of patients.
temperature and WBC, may not be evident. If an infection Important assessment data include body gestures, facial
is suspected, consider potential sources that can be readily expressions, eye movements, involuntary movements, and
addressed such as an invasive line or urinary catheter. changes in physiologic parameters, particularly heart rate,
blood pressure, and respiratory rate.
Integumentary System
The skin is the first line of defense against infection so assess- Anxiety and Stress
ment parameters are focused on evaluating the intactness of Anxiety is both psychologically and physiologically exhaust-
the skin. Skin assessment can be undertaken while performing. Being in a prolonged state of arousal is hard work and uses
ing other system assessments; for example, while listening to adaptive reserves needed for recovery. The progressive care
breath sounds or bowel sounds, the condition of the thoracic environment can be stressful, full of constant auditory, visual,
cavity or abdominal skin can be observed, respectively. It is and tactile stimuli, and may contribute to a patient’s anxiety
important that a thorough head-to-toe, anterior, posterior, level. The progressive care setting may force isolation from
and between skin folds assessment is performed and docu- social supports, dependency, loss of control, trust in unknown
mented on admission to the progressive care unit to iden- care providers, helplessness, and an inability to solve problems.
tify any preexisting skin integrity concerns that need to be Restlessness, distractibility, hyperventilation, and unrealistic
immediately addressed and to establish a baseline for com- demands for attention are warning signs of escalating anxiety.
parison with future assessments. Medications such as interferon, corticosteroids,
Inspect the skin for overall integrity, color, temperature, angiotensin-converting enzyme inhibitors, and vasopres-
and turgor. Note the presence of rashes, striae, discoloration, sors can induce anxiety. Abrupt withdrawal from benzodi-
scars, or lesions. For any abrasions, lesions, pressure injuries, azepines, caffeine, nicotine, and narcotics as well as akathisia
or wounds, note the size, depth, and presence or absence from phenothiazines may mimic anxiety. Additional etio-
of drainage. As required by institution policy, photograph logic variables associated with anxiety include pain, sleep
or document the presence of all wounds. Consider use of a loss, delirium, hypoxia, ventilator synchronization or
skin integrity risk assessment tool to determine immediate weaning, fear of death, loss of control, high-technology
interventions that may be needed to prevent development or equipment, and a dehumanizing setting. Admission to or
progression of pressure injury. repeated transfers may also induce anxiety.

Coping Styles they have an advance directive, a durable power of attorney

Individuals cope with an acute illness in different ways and for healthcare or a Medical Order for Life-Sustaining Treat-
understanding their pre-illness coping style, personality ment (MOLST) on file, or if they have discussed their wishes
traits, or temperament allows the nurse to anticipate coping with any family members or friends. Progressive care prac-
styles in the progressive care setting. Include the patient’s titioners need to be flexible around traditional legal require-
family when assessing previous resources, coping skills, or ments of “next of kin” so that communication is extended
defense mechanisms that strengthen adaptation or problem- to, and sought from, surrogate decision-makers identified
solving resolution. For instance, some patients want to be by the patient.
informed of everything that is happening with them in the Families can have a positive impact on the patient’s
progressive care unit. Providing information reduces their ability to cope with and recover from an acute illness. The
anxiety and gives them a sense of control. Other patients pre- family’s access to the patient is crucial and open visitation,
fer to have others receive information about them and make with policies and protections in place to prevent violence
decisions for them. Giving them detailed information only and incivility, is encouraged. All visitors will need instruc-
exacerbates their level of anxiety and diminishes their abil- tion on infection prevention strategies such as the use of
ity to cope. Understanding the meaning that the patient and isolation, donning and doffing of personal protective equip-
family assign to this illness event is crucial to evaluating their ment, and handwashing. Each family system is unique and
ability to cope. Does the coping resource fit with the event varies by culture, values, religion, prior experiences with
and meet the patient’s and family’s need? health care, socioeconomic status, psychological integrity,
This may also be the time to conduct a brief assessment role expectations, communication patterns, and health
of the spiritual beliefs and needs of the patient and family as beliefs. It is important to assess the family’s needs, develop
this may be a powerful tool to assist them in their coping. trust, and seek resources to optimize family impact on the
Minimally, patients are asked if they have a faith or spiritual patient and support family collaboration with the health-
preference and offered the support of a chaplain, or other care team. Areas for family needs assessments are outlined
spiritual guide. In addition, patients are also asked about in Table 1-5.
spiritual and cultural healing practices that are important to
them to determine whether those can be continued during Unit Orientation
their progressive care unit stay. The progressive care nurse takes the time to educate the
Patients’ and families use different modes of interacting patient and family about the specialized progressive care
and coping to feel safe. Persons who are stoic may be wary unit environment. Provide simple explanations of the equip-
of “bothering” the busy staff and may not admit they have ment being used, the visitation policies, the routines of the
pain because family or others are nearby. Other patients may unit, and how the patient can communicate needs to the
express their anxiety and stress through behaviors learned in unit staff. Give the family information about how to con-
past stressful events. Impulsive behaviors, deception, super- tact the unit and provide the names of healthcare team
ficial charm, splitting among the healthcare team, and gen- members including the charge nurse and unit manager in
eral avoidance of rules or limits are some examples of modes case problems or concerns arise during the progressive care
of interacting and coping that are attempts to feel safe. Still unit stay. Explain to the patient and family how they will be
other patients may withdraw and actually request the use of involved in receiving updates and given opportunities to ask
sedatives and sleeping medications to blunt the stimuli and questions.
stress of the environment.
Fear has an identifiable source and plays an important Referrals
role in the ability of the patient to cope. Treatments, pro- After completing the comprehensive assessment, the pro-
cedures, pain, and separation are common objects of fear. gressive care nurse analyzes the information gathered and
The dying process elicits specific fears, such as fear of the determines the need to make referrals to other healthcare
unknown, loneliness, loss of body, loss of self-control, suf- providers and resources (Table 1-11). To ensure appropriate
fering, pain, loss of identity, and loss of everyone loved by and timely discharge, maintain continuity of care and pro-
the patient. The family, as well as the patient, experiences the mote appropriate resource management, referrals are initi-
grieving process, which includes the phases of denial, shock, ated as soon as possible. If any ancillary service referrals have
anger, bargaining, depression, and acceptance. already been initiated in the ICU or medical-surgical unit,
those services are notified regarding the transfer in order to
Family Needs avoid any gaps in coverage.
The concept of family includes any loving, supportive per-
son regardless of social and legal boundaries. Ideally the
patient is asked to identify their family and to select who Transition/Discharge Planning
should receive information about them, and who is the deci- It is important that transition and/or discharge plan-
sion maker if they become unable to make decisions on their ning starts on arrival of the patient to the progressive care
own. This may also be an opportune time to ask whether unit. Lengths of stay continue to decrease for patients in

TABLE 1-11. EXAMPLES OF POTENTIAL REFERRALS NEEDED FOR PROGRESSIVE • Before and after transport out of the progressive care
CARE PATIENTS unit for diagnostic procedures or other events
Referral Resources Needed • Deterioration in physiologic or mental status
Social work • Financial needs/resources for patient and/or family • Initiation of any new therapy
• Coping resources for patient and/or family
As with the arrival quick check, the ongoing assessment
• Resources to assist with transition planning
section is offered as a generic template that can be used as a
Nutrition • Nutritional status at risk and in need of in-depth
nutritional assessment basis for all patients (Table 1-12). More in-depth and system-
• Altered nutritional status on admission specific assessment parameters are added based on the
• Education to patient/family about nutrition and diet patient’s diagnosis and pathophysiologic problems.
after discharge
Therapies • Physical therapy for maintaining or improving
physical flexibility and strength TABLE 1-12. ONGOING ASSESSMENT TEMPLATE
• Occupational therapy for assistive devices
• Speech therapy for assessment of ability to swallow Body System Assessment Parameters
or communication needs Nervous • LOC
• All above three therapies for input on the appropriate • Pupils
discharge plan • Motor strength of extremities
Pastoral care • Spiritual guidance for patient and/or family Cardiovascular • Blood pressure
• Coping resources for patient and/or family • Heart rate and rhythm
Enterostomal • Stoma assessment and needs • Heart sounds
nursing • In-depth skin integrity needs • Capillary refill
• Teaching for patient/family how to care for new • Peripheral pulses
stoma • Patency of IVs
Ethics committee • Decisions involving significant ethical complexity • Verification of IV solutions and medications
• Decisions involving disagreements over care • Hemodynamic pressures and waveforms
between care providers or between care providers • Daily weights
and patient/family Respiratory • Respiratory rate and rhythm
Care coordinator • Anticipate transition needs throughout and post • Breath sounds
hospitalization • Color and amount of secretions
• Noninvasive technology information (eg, pulse
Palliative care • Additional support, symptom management, goals of
oximetry)
care conversations
• Mechanical ventilatory parameters
• Location, patency, and function of chest tubes
• Arterial and venous blood gases
progressive care, creating a challenge for progressive care Renal • Intake and output
nurses to assess the appropriate transition location for the • Color, clarity, and amount of urinary output
• Blood urea nitrogen (BUN)/creatinine values
progressive care patient adequately. Educational and logisti-
Gastrointestinal • Bowel sounds
cal processes need to be put into place in a timely manner so
• Contour of abdomen
as to avoid any delays in patient progress and recovery. This • Position and patency of drainage tubes
necessitates early and active involvement by all appropriate • Position of feeding tube
healthcare team members to ensure smooth transitioning. • Color and amount of secretions
• Bilirubin and albumin values
Endocrine, • Fluid balance
ONGOING ASSESSMENT hematologic, and • Electrolyte and glucose values
immunologic • CBC and coagulation values
After the arrival quick check and comprehensive assess- • Temperature
ments are completed, all subsequent assessments are used to • WBC with differential count
determine trends, evaluate response to therapy, and identify Integumentary • Color and temperature of skin
new potential problems or changes from the comprehensive • Skin integrity
• Areas of redness
baseline assessment. Ongoing assessments become more
Pain/discomfort • Assessed in each system
focused, and the frequency is driven by the stability of the • Response to interventions
patient; however, routine periodic assessments are the norm. Psychosocial • Mental status and behavioral responses
Stable patients are assessed according to unit protocol, but an • Reaction to acute illness experience (eg, stress,
increased level of frequency is required for patients who are anxiety, coping, mood)
exhibiting changes in physiological status. Additional assess- • Presence of cognitive impairments (dementia,
ments are done when any of the following situations occur: delirium), depression, or demoralization
• Family functioning and needs
• Caregiver change or handoff • Ability to communicate needs and participate in care
• Before and after any major procedural intervention, • Sleep patterns
• Preparation for transition to the next level of care
such as chest tube insertion

