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Clinical Problems, 7
th
edition
Key Points
Chapter 1: Nursing Practice Today
Nursing involves the (1) protection, promotion, and optimization of health and ailities!
(") prevention of illness and in#ury! ($) alleviation of suffering through the diagnosis and
treatment of human response! and (%) advocacy in the care of individuals, families,
communities, and populations&
Nurses offer s'illed care to those recuperating from illness or in#ury, advocate for
patients( rights, teach patients so that they can ma'e informed decisions, support patients
at critical times, and help them navigate the increasingly comple) health care system&
Certification in nursing specialties (e&g&, amulatory care, critical care, gerontologic,
pediatric, psychiatric and mental health, and community health nursing) is offered
through a variety of nursing organizations&
*ntry+level nurses ,ith an associate or accalaureate degree in nursing are prepared to
function as generalists& -ith additional preparation, nurses can assume roles such as
clinical nurse specialist and nurse practitioner&
The e)act roles (i&e&, independent, dependent, collaorative) of the nurse are often
determined y state and agency policies& .n most cases, the nurse(s role is one of
/interdependence and co+participation0 ,ith the patient and other health team memers&
Delegation of nursing interventions to licensed practical nurses1licensed vocational
nurses (2PNs123Ns) and unlicensed assistive personnel (45P) is an important function
of the professional nurse&
Healthy People 2010 is a road+ased program that involves government, private, pulic,
and nonprofit organizations in preventing disease and promoting health&
!idence-based "ractice (*6P) is the conscientious use of the est evidence (e&g&,
findings from research) in comination ,ith clinician e)pertise and patient preferences
and values in clinical decision+ma'ing&
Nursing informatics is a specialty that integrates nursing science, computer science, and
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Key Points
information science in identifying, collecting, processing, and managing data and
information to support nursing practice, administration, education, and research&
The five elements of the nursing "rocess are assessment, diagnosis, planning,
implementation, and evaluation& ;nce egun, the nursing process is not only continuous
ut it is also cyclic in nature&
Standardi#ed nursing terminologies can promote continuity of patient care and provide
data that can support the crediility of the profession&
Nursing diagnoses descrie health states that nurses can legally diagnose and treat& 5
three+part nursing diagnosis statement includes the prolem, etiology, and signs and
symptoms&
Collaborati!e "roblems are potential or actual complications of disease or treatment that
nurses treat ,ith other health care providers, most fre<uently physicians&
The Nursing $utcomes Classification %N$C& is a research+ased, standardized
language for nursing outcomes& .t is used to evaluate the effects of nursing interventions&
N;C is a list of measures that descries patient outcomes influenced y nursing
interventions&
The Nursing 'nter!entions Classification %N'C& includes independent and collaorative
interventions that nurses carry out, or direct others to carry out, on ehalf of patients&
5 nursing inter!ention is any treatment ased on clinical #udgment and 'no,ledge that
a nurse performs to enhance "atient outcomes(
The setting of specific outcomes ,ith outcome indicators is necessary for systematic
measurement of the patient(s progress&
;utcomes may e developed y ,riting specific outcome statements or choosing
outcomes from the Nursing ;utcomes Classification (N;C)&
The Nursing .nterventions Classification (N.C) includes treatments (oth physiologic and
psychosocial) that nurses perform in all settings and specialties&
N.C and N;C provide a common language for communication among nurses and
facilitate computer collection of standardized nursing data&
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Key Points
=uring the e!aluation phase, the nurse determines ,hether the patient outcomes and
nursing interventions ,ere realistic, measurale, and achievale&
5ssessment, diagnosis, outcomes, interventions, and evaluation of the patient(s response
to care are a critical part of the patient(s record&
-hen nursing terminologies are used in information systems for documentation of
nursing practice, nurses can trac' and report on the enefits of nursing care&
Lewis et al: Medical-Surgical Nursing: Assessment and Management of
Clinical Problems, 7
th
edition
Key Points
Chapter ": >ealth =isparities
Determinants of health are those factors that influence the health of individuals&
)ealth dis"arities refer to differences in measures in the health status among groups of
people in a community, a state, or the entire nation&
?acial, ethnic, and cultural differences e)ist in the health screening ehaviors, treatments
provided, and access to health care providers&
@actors such as stereotyping and pre#udice can affect health care see'ing ehavior in
minority populations&
=iscrimination and ias occur ,hen negative treatment occurs ased on race, ethnicity,
gender, aging, and se)ual orientation&
4se of standardized evidence+ased guidelines can reduce health disparities in diagnosis
and treatment&
.nterpersonal s'ills such as active listening, relationship uilding, and effective
communication are asic to the delivery of high <uality and e<uitale health care&
Lewis et al: Medical-Surgical Nursing: Assessment and Management of
Clinical Problems, 7
th
edition
Key Points
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Chapter %: >ealth >istory and Physical *)amination
The nurse and physician oth otain a patient history and perform a physical
e)amination, ut they use different formats and analyze the data differently&
The nursing assessment includes oth su#ective and o#ective data(
o Sub*ecti!e data are ,hat the patient tells the nurse aout himself or herself&
o $b*ecti!e data are otained using inspection, palpation, percussion, and
auscultation during the physical e)amination&
5 comprehensive database includes information aout the patient(s health status, health
maintenance ehaviors, individual coping patterns, support systems, current development
tas's, and any ris' factors or lifestyle changes&
-hen a patient is unale to provide data (e&g&, the person is aphasic or unconscious), the
person assuming responsiility for the patient(s ,elfare can e as'ed aout the patient&
Patients should e informed that federal legislation affects the e)change, privacy, and
security of an individual(s health information&
5ssessment data should e otained and organized systematically so that they can e
analyzed to ma'e #udgments aout the patient(s health status and health prolems&
;ne frame,or' for otaining data uses the functional health "atterns developed y
Aordon&
Bu#ective data include past health history, medications, surgery, or other treatments&
The t,o types of physical e)aminations are as follo,s:
o Screening
o +ocused (prolem+centered)
Lewis et al: Medical-Surgical Nursing: Assessment and Management of
Clinical Problems, 7
th
edition
Key Points
Chapter C: Patient and @amily Teaching
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Bpecific goals for patient education include health promotion, prevention of disease,
management of illness, and appropriate selection and use of treatment options&
5 teaching "lan includes assessment of the patient(s aility, need, and readiness to learn as
,ell as identification of prolems that can e resolved ,ith teaching&
Learning occurs ,hen there is an internal mental change characterized y rearrangement of
neural path,ays&
,eaching is a process of delierately arranging e)ternal conditions to promote the internal
transformation that results in a change in ehavior&
-hen teaching adults, it is important to identify ,hat is valued y the person to enhance
motivation&
-einforcement is a strong motivational factor for maintaining ehavior& Positive
reinforcement involves re,arding a desired ehavior ,ith a positive stimulus to increase its
occurrence&
?e<uired s'ills for the nurse as a teacher include 'no,ledge of the su#ect matter,
communication s'ills, and empathy&
6ecause of shortened hospital stays and clinic visits, the nurse and the patient need to set
priorities of the patient(s learning needs so that teaching can occur during any contact ,ith the
patient or family&
*ducation of family memers is important ecause family memers can promote the patient(s
self+care and prevent complications&
The teaching "rocess involves development of a plan that includes assessment, diagnosis,
setting patient outcomes or o#ectives, intervention, and evaluation&
The patient(s e)periences, rate of learning, and aility to retain information are affected y age&
Pain, fatigue, and certain medications influence the patient(s aility to learn&
5n)iety and depression can negatively affect the patient(s motivation and readiness to learn&
5n individual(s elief in his or her capaility to produce and regulate events in life affects
motivation, thought patterns, ehavior, and emotions&
)ealth literac. is defined as the degree to ,hich individuals have the capacity to otain,
process, and understand asic health information and services needed to ma'e appropriate
health decisions&
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*ach person has a distinct style of learning& The three learning styles are as follo,s:
(1) 3isual (reading)
(") 5uditory (listening)
($) Physical (doing things)
Learning ob*ecti!es are ,ritten statements that define e)actly ho, patients demonstrate their
mastery of the content&
2earning o#ectives contain the follo,ing four elements:
(1) -ho ,ill perform the activity or ac<uire the desired ehavior
(") The actual ehavior that the learner ,ill e)hiit to demonstrate mastery of the o#ective
($) The conditions under ,hich the ehavior is to e demonstrated
(%) The specific criteria that ,ill e used to measure the patient(s success
Belecting a particular strategy is determined y at least three factors:
(1) Patient characteristics (e&g&, age, educational ac'ground, nature of illness, culture)
(") Bu#ect matter
($) 5vailale resources
6ecause of e)tent of health illiteracy, it is no, recommended that all patient education
materials e ,ritten at the Cth+ to Dth+grade reading level&
*valuation strategies for teaching include oserving the patient directly, oservation of veral
and nonveral cues, discussion ,ith the patient or family memer, using a standardized
measurement tool, and the patient(s self+evaluation of progress&
Lewis et al: Medical-Surgical Nursing: Assessment and Management of
Clinical Problems, 7
th
edition
Key Points
Chapter D: ;lder 5dults
Ageism (negative attitude ased on another(s age) can lead to discrimination and
disparities in health care provided to older adults&
5ging affects every ody system& /iologic aging is a alance of positive (e&g&, healthy
diet, e)ercise, coping, resources) and negative factors (e&g&, smo'ing, oesity)&
6iologic theories can e divided into stochastic and non-stochastic theories&
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;lder ,omen are especially at ris' for chronic health prolems, including arthritis,
hypertension, stro'es, and diaetes&
The frail elderl. are individuals ,ho are more vulnerale ecause of declining physical
health and limited resources&
Acti!ities of dail. li!ing (5=2), including athing, dressing, eating, toileting, and
transferring, are important for the nurse to assess in the older patient living ,ith chronic
illness&
@or the hospitalized older adult, there are special concerns related to high surgical ris',
acute confusional state, nosocomial infection, and premature discharge ,ith an unstale
condition&
The intensity and comple)ity of caregiving place the caregi!er at ris' for high levels of
stress& This may lead to emotional prolems, including depression, anger, and resentment&
@amily memers are perpetrators in appro)imately E out of 18 cases of domestic elder
abuse and neglect(
Continuing care retirement communities, congregate housing, and assisted living
facilities are housing options for the older adult&
>ome health care services re<uire physician recommendation and s'illed nursing care for
:edicare reimursement&
*thical issues surrounding care of the older adult include using restraints, evaluating the
patient(s aility to ma'e decisions, initiating resuscitation, treating infections, providing
nutrition and hydration, and advocating for an institutional ethics committee&
?educing disaility through geriatric rehabilitation is important to the <uality of life of
the older adult&
5ge+related changes in pharmacodynamics and pharmaco'inetics of drugs, as ,ell as
"ol."harmac., put the older adult at ris' for adverse drug reactions&
=epression is the most common mood disorder in older adults&
The comprehensive nursing geriatric assessment includes a thorough history using a
functional health pattern format, physical assessment, mood assessment, mental status
evaluation, 5=2 and instrumental 5=2 (.5=2) evaluation, and social+environmental
assessment&
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Lewis et al: Medical-Surgical Nursing: Assessment and Management of
Clinical Problems, 7
th
edition
Key Points
Chapter 9: Community+6ased Nursing and >ome Care
The focus of communit.-based nursing is the illness+oriented care of individuals and
families throughout the lifespan&
:any factors are changing the health care system, including socioeconomic status,
demographics, prevalence and type of illness, technology, and increased consumerism&
The goals of case management are to provide <uality care along a continuum, decrease
fragmentation of care across many settings, enhance the patient(s <ualify of life, and
contain cost&
The use of =iagnosis ?elated Aroups (=?As) has had a dramatic impact on health care&
>ealth care is constrained y third+party payer cost containment&
Community+ased settings ,here nursing care is delivered include ambulator. care,
transitional care, and long-term care (s'illed nursing, intermediate care, and residential
care facilities)&
Communit.-oriented nursing involves the engagement of nursing in promoting and
protecting the health of populations&
)ome health care may include health maintenance, education, illness prevention,
diagnosis and treatment of disease, palliative care, and rehailitation&
S0illed nursing care may include oservation, assessment, management evaluation,
teaching, training, administration of medications, ,ound care, tue feeding, catheter care,
and ehavioral health interventions&
.n home care situations, it is common for caregivers to ecome physically, emotionally,
and economically over,helmed ,ith responsiilities and demands of caregiving&
The home health care team may include the patient, family, nurses, physician, social
,or'er, physical therapist, occupational therapist, speech therapist, home health aide,
pharmacist, respiratory therapist, and dietitian&
Lewis et al: Medical-Surgical Nursing: Assessment and Management of
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Key Points
Clinical Problems, 7
th
edition
Key Points
Chapter F: Complementary and 5lternative Therapies
Com"lementar. and alternati!e thera"ies include a road domain of resources,
including health systems, modalities, and practices other than those intrinsic to the
dominant health system of a particular society or culture&
This definition highlights that ,hat might e considered /complementary and alternative0
in one country or at one period of history might e considered /conventional0 in another
place or time&
.ndividuals often /self+select0 these therapies, using them ,ithout professional
supervision&
Nearly half of the users of these therapies do not consult an alternative and
complementary practitioner or disclose such use to their traditional health care provider&
Patients should e advised that complementary therapies do not replace conventional
therapies, ut can often e used in comination ,ith conventional therapies&
,raditional Chinese Medicine (TC:) is a complete system of medicine ,ith an
individualized form of diagnosis and treatment, as ,ell as having its focus on prevention&
TC: includes acupuncture, Chinese heral medicine, and other modalities&
Mind-bod. inter!entions are a variety of techni<ues designed to facilitate the mind(s
capacity to affect ody function, including ehavioral, psychologic, social, and spiritual
approaches to health such as imagery, iofeedac', prayer, and meditation&
;ver the past $8 years, a resurgence of interest in herbal thera". has occurred in
countries ,hose health care is dominated y the iomedical model&
:edicinal plants ,or' in much the same ,ay as drugs! oth are asored and trigger
iologic effects that can e therapeutic& :any have more than one physiologic effect and
thus have more than one condition for ,hich they can e used&
Patients should e advised that if they ta'e heral therapies, they should adhere to the
suggested dosage& >eral preparations ta'en in large doses can e to)ic&
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Mani"ulati!e and bod.-based methods include interventions and approaches to health
care ased on manipulation or movement of the ody& *)amples include chiropractic
therapy, yoga, massage, and acupressure&
Massage is a form of touch and also a form of caring, communication, and comfort&
Nurses can use specific massage techni<ues as part of nursing care, ,hen indicated y the
nursing diagnosis or patient assessment&
nerg. thera"ies are those that involve the manipulation of energy fields such as
Therapeutic Touch, >ealing Touch, and ?ei'i&
,hera"eutic ,ouch (TT) is a method of detecting and alancing human energy that ,as
developed #ointly y a nurse and a traditional healer&
.t is important for the nurse to collect data on the patient(s use of complementary and
alternative therapies&
Lewis et al: Medical-Surgical Nursing: Assessment and Management of
Clinical Problems, 7
th
edition
Key Points
Chapter E: Btress and Btress :anagement
Stress occurs ,hen individuals perceive that they cannot ade<uately cope ,ith the
demands eing made on them or ,ith the threats to their ,ell+eing&
Key personal characteristicsGsuch as hardiness, sense of coherence, resilience, and
attitudeGuffer the impact of stress&
The physiologic response of the person to stress is reflected in the interrelationship of the
nervous, endocrine, and immune systems& Btress activation of these systems affects other
systems, such as the cardiovascular, respiratory, gastrointestinal, renal, and reproductive
systems&
Btress can have effects on cognitive function, including poor concentration, memory
prolems, distressing dreams, sleep disturances, and impaired decision+ma'ing&
2ong+term stress may increase the ris' of cardiovascular diseases such as atherosclerosis
and hypertension& ;ther conditions either precipitated or aggravated y stress include
migraine headaches, irritale o,el syndrome, and peptic ulcers&
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Co"ing is defined as a person(s cognitive and ehavioral efforts to manage specific
e)ternal or internal stressors that seem to e)ceed availale resources&
Coping can e either positive or negative& Positive coping includes activities such as
e)ercise and use of social support& Negative coping may include sustance ause and
denial&
Coping strategies can also e divided into t,o road categories: emotion+focused coping
and prolem+focused coping&
motion-focused co"ing involves managing the emotions that an individual feels ,hen
a stressful event occurs& Problem-focused co"ing attempts to find solutions to resolve
the prolems causing the stress&
-ela1ation strategies can e used to cope ,ith stressful circumstances and elicit the
rela)ation response&
The rela1ation res"onse is the state of physiologic and psychologic deep rest& .t is the
opposite of the stress response and is characterized y decreased sympathetic nervous
system activity, ,hich leads to decreased heart rate and respiratory rate, decreased lood
pressure, decreased muscle tension, decreased rain activity, and increased s'in
temperature&
?egular elicitation of the rela)ation response can e achieved through rela)ation
reathing, meditation, imagery, music, muscle rela)ation, and massage&
Lewis et al: Medical-Surgical Nursing: Assessment and Management of
Clinical Problems, 7
th
edition
Key Points
Chapter 18: Pain
Pain is defined as ,hatever the person e)periencing the pain says it is, e)isting ,henever
the person says it does&
4ntreated pain can result in unnecessary suffering, physical and psychosocial
dysfunction, impaired recovery from acute illness and surgery, immunosuppression, and
sleep disturances&
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.nade<uate pain management may e due to (1) insufficient 'no,ledge and s'ills to
assess and treat pain! (") un,illingness of providers to elieve patients( report of pain! ($)
lac' of time, e)pertise, and perceived importance of conducting regular pain assessments!
