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Test Bank for Introduction to Critical Care Nursing, 5th Edition: Mary Lou Sole

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Test Bank for Introduction to Critical Care Nursing, 5th Edition: Mary Lou Sole

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ISBN-10 ‏ : ‎ 1416056564
ISBN-13 ‏ : ‎ 978-1416056560
Author: Sole

Here’s the essential information you need to know in critical care nursing ― all in one concise text! Using a to-the-point, reader friendly approach, Introduction to Critical Care Nursing, 5th Edition, provides authoritative, real-world information on the important concepts of critical care nursing and the assessment and technical skills associated with the management of critically ill patients. The latest content on the technology makes it easy to learn and understand how to use the equipment you’ll use in the field. Nursing care chapters are organized according to the nursing process framework, and you’ll find detailed nursing care plans in every management chapter. Case studies and critical thinking questions challenge you to apply what you’ve learned, and user-friendly features throughout the text (updated pharmacology tables, clinical and laboratory alerts, and evidence-based practice boxes) help you bridge the gap between concepts and clinical practice.

Table contents:

Part I Fundamental Concepts
CHAPTER 1 Overview of Critical Care Nursing
DEFINITION OF CRITICAL CARE NURSING
EVOLUTION OF CRITICAL CARE
PROFESSIONAL ORGANIZATIONS
American Association of Critical-Care Nurses
BOX 1-1 Role of the Critical Care Nurse as Patient Advocate
BOX 1-2 Desired Competencies of Nurses Caring for the Critically Ill
Society of Critical Care Medicine
Other Professional Organizations
CERTIFICATION
STANDARDS
BOX 1-3 Standards of Critical Care Professional Practice
TRENDS AND ISSUES
BOX 1-4 Examples of Patient Safety Goals
BOX 1-5 Interventions to Reduce Harm and Prevent Injury
BOX 1-6 Items to Consider in Daily Multidisciplinary Rounds
SUMMARY
CRITICAL THINKING QUESTIONS
REFERENCES
CHAPTER 2 The Critical Care Experience
INTRODUCTION
THE CRITICAL CARE ENVIRONMENT
TABLE 2-1 Noise Levels Associated with Patient Care Devices and Activities
Critical Care Culture
Communication
BOX 2-1 Elements of the Healthy Work Environment Initiative
FIGURE 2-1 Interdependence of healthy work environment, clinical excellence, and optimal patient outcomes.
BOX 2-2 Barriers to Effective Handoff Communication
Communication Techniques from Industry: Crew Resource Management
BOX 2-3 Situation, Background, Assessment, Recommendation (SBAR)
Collaboration
THE CRITICALLY ILL PATIENT
BOX 2-4 Patients’ Recollection of the Critical Care Experience
Cultural Considerations
TABLE 2-2 Cultural Considerations
Discharge from Critical Care and Quality of Life after Critical Care
Geriatric Concerns
FAMILY MEMBERS OF THE CRITICALLY ILL PATIENT
EVIDENCE-BASED PRACTICE
PROBLEM
QUESTION
REFERENCE
EVIDENCE
DECISION MAKING
FAMILY COPING
STAFF STRESS
CULTURAL SUPPORT OF FAMILY
SPIRITUAL AND RELIGIOUS SUPPORT
FAMILY VISITATION
FAMILY ENVIRONMENT OF CARE
FAMILY PRESENCE DURING ROUNDS
FAMILY PRESENCE DURING RESUSCITATION
PALLIATIVE CARE
IMPLICATIONS FOR NURSING
Family Assessment
Family Needs
Visitation
Family Presence during Procedures and Resuscitation
BOX 2-5 Benefits of Family Presence
THE CRITICAL CARE NURSE
AACN SYNERGY MODEL FOR PATIENT CARE
TABLE 2-3 American Association of Critical-Care Nurses Synergy Model Nurse Competencies
BOX 2-6 American Association of Critical-Care Nurses Synergy Model Patient Characteristics
SUMMARY
CRITICAL THINKING QUESTIONS
REFERENCES
CHAPTER 3 Ethical and Legal Issues in Critical Care Nursing
INTRODUCTION
ETHICAL OBLIGATIONS AND NURSE ADVOCACY
ETHICAL DECISION MAKING
ETHICAL PRINCIPLES
FIGURE 3-1 The process of ethical decision making.
BOX 3-1 Ethical Principles
Moral Theories
INCREASING NURSES’ INVOLVEMENT IN ETHICAL DECISION MAKING
TABLE 3-1 Moral Theories
BOX 3-2 Situations Where Ethics Consultation May Be Considered
BOX 3-3 Ethics Consultation Services
BOX 3-4 Internet Resources for Bioethics
LEGAL ACCOUNTABILITY IN NURSING
Licensure and Mandatory Education
Criminal Lawsuits
Medical Malpractice
Duty to Treat and Abandonment
SELECTED ETHICAL AND LEGAL ISSUES
Informed Consent
Elements of Informed Consent
Informed Consent of Adolescents
Decisions Regarding Life-Sustaining Treatment
TABLE 3-2 Landmark Legal Cases in the Right-to-Die Debate
BOX 3-5 Definitions in Critical Care Decision Making
Cardiopulmonary Resuscitation Decisions
Withholding or Withdrawal of Life Support
End-of-Life Issues
Patient Self-Determination Act
Advance Directives
Organ and Tissue Transplantation
TABLE 3-3 Organ and Tissue Transplantation
BOX 3-6 Criteria Used to Determine Brain Death*
Ethical Concerns Surrounding Transplantation
CASE STUDY
QUESTIONS
SUMMARY
CRITICAL THINKING QUESTIONS
REFERENCES
CHAPTER 4 End-of-Life Care in the Critical Care Unit
INTRODUCTION
ETHICAL AND LEGAL CONCERNS
BOX 4-1 Definition of Medical Futility
Effects on Nurses and the Health Care Team
DIMENSIONS OF END-OF-LIFE CARE
Palliative Care
Communication and Conflict Resolution
Withholding, Limiting, or Withdrawing Therapy
BOX 4-2 Guidelines for Effective Communication to Facilitate End-of-Life Care
BOX 4-3 Ethical Principles for Withholding and Withdrawing Life-Sustaining Treatment
Ventilator Withdrawal
CLINICAL ALERT
Ventilator Withdrawal
Other Commonly Withheld Therapies
Emotional and Psychological Care of the Patient/Family
FIGURE 4-1 Guidelines for pharmacological interventions during withdrawal of life support.
EVIDENCE-BASED PRACTICE
PROBLEM
QUESTIONS
REFERENCE
EVIDENCE
IMPLICATIONS FOR NURSING
Caregiver Organizational Support
BOX 4-4 Nursing Interventions to Support Care at the End of Life
CULTURALLY COMPETENT END-OF-LIFE CARE
BOX 4-5 End-of-Life Online Resources
CASE STUDY
QUESTIONS
SUMMARY
CRITICAL THINKING QUESTIONS
REFERENCES
Part II Tools for the Critical Care Nurse
CHAPTER 5 Comfort and Sedation
INTRODUCTION
DEFINITIONS OF PAIN AND ANXIETY
FIGURE 5-1 The anxiety-pain cycle.
Box 5-1 Gate Control Theory of Pain
PREDISPOSING FACTORS TO PAIN AND ANXIETY
PHYSIOLOGY OF PAIN AND ANXIETY
Pain
TABLE 5-1 Physiological Responses to Pain and/or Anxiety
FIGURE 5-2 Transmission of pain signals into the brainstem, thalamus, and cerebral cortex by way of the “fast” pain pathway and “slow” pain pathway.
TABLE 5-2 Neuroimaging Studies
Anxiety
POSITIVE EFFECTS OF PAIN AND ANXIETY
NEGATIVE EFFECTS OF PAIN AND ANXIETY
Physical Effects
Psychological Effects
ASSESSMENT
Pain Measurement Tools
Pain Measurement Tools for Nonverbal Patients
Adult Behavioral Pain Tools
FIGURE 5-3 A version of the FACES scale.
FIGURE 5-4 The Visual Analog Scale.
TABLE 5-3 The Behavioral Pain Scale*
Pediatric Pain Tools
TABLE 5-4 Critical-Care Pain Observation Tool
TABLE 5-5 The FLACC Scale
Anxiety and Sedation Measurement Tools
Sedation Scales
Continuous Monitoring of Sedation
TABLE 5-6 Richmond Agitation-Sedation Scale
FIGURE 5-5 The Bispectral Index (BIS) monitor and electrode.
TABLE 5-7 The Ramsay Sedation Scale
TABLE 5-8 Sedation-Agitation Scale
PAIN AND ANXIETY ASSESSMENT CHALLENGES
Delirium
TABLE 5-9 Clinical Subtypes of Delirium
TABLE 5-10 Risk Factors for Delirium
BOX 5-2 The Confusion Assessment Method for the Critical Care Unit
Neuromuscular Blockade
EVIDENCE-BASED PRACTICE
PROBLEM
QUESTIONS
REFERENCE
EVIDENCE
IMPLICATIONS FOR NURSING
FIGURE 5-6 A train-of-four peripheral nerve stimulator.
BOX 5-3 Nursing Care of the Patient Receiving Neuromuscular Blockade
MANAGEMENT OF PAIN AND ANXIETY
Nonpharmacological Management
Environmental Manipulation
TABLE 5-11 PHARMACOLOGY Drugs Frequently Used in the Treatment of Anxiety, Pain, or for Neuromuscular Blockade*
Guided Imagery
Music Therapy
Pharmacological Management
Opioids
CLINICAL ALERT
Cautions in Use of Cyclooxygenase-2 (COX-2) Inhibitors and NSAIDs
FIGURE 5-7 A patient-controlled analgesia infusion pump.
Patient-Controlled Analgesia
BOX 5-4 Typical Patient Criteria for Patient-Controlled Analgesia Therapy
Epidural Analgesia
BOX 5-5 Potential Benefits of Epidural Analgesia
Nonsteroidal Antiinflammatory Drugs
Sedative Agents
Tolerance and Withdrawal
MANAGEMENT CHALLENGES
Invasive Procedures
FIGURE 5-8 Sample algorithm of sedation guidelines.
Substance Abuse
FIGURE 5-9 The Cleveland Clinic Foundation Procedural Sedation Record: Nursing Assessment Page.
Restraining Devices
Effects of Aging
TABLE 5-12 Common Restraining Devices
GERIATRIC CONSIDERATIONS
CASE STUDY
QUESTIONS
SUMMARY
CRITICAL THINKING QUESTIONS
REFERENCES
CHAPTER 6 Nutritional Support
INTRODUCTION
GASTROINTESTINAL TRACT
UTILIZATION OF NUTRIENTS
ASSESSMENT OF NUTRITIONAL STATUS
GERIATRIC CONSIDERATIONS
OVERVIEW OF NUTRITIONAL SUPPORT
Enteral Nutrition
Parenteral Nutrition
EVIDENCE-BASED PRACTICE
PROBLEM
QUESTION
REFERENCE
EVIDENCE
IMPLICATIONS FOR NURSING
Nutritional Additives
NUTRITIONAL THERAPY GOAL
TABLE 6-1 Components of Immune-Enhancing Formulas
TABLE 6-2 Estimation of Nutrient Needs
TABLE 6-3 Enteral Formulas
PRACTICE GUIDELINES
Enteral Nutrition
Parenteral Nutrition
Drug-Nutrient Interactions
Monitoring Nutritional Status and Monitoring for Complications
TABLE 6-4 Tube Feeding Complications and Nursing Interventions
CLINICAL ALERT
Assessment of Feeding Tube Placement
LABORATORY ALERT
MONITORING AND EVALUATING THE NUTRITION CARE PLAN
CASE STUDY
QUESTIONS
SUMMARY
CRITICAL THINKING QUESTIONS
REFERENCES
CHAPTER 7 Dysrhythmia Interpretation and Management
INTRODUCTION
BASIC ELECTROPHYSIOLOGY
Automaticity
The Cardiac Cycle
Cardiac Action Potential
FIGURE 7-1 Cardiac action potential with the electrocardiogram and movement of electrolytes. ATP, Adenosine triphosphate; Ca, calcium; K, potassium; Na, sodium.
Relationship Between Electrical Activity and Muscular Contraction
PHARMACOLOGY TABLE 7-1 Antidysrhythmic Drug Classifications
CLINICAL ALERT
Antidysrhythmic Drugs
Normal Cardiac Conduction Pathway
FIGURE 7-2 The electrical conduction system of the heart. Arrows indicate direction of electrical currents. The ECG represents the net sum of these currents. RA, Right atrium; RV, right ventricle; LA, left atrium; LV, left ventricle.
THE 12-LEAD ELECTROCARDIOGRAPHY SYSTEM
Standard Limb Leads
Augmented Limb Leads
FIGURE 7-3 Orientation of leads I, II, and III. Lead I records the difference in electrical potentials between the left arm and right arm. Lead II records it between the left leg and right arm. Lead III records it between the left leg and left arm.
FIGURE 7-4 A, Einthoven’s triangle. B, The triangle is converted to a triaxial diagram by shifting leads I, II, III that they intersect at a common point.
FIGURE 7-5 Triaxial lead diagram showing the relationship of the three augmented (unipolar) leads aVR, aVL, and aVF. Notice that each lead is represented by an axis with a positive and negative pole. The term unipolar was used to mean that the leads record the voltage in one location relative to about zero potential instead of relative to the voltage in one other extremity.
Precordial Leads
FIGURE 7-6 The precordial leads. The positive poles of the chest leads point anteriorly and the negative poles (dashed lines) point posteriorly.
FIGURE 7-7 Limb leads and V1 electrode placement and their respective waveforms: A, Lead I; B, lead II; C, lead III; and D, lead V1.
Continuous Cardiac Monitoring
TABLE 7-2 Recommended Electrocardiographic Monitoring Leads for Specific Clinical Incidents
FIGURE 7-8 Lead placement when using a five-lead cable. The chest lead is shown in the V1 position.
TABLE 7-3 Indications for Cardiac Dysrhythmia Monitoring3
ANALYZING THE BASIC ELECTROCARDIOGRAPHIC TRACING
Measurements
FIGURE 7-9 The ECG is usually recorded on a graph divided into millimeter squares, with darker lines marking 5-mm squares. Time is measured on the horizontal axis. With a paper speed of 25 mm/sec, each small (1-mm) box side equals 0.04 second and each larger (5-mm) box side equals 0.2 second. The amplitude of any wave is measured in millimeters on vertical axis.
Waveforms and Intervals
P Wave
FIGURE 7-10 The P wave represents atrial depolarization. The PR interval is the time from initial stimulation of the atria to initial stimulation of the ventricles. The QRS represents ventricular depolarization. The ST segment, T wave, and U wave are produced by ventricular depolarization.
PR Interval
QRS Complex
FIGURE 7-11 A, A positive complex is seen in any lead if the wave of depolarization spreads toward the positive pole of the lead. B, A negative complex is seen if the depolarization wave spreads toward the negative pole (away from the positive pole) of the lead. C, A biphasic (partly positive, partly negative) complex is seen if the mean direction of the wave is at right angles. These apply to the P wave, QRS, and T wave.
FIGURE 7-12 Different types of QRS complexes. An R wave is a positive waveform. A negative deflection before the R wave is a Q wave. The S wave is a negative deflection after the R wave. If the waveform is tall or deep, the letter naming the waveform is a capital letter. If the waveform is small in either direction, the waveform is labeled with a lower case letter.
QRS Interval
FIGURE 7-13 Pathological Q wave (abnormal Q wave) 0.04 seconds wide and at least one fourth the height of the R wave.
T Wave
ST Segment
QT Interval
FIGURE 7-14 A, Step-by-step sequence of ventricular depolarization in right bundle branch block. B, The sequence of ventricular depolarization in left bundle branch block produces a wide QS complex in lead V1 and a wide R wave in lead V6. LV, Left ventricle; RV, right ventricle.