SELECTED BIBLIOGRAPHY 17
PRINCIPLES OF MANAGEMENT American Association of Critical-Care Nurses. Practice Alert:

Obtaining Accurate Non-Invasive Blood Pressure Measurements
• There are four distinct components in the assess- in Adults. Aliso Viejo, CA: AACN; 2016. https://www.aacn.org/
ment of a patient admitted to progressive care: clinical-resources/practice-alerts/obtaining-accurate-noninvasive-
(1) the prearrival assessment, (2) the admission quick blood-pressure-measurements-in-adults.
check, (3) the comprehensive initial assessment, and Bickley LS. Bates’ Guide to Physical Examination and History Taking.
(4) ongoing assessment. 13th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2020.
• The admission quick check is systematic so as not Hartjes TM. AACN Core Curriculum for High Acuity, Progressive,
to miss subtle signs or cues. It is also used to ensure and Critical Care. 7th ed. St. Louis, MO: Elsevier; 2018.
that patients’ urgent needs are met. For instance, the Prin M, Wunsch H. The role of stepdown beds in hospital care.
Am J Respir Crit Care Med. 2014;190(11):1210-1216.
patient’s mental status can be observed during trans-
Stacy KM. Progressive care units: different but the same. Crit Care
fer from stretcher to hospital bed.
Nurs. 2011;31(3):77-83.
• A common standard assessment approach is a combi- Weigand DLM. AACN Procedure Manual for High Acuity, Progres-
nation of a body systems approach and a head-to-toe sive, and Critical Care. 7th ed. St. Louis, MO: Elsevier; 2017.
approach. A consistent process is applied to ensure
complete information is gathered, while additional
Evidence-Based Practice
attention is given to certain systems according to the
patient’s presenting pathology. Bressan V, Mio M, Palese A. Nursing handovers and patient safety:
findings from an umbrella review. J Adv Nurs. 2020;76(4):927-938.
• Assessment focuses first on the patient and then on
Cox J. Pressure injury risk factors in adult critical care patients: a
the technology.
review of the literature. Ostomy Wound Manage. 2017;63(11):30-43.
• Planning for the transition of the patient out of pro- Fernandes A, Jaeger MS, Chudow M. Post-intensive care syndrome:
gressive care begins at the time of admission. a review of preventive strategies and follow-up care. Am J Health
Syst Pharm. 2019;76(2):119-122.
Kruschke C, Butcher HK. Evidence-based practice guideline: fall
SELECTED BIBLIOGRAPHY prevention for older adults. J Gerontol Nurs. 2017;43(11):15-21.
Marra A, Ely EW, Pandharipande PP, Patel MB. The ABCDEF
Progressive Care Assessment bundle in critical care. Crit Care Clin. 2017;33(2):225-243.
American Association of Critical-Care Nurses. Practice Alert: Matt B, Schwarzkopf D, Reinhart K, König C, Hartog CS. Relatives’
Assessment and Management of Delirium across the Lifespan. perception of stressors and psychological outcomes—results
Aliso Viejo, CA: AACN; 2016. https://www.aacn.org/clinical- from a survey study. J Crit Care. 2017;39:172-177. doi:10.1016/
resources/practice-alerts/assessment-and-management-of- j.jcrc.2017.02.036.
delirium-across-the-life-span. Includes an Evidence Update Pittman J, Beeson T, Dillon J, Yang Z, Cuddigan J. Hospital-acquired
from October 1, 2018. pressure injuries in critical and progressive care: avoidable versus
American Association of Critical-Care Nurses. Practice Alert: unavoidable. Am J Crit Care. 2019;28(5):338-350.
Ensuring Accurate ST Monitoring. Aliso Viejo, CA: AACN; 2016. Stafos A, Stark S, Barbay K, et al. Identifying hospital patients at risk
https://www.aacn.org/clinical-resources/practice-alerts/st-segment- for harm: a comparison of nurse perceptions vs. electronic risk
monitoring. Includes an Evidence Update from May 17, 2018. assessment tool scores. Am J Nurs. 2017;117(4):26-31.

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2
Planning Care for
Progressive Care
Patients and
Their Families
Lynn Orser
KNOWLEDGE COMPETENCIES
1. Discuss the importance of an interprofessional 4. Describe interventions to promote family-
plan of care for optimizing clinical outcomes. centered care and patient and family education.
2. Describe interventions for prevention of common 5. Identify necessary equipment and personnel
complications in progressive care patients: required to safely transport the progressive care
• Venous thromboembolism patient within the hospital.
• Infection 6. Describe transfer-related complications and pre-
• Sleep pattern disturbances ventive measures to be taken before and during
• Fall patient transport.
• Skin breakdown
• Delirium
3. Discuss interventions to maintain psychosocial
integrity and minimize anxiety for the progressive
care patient and family members.
It is important to be mindful of the unique needs of patients case, it is important to reassure the patient and family that the
and their families as they transition from the intensive care or progressive care nurses have the skills and equipment needed
medical-surgical environment to a progressive care environ- to monitor and meet the needs of the patient.
ment. Since lengths of stay in progressive care are typically The achievement of optimal clinical outcomes in the
short, preparation for the next anticipated level of care is initi- progressive care patient requires a coordinated approach to
ated on arrival to the progressive care unit. Patient and family care delivery by interprofessional team members. Experts in
education is key to preparing for care transitions or potential nutrition, respiratory therapy, progressive care nursing and
discharge to home. It is also important to recognize anxiety medicine, psychiatry, and social work, as well as other dis-
that the patient may experience during transitions of care. If the ciplines, work collaboratively to effectively and efficiently
patient is transferring from critical care to progressive care, the provide optimal care.
patient and family may feel nervous at the perceived decrease in An interprofessional plan of care is a useful approach
level of nursing vigilance and technology. This can create ques- to facilitate the coordination of a patient’s care by the inter-
tions on the part of the patient and family as to whether staff will professional team and optimize clinical outcomes. These
be available to respond quickly to patient needs and changes in interprofessional plans of care are increasingly being used
condition. Conversely, if a patient is transferred to the progres- to replace individual, discipline-specific plans of care. Each
sive care unit from a medical-surgical area because of declining clinical condition presented in this text discusses the man-
physiologic status, anxiety on the part of the patient and family agement of patient needs or problems with an integrated,
is related to the uncertainty of the patient’s condition. In either interprofessional approach.
19

20 CHAPTER 2. Planning Care for Progressive Care Patients and Their Families
The following section provides an overview of interprofes- The suggested activities within each of these categories
sional plans of care and their benefits. In addition, this chapter may be divided into daily activities or grouped into phases
discusses patient management approaches to needs or problems of the hospitalization (eg, preoperative, intraoperative, and
during acute illnesses that are not diagnosis specific but com- postoperative phases). All staff members who use the plan of
mon to a majority of progressive care patients, such as sleep care require education as to its specifics. This team approach
deprivation, pressure injury, and patient and family education. in development and utilization optimizes communication,
Additional discussion of these needs or problems is also pre- collaboration, coordination, and commitment in using the
sented in other chapters related to specific disease management. plan to achieve patient outcomes.
Interprofessional plans of care are evolving into many
different forms and the documentation varies widely across
INTERPROFESSIONAL PLAN OF CARE institutions. Some electronic formats mimic the paper ver-
An interprofessional plan of care is a set of expectations for sion. Other institutions may incorporate pieces of the plan
the major components of care a patient receives during the of care into varied electronic flow sheets (eg, orders, assess-
hospitalization to manage a specific medical or surgical prob- ments, interventions, education, outcomes, specific plans
lem. Other types of plans include clinical pathways, protocols, of care). Regardless of the specific format, a wide range of
and care maps. The interprofessional plan of care expands disciplines uses interprofessional plans of care. Each indi-
the concept of a medical or nursing care plan and provides a vidual who assesses progress toward patient goals and imple-
multidisciplinary, comprehensive blueprint for patient care. ments various aspects of the interprofessional plan of care is
The result is a diagnosis-specific plan of care that focuses the accountable for documenting on the care plan in the approved
entire care team on expected patient outcomes. format. Specific patient goals on the plan of care can then be
The interprofessional plan of care outlines the tests, evaluated and tracked to determine if they are met, not met,
medications, care, and treatments needed to discharge the or are not applicable. Goals on the plan of care that are not
patient in a timely manner with all patient outcomes met. completed typically are termed variances, which are devia-
These plans have a variety of benefits for both patients and tions from the expected activities or goals outlined. Goal out-
the hospital system: comes on the plan of care that occur early are termed positive
variances. Negative variances are those planned outcomes that
• Improved patient outcomes (eg, survival rates, are not accomplished on time. Negative variances typically
morbidity) include goals not completed or achieved due to the patient’s
• Increased quality and continuity of care condition, hospital system challenges (diagnostic studies or
• Improved communication and collaboration therapeutic interventions not completed within the optimal
• Identification of hospital system problems time frame), or lack of orders. Assessing patient progression
• Coordination of necessary services and reduced on the plan of care helps caregivers to have an overall pic-
duplication ture of patient recovery as compared to the goals and can
• Prioritization of activities be helpful in early recognition and resolution of problems.
• Reduced length of stay (LOS) and healthcare costs It is important to remember that individual discipline docu-
Teams of individuals who closely interact with a spe- mentation on the plan of care does not preclude the need for
cific patient population develop interprofessional plans of ongoing, direct communication and collaboration between
care. It is this process of multiple disciplines communicating disciplines in order to facilitate optimal patient care and
and collaborating around the needs of the patient that creates achievement of goals.
benefits for the patients. Representatives of disciplines com-
monly involved in developing plans of care include provid-
ers, nurses, respiratory therapists, physical therapists, social PLANNING CARE THROUGH STAFFING CONSIDERATIONS
workers, and dieticians. The format for the interprofessional Planning care for individual acutely ill patients begins with
plans of care typically includes the following categories: ensuring each nurse caring for a patient has the correspond-
• Discharge outcomes ing competencies and skills to meet the patient’s needs. The
• Patient goals (eg, pain control, activity level, absence American Association of Critical-Care Nurses has developed
of complications) the AACN Synergy Model for Patient Care to delineate core
• Assessment and evaluation patient characteristics and needs that drive the core compe-
• Consultations tencies of nurses required to care for patients and families
• Tests (Table 2-1). All eight competencies identified in the Synergy
• Medications Model are essential for the progressive care nurse’s practice,
• Nutrition though the extent to which any particular competency is
• Activity needed on a daily basis depends on the patient’s needs at that
• Education point in time. When making patient staffing assignments,
• Discharge planning the charge nurse or nurse manager assesses the priority needs