(%) inaccurate and inade<uate information regarding addiction, tolerance, respiratory
depression, and other side effects of opioids! and (C) fear that aggressive pain
management may hasten or cause death&
Components of the nursing role include (1) assessing pain and communicating this
information to other health care providers, (") ensuring the initiation and coordination of
ade<uate pain relief measures, ($) evaluating the effectiveness of these interventions, and
(%) advocating for people ,ith pain&
Pain has many dimensions and components, including the follo,ing:
o The physiologic dimension of pain includes the genetic, anatomic, and physical
determinants of pain&
o The affective component of pain is the emotional response to the pain e)perience&
o The behavioral component of pain refers to the oservale actions used to e)press
or control the pain&
o The cognitive component of pain refers to eliefs, attitudes, memories, and
meaning attriuted to the pain&
o The sociocultural dimension of pain encompasses factors such as demographics,
support systems, social roles, and culture&
The emotional distress of pain can cause suffering, ,hich is defined as the state of severe
distress associated ,ith events that threaten the intactness of the person&
Culture also affects the e)perience of pain, specifically the pain e)pression, medication
use, and pain+related eliefs and coping&
Pain is most commonly categorized as nociceptive or neuropathic ased on underlying
pathology or as acute or chronic&
Nocice"tion is the physiologic process y ,hich information aout tissue damage is
communicated to the central nervous system& Nociception involves transduction,
transmission, perception, and modulation&
o ,ransduction is the conversion of a mechanical, thermal, or chemical stimulus
into a neuronal action potential&
No)ious (tissue+damaging) stimuli cause the release of numerous
chemicals into the area surrounding the peripheral nociceptors&
.nflammation and the suse<uent release of chemical mediators increase
the li'elihood of transduction&
The pain produced from activation of peripheral nociceptors is called
nociceptive pain&
Pain arising from anormal processing of stimuli y the nervous system is
called neuropathic pain&
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=ecreasing the effects of chemicals released at the periphery is the asis of
several drugs (e&g&, nonsteroidal antiinflammatory drugs HNB5.=sI)&
o ,ransmission is the movement of pain impulses from the site of transduction to
the rain&
Dermatomes are areas on the s'in that are innervated primarily y a
single spinal cord segment&
-eferred "ain must e considered ,hen interpreting the location of pain
reported y the person ,ith in#ury to or disease involving visceral organs&
o Perce"tion occurs ,hen pain is recognized, defined, and responded to y the
individual e)periencing the pain& The rain is necessary for pain perception&
o Modulation involves the activation of descending path,ays that e)ert inhiitory
or facilitatory effects on the transmission of pain&
Neuropathic pain is further classified as somatic and visceral&
o Somatic "ain is characterized y deep aching or throing that is ,ell localized
and arises from one, #oint, muscle, s'in, or connective tissue&
o 2isceral "ain, ,hich may result from stimuli such as tumor involvement or
ostruction, arises from internal organs&
Neuro"athic "ain is caused y damage to peripheral nerves or CNB& Common causes of
neuropathic pain include trauma, inflammation, metaolic disease, infections of the
nervous system, tumors, to)ins, and neurologic disease&
5cute pain and chronic pain are different as reflected in their cause, course,
manifestations, and treatment&
o Acute "ain typically diminishes over time as healing occurs&
o Chronic "ain, or persistent pain, lasts for longer periods, often defined as longer
than $ months or past the time ,hen an e)pected acute pain or acute in#ury should
suside&
The goals of a nursing pain assessment are (1) to descrie the patient(s multidimensional
pain e)perience for the purpose of identifying and implementing appropriate pain
management techni<ues and (") to identify the patient(s goal for therapy and resources
for self+management&
5 comprehensive assessment of pain includes descriing the onset, duration,
characteristics, pattern, location, intensity, <uality, and associated symptoms such as
an)iety and depression&
/rea0through "ain is a transient, moderate to severe pain that occurs eyond the pain
treated y current analgesics&
Pain scales are useful tools to help the patient communicate pain intensity& Bcales must e
ad#usted for age and cognitive development&
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Patients typically descrie neuropathic pain as a urning, numing, shooting, staing, or
itchy sensation&
Nociceptive pain may e descried as sharp, aching, throing, and cramping& 5ssociated
symptoms such as an)iety, fatigue, and depression may e)acerate or e e)acerated y
pain&
Btrategies for pain management include prescription and nonprescription drugs and
nondrug therapies such as hot and cold applications, complementary and alternative
therapies (e&g&, heral products, acupuncture), and rela)ation strategies (e&g&, imagery)&
o 5ll strategies must e documented, oth those that ,or' and those that are
ineffective&
o Patient and family eliefs, attitudes, and e)pectations influence responses to pain
and pain treatment&
Pain medications generally are divided into three categories: nonopioids, opioids, and co+
analgesic or ad#uvant drugs&
o :ild pain often can e relieved using nonopioids alone&
o :oderate to severe pain usually re<uires an opioid&
o Neuropathic pain often re<uires a co+analgesic and ad#uvant drug&
o Nonopioid pain medications include acetaminophen, aspirin, and nonsteroidal
antiinflammatory agents (NB5.=s)&
NB5.=s are associated ,ith a numer of side effects, including leeding tendencies,
gastrointestinal ulcers and leeding, and renal and CNB dysfunction&
$"ioids are the strongest analgesics availale&
o ;pioids produce their effects y inding to receptors in the CNB&
o Common side effects of opioids include constipation, nausea, vomiting, sedation,
respiratory depression, and pruritus&
o 5 o,el regimen should e instituted at the eginning of opioid therapy and
should continue for as long as the person ta'es opioids&
o Concerns aout sedation and respiratory depression are t,o of the most common
fears associated ,ith opioids&
o .f severe respiratory depression occurs and stimulation of the patient (calling and
sha'ing patient) does not reverse the somnolence or increase the respiratory rate
and depth, nalo)one (Narcan), an opioid antagonist, can e administered
intravenously or sucutaneously&
Ad*u!ant analgesic thera"ies include antidepressants, antiseizure drugs,
"
+adrenergic
agonists, and corticosteroids&
o Tricyclic antidepressants enhance the descending inhiitory system and are
effective for a variety of pain syndromes, particularly neuropathic pain
syndromes&
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o 5ntiseizure or antiepileptic drugs (5*=s) affect oth peripheral nerves and the
CNB and are effective for neuropathic pain and prophylactic treatment of
migraine headaches&
o Clonidine (Catapres) and tizanidine (Janafle)) are the most ,idely used
"
+
adrenergic agonists and may e used for chronic headache and neuropathic pain&
o CorticosteroidsGincluding de)amethasone H=ecadronI, prednisone, and
methylprednisolone H:edrolIGare used for management of acute and chronic
cancer pain, pain secondary to spinal cord compression, and inflammatory #oint
pain syndromes&
5ppropriate analgesic scheduling focuses on prevention or control of pain rather than the
provision of analgesics only after the patient(s pain has ecome severe&
3uianalgesic dose refers to a dose of one analgesic that is e<uivalent in pain+relieving
effects compared ,ith another analgesic&
;pioids and other analgesic agents can e delivered via many routes&
o :ost pain medications are availale in oral preparations, such as li<uid and talet
formulations& ;pioids can e administered under the tongue or held in the mouth
and asored into systemic circulation, ,hich ,ould e)empt them from the first+
pass effect&
o @entanyl citrate (5cti<) is administered transmucosally&
o .ntranasal administration allo,s delivery of a medication (e&g&, utorphanol
HBtadolI) to highly vascular mucosa and avoids the first+pass effect&
o 5nalgesics availale as rectal suppositories include hydromorphone,
o)ymorphone, morphine, and acetaminophen&
o .ntravenous administration is the est route ,hen immediate analgesia and rapid
titration are necessary&
o .ntraspinal (epidural or intrathecal) opioid therapy involves inserting a catheter
into the suarachnoid space (intrathecal delivery) or the epidural space (epidural
delivery)&
o .ntraspinally administered analgesics are highly potent ecause they are delivered
close to the receptors in the spinal cord dorsal horn&
2ong+term epidural catheters may e placed for patients ,ith terminal
cancer or those ,ith certain pain syndromes that are unresponsive to other
treatments&
.ntraspinal catheters can e surgically implanted for long+term pain relief&
5 specific type of .3 delivery system is "atient-controlled analgesia
(PC5) or demand analgesia& .t can also e connected to an epidural
catheter (patient+controlled epidural analgesia HPC*5I)& -ith PC5, a dose
of opioid is delivered ,hen the patient decides that a dose is needed&
Neuroablati!e inter!entions are performed for severe pain that is unresponsive to all
other therapies&
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Neuroaugmentation involves electrical stimulation of the rain and the spinal cord&
:assage (superficial or deep) is a common therapy for pain& 5 trigger "oint is a
circumscried hypersensitive area ,ithin a tight and of muscle and is caused y acute or
chronic muscle strain&
*)ercise is a critical part of the treatment plan for patients ,ith chronic pain, particularly
those e)periencing musculos'eletal pain&
,ranscutaneous electrical ner!e stimulation (T*NB) involves the delivery of an
electric current through electrodes applied to the s'in surface over the painful region, at
trigger points, or over a peripheral nerve&
Percutaneous electrical ner!e stimulation (P*NB) stimulates deeper peripheral tissues
through a needle ,ith an attached stimulator& The needle is inserted near a large
peripheral or spinal nerve&
5cupuncture is a techni<ue of Traditional Chinese :edicine in ,hich very thin needles
are inserted into the ody at designated points to reduce musculos'eletal pain, repetitive
strain disorders, myofascial pain syndrome, postsurgical pain, postherpetic neuralgia,
peripheral neuropathic pain, and headaches&
>eat therapy can e either superficial or deep&
Cold therapy involves the application of either moist or dry cold to the s'in&
Techni<ues to alter the affective, cognitive, and ehavioral components of pain include
distraction, hypnosis, and rela)ation strategies&
The nurse acts as planner, educator, patient advocate, interpreter, and supporter of the
patient in pain and the patient(s family& .t is important to realize that a nurse(s eliefs and
attitudes may hinder appropriate pain management&
Aerontologic considerations:
o Treatment of pain in the elderly patient is complicated&
o ;lder adults metaolize drugs more slo,ly than younger persons and thus are at
greater ris' for higher lood levels and adverse effects&
o The use of NB5.=s in elderly patients is associated ,ith a high fre<uency of
serious A. leeding&
o ;lder people often ta'e many drugs for one or more chronic conditions&
o Cognitive impairment and ata)ia can e e)acerated ,hen analgesics such as
opioids, antidepressants, and antiseizure drugs are used&
o >ealth care providers for older patients should titrate drugs slo,ly and monitor
carefully for side effects&
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Lewis et al: Medical-Surgical Nursing: Assessment and Management of
Clinical Problems, 7
th
edition
Key Points
Chapter 11: *nd+of+2ife and Palliative Care
nd-of-life care (*;2 care) is the term currently used to descrie issues related to dying
and death care&
*;2 care focuses on the physical and psychosocial needs of the patients and their
families at the end of life&
Death is the irreversile cessation of circulatory and respiratory function or the
irreversile cessation of all functions of the entire rain, including the rainstem&
/erea!ement is an individual(s emotional response to the loss of a significant person&
4rief develops from ereavement and is a dynamic psychologic and physiologic
response follo,ing the loss&
5ssessment of spiritual needs in *;2 care is a 'ey consideration&
@amily involvement is integral to providing culturally competent *;2 care&
Persons ,ho are legally competent may choose organ donation&
Ad!ance care "lanning is focused on anticipated challenges that the patient and family
,ill face ecause of illness, medical treatment, and other concerns&
The nurse needs to e a,are of legal issues and the ,ishes of the patient&
Ad!ance directi!es and organ donor information should e located in the medical record
and identified on the patient(s record and1or the nursing care plan&
Palliati!e care is the active total care of patients ,hose disease is not responsive to
curative treatment& Palliative care focuses on controlling pain and other symptoms, as
,ell as reducing psychologic, social, and spiritual distress for the patient and the family&
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Palliative care is the frame,or' for hos"ice care& Palliative care can start much earlier in
a disease process, ,hereas hospice traditionally is limited to the pro#ected last D months
of life&
5dmission to a hospice program has t,o criteria: (1) the patient must desire the services!
and (") a physician must certify that the patient has D months or less to live&
The o#ective of a ereavement program is to provide support and to assist survivors in
the transition to a life ,ithout the deceased person&
The physical assessment is areviated in *;2 care and focuses on changes that
accompany terminal illness and the specific disease process&
@amilies need ongoing information on the disease, the dying process, and any care that
,ill e provided&
?espiratory distress and shortness of reath (dyspnea) are common near the end of life&
The sensation of air hunger results in an)iety for the patient and family memers&
:ost terminally ill and dying people do not ,ant to e alone and fear loneliness&
Priority interventions for grief must focus on providing an environment that allo,s the
patient to e)press feelings&
People ,ho are dying deserve and re<uire the same physical care as people ,ho are
e)pected to recover&
To meet the holistic needs of the patient, the nurse collaorates ,ith the social ,or'er,
chaplain, physical therapist, occupational therapists, certified nursing assistants, and
physician&
The patient near death may seem to e ,ithdra,n from the physical environment,
maintaining the aility to hear ,hile not eing ale to respond&
.t is important not to delay or deny pain relief measures to a terminally ill patient&
B'in integrity is difficult to maintain at the end of life due to immoility, urinary and
o,el incontinence, dry s'in, nutritional deficits, anemia, friction, and shearing forces&
5fter the patient is pronounced dead, the nurse prepares or delegates preparation of the
ody for immediate vie,ing y the family ,ith consideration for cultural customs and in
accordance ,ith state la, and agency policies and procedures&
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The role of caregiver includes ,or'ing and communicating ,ith the patient, supporting
the patient(s concerns, helping the patient resolve any unfinished usiness, ,or'ing ,ith
other family memers and friends, and dealing ,ith the caregiver(s o,n needs and
feelings&
5n understanding of the grieving process as it affects oth the patient and the family
caregivers is of great importance&
?ecognizing signs and ehaviors among family memers ,ho may e at ris' for
anormal grief reactions is an important nursing intervention&
Caring for dying patients is intense and emotionally charged& .t is important to consider
interventions that help ease physical and emotional stress for the nurse&
Terminal illness and dying are e)tremely personal events that affect the patient, the
family, and health care providers&
Lewis et al: Medical-Surgical Nursing: Assessment and Management of
Clinical Problems, 7
th
edition
Key Points
Chapter 1": 5ddictive 6ehaviors
The illicit sustances most commonly used in the 4nited Btates include
mari#uana1hashish, cocaine, hallucinogens, and heroin&
Compulsive ehaviors, including eating disorders, gamling, computer gaming and
interacting, and e)cessive e)ercise, are considered addicti!e beha!iors(
Addiction is a comple) disorder that is a treatale, chronic, relapsing disease& .t is
considered a ioehavioral disorder&
5ddiction results from the prolonged effects of addictive drugs or ehaviors on the rain&
The brain reward s.stem is a system that creates the sensation of pleasure& The
neurotransmitter dopamine plays a role in addiction&
Aenetics, environment, and sociocultural factors contriute to addiction&
Toacco:
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o The most common addictive ehavior is toacco use& The complications
associated ,ith the use of toacco (nicotine) are related to dose and method of
ingestion&
o Toacco use is the leading cause of preventale illness and death in the 4nited
Btates&
Cocaine:
o .s the most potent of the aused stimulants& 6esides its effects on the rain re,ard
system, cocaine produces adrenalin+li'e effects&
o Persons ,ho ause cocaine have prolems related to sleep, appetite, depression,
respiratory infections, chest pain, and1or headaches&
5mphetamines stimulate the central and peripheral nervous systems& They cause
increased alertness, improved performance, relief of fatigue, and anore)ia&
Caffeine promotes alertness and alleviates fatigue& .t is a ,ea' CNB stimulant&
5lcohol:
o .s consumed y almost C8K of 5mericans over the age of 1"& 5lcohol ause
affects 18K of the population&
o 5lcoholism is a chronic and potentially fatal disease if not treated&
o .n alcoholics, arupt ,ithdra,al may have life+threatening effects& Persons ,ho
ause alcohol often have a numer of health prolems&
o 5cute alcohol to)icity can occur ,ith inge drin'ing or the use of alcohol ,ith
other CNB depressants&
Bedative+hypnotic agents:
o Commonly used ones include ariturates, enzodiazepines, and ariturate+li'e
drugs&
o Bedative+hypnotics act on the CNB to cause sedation at lo, doses and sleep at
high doses& Tolerance develops rapidly&
Bigns and symptoms of opioid overdose include pinpoint pupils, clammy s'in, depressed
respiration, coma, and death (if not treated)&
;pioid overdose can precipitate a medical emergency&
Cannais (or mari#uana) is the most ,idely used illicit drug in North 5merica& :ari#uana
produces euphoria, sedation, and hallucinations&
The nurse must e alert to signs and symptoms of the many health prolems associated
,ith addictive ehaviors&
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.t is important for the nurse to promote an open and non#udgmental communication style
,ith the patient&
5 drug o!erdose is an emergency situation, and management is ased on the type of
sustance involved&
.n general, withdrawal signs and symptoms are opposite in nature from the direct effects
of the drug&
The patient ,ho is dependent on sustances is at ris' for postoperative complications&
Bevere pain should e treated ,ith opioids and at a much higher dosage than that used
,ith drug+naLve persons&
.t is the nurse(s responsiilityGin collaoration ,ith a multidisciplinary team composed
of physicians, social ,or'ers, and addiction specialistsGto address the patient(s
sustance ause prolem and motivate the patient to change ehaviors and see' treatment
for the addiction&
Lewis et al: Medical-Surgical Nursing: Assessment and Management of
Clinical Problems, 7
th
edition
Key Points
Chapter 1$: .nflammation and -ound >ealing
The inflammator. res"onse is a se<uential reaction to cell in#ury& .t neutralizes and
dilutes the inflammatory agent, removes necrotic materials, and estalishes an
environment suitale for healing and repair&
The asic types of inflammation are acute, suacute, and chronic&
o .n acute inflammation, the healing occurs in " to $ ,ee's and usually leaves no
residual damage&
o Subacute inflammation has the features of the acute process ut lasts longer&
o Chronic inflammation lasts for ,ee's, months, or even years&
The inflammatory response can e divided into a vascular response, a cellular response,
formation of e)udate, and healing&
The !ascular res"onse results in vasodilation causing hyperemia (increased lood flo,
in the area), ,hich raises filtration pressure&
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Key Points
=uring the cellular res"onse, neutrophils and monocytes move to the inner surface of the
capillaries (margination) and then through the capillary ,all (diapedesis) to the site of
in#ury&
1udate consists of fluid and leu'ocytes that move from the circulation to the site of
in#ury& The nature and <uantity of e)udate depend on the type and severity of the in#ury
and the tissues involved&
)ealing includes the t,o ma#or components of regeneration and repair& -egeneration is
the replacement of lost cells and tissues ,ith cells of the same type& -e"air is the more
common type of healing and usually results in scar formation&
The est management of inflammation is the prevention of infection, trauma, surgery, and
contact ,ith potentially harmful agents&
The purposes of wound management include (1) cleaning a ,ound to remove any dirt
and deris from the ,ound ed, (") treating infection to prepare the ,ound for healing,
and ($) protecting a clean ,ound from trauma so that it can heal normally&
5 "ressure ulcer is a localized area (usually over a ony prominence) of tissue necrosis
caused y unrelieved pressure that occludes lood flo, to the tissues& Pressure ulcers
generally fall under the category of healing y secondary intention&
Care of a patient ,ith a pressure ulcer re<uires local care of the ,ound and support
measures of the whole person, including ade<uate nutrition, pain management, control of
other medical conditions, and pressure relief&
Lewis et al: Medical-Surgical Nursing: Assessment and Management of
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edition
Key Points
Chapter 1%: Aenetics, 5ltered .mmune ?esponses, and Transplantation
4N,'CS
Aenetic disorders can e categorized into autosomal dominant, autosomal recessive, or
se)+lin'ed (M+lin'ed) recessive disorders&
o Autosomal dominant disorders are caused y a mutation of a single gene pair
(heterozygous) on a chromosome&
o Autosomal recessi!e disorders are caused y a mutation in t,o gene pairs
(homozygous) on a chromosome&
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o M+lin'ed recessive disorders are caused y a mutation on the M chromosome&
The different types of genetic testing include direct testing, lin'age testing, iochemical
testing, and 'aryotyping&
4ene thera". is an e)perimental techni<ue used to replace or repair defective or missing
genes ,ith normal genes&
Stem cells are cells in the ody that have the aility to differentiate into other cells& Btem
cells can e divided into t,o types: emryonic and adult&
AL,-D 'MM5N -SP$NSS
'mmunit. is a state of responsiveness to foreign sustances such as microorganisms and
tumor proteins& .mmune responses serve three functions: defense, homeostasis, and
surveillance&
.mmunity is classified as innate (natural) or ac<uired& 5c<uired immunity is the
development of immunity, either active or passive&
The immune response involves comple) interactions of T cells, 6 cells, monocytes, and
neutrophils& These interactions depend on c.to0ines (solule factors secreted y -6Cs
and a variety of other cells in the ody) that act as messengers et,een the cell types&
)umoral immunit. consists of antiody+mediated immunity& .n contrast, immune
responses initiated through specific antigen recognition y T cells are termed cell-
mediated immunit.( 6oth humoral and cell+mediated immunity are needed to remain
healthy&
'mmunocom"etence e)ists ,hen the ody(s immune system can identify and inactivate
or destroy foreign sustances&
5 h."ersensiti!it. reaction occurs ,hen the immune response is overreactive against
foreign antigens or fails to maintain self+tolerance& This results in tissue damage&
5lthough an alteration of the immune system may e manifested in many ,ays, allergies
or type . hypersensitivity reactions are seen most fre<uently&
o Common allergic reactions include anaphyla)is and atopic reactions&
o 5llergic rhinitis, atopic dermatitis, urticaria, and angioedema are common type .