CLINICAL ALERT
ST Segment Monitoring Practice for Ischemia2
FIGURE 7-15 Abnormal QT interval prolongation in patient taking quinidine. The QT interval (0.6 seconds) is markedly prolonged for the heart rate (65/min) and the QT interval is greater than one half the R-R interval.
CLINICAL ALERT
QT Interval and ECG Monitoring for Detection of Proarrhythmias2
Box 7-1 Systematic Approach for Rhythm Interpretation
SYSTEMATIC INTERPRETATION OF DYSRHYTHMIAS
Rhythmicity
FIGURE 7-16 Establishing ventricular rhythmicity with calipers.
FIGURE 7-17 Establishing ventricular rhythmicity with paper and pencil.
Rate
FIGURE 7-18 Calculating ventricular rate with the rule of 1500. Count the number of small boxes between QRS complexes. In this strip there are 15 small squares between QRS complexes; 1500 divided by 15 equals a heart rate of 100.
Waveform Configuration and Location
Configuration
Location
Intervals
Basic Dysrhythmias
Normal Sinus Rhythm
FIGURE 7-19 Normal sinus rhythm. Rhythm strip generated by the AA-700 Rhythm Simulator.
FIGURE 7-20 Sinus tachycardia.
Critical Criteria for Diagnosis of Normal Sinus Rhythm
Hemodynamic Effects.
Dysrhythmias of the Sinoatrial Node
Sinus Tachycardia
Exercise.
Stimulants.
Increased Body Temperature.
Alterations in Fluid Status.
Critical Criteria for Diagnosis of Sinus Tachycardia
Hemodynamic Effects.
Sinus Bradycardia
Bradycardia as a Normal Finding.
Increased Vagal Stimulation.
Drug Effects.
SA Node Ischemia.
Effects of Hypoxemia.
Increased Intracranial Pressure.
Critical Criteria for Diagnosis of Sinus Bradycardia
Hemodynamic Effects.
Box 7-2 Categories of Drugs
Box 7-3 Symptoms of Decreased Cardiac Output
FIGURE 7-21 Sinus bradycardia. Notice the negative P waves and QRS because this is lead aVR.
Sinus Dysrhythmia
Critical Criteria for Diagnosis of Sinus Dysrhythmia
Hemodynamic Effects.
Sinus Pauses and Sinus Arrest
Enhanced Vagal Tone.
FIGURE 7-22 Sinus dysrhythmia. Normally, the heart rate increases slightly with inspiration and decreases slightly with expiration.
FIGURE 7-23 Sinus arrest/sinus exit block. Note the junctional escape beat at the end of the pause.
Coronary Artery Disease.
Effects of Drugs.
Critical Criteria for Diagnosis of Sinus Arrest and Sinus Exit Block
Hemodynamic Effects.
Dysrhythmias of the Atria
Stress.
Electrolyte Imbalances.
Hypoxemia.
Injury to the Atria.
Digitalis Toxicity.
Hypothermia.
Hyperthyroidism.
Alcohol Intoxication.
Pericarditis.
Premature Atrial Contractions
FIGURE 7-24 Premature atrial contractions shown in the fifth and seventh beats. The P wave occurs on the T wave for these premature atrial contractions.
Critical Criteria for Diagnosis of Premature Atrial Contractions
Critical Criteria for Diagnosis of Blocked Premature Atrial Contractions
Hemodynamic Effects.
Atrial Tachycardia
FIGURE 7-25 Compensatory pause. PVC, Premature ventricular contraction.
Box 7-4 Compensatory versus Noncompensatory Pause
FIGURE 7-26 A, The fifth beat is an atrial premature contraction. B, Blocked premature atrial contraction (PAC).
Box 7-5 Supraventricular Tachycardia
FIGURE 7-27 Notice the marked regularity of rhythm in this paroxysmal supraventricular tachycardia (PSVT). The rate is 170 beats per minute.
Critical Criteria for Diagnosis of Atrial Tachycardia
Hemodynamic Effects.
Wolff-Parkinson with Preexcitation Patterns (Figure 7-29)
Wandering Atrial Pacemaker
FIGURE 7-28 A, Normal sinus rhythm. B, With atrial tachycardia (AT), a focus (X) outside the sinoatrial (SA) node fires off automatically at a rapid rate. C, With atrioventricular (AV) nodal reentrant tachycardia (AVNRT), the cardiac stimulus originates as a wave of excitation that spins around the AV nodal (junctional) area. As a result, retrograde P waves may be buried in the QRS or appear immediately before or just after the QRS complex (arrows) because of nearly simultaneous activation of the atria and ventricles. D, A similar type of reentrant (circus movement) mechanism in Wolff-Parkinson-White syndrome. This mechanism is referred to as atrioventricular reentrant tachycardia (AVRT). Note the P wave in lead II somewhat after the QRS complex.
Critical Criteria for Diagnosis of Wandering Atrial Pacemaker
Hemodynamic Effects.
Multifocal Atrial Tachycardia
FIGURE 7-29 Preexcitation via the bypass tract in the Wolff-Parkinson White (WPW) pattern is associated with a triad finding.
FIGURE 7-30 Wandering atrial pacemaker. Note the varying P-wave morphologies.
Critical Criteria for Diagnosis of Multifocal Atrial Tachycardia
Hemodynamic Effects.
Atrial Flutter
FIGURE 7-31 Multifocal atrial tachycardia.
Critical Criteria for Diagnosis of Atrial Flutter
Hemodynamic Effects.
Atrial Fibrillation
FIGURE 7-32 Atrial flutter with a fixed degree of block. Note the sawtooth configuration and the negative orientation of the flutter waves. Rhythm generated by the AA-700 Rhythm Simulator.
FIGURE 7-33 Atrial flutter with varying degrees of block.
FIGURE 7-34 Atrial fibrillation.
FIGURE 7-35 Aberrancy is most likely to result when the right bundle branch blocks. The impulse must depolarize the left side of the heart first. The impulse then crosses the septum and abnormally depolarizes the right side of the heart. This results in a widened QRS complex.
EVIDENCE-BASED PRACTICE
PROBLEM
REFERENCE
QUESTION
EVIDENCE
IMPLICATIONS FOR NURSING
Critical Criteria for Diagnosis of Atrial Fibrillation
FIGURE 7-36 Atrial fibrillation. Note Ashman’s beat, following a long-short cycle.
CLINICAL ALERT
Hemodynamic Effects.
Dysrhythmias of the Atrioventricular Node
Junctional Rhythm
P-Wave Changes.
FIGURE 7-37 Junctional (nodal) rhythm. Note absence of P waves.
FIGURE 7-38 Junctional (nodal) rhythm. Note the inverted P wave and the shortened PR interval.
FIGURE 7-39 Junctional (nodal) rhythm. Note the P waves after the QRS complex.
Critical Criteria for Diagnosis of Junctional Rhythm
Hemodynamic Effects.
Accelerated Junctional Rhythm and Junctional Tachycardia
Critical Criteria for Diagnosis of Accelerated Junctional and Junctional Tachycardia
Hemodynamic Effects.
Premature Junctional Contractions
FIGURE 7-40 Junctional tachycardia. Note the short PR interval and heart rate of 70 beats per minute. Rhythm generated by the AA-700 Rhythm Simulator.
FIGURE 7-41 Premature junctional contractions. A, Third beat with a shortened PR interval and an inverted P wave. B, Fourth beat, no P waves visible. C, Third beat with a retrograde P wave.
Critical Criteria for Diagnosis of Premature Junctional Contractions
Hemodynamic Effects.
Dysrhythmias of the Ventricle
FIGURE 7-42 Unifocal premature ventricular contractions.
Myocardial Ischemia, Injury, and Infarction.
Hypokalemia.
Hypomagnesemia.
Hypoxemia.
Acid-Base Imbalances.
Premature Ventricular Contractions
FIGURE 7-43 Multifocal premature ventricular contractions. Note the compensatory pause.
FIGURE 7-44 Premature ventricular contractions in a bigeminal pattern. Rhythm strip generated by the AA-700 Rhythm Simulator.
FIGURE 7-45 Two premature ventricular contractions in a row (pair).
FIGURE 7-46 Three premature ventricular contractions in a row (triplet).
FIGURE 7-47 A, R-on-T phenomenon in a patient with an acute myocardial infarction. B, In the same patient, the R-on-T phenomenon causes ventricular fibrillation.
Critical Criteria for Diagnosis of Premature Ventricular Contractions
Hemodynamic Effects.
Ventricular Tachycardia
FIGURE 7-48 Ventricular tachycardia. Rhythm strip generated by the AA-700 Rhythm Simulator.
Critical Criteria for Diagnosis of Ventricular Tachycardia
Hemodynamic Effects.
Ventricular Fibrillation
Critical Criteria for Diagnosis of Ventricular Fibrillation
Hemodynamic Effects.
Idioventricular Rhythm
FIGURE 7-49 Fine ventricular fibrillation.
FIGURE 7-50 Coarse ventricular fibrillation.
FIGURE 7-51 Idioventricular rhythm.
Critical Criteria for Diagnosis of Idioventricular Rhythm
Hemodynamic Effects.
Accelerated Idioventricular Rhythm
Critical Criteria for Diagnosis of Accelerated Idioventricular Rhythm
Hemodynamic Effects.
FIGURE 7-52 Accelerated idioventricular rhythm.
FIGURE 7-53 Ventricular standstill or asystole.
Ventricular Standstill (Asystole)
Critical Criteria for Diagnosis of Ventricular Standstill (Asystole)
Hemodynamic Effects.
Atrioventricular Blocks
Coronary Artery Disease.
Infectious and Inflammatory Processes.
Enhanced Vagal Tone.
Effects of Drugs.
First-Degree Block
Critical Criteria for the Diagnosis of First-Degree Block
Hemodynamic Effects.
Second-Degree Block
GERIATRIC CONSIDERATIONS
Second-Degree Block Type I: Mobitz I or Wenckebach’s Phenomenon
Critical Criteria for Diagnosis of Second-Degree Block Type I
Hemodynamic Effects.
Second-Degree Block Type II: Mobitz II
FIGURE 7-54 First-degree block. Rhythm strip generated by the AA-700 Rhythm Simulator.
FIGURE 7-55 Second-degree block, Mobitz type I, or Wenckebach’s phenomenon. Note the steadily lengthening PR interval. Rhythm strip generated by the AA-700 Rhythm Simulator.
FIGURE 7-56 Second-degree block, Mobitz type II. Note the fixed PR interval. Rhythm strip generated by the AA-700 Rhythm Simulator.
Critical Criteria for Diagnosis of Second-Degree Block Type II
Hemodynamic Effects.
Third-Degree Block (Complete Heart Block)
Critical Criteria for Diagnosis of Third-Degree Block (Complete Heart Block)
FIGURE 7-57 Third-degree block with ventricular escape. Rhythm strip generated by the AA-700 Rhythm Simulator.
Hemodynamic Effects.
INTERVENTIONS FOR DYSRHYTHMIAS
Tachydysrhythmias
Bradydysrhythmias
ELECTRICAL PACEMAKERS
Rate.
Mode.
Electrical Output.
Sensitivity.
AV Internal.
Pacemaker Rhythms.
Pacemaker Malfunction.
Failure to Pace.
FIGURE 7-58 Paced rhythm: atrial. Note the spike in front of the P wave. Rhythm strip generated by the AA-700 Rhythm Simulator.
FIGURE 7-59 Paced rhythm: ventricular. Note the spike in front of the QRS complex. Rhythm strip generated by the AA-700 Rhythm Simulator.
FIGURE 7-60 Paced rhythm: dual chamber. Note the spikes before the P wave and the QRS complex. Rhythm strip generated by the AA-700 Rhythm Simulator.
Failure to Capture.
Failure to Sense.
FIGURE 7-61 Paced rhythm with failure to capture.
FIGURE 7-62 Paced rhythm with failure to capture (seventh spike) and failure to sense, note arrow (eighth spike).
Biventricular Pacemaker
FIGURE 7-63 Biventricular pacing with wires of the right atrium/ventricle and left ventricle.
FIGURE 7-64 Patient’s actual rhythm (top strip, note the wide QRS). Biventricular pacing of right and left ventricle (bottom strip, note the QRS is not as wide as the top strip).
NURSING CARE PLAN
NURSING DIAGNOSIS
PATIENT OUTCOMES
Maintains optimal cardiac output
CASE STUDY
QUESTIONS
SUMMARY
CRITICAL THINKING QUESTIONS
REFERENCES
CHAPTER 8 Hemodynamic Monitoring
INTRODUCTION
REVIEW OF ANATOMY AND PHYSIOLOGY
Cardiovascular System Structure
Heart
Arteries
Capillaries
FIGURE 8-1 Diagram of the cardiovascular system.
Veins
FIGURE 8-2 Cardiac cycle.
Blood
Principles of Physics
FIGURE 8-3 Relationship between vessel diameter, flow, and resistance. A, Effect of lumen diameter on flow through vessel. d, Diameter. B, Blood flows with great speed in the large arteries. However, branching of arterial vessels increases the total cross-sectional areas of the arterioles and capillaries, thus reducing the flow rate.
Components of Cardiac Output
FIGURE 8-4 Cardiac output components. Cardiac output is determined by heart rate and stroke volume.
FIGURE 8-5 Normal blood flow through the heart and intrachamber pressures; arrows indicate the normal direction of blood flow. This schematic representation of the heart shows all four chambers and valves visible in the anterior view to facilitate conceptualization of blood flow.
Regulation of Cardiovascular Function
Effects of Aging
FIGURE 8-6 Factors regulating blood flow.
HEMODYNAMIC MONITORING MODALITIES
FIGURE 8-7 Impact of age-related changes on cardiac function.
Noninvasive Monitoring
Noninvasive Blood Pressure
Jugular Venous Pressure
Lactate
TABLE 8-1 Normal Hemodynamic Values
Invasive Hemodynamic Monitoring
Indications
BOX 8-1 Indications for Invasive Hemodynamic Monitoring
Arterial Lines
Central Venous Catheter
Pulmonary Artery Catheter
FIGURE 8-8 Assessment of jugular venous pressure:1.Place the patient in a supine position with the head of bed elevated 30 to 45 degrees.2.Position yourself at the patient’s right side.3.Have the patient turn head slightly to the left.4.If you cannot readily identify the jugular vein, place light pressure with your fingertips across the sternocleidomastoid muscle just superior and parallel to the clavicle. This pressure obstructs the external jugular vein and allows it to fill. Shine a pen light tangentially across the neck to accentuate the pulsations.5.Assess for jugular venous distention at end exhalation.6.Any fullness in the vein extending >3 cm above the sternal angle or angle of Louis is considered elevated jugular venous pressure. The higher the degree of elevation, the higher the central venous pressure.7.Observe the highest point of pulsation in the internal jugular vein at end exhalation.8.Measure the vertical distance between this pulsation and the angle of Louis in centimeters.9.Add 5 cm to this number for an estimation of central venous pressure.10.Normal is 7 to 9 cm.
Equipment Common to All Intravascular Monitoring
BOX 8-2 Complications of Invasive Hemodynamic Monitoring Devices
FIGURE 8-9 Components of an invasive monitoring system connected to one flush solution. A, Invasive catheter. B, Noncompliant pressure tubing. C, Transducer and zeroing stopcock. D, Pressurized flush system. E, Bedside monitoring system. (Not to scale)
Nursing Implications
FIGURE 8-10 Example of a triple-lumen central line to measure central venous pressure and oxygen saturation.
FIGURE 8-11 Example of a pulmonary artery catheter with capability of monitoring mixed venous oxygenation.
FIGURE 8-12 A schematic of a typical pressure transducer.
Leveling the Air-Fluid Interface (Zeroing Stopcock)
FIGURE 8-13 Locating the phlebostatic axis in the supine position.
Patient Position
CLINICAL ALERT
Hemodynamic Monitoring
FIGURE 8-14 A, Optimal Dynamic Response Test. B, Overdamped Dynamic Response Test. C, Underdamped Dynamic Response Test.