PATIENT SAFETY CONSIDERATIONS IN PLANNING CARE 21
TABLE 2-1. CORE PATIENT CHARACTERISTICS AND NURSE COMPETENCIES AS DEFINED IN THE SYNERGY MODEL
Patient Characteristics Description

Resiliency The capacity to return to a restorative level of functioning using compensatory/coping mechanisms
Vulnerability Susceptibility to actual or potential stressors that may adversely affect patient outcomes
Stability The ability to maintain a steady-state equilibrium
Complexity The intricate entanglement of two or more systems
Resource availability Extent of resources (technical, fiscal, personal, psychological, and social) the patient/family bring to the situation
Participation in care Extent to which patient/family engages in aspects of care
Participation in decision-making Extent to which patient/family engages in decision-making
Predictability Characteristic that allows one to expect a certain course of events or course of illness
Nurse Competencies Description

Clinical judgment Clinical reasoning (clinical decision-making, critical thinking, and global understanding of situation) coupled with nursing
skills (formal and informal experiential knowledge and evidence-based practice)
Advocacy and moral agency Working on another's behalf and representing concerns of patients/families and nursing staff
Caring practices Activities that create a compassionate, supportive, and therapeutic environment
Collaboration Working with others in a way that promotes each person's contributions toward achieving optimal patient/family goals
Systems thinking Body of knowledge that allows the nurse to manage environment and system resources for patients, families, and staff
Response to diversity The sensitivity to recognize, appreciate and incorporate differences into the provision of care. Differences may include but are
not limited to, cultural differences, spiritual beliefs, gender, race, ethnicity, lifestyle, socioeconomic status, age, and values
Facilitation of learning Ability to facilitate learning for patients, families, and staff
Clinical inquiry Ongoing process of questioning and evaluating practice and providing informed practice
Data from American Association of Critical-Care Nurses. The AACN Synergy Model for Patient Care. Aliso Viejo, CA: AACN.
of the patient and assigns a nurse who has the proficiencies

to meet those patient needs. By matching the competencies ESSENTIAL CONTENT CASE
of the nurse with the needs of the patient, synergy occurs
resulting in optimal patient outcomes. Synergy Between Patient
Nurses in progressive care units juggle many tasks at Characteristics and Nurse
a time. This requires concentration and attention to detail.
Long shifts can contribute to mental fatigue. Research shows
Competencies
that restorative breaks at work help manage fatigue and MG is an 83-year-old woman with a history of coronary
improve concentration. It is important for the progressive heart disease and metastatic breast cancer who is trans-
care nurse to plan breaks into their shift, as self-care contrib- ferred to the progressive care unit with shortness of breath.
utes to improved patient care. Her respiratory status is continuing to worsen and CPAP is
initiated though the physician is evaluating MG for poten-
tial intubation and sedation. In addition, MG is experi-
PATIENT SAFETY CONSIDERATIONS IN PLANNING CARE encing episodes of tachycardia. It has been determined the
shortness of breath is due to a large, pleural effusion. MG
Progressive care units are high-technology, high-intervention is widowed with three children who are very supportive,
environments with multiple disciplines caring for the patient. but all live at least 5 hours away and are unclear about their
mother’s wishes regarding medical treatment or her goals
Progressive care nurses need to be especially thoughtful of of care.
minimizing the safety risks inherent in such an environment.
Progressive care units are constantly working to improve Case Question 1: Based on the Synergy Model (see
Table 2-1), what four priority patient characteristics
ways to optimize care and minimize risks to patients. would the charge nurse consider in making a nurse
As the nurse develops an ongoing plan of care, safety assignment for MG?
considerations are also incorporated. Conditions of acutely
Case Question 2: The charge nurse assigns Rebecca to
ill patients can change quickly, so ongoing awareness and care for MG. What particular skills will Rebecca use in
vigilance is the key even when the patient appears to be caring for MG during the upcoming shift?
stable or improving. The progressive care unit environment
Answers
itself can contain safety issues. Inappropriate use of medi- 1. MG’s priority characteristics include instability, mini-
cal gas equipment or ventilator settings, electrical equip- mally resilient, vulnerable, and currently unable to fully
ment with invasive lines, certain types of restraints, bedside participate in decision-making.
rails, and cords and tubing lying on the floor may all be haz- 2. Clinical judgment, advocacy and moral agency, and
ardous to the acutely ill patient. In addition, with so many caring practices.
healthcare disciplines involved in the care of each patient,

it is imperative that communication remain accurate and to higher glucose levels every morning around 10 am. When
timely. Use of a standardized handoff communication looking at the whole picture, the nurse realizes that the patient
tool (eg, SBAR; see Chapter 1, Assessment of Progressive is receiving several medications in the early morning that are
Care Patients and Their Families) is a fundamental step in mixed in a dextrose diluent. Recognition of this pattern helps
preventing errors related to poor communication among the nurse to stabilize swings in blood glucose.
healthcare providers.
Finally, as described in more detail later, many com- Venous Thromboembolism
mon complications can be prevented by patient safety initia-
Progressive care patients are at increased risk of venous
tives that reduce the risk of ventilator-acquired pneumonia,
thromboembolism (VTE) due to their underlying condi-
central line-associated bloodstream infections, catheter-
tion and immobility. Routine interventions can prevent this
associated urinary tract infections, and Clostridium difficile
potentially devastating complication from occurring. There is
and multidrug-resistant organisms (MDROs). Initiatives
increasing evidence to support early and progressive mobility
that promote hand hygiene, meticulous care of patients, and
of patients to decrease the risk of VTEs in addition to improv-
attention to the environment, including cleaning of reusable
ing respiratory function and muscle strength. It takes a team
equipment, can prevent transmission of pathogens from one
effort to fully implement early mobility protocols, including
patient to another. Another approach is incorporating daily
nurses, physical therapists, respiratory therapists, and provid-
discussions with the healthcare team about the use of inva-
ers. Increased mobility is emphasized as soon as the patient
sive lines and catheters. Removing invasive equipment as
is stable. Even transferring the patient from the bed to the
soon as clinically appropriate can prevent pathogen exposure
chair changes the positioning of extremities and improves cir-
from becoming an infection.
culation. Additionally, use of sequential compression devices
assists in enhancing lower extremity circulation. Avoid plac-
ing intravenous (IV) access in the groin site or lower limbs
PREVENTION OF COMMON COMPLICATIONS
as this impedes mobility and potentially impedes blood flow
The development of an acute illness, regardless of its cause, and can thus increase VTE risk. Ensure adequate hydration.
predisposes the patient to a number of physiologic and psy- Many patients may also be placed on low-dose heparin or
chological complications. A major focus when providing enoxaparin protocols as a preventative measure.
care to progressive care patients is the prevention of compli-
cations associated with acute illness. The following content Hospital-Acquired Infections
describes some of the most common complications.
Acutely ill patients are vulnerable to infection during their
stay in the progressive care unit. Every day 1 in 31 hospital-
Physiologic Instability ized patients in the United States has at least one healthcare-
Ongoing assessments and monitoring of progressive care associated infection. In general, the risk of hospital-acquired
patients (see Table 1-12) are key to early identification of infections is due to the use of multiple invasive devices and
physiologic changes and to ensuring that the patient is pro- the frequent presence of debilitating underlying diseases.
gressing to the identified transition goals. It is important for Hospital-acquired infections increase the patient’s LOS and
the nurse to use critical thinking skills throughout the provi- hospitalization costs and can markedly increase mortality
sion of care to accurately analyze patient changes. rates depending on the type and severity of the infection and
After each assessment, the data obtained are looked at the underlying disease. The most common hospital-acquired
in totality as they relate to the status of the patient. When an infections are urinary tract infections, and hospital-acquired
assessment changes in one body system, rarely does it remain pneumonias. Details of specific risk factors and control mea-
an isolated issue, but rather it frequently either impacts or sures for the prevention of hospital-acquired pneumonias
is a result of changes in other systems. Only by analyzing are presented in Chapter 10 (Respiratory System). Other
the entire patient assessment can the nurse see what is truly frequent infections include bloodstream and surgical site
happening with the patient and anticipate interventions and infections. In addition, C. difficile and MDRO infections
responses. have steadily increased in incidence over the past decades
When assuming care of the patient, define patient goals with a sharp increase after the onset of the COVID-19 pan-
to achieve by the end of the shift based on either the plan of demic. This is particularly concerning as there are very lim-
care or the initial patient assessment. This provides opportuni- ited options for treating these MDROs. It is imperative for
ties to evaluate care over a period of time. It prevents a narrow progressive care practitioners to understand the processes
focus on the completion of individual tasks and interventions that contribute to these potentially lethal infections and their
and encourages a broader consideration of the overall pro- roles in preventing them.
gression of the patient toward various goals. In addition, this
broader view allows the nurse to anticipate the potential patient Prevention
responses to interventions. For instance, the nurse notices that Standard precautions, sometimes referred to as universal
a patient requires an increase in insulin infusion in response precautions or body substance isolation, refer to the basic