hypersensitivity reactions&
5fter an allergic disorder is diagnosed, the therapeutic treatment is aimed at reducing
e)posure to the offending allergen, treating the symptoms, and if necessary, desensitizing
the person through immunotherapy&
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Ana"h.lactic reactions occur suddenly in hypersensitive patients after e)posure to the
offending allergen& They may occur follo,ing parenteral in#ection of drugs (especially
antiiotics), lood products, and insect stings&
:ost allergic reactions are chronic and are characterized y remissions and e)acerations
of symptoms&
The ma#or categories of drugs used for symptomatic relief of chronic allergic disorders
include antihistamines, sympathomimetic1decongestant drugs, corticosteroids, antipruritic
drugs, and mast cellNstailizing drugs&
.mmunotherapy is the recommended treatment for control of allergic symptoms ,hen the
allergen cannot e avoided and drug therapy is not effective&
T,o types of late) allergies can occur: type .3 allergic contact dermatitis and type .
allergic reactions&
Multi"le chemical sensiti!ities (:CB) is an ac<uired disorder in ,hich certain people
e)posed to various foods and chemicals in the environment have many symptoms related
to multiple ody systems&
The human leu0oc.te antigen (>25) system consists of a series of lin'ed genes that
occur together on the si)th chromosome in humans& 6ecause of its importance in the
study of tissue matching, the chromosomal region incorporating the >25 genes is termed
the ma#or histocompatiility comple)&
Autoimmunit. is an immune response against self& The immune system no longer
differentiates self from nonself&
.mmunodeficiency disorders involve an impairment of one or more immune mechanisms,
,hich include the follo,ing:
(1) Phagocytosis
(") >umoral response
($) Cell+mediated response
(%) Complement
(C) 5 comined humoral and cell+mediated deficiency
.mmunodeficiency disorders are primary if the immune cells are improperly developed or
asent and secondary if the deficiency is caused y illnesses or treatment&
,-ANSPLAN,A,'$N
Commonly transplanted organs and tissues include corneas, 'idneys, s'in, one marro,,
heart valves, one, and connective tissues&
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The degree of >25 matching re<uired or deemed suitale for successful solid organ
transplantation depends on the type of organ and the transplant center at ,hich the
transplant is eing performed&
?e#ection of organs occurs if the donor organ does not perfectly match the recipient(s
>25s& The re#ection can e prevented y closely matching 56;, ?h, and >25s et,een
donor and recipient&
The three types of organ re#ection can e classified as hyperacute, acute, and chronic&
The goal of immunosu""ressi!e thera". is to ade<uately suppress the immune response
to prevent re#ection of the transplanted organ ,hile maintaining sufficient immunity to
prevent over,helming infection&
Commonly used immunosuppressive drugs include corticosteroids, cyclosporine,
tacrolimus (Prograf), and mycophenolate mofetil (CellCept)&
Lewis et al: Medical-Surgical Nursing: Assessment and Management of
Clinical Problems, 7
th
edition
Key Points
Chapter 1C: .nfection and >uman .mmunodeficiency 3irus .nfection
'N+C,'$N
5n infection is an invasion of the ody y a pathogen (any microorganism that causes
disease) and the resulting signs and symptoms that develop in response to the invasion&
The most common causes of infection are acteria, viruses, fungi, and protozoa&
5n emerging infection is an infectious disease ,hose incidence has increased in the past
"8 years or threatens to increase in the immediate future&
*merging infectious diseases can originate from un'no,n sources, contact ,ith animals,
changes in 'no,n diseases, or iologic ,arfare&
-esistance occurs ,hen pathologic organisms change in ,ays that decrease the aility of
a drug (or a family of drugs) to treat disease&
:ethicillin+resistant Staphylococcus aureus (:?B5), vancomycin+resistant enterococci
(3?*), and penicillin+resistant Streptococcus pneumoniae are three of the most
troulesome antiiotic+resistant acteria currently causing prolems in North 5merica&
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Nosocomial infections are infections that are ac<uired as a result of e)posure to a
microorganism in a hospital setting and typically occur ,ithin 9" hours of
hospitalization&
@or older adult patients, the rate of nosocomial infection is t,o to three times higher than
for younger patients&
)5MAN 'MM5N$D+'C'NC6 2'-5S 'N+C,'$N
The human immunodeficienc. !irus (>.3) is a rionucleic acid (?N5) virus, ,hich
means it replicates going from ?N5 to deo)yrionucleic acid (=N5)&
>.3 can only e transmitted under specific conditions that allo, contact ,ith infected
ody fluids, including lood, semen, vaginal secretions, and reast mil'&
Be)ual contact ,ith an >.3+infected partner is the most common mode of transmission&
.mmune dysfunction in >.3 disease is caused predominantly y damage to and
destruction of C=%
O
T cells (also 'no,n as T helper cells or C=%
O
T lymphocytes)&
The ma#or concern related to immune suppression is the development of o""ortunistic
diseases (infections and cancers that occur in immunosuppressed patients that can lead to
disaility, disease, and death)&
>.3 infections are divided into acute, early chronic, intermediate chronic, and late
chronic infection&
2ate chronic infection is also 'no,n as ac3uired immunodeficienc. s.ndrome (5.=B)&
The most useful screening tests for >.3 are those that detect >.3+specific antiodies& The
ma#or prolem ,ith these tests is that there is a median delay of " months after infection
efore antiodies can e detected& This creates a window "eriod during ,hich an
infected individual may not test positive for >.3+antiody&
The goals of drug therapy in >.3 infection are to (1) decrease the !iral load, (") maintain
or raise C=%
O
T cell counts, and ($) delay the development of >.3+related symptoms and
opportunistic diseases&
The ma#or drug classifications for >.3 include nonnucleoside reverse transcriptase
inhiitors (NN?T.s), nucleoside reverse transcriptase inhiitors (N?T.s), nucleotide
reverse transcriptase inhiitors (Nt?T.s), protease inhiitors (P.s), and entry inhiitors&
:anagement of >.3 is complicated y the many opportunistic diseases that can develop
as the immune system deteriorates&
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Key Points
*)amples of opportunistic infections include Pneumocystis jiroveci pneumonia (PCP),
Mycobacterium avium comple) (:5C), and Kaposi sarcoma&
Nursing care for individuals not 'no,n to e infected ,ith >.3 should focus on
ehaviors that could put the person at ris' for >.3 infection and other se)ually
transmitted and lood+orne diseases&
The overriding goals of therapy for infected individuals are to 'eep the viral load as lo,
as possile for as long as possile, maintain or restore a functioning immune system,
improve the patient(s <uality of life, prevent opportunistic disease, reduce >.3+related
disaility and death, and prevent ne, infections&
>.3+infected patients share prolems e)perienced y all individuals ,ith chronic
diseases, ut these prolems are e)acerated y negative social constructs surrounding
>.3&
Lewis et al: Medical-Surgical Nursing: Assessment and Management of
Clinical Problems, 7
th
edition
Key Points
Chapter 1D: Cancer
Cancer encompasses a road range of diseases of multiple causes that can arise in any
cell of the ody capale of evading regulatory controls over proliferation and
differentiation&
T,o ma#or dysfunctions present in the process of cancer are (1) defective cellular
proliferation (gro,th) and (") defective cellular differentiation&
Cancer cells usually proliferate at the same rate of the normal cells of the tissue from
,hich they arise& >o,ever, cancer cells divide indiscriminately and haphazardly and
sometimes produce more than t,o cells at the time of mitosis&
Protooncogenes are normal cellular genes that are important regulators of normal
cellular processes& -hen these genes ecome mutated, they can egin to function as
oncogenes (tumor+inducing genes)&
Tumors can e classified as enign or malignant&
o /enign neo"lasms are ,ell+differentiated&
o Malignant neo"lasms range from ,ell+differentiated to undifferentiated&
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Key Points
The stages of cancer include initiation, promotion, and progression&
o The first stage, initiation, is the occurrence of a mutation in the cell(s genetic
structure, resulting from an inherited mutation, an error that occurs during =N5
replication, or follo,ing e)posure to a chemical, radiation, or viral agent&
o Promotion, the second stage in the development of cancer, is characterized y the
reversile proliferation of the altered cells&
o Progression, the final stage, is characterized y increased gro,th rate of the
tumor, increased invasiveness, and spread of the cancer to a distant site
(metastasis)&
Bince cancer cells arise from normal human cells, the immune response mounted against
cancer cells may e inade<uate to effectively eradicate them&
The process y ,hich cancer cells evade the immune system is termed immunologic
escape&
Tumors can e classified according to anatomic site, histologic %grading&, and e)tent of
disease (staging)&
o .n the anatomic classification of tumors, the tumor is identified y the tissue of
origin, the anatomic site, and the ehavior of the tumor (i&e&, enign or malignant)&
o .n histologic grading of tumors, the appearance of cells and the degree of
differentiation are evaluated pathologically& @or many tumor types, four grades
are used to evaluate anormal cells ased on the degree to ,hich the cells
resemle the tissue of origin&
o The staging classification system is ased on a description of the e)tent of the
disease rather than on cell appearance&
The iopsy procedure is the only definitive means of diagnosing cancer&
The goal of cancer treatment is cure, control, or palliation&
o -hen cure is the goal, the treatment offered is e)pected to have the greatest
chance of disease eradication and may involve local therapy (i&e&, surgery or
radiation) alone or in comination ,ith or ,ithout periods of ad#unctive systemic
therapy (i&e&, chemotherapy)&
o Control is the goal of the treatment plan for many cancers that cannot e
completely eradicated ut are responsive to anticancer therapies and, as ,ith other
chronic illnesses such as diaetes mellitus and heart failure, can e managed for
long periods of time ,ith therapy&
o -ith palliation, relief or control of symptoms and the maintenance of a
satisfactory <uality of life are the primary goals rather than cure or control of the
disease process&
:odalities for cancer treatment ,ith all three goals include surgery, chemotherapy,
radiation therapy, and iologic and targeted therapy&
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Key Points
The goal of chemothera". is to eliminate or reduce the numer of malignant cells
present in the primary tumor and metastatic tumor site(s)&
Chemotherapeutic drugs are classified in general groups according to their molecular
structure and mechanisms of action&
Chemotherapy can e administered y multiple routes, such as central vascular access
devices, peripherally inserted central venous catheters, or implanted infusion ports&
?egional treatment ,ith chemotherapy involves the delivery of the drug directly to the
tumor site&
Chemotherapy+induced side effects are the result of the destruction of normal cells,
especially those that are rapidly proliferating such as those in the one marro,, lining of
the gastrointestinal system, and the integumentary system (s'in, hair, and nails)&
-adiation is the emission and distriution of energy through space or a material medium&
?adiation is used to treat a carefully defined area of the ody to achieve local control of
disease&
Bimulation is a part of radiation treatment planning used to determine the optimal
treatment method y focusing on the geometric aspects of treatment&
Nurses play a 'ey role in assisting patients to cope ,ith the psychoemotional issues
associated ,ith receiving cancer treatment&
*ducating patients aout their treatment regimen, supportive care options (e&g&,
antiemetics, antidiarrheals), and ,hat to e)pect during the course of treatment is
important to help decrease fear and an)iety, encourage adherence, and guide at+home
self+management&
:yelosuppression is one of the most common effects of chemotherapy, and, to a lesser
e)tent, it can also occur ,ith radiation&
@atigue is a nearly universal symptom affecting 98K to 188K of patients ,ith cancer&
The intestinal mucosa is one of the most sensitive tissues to radiation and chemotherapy&
Nausea and vomiting are common se<uelae of chemotherapy and, in some instances,
radiation therapy&
6iologic and targeted therapy can e effective alone or in comination ,ith surgery,
radiation therapy, and chemotherapy&
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Key Points
/iologic thera". consists of agents that modify the relationship et,een the host and the
tumor y altering the iologic response of the host to the tumor cells&
,argeted thera". interferes ,ith cancer gro,th y targeting specific cellular receptors
and path,ays that are important in tumor gro,th&
Capillary lea' syndrome, pulmonary edema, one marro, depression, and fatigue are
associated ,ith iologic therapy&
)emato"oietic stem cell trans"lantation is an effective, lifesaving procedure for a
numer of malignant and nonmalignant diseases&
o >ematopoietic stem cell transplants are categorized as allogeneic, syngeneic, or
autologous&
o .n allogeneic transplantation, stem cells are ac<uired from a donor ,ho has een
determined to e human leu'ocyte antigen (>25)Nmatched to the recipient&
o Byngeneic transplantation is a type of allogeneic transplant that involves otaining
stem cells from one identical t,in and infusing them into the other&
o .n autologous transplantation patients receive their o,n stem cells ac' follo,ing
myeloalative (destroying one marro,) chemotherapy&
4ene thera". is an e)perimental therapy that involves introducing genetic material into
a person(s cell to fight a disease, such as cancer&
Cancer patients may develop complications related to the continual gro,th of the
malignancy into normal tissue or to the side effects of treatment&
:oderate to severe pain occurs in appro)imately C8K of patients ,ho are receiving
active treatment for their cancer and in F8K to E8K of patients ,ith advanced cancer&
Lewis et al: Medical-Surgical Nursing: Assessment and Management of
Clinical Problems, 7
th
edition
Key Points
Chapter 19: @luid, *lectrolyte, and 5cid+6ase .malances
6ody fluids and electrolytes play an important role in homeostasis(
:any diseases and their treatments have the aility to affect fluid and electrolyte
alance&
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Key Points
-ater is the primary component of the ody, accounting for appro)imately D8K of the
ody ,eight in the adult&
The t,o ma#or fluid compartments in the ody are intracellular and e)tracellular&
The measurement of electrol.tes is important to the nurse in evaluating electrolyte
alance, as ,ell as in determining the composition of electrolyte preparations&
$smolalit. is important ecause it indicates the ,ater alance of the ody&
.n the metaolically active cell, there is a constant e)change of sustances et,een the
cell and the interstitium, ut no net gain or loss of ,ater occurs&
The ma#or colloid in the vascular system contriuting to the total osmotic "ressure is
protein&
The amount and direction of movement et,een the interstitium and the capillary are
determined y the interaction of (1) capillary h.drostatic "ressure, (") plasma oncotic
pressure, ($) interstitial hydrostatic pressure, and (%) interstitial oncotic pressure&
.f capillary or interstitial pressures are altered, fluid may anormally shift from one
compartment to another, resulting in edema or deh.dration&
@luid is dra,n into the plasma space ,henever there is an increase in the plasma osmotic
or oncotic pressure& This could happen ,ith administration of colloids, de)tran,
mannitol, or hypertonic solutions&
+irst s"acing descries the normal distriution of fluid in the intracellular fluid (.C@)
and e)tracellular fluid (*C@) compartments& Second s"acing refers to an anormal
accumulation of interstitial fluid (i&e&, edema)& ,hird s"acing occurs ,hen fluid
accumulates in a portion of the ody from ,hich it is not easily e)changed ,ith the rest
of the *C@&
-ater alance is maintained via the finely tuned alance of ,ater inta'e and e)cretion&
5n intact thirst mechanism is important for fluid alance& The patient ,ho cannot
recognize or act on the sensation of thirst is at ris' for fluid deficit and hyperosmolality&
5n increase in plasma osmolality or a decrease in circulating lood volume ,ill
stimulate antidiuretic hormone (5=>) secretion& ?eduction in the release or action of
5=> produces diaetes insipidus&
5ldosterone is a mineralocorticoid ,ith potent sodium+retaining and potassium+e)creting
capaility&
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Key Points
The primary organs for regulating fluid and electrolyte alance are the 'idneys, lungs,
and gastrointestinal tract&
'nsensible water loss, ,hich is invisile vaporization from the lungs and s'in, assists in
regulating ody temperature&
-ith severely impaired renal function, the 'idneys cannot maintain fluid and electrolyte
alance& This condition results in edema, potassium, and phosphorus retention, acidosis,
and other electrolyte imalances&
Btructural changes to the 'idney and a decrease in the renal lood flo, lead to a decrease
in the glomerular filtration rate, decreased creatinine clearance, the loss of the aility to
concentrate urine and conserve ,ater, and narro,ed limits for the e)cretion of ,ater,
sodium, potassium, and hydrogen ions&
@luid and electrolyte imalances are commonly classified as deficits or e)cesses&
@luid volume deficit can occur ,ith anormal loss of ody fluids (e&g&, diarrhea, fistula
drainage, hemorrhage, polyuria), inade<uate inta'e, or a plasma+to+interstitial fluid shift&
The use of "%hour inta'e and output records gives valuale information regarding fluid
and electrolyte prolems&
:onitoring the patient for cardiovascular and neurologic changes is necessary to prevent
or detect complications from fluid and electrolyte imalances&
5ccurate daily ,eights provide the easiest measurement of volume status& -eight
changes must e otained under standardized conditions&
*dema is assessed y pressing ,ith a thum or forefinger over the edematous area&
The rates of infusion of .3 fluid solutions should e carefully monitored&
The goal of treatment in fluid and electrolyte imalances is to treat the underlying cause&
S$D'5M
.s the ma#or *C@ cation&
5n elevated serum sodium may occur ,ith ,ater loss or sodium gain&
Hyponatremia:
o Common causes include ,ater e)cess from inappropriate use of sodium+free or
hypotonic .3 fluids&
o Bymptoms of hyponatremia are related to cellular s,elling and are first
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Key Points
manifested in the central nervous system (CNB)&
P$,ASS'5M
.s the ma#or .C@ cation&
@actors that cause potassium to move from the .C@ to the *C@ include acidosis, trauma
to cells (as in massive soft tissue damage or in tumor lysis), and e)ercise&
Hyperkalemia
o The most common cause is renal failure& >yper'alemia is also common ,ith