Zero Referencing
Dynamic Response Testing
BOX 8-3 Abnormal Dynamic Response Test: Causes and Interventions
Overdamped system
Underdamped system
Infection Control
BOX 8-4 General Nursing Strategies for Managing Hemodynamic Monitoring Systems
Arterial Pressure Monitoring
BOX 8-5 Allen’s and Modified Allen’s Test Procedure
Allen’s Test
Modified Allen’s Test
Complications
FIGURE 8-15 A, Normal arterial pressure tracing; 1, peak systolic pressure; 2, dicrotic notch; 3, diastolic pressure; 4, anacrotic notch. B, Arterial pressure waveform obtained from arterial line.
Clinical Considerations
BOX 8-6 Causes of Higher Noninvasive versus Invasive Blood Pressure
Nursing Implications
Right Atrial Pressure/Central Venous Pressure Monitoring
FIGURE 8-16 Position of central venous catheter in right atrium along with associated waveforms.
Complications
FIGURE 8-17 Identifying the a, c, and v waveforms to determine right atrial pressure.
BOX 8-7 Methods for Determining Accurate Right Atrial Pressure
Pre-c method
Mean of the a waves
Z-point method
Clinical Considerations
Nursing Implications
Pulmonary Artery Pressure Monitoring
FIGURE 8-18 A five-lumen pulmonary artery (PA) catheter containing the four-lumen components in addition to a second proximal lumen for infusion of fluid or medications.
Hemodynamic Parameters Monitored via the PAC
FIGURE 8-19 Position of pulmonary artery (PA) catheter and associated waveforms. (A) Dual-channel tracing of cardiac rhythm with pressure waveforms obtained as the PA catheter is inserted into the right atrium (RA) and right ventricle (RV); (B) dual-channel tracing of cardiac rhythm with RV, PA, and pulmonary artery occlusion pressure (PAOP) waveforms as the catheter is floated into proper position; (C), PA catheter in pulmonary artery; (D) PA catheter floating into pulmonary capillary with balloon inflated for PAOP measurements.
Clinical Considerations
FIGURE 8-20 Effect of respiration on pulmonary artery waveforms in patients with spontaneous breathing (A) and mechanical ventilation (B).
Nursing Implications
Controversy Surrounding the PAC
Cardiac Output Monitoring
Thermodilution Cardiac Output
BOX 8-8 Interpretation of Abnormal Cardiac Output/Index Values
Low Cardiac Output/Index
High Cardiac Output/Index
EVIDENCE-BASED PRACTICE
PROBLEM
QUESTION
REFERENCES
EVIDENCE
Implications for Nursing
Continuous Cardiac Output
FIGURE 8-21 Illustration of the closed injectate delivery system (room temperature fluids) for thermodilution cardiac output measurement.
FIGURE 8-22 Illustration of injection of fluid into the right atrium (RA) for cardiac output measurement.
BOX 8-9 Steps to Ensure Accurate Thermodilution Cardiac Output Measurements
Oxygen Delivery and Consumption
FIGURE 8-23 A sample monitor interface displaying hemodynamic parameters and trends, including continuous cardiac output (CCO) and mixed venous oxygen saturation (SvO2).
TABLE 8-2 Hemodynamic Calculations
TABLE 8-3 Alterations in Mixed Venous Oxygen Saturation
BOX 8-10 Esophageal Doppler Monitoring Indications and Contraindications
Indications
Contraindications
EMERGING TECHNIQUES AND TECHNOLOGIES
Esophageal Doppler Monitoring
FIGURE 8-24 Esophageal Doppler probe placement.
BOX 8-11 Nurse-Driven Protocol Using Esophageal Doppler Monitoring to Guide Therapy14
FIGURE 8-25 A, CardioQ monitoring system for assessing cardiac output and function via the esophageal Doppler probe. B, Numeric and graphic data provided by the CardioQ device.
TABLE 8-4 Interpretation Guidelines for Esophageal Doppler Monitoring
Pulse Contour Cardiac Output Monitoring
FIGURE 8-26 Schematic of the LiDCO system for assessing cardiac output via the pulse contour analysis method.
FIGURE 8-27 Example of information provided by LiDCO device.
Assessing Effect of Respiratory Variation on Hemodynamic Parameters
Right Atrial Pressure Variation
Systolic Pressure Variation
Arterial Pulse Pressure Variation
Stroke Volume Variation
CASE STUDY
QUESTIONS
SUMMARY
CRITICAL THINKING QUESTIONS
REFERENCES
CHAPTER 9 Ventilatory Assistance
INTRODUCTION
REVIEW OF RESPIRATORY ANATOMY AND PHYSIOLOGY
Upper Airway
Lower Airway
FIGURE 9-1 Anatomy of the respiratory system. The lungs are located in the thoracic cavity. The diaphragm forms the floor of the thoracic cavity and separates it from the abdominal cavity. The internal view of one lung shows air passages.
FIGURE 9-2 The vocal cords/glottis.
Lungs
FIGURE 9-3 Structure and function of the alveolus.
PHYSIOLOGY OF BREATHING
Gas Exchange
FIGURE 9-4 Schematic view of the process of gas exchange. Hgb, Hemoglobin.
Regulation of Breathing
Respiratory Mechanics
Work of Breathing
FIGURE 9-5 Diffusion of oxygen and carbon dioxide at the alveolar-capillary membrane.
Compliance
Resistance
LUNG VOLUMES AND CAPACITIES
TABLE 9-1 Lung Volumes and Capacities
FIGURE 9-6 Lung volumes and capacities.
GERIATRIC CONSIDERATIONS
PHYSIOLOGICAL CHANGES WITH AGING
ASSESSMENT CHANGES
NORMAL FINDINGS BECAUSE OF AGING PROCESS
INCREASED RISK FOR
RESPIRATORY ASSESSMENT
Health History
Physical Examination
Inspection
FIGURE 9-7 Breathing patterns.
Palpation
Percussion
Auscultation
FIGURE 9-8 Systematic method for palpation, percussion, and auscultation of the lungs in anterior (A), posterior (B), and lateral regions (C and D). The techniques should be performed systematically to compare right and left lung fields.
TABLE 9-2 Percussion of the Chest Wall
Breath Sounds
TABLE 9-3 Normal Breath Sounds
Arterial Blood Gas Interpretation
Oxygenation
Partial Pressure of Arterial Oxygen.
Arterial Oxygen Saturation of Hemoglobin.
TABLE 9-4 Adventitious Breath Sounds
TABLE 9-5 Blood Gas Interpretation
Ventilation and Acid-Base Status
pH.
Box 9-1 Signs and Symptoms of Hypoxemia
Integumentary System
Respiratory System
Central Nervous System
Partial Pressure of Arterial Carbon Dioxide.
FIGURE 9-9 Oxyhemoglobin dissociation curve. A PaO2 of 60 mm Hg correlates with an oxygen saturation of 90%. When the PaO2 falls below 60 mm Hg, small changes in PaO2 are reflected in large changes in oxygen saturation. Shifts in the oxyhemoglobin curve. L, Left shift; N, normal; R, right shift.
Sodium Bicarbonate.
Buffer Systems.
Box 9-2 Causes of Common Acid-Base Abnormalities
Respiratory Acidosis: Retention of CO2
Respiratory Alkalosis: Hyperventilation
Metabolic Acidosis
Increased Acids
Loss of Base
Metabolic Alkalosis
Gain of Base
Loss of Metabolic Acids
Base Excess or Base Deficit.
Compensation.
Steps in Arterial Blood Gas Interpretation
Step 1: Look at Each Number Individually and Label It.
FIGURE 9-10 The kidneys and lungs work together to compensate for acid-base imbalances in the respiratory or metabolic systems. HCO3−, Bicarbonate; H2CO3, carbonic acid.
LABORATORY ALERT
Arterial Blood Gas Critical Values*
Step 2: Evaluate Oxygenation.
Step 3: Determine Acid-Base Status.
Step 4: Determine Whether Primary Acid-Base Disorder Is Respiratory or Metabolic.
Step 5: Determine Whether Any Form of Compensatory Response Has Taken Place.
Box 9-3 Examples of Arterial Blood Gases and Compensation
Noninvasive Assessment of Gas Exchange
Assessment of Oxygenation
Pulse Oximetry.
Assessment of Ventilation
End-Tidal Carbon Dioxide Monitoring.
Colorimetric Carbon Dioxide Detector.
FIGURE 9-11 Disposable colorimetric carbon dioxide (CO2) detector for confirming endotracheal tube placement. Detection of CO2 confirms tube placement in the lungs because the only source of CO2 is the alveoli.
OXYGEN ADMINISTRATION
Humidification
Picking the Best Device
Fit and Function
Total Flow
Oxygen Delivery Devices
Nasal Cannula (Variable Performance)
Simple Face Mask (Variable Performance)
Face Masks with Reservoirs (Variable Performance)
Venturi or Air-Entrainment Mask (Fixed Performance)
FIGURE 9-12 Partial rebreathing and nonrebreathing oxygen masks.
FIGURE 9-13 Air-entrainment (Venturi) mask with various jet orifices. Each orifice provides a specific delivered FiO2.
Air Entrainment with Aerosol and Humidity Delivery (Variable or Fixed Performance)
FIGURE 9-14 Devices used to apply high-flow, high-humidity oxygen therapy. A, Aerosol mask. B, Face tent. C, Tracheostomy collar. D, Briggs T-piece.
Manual Resuscitation Bag (Variable Performance)
AIRWAY MANAGEMENT
Positioning
Oral Airways
FIGURE 9-15 Maintaining a patent airway with an oral airway.
Box 9-4 Insertion of Oral Airway
Nasopharyngeal Airways
FIGURE 9-16 The nasopharyngeal airway is used to relieve upper airway obstruction and to facilitate passage of a suction catheter.
Box 9-5 Insertion of Nasal Airway
FIGURE 9-17 Endotracheal tube.
Box 9-6 Oral versus Nasotracheal Intubation
Oral Intubation
Advantages
Disadvantages
Nasotracheal Intubation
Advantages
Disadvantages
Endotracheal Intubation
FIGURE 9-18 Equipment used for endotracheal intubation: A, stylet (disposable); B, endotracheal tube with 10-mL syringe for cuff inflation; C, laryngoscope handle with attached curved blade (left) and straight blade (right); D, water-soluble lubricant; E, colorimetric CO2 detector to check tube placement; F, tape or G, commercial device to secure tube; H, Yankauer disposable pharyngeal suction device; I, Magill forceps (optional). Additional equipment, not shown, includes suction source and stethoscope.
Procedure for Oral Endotracheal Intubation
FIGURE 9-19 Elevating the head with a blanket or folded towels places the patient in the „sniffing position” to facilitate endotracheal intubation.
Procedure for Nasotracheal Intubation
Verification of Endotracheal Tube Placement
Tracheostomy
FIGURE 9-20 Two methods for securing the endotracheal tube: tape (A) and harness device (B). Harness device shown is the SecureEasy Endotracheal Tube Holder. Nonelastic headgear reduces the risk of self-extubation. A soft bite block prevents tube occlusion.
Tracheostomy Tube Designs
Cuffed versus Uncuffed Tracheostomy Tubes.
FIGURE 9-21 General design features of the tracheostomy tube.
Single- versus Double-Cannula Tracheostomy Tubes.
Fenestrated Tracheostomy Tube.
Speaking Tracheostomy Valves.
Endotracheal Suctioning
Box 9-7 Key Points for Endotracheal Suctioning
FIGURE 9-22 Closed tracheal suction device.
EVIDENCE-BASED PRACTICE
PROBLEM
QUESTION
REFERENCE
EVIDENCE
IMPLICATIONS FOR NURSING
MECHANICAL VENTILATION
Indications
Positive-Pressure Ventilation
Ventilator Settings
Fraction of Inspired Oxygen
FIGURE 9-23 Concept of positive-pressure ventilation.
Tidal Volume
FIGURE 9-24 Examples of mechanical ventilators, their control panels and graphic interface unit (GIU). A, Servo ventilator 300A control panel. B, Puritan Bennett 840 ventilator GIU.
Exhaled Tidal Volume.
Respiratory Rate
Inspiratory-to-Expiratory Ratio
Inverse Inspiratory-to-Expiratory Ratio
Positive End-Expiratory Pressure
FIGURE 9-25 Effect of application of positive end-expiratory pressure (PEEP) on the alveoli.
Auto-PEEP.
Sensitivity
Sigh
Patient Data
Peak Inspiratory Pressure
Total Respiratory Rate
Modes of Mechanical Ventilation
Volume-Controlled Ventilation
Assist/Control Ventilation.
FIGURE 9-26 Waveforms of volume-controlled ventilator modes. A, Volume assist control (A/C) ventilation. The patient may trigger additional breaths above the set rate. The ventilator delivers the same volume for ventilator-triggered and patient-triggered (assisted) breaths. B, Synchronized intermittent mandatory ventilation (SIMV). Both spontaneous and mandatory breaths are graphed. Mandatory breaths receive the set tidal volume (VT). VT of spontaneous breaths depends on work patient is capable of generating, lung compliance, and airway resistance.
Synchronized Intermittent Mandatory Ventilation.
Pressure-Controlled Ventilation
Continuous Positive Airway Pressure.
Pressure Support.
FIGURE 9-27 Continuous positive airway pressure (CPAP) is a spontaneous breathing mode. Positive pressure at end expiration splints alveoli and supports oxygenation. I, Inspiration; E, Expiration.
FIGURE 9-28 Pressure support ventilation requires the patient to trigger each breath, which is then supported by pressure on inspiration. Patient may vary amount of time in inspiration, respiratory rate, and tidal volume (VT).
Pressure Assist/Control.
FIGURE 9-29 Synchronized intermittent mandatory ventilation (SIMV) with pressure support (PS). SIMV breaths receive set tidal volume (VT). Pressure support is applied to the spontaneous, patient-triggered breaths.
FIGURE 9-30 Pressure assist/control ventilation. Patient can trigger additional breaths above the set rate. Patient- and ventilator-triggered breaths receive the same inspiratory pressure.
Pressure-Controlled Inverse-Ratio Ventilation.
FIGURE 9-31 Airway pressure—release ventilation. See text below for description.
Airway Pressure—Release Ventilation.
Noninvasive Positive-Pressure Ventilation
FIGURE 9-32 Masks used for noninvasive positive-pressure ventilation. A, Nasal. B, Oronasal. C, Total face mask.
FIGURE 9-33 Noninvasive positive-pressure ventilation (NIPPV) may be administered through a mask with the BiPAP Vision ventilator. This ventilator is capable of operating in four modes: pressure support (PS); spontaneous/timed (S/T) mode, which is pressure support with back-up pressure control; timed (T), which is pressure control; and continuous positive airway pressure (CPAP). (Courtesy of Respironics, Murrysville, PA.)
Advanced Methods and Modes of Mechanical Ventilation
Respiratory Monitoring During Mechanical Ventilation
Alarm Systems
Volume Alarms.
Pressure Alarms.
Apnea Alarm.
TABLE 9-6 Management of Common Ventilator Alarms
Complications of Mechanical Ventilation
Airway Problems
Intubation of Right Mainstem Bronchus.
CLINICAL ALERT
Implementation of the Ventilator Bundle
Endotracheal Tube Out of Position.
Unplanned Extubation.
Laryngeal and Tracheal Injury.
Damage to the Oral or Nasal Mucosa.
FIGURE 9-34 Monitoring endotracheal tube cuff pressures.
Box 9-8 Strategies for Unplanned or Self-Extubation
Pulmonary System
Trauma.
Oxygen Toxicity.
Respiratory Acidosis or Alkalosis.
Infection.