PREVENTION OF COMMON COMPLICATIONS 23
precautions that are to be used on all patients, regardless The current recommendation from the United States
of their diagnosis. The general premise of standard pre- Centers for Disease Control and Prevention (CDC) is that
cautions is that all body fluids have the potential to trans- peripheral IV lines remain in place no longer than 72 to
mit any number of infectious diseases, both bacterial and 96 hours. There is no standard recommendation for routine
viral. Certain basic principles are followed to prevent direct removal of central venous catheters when required for pro-
and indirect transmission of these organisms. Nonsterile longed periods. If the patient begins to show signs of sepsis
examination gloves are worn when performing venipunc- that could be catheter-related, these catheters are removed.
ture, touching nonintact skin or mucous membranes of the More important than the length of time the catheter is in
patient, or touching any moist body fluid. This includes place is how carefully the catheter was inserted and cared for
urine, stool, saliva, emesis, sputum, blood, and any type while in place. All catheters placed in an emergency situation
of drainage. Other personal protective equipment, such as are replaced as soon as possible or within 48 hours. Dress-
face shields, masks, and protective gowns, are worn when- ings are kept dry and intact and changed at the first signs
ever there is a risk of splashing body fluids into the face or of becoming damp, soiled, or loosened. Protocols require IV
onto clothing. This protects not only the healthcare worker tubing changes at specific intervals, usually every 4 to 7 days
but also prevents any contamination that may be transmit- (https://www.cdc.gov/infectioncontrol/guidelines/bsi/
ted between patients via the caregiver. Additional specific recommendations.html), with the exception of tubing for
infection control measures are aimed at modes of disease blood, blood products, or lipid-based products, which
transmission. See Table 2-2 for examples of isolation pre- require more frequent changes, per CDC Guidance.
caution categories and the types of infections for which Strategies to prevent aspiration, a risk factor for
they are instituted. hospital-acquired pneumonia include the following: main-
Other interventions to prevent nosocomial infections tain the head of the bed at greater than or equal to 30°, assess
are similar regardless of the site. Maintaining glycemic con- tolerance to enteral feeding and adjust feeding rates accord-
trol can minimize the risk of infection in patients with diabe- ingly, and wash hands before and after contact with patient
tes and those without diabetes. Invasive lines or tubes never secretions or respiratory equipment (refer to Chapters 5
remain in place longer than necessary and never for staff and 14 for specific content related to these recommenda-
convenience or patient preference. Use closed drainage sys- tions). Consider performing a swallow screen with patient
tems whenever possible and avoid breaks in systems such as reports of swallowing difficulties or with observed difficulty
urinary drainage systems, IV lines, and ventilator tubing. Use swallowing such as coughing or choking with oral intake.
of aseptic technique is essential if breaks into these systems Performing routine oral care will also decrease the risk of
are necessary. Hand hygiene before and after any manipula- microaspiration of oral bacteria.
tion of invasive lines is essential. Hand hygiene is one of the most important defenses to
preventing infection. Hand hygiene is defined by the CDC as
using either hand washing (soap and water), antiseptic hand
TABLE 2-2. ISOLATION CATEGORIES AND RELATED INFECTION EXAMPLES wash, antiseptic hand rub (alcohol-based hand sanitizer
including foam or gel), or surgical hand antisepsis. It has
Isolation Categories Infection Examples When Used
been estimated that healthcare workers cleanse their hands
Standard precautions Apply to the care of all patients and includes hand
hygiene, and gloves for contact with blood and
as much as 50% fewer times than necessary. It is important
body fluids to involve all disciplines in encouraging and reminding each
Airborne precautions Tuberculosis, measles (rubeola), varicella (includes other to perform hand hygiene when it has been overlooked.
use of an N95 or equivalent respiratory Some institutions also encourage patients and families to be
protection) partners in hand hygiene efforts by asking care providers if
Droplet precautions Neisseria meningitidis, Haemophilus influenzae, they have cleansed their hands prior to patient contact.
pertussis, mumps, whooping cough (includes Hand washing is defined by the CDC as vigorous rub-
use of a medical-surgical face mask)
bing together of lathered hands with soap and water for
Contact precautions Vancomycin-resistant enterococcus (VRE),
methicillin-resistant Staphylococcus aureus
20 seconds followed by a thorough rinsing under a stream
(MRSA), Clostridium difficile, scabies, impetigo, of running water. Particular attention is paid around rings,
varicella, respiratory syncytial virus (includes between fingers and under fingernails. It is best to keep natu-
use of a gown and gloves for all interactions; ral fingernails well trimmed and unpolished. Cracked nail
for patients with C. difficile soap and water are polish is a good place for microorganisms to hide.
required for hand hygiene)
Artificial fingernails are not worn in any healthcare set-
Transmission-based COVID-19 (A NIOSH-approved N95 or equivalent
precautions for or higher-level respirator, gown, gloves, eye
ting because they are virtually impossible to clean without a
known or suspected protection. CDC guidance includes strategies nailbrush and vigorous scrubbing. Hand washing with soap
COVID-19 used when supplies are short. Resource limited and water is performed when hands are visibly soiled, after
settings may use a medical-surgical facemask. exposure to known or suspected C. difficile, after known or
N95 or equivalent protection must be worn for suspected exposure to infectious diarrhea during norovirus
aerosol-generating procedures)
outbreak, before eating, and after using restroom. Use of

alcohol-based waterless cleansers is convenient and effective and (7) use a skin care protocol with ointment barriers for
when no visible soiling or contamination has occurred and patients experiencing incontinence to prevent skin irritation
after all other activities. Hand hygiene is performed prior to and tissue breakdown. There is also emerging evidence for
donning examination gloves to carry out patient-care activi- the use of polyurethane foam dressings prophylactically over
ties and after removing examination gloves. bony prominences that are exposed to shear and friction,
Dry, cracked skin, a long-standing problem associated though this intervention needs to be carefully considered
with hand washing, has new significance with the emer- based on individual patients and their conditions.
gence of blood-borne pathogens. Frequent hand washing,
especially with antimicrobial soap, can lead to extremely dry Sleep Pattern Disturbance
skin. The frequent use of gloves has been associated with
Progressive care patients are at risk for altered sleep patterns.
increased sensitivities and allergies, causing even more skin
Sleep is a problem for patients for many reasons, not the least
breakdown. Breaks in skin integrity can put the healthcare
of which are the pain and anxiety of an acute illness within
provider at risk for blood-borne pathogen transmission, as
an environment that is inundated with the multiple activities
well as for colonization or infection with bacteria. Attention
of healthcare providers. Table 2-3 identifies the many reasons
to skin care is extremely important for the progressive care
for patients to experience sleep deprivation. The priority of
practitioner who is using antimicrobial soap and gloves fre-
sleep in the hierarchy of patient needs is often perceived to
quently. Hospital-approved lotions and emollients are used
be low by clinicians. This contradicts patients’ own state-
to prevent dryness and reduce the risk of cracking. If skin
ments about the progressive care experience. Patients com-
breakdown does occur, the employee health nurse is con-
plain about lack of sleep as a major stressor along with the
sulted for possible treatment or work restriction until the
discomfort of unrelieved pain. The vicious cycle of under-
condition resolves.
treated pain, anxiety, and sleeplessness continues unless cli-
nicians intervene to break the cycle with simple but essential
Pressure Injury interventions individualized to each patient.
Pressure injury is a major risk with progressive care patients Noise from patient-care activities, monitor alarms,
due to immobility, poor nutrition, invasive lines, surgi- lights, and frequent patient interruptions are common in
cal sites, poor circulation, edema, and incontinence issues. many progressive care settings, with staff able to tune out the
Skin can become fragile and easily tear. Pressure injury can disturbances after they have worked in the setting for even
start to occur in as little as 2 hours in an immobile patient. a short period of time. Subjecting patients to these environ-
Healthy people constantly reposition themselves, even in mental stimuli and interruptions to rest/sleep can quickly
their sleep, to relieve areas of pressure. Progressive care lead to sleep deprivation. Psychological changes in sleep
patients who cannot reposition themselves rely on caregiv-
ers to assist them. Pay particular attention to pressure points
TABLE 2-3. FACTORS CONTRIBUTING TO SLEEP DISTURBANCES IN
that are most prone to injury, namely, heels, elbows, coccyx, PROGRESSIVE CARE
and occiput. When receiving progressive care patients fol-
Illness
lowing prolonged surgical procedures, ask the perioperative
• Metabolic changes
providers about the patient’s positioning during the proce- • Underlying diseases (eg, cardiovascular disease, chronic obstructive
dure. This will help determine the need for close monitoring pulmonary disease [COPD], dementia)
of the related pressure points for early indication of deep tis- • Pain
sue injury. Also, be cognizant of equipment that may con- • Anxiety, fear
• Delirium
tribute to pressure injuries, such as drainage tubes and even
Medications
bed rails, if patients are positioned in constant contact with • Analgesics
them. As the patient’s condition changes, so does the risk of • Antidepressants
developing a pressure injury. Routine use of a risk assess- • Beta-blockers
ment tool alerts the caregiver to increasing or decreasing risk • Bronchodilators
• Benzodiazepines
of pressure injury and the need for changes in interventions.
• Corticosteroids
There are many simple interventions to maintain skin Environment
integrity: (1) reposition the patient minimally every 2 hours, • Noise
particularly if they are not spontaneously moving; (2) use • Roommate or other patients
pressure-reduction mattresses for patients at high risk of • Staff conversations
• Television/radio
injury; (3) elevate heels off the bed using pillows placed
• Equipment alarms
under the calves or heel protectors; (4) consider elbow pads; • Frequent care interruptions
(5) avoid long periods of sitting in a chair without reposi- • Lighting
tioning; (6) inflatable cushions (donuts) are never used for • Lack of usual bedtime routine
either the sacrum or the head because they can actually • Room temperature
• Uncomfortable sleep surface
cause increases in pressure on surrounding skin surfaces;