massive cell destruction (e&g&, urn or crush in#ury, tumor lysis)! rapid transfusion
of stored, hemolyzed lood! and cataolic states (e&g&, severe infections)&
o :anifestations of hyper'alemia include cramping leg pain, follo,ed y ,ea'ness
or paralysis of s'eletal muscles&
o 5ll patients ,ith clinically significant hyper'alemia should e monitored
electrocardiographically to detect dysrhythmias and to monitor the effects of
therapy& Cardiac depolarization is decreased, leading to flattening of the P ,ave
and ,idening of the P?B ,ave& ?epolarization occurs more rapidly, resulting in
shortening of the PT interval and causing the T ,ave to e narro,er and more
pea'ed& 3entricular firillation or cardiac standstill may occur&
o The patient e)periencing dangerous cardiac dysrhythmias should receive .3
calcium gluconate immediately ,hile the potassium is eing eliminated and
forced into cells&
Hypokalemia
o The most common causes are from anormal losses via either the 'idneys or the
gastrointestinal tract& 5normal losses occur ,hen the patient is diuresing,
particularly in the patient ,ith an elevated aldosterone level&
o .n the patient ,ith hypo'alemia, cardiac changes include impaired repolarization,
resulting in a flattening of the T ,ave and eventually in emergence of a 4 ,ave&
The incidence of potentially lethal ventricular dysrhythmias is increased in
hypo'alemia&
o Patients ta'ing digo)in e)perience increased digo)in to)icity if their serum
potassium level is lo,& B'eletal muscle ,ea'ness and paralysis may occur ,ith
hypo'alemia& Bevere hypo'alemia can cause ,ea'ness or paralysis of respiratory
muscles, leading to shallo, respirations and respiratory arrest&
o >ypo'alemia is treated y giving potassium chloride supplements and increasing
dietary inta'e of potassium&
CALC'5M
Hypercalcemia
o 5out t,o thirds of cases are caused y hyperparathyroidism and one third are
caused y malignancy, especially from reast cancer, lung cancer, and multiple
myeloma&
o :anifestations of hypercalcemia include decreased memory, confusion,
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Key Points
disorientation, fatigue, muscle ,ea'ness, constipation, cardiac dysrhythmias, and
renal calculi&
o Treatment of hypercalcemia is promotion of e)cretion of calcium in urine y
administration of a loop diuretic and hydration of the patient ,ith isotonic saline
infusions&
Hypocalcemia
o .s caused y a decrease in the production of parathyroid hormone&
o >ypocalcemia is characterized y increased muscle e)citaility resulting in
tetany&
o 5 patient ,ho has had nec' surgery including thyroidectomy is oserved
carefully for signs of hypocalcemia&
Phos"hate
The ma#or condition that can lead to hyperphosphatemia is acute or chronic renal failure&
>ypophosphatemia (lo, serum phosphate) is seen in the patient ,ho is malnourished or
has a malasorption syndrome&
MA4NS'5M
>ypomagnesemia (lo, serum magnesium level) produces neuromuscular and CNB
hyperirritaility&
>ypermagnesemia usually occurs only ,ith an increase in magnesium inta'e
accompanied y renal insufficiency or failure&
AC'D-/AS 'M/ALANCS
Patients ,ith diaetes mellitus, chronic ostructive pulmonary disease, and 'idney
disease fre<uently develop acid+ase imalances& 3omiting and diarrhea may cause loss
of acids and ases&
The nurse must al,ays consider the possiility of acid+ase imalance in patients ,ith
serious illnesses&
The buffer s.stem is the fastest acting system and the primary regulator of acid+ase
alance&
The lungs help maintain a normal p> y e)creting C;
"
and ,ater, ,hich are y+products
of cellular metaolism&
The three renal mechanisms of acid elimination are secretion of small amounts of free
hydrogen into the renal tuule, comination of >
O
,ith ammonia (N>
$
) to form
ammonium (N>
%
O
), and e)cretion of ,ea' acids&
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Key Points
5cid+ase imalances are classified as respiratory or metaolic&
o -es"irator. acidosis (caronic acid e)cess) occurs ,henever there is
hypoventilation&
o -es"irator. al0alosis (caronic acid deficit) occurs ,henever there is
hyperventilation&
o Metabolic acidosis (ase icaronate deficit) occurs ,hen an acid other than
caronic acid accumulates in the ody or ,hen icaronate is lost from ody
fluids&
o Metabolic al0alosis (ase icaronate e)cess) occurs ,hen a loss of acid
(prolonged vomiting or gastric suction) or a gain in icaronate occurs&
5rterial lood gas (56A) values provide valuale information aout a patient(s acid+ase
status, the underlying cause of the imalance, the ody(s aility to regulate p>, and the
patient(s overall o)ygen status&
.n cases of acid+ase imalances, the treatment is directed to,ard correction of the
underlying cause&
@luid replacement therapy is used to correct fluid and electrolyte imalances&
o 5 h."otonic solution provides more ,ater than electrolytes, diluting the *C@&
o Plasma e)panders stay in the vascular space and increase the osmotic pressure&
o 5 h."ertonic solution initially raises the osmolality y the *C@ and e)pands it&
Lewis et al: Medical-Surgical Nursing: Assessment and Management of
Clinical Problems, 7
th
edition
Key Points
Chapter 1F: Nursing :anagement: Preoperative Care
Surger. is performed to diagnose, cure, palliate, prevent, e)plore, and1or provide
cosmetic improvement&
Ambulator. surger. is generally preferred y patients, physicians, and third+party
payers&
The preoperative nursing assessment is performed to:
o =etermine the patient(s psychologic and physiologic factors that may contriute
to operative ris' factors
o *stalish aseline data
o .dentify and document the surgical site
o .dentify prescription and over+the+counter (;TC) drugs and heral products
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Key Points
o Confirm laoratory results
o Note cultural and ethnic factors that may affect the surgical e)perience
o 3alidate that the consent form has een signed and ,itnessed
Common fears associated ,ith surgery include the potential for death, permanent
disaility resulting from surgery, pain, change in ody image, or results of a diagnostic
procedure&
.n the nursing assessment, information should also e otained aout the patient(s family
concerning any history of adverse reactions to or prolems ,ith anesthesia&
5ll findings on the medication history should e documented and communicated to the
intraoperative and postoperative personnel&
Patients should also e screened for possile late) allergies&
The preoperative assessment of the older person(s aseline cognitive function is
especially crucial for intraoperative and postoperative evaluation&
The patient ,ith diaetes mellitus is especially at ris' for adverse effects of anesthesia
and surgery&
;esity stresses oth the cardiac and pulmonary system and ma'es access to the surgical
site and anesthesia administration more difficult&
Preoperative teaching involves the follo,ing:
o Three types of information: sensory, process, and procedural&
o =ifferent patients, ,ith varying cultures, ac'grounds, and e)periences, may ,ant
different types of information&
o 5ll teaching should e documented in the patient(s medical record&
o 5ll patients should receive instruction aout deep reathing, coughing, and
moving postoperatively&
'nformed consent:
o .s an active, shared decision+ma'ing process et,een the provider and the
recipient of care&
o 5 true medical emergency may override the need to otain consent&
;n the day of surgery, the nurse is responsile for the follo,ing:
o @inal preoperative teaching
o 5ssessment and communication of pertinent findings
o *nsuring that all preoperative preparation orders have een completed
o *nsuring that records and reports are present and complete to accompany the
patient to the ;?
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Key Points
o 3erifying the presence of a signed operative consent
o 2aoratory data
o 5 history and physical e)amination report
o 5 record of any consultations
o 6aseline vital signs
o Nurses( notes complete to that point&
Preoperative medications may include the follo,ing:
o 6enzodiazepines and ariturates for sedation and amnesia
o 5nticholinergics to reduce secretions
o ;pioids to decrease intraoperative anesthetic re<uirements and pain
o 5dditional drugs include antiemetics, antiiotics, eye drops, and regular
prescription drugs
@re<uently performed procedures in the older adult are cataract e)traction, coronary and
vascular procedures, prostate surgery, herniorrhaphy, cholecystectomy, and hip repair&
;lder adults may have sensory, motor, and cognitive deficits necessitating that more time
may e needed to complete preoperative testing and understand preoperative instructions&
These changes also re<uire attention to promote patient safety and prevent in#ury&
Lewis et al: Medical-Surgical Nursing: Assessment and Management of
Clinical Problems, 7
th
edition
Key Points
Chapter 1E: Nursing :anagement: .ntraoperative Care
The surgical suite is divided into three distinct areas: unrestricted, semirestricted, and
restricted&
o The unrestricted area is ,here personnel in street clothes can interact ,ith those
in scru clothing&
o .n the semirestricted area, personnel must ,ear surgical attire and cover all head
and facial hair&
o .n the restricted area,hich includes the o"erating room (;?), the sin' area,
and clean coreGmas's are re<uired to supplement surgical attire&
.n the holding area, the perioperative nurse ma'es the final identification and assessment
efore the patient is transferred into the ;? for surgery& Procedures such as inserting
intravenous (.3) catheters and arterial lines, removing casts, and drug administration may
occur here&
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Key Points
The ;? is a uni<ue acute care setting removed from other hospital clinical units& .t is
controlled geographically, environmentally, and acteriologically, and it is restricted in
terms of the inflo, and outflo, of personnel&
The "erio"erati!e nurse is a registered nurse ,ho implements patient care during the
perioperative period& This includes the follo,ing:
o Preparing the ;? for the patient
o Berving as the patient(s advocate during surgery
o 5ssessing the patient for additional needs or tas's efore surgery
o *ducating the patient and family memers
The function of circulating is implemented y the perioperative nurse ,ho is not
scrued, go,ned, and gloved and remains in the unsterile field&
The function of scrubbing is implemented y the nurse ,ho follo,s the designated
scru procedure, is go,ned and gloved in sterile attire, and remains in the sterile field&
The registered nurse first assistant %-N+A& ,or's in collaoration ,ith the surgeon to
produce an optimal surgical outcome for the patient&
5ssessment data important to intraoperative nursing care include the patient(s vital signs,
height, ,eight, and age! allergic reactions to food, drugs, and late)! condition and
cleanliness of s'in! s'eletal and muscle impairments! perceptual difficulties! level of
consciousness! nothing+y+mouth (NP;) status! and any sources of pain or discomfort&
Burgical hand antisepsis is re<uired of all sterile memers of the surgical team (scru
assistant, surgeon, and assistant)&
The center of the sterile field is the site of the surgical incision&
The nurse must understand the mechanism of anesthetic administration and the
pharmacologic effects of the agents as ,ell as the location of all emergency drugs and
e<uipment in the ;? area&
.t is a nursing responsiility to secure the patient(s e)tremities, provide ade<uate padding
and support, and otain sufficient physical or mechanical help to avoid unnecessary
straining of self or patient&
The tas' of prepping the patient for surgery is usually the responsiility of the circulating
nurse&
The patient(s response to nursing care is evaluated y the ;? nurse, ased on outcome
criteria estalished during the development of the patient(s plan of care&
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Key Points
ANS,)S'A
5n asolute contraindication of any anesthetic techni<ue is patient refusal&
:oderate sedation1analgesia (conscious sedation):
o .s a drug+induced depression of consciousness that retains the patient(s aility to
maintain her or his o,n air,ay and respond appropriately to veral commands
o .n this type of anesthesia, the patient achieves a level of emotional and physical
acceptance of a painful procedure (e&g&, colonoscopy)&
4eneral anesthesia:
o :ay e administered y intravenous, inhalation, or rectal routes, or as a
comination of these&
o Nearly all routine general anesthetics egin ,ith an .3 induction agent&
.nhalation agents:
o 5dministered y an endotracheal tue, a laryngeal mas' air,ay, or a
tracheostomy and enter the ody via the lung alveoli&
o Complications of inhalation anesthesia include coughing, laryngospasm,
ronchospasm, increased secretions, and respiratory depression&
=rugs to achieve unconsciousness, analgesia, amnesia, muscle rela)ation, or autonomic
nervous system control are added to an inhalation anesthetic and are termed ad#uncts&
Local anesthesia administered either topically or y in#ection allo,s for an operative
procedure to e performed on a particular part of the ody ,ithout loss of consciousness
or sedation&
The initial clinical manifestations of anaphyla)is may e mas'ed y anesthesia&
To prevent malignant h."erthermia, it is important for the nurse to otain a careful
family history and e alert to its development perioperatively&
Lewis et al: Medical-Surgical Nursing: Assessment and Management of
Clinical Problems, 7
th
edition
Key Points
Chapter "8: Nursing :anagement: Postoperative Care
The postoperative period egins immediately after surgery and continues until the patient is
discharged from medical care&
P$S,ANS,)S'A CA- 5N',
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Key Points
Priority care in the "ostanesthesia care unit (P5C4) includes monitoring and
management of respiratory and circulatory function, pain, temperature, and the surgical
site&
5ssessment egins ,ith an evaluation of the air,ay, reathing, and circulation (56C)&
5ny evidence of respiratory compromise re<uires prompt intervention&
Pulse o)imetry monitoring is initiated ecause it provides a noninvasive means of
assessing the ade<uacy of o)ygenation&
*lectrocardiographic (*CA) monitoring is initiated to determine cardiac rate and rhythm&
The initial neurologic assessment focuses on level of consciousness, orientation, sensory
and motor status, and size, e<uality, and reactivity of the pupils&
6ecause hearing is the first sense to return, the nurse e)plains all activities to the patient
from the moment of admission to the P5C4&
P$,N,'AL C$MPL'CA,'$NS 'N ,) PAC5
-es"irator.
.n the immediate postanesthesia period, the most common causes of air,ay compromise
include airwa. obstruction, hypo)emia, and hypoventilation&
Patients at ris' include those ,ho have had general anesthesia, are older, smo'e heavily,
have lung disease, are oese, or have undergone air,ay, thoracic, or adominal surgery&
)."o1emia, specifically an arterial o)ygen tension (Pa;
"
) of less than D8 mm >g, is
characterized y a variety of nonspecific clinical signs and symptoms, ranging from
agitation to somnolence, hypertension to hypotension, and tachycardia to radycardia&
o The most common cause of postoperative hypo)emia is atelectasis, ,hich
occurs as a result of retained secretions or decreased respiratory e)cursion&
o ;ther causes include pulmonary edema, aspiration, and bronchos"asm(
)."o!entilation is characterized y a decreased respiratory rate or effort, hypo)emia,
and an increasing arterial caron dio)ide tension (PaC;
"
), ,hich also 'no,n as
hypercapnia&
The nurse evaluates air,ay patency! chest symmetry! and the depth, rate, and character of
respirations& The chest ,all is oserved for symmetry of movement ,ith a hand placed
lightly over the )iphoid process& 6reath sounds are auscultated anteriorly, laterally, and
posteriorly&
?egular monitoring of vital signs and use of pulse o)imetry are necessary for early
recognition of respiratory prolems&
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Key Points
The presence of hypo)emia from any cause may e reflected y rapid reathing, gasping,
apprehension, restlessness, and a rapid or thready pulse&
Proper positioning facilitates respiration and protects the air,ay& 4nless contraindicated
y the surgical procedure, the unconscious patient is positioned in a lateral /recovery0
position& ;)ygen therapy ,ill e used if the patient has had general anesthesia and1or the
anesthesia care provider (5CP) orders it&
Cardio!ascular
The most common cardiovascular prolems include hypotension, hypertension, and
dysrhythmias& Patients at greatest ris' include those ,ith alterations in respiratory
function, a history of cardiovascular disease, the elderly, the deilitated, and the critically
ill&
Hypotension is most commonly caused y unreplaced fluid and lood loss, ,hich may
lead to hypovolemic shoc'& Treatment of hypotension egins ,ith o)ygen therapy to
promote o)ygenation of hypoperfused organs&
Hypertension is most fre<uently the result of pain, an)iety, ladder distention, or
respiratory compromise& Treatment of hypertension ,ill center on eliminating the
precipitating cause&
Dysrhythmias are often the result of hypo'alemia, hypo)emia, hypercaria, alterations in
acid+ase status, circulatory instaility, hypothermia, pain, surgical stress, and pree)isting
heart disease& Treatment is directed to,ard eliminating the cause&
3ital signs are monitored fre<uently (i&e&, every 1C minutes, or more often until stailized,
and then at less+fre<uent intervals)&
The anesthesia care provider (5CP) or surgeon should e notified if the follo,ing occur:
o Bystolic 6P is less than E8 mm >g or greater than 1D8 mm >g&
o Pulse rate is less than D8 eats per minute or more than 1"8 eats per minute&
o Pulse pressure (difference et,een systolic and diastolic pressures) narro,s&
o 6P gradually decreases during several consecutive readings&
o There is a change in cardiac rhythm&
o There is a significant variation from preoperative readings&
Neurologic
mergence delirium, or /,a'ing up ,ild,0 can include restlessness, agitation,
disorientation, thrashing, and shouting& .t may e caused y anesthetic agents, hypo)ia,
ladder distention, pain, electrolyte anormalities, or the patient(s state of an)iety
preoperatively&
Dela.ed emergence is most commonly caused y prolonged drug action, particularly of
opioids, sedatives, and inhalational anesthetics, as opposed to neurologic in#ury&
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The most common cause of postoperative agitation is hypo)emia&
4ntil the patient is a,a'e and ale to communicate effectively, it is the responsiility of
the P5C4 nurse to act as a patient advocate and to maintain the patient(s safety&
The patient(s level of consciousness, orientation, and memory and aility to follo,
commands are assessed& The size, reactivity, and e<uality of the pupils are determined&
Pain is a common prolem and a significant fear for the patient in the P5C4&
/od. ,em"erature
)."othermia, a core temperature less than ED&FQ @ ($DQ C), occurs ,hen heat loss is
greater than heat production& >eat loss during the perioperative period can e due to
radiation, convection, conduction, and evaporation, infusion of cool .3 fluids, and
ventilation ,ith dry gases&
@re<uent assessment of the patient(s temperature is important to detect patterns of
hypothermia and1or fever&
P$,N,'AL P-$/LMS 'N ,) CL'N'CAL 5N',
-es"irator.