Cardiovascular System
Gastrointestinal System
Psychosocial Complications
NURSING CARE
Communication
NURSING CARE PLAN for the Mechanically Ventilated Patient21
NURSING DIAGNOSIS
PATIENT OUTCOMES
NURSING DIAGNOSIS
PATIENT OUTCOMES
NURSING DIAGNOSIS
PATIENT OUTCOMES
NURSING DIAGNOSIS
PATIENT OUTCOMES
NURSING DIAGNOSIS
PATIENT OUTCOMES
NURSING DIAGNOSIS
PATIENT OUTCOME
NURSING DIAGNOSIS
PATIENT OUTCOME
Medications
WEANING PATIENTS FROM MECHANICAL VENTILATION
Methods for Weaning
Synchronized Intermittent Mandatory Ventilation
Pressure Support
T-Piece
Continuous Positive Airway Pressure
Approach to Weaning Using Best Evidence
Assessment for Readiness to Wean (Wean Screen)
Box 9-9 Evidence-Based Guidelines for Weaning from Mechanical Ventilation39,40
Weaning Process (Weaning Trial)
Box 9-10 Assessment Parameters Indicating Readiness to Wean
Underlying Cause for Mechanical Ventilation Resolved
Hemodynamic Stability; Adequate Cardiac Output
Adequate Respiratory Muscle Strength
Adequate Oxygenation Without a High FiO2 and/or a High PEEP
Absence of Factors that Impair Weaning
Box 9-11 Criteria for Discontinuing Weaning
Respiratory
Cardiovascular
Neurological
Extubation
CASE STUDY
QUESTIONS
SUMMARY
CRITICAL THINKING QUESTIONS
REFERENCES
CHAPTER 10 Code Management
INTRODUCTION
ROLES OF CAREGIVERS IN CODE MANAGEMENT
Code Team
Leader of the Code
TABLE 10-1 Roles and Responsibilities of Code Team Members
Code Nurses
Primary Nurse.
Second Nurse.
Nursing Supervisor.
Anesthesiologist or Nurse Anesthetist
Respiratory Therapist
Pharmacist or Pharmacy Technician
Electrocardiogram Technician
Chaplain
Other Personnel
EQUIPMENT USED IN CODES
FIGURE 10-1 A typical crash cart.
TABLE 10-2 Typical Contents of a Crash Cart
RESUSCITATION EFFORTS
TABLE 10-3 Flow of Events during a Code
Basic Life Support
Airway
Breathing
BOX 10-1 Steps in Basic Cardiac Life Support
Airway
Breathing
Circulation
Defibrillation
FIGURE 10-2 Head-tilt/chin-lift technique for opening the airway. A, Obstruction by the tongue. B, Head-tilt/chin-lift maneuver lifts tongue relieving airway obstruction.
FIGURE 10-3 Mouth-to-mask ventilation.
FIGURE 10-4 Rescue breathing with bag-valve device.
Circulation
Advanced Cardiac Life Support
Primary Survey
Secondary Survey
Airway
Breathing
FIGURE 10-5 Ventilation with a bag-valve device connected to endotracheal tube.
Circulation
FIGURE 10-6 End-tidal carbon dioxide detector connected to an endotracheal tube. Exhaled carbon dioxide reacts with the device to create a color change indicating correct endotracheal tube placement.
Differential Diagnosis
Recognition and Treatment of Dysrhythmias
Ventricular Fibrillation and Pulseless Ventricular Tachycardia
Critical Actions
Pulseless Electrical Activity and Asystole
Critical Actions
Symptomatic Bradycardia
Critical Actions
BOX 10-2 Signs and Symptoms of Low Cardiac Output Associated with Bradycardia
Unstable Tachycardia
Critical Actions
Electrical Therapy
Defibrillation
Definition.
FIGURE 10-7 Defibrillator.
Procedure.
FIGURE 10-8 Paddle placement for defibrillation.
FIGURE 10-9 Anteroposterior placement of adhesive electrode pads for defibrillation or transcutaneous pacing.
BOX 10-3 Procedure for External Defibrillation
Automated External Defibrillation
Definition.
Indications.
Procedure.
Cardioversion
Definition.
FIGURE 10-10 Automatic external defibrillator.
BOX 10-4 Procedure for Automated External Defibrillator Operation
Procedure.
FIGURE 10-11 Approximate location of the vulnerable period.
BOX 10-5 Procedure for Synchronous Cardioversion
Special Situations
FIGURE 10-12 Monitor/defibrillator demonstrating marked R waves for cardioversion.
Transcutaneous Cardiac Pacing
Definition.
Procedure.
FIGURE 10-13 Transcutaneous pacemaker-defibrillator.
FIGURE 10-14 Electrical capture of transcutaneous pacemaker. Note the pacemaker spikes followed by a wide QRS complex and a tall T wave.
BOX 10-6 Procedure for Transcutaneous Pacemaker
PHARMACOLOGICAL INTERVENTION DURING A CODE
Oxygen
Epinephrine (Adrenalin)
BOX 10-7 Effects of Adrenergic Receptor Stimulation
Alpha
Beta1
Beta2
Vasopressin
Atropine
PHARMACOLOGY TABLE 10-4 Drugs Frequently Used in Code Management
Amiodarone (Cordarone)
Lidocaine (Xylocaine)
Procainamide (Pronestyl)
Adenosine (Adenocard)
Magnesium
Sodium Bicarbonate
FIGURE 10-15 Atrioventricular block after intravenous administration of adenosine.
FIGURE 10-16 Torsades de pointes. The QRS complex seems to spiral around the isoelectric line.
Dopamine (Intropin)
Calcium Chloride
SPECIAL PROBLEMS DURING A CODE
GERIATRIC CONSIDERATIONS
Tension Pneumothorax
Pericardial Tamponade
DOCUMENTATION OF CODE EVENTS
FIGURE 10-17 Tension pneumothorax. On inspiration, air enters the pleural space. On expiration, air is unable to escape the pleural space. Pressure increases, causing the lung on the affected side to collapse and the trachea to shift to the opposite side.
CARE OF THE PATIENT AFTER RESUSCITATION
FIGURE 10-18 Sample of a code record used for documenting activities during a code.
LABORATORY ALERTS
Therapeutic Hypothermia After Cardiac Arrest
EVIDENCE-BASED PRACTICE
Therapeutic Hypothermia
PROBLEM
QUESTION
REFERENCES
EVIDENCE
IMPLICATIONS FOR NURSING
Family Presence during Resuscitation
EVIDENCE-BASED PRACTICE
Code Management
PROBLEM
QUESTION
REFERENCES
EVIDENCE
NURSING IMPLICATIONS
Rapid Response Teams
SUMMARY
CRITICAL THINKING QUESTIONS
REFERENCES
Part III Nursing Care during Critical Illness
CHAPTER 11 Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
INTRODUCTION
REVIEW OF ANATOMY AND PHYSIOLOGY
FIGURE 11-1 Microcirculation. AV, Arteriovenous.
Pathophysiology
TABLE 11-1 Classification of Shock
Stages of Shock
Stage I: Initiation
Stage II: Compensatory Stage
Neural Compensation.
Endocrine Compensation.
FIGURE 11-2 Impairment of cellular metabolism by shock. ATP, Adenosine triphosphate; Na, sodium; NH 4, ammonia; K, potassium.
TABLE 11-2 Stages of Shock
FIGURE 11-3 The renin-angiotensin-aldosterone system.
Chemical Compensation.
Stage III: Progressive Stage
Stage IV: Refractory Stage
Systemic Inflammatory Response Syndrome (SIRS)
Effects of Aging
ASSESSMENT
Clinical Presentation
Central Nervous System
Cardiovascular System
CLINICAL ALERT
TABLE 11-3 Hemodynamic Alterations in Shock States
Respiratory System
Renal System
Gastrointestinal System
Hematological System
Integumentary System
Laboratory Studies
LABORATORY ALERTS
MANAGEMENT
Maintenance of Circulating Blood Volume and Adequate Hemoglobin Level
Intravenous Access
Fluid Challenge
Types of Fluids
FIGURE 11-4 Fluid challenge algorithm. CVP, Central venous pressure; PAOP, pulmonary artery occlusion pressure.
EVIDENCE-BASED PRACTICE
PROBLEM
QUESTION
REFERENCES
EVIDENCE
IMPLICATIONS FOR NURSING
Maintenance of Arterial Oxygen Saturation and Ventilation
Pharmacological Support
Cardiac Output
FIGURE 11-5 Therapeutic manipulation of cardiac output and myocardial oxygen consumption. ACE, Angiotensin converting enzyme; ARB, angiotensin receptor blocker; CI, cardiac index; CO, cardiac output; CVP, central venous pressure; IABP, intra-aortic balloon pump; LR, lactated Ringer’s; LV, left ventricle; LVSWI, left ventricular stroke work index; NS, normal (0.9%) saline; NTG, nitroglycerin; PAOP, pulmonary artery occlusive pressure; PDE, phosphodiesterase; PVR, pulmonary vascular resistance; RAP, right atrial pressure; RV, right ventricle; RVSWI, right ventricular stroke work index; SVR, systemic vascular resistance.
PHARMACOLOGY TABLE 11-4 Medications Commonly Used in Shock
Preload
Afterload
Contractility
Other Medications
Maintenance of Body Temperature
Nutritional Support
Maintenance of Skin Integrity
Psychological Support
NURSING DIAGNOSIS
NURSING CARE PLAN for the Patient in Shock
NURSING DIAGNOSIS
PATIENT OUTCOMES
Adequate tissue perfusion
SPECIFIC CLASSIFICATIONS OF SHOCK
Hypovolemic Shock
TABLE 11-5 Summary of Classifications of Shock
FIGURE 11-6 Hypovolemic shock.
TABLE 11-6 Severity of Hemorrhagic Shock
Cardiogenic Shock
FIGURE 11-7 Cardiogenic shock. ADH, Antidiuretic hormone; SVR, systemic vascular resistance.
FIGURE 11-8 Cycle of cardiogenic shock.
FIGURE 11-9 Intraaortic balloon pump. The balloon is deflated during systole (A) and inflated during diastole (B).
Obstructive Shock
FIGURE 11-10 Obstructive shock.
Distributive Shock
Neurogenic Shock
FIGURE 11-11 Neurogenic shock. SVR, Systemic vascular resistance.
Anaphylactic Shock
FIGURE 11-12 Anaphylactic shock. IgE, Immunoglobulin E; SVR, systemic vascular resistance.
Septic Shock
TABLE 11-7 Clinical Condition, Diagnostic Criteria, and Management in the Continuum of Sepsis
FIGURE 11-13 Sepsis and septic shock pathophysiology.
TABLE 11-8 Stages of Septic Shock
MULTIPLE ORGAN DYSFUNCTION SYNDROME
FIGURE 11-14 Pathogenesis of multiple organ dysfunction syndrome. MODS, Multiple organ dysfunction syndrome; GI, gastrointestinal; PAF, platelet activating factor; WBCs, white blood cells; MDF, myocardial depressant factor.
PATIENT OUTCOMES
TABLE 11-9 Multiple Organ Dysfunction Syndrome
CASE STUDY
QUESTIONS
SUMMARY
CRITICAL THINKING QUESTIONS
REFERENCES
CHAPTER 12 Cardiovascular Alterations
INTRODUCTION
NORMAL STRUCTURE AND FUNCTION OF THE HEART
FIGURE 12-1 The heart lies in the mediastinum, between the lungs. Its apex rests on the diaphragm. The heart is covered by the pericardium. The inset shows the layers of the heart muscle and the pericardium.
FIGURE 12-2 Structure of the heart and course of blood flow through the heart chambers.
Autonomic Control
Coronary Circulation
FIGURE 12-3 A, The atrioventricular (AV) valves in the open position and the semilunar (SL) valves in the closed position. B, The AV valves in the closed position and the SL valves in the open position.
FIGURE 12-4 Autonomic control of circulation. AV, Atrioventricular; Pvv, pulmonary venules; Raa, renal arterioles; SA, sinoatrial.
BOX 12-1 Coronary Artery Distribution
Right Coronary Artery
Left Anterior Descending Artery
Circumflex Artery
Other Cardiac Functions
Heart Sounds
FIGURE 12-5 The coronary vessels.
FIGURE 12-6 Chest areas from which each valve sound is best heard.
TABLE 12-1 Grading of Heart Murmurs
Heart Murmur
CORONARY ARTERY DISEASE
Pathophysiology
Assessment
Patient Assessment
FIGURE 12-7 Schematic of atherosclerotic plaque. 1. Accumulation of lipoprotein particles in the intima. 2. Oxidative stress. 3. Induction of the cytokines and movement into the intima. 4. Blood monocytes encounter stimuli that augment their expression of scavenger receptors. 5. Scavenger receptors mediate the uptake of modified lipoprotein particles and promote the development of foam cells. Cytokines and superoxide anion (O2−). 6. Smooth muscle cells divide and migrate into the intima from the media. 7. Smooth muscle cells promote extracellular atherosclerotic plaque growth. Fatty streaks evolve into fatty lesions. 8. Calcification can occur and fibrosis continues.
BOX 12-2 Risk Factors for Coronary Artery Disease
Gender
Heredity
Age
Smoking
Blood Cholesterol
High Blood Pressure
Physical Inactivity
Overweight and Obesity
Diabetes
BOX 12-3 Questioning of Activities for Stress Reduction
CLINICAL ALERT
TABLE 12-2 Major Systems Assessment
Diagnostic Studies
12-Lead Electrocardiography.
Holter Monitor.
Exercise Tolerance Test (ETT) or Stress Test.
Chest X-ray.
Echocardiography.
Transesophageal Echocardiography.
Diagnostic Heart Scans.
Technetium-99m Stannous Pyrophosphate.
Thallium-201.
Multigated Blood Pool Study.
Nitroglycerin MUGA.
Sestamibi Exercise Testing and Scan.
Single Photon Emission Computed Tomography.
Cardiac Catheterization and Arteriography.
Magnetic Resonance Imaging.
FIGURE 12-8 FemoStop in correct position.
BOX 12-4 Nursing Care after Cardiac Catheterization and Arteriography
Electrophysiology Study.
Laboratory Diagnostics
Serum Electrolytes.
Serum Enzymes.
TABLE 12-3 ECG Changes Associated with Electrolyte Imbalances
Nursing Diagnoses
Interventions
Nursing Interventions
Medical Management
Medications to Reduce Serum Lipid Levels.
PHARMACOLOGY TABLE 12-4 Medications for Lowering Cholesterol and Triglycerides
LABORATORY ALERT
Medications to Prevent Platelet Adhesion and Aggregation.
Patient Outcomes
ANGINA
Pathophysiology
Types of Angina
BOX 12-5 Factors That Influence Oxygen Demand and Supply
Increased Oxygen Demand
Reduced Oxygen Supply
Assessment
CLINICAL ALERT
Diagnostic Studies
Nursing Diagnoses
Interventions
Nursing Interventions
Medical Interventions
PHARMACOLOGY TABLE 12-5 Drugs for Acute Coronary Syndromes
BOX 12-6 Instructions Regarding Nitroglycerin
Outcomes
ACUTE MYOCARDIAL INFARCTION
Pathophysiology
EVIDENCE-BASED PRACTICE
PROBLEM
QUESTION
REFERENCE
EVIDENCE
IMPLICATIONS FOR NURSING
FIGURE 12-9 Electrocardiographic alterations associated with the three zones of myocardial infarction.
Assessment
Patient Assessment
Diagnosis
Nursing Diagnoses
Complications
Medical Interventions
TABLE 12-6 Myocardial Infarction by Site, Electrocardiographic Changes, and Complications
Pain Relief.
Oxygen.
Antidysrhythmics.
Prevention of Platelet Aggregation.
Thrombolytic Therapy.
TABLE 12-7 Criteria for Diagnosis of Acute Coronary Syndrome
Percutaneous Coronary Intervention.
NURSING CARE PLAN for the Patient with Acute Myocardial Infarction
NURSING DIAGNOSIS
PATIENT OUTCOMES
NURSING DIAGNOSIS
PATIENT OUTCOMES
NURSING DIAGNOSIS
PATIENT OUTCOMES
NURSING DIAGNOSIS
PATIENT OUTCOMES
PHARMACOLOGY TABLE 12-8 Thrombolytics
Facilitated Percutaneous Coronary Intervention.