PREVENTION OF COMMON COMPLICATIONS 25
TABLE 2-4. EVIDENCE-BASED PRACTICE: SLEEP PROMOTION IN prevent a fall. Patients who recurrently attempt to get out of
PROGRESSIVE CARE bed independently may be safer if they are assisted to a chair,
• Assess patient’s usual sleep patterns if they have family present, or if staffing permits, with the
• Minimize effects of underlying disease process as much as possible (eg, ongoing observation by a staff member.
reduce fever, control pain, minimize metabolic disturbances) A vulnerable time for a potential fall is when patients
• Avoid medications that disturb sleep patterns
• Consult with providers to continue behavioral medications during
need to urgently use the restroom or after being assisted
hospital stay to the restroom, they believe they can return to bed unas-
• Mimic patients’ usual bedtime routine as much as possible sisted. Interventions to address this risk are routine round-
• Minimize environmental impact on sleep as much as possible ing on patients to address their hygiene and other essential
• Utilize complementary therapies to promote sleep as appropriate needs proactively as well as staying near or in the bathroom
with the patient who is at high risk for falls and who may be
reluctant to ask for help returning to bed. Collaboration with
deprivation include confusion, irritability, and agitation. other professionals, such as physical therapy and occupa-
Physiologic changes include depressed immune and respira- tional therapy, may be instrumental in identifying additional
tory systems and a decreased pain threshold. Patients may interventions to prevent falls. Delirium in a mobile patient
already be sleep-deprived when they are admitted to the pro- may present a particularly high risk for falls, and in these
gressive care setting. The progressive care unit routine can cases, interventions to address the delirium, as described
help start to reestablish a healing sleep pattern. later, take on added importance.
Enhancing patients’ sleep potential in the progres-
sive care setting involves knowledge of how the environ- Psychosocial Impact
ment affects the patient and where to target interventions
Basic Tenets
to best promote sleep and rest. A nighttime sleep protocol
Healthcare providers are becoming increasingly aware that
where patients are closely monitored but untouched from
time spent in the intensive care unit (ICU) can have long-
1 to 5 am is an excellent example of eliminating the hourly
term physical, mental, and cognitive changes, impacting
disturbances that may have been occurring in the ICU.
patients and families for years following the illness. This
Encouraging blocks of time for sleep and careful assess-
Post-Intensive Care Syndrome (PICS) can result in survi-
ment of the quantity and quality of sleep are important to
vors and their family members exhibiting signs of post-
patient well-being. The middle-of-the-night bath is not a
traumatic stress disorder (PTSD). The progressive care
standard of care for any patient. Table 2-4 details basic rec-
nurse may see evidence of this in patients and families in
ommendations for sleep assessment, protecting or shield-
the progressive care unit. While the evidence is still emerg-
ing the patient from the environment, and modifying the
ing on strategies to prevent and treat PICS, there are basic
internal and external environments of the patient. When
interventions that can be done on the progressive care
these activities are incorporated into standard practice rou-
unit. Keys to maintaining psychological integrity during
tines, progressive care patients receive optimal opportunity
and after an acute illness include (1) keeping stressors at
to achieve sleep.
a minimum; (2) encouraging family participation in care;
(3) promoting a proper sleep-wake cycle; (4) encouraging
Falls communication, questions, and honest and positive feed-
Progressive care patients are encouraged to increase mobility back; (5) empowering the patient to participate in decisions
following a prolonged critical illness, or they may be fairly as appropriate; (6) providing patient and family education
mobile at baseline and require progressive care for an acute about unit expectations and rules, procedures, medications,
illness. While patients who are mobile face a lower risk of and the patient’s physical condition; (7) ensuring pain relief
complications such as pressure injury and VTE, this increase and comfort; and (8) providing consistent care providers.
in activity does introduce a concern for falls, particularly It is also important to have the patient’s usual sensory and
when physical mobility is coupled with impaired cognitive physical aids available, such as glasses, hearing aids, and
function. Planning the care of patients at risk for falls includes dentures, as they may help prevent confusion. Encourage
consideration of side rail position, bed height, frequency of the family to bring something familiar or personal from
patient observation, and consistent simple instructions to home, such as a family or pet picture.
the patient and family.
Many hospitals have specific programs for assessing all Delirium
patients for the risk of falls and interventions to implement Delirium is evidenced by disorientation, confusion, per-
based on the individual risk for each patient. For example, ceptual disturbances, restlessness, distractibility, and
patients who are at high risk of falling may be better served sleep-wake cycle disturbances. Any prior LOS in an ICU
when placed in rooms where they can be easily observed. may have already resulted in, or put a patient at risk for,
Keeping items of importance, such as the television remote, development of confusion. Causes of confusion are usu-
the urinal, and the call light within easy reach may also ally multifactorial and include metabolic disturbances,

polypharmacy, immobility, infections (particularly urinary may be embarrassed and feel guilty if they were combative
tract and respiratory infections), dehydration, electrolyte during their illness.
imbalances, sensory impairment, and environmental chal-
lenges. Treatment of delirium is a challenge, and therefore Depression
prevention is ideal. Depression occurring with a medical illness affects long-
Delirium occurs most often in postsurgical and elderly term recovery by lengthening the course of the illness and
patients and is the most common cause of disruptive behavior increasing morbidity and mortality. Risk factors that predis-
in progressive care. It is not unusual for providers to suspect pose for depression with medical disorders include social
delirium when acutely ill patients are confused and restless; isolation, recent loss, pessimism, financial pressures, history
however, there are several different subtypes of delirium: of mood disorder, alcohol or substance abuse/withdrawal,
hyperactive (restlessness, agitation, irritability, aggression); previous suicide attempts, and pain. Many patients arrive in
hypoactive (slow response to verbal stimuli, psychomotor the hospital with a history of treatment for depression that
slowing); and mixed delirium (both hyperactive and hypo- can be exacerbated by an acute illness crisis. It is important
active behaviors). Assessment of delirium should be routine that healthcare providers maintain the patient’s psychiatric
in the progressive care unit, and there are several valid and medication regimen if at all possible in order to avoid wors-
reliable tools that can be used to identify delirium, includ- ening the patient’s psychological status.
ing the Brief Confusion Assessment Method (bCAM) and Educating the patient and family about the temporary
Confusion Assessment Method for Intensive Care Units nature of most depressions during acute illness assists in
(CAM-ICU). providing reassurance that this is not an unusual phenom-
Often mislabeled as psychosis, delirium is not psycho- enon. Severe depressive symptoms often respond to phar-
sis. Sensory overload is a common risk factor that contrib- macologic intervention, so a psychiatric consultation may
utes to delirium in the acutely ill. Medications that may also be warranted. Keep in mind that it may take several weeks
play a role in instigating delirium include prochlorperazine, for antidepressants to reach their full effectiveness. The
diphenhydramine, famotidine, benzodiazepines, opioids, best way to assess depression is to ask directly. Allow the
and antiarrhythmic medications. patient to direct the conversation. If negative distortions
After recognizing the risk for delirium, nurses can take about illness and treatment are communicated, it is appro-
action to prevent it. The best approaches are multimodal, priate to correct, clarify, and reassure with realistic infor-
employing a variety of interventions simultaneously, often mation to promote a more hopeful outcome. Consistency
referred to as a “bundle” of care. A typical bundle to prevent in care providers promotes trust in an ongoing relationship
delirium might include addressing pain, implementing early and enhances recovery.
mobility, ensuring adequate sleep, providing assistive devices A patient who has attempted suicide or is suicidal can
such as glasses and hearing aids to address sensory deficits be frightening to hospital staff. Staff members are often
and minimizing the use of medications that contribute to uncertain of what to say when the patient says, “I want to
delirium. Family involvement in reorienting the patient and kill myself … my life no longer has meaning.” Ask the patient
providing familiar faces and voices is also helpful in prevent- if they are feeling suicidal; such questions do not promote
ing delirium. suicidal thoughts. Many times the communication of feel-
Once delirium develops, the first priority is to identify ing suicidal is a cover for wanting to discuss fear, pain, or
the cause. Is there a physiologic change such as an electrolyte loneliness. A psychiatric referral is recommended in these
abnormality, hypoxemia, or an adverse reaction to a medi- situations for further evaluation and intervention. Patients
cation? Are the patient’s underlying health problems, such who are suicidal with an active plan are monitored for safety
as heart failure, poorly controlled? Could the patient have a to prevent self-harm based on the facility’s policy and on psy-
new infection? Is the patient in pain? Once a cause is identi- chiatry recommendations.
fied, collaborate with providers in the selection of an appro-
priate treatment plan. Medication for managing delirium is Anxiety
best reserved for those cases in which behavioral interven- Medical disorders can cause anxiety and panic-like symp-
tions have failed. Restraints are discouraged because they toms, which are distressing to the patient and family and
tend to increase agitation. may exacerbate the medical condition. Treatment of the
If the patient demonstrates a paranoid element in his underlying medical condition may decrease the concomitant
or her delirium, avoid confrontation and remain at a safe anxiety. Both pharmacologic and nonpharmacologic inter-
distance. Accept bizarre statements calmly, without agree- ventions can be helpful in managing anxiety during acute
ment. Explain to the family that the behaviors are symptoms illness. Pharmacologic agents for anxiety are discussed in
that will most likely resolve with time, resumption of normal Chapter 6 (Pain and Sedation Management) and Chapter
sleep patterns, and medication. Delirious patients usually 7 (Pharmacology). Goals of pharmacologic therapy are to
remember the events, thoughts, conversations, and provider titrate the drug dose so that the patient can remain cogni-
responses that occur during delirium. The recovered patients zant and interactive with staff, family, and environment; to