Common causes of respiratory prolems are atelectasis and pneumonia, especially
after adominal and thoracic surgery&
=eep reathing is encouraged to facilitate gas e)change& The patient should e
encouraged to reathe deeply 18 times every hour ,hile a,a'e&
The patient(s position should e changed every 1 to " hours to allo, full chest
e)pansion and to increase perfusion of oth lungs& 5mulation, not #ust sitting in a
chair, should e aggressively carried out as soon as physician approval is given&
Cardio!ascular
Postoperative fluid and electrolyte imalances are contriuting factors to cardiovascular
prolems& @luid overload may occur ,hen .3 fluids are administered too rapidly, ,hen
chronic (e&g&, cardiac, renal) disease e)ists, or ,hen the patient is an older adult&
S.nco"e (fainting) may occur as a result of decreased cardiac output, fluid deficits, or
defects in cereral perfusion&
5n accurate inta'e and output record should e 'ept, and laoratory findings (e&g&,
electrolytes, hematocrit) should e monitored&
The nurse should e alert for symptoms of too slo, or too rapid a rate of fluid
replacement&
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Key Points
>ypo'alemia causing dysrhythmias can e a conse<uence of urinary and gastrointestinal
(A.) tract losses, and inade<uate potassium replacement&
=eep vein thromosis (=3T) may form in leg veins as a result of inactivity, ody
position, and pressure, all of ,hich lead to venous stasis and decreased perfusion&
o 2eg e)ercises should e encouraged 18 to 1" times every 1 to " hours ,hile
a,a'e& *arly amulation is the most significant general nursing measure to
prevent postoperative complications&
o Bucutaneous heparin (or lo,+molecular+,eight heparin H2:->I) in
comination ,ith antiemolism stoc'ings are used to prevent =3T&
Neurologic
T,o types of postoperative cognitive impairment are seen in surgical patients: delirium
and postoperative cognitive dysfunction&
Confusion or delirium may arise from a variety of psychologic and physiologic sources,
including fluid and electrolyte imalances, hypo)emia, drug effects, sleep deprivation,
and sensory deprivation or overload&
5lcohol ,ithdra,al delirium is a reaction characterized y restlessness, insomnia and
nightmares, irritaility, and auditory or visual hallucinations&
To prevent or manage postoperative delirium, the nurse should address factors 'no,n to
contriute to the condition&
The nurse should attempt to prevent psychologic prolems in the postoperative period y
providing ade<uate support for the patient&
Pain is a common prolem during the postoperative period& Pain can contriute to
dysfunction of the immune system and lood clotting, delayed return of normal gastric
and o,el function, and increased ris' of atelectasis and impaired respiratory function&
The patient(s self+report is the single most reliale indicator of pain&
.dentifying the location of the pain is important& .ncisional pain is to e e)pected, ut
other causes of pain, such as a full ladder, may e present&
The most effective interventions for postoperative pain management include using a
variety of analgesics&
Postoperative pain relief is a nursing responsiility& The nurse should notify the physician
and re<uest a change in the order if the analgesic either fails to relieve the pain or ma'es
the patient e)cessively lethargic or somnolent&
Patient+controlled analgesia (PC5) and e"idural analgesia are t,o alternative
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Key Points
approaches for pain control&
/od. ,em"erature and 'nfection
Temperature variation provides valuale information aout the patient(s status& @ever
may occur at any time& 5 mild elevation (up to 188&%Q @ H$FQ CI) during the first %F hours
usually reflects the surgical stress response&
-ound infection, particularly from aeroic organisms, is often accompanied y a fever
that spi'es in the afternoon or evening and returns to near+normal levels in the morning&
.ntermittent high fever accompanied y sha'ing chills and diaphoresis suggests
septicemia&
4astrointestinal
Numerous factors have een identified as contriuting to the development of nausea and
vomiting, including gender (female), history of motion sic'ness or previous postoperative
nausea and vomiting, anesthetics or opioids, and duration and type of surgery&
o .f vomiting occurs, it is important to determine the <uantity, characteristics,
and color of the vomitus&
o The adomen is assessed for distention and the presence of o,el sounds& 5ll
four <uadrants are auscultated to determine the presence, fre<uency, and
characteristics of the sounds&
o Postoperative nausea and vomiting are treated ,ith the use of antiemetic or
pro'inetic drugs&
o 5dominal distention is caused y decreased peristalsis as a result of handling
of the intestine during surgery and limited dietary inta'e efore and after
surgery&
o 5dominal distention may e prevented or minimized y early and fre<uent
amulation&
5 nasogastric tue may e used to decompress the stomach to prevent nausea,
vomiting, and adominal distention&
5rinar.
2o, urine output (F88 to 1C88 ml) in the first "% hours after surgery may e e)pected,
regardless of fluid inta'e&
5cute urinary retention can occur in the postoperative period due to anesthesia, location of
the surgery (e&g&, lo,er adominal, pelvic), pain, immoility, and the recument position
in ed&
o The urine of the postoperative patient should e e)amined for oth <uantity and
<uality&
o :ost patients urinate ,ithin D to F hours after surgery& .f no voiding occurs, the
adominal contour should e inspected and the ladder assessed for distention&
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Key Points
7ound 'nfection
-ound infection may result from contamination of the ,ound from three ma#or sources:
e)ogenous flora present in the environment and on the s'in, oral flora, and intestinal
flora&
The incidence of ,ound sepsis is higher in patients ,ho are malnourished,
immunosuppressed, or older, or ,ho have had a prolonged hospital stay or a lengthy
surgical procedure (lasting more than $ hours)&
*vidence of ,ound infection usually does not ecome apparent efore the third to the
fifth postoperative day&
o 2ocal manifestations include redness, s,elling, and increasing pain and tenderness at
the site&
o Bystemic manifestations are fever and leu'ocytosis&
Nursing assessment of the ,ound and dressing re<uires 'no,ledge of the type of ,ound, the
drains inserted, and e)pected drainage related to the specific type of surgery&
o 5 small amount of serous drainage is common from any type of ,ound&
o .f a drain is in place, a moderate to large amount of drainage may e e)pected&
o =rainage is e)pected to change from sanguineous (red) to serosanguineous (pin') to
serous (clear yello,)& The drainage output should decrease over hours or days,
depending on the type of surgery&
o -ound infection may e accompanied y purulent drainage& 7ound dehiscence
(separation and disruption of previously #oined ,ound edges) may e preceded y a
sudden discharge of ro,n, pin', or clear drainage&
o -hen drainage occurs on the dressing, the type, amount, color, consistency, and odor
of drainage are noted&
D'SC)A-4
The choice of discharge site is ased on patient acuity, access to follo,+up care, and the
potential for postoperative complications&
The decision to discharge the patient from the P5C4 is ased on ,ritten discharge
criteria&
=ischarge to the clinical unit:
o 3ital signs should e otained, and patient status should e compared ,ith the
report provided y the P5C4& =ocumentation of the transfer is then completed,
follo,ed y a more in+depth assessment& Postoperative orders and appropriate
nursing care are then initiated&
5mulatory surgery discharge:
o The patient leaving an amulatory surgery setting must e moile and alert to
provide a degree of self+care ,hen discharged to home&
o The nurse specifically documents the discharge instructions provided to the
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Key Points
patient and family&
4-$N,$L$4'C C$NS'D-A,'$NS
;lder adults have decreased respiratory function, including decreased aility to cough,
decreased thoracic compliance, and decreased lung tissue, placing them at greater ris'
during the perioperative period&
=rug to)icity is a potential prolem& ?enal and liver function must e carefully assessed
in the postoperative phase to prevent drug overdosage and to)icity&
Lewis et al: Medical-Surgical Nursing: Assessment and Management of
Clinical Problems, 7
th
edition
Key Points
Chapter "1: Nursing 5ssessment: 3isual and 5uditory Bystems
S,-5C,5-S AND +5NC,'$NS
The visual system includes e)ternal tissues and structures surrounding the eye&
o *)ternal structures include the eyero,s, eyelids, eyelashes, lacrimal system,
con*uncti!a, cornea, sclera, and e)traocular muscles&
o .nternal structures include the iris, lens, ciliary ody, choroid, and retina(
The cornea, a3ueous humor, lens, and vitreous must all remain clear for light to reach
the retina and stimulate the photoreceptor cells&
?efraction is the aility of the eye to end light rays so that they fall on the retina& -hen
light does not focus properly, it is called refractive error&
Types of refractive errors are m.o"ia (nearsightedness) and h."ero"ia (farsightedness)&
Astigmatism is caused y corneal unevenness resulting in visual distortion& Presyopia is
a type of hyperopia due to aging&
The auditory system consists of peripheral and central systems&
o Peripheral system includes the e)ternal, middle, and inner ear and is involved
,ith sound reception and perception&
o The central system (rain and its path,ays) integrates and assigns meaning to
,hat is heard&
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Key Points
Presb.cusis can result from aging or insults from a variety of sources& ,innitus, or
ringing in the ears, may accompany the hearing loss that results from the aging process&
*)ternal and middle ear portions conduct and amplify sound ,aves from the
environment& Prolems located in these areas cause conductive hearing loss ,ith changes
in sound perception1sensitivity&
The inner ear functions in hearing and alance& Prolems located in this area or along the
nerve path,ay from the rain cause sensorineural hearing loss ,ith changes in tone
perception1sensitivity&
Central auditory system prolems cause central hearing loss ,ith difficulty in
understanding the meaning of ,ords&
ASSSSMN, AND D'A4N$S,'C S,5D'S
Patient information otained should include past eye1ear health and family history&
>istory also should include specific diseases and medications 'no,n to cause vision and
hearing prolems& Past history of visual and auditory tests and eye1ear trauma is also
noted&
3isual assessment determines visual acuity, aility to #udge closeness and distance,
e)traocular muscle function, evaluating visual fields and pupil function, and measuring
intraocular pressure&
5uditory assessment notes head posturing and appropriateness of responses ,hen
spea'ing to the patient and alance& Prolems ,ith alance may present as n.stagmus or
!ertigo(
3isual and auditory e)ternal structures are assessed y inspection for symmetry and
deformity& Bome eye structures must e visualized ,ith an ophthalmoscope! an otoscope
is used for further assessment of certain ear structures&
3isual assessment can include color vision and stereopsis ,ith auditory assessment often
including ,hisper1spo'en ,ord testing, audiometry, and tuning for' tests&
Lewis et al: Medical-Surgical Nursing: Assessment and Management of
Clinical Problems, 7
th
edition
Key Points
Chapter "": Nursing :anagement: 3isual and 5uditory Prolems
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Key Points
P-$/LMS $+ ,) 6
-+-AC,'2 --$-S
-efracti!e errors are the most common visual prolems& They occur ,hen light rays do
not converge into a single focus on the retina&
M.o"ia, or nearsightedness, is the most prevalent refractive error&
)."ero"ia refers to farsightedness&
Presb.o"ia is farsightedness due to decreased accommodative aility of the aging eye&
:ost refractive errors are corrected y lenses (eyeglasses or contact lenses), refractive
surgery, or surgical implantation of an artificial lens&
8,-A$C5LA- D'S$-D-S
5 hordeolum (sty) is an infection of seaceous glands in the lid margin&
5 chala#ion is a chronic inflammatory granuloma of meiomian (seaceous) glands in
the lid&
/le"haritis is a common chronic ilateral inflammation of the lid margins&
Con*uncti!itis is infection or inflammation of the con#unctiva&
o 5cute acterial con#unctivitis (pin'eye) is common&
o .t occurs initially in one eye and can spread rapidly to the unaffected eye&
o .t is usually self+limiting, ut antiiotic drops shorten the course of the disorder&
Trachoma is a chronic con#unctivitis caused y Chlamydia trachomatis&
o .t is a gloal cause of lindness&
o .t is preventale and transmitted mainly y hands and flies&
9eratitis is corneal inflammation or infection&
o The cornea can ecome infected y acteria, viruses, or fungi&
o Topical antiiotics are generally effective, ut eradicating infection may re<uire
antiiotics administered y sucon#unctival in#ection or .3&
o ;ther causes are chemical damage, contact lens ,ear, and contaminated products
(e&g&, lens care solutions, cosmetics)&
o Tissue loss due to infection produces corneal ulcers&
o Treatment is aggressive to avoid permanent loss of vision& 5n untreated ulcer can
result in corneal scarring and perforation&
CA,A-AC,
5 cataract is an opacity ,ithin the lens&
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Key Points
Bymptoms of cataracts are decreased vision, anormal color perception, and glare&
?emoval of the cataract is the most common surgery for older adults& :ost patients
undergoing cataract removal have an intraocular lens implanted during surgery&
5fter cataract surgery, the eyes are temporarily covered ,ith a patch and protective
shield&
Postoperative nursing goals include teaching aout eye care, activity restrictions,
medications, follo,+up visit schedule, and signs1symptoms of possile complications&
>ealing is complete around D to F ,ee's postoperatively&
-,'N$PA,)6
-etino"ath. is microvascular damage to the retina that can lead to lurred and
progressive vision loss&
.t is often associated ,ith diaetes mellitus and hypertension&
Nonproliferative diaetic retinopathy is characterized y capillary microaneuryms, retinal
s,elling, and hard e)udates&
o :acular edema represents a ,orsening as plasma lea's from macular lood
vessels&
o .t may e treated ,ith laser photocoagulation&
>ypertensive retinopathy is caused y high lood pressure that creates loc'ages in
retinal lood vessels&
o ;n e)amination, retinal hemorrhages and macula s,elling are noted&
o Bustained, severe hypertension can cause sudden visual loss ,ith optic disc and
nerve s,elling&
o Treatment focuses on lo,ering the lood pressure&
-,'NAL D,AC)MN,
-etinal detachment is a separation of the retina and underlying epithelium ,ith fluid
accumulation et,een the t,o layers&
=etachment is caused y a retinal rea', ,hich is interruption in the full thic'ness of
retinal tissue&
4ntreated, symptomatic retinal detachment results in lindness&
6rea's are classified as tears or holes&
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Key Points
Bymptoms are light flashes, floaters, and1or rings in vision& ;nce detached, painless loss
of peripheral or central vision occurs&
Treatment of retinal detachment is to first seal retinal rea's and then relieve in,ard
traction on retina&
Beveral types of surgery used include laser photocoagulation and cryope)y and then
scleral uc'ling&
3isual prognosis varies, depending on the e)tent, length, and area of detachment&
=ischarge planning and teaching are important, ,ith the nurse eginning this process
early as the patient is not hospitalized for long&
A4--LA,D MAC5LA- D4N-A,'$N
Age-related macular degeneration (5:=) is the most common cause of irreversile
central vision loss in older adults&
5:= is related to retinal aging& @amily history is another strong predictor of ris'&
5:= has t,o forms: dry (none)udative) and ,et (e)udative)&
o =ry 5:= is more common, ,ith close vision tas's ecoming more difficult&
5trophy of macular cells leads to slo,, progressive, and painless vision loss&
o -et 5:= is more severe, ,ith rapid onset and development of anormal lood
vessels related to the macula& Bymptoms are lurred, distorted, and dar'ened
vision ,ith visual field lind spots&
o -et 5:= treatment includes laser photocoagulation, photodynamic therapy, and
intravitreous in#ectale drugs& 3itamin and mineral supplements may e
considered&
4LA5C$MA
4laucoma is associated ,ith increased intraocular pressure (.;P), optic nerve atrophy,
and peripheral visual field loss&
Alaucoma often occurs ,ith advanced age and is a ma#or cause of permanent lindness&
*tiology is due to conse<uences of elevated .;P& Alaucoma is largely preventale ,ith
early detection and treatment&
T,o types of glaucoma include: primary angle+closure glaucoma (P5CA) and primary
open+angle glaucoma (P;5A), ,hich is the more common&
o -ith P;5A, fe, symptoms e)ist and it is often not noticed until peripheral vision
is severely compromised&
o Bymptoms of P5CA include sudden, e)cruciating eye pain along ,ith nausea and
vomiting&
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Key Points
o Therapy is to lo,er .;P to prevent optic nerve damage through drugs, argon laser
traeculoplasty, traeculectomy, and iridotomy& The nurse should teach aout
glaucoma ris' and the importance of early detection and treatment&
P-$/LMS $+ ,) A-
8,-NAL $,','S
1ternal otitis involves inflammation or infection of the auricle and ear canal epithelium
due to infection&
Bymptoms are pain, ear canal s,elling, and drainage&
Therapy is analgesics, antiiotics, and compresses&
AC5, $,','S MD'A
4ntreated or repeated attac's of acute otitis media in early childhood may lead to chronic
middle ear infection&
Bymptoms include purulent e)udate and inflammation that can involve the ossicles,
eustachian tue, and mastoid one&
.t is often painless&
Treatment may include antiiotics and surgery&
M:N';-<S D'SAS
M=ni>re<s disease is characterized y symptoms of inner ear disease ,ith episodic
vertigo, tinnitus, fluctuating sensorineural hearing loss, and aural fullness&
The cause is un'no,n, ut results in e)cessive accumulation of endolymph&
5ttac's may egin ,ith sense of ear fullness, tinnitus, and decreased hearing acuity&
The duration of attac's is hours to days, and attac's occur several times a year&
;ther symptoms are pallor, s,eating, nausea, and vomiting&
>earing loss fluctuates, and ,ith continued attac's, recovery lessens, eventually leading
to permanent hearing loss&
=rugs are used et,een and during attac's&
.f not relieved, surgeries include endolymphatic sac decompression and vestiular nerve
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resection&
Nursing care minimizes vertigo and provides for patient safety ,ith acute attac's&
)A-'N4 D'S$-D-S
>earing disorders are the primary handicapping disaility in the 4nited Btates&
Conductive hearing loss:
o ;ccurs in outer and middle ear and impairs the sound eing conducted from outer
to inner ear&
o .t is caused y conditions interfering ,ith air conduction, such as otitis media
,ith effusion, impacted cerumen and foreign odies, middle ear disease, and
otosclerosis(
Sensorineural hearing loss:
o .s due to impairment of inner ear or vestiulocochlear nerve (CN 3...)&
o Causes include congenital and hereditary factors, noise trauma, aging, :RniSre(s
disease, and ototo)icity&
o The main prolems are the aility to hear sound ut not to understand speech and
lac' of understanding of the prolem&
Bigns of hearing loss include as'ing others to spea' up, ans,ering <uestions
inappropriately, not responding ,hen not loo'ing at spea'er, straining to hear, and
increasing sensitivity to slight increases in noise level&
;ften the patient is una,are of minimal hearing loss& 5ssistive devices and techni<ues
include hearing aids, speech reading, and a cochlear implant&
Prevention of hearing loss focuses on participation in hearing conservation programs in
the ,or' environment, monitoring for side effects and level of ototo)ic drugs (e&g&,
salicylates, diuretics, antineoplastics), and avoidance of oth continued e)posure to high
noise levels (aove FC to EC deciels) and industrial drugs and chemicals (e&g&, toluene,
caron disulfide, mercury)&
Presb.cusis (hearing loss associated ,ith aging) includes loss of peripheral auditory
sensitivity, decline in ,ord recognition aility, and associated psychologic and
communication issues&
Lewis et al: Medical-Surgical Nursing: Assessment and Management of
Clinical Problems, 7
th
edition
Key Points
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Key Points
Chapter "$: Nursing 5ssessment: .ntegumentary Bystem
S,-5C,5-S AND +5NC,'$NS
The e"idermis is the outermost s'in layer& The dermis is the second s'in layer! it
contains the collagen undles ,hile it supports the nerve and vascular net,or'&
The sucutaneous layer is composed of fat and loose connective tissue&
The primary function of s'in is to protect underlying ody tissues y serving as a surface
arrier to the e)ternal environment& B'in also is a arrier against acteria, viruses, and
e)cessive ,ater loss& @at in the sucutaneous layer insulates the ody and provides
protection from trauma&
T,o ma#or types of epidermal cells include melanocytes (CK) and 'eratinocytes (E8K)&
o Melanoc.tes contain melanin, a pigment giving color to s'in and hair and
protecting the ody from damaging ultraviolet (43) sunlight& :ore melanin
results in dar'er s'in color&
o 9eratinoc.tes produce firous protein, 'eratin, ,hich is vital to protective arrier
function of s'in&
The dermis is the connective tissue elo, the epidermis& .t is highly vascular and assists
in the regulation of ody temperature and lood pressure&
The dermis is divided into t,o layers: upper thin papillary layer and deeper, thic'er
reticular layer&
Collagen forms the largest part of the dermis and is responsile for the mechanical
strength of the s'in&
B'in appendages include hair, nails, and glands (seaceous, apocrine, and eccrine)& These
structures develop from the epidermal layer and receive nutrients, electrolytes, and fluids
from the dermis& >air and nails form from specialized 'eratin that ecomes hardened&
Nail color ranges from pin' to yello, or ro,n, depending on the s'in color& Pigmented
longitudinal ands (melanonychea striata) may occur in the nail ed in most people ,ith
dar' s'in&
Sebaceous glands secrete seum, ,hich is emptied into hair follicles& Beum prevents
s'in and hair from ecoming dry&
A"ocrine sweat glands are located in the a)illae, reast areolae, umilical and
anogenital areas, e)ternal auditory canals, and eyelids& They secrete a thic', mil'y
sustance that ecomes odoriferous ,hen altered y s'in surface acteria&
ccrine sweat glands are ,idely distriuted over the ody, e)cept in a fe, areas such as
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Key Points
lips& These glands cool the ody y evaporation, e)crete ,aste products through s'in
pores, and moisturize surface cells&
-ith aging, the follo,ing changes occur in the s'in: fe,er melanocytes (gray and ,hite
hair), less volume in the dermis, nail plate thinning, nails ecome rittle and prone to
splitting and yello,ing, s'in ,rin'ling, decreased sucutaneous fat, hypothermia, and
s'in shearing&
ASSSSMN,
Bpecific s'in areas should e assessed during the e)amination of other ody sites, unless
the chief complaint is of dermatologic nature&
.nformation related to sensitivities should e otained& >istory of chronic or unprotected
e)posure to 43 light, including tanning ed use and radiation treatments, should e
noted&
The patient should e <uestioned aout s'in+related prolems occurring as result of
ta'ing medications, self+care haits related to daily hygiene, family history of any s'in
disease, and feelings related to altered ody image in relation to s'in condition&
Primary s'in lesions develop on previously unaltered s'in& These include macule, papule,
vesicle, pla<ue, ,heal, and pustule&
Becondary s'in lesions change ,ith time or occur ecause of factors such as scratching or
infection and include fissure, scale, scar, ulcer, and e)coriation&
The s'in should e inspected for general color and pigmentation, vascularity, ruising,
and presence of lesions or discolorations, and palpated for information aout temperature,
turgor and moility, moisture, and te)ture&
Btructures of dar' s'in are often more difficult to assess& 5ssessment is easier ,here the
epidermis is thin and pigmentation is not influenced y sun e)posure such as lips,
mucous memranes, nail eds, and protected areas such as uttoc's&
Palmar and plantar surfaces are lighter than other s'in areas in dar'er+s'inned
individuals& ?ashes are often difficult to oserve and may need palpation&
.ndividuals ,ith dar' s'in are predisposed to "seudofolliculitis, 0eloids, and mongolian
s"ots( Cyanosis may e difficult to determine ecause normal luish hue occurs in dar'+
s'inned persons&
D'A4N$S,'C S,5D'S
6iopsy is one of most common diagnostic tests in evaluation of s'in lesions& Techni<ues
include punch, incisional, e)cisional, and shave iopsies&
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Key Points
;ther diagnostic procedures include stains and cultures for fungal, acterial, and viral
infections&
Lewis et al: Medical-Surgical Nursing: Assessment and Management of
Clinical Problems, 7
th
edition
Key Points
Chapter "%: Nursing :anagement: .ntegumentary Prolems
>ealth promotion activities for good s'in health include asvoidance of environmental
hazards, ade<uate rest and e)ercise, and proper hygiene and nutrition&
Bun safety includes sun avoidance, especially during midday hours, protective clothing,
and sunscreen&
5ctinic 'eratoses, asal cell carcinoma, s<uamous cell carcinoma, and malignant
melanoma are prolems associated ,ith sun e)posure&
Actinic 0eratosis:
o .s a premalignant form of s<uamous cell carcinoma affecting nearly all the older
,hite population&
o 5 typical lesion is an irregularly shaped, flat, slightly erythematous papule ,ith
indistinct orders and an overlying hard 'eratotic scale or horn&
o Treatment includes cryosurgery, fluorouracil (C+@4), surgical removal, tretinoin
(?etin+5), chemical peeling agents, and dermarasion&
B'in cancer is the most common malignant condition& Patients should e taught to self+
e)amine their s'in monthly&
The cornerstone of self+s'in e)amination is the 56C= rule& *)amine s'in lesions for
Asymmetry, /order irregularity, Color change1variation, and Diameter of D mm or more&
?is' factors for s'in cancer include fair s'in type (londe or red hair and lue or green
eyes), history of chronic sun e)posure, family history of s'in cancer, and e)posure to tar
and systemic arsenicals&
Nonmelanoma s'in cancers do not develop from melanocytes, as melanoma s'in cancers
do& .nstead, they are a neoplasm of the epidermis& :ost common sites are in sun+e)posed
areas&
/asal cell carcinoma (6CC):
o .s a locally invasive malignancy from epidermal asal cells&
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Key Points
o .s the most common type of s'in cancer and the least deadly&
o Tissue iopsy is needed to confirm the diagnosis&
o Treatments of electrodessication and curettage, cr.osurger., and e)cision all
have cure rate of more than E8K&
S3uamous cell carcinoma (BCC):
o .s a malignant neoplasm of 'eratinizing epidermal cells&
o .s less common than 6CC&
o Can e very aggressive, has the potential to metastasize, and may lead to death if
not treated early&
o Pipe, cigar, and cigarette smo'ing area are also ris' factors for BCC! therefore
BCC is also found on mouth and lips&
o 6iopsy is performed ,hen a lesion is suspected of eing BCC&
o Treatment includes electrodesiccation and curettage, e)cision, radiation therapy,
intralesional in#ection of C+@4 or methotre)ate, and :ohs( surgery&
Malignant melanoma:
o .s a tumor arising in melanocytes&
o :elanomas can metastasize to any organ&
o .s the most deadly s'in cancer, and its incidence is increasing faster than that of
any other cancer&
o .ndividuals should consult health care provider if moles or lesions sho, any
clinical signs (56C=s) of melanoma&
o :elanoma can also occur in eyes, meninges, and lymph nodes&
o Buspicious lesions should e iopsied using e)cisional iopsy&
o .mportant prognostic factor of melanoma is tumor thic'ness at time of diagnosis&
o .nitial treatment for melanoma is surgery&
o :elanoma spread to lymph nodes or neary sites often re<uires chemotherapy,
iologic therapy (e&g&, T+interferon, interleu'in+"), and1or radiation therapy&
o Btage . is 188K curale ,ith stage .3 eing mostly palliative care&
5normal nevus pattern called dysplastic nevus syndrome identifies individual at
increased ris' of melanoma& D.s"lastic ne!i (=N), or atypical moles, are nevi UC mm
across ,ith irregular orders and varying color&
Staphylococcus aureus and group 5 V+hemolytic streptococci are ma#or types of acteria
responsile for primary and secondary s'in infections& >erpes simple), herpes zoster, and
,arts are the most common viral infections affecting the s'in&
4ltraviolet light, or a comination of t,o types (435 and 436), is used to treat many
conditions& 43 ,avelengths cause erythema, des<uamation, and pigmentation and may
cause temporary suppression of asal cell mitosis follo,ed y reound increase in cell
turnover&
?adiation use for treatment of cutaneous malignancies varies greatly& 2asers are used for
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Key Points
many dermatologic prolems&
5ntiiotics are used topically and systemically to treat dermatologic prolems, and are
often used in comination& Common ;TC topical antiiotics include acitracin and
polymy)in 6&
Corticosteroids are particularly effective in treating a ,ide variety of dermatologic
conditions and are used topically, intralesionally, or systemically& >igh+potency
corticosteroids may produce side effects ,hen use is prolonged, including s'in atrophy,
rosacea eruptions, severe e)acerations of acne vulgaris, and dermatophyte infections&
;ral antihistamines are used to treat conditions that e)hiit urticaria, angioedema, and
pruritus& Topical immune response modifiers such as pimecrolimus (*lidel) and
tacrolimus (Protopic) are ne,er nonsteroidal medications used in atopic dermatitis&
=iagnostic and surgical therapy techni<ues include s'in scraping, electrodesiccation and
electrocoagulation, curettage, punch iopsy, cryosurgery, and e)cision&
-et dressings are commonly used ,hen s'in is oozing from infection and1or
inflammation, and to relieve itching, suppress inflammation, and deride a ,ound&
6aths are used ,hen large ody areas need to e treated& They also have sedative and
antipruritic effects&
Careful hand ,ashing and safe disposal of soiled dressings are the est means of
preventing spread of s'in prolems&
Cosmetic procedures include chemical peels, to)in in#ections, collagen fillers, laser
surgery, reast enlargement and reduction, laser surgery, face+lift, eyelid+lift, and
liposuction& Preoperative management includes informed consent and realistic
e)pectations of ,hat cosmetic surgery can accomplish&
B'in grafts may e necessary to provide protection to underlying structures or to
reconstruct areas for cosmetic or functional purposes& .deally, ,ounds heal y primary
intention&
T,o types of grafts are free grafts and s'in flaps& Boft tissue e)pansion is a techni<ue for
resurfacing a defect, such as a urn scar, removing a disfiguring mar', such as a tattoo, or
as a preliminary step in reast reconstruction&
Lewis et al: Medical-Surgical Nursing: Assessment and Management of
Clinical Problems, 7
th
edition
Key Points
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Key Points
Chapter "C: Nursing :anagement: 6urns
/urns are ody tissue in#uries due to heat, cold, chemicals, electrical current, or
radiation&
Smo0e and inhalation in*uries result from inhalation of hot air or no)ious chemicals&
The resulting effect of urns is influenced y the temperature of the urning agent, the
duration of contact time, and the tissue type in#ured&
6urn prevention programs focus on child+resistant lighters! nonflammale children(s
clothing! stricter uilding codes! smo'e detectors1alarms! and fire sprin'lers&
Nurses need to advocate for scald+ and fire ris'Nreduction strategies in the home&
;ccupational health nurses need to educate ,or'ers to reduce scald, chemical, electrical,
and thermal in#uries in the ,or' setting&
6urn treatment is related to in#ury severity determined y depth& The e)tent is calculated
y the percent of the total ody surface area (T6B5), location, and patient ris' factors&
6urns are defined y degrees: first degree (same as sunurn), second degree, and third
degree& 5 more precise definition of second+ and third+degree urns includes the depth of
s'in destruction: "artial-thic0ness and full-thic0ness(
Becond+ and third+degree urn e)tent can e determined using total ody surface area
ased on t,o guides: 2und+6ro,der chart and ?ule of Nines& 6urn e)tent is often revised
after edema susides and demarcation of in#ury zones occurs&
@ace, nec', and circumferential urns to the chest1ac' area may inhiit respiratory
function ,ith mechanical ostruction secondary to edema or leathery, devitalized tissue
(eschar) formation& These in#uries may cause inhalation in#ury and respiratory mucosal
damage&
>ands, feet, and eye urns may ma'e self+care difficult and #eopardize future function&
6uttoc's or genitalia urns are susceptile to infection& Circumferential urns to
e)tremities can cause circulatory compromise distal to the urn&
6urn management is organized chronologically into three phases: emergent
(resuscitative), acute (,ound healing), and rehailitation (restorative)& ;verlaps in care
e)ist from one phase to another&
M-4N, P)AS
Period of time re<uired to resolve immediate, life+threatening prolems& Phase may last
from time of urn to $ or more days, ut it usually lasts "% to %F hours&
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Key Points
5 primary concern is the onset of hypovolemic shoc' and edema formation& To,ard the
end of the phase, if fluid replacement is ade<uate, the capillary memrane permeaility is
restored& @luid loss and edema formation cease& The interstitial fluid gradually returns to
the vascular space& =iuresis occurs ,ith lo, urine specific gravities&
:anifestations include shoc' from the pain and hypovolemia& 5reas of full+thic'ness and
deep partial+thic'ness urns are initially anesthetic ecause the nerve endings are
destroyed& Buperficial to moderate partial+thic'ness urns are painful&
Bhivering occurs as a result of chilling, and most patients are alert& 4nconsciousness or
altered mental status is usually a result of hypo)ia associated ,ith smo'e inhalation, head
trauma, or e)cessive sedation or pain medication&
Complications:
o Cardiovascular system dysrhythmias and hypovolemic shoc'
o !espiratory system vulnerale to upper air,ay in#ury causing edema formation
and ostruction of air,ay, and inhalation in#ury
o !enal system if patient is hypovolemic, 'idney lood flo, may decrease, causing
renal ischemia& .f it continues, acute renal failure may develop& -ith full+
thic'ness and electrical burns, myogloin and hemogloin are released into the
loodstream and occlude the renal tuules&
:anagement includes a rapid and thorough assessment and intervention of air,ay
management, fluid therapy, and ,ound care& 5nalgesics are ordered to promote patient
comfort& *arly in the posturn period, .3 pain medications are given&
*arly and aggressive nutritional support decreases mortality and complications, optimizes
healing of urn, and minimizes negative effects of h."ermetabolism and cataolism&
AC5, P)AS
6egins ,ith the moilization of e)tracellular fluid and suse<uent diuresis& Phase
concludes ,hen urned area is completely covered y s'in grafts or ,hen ,ounds are
healed& This may ta'e ,ee's or many months&
:anifestations include eschar from partial+thic'ness ,ounds& ;nce removed, re+
epithelialization appears as red or pin' scar tissue&
:argins of full+thic'ness eschar ta'e longer to separate& 5s a result, they re<uire surgical
debridement and s'in grafting for healing&
6ecause the ody is trying to reestalish fluid and electrolyte homeostasis, it is important
for the nurse to follo, the patient(s serum electrolyte levels closely (hypo+ or
hypernatremia, hypo+ or hyper'alemia)&
Complications include ,ound infection progressing to transient acteremia as result of
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Key Points
manipulation (e&g&, after hydrotherapy and deridement)& Bame cardiovascular and
respiratory system complications as in emergent phase may continue&
Patient can ecome e)tremely disoriented, ,ithdra,, or e comative&
This is a transient state, lasting from a day to several ,ee's& ?ange of motion may e
limited and contractures can occur& Paralytic ileus results from sepsis& =iarrhea and
constipation may also occur&
:anagement involves ,ound care ,ith daily oservation, assessment, cleansing,
deridement, and dressing reapplication&
.ndividualized and consistent pain assessment and care are essential& Note t,o 'inds of
pain: continuous, ac'ground pain e)isting throughout day and night, and treatment pain
associated ,ith dressing changes, amulation, and rehailitation activities&
@irst line of treatment is pharmacologic& Then use nonpharmacologic strategies, such as
rela)ation tapes, visualization, hypnosis, guided imagery, and iofeedac'& ?igorous
physical therapy throughout recovery is imperative to maintain #oint function& Nutritional
therapy provides ade<uate calories and protein to promote healing&
-)A/'L',A,'$N P)AS
6egins ,hen ,ounds have healed and patient is ale to resume self+care activity& Phase
occurs as early as " ,ee's or as long as 9 to F months after the urn&
Aoals are to assist the patient in resuming a functional role in society and accomplish
functional and cosmetic reconstructive surgery&
:anifestations include ne, s'in appearing flat and pin', then raised and hyperemic!