Medications.
Nitrates.
Beta-Blockers.
Angiotensin-Converting Enzyme Inhibitors.
Outcomes
INTERVENTIONAL CARDIOLOGY
Percutaneous Transluminal Coronary Angioplasty
FIGURE 12-10 Coronary angioplasty procedure. A-D, Order of procedure.
Complications
Intracoronary Stent
FIGURE 12-11 Radiographs of patients with triple-vessel disease with images before (A and B) and after (C and D) angioplasty.
SURGICAL REVASCULARIZATION
Coronary Artery Bypass Graft
FIGURE 12-12 Coronary artery bypass graft surgery. Saphenous vein is harvested from the leg using either a traditional long incision or less-invasive videoscopic harvesting (A). The vein is then anastomosed to the coronary artery (B).
Minimally Invasive Coronary Artery Surgery
Transmyocardial Revascularization
BOX 12-7 Key Points for Maintaining Chest and Mediastinal Tubes
Definitions
Baseline Assessment
Maintaining the Chest Drainage System
Assisting with Removal
Autotransfusion
Management after Cardiac Surgery
Complications of Cardiac Surgery
CARDIAC DYSRHYTHMIAS
BOX 12-8 Nursing Interventions after Cardiac Surgery
Radiofrequency Catheter Ablation
PHARMACOLOGY TABLE 12-9 Medications Used to Treat Dysrhythmias
Permanent Pacemakers
Implantable Cardioverter-Defibrillator
TABLE 12-10 Modified Generic Code for Pacemakers
BOX 12-9 Indications for an Implantable Cardioverter-Defibrillator
BOX 12-10 Patient and Family Teaching for an Implantable Cardioverter-Defibrillator
Preprocedural Teaching
Postprocedural Teaching
HEART FAILURE
Pathophysiology
TABLE 12-11 Heart Failure Stages and Descriptions
BOX 12-11 Causes of Heart Failure
Left Heart Systolic Failure
Left Heart Diastolic Failure
Right Heart Systolic Failure
Right Heart Diastolic Failure
BOX 12-12 Signs and Symptoms of Heart Failure
Left-Sided Heart Failure: Poor Pump
Right Sided Hearty Failure: Excess Volume
Assessment
Nursing Diagnoses
Interventions
NURSING CARE PLAN for the Patient with Heart Failure
NURSING DIAGNOSIS
PATIENT OUTCOMES
NURSING DIAGNOSIS
PATIENT OUTCOMES
NURSING DIAGNOSIS
PATIENT OUTCOMES
NURSING DIAGNOSIS
PATIENT OUTCOMES
NURSING DIAGNOSIS
PATIENT OUTCOMES
NURSING DIAGNOSIS
PATIENT OUTCOME
PHARMACOLOGY TABLE 12-13 Specific Medications for Heart Failure
TABLE 12-12 Medication Subsets for Heart Failure
Complications
Pulmonary Edema
TRANSPLANTATION Cardiac
INDICATIONS
CRITERIA FOR TRANSPLANT RECIPIENT
CRITERIA FOR DONOR
PATIENT MANAGEMENT
COMPLICATIONS
PREVENTING REJECTION
REFERENCES
Cardiogenic Shock
PERICARDIAL DISEASE
Pericarditis
ENDOCARDITIS
VASCULAR ALTERATIONS
FIGURE 12-13 Anatomy of the aorta and its major branches.
Aortic Aneurysms
FIGURE 12-14 The four types of aneurysms.
Aortic Dissection
Nursing Assessment
Diagnostic Studies
GENETICS
MARFAN SYNDROME
REFERENCES
Treatment
FIGURE 12-15 Surgical repair of an abdominal aortic aneurysm. The aneuysmal sac is incised (A). The synthetic graft is inserted (B), and the native aortic wall is sutured over the synthetic graft (C).
BOX 12-13 Nursing Interventions after Aortic Surgery
CASE STUDY
QUESTIONS
SUMMARY
GERIATRIC CONSIDERATIONS
MEDICATIONS
PROCEDURES
SURGERY
POSTOPERATIVE
FAMILY
REHABILITATION
CRITICAL THINKING QUESTIONS
REFERENCES
CHAPTER 13 Nervous System Alterations
INTRODUCTION
ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEM
Cells of the Nervous System
FIGURE 13-1 A neuron, the basic element of the nervous system.
Transmission of Nerve Impulses
Synapses
Neurotransmitters
Cerebral Circulation
TABLE 13-1 Common Neurotransmitters and Their Actions
Brain Metabolism
FIGURE 13-2 Arteries at the base of the brain. The arteries that compose the circle of Willis are the two anterior cerebral arteries, joined to each other by the anterior communicating two short segments of the internal carotids, off of which the posterior communicating arteries connect to the posterior cerebral arteries.
Brain Barrier System
Ventricular System and Cerebrospinal Fluid
FUNCTIONAL AND STRUCTURAL DIVISIONS OF THE CENTRAL NERVOUS SYSTEM
Meninges
FIGURE 13-3 Cerebrospinal fluid (CSF) circulation. Arrows represent the route of CSF. CSF is produced in the ventricles and returns to the venous circulation in the superior sagittal sinus.
Brain (Encephalon)
Cerebrum
FIGURE 13-4 Frontal section of the skull and brain showing the relationships of the meninges.
FIGURE 13-5 Major divisions of the central nervous system.
FIGURE 13-6 The structures of the brain (midsagittal section).
FIGURE 13-7 Cerebral hemispheres.
Diencephalon
Brainstem
Cerebellum
Specialized Systems within the Central Nervous System
Spinal Cord
FIGURE 13-8 Each of the 31 pairs of spinal nerves exit the spinal cavity from the vertebrae. The names of the vertebrae are listed on the left, and the corresponding spinal nerves are listed on the right.
Plexuses
Peripheral Nervous System
Autonomic Nervous System
FIGURE 13-9 Dermatome distribution of spinal nerves. A, Anterior view. B, Posterior view. C, Side view.
Effects of Aging
TABLE 13-2 The Cranial Nerves and Assessment in the Critically Ill Patient
GERIATRIC CONSIDERATIONS
Assessment
CLINICAL ALERT
Neurological Assessment
Mental Status.
FIGURE 13-10 The Glasgow Coma Scale is based on eye opening, movement, and verbal responses. Each response is given a number, and the three scores are summed. Scores range from 3 to 15.
Language Skills.
Memory.
Cranial Nerve Functioning.
Motor Status.
Spontaneous Movement.
Muscle Strength.
Muscle Tone.
Deep Tendon Reflexes.
Babinski’s Reflex.
Coordination.
Abnormal Posture.
Sensory Assessment.
FIGURE 13-11 Deep tendon reflexes. A, Biceps. B, Triceps. C, Brachioradialis. D, Patellar. E, Achilles.
Respiratory Assessment.
Hourly Assessment.
INCREASED INTRACRANIAL PRESSURE
FIGURE 13-12 Babinski’s reflex. A, Light pressure is applied with a hard object to the lateral surface of the sole, starting at the heel and going over the ball of the foot ending beneath the great toe. B, Normal response is flexion of all toes. C, Positive Babinski’s response is dorsiflexion of the great toe and fanning of the other toes.
FIGURE 13-13 Abnormal motor responses. A, Flexion posturing. B, Extensor posturing. C, Flexion posturing on right side and extensor posturing on left side.
TABLE 13-3 Spinal Nerve Innervation of Major Muscle Groups
Pathophysiology
TABLE 13-4 Respiratory Patterns in Neurological Disorders
FIGURE 13-14 Intracranial pressure–volume curve. Between points A and B, intracranial compliance is present. Intracranial pressure (ICP) is normal, and increases in intracranial volume are tolerated without large increases in ICP. As compliance is lost, small increases in volume result in large and dangerous increases in ICP (points C and D).
FIGURE 13-15 Pathophysiology flow diagram for increased intracranial pressure.
TABLE 13-5 Components of the Hourly Neurological Assessment for Patients with Increased Intracranial Pressure, Head Injury, or Acute Stroke
TABLE 13-6 Herniation Syndromes
Causes of Increased Intracranial Pressure
Increased Brain Volume
BOX 13-1 Risk Factors for Increased Intracranial Pressure
Increased Brain Volume
Increased Cerebral Blood Flow
Increased Cerebrospinal Fluid
Increased Cerebral Blood Volume
Loss of Autoregulation.
Decreased Cerebral Oxygenation.
Increased Metabolic Demands.
Obstructed Venous Outflow.
FIGURE 13-16 Herniation syndromes. A, Normal intracranial structures. B, Supratentorial herniation syndromes. C, Cerebellar tonsil herniation.
CLINICAL ALERT
Optimal Positioning
Increased Cerebrospinal Fluid
Assessment
Monitoring Techniques
Intracranial Pressure Monitoring.
FIGURE 13-17 Intracranial pressure monitoring sites.
Intracranial Pressure Waveform Monitoring.
FIGURE 13-18 Intracranial pressure (ICP) waveforms. A, Normal ICP waveform. B, Abnormal waveform.
TABLE 13-7 Intracranial Pressure Monitoring Devices3
Ventriculostomy.
Hemodynamic Monitoring.
Cerebral Oxygenation Monitoring.
FIGURE 13-19 Becker external drainage and monitoring system. (Courtesy of Medtronic, Minneapolis, MN.)
Respiratory Monitoring.
Bedside Electroencephalographic Monitoring.
Diagnostic Testing
Nursing Diagnoses
Management
Medical and Nursing Interventions (Nonsurgical)
Nursing Actions to Manage Intracranial Pressure.
NURSING CARE PLAN for the Patient with Traumatic Brain Injury, Increased Intracranial Pressure, or Acute Stroke
NURSING DIAGNOSIS
PATIENT OUTCOMES
Optimal cerebral perfusion
NURSING DIAGNOSIS
PATIENT OUTCOMES
Improved cerebral tissue perfusion
NURSING DIAGNOSIS
Optimal gas exchange
Optimal gas exchange
NURSING DIAGNOSIS
PATIENT OUTCOMES
Optimal fluid balance
NURSING DIAGNOSIS
Optimal nutrition
Optimal nutrition
NURSING DIAGNOSES
PATIENT OUTCOMES
Free of infection
NURSING DIAGNOSIS
PATIENT OUTCOMES
Optimal thought processes
NURSING DIAGNOSIS
PATIENT OUTCOME
Family demonstrates effective adaptation to the situation
Medical Management.
Adequate Oxygenation.
Management of Carbon Dioxide.
Diuretics.
Optimal Fluid Administration.
Blood Pressure Management.
Reducing Metabolic Demands.
Temperature Control.
Sedation.
PHARMACOLOGY TABLE 13-8 Frequently Used Drugs in Nervous System Alterations
EVIDENCE-BASED PRACTICE
PROBLEM
QUESTION
REFERENCE
EVIDENCE
IMPLICATIONS FOR NURSING
Seizure Prophylaxis.
Neuromuscular Blockade and Barbiturate Therapy.
Surgical Interventions
Psychosocial Support
TRAUMATIC BRAIN INJURY
Pathophysiology
FIGURE 13-20 Pathophysiology flow diagram for traumatic brain injury. CSF, Cerebrospinal fluid; Ca++, calcium; ICP, intracranial pressure.
TABLE 13-9 Types of Traumatic Injury with Associated Signs and Symptoms
Scalp Lacerations
FIGURE 13-21 Coup and contrecoup head injury after blunt trauma. A, Coup injury: impact against object. a, Site of impact and direct trauma to the brain. b, Shearing of the subdural veins. c, Trauma to the base of the brain. B, Contrecoup injury: impact within skull. a, Site of impact from brain hitting opposite side of skull. b, Shearing forces throughout the brain. These injuries occur in one continuous motion—the head strikes the wall (coup), then rebounds (contrecoup).
Skull Fractures
Linear Skull Fracture.
FIGURE 13-22 Skull fractures. A, Linear; open, depressed; basilar and comminuted fractures. B, View of base of skull with fractures.
Depressed Skull Fracture.
FIGURE 13-23 A, Raccoon eyes, rhinorrhea. B, Battle’s sign with otorrhea. C, Halo or ring sign.
Comminuted Skull Fracture.
Brain Injury
Primary Brain Injury.
Concussion.
Contusion.
Diffuse Axonal Injury.
Penetrating Injury.
FIGURE 13-24 Types of hematomas. A, Subdural (takes on contour of brain). B, Epidural. C, Intracerebral.
Hematoma.
Epidural Hematoma.
Subdural Hematoma.
Intracerebral Hematoma.
Secondary Brain Injury.
Assessment
Nursing Diagnoses
Management
Medical (Nonsurgical) Interventions
Surgical Interventions
ACUTE STROKE
GENETICS
APOLIPOPROTEIN E AND COGNITIVE RECOVERY AFTER BRAIN INJURY
REFERENCES
Pathophysiology
Ischemic Stroke
Large Artery Atherosclerosis.
FIGURE 13-25 Proximal occlusion of left middle cerebral artery with infarction. Ischemic penumbra represents regional blood flow at about 25 mL/100 g/min. Ischemic penumbra is the area where acute therapies for stroke are targeted.
Cardioembolic Stroke.
Lacunar Stroke.
FIGURE 13-26 Common arterial and cardiac abnormalities causing ischemic stroke.
Cryptogenic Stroke.
Hemorrhagic Stroke
Intraparenchymal Hemorrhage.
Ruptured Cerebral Aneurysm with Subarachnoid Hemorrhage.
Arteriovenous Malformation.
Assessment
BOX 13-2 Signs and Symptoms of Stroke
TABLE 13-10 National Institutes of Health Stroke Scale
Diagnostic Tests
Management
Nursing Diagnoses
Ischemic Stroke
Thrombolytic Candidates.
BOX 13-3 Diagnostic Testing for Stroke
Initial Diagnostic Testing
Additional Diagnostic Testing1
Nonthrombolytic Candidates.
BOX 13-4 Administration of Tissue Plasminogen Activator for Acute Ischemic Stroke
Inclusion Criteria
Exclusion Criteria
Administration
Other Ischemic Events
Transient Ischemic Attacks.
Hemorrhagic Stroke
Intraparenchymal Stroke.
Subarachnoid Hemorrhage
Arteriovenous Malformation
Postoperative Neurosurgical Care
SEIZURES AND STATUS EPILEPTICUS
TABLE 13-11 Classification of Seizures
Pathophysiology of Status Epilepticus
Assessment
Diagnostic Tests
Management
Nursing Diagnoses
Nursing and Medical Interventions
CENTRAL NERVOUS SYSTEM INFECTIONS
Bacterial Meningitis
Pathophysiology
BOX 13-5 Causes of Meningitis
Bacterial
Viruses
Fungal
Assessment
Diagnostic Tests
Management
Nursing Diagnoses.
TABLE 13-12 Manifestations of Cranial Nerve Inflammation in Bacterial Meningitis
Nursing and Medical Management.
SPINAL CORD INJURY
Pathophysiology
Assessment
Airway and Respiratory Assessment
Neurological Assessment
Hemodynamic Assessment
FIGURE 13-27 Pathophysiology flow diagram for spinal cord injury. ANS, Autonomic nervous system; K+, potassium; Na+, sodium; Ca2+, calcium; O2, oxygen; PaO2, partial pressure of oxygen in arterial blood; PaCO2, partial pressure of carbon dioxide in arterial blood.
Bowel and Bladder Function
FIGURE 13-28 Common spinal cord syndromes.