PATIENT AND FAMILY EDUCATION 27
complement pain control; and to assist in promoting sleep. education provides patients and family members a mecha-
There are also a variety of nonpharmacologic interventions nism by which fears and concerns can be put in perspective
to decrease or control anxiety: and confronted so that they can become active members in
the decisions made about care.
• Breathing techniques: These techniques target somatic
Providing patient and family education in acute care
symptoms and include deep and slow abdominal
is challenging; multiple barriers (eg, environmental factors,
breathing patterns. It is important to demonstrate
patient stability, patient and family anxiety) are overcome or
and do the breathing with patients, as their height-
adapted to provide this essential intervention. The impor-
ened anxiety decreases their attention span. Practic-
tance of education, coupled with the barriers common in
ing this technique may decrease anxiety and assist the
progressive care, necessitates that education be a continuous
patient through difficult procedures.
ongoing process engaged by all members of the team.
• Muscle relaxation: Reduce psychomotor tension with
Education in the progressive care setting is most often
muscle relaxation. Again, the patient will most likely
done informally, though some patients may be able to toler-
be unable to cue himself or herself, so this is an excel-
ate more formal sessions. Education of the patient and family
lent opportunity for the family to participate as the
can often be subtle, occurring with each interaction between
cuing partner. Cuing might be, “The mattress under
the patient, family, and members of the healthcare team.
your head, elbow, heel, and back feels heavy against
Education may also be more direct, particularly in relation
your body, press harder, and then try to drift away
to self-care or managing equipment at home. Use of a family
from the mattress as you relax.” Mobile applications
member or friend who is a learning partner during patient
and websites with commercial relaxation techniques
education provides for the most effective learning process
are available but are not as useful as the cuing by a
and outcomes.
familiar voice.
• Imagery: Interventions targeting cognition, such as
imagery techniques, depend on the patient’s capac- Assessment of Learning Readiness
ity for attention, memory, and processing. Visu- Assessment of the patient’s and family’s learning needs
alization imagery involves recalling a pleasurable, focuses primarily on learning readiness. Learning readiness
relaxing situation; for example, a hot bath, lying on refers to that moment in time when the learner is able to
a warm beach, listening to waves, or hearing birds comprehend and synthesize the shared information. With-
sing. Guided imagery and hypnosis are additional out learning readiness, teaching may not be useful. Ques-
therapies but require some competency to be effec- tions to assess learning readiness are listed in Table 2-5.
tive; thus, a referral is suggested. Patients who prac-
tice meditation as an alternative for stress control are Strategies to Address Patient and Family Education
encouraged to continue, but the environment may
Prior to teaching, the information gathered in the assessment
need modification to optimize the effects.
is prioritized and organized into a format that is meaningful
• Preparatory information: Providing the patient and
family with preparatory information is extremely
helpful in controlling anxiety. Allowing the patient TABLE 2-5. ASSESSMENT OF LEARNING READINESS
and family to control some aspects of the treatment General Principles
process, even if only minor aspects of care, can be • Do the patient and the family have questions about the diagnosis,
anxiolytic. prognosis, treatments, or procedures?
• Distraction techniques: Distraction techniques can • What do the patient and the family desire to learn about?
also interrupt the anxiety cycle. Methods for distract- • What is the knowledge level of the individuals being taught? What do they
already know about the issues that will be taught?
ing can be listening to familiar music, watching vid-
• What is their current situation (condition and environment) and have they
eos, or counting backward from 200 by 2 rapidly. had any prior experience in a similar situation?
• Use of previous coping methods: Identify how the • Do the patient or the family have any communication barriers (eg,
patient and family have dealt with stress and anxi- language, illiteracy, culture, listening/comprehension deficits)?
ety in the past and suggest that approach if feasible. • What is patient’s or family members’ preferred method of learning?
Supporting previous coping techniques may well be Special Considerations in Progressive Care
adaptive. • Does the patient’s condition allow you to assess this information from
them (eg, physiologic/psychological stability)?
• Is the patient’s support system/family/significant other available or ready
PATIENT AND FAMILY EDUCATION to receive this information?
• What environmental factors (including time) present as barriers in the
Patient and family education in the progressive care environ- progressive care unit?
ment is essential to providing information regarding diag- • Are there other members of the healthcare team who may possess vital
assessment information?
nosis, prognosis, treatments, and procedures. In addition,

Another random document with
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admitted water drop by drop, until the sound had died away. For
these inventions and for his steam steering gears the judges made
an award.
Our foreign judges were enthusiastic about them; Horatio Allen
had fought Mr. Sickels during his whole business life and would
never allow a Sickels cut-off to be applied in the Novelty Iron Works.
For example, the directors of the Collins steamship line adopted the
Sickels cut-off, but it was put on only two of their ships, the “Arctic”
and the “Baltic,” the engines of which were built at the Allaire works.
The “Atlantic” and “Pacific,” which were engined at the Novelty
Works, did not have it, Mr. Allen absolutely refusing to allow it. To my
surprise Mr. Allen signed this award with a cordial expression of
admiration of Mr. Sickels’ genius; he had softened in his old age.
The following is a copy of this award.
INTERNATIONAL EXHIBITION, 1876.
United States Centennial Commission,

Philadelphia, 3d August, 1876.
REPORT ON AWARDS.
“Group No. XX.
“Catalogue No. 1027.
“Product, Models of Improvements in Steam-engines.
“Name and address of exhibitor, Frederick E. Sickels.
“The undersigned, having examined the products herein
described, respectfully recommend the same to the United States
Centennial Commission for Award for the following reasons, viz:
“These exhibits possess great historical interest.
“In the year 1842 Mr. Sickels patented the trip or liberating cut-off,
an invention which, in a variety of forms, has come into use
wherever steam-engines are made. In applying this invention to
poppet valves, Mr. Sickels prevented these valves from striking their
seats by his invention of the dash-pot, in which he availed himself of
the incompressibility, the indestructibility and the divisibility of water,
and which is now employed for this purpose in all such applications.
“In 1848 he patented an improvement in the method of controlling
motive power, by which method steam is applied at the present time
to various uses, notable among which is the steering of steam
vessels, the steersmen turning the wheel precisely as in steering by
hand, but all the force being exerted by the steam.
“Charles T. Porter,
“Reporting Judge.
“Approval of Group Judges,
Horatio Allen, Chas. E. Emery, Emil Brugsch,
F. Reuleaux, N. Petroff.”
James Moore
After our work was finished and I had gone home the awards were
made public; to my astonishment the award to Mr. Sickels was not
among them, so I wrote to General Walker, who was our medium of
communication with the Commission, asking the reason for this
omission. He replied that the award had been thrown out by the
Committee of Revision. “Committee of Revision!” I had never heard
of such a thing. I asked for an explanation and I learned that the
judges did not make awards, they only recommended them; the
awards were made by the Commission after they had passed the
scrutiny of the Committee of Revision. Well, who were the
Committee of Revision? I learned that the Commission consisted of
two commissioners from each State appointed by the Governor; Mr.
Corliss was a commissioner from Rhode Island. At a meeting of the
commissioners Mr. Corliss proposed the novel scheme of a
Committee of Revision, to which the action of the judges should be
submitted for approval before the awards were made. The idea
seemed to please the members of the Commission, as tending to
magnify their own importance, and it was adopted; as a matter of
usual courtesy Mr. Corliss was made chairman of the committee,
and the committee threw out the award to Mr. Sickels. I made careful
inquiry and could never learn that the Committee of Revision threw
out any other award, so it seemed evident that with the throwing out
of this award to Mr. Sickels the object of its existence was
accomplished.
In the Corliss valve system the liberation of the valve was the
fundamental idea; this was applied by him to valves moving in the
direction parallel with their seats. It not being necessary to arrest
their motion at any precise point, they were caught by air cushions at
any points after they had covered their ports. Mr. Corliss had
appropriated the liberating idea, according to “the good old rule, the
simple plan, that they may take who have the power, and they may
keep who can,” and all this machinery had been devised by him to
prevent the historical fact that the liberating idea had been invented
by Mr. Sickels from appearing in the records of the exhibition. By all
this enormous expenditure of ingenuity and influence he succeeded
in giving to this fact a prominence and importance which it would
never otherwise have had, besides advertising his efforts to
suppress it.
Mr. Horatio Allen’s life-long aversion to Mr. Sickels was caused by
professional jealousy. Mr. Allen conceived himself to be an inventor,
and for years had been cherishing a cut-off invention of his own. The
original firm was Stillman, Allen & Co., and for years Mr. Stillman had
prevented the Novelty Iron Works from being sacrificed to Mr. Allen’s
genius, but later Mr. Allen had obtained supreme control of these
works by an affiliation with Brown Brothers, the bankers, his principal
stockholders, and Mr. Stillman sold out his interest and retired from
the firm. Mr. Allen, having a clear field, now determined to put his
invention on the new steamer of the Collins line, the “Adriatic,” and
American engineers were amused at the display of this amazing
absurdity on the largest possible scale. In this construction there
were four valves; each valve was a conical plug about six feet long
and had four movements; first it was withdrawn from its seat a
distance of three inches so that it could be rotated freely, then it was
rotated first to draw off the lap. Up to this point theoretically the port
had not been opened, but the steam had been blowing into the
cylinder or out of it, as the case might be, through these enormous
cracks; the valves then rotated further to produce the opening
movement, for either admission or release; the rotation was then
reversed until it reached its original position, then the fourth
movement brought it to its seat. It is probable that the ship would
have gone to sea working steam after this ridiculous fashion, if the
complicated mechanism required to produce the four movements
had not broken down at the trial of the engines at the dock, beyond
the power of Mr. Allen’s genius to remedy; so the valves had to be
removed and the Stevens valves and Sickels cut-off were substituted
for them. The story that any sane man ever designed a four-motion
steam-engine valve, and that he made the first application of it on
the largest steamship, except the Great Eastern, then in the world, is
such a tax on credulity, that I was glad to find the following
corroboration of it in a letter to “Power,” from which I copy the
essential portion.
Emil Brugsch
“In one of Mr. Porter’s ‘Reminiscences,’ which I have mislaid, he gives an