itching occurs ,ith healing& Complications are s'in and #oint contractures and
hypertrophic scarring&
:anagement includes positioning, splinting, and e)ercise to minimize contracture&
6urned legs may e ,rapped ,ith elastic (e&g&, tensor15ce) andages to assist the
circulation to the leg graft and donor sites& Patient education and /hands+on0 instruction
need to e provided in dressing changes and ,ound care&
Continuous e)ercise and physical1occupational therapy cannot e overemphasized&
*ncouragement and reassurance are necessary for patient morale, attaining independence,
and returning to preurn activities&
@or patient ,ith emotional needs, it is important that the nurse have understanding of
circumstances of urn, family relationships, and prior coping e)periences ,ith stressful
situations& Patient may e)perience fear, an)iety, anger, guilt, and depression&
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Key Points
Lewis et al: Medical-Surgical Nursing: Assessment and Management of
Clinical Problems, 7
th
edition
Key Points
Chapter "D: Nursing 5ssessment: ?espiratory Bystem
S,-5C,5-S AND +5NC,'$NS
The primary purpose of the respiratory system is gas e)change, ,hich involves the
transfer of o)ygen and caron dio)ide et,een the atmosphere and the lood&
The upper respiratory tract includes the nose, pharyn), adenoids, tonsils, epiglottis,
laryn), and trachea&
The lo,er respiratory tract consists of the ronchi, ronchioles, alveolar ducts, and
alveoli&
.n adults, a normal tidal !olume (3T), or volume of air e)changed ,ith each reath, is
aout C88 ml&
2entilation involves ins"iration (movement of air into the lungs) and e1"iration
(movement of air out of the lungs)&
56As are measured to determine o)ygenation status and acid+ase alance& 56A
analysis includes measurement of the Pa;
"
, PaC;
"
, acidity (p>), and icaronate
(>C;
$
N
) in arterial lood&
5rterial o)ygen saturation can e monitored continuously using a pulse o"imetry proe
on the finger, toe, ear, or ridge of the nose&
The respiratory center in the rainstem medulla responds to chemical and mechanical
signals from the ody&
5 chemorece"tor is a receptor that responds to a change in the chemical composition
(PaC;
"
and p>) of the fluid around it&
Mechanical rece"tors are stimulated y a variety of physiologic factors, such as
irritants, muscle stretching, and alveolar ,all distortion&
The respiratory defense mechanisms include filtration of air, the mucociliary clearance
system, the cough refle), refle) ronchoconstriction, and alveolar macrophages&
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Key Points
ASSSSMN,
=uring nursing assessment, a cough should e evaluated y the <uality of the cough and
sputum&
=uring physical e)amination, the nose, mouth, pharyn), nec', thora), and lungs should
e assessed and the respiratory rate, depth, and rhythm should e oserved&
-hen listening to the lung sounds, there are three normal reath sounds: vesicular,
ronchovesicular, and ronchial&
Ad!entitious sounds are e)tra reath sounds that are anormal and include crac0les,
rhonchi, whee#es, and "leural friction rub(
D'A4N$S,'C S,5D'S
5 chest )+ray is the most commonly used test for assessment of the respiratory system, as
,ell as the progression of disease and response to treatment&
6ronchoscopy is a procedure in ,hich the ronchi are visualized through a fieroptic
tue and may e used for diagnostic purposes to otain iopsy specimens and assess
changes resulting from treatment&
Thoracentesis is the insertion of a large+ore needle through the chest ,all into the
pleural space to otain specimens for diagnostic evaluation, remove pleural fluid, or
instill medication into the pleural space&
Pulmonary function tests (P@Ts) measure lung volumes and airflo,&
The results of P@Ts are used to diagnose pulmonary disease, monitor disease progression,
evaluate disaility, and evaluate response to ronchodilators&
Lewis et al: Medical-Surgical Nursing: Assessment and Management of
Clinical Problems, 7
th
edition
Key Points
Chapter "9: Nursing :anagement: 4pper ?espiratory Prolems
Prolems of the upper respiratory tract include disorders of the nose, pharyn), adenoids,
tonsils, epiglottis, laryn), and trachea&
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Key Points
5 de!iated se"tum is a deflection of the normally straight nasal septum that is most
commonly caused y trauma to the nose or congenital disproportion&
-hino"last., the surgical reconstruction of the nose, is performed for cosmetic reasons or
to improve air,ay function ,hen trauma or developmental deformities result in nasal
ostruction&
Allergic rhinitis is the reaction of the nasal mucosa to a specific allergen and is classified
as either intermittent or persistent&
o .ntermittent means that the symptoms are present less than % days a ,ee' or less
than % ,ee's per year&
o Persistent means that the symptoms are present more than % days a ,ee' and for
more than % ,ee's per year&
o The most important step in managing allergic rhinitis involves identifying and
avoiding triggers of allergic reactions&
5cute viral rhinitis (also 'no,n as the common cold or acute coryza):
o .s caused y an adenovirus that invades the upper respiratory tract and often
accompanies an acute upper respiratory infection&
o ?est, fluids, proper diet, antipyretics, and analgesics are the recommended
management of acute viral rhinitis&
.n contrast to acute viral rhinitis, the onset of influenza is typically arupt ,ith systemic
symptoms of cough, fever, and myalgia often accompanied y a headache and sore throat&
o To comat the li'elihood of developing influenza, there are t,o types of flu
vaccines availale: inactivated and live, attenuated&
o The nurse should advocate the use of inactivated influenza vaccination in all
patients greater than C8 years of age or ,ho are at high ris' during routine office
visits or, if hospitalized, at the time of discharge&
Chronic and acute sinusitis develop ,hen the ostia (e)it) from the sinuses is narro,ed or
loc'ed y inflammation or hypertrophy (s,elling) of the mucosa& Chronic sinusitis lasts
longer than $ ,ee's and is a persistent infection usually associated ,ith allergies and nasal
"ol."s(
Acute "har.ngitis:
o .s an acute inflammation of the pharyngeal ,alls that may include the tonsils,
palate, and uvula&
o The goals of nursing management for acute pharyngitis are infection control,
symptomatic relief, and prevention of secondary complications&
$bstructi!e slee" a"nea, also called ostructive sleep apnea+hypopnea syndrome, is a
condition characterized y partial or complete upper air,ay ostruction during sleep&
A"nea is the cessation of spontaneous respirations lasting longer than "8 seconds&
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Key Points
5 tracheotom. is a surgical incision into the trachea for the purpose of estalishing an
air,ay&
5 tracheostom.:
o .s the stoma (opening) that results from the tracheotomy&
o .ndications for a tracheostomy are to (1) ypass an upper air,ay ostruction, (")
facilitate removal of secretions, ($) permit long+term mechanical ventilation, and
(%) permit oral inta'e and speech in the patient ,ho re<uires long+term
mechanical ventilation&
)AD AND NC9 CANC-
5rises from mucosal surfaces and is typically s<uamous cell in origin&
This category of tumors can involve paranasal sinuses, the oral cavity, and the nasopharyn),
oropharyn), and laryn)&
The choice of treatment for head and nec' cancer is ased on medical history, e)tent of
disease, cosmetic considerations, urgency of treatment, and patient choice&
5ppro)imately one third of patients ,ith head and nec' cancers have highly confined
lesions that are stages . or .. at diagnosis& Buch patients can undergo radiation therapy or
surgery ,ith the goal of cure&
5dvanced lesions are treated y a total laryngectomy in ,hich the entire laryn) and
preepiglottic region is removed and a permanent tracheostomy performed&
5fter radical nec' surgery, the patient may e unale to ta'e in nutrients through the normal
route of ingestion ecause of s,elling, the location of sutures, or difficulty ,ith
s,allo,ing& Parenteral fluids ,ill e given for the first "% to %F hours&
Lewis et al: Medical-Surgical Nursing: Assessment and Management of
Clinical Problems, 7
th
edition
Key Points
Chapter "F: Nursing :anagement: 2o,er ?espiratory Prolems
PN5M$N'A
.s an acute inflammation of the lung parenchyma&
.s caused y a microial organism&
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Key Points
:ore li'ely to result ,hen defense mechanisms ecome incompetent or are over,helmed
y the virulence or <uantity of infectious agents&
Pneumonia can e classified according to the causative organism, such as acteria,
viruses, Mycoplasma, fungi, parasites, and chemicals&
5 clinically effective ,ay to classify pneumonia is as follo,s:
o Communit.-ac3uired "neumonia is defined as a lo,er respiratory tract
infection of the lung parenchyma ,ith onset in the community or during the first "
days of hospitalization&
o )os"ital-ac3uired "neumonia is pneumonia occurring %F hours or longer after
hospital admission and not incuating at the time of hospitalization&
5spiration pneumonia refers to the se<uelae occurring from anormal entry of secretions
or sustances into the lo,er air,ay&
;pportunistic pneumonia presents in certain patients ,ith altered immune responses ,ho
are highly susceptile to respiratory infections&
There are four characteristic stages of pneumonia: congestion, red hepatization, gray
hepatization, and resolution&
Nursing management:
o .n the hospital, the nursing role involves identifying the patient at ris' and ta'ing
measures to prevent the development of pneumonia&
o The essential components of nursing care for patients ,ith pneumonia include
monitoring physical assessment parameters, facilitating laoratory and diagnostic
tests, providing treatment, and monitoring the patient(s response to treatment&
,5/-C5L$S'S %,/&
.s an infectious disease caused y Mycobacterium tuberculosis, a gram+positive, acid+fast
acillus that is usually spread from person to person via airorne droplets&
=espite the decline in T6 nation,ide, rates have increased in certain states and high rates
continue to e reported in certain populations&
The ma#or factors that have contriuted to the resurgence of T6 have een (1) high rates
of T6 among patients ,ith >.3 infection and (") the emergence of multidrug resistant
strains of M# tuberculosis#
Can present ,ith a numer of complications: the spread of the disease ,ith involvement
of many organs simultaneously (miliary T6), pleural effusion, emphysema, and
pneumonia&
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Key Points
The tuerculin s'in test (:antou) test) using purified protein derivative (PP=) is the est
,ay to diagnose latent M# tuberculosis infection, ,hereas the diagnosis of tuerculosis
disease re<uires demonstration of tuercle acilli acteriologically&
:ost T6 patients are treated on an outpatient asis& The mainstay of T6 treatment is drug
therapy& =rug therapy is used to treat an individual ,ith active disease and to prevent
disease in a T6+infected person&
Patients strongly suspected of having T6 should (1) e placed on airorne isolation, (")
receive appropriate drug therapy, and ($) receive an immediate medical ,or'up,
including chest )+ray, sputum smear, and culture&
P5LM$NA-6 +5N4AL 'N+C,'$NS
5re found fre<uently in seriously ill patients eing treated ,ith corticosteroids,
antineoplastic and immunosuppressive drugs, or multiple antiiotics&
5re also found in patients ,ith 5.=B and cystic firosis&
Community+ac<uired pulmonary lung infections include aspergillosis, cryptococcosis,
and candidiasis& These infections are not transmitted from person to person, and the
patient does not have to e placed in isolation&
L5N4 A/SCSS
.s a pus+containing lesion of the lung parenchyma that gives rise to a cavity&
.n many cases the causes and pathogenesis of lung ascess are similar to those of
pneumonia&
The onset of a lung ascess is usually insidious, especially if anaeroic organisms are the
primary cause& 5 more acute onset occurs ,ith aeroic organisms&
5ntiiotics given for a prolonged period (up to " to % months) are usually the primary
method of treatment&
N2'-$NMN,AL L5N4 D'SASS
*nvironmental or occupational lung diseases are caused or aggravated y ,or'place or
environmental e)posure and are preventale&
Pneumoconiosis is a general term for a group of lung diseases caused y inhalation and
retention of dust particles&
The est approach to management of environmental lung diseases is to try to prevent or
decrease environmental and occupational ris's&
L5N4 CANC-
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Key Points
Cigarette smo'ing is the most important ris' factor in the development of lung cancer&
Bmo'ing is responsile for appro)imately F8K to E8K of all lung cancers&
Primary lung cancers are often categorized into t,o road sutypes: nonNsmall cell lung
cancer (F8K) and small cell lung cancer ("8K)&
CT scanning is the single most effective noninvasive techni<ue for evaluating lung
cancer& 6iopsy is necessary for a definitive diagnosis&
Btaging of nonNsmall cell lung cancer is performed according to the TN: staging
system& Btaging of small cell lung cancer y TN: has not een useful ecause the cancer
is very aggressive and al,ays considered systemic&
Treatment options for lung cancer include:
o Burgical resection is the treatment of choice in nonNsmall cell lung cancer Btages .