Skin Assessment
TABLE 13-13 Components of the Hourly Neurological Assessment for Patients with Spinal Cord Injury*
Psychological Assessment
Diagnostic Studies
BOX 13-6 Autonomic Dysreflexia
Medical Emergency; Can Result in Stroke, Seizures, or Other Complications
Triggered by a Variety of Stimuli
Common Signs and Symptoms
Treatment
Management
Nursing Interventions
NURSING CARE PLAN for the Patient with Spinal Cord Injury
NURSING DIAGNOSIS
PATIENT OUTCOMES Risk for injury minimized
NURSING DIAGNOSIS
PATIENT OUTCOMES Adequate gas exchange
NURSING DIAGNOSIS
PATIENT OUTCOME
Within 24-48 hours, airway clear
NURSING DIAGNOSIS
PATIENT OUTCOME
NURSING DIAGNOSIS
PATIENT OUTCOMES Adequate CO
NURSING DIAGNOSIS
PATIENT OUTCOMES Adequate nutrition
NURSING DIAGNOSIS
PATIENT OUTCOME
NURSING DIAGNOSIS
PATIENT OUTCOMES
Free of infection
NURSING DIAGNOSIS
PATIENT OUTCOME
NURSING DIAGNOSIS
PATIENT OUTCOME
NURSING DIAGNOSIS
PATIENT OUTCOMES
Reduced fear and anxiety
NURSING DIAGNOSIS
PATIENT OUTCOME
Nursing and Medical Interventions
FIGURE 13-29 Halo vest.
Surgical Intervention
CASE STUDY
QUESTIONS
SUMMARY
CRITICAL THINKING QUESTIONS
REFERENCES
CHAPTER 14 Acute Respiratory Failure
INTRODUCTION
ACUTE RESPIRATORY FAILURE
Definition
Pathophysiology
Failure of Oxygenation
Hypoventilation.
Intrapulmonary Shunting.
FIGURE 14-1 Pulmonary causes of hypoxemia. A, Normal alveolar-capillary unit. B, Hypoventilation causes an increased PaCO2 and decreased PaO2. C, Shunt. D, Ventilation-perfusion mismatch resulting from pulmonary embolus. E, Diffusion defect due to increased interstitial fluid.
Ventilation-Perfusion Mismatch.
Diffusion Defects.
Low Cardiac Output.
Low Hemoglobin Level.
Tissue Hypoxia.
Failure of Ventilation
Hypoventilation.
Ventilation-Perfusion Mismatch.
Assessment
Effects of Aging
GERIATRIC CONSIDERATIONS
Interventions
CLINICAL ALERT
Nursing Diagnoses
RESPIRATORY FAILURE IN ACUTE RESPIRATORY DISTRESS SYNDROME
Definition
NURSING CARE PLAN for a Patient with Acute Respiratory Failure*
NURSING DIAGNOSIS
PATIENT OUTCOMEs
NURSING DIAGNOSIS
PATIENT OUTCOMES
NURSING DIAGNOSIS
PATIENT OUTCOMES
Absence of infection
NURSING DIAGNOSIS
PATIENT OUTCOMES
Anxiety decreased or absent
NURSING DIAGNOSIS
PATIENT OUTCOMES
NURSING DIAGNOSIS
PATIENT OUTCOMES
Family integrity maintained
Etiology
TABLE 14-1 Mechanical Ventilation Protocol for Acute Respiratory Distress Syndrome (NHLBI, NIH)
BOX 14-1 Possible Causes for Acute Respiratory Distress Syndrome
Direct Causes
Indirect Causes
Pathophysiology
Assessment
FIGURE 14-2 Pathogenesis of acute respiratory distress syndrome (ARDS). TNF, Tumor necrosis factor; IL-1, interleukin-1; PAF, platelet-activating factor; RBCs, red blood cells.
Interventions
Oxygenation
EVIDENCE-BASED PRACTICE
PROBLEM
QUESTION
REFERENCE
EVIDENCE
IMPLICATIONS FOR NURSING
Sedation/Comfort
Prone Positioning
Fluid and Electrolytes
Nutrition
Pharmacological Treatment
Psychosocial Support
ACUTE RESPIRATORY FAILURE IN CHRONIC OBSTRUCTIVE PULMONARY DISEASE
Pathophysiology
TABLE 14-2 Pathological and Physiological Changes in Chronic Obstructive Pulmonary Disease
Assessment
CLINICAL ALERT
Interventions
Oxygen
BOX 14-2 Treatment of Stable Chronic Obstructive Pulmonary Disease
Bronchodilator Therapy
TABLE 14-3 Bronchodilators
Corticosteroids
Antibiotics
Ventilatory Assistance
ACUTE RESPIRATORY FAILURE IN ASTHMA
Pathophysiology
Assessment
FIGURE 14-3 Airway obstruction caused by asthma. A, Normal lung. B, Bronchial asthma: thick mucus, mucosal edema, and smooth muscle spasm causing obstruction of small airways.
Interventions
BOX 14-3 Asthma Triggers
Inhalant Allergens
Occupational Exposure
Irritants
Other Factors Influencing Asthma Severity
CLINICAL ALERT
TABLE 14-4 Emergency Treatment of Severe Asthma
ACUTE RESPIRATORY FAILURE RESULTING FROM VENTILATOR-ASSOCIATED PNEUMONIA
Definition and Etiology
FIGURE 14-4 Role of airway management in the pathogenesis of ventilator-associated pneumonia.
Pathophysiology
Assessment
TABLE 14-5 Modified Clinical Pulmonary Infection Score
Interventions
Prevention
Hand Hygiene and Universal Precautions.
Respiratory Equipment.
BOX 14-4 Prevention of Ventilator-Associated Pneumonia
Patient Position and Mobility.
Oral Care.
Gastric Tubes, Nutrition, and Peptic Ulcer Prophylaxis.
BOX 14-5 Example of a Comprehensive Oral Care Protocol
Interventions
Equipment
Sedation Interruption and Daily Assessment of Readiness to Extubate.
Treatment
ACUTE RESPIRATORY FAILURE RESULTING FROM PULMONARY EMBOLISM
Definition/Classification
Etiology
Pathophysiology
BOX 14-6 Risk Factors for Venous Thromboembolism
Venous Stasis
Vessel Wall Injury
Hypercoagulability
Assessment
Diagnosis
Arterial Blood Gases.
Electrocardiogram.
Chest X-ray.
D-dimer Assay.
Ventilation-Perfusion Scan.
Duplex Ultrasonography.
Echocardiogram.
High-Resolution Multidetector Computed Tomography Angiography.
Magnetic Resonance Imaging.
Pulmonary Angiogram.
Prevention
Treatment
BOX 14-7 Nursing Measures to Prevent Venous Thromboembolism
GENETICS
CYSTIC FIBROSIS: A HERITABLE DISORDER WITH PULMONARY AND GASTROINTESTINAL COMPLICATIONS
REFERENCES
TRANSPLANTATION Lung
INTRODUCTION
CRITERIA FOR TRANSPLANT RECIPIENTS
CRITERIA FOR DONORS
PATIENT MANAGEMENT
COMPLICATIONS
PREVENTING REJECTION
REFERENCES
ACUTE RESPIRATORY FAILURE IN ADULT PATIENTS WITH CYSTIC FIBROSIS
Definition
Etiology
Interventions
CASE STUDY
QUESTIONS
SUMMARY
CRITICAL THINKING QUESTIONS
REFERENCES
CHAPTER 15 Acute Renal Failure
INTRODUCTION
REVIEW OF ANATOMY AND PHYSIOLOGY
FIGURE 15-1 Anatomy of the nephron, the functional unit of the kidney.
BOX 15-1 Functions of the Kidney
Regulation of Fluid and Electrolytes and Excretion of Waste Products
Regulation of Acid-Base Balance
FIGURE 15-2 Average pressures involved in filtration from the glomerular capillaries.
Regulation of Blood Pressure
FIGURE 15-3 Renin-angiotensin mechanism.
Effects of Aging
PATHOPHYSIOLOGY OF ACUTE RENAL FAILURE
Definition
Etiology
Prerenal Causes of Acute Renal Failure
Postrenal Causes of Acute Renal Failure
Intrarenal Causes of Acute Renal Failure
BOX 15-2 Prerenal Causes of Acute Renal Failure
Volume Depletion
Vasodilation
Impaired Cardiac Performance
Miscellaneous
BOX 15-3 Postrenal Causes of Acute Renal Failure
Acute Tubular Necrosis.
FIGURE 15-4 Schematic of loss of glomerular filtration seen in ischemic and nephrotoxic acute tubular necrosis.
BOX 15-4 Intrarenal Causes of Acute Renal Failure
Glomerular, Vascular, or Hematological Problems
Tubular Problem (Acute Tubular Necrosis or Acute Interstitial Nephritis)
Contrast-Induced Nephropathy.
EVIDENCE-BASED PRACTICE
Acute Renal Failure
PROBLEM
QUESTION
REFERENCE
EVIDENCE
IMPLICATIONS FOR NURSING
Course of Acute Renal Failure
Initiation (Onset) Phase.
Maintenance (Oliguric/Anuric) Phase.
Recovery (Diuretic) Phase.
ASSESSMENT
Patient History
BOX 15-5 Common Nephrotoxic Medications
Vital Signs
Physical Assessment
TABLE 15-1 Systemic Manifestations of Acute Renal Failure
Evaluation of Laboratory Values
CLINICAL ALERT
Serum Creatinine
TABLE 15-2 Laboratory Findings Useful in Differentiating Causes of Acute Renal Failure
Diagnostic Procedures
GERIATRIC CONSIDERATIONS
Management of Acute Renal Failure
NURSING DIAGNOSES
NURSING INTERVENTIONS
TABLE 15-3 Invasive Diagnostic Procedures for Assessing the Renal System
NURSING CARE PLAN for the Patient with Acute Renal Failure
NURSING DIAGNOSIS
PATIENT OUTCOMES
Stable fluid balance
NURSING DIAGNOSIS
PATIENT OUTCOMES
Absence of infection
NURSING DIAGNOSIS
PATIENT OUTCOMES
Adequate nutritional and caloric intake
NURSING DIAGNOSIS
PATIENT OUTCOME Anxiety levels reduced
NURSING DIAGNOSIS
PATIENT OUTCOME
CLINICAL ALERT
Fluid Volume Overload
MEDICAL MANAGEMENT OF ACUTE RENAL FAILURE
Prerenal Causes
Postrenal Causes
Intrarenal Causes: Acute Tubular Necrosis
Pharmacological Management
Diuretics.
BOX 15-6 Measures to Prevent Acute Renal Failure
Avoid Nephrotoxins
Optimize Volume Status Before Surgery or Invasive Procedures
Reduce Incidence of Nosocomial Infections
Implement Tight Glycemic Control in the Critically Ill
Aggressively Investigate and Treat Sepsis
Dopamine.
Acetylcysteine.
Fenoldopam.
Theophylline.
Miscellaneous Agents.
Epoetin Alfa (Epogen).
Pharmacological Management Considerations.
Dietary Management
BOX 15-7 Common Drugs Removed by Hemodialysis*
Management of Fluid, Electrolyte, and Acid-Base Imbalances
Fluid Imbalance.
Electrolyte Imbalance.
LABORATORY ALERT
Acute Renal Failure
FIGURE 15-5 Electrocardiographic (ECG) changes seen in hyperkalemia.
Acid-Base Imbalance.
PHARMACOLOGY TABLE 15-4 Medications to Treat Hyperkalemia
BOX 15-8 Metabolic Acidosis in Acute Renal Failure
Etiology
Signs and Symptoms
Renal Replacement Therapy
Definition.
Indications for Dialysis.
Principles and Mechanisms.
Vascular Access.
FIGURE 15-6 Central venous catheter used for hemodialysis.
FIGURE 15-7 Hemodialysis access devices.
Nursing Care of Arteriovenous Fistula or Graft.
Nursing Care of Percutaneous Catheters.
Hemodialysis.
Complications.
Nursing Care of the Patient.
BOX 15-9 Complications of Dialysis
Continuous Renal Replacement Therapy.
TABLE 15-5 Continuous Renal Replacement Therapies
Indications.
Principles.
Complications.
Nursing Care.
Peritoneal Dialysis.
FIGURE 15-8 Schematic of A, continuous venovenous hemofiltration (CVVH) and B, continuous venovenous hemofiltration dialysis (CVVHD).
Indications.
Complications.
FIGURE 15-9 Prismaflex continuous renal replacement therapy system.
Contraindications.
TRANSPLANTATION Renal
INDICATIONS
CRITERIA FOR TRANSPLANT RECIPIENT
CRITERIA FOR DONORS
PATIENT MANAGEMENT
COMPLICATIONS
PREVENTING REJECTION
REFERENCES
OUTCOMES
CASE STUDY
QUESTIONS
SUMMARY
CRITICAL THINKING QUESTIONS
REFERENCES
CHAPTER 16 Hematological and Immune Disorders
INTRODUCTION
REVIEW OF ANATOMY AND PHYSIOLOGY
Hematopoiesis
Effects of Aging
Components and Characteristics of Blood
TABLE 16-1 Hematology-Immunology Key Terms
Hematopoietic Cells
Erythrocytes
FIGURE 16-1 Hematopoietic stem cell and lineage.
FIGURE 16-2 Hematopoietic organs and their function.
GERIATRIC CONSIDERATIONS
Platelets
TABLE 16-2 Characteristics of Blood
Leukocytes
Granular Leukocytes
Neutrophils.
TABLE 16-3 Overview of Leukocytes
Eosinophils.
Basophils.
Nongranular Leukocytes (Agranulocytes)
Monocytes.
Lymphocytes.
Immune Anatomy
Immune Physiology
Nonspecific Defenses
Epithelial Surfaces.
Inflammation and Phagocytosis.
Other Nonspecific Defenses.
Specific Defenses
Humoral Immunity.
Cell-Mediated Immunity.
TABLE 16-4 Immunoglobulins
Hemostasis
FIGURE 16-3 Coagulation physiology.
Coagulation Pathway
Coagulation Antagonists and Clot Lysis
FIGURE 16-4 Coagulation cascade.
NURSING ASSESSMENT OF HEMATOLOGICAL AND IMMUNOLOGICAL FUNCTION
TRANSPLANTATION Hematopoietic Stem Cell Transplantation
INDICATIONS
CATEGORIES
TISSUE TYPING
COMPLICATIONS
REFERENCES
Past Medical History
Evaluation of Patient Complaints and Physical Examination
FIGURE 16-5 Fibrinolysis.
Diagnostic Tests
BOX 16-1 Conditions that may Indicate Hematological and Immunological Problems*
SELECTED ERYTHROCYTE DISORDERS
TABLE 16-5 Physical Assessment for Hemotological and Immune Disorders
Anemia
Pathophysiology
TABLE 16-6 Functions and Normal Values of Blood Cells
Assessment and Clinical Manifestations
TABLE 16-7 Coagulation Profile Studies
Nursing Diagnoses
TABLE 16-8 Anemias
Medical Interventions
Nursing Interventions
WHITE BLOOD CELL AND IMMUNE DISORDERS
The Immunocompromised Patient
Pathophysiology
Assessment and Clinical Manifestations
Nursing Diagnoses
Medical Interventions
TABLE 16-9 Risk Factors for Infections in the Immunocompromised Patient
CLINICAL ALERT
Infection in Immunocompromised Patients
Nursing Interventions
Neutropenia
Pathophysiology
Assessment and Clinical Manifestations
NURSING CARE PLAN for the Immunocompromised Patient
NURSING DIAGNOSIS
PATIENT OUTCOMES
Patient will remain free of infection
NURSING DIAGNOSIS
PATIENT OUTCOMES
Skin and mucous membranes intact
NURSING DIAGNOSIS
PATIENT OUTCOMES
Optimal nutritional status maintained
EVIDENCE-BASED PRACTICE
PROBLEM
QUESTION
REFERENCE
EVIDENCE
IMPLICATIONS FOR NURSING
Nursing Diagnoses
Medical Interventions
BOX 16-2 Causes of Neutropenia
Malnutrition
Health States
Medications
Nursing Interventions
Malignant White Blood Cell Disorders: Leukemia, Lymphoma, and Multiple Myeloma
Pathophysiology
Assessment and Clinical Manifestations
TABLE 16-10 Malignant White Blood Cell Disorders
Nursing Diagnoses
Medical Interventions
Nursing Interventions
SELECTED IMMUNOLOGICAL DISORDERS
Primary Immunodeficiency
Secondary Immunodeficiency
Acquired Immunodeficiency Syndrome
Pathophysiology.