account of the alterations to the last steamer of the E. K. Collins lines, the
‘Adriatic.’ His description of Horatio Allen’s cock-valves and their motions is
absolutely correct. The writer made the greater part of the detail drawings by which
the new valves and the Sickels cut-off were placed on the ‘Adriatic.’
Peter Van Brock.
Jefferson, Iowa.”
These engines, as further designed by Mr. Allen, were afterwards

described by Zerah Colburn in the London Engineer in his usual
caustic style. His description began with this expression: “These
engines are fearfully and wonderfully made.”
I had hoped that my old friend Daniel Kinnear Clark might turn up
as the English member in our group of judges at the Centennial
Exposition, but in this I was disappointed. The English judge in our
group was Mr. Barlow, son of the celebrated author of “A Treatise on
the Strength of Materials,” which, if I remember rightly, was the first
authoritative treatise on that subject. Mr. Barlow, however, was not of
much help to us; he came late and attended but one meeting. That, I
remember very well, was the meeting at which I presented my
classification. He left Philadelphia with his son to visit Niagara Falls,
and we never saw him again. I remember his giving me a very
cordial invitation to visit him when I should find myself in England.
Two of my English engineering acquaintances appeared at this
exhibition. One of them was a judge in the group which embraced
sewing machines. I remember asking him what was the most
interesting mechanical device he had seen at the exhibition; he told
me it was the automatic tension in the Wilcox & Gibbs sewing
machine. In a walk with him through Machinery Hall one day, I called
his attention to a locomotive built by the Baldwin Locomotive Works.
After looking it over cursorily he remarked that he did not see
anything particular in it. I could not help replying, “That may not be
the fault of the locomotive.” I had thought him a light weight in
England, and that superficial remark confirmed my opinion. The
other friend, as I am proud to call him, I have always considered
mechanically the most interesting man I ever met. It was Mr. Smith,
of Smith & Coventry, the machine-tool builders of Salford. Mr. Smith
was the brains of the concern. He had come over to learn what
America could teach him, and the only thing he took back, so far as I
know, was the twist-drill, the manufacture of which was begun by
that firm after his return. I shall have something to add later to what I
have already said respecting his wonderful improvements in
machine tools. In one of the pleasant walks we took together, our
attention was arrested by the exhibit of Riehlé Brothers, the
celebrated scale manufacturers of Philadelphia. Among other novel
and interesting features of their exhibit this firm showed a ³⁄₄-inch
bolt broken by a stress applied to it through a nut of only one half the
standard thickness, or three eighths of an inch deep, and that run on
loosely by hand. This astonishing revelation drew from Mr. Smith the
ejaculation, “Why, old Whitworth lied.” Mr. Whitworth had stated that
he had ascertained by experiment that a nut to be as strong as the
bolt must have a depth equal to the diameter of the bolt, and this had
been accepted as mechanical truth by the entire engineering world,
no one ever thinking to make the simple measurement which would
show that the force required to strip the threads of any bolt in a nut of
this standard depth would be nearly three times the strength of the
bolt. He was, of course, highly interested in the wonderful steelyards
made by this firm, which would weigh anything that could be lifted by
a crane. His only discovery respecting machine tools was, that their
manufacture in the United States was generally very inferior.
It was fortunate that I had prepared the drawings according to my
revised model for three or four sizes of the engines, as otherwise I
should not have been able to accept the position offered me at the
Philadelphia exposition. I received two more orders before May 24,
and two more during the summer, but with the preparations I had
made and Mr. Goodfellow’s familiarity with the work, everything went
on smoothly during my absence.
CHAPTER XXIV
Engine Building in Newark. Introduction of Harris Tabor.
fter my return from Philadelphia the first order I

received was a very important one. On the advice of
Mr. Holley, the Albany and Rensselaer Iron and Steel
Co. of Troy, N. Y., decided to order from me two
engines for the new roll trains they were about to
establish; this being the first opportunity I had of
applying my engine in what proved to be its most important field.
These were a 22×36-inch engine to drive a 16-inch train for rolling
light steel rails, and an 18×30-inch engine to drive an 8- or 10-inch
train for rolling merchant steel. These engines did not run rapidly; the
first was a direct-connected engine making only 75 revolutions per
minute; the second made only 112 revolutions per minute, but was
belted to drive the train at twice that speed.
Mr. Corning, president of the company, did not like the slow way in
which the rails were turned out of the former train. I happened to be
standing with him observing this work when he asked a boy why the
billets were not fed to the rolls faster. The boy replied, “Because the
gentlemen at the hooks could not catch them, sir.” Where are the
gentlemen at the hooks to-day, when rails 200 feet long are turned
out of the rolls?
These engines stood near each other, the trains extending in
opposite directions. The battery of boilers was located at a
considerable distance from them. I set between them a vertical
steam receiver, four feet in diameter and twelve feet high. This
receiver performed two functions: it maintained the steam pressure
at the cylinders and separated the steam from the water carried over.
This latter was accomplished by admitting the steam at the top of the
receiver by a pipe extending two thirds of the way to the bottom,
draining the water from the bottom by means of a Nason steam trap,
and taking the dry steam to the engine from the top of the receiver.
This was my first application of this method, which afterwards proved
most valuable in cases of greater importance. These engines were
of the highest interest to me, as their successful running opened the
door to that important field.
While they were still lying on the floor of the shop ready for
shipment, I had an opportunity of submitting them to the criticism of
William R. Jones, the manager of the Edgar Thompson Steel Works,
to whom, as already related, I had sold a small engine and
governors for his large ones. I had not made these engines properly
in one respect, as he pointed out to me that, for rolling-mill uses,
they must be made capable of being run backwards by hand from
any position, a requirement of which I had been ignorant. I soon
made the necessary additions to the valve-gear which enabled this
to be done. I never knew how Mr. Jones came to make this
opportune visit, but undoubtedly Mr. Holley sent him.
I had another visitor before these engines were shipped. It was the
manager of the Laclede rolling mill at St. Louis, accompanied by his
engineer. They had designed a system of driving several trains of
rolls from one engine, the power of which was to be transmitted
through gearing. They were greatly fascinated by the appearance of
the engines, and gave me an order for a large engine on the spot.
This engine afforded me a curious experience. When it was
started, teeth were broken out of the gear at the very first revolution,
and I received a telegram from them telling me of this misfortune and
that I must come to St. Louis immediately and see what was the
trouble with the engine. I was too busy to go myself, but Mr. Phillips
kindly permitted his engineer, Mr. Collins, to go in my place. Mr.
Collins took with him everything necessary to expose the defect,
whatever it might be, which we expected would be found in the
gearing. Among other things he had the pattern-maker prepare for
him two or three short pieces of lath about two inches wide and one
eighth of an inch thick; these latter proved to be all that he needed.
On his arrival the proprietors assured him there could be no fault
with the gearing, for they had it made by the most eminent
engineering firm in St. Louis. The members of this firm showed him
triumphantly the broken pieces and directed his attention to the
perfect soundness of the metal, as proved by the fractured surfaces.
His first experiment was to whittle an end of one piece of lath to fit
exactly between two teeth of a wheel at one end of the space. To his
amazement he found that this templet would not fit in any other
space around the whole wheel, every one was in some degree or
other too large or too small; neither would the templet fit in the
opposite end of the same space. This one experiment settled the
matter; the engine, to be sure, had broken the gears, because the
larger teeth of the driving-wheels had wedged into the smaller
spaces of the driven wheels. How such work could be produced was
a puzzle to Mr. Collins; as for myself, I have never wondered at any
imperfection in gearing since my experience with Mr. Whitworth’s
work. The owners of the rolling mill applied for advice to Samuel T.
Wellman, the manager of the Otis Steel Works at Cleveland. He
gave them the sensible advice to abandon altogether the plan of
driving through gearing, and to drive each train by a separate
engine, directly connected, which my high-speed engine would
enable them to do. This was the first I heard of Mr. Wellman, with
whom I was afterwards to have such pleasant relations.
While on the subject of gearing I will state a couple of incidents.
One of my first small engines I sold to Mr. Albright of Newark, a
harness-maker. Half of the power of the engine was to be
transmitted to an adjoining building driving a vertical shaft through a
pair of miter gears. It was required that these should run noiselessly,
which at 350 revolutions per minute seemed a difficult thing to
accomplish. I had the gears cut in the best gear cutter I knew of, and
fitted them to run in a lathe, the spindle of the driven gear running in
a frame made for the purpose, and being provided with a friction
wheel and brake. To make sure that the same teeth and spaces
should always come together, I made a prick-punch mark on one
tooth and behind the corresponding space. When started at 350
revolutions they rattled finely. The resistance of the friction brake
was sufficient to make the points of contact on the teeth mark
themselves well in 15 minutes’ running. I then took them down and
carefully removed the bright spots on the surface with a scraper. The
next time the noise was more than half gone, and four successive
scrapings by a skillful workman cured it entirely. There is this
encouragement in correcting gearing, that its subsequent running
always tends to improve the truth of the surfaces; they wear to a
more general contact.
One day I had a letter from Mr. Barclay, the miller for whom I had
made my first engine in Harlem, and which I arranged to drive his
millstones by belting. He told me he had moved his mill from
Harrison Street to a building on North Moore Street, New York, and
he found there was something the matter with the engine. (In these
cases there is always something the matter with the engine.) It used
to drive three runs of stones, now it would only drive two, and he
burned a great deal more coal than before. He wanted me to come
and see what the matter was. The moment I opened the door of his
mill I knew what the matter was. I heard the roar of rough gearing
and was pretty mad. I told him I hoped he liked that music, for it cost
him more than half the coal he was burning to keep it up. I gave him
a sharp piece of my mind for changing the system of driving from
that which I had provided without consulting me on the subject. I told
him when he threw out his gearing and put the pulleys and belts
back just as I made them, he would find the engine would give him
the same power that it had done for five or six years in its old
location.
Robert W. Hunt
In the first engines which I built in Newark the governor had a
more or less uncomfortable action. This annoyed me exceedingly. It
did not sensibly affect the running of the engine, but was a drawback
to the appearance of the engine in motion. I was utterly at a loss how
to account for it, so I finally determined I would solve the problem by
a comparison of two engines of the same size. One of these was the
smaller engine for the rolling mill at Troy, where the action of the
governor was quite satisfactory; the other was an engine I had made
for the Newark Lime and Cement Company, in which the action of
the governor was very unsatisfactory. After some weeks of
comparison I gave the problem up: I could get no light on the
subject. Soon after I had occasion to go to Troy and found my
smaller engine running at double its former speed or at 224
revolutions per minute. Mr. Robert W. Hunt, the general
superintendent, informed me that they planned to employ this speed
when rolling steel to finish at very small sizes, which they were then
doing for the first time. The action of the governor which had before
been so perfect was now most abominable; the counterpoise flying
up and down furiously between the extreme points of its action. I told
Mr. Hunt that something was hindering the action of the governor,
and asked him if he would have an examination made and let me
know what he found. A few days after I received a letter from him
saying he had found nothing at all, but he added that that order had
been completed and the engine was running at its old speed, and
the governor was working as well as ever. In an instant the truth
flashed upon me; it was the inertia of those polished cast-iron disks
on the rocker-shaft which I had thought so much of that caused all
the trouble. This inertia, increasing as the square of the speed, had
offered four times the resistance to the reversing of their motion
when the speed of the engine was doubled, and the pressure of the
link which was necessary to overcome this resistance held the block
fast. The governor could not move it until it had accumulated
sufficient force by change of its speed; then it moved it too far, and
so it was kept in constant violent motion from one end to the other of
its range of action. I was thoroughly ashamed of myself that when I
had made the subject of inertia a study for years this action should
have been going on so long, the most prominent thing before my
eyes, and I never saw it. I had use enough at once for my new
insight as will appear.
The Gautier steel works, which had been located in Jersey City,
were removing to Johnstown, Penn., having formed an alliance with
the Cambria Iron and Steel Company. Mr. Stephen W. Baldwin, then
manager of the Gautier Company, had given me an order for an
engine suitable for driving at 230 revolutions per minute their ten-
inch train, or it may have been an eight-inch. I went to Jersey City
and made a careful measurement of the indicated power required to
drive this train. The engine used was rather a large one, with a large
and heavy fly-wheel running at slow speed and driving the train at
this rapid speed by means of a belt. I found that my 10-inch by 20-
inch engine directly connected with the train would, at 230
revolutions per minute, be capable of furnishing twice the power they
were then using. I built an engine of that size with a fly-wheel about 8
feet in diameter, shipped it to Johnstown, and sent George Garraty,
my most trusty erecter, to set it up. I should say that Mr. Baldwin had
meantime severed his connection with the Gautier Steel Company,
and it was then in the hands of parties who were strangers to my
engines. I received a letter from Garraty stating that on his arrival he
had found them just about to send the engine back; everybody about
the works had agreed that a man who sent that little engine to drive
that train to roll steel was a fool. At his solicitation they promised to
do nothing until they should hear from me. I then wrote to the
president, Mr. Douglas, stating I had carefully measured the utmost
power which that train had required at Jersey City, and had furnished
an engine capable of supplying double that power with ease, and I
was sure he would run no risk in setting it up. This he consented to
do. While Garraty was erecting the engine they were making
preparations in the mill to stall it if possible. There was great
excitement when it was started; the furnace men worked like
beavers and succeeded in feeding billets to the train twice as rapidly
as ever before, but they could not bring down its speed in the least.
Finally they lowered the steam pressure, but the engine did not stop
until they had brought this down to 40 pounds. Then a great shout
went up, not for themselves but for the engine, which had shown
itself capable of doubling the output of that train, and telegrams were
hurried off to the stockholders of the concern in New York and
Philadelphia to relieve their anxiety. Garraty left that night and
reported himself to me the following morning. After giving an account
of the success of the engine he added: “But the governor is working
very badly; they have not noticed it yet as they have thought only of
the running of the train, but they will.” By a remarkable coincidence I
had that very morning received the letter from Mr. Hunt which had
opened my eyes to the cause of this bad action; the day before I
could not have understood it.
Stephen W. Baldwin
Within twenty-four hours after my interview with Garraty I had