Assessment and Clinical Manifestations.
FIGURE 16-6 Human immunodeficiency virus (HIV) pathophysiology. CMV, Cytomegalovirus; CNS, central nervous system; ELISA, enzyme-linked immunosorbent assay; TB, tuberculosis.
Nursing Diagnoses.
Medical Interventions.
Nursing Interventions.
BLEEDING DISORDERS
The Bleeding Patient
Pathophysiology
Assessment and Clinical Manifestations
Nursing Diagnoses
Medical Interventions
NURSING CARE PLAN for the Patient with a Bleeding Disorder
NURSING DIAGNOSIS
PATIENT OUTCOMES
Adequate perfusion maintained and damage to vital organs prevented
NURSING DIAGNOSIS
PATIENT OUTCOMES Free of bleeding and normovolemic
Nursing Interventions
TABLE 16-11 Summary of Blood Products and Administration
Thrombocytopenia
Pathophysiology
Assessment and Clinical Manifestations
Box 16-3 Causes of Thrombocytopenia
Bone Marrow Suppression
Interference with Platelet Production (Other than Nonspecific Marrow Suppression)
Platelet Destruction Outside the Bone Marrow
Immune Response Against Platelets
Interference with Platelet Function
Nursing Diagnoses
Medical Interventions
Box 16-4 Heparin-Induced Thrombocytopenia11,15,22
Definition
Risks
Complications
Diagnosis
Treatment
CLINICAL ALERT
Bleeding Disorders
Nursing Interventions
Disseminated Intravascular Coagulation
Pathophysiology
Assessment and Clinical Manifestations
FIGURE 16-7 Pathophysiology of disseminated intravascular coagulopathy.
Nursing Diagnoses
Medical Interventions
TABLE 16-12 Causes of Disseminated Intravascular Coagulation
GENETICS
FACTOR V LEIDEN: AN INHERITED CLOTTING DISORDER
REFERENCES
LABORATORY FINDINGS
Disseminated Intravascular Coagulation
Nursing Interventions
CASE STUDY
QUESTIONS
SUMMARY
CRITICAL THINKING QUESTIONS
REFERENCES
CHAPTER 17 Gastrointestinal Alterations
INTRODUCTION
REVIEW OF ANATOMY AND PHYSIOLOGY
Gastrointestinal Tract
Gut Wall
Mucosa.
Gastric Mucosal Barrier.
FIGURE 17-1 The gastrointestinal system.
Submucosa.
Oropharyngeal Cavity
Mouth.
BOX 17-1 Swallowing Stages
Oral: Voluntary
Pharyngeal: Involuntary
Esophageal: Involuntary
Salivary Glands.
Pharynx.
Esophagus
FIGURE 17-2 The stomach.
Stomach
TABLE 17-1 Gastric Secretions
Small Intestine
TABLE 17-2 Electrolyte and Acid-Base Disturbances Associated with the Gastrointestinal Tract
TABLE 17-3 Pancreatic Enzymes and Their Actions
Large Intestine
Accessory Organs
Pancreas
FIGURE 17-3 The intestinal system.
FIGURE 17-4 The pancreas.
Liver
FIGURE 17-5 The normal liver lobule.
Vascular Functions
Blood Storage.
Blood Filtration.
BOX 17-2 Functions of the Liver
Vascular Functions
Secretory Functions
Metabolic Functions
Storage Functions
Secretory Functions
Bile Production.
Bilirubin Metabolism.
Metabolic Functions
Carbohydrate Metabolism.
Fat Metabolism.
Protein Metabolism.
Production and Removal of Blood Clotting Factors.
Detoxification.
Storage, Synthesis, and Transport of Vitamins and Minerals.
Gallbladder
Neural Innervation of the Gastrointestinal System
Hormonal Control of the Gastrointestinal System
Blood Supply of the Gastrointestinal System
Geriatric Concerns
TABLE 17-4 Actions of Gastrointestinal Hormones
GENERAL ASSESSMENT OF THE GASTROINTESTINAL SYSTEM
History
Inspection
GERIATRIC CONSIDERATIONS
Skin Color and Texture
Symmetry and Contour of Abdomen
Masses and Pulsations
Peristalsis and Movement
Auscultation
BOX 17-3 Causes of Increased and Decreased Bowel Sounds
Causes of Decreased Bowel Sounds
Causes of Increased Bowel Sounds
Percussion
Palpation
ACUTE GASTROINTESTINAL BLEEDING
Pathophysiology
Peptic Ulcer Disease
FIGURE 17-6 Duodenal ulcer. A, Deep ulceration in the duodenal wall extending as a crater through the entire mucosa and into the muscle layers. B, Duodenal ulcer.
BOX 17-4 Causes of Gastrointestinal Bleeding
Causes of Upper Gastrointestinal Bleeding
Causes of Lower Gastrointestinal Bleeding8
Stress Ulcers
BOX 17-6 Contributing Factors to Ulcer Formation8
BOX 17-5 Risk Factors for Peptic Ulcer Disease
Mallory-Weiss Tear
TABLE 17-5 Selected Studies of Gastrointestinal Function14
TABLE 17-6 Characteristics of Gastric and Duodenal Ulcers
Esophageal Varices
FIGURE 17-7 The liver and collateral circulation.
Assessment
Clinical Presentation
CLINICAL ALERT
Clinical Signs and Symptoms of Upper Gastrointestinal Bleeding9
Nursing Assessment
FIGURE 17-8 Pathophysiology flow diagram of acute upper gastrointestinal (GI) bleeding. BP, Blood pressure.
Medical Assessment
Laboratory Studies.
LABORATORY ALERTS
Upper Gastrointestinal Bleeding5
Complete Blood Count
Serum Electrolyte Panel
Hematology Profile
Arterial Blood Gases
Gastric Aspirate for pH and Guaiac
Endoscopy and Barium Study.
Nursing Diagnoses
Collaborative Management: Nursing and Medical Considerations
NURSING CARE PLAN for the Patient with Acute Gastrointestinal Bleeding
NURSING DIAGNOSIS
PATIENT OUTCOMES
Adequate circulating blood volume
NURSING DIAGNOSIS
PATIENT OUTCOMES
Adequate tissue perfusion
NURSING DIAGNOSIS
PATIENT OUTCOMES
BOX 17-7 Management of Upper Gastrointestinal Bleeding
Hemodynamic Stabilization
Definitive and Supportive Therapies
Hemodynamic Stabilization
Gastric Lavage
Pharmacological Therapy
Antibiotics.
Endoscopic Therapy
PHARMACOLOGY TABLE 17-7 Pharmacological Treatments to Decrease Gastric Acid Secretion and/or Reduce Acid Effects on Gastric Mucosa10
Surgical Therapy
GENETICS
Cytochrome P450 Enzymes and the Patient’s Response to Drugs
REFERENCES
FIGURE 17-9 Billroth I and II procedures.
Nursing Diagnoses
Recognition of Potential Complications
CLINICAL ALERT
Acute Gastric Perforation9
Treatment of Variceal Bleeding
Somatostatin or Octreotide
Vasopressin
Endoscopic Procedures
17-8 Vasopressin (Pitressin) Therapy10
Mechanism of Action
Dose
Side Effects
Nursing Considerations
Transjugular Intrahepatic Portosystemic Shunt
FIGURE 17-10 Sengstaken-Blakemore tube.
Esophagogastric Tamponade
Surgical Interventions
FIGURE 17-11 Types of portacaval shunts. A, Normal portal circulation. B, End-to-side shunt. C, Side-to-side shunt.
Patient Outcomes
ACUTE PANCREATITIS
Pathophysiology
BOX 17-9 Systemic Complications of Acute Pancreatitis
Pulmonary
Cardiovascular
Hematological
Gastrointestinal
Renal
Metabolic
Assessment
History and Physical Examination
BOX 17-10 Causes of Acute Pancreatitis
LABORATORY ALERTS
Pancreatitis5
CLINICAL ALERT
Signs and Symptoms of Acute Pancreatitis9
Diagnostic Tests
BOX 17-11 Other Conditions Associated with Increased Serum Amylase Levels
Predicting the Severity of Acute Pancreatitis
BOX 17-12 Ranson Criteria for Predicting Severity of Acute Pancreatitis*
At Admission or on Diagnosis
During Initial 48 Hours
Nursing Diagnoses
Medical and Nursing Interventions
Fluid Replacement
EVIDENCE-BASED PRACTICE
PROBLEM
QUESTION
REFERENCES
EVIDENCE
IMPLICATIONS FOR NURSING
NURSING CARE PLAN
for the Patient with Acute Pancreatitis
NURSING DIAGNOSIS
PATIENT OUTCOMES
Adequate fluid volume
NURSING DIAGNOSIS
PATIENT OUTCOMES
NURSING DIAGNOSIS
PATIENT OUTCOMES
Adequate nutrition
NURSING DIAGNOSIS
PATIENT OUTCOMES
Adequate gas exchange
NURSING DIAGNOSIS
PATIENT OUTCOMES
Electrolyte Replacement
Nutrition Support
Comfort Management
Pharmacological Intervention
Treatment of Systemic Complications
Surgical Therapy
Patient Outcomes
HEPATIC FAILURE
Pathophysiology
Hepatitis
Assessment.
Nursing Diagnoses.
Medical and Nursing Interventions.
BOX 17-13 Modes of Transmission for Hepatitis
CLINICAL ALERT
Signs and Symptoms of Fulminant Hepatic Failure9
TABLE 17-8 Characteristics of Hepatitis
TRANSPLANTATION Liver
INDICATIONS
CRITERIA FOR TRANSPLANT RECIPIENTS
CRITERIA FOR DONORS
PATIENT MANAGEMENT
COMPLICATIONS
PREVENTING REJECTION
REFERENCES
BOX 17-14 Common Hepatotoxic Drugs
Analgesics
Anesthetics
Anticonvulsants
Antidepressants
Antimicrobial Agents
Antipsychotic Drugs
Cardiovascular Drugs
Hormonal Agents
Sedatives
Others
Cirrhosis
Fatty Liver
Assessment of Hepatic Failure
Presenting Clinical Signs
Portal Hypertension.
TABLE 17-9 Characteristics of Types of Cirrhosis
BOX 17-15 Clinical Signs and Symptoms of Liver Disease
Cardiac
Dermatological
Electrolytes
Endocrine
Fluid Alterations
Gastrointestinal
Hematological
Immune System
Neurological
Pulmonary
Renal
Impaired Metabolic Processes.
Impaired Bile Formation and Flow.
Nursing Diagnoses
NURSING CARE PLAN for the Patient with Hepatic Failure
NURSING DIAGNOSIS
PATIENT OUTCOMES
Adequate fluid volume
NURSING DIAGNOSIS
PATIENT OUTCOMES
Adequate nutrition
NURSING DIAGNOSIS
PATIENT OUTCOMES
Effective breathing
NURSING DIAGNOSIS
PATIENT OUTCOMES
Normal thought processes
Medical and Nursing Interventions
Diagnostic Tests
Supportive Therapy
LABORATORY ALERTS
Liver Failure5
From Chernecky, C. C., & Berger, B. J. (2008). Laboratory tests and diagnostic procedures (5th ed.). Philadelphia: Saunders.
Support for the Failing Liver
Treatment of Complications
Ascites.
BOX 17-16 Physiological Effects of Abdominal Compartment Syndrome
Cardiovascular
Respiratory
Hepatic and Renal
Gastrointestinal
Neurological
Portal Systemic Encephalopathy.
FIGURE 17-12 The Denver shunt. Percutaneous placement of both the venous and peritoneal catheters of a Denver Ascites Shunt. Venous catheter placement into the (A) subclavian and (B) internal jugular vein.
BOX 17-17 Stages of Portal Systemic Encephalopathy
Stage 1
Stage 2
Stage 3
Stage 4
Hepatorenal Syndrome.
Patient Outcomes
CASE STUDY
QUESTIONS
SUMMARY
CRITICAL THINKING QUESTIONS
REFERENCES
CHAPTER 18 Endocrine Alterations
INTRODUCTION
Changes in the Endocrine System in Critical Illness
Disease States of the Endocrine System
HYPERGLYCEMIA IN THE CRITICALLY ILL PATIENT
FIGURE 18-1 Feedback system for cortisol regulation.
Achieving Glycemic Control
Hypoglycemia as a Preventable Adverse Effect of Glucose Management
GERIATRIC CONSIDERATIONS
PANCREAS
ADRENAL
THYROID
PITUITARY
The Diabetic Patient in the Critical Care Unit
Box 18-1 Risk Factors for the Development of Hyperglycemia in the Critically Ill Patient16,19
Box 18-2 Key Components of a Glucose Management Protocol
PANCREATIC ENDOCRINE EMERGENCIES
Review of Physiology
TABLE 18-1 Types of Insulin
Box 18-3 Physiological Activity of Insulin
Carbohydrate Metabolism
Fat Metabolism
Protein Metabolism
Effects of Aging
Hyperglycemic Crises
Pathogenesis
CLINICAL ALERT
Metabolic Syndrome
GENETICS
Type 2 Diabetes Mellitus: A Complex Disease with Complex Genetics
REFERENCES
FIGURE 18-2 Pathophysiology of diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS).
Etiology of Diabetic Ketoacidosis.
Box 18-4 Factors Leading to Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State
Common Factors
Medications
DKA-Specific Factors
HHS-Specific Factors
Etiology of Hyperosmolar Hyperglycemic State.
Pathophysiology of Diabetic Ketoacidosis
FIGURE 18-3 Intracellular/extracellular shifts in hyperglycemic crises. DKA, Diabetic ketoacidosis.
Box 18-5 Calculation for Anion Gap
Pathophysiology of Hyperosmotic Hyperglycemic State
Box 18-6 HHS and Other Synonymous Acronyms
Assessment
Clinical Presentation.
TABLE 18-2 Manifestations of Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State
Laboratory Evaluation.
LABORATORY ALERTS
Pancreatic Endocrine Disorders
Nursing and Medical Interventions
EVIDENCE-BASED PRACTICE
PROBLEM
QUESTION
REFERENCES
EVIDENCE
IMPLICATIONS FOR NURSING
Respiratory Support.
Fluid Replacement.
Insulin Therapy.
Box 18-7 Signs and Symptoms of Fluid Overload
Electrolyte Management.
Treatment of Acidosis.
Patient and Family Education.
Patient Outcomes
NURSING CARE PLAN for the Patient with Hyperglycemic Crisis
NURSING DIAGNOSIS
PATIENT OUTCOMES
Normal respiratory rate and pattern
NURSING DIAGNOSIS
PATIENT OUTCOMES
Adequate fluid volume status
NURSING DIAGNOSIS
PATIENT OUTCOMES
Effective therapeutic management of diabetes
Hypoglycemia
Pathophysiology
Etiology
FIGURE 18-4 Pathophysiology of hypoglycemia.
Assessment
Clinical Presentation.
Box 18-8 Causes of Hypoglycemia
Excess Insulin or Oral Hypoglycemics
Decreased Oral, Enteral, or Parenteral Intake
Underproduction of Glucose
Too Rapid Utilization of Glucose
TABLE 18-3 Signs and Symptoms of Hypoglycemia
Laboratory Evaluation.
Nursing Diagnoses
Box 18-9 Treatment of Hypoglycemia
Mild Hypoglycemia
Moderate Hypoglycemia
Severe Hypoglycemia
Nursing and Medical Interventions
Box 18-10 Sources of 15 Grams of Carbohydrates
Patient Outcomes
ACUTE AND RELATIVE ADRENAL INSUFFICIENCY
Etiology
Box 18-11 Causes of Adrenal Insufficiency
Primary
Secondary
Box 18-12 Therapeutic Uses of Corticosteroids
Replacement Therapy in Patients with Primary or Secondary Adrenal Cortical Insufficiency
Review of Physiology
Box 18-13 Physiological Effects of Glucocorticoids (Cortisol)
Pathophysiology
FIGURE 18-5 Physiology of aldosterone release.
Assessment
Clinical Presentation
Box 18-14 Risk Factor Analysis for Adrenal Crisis
Cardiovascular System.
Neurological System.
FIGURE 18-6 Pathophysiological effects of adrenal insufficiency. BUN, Blood urea nitrogen; ECG, electrocardiogram; MSH, melanocyte-stimulating hormone.
Gastrointestinal System.
Genitourinary System.
Box 18-15 Progressive Signs of Chronic Adrenal Insufficiency
Laboratory Evaluation
LABORATORY ALERTS
Adrenal Disorders
Nursing Diagnoses
Box 18-16 Cosyntropin Stimulation Test
Standard Method
Test Response
Nursing and Medical Interventions
Fluid and Electrolyte Replacement
Hormonal Replacement
PHARMACOLOGY TABLE 18-4 Medications Used to Treat Adrenal Crisis
Box 18-17 Treatment of Adrenal Crisis
Identify and Treat Precipitating Event
Replace Fluid and Electrolytes
Hormonal Replacement
Patient Education
Patient and Family Education
THYROID GLAND IN CRITICAL CARE
Review of Physiology
Box 18-18 Physiological Effect of Thyroid Hormones
Major Effects
Other Effects
FIGURE 18-7 Feedback systems for thyroid hormone regulation.
Box 18-19 Causes of Blockage of Conversion from Thyroxine to Triiodothyronine
Effects of Aging
Thyroid Function in the Critically Ill
THYROID CRISES
Etiology
Box 18-20 Causes of Hyperthyroidism
Most Common
Other Causes
Rare Causes
Associated with Other Disorders*
Thyrotoxic Crisis (Thyroid Storm)
Pathophysiology
Box 18-21 Causes of Hypothyroidism
Primary Thyroid Disease
Secondary (Pituitary) or Tertiary (Hypothalamus) Disease
Assessment
Clinical Presentation
Thermoregulation Disturbances.
Neurological Disturbances.
Cardiovascular Disturbances.
Box 18-22 Progressive Signs of Hyperthyroidism
Pulmonary Disturbances.
Gastrointestinal Disturbances.
Musculoskeletal Disturbances.
Laboratory Evaluation.
Nursing Diagnoses
TABLE 18-5 Thyroid Crises
Nursing and Medical Interventions
Box 18-23 Treatment of Thyroid Storm
Antagonize Peripheral Effects of Thyroid Hormone
Inhibit Hormone Biosynthesis
Block Thyroid Hormone Release
Give 1-2 Hours after Proplylthiouracil or Methimazole Loading Dose
Secondary Options
Supportive Therapy
Identify and Treat Precipitating Cause
Patient and Family Education
LABORATORY ALERTS
Thyroid Disorders
Antagonism of Peripheral Effects of Thyroid Hormones.
Inhibition of Thyroid Hormone Biosynthesis.
Blockage of Thyroid Hormone Release.
Supportive Care.
Patient and Family Education.
Patient Outcomes
Myxedema Coma
Pathophysiology
Etiology
Assessment
Clinical Presentation.
Cardiovascular Disturbances.
Box 18-24 Progressive Signs of Hypothyroidism
Pulmonary Disturbances.
Neurological Disturbances.
Skeletal Muscle Disturbances.
Laboratory Evaluation.
Nursing Diagnoses
Nursing and Medical Interventions
Box 18-25 Treatment of Myxedema Coma
Thyroid Replacement.
Fluid and Electrolyte Restoration.
Supportive Care.
Patient and Family Education.
Patient Outcomes
ANTIDIURETIC HORMONE DISORDERS
Review of Physiology
FIGURE 18-8 Hypothalamic–posterior pituitary system.
Diabetes Insipidus
Etiology
Box 18-26 Causes of Diabetes Insipidus
Antidiuretic Hormone Deficiency (Neurogenic Diabetes Insipidus)
Antidiuretic Hormone Insensitivity (Nephrogenic Diabetes Insipidus)
Secondary Diabetes Insipidus
Pathophysiology
FIGURE 18-9 Physiology of antidiuretic hormone (ADH) release. BP, Blood pressure.
TABLE 18-6 Electrolyte and Fluid Findings in ADH Disorders
Assessment
Clinical Presentation.
Laboratory Evaluation.
Nursing Diagnoses
Nursing and Medical Interventions
Volume Replacement.
Hormone Replacement.
LABORATORY ALERTS
Pituitary Disorders
Nephrogenic Diabetes Insipidus.
Patient and Family Education.
Patient Outcomes
Syndrome of Inappropriate Antidiuretic Hormone
Etiology
Pathophysiology
Assessment
Clinical Presentation.
Box 18-27 Causes of Syndrome of Inappropriate Antidiuretic Hormone
Ectopic Antidiuretic Hormone Production
Central Nervous System Disorders
Drugs
Positive-Pressure Ventilation
Central Nervous System.
Gastrointestinal System.
Cardiovascular System.
Pulmonary System.
Laboratory Evaluation.
Nursing Diagnoses
Nursing and Medical Interventions
Fluid Balance.
Box 18-28 Treatments for Chronic or Resistant Syndrome of Inappropriate Antidiuretic Hormone
Nursing.
Patient and Family Education.
Patient Outcomes
CASE STUDY
QUESTIONS
SUMMARY
CRITICAL THINKING QUESTIONS
REFERENCES
CHAPTER 19 Trauma and Surgical Management
INTRODUCTION
TRAUMA DEMOGRAPHICS
SYSTEMS APPROACH TO TRAUMA CARE
Trauma System
Levels of Trauma Care
Trauma Continuum
Injury Prevention
Trauma Team Concept
Box 19-1 Multidisciplinary Trauma Team
Prehospital Care and Transport
Trauma Triage
Disaster and Mass Casualty Management
MECHANISMS OF INJURY
Blunt Trauma
Penetrating Trauma
FIGURE 19-1 Potential sites of blunt trauma injury in unrestrained passenger and driver in a motor vehicle crash. A, Unrestrained passenger in front seat. B, Unrestained driver. C, Lateral impact collision.
Blast Injuries
EMERGENCY CARE PHASE
Initial Patient Assessment
Primary and Secondary Survey
TABLE 19-1 Primary Survey: ABCDE
RESUSCITATION PHASE
Establishing Airway Patency
TABLE 19-2 Secondary Survey
Maintaining Effective Breathing
Maintaining Circulation
TABLE 19-3 Specific Interventions for Ineffective Breathing Patterns
Diagnostic Testing
Adequacy of Resuscitation
Fluid Resuscitation
TABLE 19-4 Responses to Initial Fluid Resuscitation*
EVIDENCE-BASED PRACTICE
PROBLEM
Question
REFERENCE
EVIDENCE
IMPLICATIONS FOR NURSING
Assessment of Neurological Disabilities
Exposure and Environmental Considerations
FIGURE 19-2 Medi-Temp Blood and Fluid Warmer.
TABLE 19-5 Rewarming Strategies
ASSESSMENT AND MANAGEMENT OF SPECIFIC ORGAN INJURIES
Thoracic Injuries
Cardiac Tamponade
Cardiac Contusion
Aortic Disruption
Tension Pneumothorax
Hemothorax
Open Pneumothorax
Pulmonary Contusion
Rib Fractures and Flail Chest
Abdominal Injuries
Musculoskeletal Injuries
FIGURE 19-3 Common types of fractures.
Complications
Compartment Syndrome.
Rhabdomyolysis.
Deep Vein Thrombosis.
Fat Embolism Syndrome.
CRITICAL CARE PHASE
Damage-Control Surgery
Postoperative Management
GERIATRIC CONSIDERATIONS
SPECIAL CONSIDERATIONS AND POPULATIONS
Effects of Aging
Alcohol and Drug Abuse
Box 19-2 Signs and Symptoms of Alcohol Withdrawal
Family and Patient Coping
REHABILITATION
CASE STUDY
QUESTIONS
SUMMARY
CRITICAL THINKING QUESTIONS
REFERENCES
CHAPTER 20 Burns
INTRODUCTION
REVIEW OF ANATOMY AND PHYSIOLOGY OF THE SKIN
Effects of Aging
FIGURE 20-1 Anatomy of the skin.
MECHANISMS OF INJURY
Thermal Injury
Chemical Injury
Electrical Injury
TABLE 20-1 Types of Smoke Inhalation Injury
Inhalation Injury
Carbon Monoxide Poisoning
TABLE 20-2 Carboxyhemoglobin
Injury Above the Glottis
CLINICAL ALERT
Clinical Indicators of Inhalation Injury
Injury Below the Glottis
BURN CLASSIFICATION AND SEVERITY
CLINICAL ALERT
Guidelines for Burn Center Referral
Depth of Injury
TABLE 20-3 Depth of Burn Injury
Extent of Injury
PHYSIOLOGICAL RESPONSES TO BURN INJURY
FIGURE 20-2 Zones of thermal injury.
FIGURE 20-3 The rule of nines. TBSA, Total body surface area. EXAMPLE: An adult with superficial burns to the face and partial-thickness burns to the lower half of the right arm, entire left arm, and chest: 4.5% (lower right arm) + 9% (entire left arm) + 9% (chest or upper anterior trunk) = 22.5% TBSA (the superficial burns to the face are not included in the %TBSA calculation).
FIGURE 20-4 Burn estimate and diagram. Ant, Anterior; post, posterior; L, left; R, right; R. U., right upper; R. L., right lower; L. U., left upper; L. L., left lower.
FIGURE 20-5 Overview of physiological changes that occur after acute burn injury. TBSA, Total body surface area; TNF, tumor necrosis factor.
FIGURE 20-6 Pathophysiology of extensive burn injury. *A response associated with burn injury greater than 20% to 25% total body surface area (%TBSA). CO, Cardiac output; H2O, water; Hct, hematocrit; SVR, systemic vascular resistance; UO, urinary output.
FIGURE 20-7 Burn edema and shock development. H2O, Water; K, potassium; Na, sodium.
Cardiovascular Response
Host Defense Mechanisms
Pulmonary Response
Renal Response
Gastrointestinal Response
Metabolic Response
PHASES OF BURN CARE ASSESSMENT AND COLLABORATIVE INTERVENTIONS
Resuscitative Phase: Prehospital
Primary Survey
NURSING CARE PLAN for Resuscitative and Acute Care Phases of Major Burn Injury
NURSING DIAGNOSIS
PATIENT OUTCOMES
Adequate airway clearance and gas exchange
NURSING DIAGNOSIS
Adequate fluid volume
PATIENT OUTCOMES
NURSING DIAGNOSIS
PATIENT OUTCOME
Normothermia
NURSING DIAGNOSIS
PATIENT OUTCOMES
Adequate tissue perfusion
NURSING DIAGNOSIS
PATIENT OUTCOMES
Relief of pain
NURSING DIAGNOSIS
PATIENT OUTCOMES
Absence of infection
NURSING DIAGNOSES
PATIENT OUTCOMES
Absence of injury and adequate nutrition
NURSING DIAGNOSIS
PATIENT OUTCOMES
Physical mobility
NURSING DIAGNOSIS
PATIENT OUTCOMES
Effective coping
Stopping the Burning Process.
FIGURE 20-8 Major burn injury: primary survey. BP, Blood pressure; CPR, cardiopulmonary resuscitation.
Airway (with Cervical Spine Precautions).
Breathing.
Circulation.
Secondary Survey
FIGURE 20-9 Major burn injury: secondary survey. ABG, Arterial blood gas; ECG, electrocardiogram; IV, intravenous; LR, lactated Ringer’s solution.
Resuscitative Phase: Emergency Department and Critical Care Burn Center
Transfer to a Burn Center
Primary Survey
Airway.
Breathing.
FIGURE 20-10 Burn center transfer form. ABG, Arterial blood gas; CIRC, circulatory; CO, carbon monoxide; ET, endotracheal tube; GI/GU, gastrointestinal/genitourinary; HEENT, head, eyes, ears, nose, throat; NG, nasogastric tube; O2, oxygen.
FIGURE 20-11 Facial edema.
FIGURE 20-12 Escharotomy.
Circulation
Fluid Resuscitation.
BOX 20-1 Burn Fluid Resuscitation Formula
First 24 Hours Administer
ABLS Consensus Formula (Based on the Parkland Formula)
Second 24 Hours Administer
Parkland Formula
End Point Monitoring.
EVIDENCE-BASED PRACTICE
PROBLEM
REFERENCES
EVIDENCE
IMPLICATIONS FOR NURSING
Peripheral Circulation.
Secondary Survey
Cardiovascular System.
Neurological Status.
Renal Status.
Gastrointestinal System.
Integumentary System.
Blood and Electrolytes.
Acute Care Phase: Critical Care Burn Center
LABORATORY ALERTS
Respiratory System
Cardiovascular System
Neurological Status
Renal Status
Gastrointestinal System
Integumentary System
Blood and Electrolytes
SPECIAL CONSIDERATIONS AND AREAS OF CONCERN
Burns of the Face
Burns of the Ears
Burns of the Eyes
Burns of the Hands, Feet, or Major Joints
Burns of the Genitalia and Perineum
Electrical Injury
Chemical Injury
BOX 20-2 Manifestations and Complications of Electrical Injury
Abuse and Neglect
FIGURE 20-13 Child abuse by hot water immersion. The thigh burn wound edges have a clear demarcation line (are in a straight line), and there are no splash marks. The parents delayed seeking medical treatment for the child’s burns until 3 days after injury (note the dry, crusty appearance of the wounds). The child also had a forearm fracture and multiple areas of bruising on the body.
PAIN CONTROL
INFECTION CONTROL
WOUND MANAGEMENT
Wound Care
Topical Agents and Dressings
PHARMACOLOGY TABLE 20-4 Topical Antimicrobial Agents for Burn Wound Management
TABLE 20-5 Biological and Biosynthetic Dressings
Surgical Excision and Grafting
FIGURE 20-14 A, Vacuum-assisted closure (VAC) device. B, The device creates a negative-pressure dressing to decompress edematous interstitial spaces and to increase local perfusion, help draw wound edges closed uniformly, remove wound fluid, and provide a closed, moist healing environment.
FIGURE 20-15 Excision and autografting. A, Surgical debridement (excision) with meshed autograft placement in the operating room. B, Meshed autograft postoperative day 2. C, Comparison of sheet autograft (on hand) versus meshed autograft (on forearm) 3 weeks postoperatively. Use of meshed autograft allows larger body surface area coverage, but it also typically leads to more scarring and a less cosmetically pleasing appearance.
TABLE 20-6 Autograft Skin: Nursing Implications
NUTRITIONAL CONSIDERATIONS
TABLE 20-7 Types of Donor Site Dressings
PSYCHOSOCIAL CONSIDERATIONS
GERIATRIC CONCERNS
BOX 20-3 Stages of Postburn Psychological Adaptation
Survival Anxiety
Search for Meaning
Investment in Recuperation
Investment in Rehabilitation
Reintegration of Identity
GERIATRIC CONSIDERATIONS
NONBURN INJURY
Severe Exfoliative Disorders
Toxic Epidermal Necrolysis, Stevens-Johnson Syndrome, Erythema Multiforme
Staphylococcal Scalded Skin Syndrome
Necrotizing Soft Tissue Infections
DISCHARGE PLANNING
BURN PREVENTION
BOX 20-4 Strategies for Preventing Burn Injuries
Cook with Care
Hot Liquids Cause Scalds
Home Precautions
Fire Extinguishers and Smoke Detectors
Occupation-Related Precautions
CASE STUDY
QUESTIONS
SUMMARY
CRITICAL THINKING QUESTIONS
REFERENCES

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