started for Johnstown, carrying with me two light steel levers to
replace those disks. In that time I had made the drawings and had
the levers forged and finished, joint-pins set and keyways cut,
perfect duplicates of the disks in all their working features. When I
told my purpose to Mr. Douglas he smiled and said for the life of him
he could not see what disks on the rocker-shaft had to do with the
governor action. However, they had not yet started their night shift,
so I might have the engine after 6 o’clock, but it must be ready for
use at 6 o’clock the next morning. I told him that as the change
would probably occupy me less than an hour, I thought I might safely
assure him on that point. I engaged a machinist with the engineer to
help me at 7 o’clock in the evening and amused myself the rest of
the day about the mill. The furious governor action was so irritating I
did not stay long in the engine-room. In the evening we had the disks
off and the levers on and all connected up, ran the engine idle for a
few minutes to see that all was right and I was back in my hotel
within the hour, which illustrated the advantage of working to gauges.
I had taken off 29 pounds weight, that being the difference between
the weight of the disks and the levers. Next morning I went down to
see the effect of this change. It seemed magical. The governor
appeared to have gone to sleep, it was not taking any interest in the
activity about it; the counterpoise stood at about the middle of its
range of action, only moving lazily a short distance up or down
occasionally. After calling Mr. Douglas in to see what disks on the
rocker-shaft, with their motion reversed 460 times a minute, had to
do with the governor action, and hearing his expressions of
admiration, I took the next train home. As might be supposed I was
not long in eliminating all traces of this blunder from drawings and
from engines already made.
I had an order from John W. Hyatt of Newark for a 6×12-inch
engine to make 450 revolutions per minute, to drive an attrition mill
running at 900 revolutions per minute, in which he pulverized bones
to dust for manufacturing artificial ivory. This was the highest number
of revolutions per minute that I had ever employed, and perhaps it
was the most absolutely silent running engine that I ever made. Not
long after its completion I had a call from a young gentleman who
introduced himself to me as Harris Tabor. He told me he had
invented a steam-engine indicator which he thought would be
superior to the Richards indicator, as the pencil movement was very
much lighter and would draw a straight vertical line. He said he
called in the hope that I might give him an opportunity to test his
indicator on a very high-speed engine. I told him I thought I could do
just what he wanted. I took him down to Mr. Hyatt’s place where the
engine was running with the indicator rig on it which I had been
using; he was, of course, greatly pleased with this remarkable
opportunity. He took a number of diagrams with his indicator, and
they proved to be quite free from the vibrations which were produced
by the Richards indicator at the same speed. I gave him a certificate
that these diagrams had been taken by his indicator from a Porter-
Allen engine at a speed of 450 revolutions per minute. With these he
started for Boston to see Mr. Ashcroft. With the result of that
interview the engineering world is familiar. To my great regret not one
of the diagrams taken at that time has been preserved either by Mr.
Tabor, Mr. Ashcroft or myself, an omission that none of us can
account for. The Hyatt plant was afterwards, I understood, removed
to Albany, N. Y.
I had a singular experience with another 6×12-inch engine which I
sold to William A. Sweet, elder brother of Prof. John E. Sweet, for
use in his spring manufactory in Syracuse, N. Y. Mr. Sweet had two
batteries of boilers set at some distance from each other and at
different elevations; these were connected by a pipe which was
necessarily inclined. About the middle of the length of this pipe a
stop-valve had been introduced, and when this valve was shut the
pipe in the upper end of it was, of course, partly filled with water. My
engine received its steam from the bottom of this pipe below the
stop-valve. The boilers at the lower end were one day overloaded,
and while I happened to be present Mr. Sweet himself opened the
stop-valve for the purpose of getting an additional supply of steam
from the upper battery, but he did not get it. What he did get was a
charge of solid water, which brought my engine to an instantaneous
stop from a speed of 350 revolutions per minute. I was standing near
the engine and saw shooting out from the joint of the back cylinder
head a sheet of water, which at the top struck the roof of the building.
On examination it was found that the steel key of the fly-wheel had
been driven into the wrought-iron shaft almost half an inch and the
shaft was bent. The engine suffered no other injury; the bolts of the
cylinder head had not been strained to their elastic limit, and the nuts
did not require to be tightened. The shaft was straightened, new key-
seats were cut for the fly-wheel, and the engine worked as well as
ever—a pretty good proof of its general strength.

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AACN Essentials of Progressive Care

Nursing, 5e (Sep 22,

Sarah A. Delgado, MSN, RN, ACNP

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eBook conversion by codeMantra

Library of Congress Control Number: 2023936310

Section I. The Essentials........................................................................................................................................................................................................................................ 1

Section II. Pathologic Conditions..................................................................................................................................................................................................................... 217

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13. Hematologic and Immune Systems................................................................................................................................................. 337

Section III. Advanced Concepts........................................................................................................................................................................................................................ 443

Section IV. Key Reference Information............................................................................................................................................................................................................. 543

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Section I. The Essentials........................................................................................................................................................................................................................................ 1

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Tissue Perfusion Markers 91

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Special Considerations For Pain Management In Older Adults 153

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Section II. Pathologic Conditions..................................................................................................................................................................................................................... 217

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Diagnostic Testing 319

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Magnesium Imbalance: Hypermagnesemia 394 / Magnesium Imbalance: Hypomagnesemia 394 /

Section III. Advanced Concepts........................................................................................................................................................................................................................ 443

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Cardiac Pacemakers 482

Section IV. Key Reference Information............................................................................................................................................................................................................. 543

Index .................................................................................................................................................................................................................................................................... 559

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ESSENTIAL CONTENT CASE

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Body System History Questions

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TABLE 1-8. PHYSIOLOGIC EFFECTS OF AGING

Body System Effects

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Coping Styles they have an advance directive, a durable power of attorney

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PRINCIPLES OF MANAGEMENT American Association of Critical-Care Nurses. Practice Alert:

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Patient Characteristics Description