and .., ecause the disease is potentially curale ,ith resection&
o ?adiation therapy used ,ith the intent to cure may e moderated in the individual
,ho is unale to tolerate surgical resection due to comoridities& .t may also e
used as ad#uvant therapy after resection of the tumor&
o Chemotherapy may e used in the treatment of nonresectale tumors or as
ad#uvant therapy to surgery in nonNsmall cell lung cancer&
The overall goals of nursing management of a patient ,ith lung cancer ,ill include (1)
effective reathing patterns, (") ade<uate air,ay clearance, ($) ade<uate o)ygenation of
tissues, (%) minimal to no pain, and (C) a realistic attitude to,ard treatment and
prognosis&
PN5M$,)$-A8
?efers to air in the pleural space& 5s a result of the air in the pleural space, there is partial
or complete collapse of the lung&
Types of pneumothora) include:
o Closed "neumothora1 has no associated e)ternal ,ound& The most common
form is a spontaneous pneumothora), ,hich is accumulation of air in the pleural
space ,ithout an apparent antecedent event&
o $"en "neumothora1 occurs ,hen air enters the pleural space through an
opening in the chest ,all& *)amples include sta or gunshot ,ounds and surgical
thoracotomy&
o ,ension "neumothora1 is a pneumothora) ,ith rapid accumulation of air in the
pleural space causing severely high intrapleural pressures ,ith resultant tension
on the heart and great vessels& .t may result from either an open or a closed
pneumothora)&
o )emothora1 is an accumulation of lood in the intrapleural space& .t is fre<uently
found in association ,ith open pneumothora) and is then called a
hemopneumothora)&
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Key Points
o Ch.lothora1 is lymphatic fluid in the pleural space due to a lea' in the thoracic
duct& Causes include trauma, surgical procedures, and malignancy&
Treatment depends on the severity of the pneumothora) and the nature of the underlying
disease&
+LA'L C)S,
?esults from multiple ri fractures, causing an unstale chest ,all& The diagnosis of flail
chest is made on the asis of fracture of t,o or more ris, in t,o or more separate locations,
causing an unstale segment&
.nitial therapy consists of air,ay management, ade<uate ventilation, supplemental o)ygen
therapy, careful administration of .3 solutions, and pain control&
The definitive therapy is to ree)pand the lung and ensure ade<uate o)ygenation&
C)S, ,5/S AND PL5-AL D-A'NA4
The purpose of chest tues and pleural drainage is to remove the air and fluid from the
pleural space and to restore normal intrapleural pressure so that the lungs can ree)pand&
Chest tue malposition is the most common complication&
?outine monitoring is done y the nurse to evaluate if the chest drainage is successful y
oserving for tidaling in the ,ater+seal chamer, listening for reath sounds over the lung
fields, and measuring the amount of fluid drainage&
C)S, S5-4-6
,horacotom. (surgical opening into the thoracic cavity) surgery is considered ma#or
surgery ecause the incision is large, cutting into one, muscle, and cartilage& The t,o types
of thoracic incisions are median sternotomy, performed y splitting the sternum, and lateral
thoracotomy&
3ideo+assisted thoracic surgery (35TB) is a thorascopic surgical procedure that in many
cases can avoid the impact of a full thoracotomy& The procedure involves three to four 1+
inch incisions made on the chest that allo, the thorascope (a special fieroptic camera) and
instruments to e inserted and manipulated&
PL5-AL ++5S'$N
Pleural effusion is a collection of fluid in the pleural space& .t is not a disease ut rather a
sign of a serious disease&
Pleural effusion is fre<uently classified as transudative or e)udative according to ,hether
the protein content of the effusion is lo, or high, respectively&
o 5 transudate occurs primarily in noninflammatory conditions and is an
accumulation of protein+poor, cell+poor fluid&
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Key Points
o 5n e)udative effusion is an accumulation of fluid and cells in an area of
inflammation&
o 5n em".ema is a pleural effusion that contains pus&
The type of pleural effusion can e determined y a sample of pleural fluid otained via
thoracentesis (a procedure done to remove fluid from the pleural space)&
The main goal of management of pleural effusions is to treat the underlying cause&
PL5-'S6
Pleuris. %"leuritis& is an inflammation of the pleura& The most common causes are
pneumonia, T6, chest trauma, pulmonary infarctions, and neoplasms&
Treatment of pleurisy is aimed at treating the underlying disease and providing pain
relief&
A,LC,AS'S
.s a condition of the lungs characterized y collapsed, airless alveoli&
The most common cause of atelectasis is air,ay ostruction that results from retained
e)udates and secretions& This is fre<uently oserved in the postoperative patient&
'D'$PA,)'C P5LM$NA-6 +'/-$S'S
.diopathic pulmonary firosis is characterized y scar tissue in the connective tissue of
the lungs as a se<uela to inflammation or irritation&
The clinical course is variale and the prognosis poor, ,ith a C+year survival rate of $8K
to C8K after diagnosis&
SA-C$'D$S'S
Barcoidosis is a chronic, multisystem granulomatous disease of un'no,n cause that
primarily affects the lungs&
The disease may also involve the s'in, eyes, liver, 'idney,
heart, and lymph nodes&
The disease is often acute or suacute and self+limiting, ut in others it is chronic ,ith
remissions and e)acerations&
P5LM$NA-6 DMA
Pulmonar. edema is an anormal accumulation of fluid in the alveoli and interstitial
spaces of the lungs&
.t is considered a medical emergency and may e life+threatening&
The most common cause of pulmonary edema is left+sided heart failure&
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Key Points
P5LM$NA-6 M/$L'SM
Pulmonar. embolism (P*) is the loc'age of pulmonary arteries y a thromus, fat, or
air emoli, or tumor tissue&
:ost pulmonary emolisms arise from thromi in the deep veins of the legs&
The most common ris' factors for pulmonary emolism are immoilization, surgery
,ithin the last $ months, stro'e, history of deep vein thromosis, and malignancy&
Pulmonary infarction (death of lung tissue) and pulmonary hypertension are common
complications of pulmonary emolism&
The o#ectives of treatment are to (1) prevent further gro,th or multiplication of thromi
in the lo,er e)tremities, (") prevent emolization from the upper or lo,er e)tremities to
the pulmonary vascular system, and ($) provide cardiopulmonary support if indicated&
P5LM$NA-6 )6P-,NS'$N
Pulmonar. h."ertension can occur as a primary disease (primary pulmonary
hypertension) or as a secondary complication of a respiratory, cardiac, autoimmune,
hepatic, or connective tissue disorder (secondary pulmonary hypertension)&
Primary pulmonary hypertension is a severe and progressive disease& .t is characterized
y mean pulmonary arterial pressure greater than "C mm >g at rest (normal 1" to 1D mm
>g) or greater than $8 mm >g ,ith e)ercise in the asence of a demonstrale cause&
Primary pulmonary hypertension is a diagnosis of e)clusion& 5ll other conditions must e
ruled out&
5lthough there is no cure for primary pulmonary hypertension, treatment can relieve
symptoms, increase <uality of life, and prolong life&
Becondary pulmonary hypertension (BP>) occurs ,hen a primary disease causes a
chronic increase in pulmonary artery pressures& Becondary pulmonary hypertension can
develop as a result of parenchymal lung disease, left ventricular dysfunction, intracardiac
shunts, chronic pulmonary thromoemolism, or systemic connective tissue disease&
C$- P5LM$NAL
Cor "ulmonale is enlargement of the right ventricle secondary to diseases of the lung,
thora), or pulmonary circulation& Pulmonary hypertension is usually a pree)isting
condition in the individual ,ith cor pulmonale&
The most common cause of cor pulmonale is C;P=&
The primary management of cor pulmonale is directed at treating the underlying
pulmonary prolem that precipitated the heart prolem&
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Key Points
L5N4 ,-ANSPLAN,A,'$N
There are four types of transplant procedures availale: single lung transplant, ilateral
lung transplant, heart+lung transplant, and transplant of loes from living related donor&
2ung transplant recipients are at high ris' for acterial, viral, fungal, and protozoal
infections& .nfections are the leading cause of death in the early period after the
transplant&
.mmunosuppressive therapy usually includes a three+drug regimen of cyclosporine or
tacrolimus, azathioprine (.muran) or mycophenolate mofetil (CellCept), and prednisone&
Lewis et al: Medical-Surgical Nursing: Assessment and Management of
Clinical Problems, 7
th
edition
Key Points
Chapter "E: Nursing :anagement: ;structive Pulmonary =iseases
AS,)MA
Asthma is a chronic inflammatory lung disease that results in recurrent episodes of airflo,
ostruction, ut it is usually reversile& The chronic inflammation causes an increase in
air,ay hyperresponsiveness that leads to recurrent episodes of ,heezing, reathlessness,
chest tightness, and cough, particularly at night or in the early morning&
5lthough the e)act mechanisms that cause asthma remain un'no,n, triggers are involved&
o 5llergic asthma may e related to allergies, such as tree or ,eed pollen, dust
mites, molds, animals, feathers, and coc'roaches&
o 5sthma that is induced or e)acerated during physical e)ertion is called e)ercise+
induced asthma& Typically, this type of asthma occurs after vigorous e)ercise, not
during it&
o 3arious air pollutants, cigarette or ,ood smo'e, vehicle e)haust, elevated ozone
levels, sulfur dio)ide, and nitrogen dio)ide can trigger asthma attac's&
o ;ccupational asthma occurs after e)posure to agents of the ,or'place& These
agents are diverse such as ,ood and vegetale dusts (flour), pharmaceutical
agents, laundry detergents, animal and insect dusts, secretions and serums (e&g&,
chic'ens, cras), metal salts, chemicals, paints, solvents, and plastics&
o ?espiratory infections (i&e&, viral and not acterial) or allergy to microorganisms is
the ma#or precipitating factor of an acute asthma attac'&
o Bensitivity to specific drugs may occur in some asthmatic persons, especially
those ,ith nasal polyps and sinusitis, resulting in an asthma episode&
o Aastroesophageal reflu) disease can also trigger asthma&
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Key Points
o Crying, laughing, anger, and fear can lead to hyperventilation and hypocapnia
,hich can cause air,ay narro,ing&
The characteristic clinical manifestations of asthma are ,heezing, cough, dyspnea, and
chest tightness after e)posure to a precipitating factor or trigger& *)piration may e
prolonged&
5sthma can e classified as mild intermittent, mild persistent, moderate persistent, or
severe persistent&
Bevere acute asthma can result in complications such as ri fractures, pneumothora),
pneumomediastinum, atelectasis, pneumonia, and status asthmaticus& Status asthmaticus is
a severe, life+threatening asthma attac' that is refractory to usual treatment and places the
patient at ris' for developing respiratory failure&
=iagnosis: there is some controversy aout ho, to est diagnose asthma& .n general, the
health care provider should consider the diagnosis of asthma if various indicators (i&e&,
clinical manifestations, health history, and pea' flo, variaility) are positive&
Patient education remains the cornerstone of asthma management and should e carried out
y health care providers providing asthma care& =esirale therapeutic outcomes include (1)
control or elimination of chronic symptoms such as cough, dyspnea, and nocturnal
a,a'enings! (") attainment of normal or nearly normal lung function! ($) restoration or
maintenance of normal levels of activity! (%) reduction in the numer or elimination of
recurrent e)acerations! (C) reduction in the numer or elimination of emergency
department visits and acute care hospitalizations! and (D) elimination or reduction of side
effects of medications&
:edications are divided into t,o general classifications: (1) long+termNcontrol medications
to achieve and maintain control of persistent asthma, and (") <uic'+relief medications to
treat symptoms and e)acerations&
o 6ecause chronic inflammation is a primary component of asthma, corticosteroids,
,hich suppress the inflammatory response, are the most potent and effective
antiinflammatory medication currently availale to treat asthma
o :ast cell stailizers are nonsteroidal antiinflammatory drugs that inhiit the .g*+
mediated release of inflammatory mediators from mast cells and suppress other
inflammatory cells (e&g&, eosinophils)&
o The use of leu'otriene modifiers can successfully e used as add+on therapy to
reduce (not sustitute for) the doses of inhaled corticosteroids&
o Bhort+acting inhaled V
"
+adrenergic agonists are the most effective drugs for
relieving acute ronchospasm& They are also used for acute e)acerations of
asthma&
o :ethyl)anthine (theophylline) preparations are less effective long+term control
ronchodilators as compared to V
"
+adrenergic agonists&
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Key Points
o 5nticholinergic agents (e&g&, ipratropium H5troventI, tiotropium HBpirivaI) loc'
the ronchoconstricting influence of parasympathetic nervous system&
;ne of the ma#or factors for determining success in asthma management is the correct
administration of drugs&
.nhalation devices include metered+dose inhalers, dry po,der inhalers, and neulizers&
Beveral nonprescription comination drugs are availale over the counter& 5n important
teaching responsiility is to ,arn the patient aout the dangers associated ,ith
nonprescription comination drugs&
5 goal in asthma care is to ma)imize the aility of the patient to safely manage acute
asthma episodes via an asthma action plan developed in con#unction ,ith the health care
provider& 5n important nursing goal during an acute attac' is to decrease the patient(s sense
of panic&
-ritten asthma action plans
should e developed together ,ith the patient and family,
especially for those ,ith moderate or severe persistent asthma or a history of severe
e)acerations&
C)-$N'C $/S,-5C,'2 P5LM$NA-6 D'SAS
Chronic obstructi!e "ulmonar. disease (C;P=) is a preventale and treatale disease
state characterized y airflo, limitation that is not fully reversile& The airflo, limitation is
usually progressive and associated ,ith an anormal inflammatory response of the lungs to
no)ious particles or gases, primarily caused y cigarette smo'ing&
.n addition to cigarette smo'e, occupational chemicals, and air pollution, infections are ris'
factors for developing C;P=& Bevere recurring respiratory tract infections in childhood
have een associated ,ith reduced lung function and increased respiratory symptoms in
adulthood&
?
-Antitr."sin deficienc., an autosomal recessive disorder, is a genetic ris' factor that can
lead to C;P=&
5ging results in changes in the lung structure, the thoracic cage, and the respiratory
muscles, and as people age there is gradual loss of the elastic recoil of the lung& Therefore
some degree of emphysema is common in the lungs of the older person, even a nonsmo'er&
The term chronic ostructive pulmonary disease encompasses t,o types of ostructive
air,ay diseases, chronic ronchitis and emphysema&
o Chronic bronchitis is the presence of chronic productive cough for $ months in
each of " consecutive years in a patient in ,hom other causes of chronic cough
have een e)cluded&
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Key Points
o m"h.sema is an anormal permanent enlargement of the airspaces distal to the
terminal ronchioles, accompanied y destruction of their ,alls and ,ithout
ovious firosis&
5 diagnosis of C;P= should e considered in any patient ,ho has symptoms of cough,
sputum production, or dyspnea, and1or a history of e)posure of ris' factors for the disease&
5n intermittent cough, ,hich is the earliest symptom, usually occurs in the morning ,ith
the e)pectoration of small amounts of stic'y mucus resulting from outs of coughing&
C;P= can e classified as at ris', mild, moderate, severe, and very severe&
Complications of C;P= include the follo,ing:
o Cor "ulmonale is hypertrophy of the right side of the heart, ,ith or ,ithout heart
failure, resulting from pulmonary hypertension and is a late manifestation of
chronic pulmonary heart disease&
o *)acerations of C;P= are signaled y a change in the patient(s usual dyspnea,
cough, and1or sputum that is different than the usual daily patterns& These flares
re<uire changes in management&
o Patients ,ith severe C;P= ,ho have e)acerations are at ris' for the
development of respiratory failure&
o The incidence of peptic ulcer disease is increased in the person ,ith C;P=&
o 5n)iety and depression can complicate respiratory compromise and may
precipitate dyspnea and hyperventilation&
The diagnosis of C;P= is confirmed y pulmonary function tests& Aoals of the diagnostic
,or'up are to confirm the diagnosis of C;P= via spirometry, evaluate the severity of the
disease, and determine the impact of disease on the patient(s <uality of life& -hen the
@*3
1
1@3C ratio is less than 98K, it suggests the presence of ostructive lung disease&
The primary goals of care for the C;P= patient are to (1) prevent disease progression, (")
relieve symptoms and improve e)ercise tolerance, ($) prevent and treat complications, (%)
promote patient participation in care, (C) prevent and treat e)acerations, and (D) improve
<uality of life and reduce mortality&
Cessation of cigarette smo'ing in all stages of C;P= is the single most effective and cost+
effective intervention to reduce the ris' of developing C;P= and stop the progression of
the disease&
5lthough patients ,ith C;P= do not respond as dramatically as those ,ith asthma to
ronchodilator therapy, a reduction in dyspnea and an increase in @*3
1
are usually
achieved& Presently no drug modifies the decline of lung function ,ith C;P=&
;
"
therapy is fre<uently used in the treatment of C;P= and other prolems associated ,ith
hypo)emia& 2ong+term ;
"
therapy improves survival, e)ercise capacity, cognitive
performance, and sleep in hypo)emic patients&
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Key Points
o ;
"
delivery systems are classified as lo,+ or high+flo, systems& :ost methods of
;
"
administration are lo,+flo, devices that deliver ;
"
in concentrations that vary
,ith the person(s respiratory pattern&
o =ry ;
"
has an irritating effect on mucous memranes and dries secretions&
Therefore it is important that ;
"
e humidified ,hen administered, either y
humidification or neulization&
Three different surgical procedures have een used in severe C;P=:
o 2ung volume reduction surgery is used to reduce the size of the lungs y
removing aout $8K of the most diseased lung tissue so the remaining healthy
lung tissue can perform etter&
o 5 ullectomy is used for certain patients and can result in improved lung function
and reduction in dyspnea&
o .n appropriately selected patients ,ith very advanced C;P=, lung transplantation
improves functional capacity and enhances <uality of life&
?espiratory therapy (?T) and physical therapy (PT) rehailitation activities are performed
y respiratory therapists or physical therapists, depending on the institution& ?T and1or PT
activities include reathing retraining, effective cough techni<ues, and chest physiotherapy&
o Pursed-li" breathing is a techni<ue that is used to prolong e)halation and
therey prevent ronchiolar collapse and air trapping& ;ften instinctively patients
,ill perform this techni<ue&
o The main goals of effective coughing are to conserve energy, reduce fatigue, and
facilitate removal of secretions& >uff coughing is an effective techni<ue that the
patient can e easily taught&
o Chest "h.siothera". consists of percussion, viration, and postural drainage&
-eight loss and malnutrition are commonly seen in the patient ,ith severe emphysematous
C;P=& The patient ,ith C;P= should try to 'eep the ody mass inde) (6:.) et,een "1
and "C 'g1m
"
&
The patient ,ith C;P= ,ill re<uire acute intervention for complications such as
e)acerations of C;P=, pneumonia, cor pulmonale, and acute respiratory failure&
Pulmonary rehailitation should e considered for all patients ,ith symptomatic C;P= or
having functional limitations& The overall goal is to increase the <uality of life&
-al'ing is y far the est physical e)ercise for the C;P= patient& 5de<uate sleep is also
e)tremely important&
C6S,'C +'/-$S'S
C.stic fibrosis (C@) is an autosomal recessive, multisystem disease characterized y
altered function of the e)ocrine glands primarily involving the lungs, pancreas, and s,eat
glands&
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Key Points
.nitially, C@ is an ostructive lung disease caused y the overall ostruction of the air,ays
,ith mucus& 2ater, C@ also progresses to a restrictive lung disease ecause of the firosis,
lung destruction, and thoracic ,all changes&
The ma#or o#ectives of therapy in C@ are to (1) promote clearance of secretions, (") control
infection in the lungs, and ($) provide ade<uate nutrition&
/-$NC)'C,AS'S
/ronchiectasis is characterized y permanent, anormal dilation of one or more large
ronchi& The pathophysiologic change that results in dilation is destruction of the elastic
and muscular structures supporting the ronchial ,all&
The hallmar' of ronchiectasis is persistent or recurrent cough ,ith production of large
amounts of purulent sputum, ,hich may e)ceed C88 ml1day&
6ronchiectasis is difficult to treat& Therapy is aimed at treating acute flare+ups and
preventing decline in lung function&
5ntiiotics are the mainstay of treatment and are often given empirically, ut attempts are
made to culture the sputum& 2ong+term suppressive therapy ,ith antiiotics is reserved for
those patients ,ho have symptoms that recur a fe, days after stopping antiiotics&
5n important nursing goal is to promote drainage and removal of ronchial mucus&
Lewis et al: Medical-Surgical Nursing: Assessment and Management of
Clinical Problems, 7
th
edition
Key Points
C>5PT*? $8: N4?B.NA 5BB*BB:*NT: >*:5T;2;A.C BWBT*:
S,-5C,5-S AND +5NC,'$NS
)ematolog. is the study of lood and lood+forming tissues& This includes the one
marro,, lood, spleen, and lymph system&
6lood cell production (hemato"oiesis) occurs ,ithin the one marro,& /one marrow is
the soft material that fills the central core of ones&
6lood is a type of connective tissue that performs three ma#or functions: transportation,
regulation, and protection& There are t,o ma#or components to lood: plasma and lood
cells&
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Key Points
Plasma is composed primarily of ,ater, ut it also contains proteins, electrolytes, gases,
nutrients, and ,aste&
There are three types of lood cells: erythrocytes (?6Cs), leu'ocytes (-6Cs), and
thromocytes (platelets)&
r.throc.tes are primarily composed of a large molecule called hemogloin&
)emoglobin, a comple) protein+iron compound composed of heme (an iron compound)
and gloin (a simple protein), functions to ind ,ith o)ygen and caron dio)ide&
Leu0oc.tes (-6Cs) appear ,hite ,hen separated from lood& There are five different
types of leu'ocytes, each of ,hich has a different function&
o Aranulocytes (neutrophils, eosinophils, asophils): the primary function of the
granulocytes is "hagoc.tosis, a process y ,hich -6Cs ingest or engulf any
un,anted organism and then digest and 'ill it& The neutrophil is the most common
type of granulocyte&
o 2ymphocytes: the main function of lymphocytes is related to the immune
response& 2ymphocytes form the asis of the cellular and humoral immune
responses&
o :onocytes: monocytes are phagocytic cells& They can ingest small or large
masses of matter, such as acteria, dead cells, tissue deris, and old or defective
?6Cs&
The primary function of thromboc.tes, or platelets, is to initiate the clotting process y
producing an initial platelet plug in the early phases of the clotting process&
)emostasis is a term used to descrie the lood clotting process& This process is
important in minimizing lood loss ,hen various ody structures are in#ured&
@our components contriute to normal hemostasis: vascular response, platelet plug
formation, the development of the firin clot on the platelet plug y plasma clotting
factors, and the ultimate lysis of the clot&
5nother component of the hematologic system is the spleen, ,hich is located in the upper
left <uadrant of the adomen& The functions of the spleen can e classified into four
ma#or functions: hematopoietic, filtration, immunologic, and storage&
The lymph systemGconsisting of lymph fluid, lymphatic capillaries, ducts, and lymph
nodesGcarries fluid from the interstitial spaces to the lood&
ASSSSMN,
:uch of the evaluation of the hematologic system is ased on a thorough health history,
and a numer of health patterns should e assessed&
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Key Points
5 complete physical e)amination is necessary to accurately e)amine all systems that
affect or are affected y the hematologic system, including an assessment of lymph
nodes, liver, spleen, and s'in&
D'A4N$S,'C S,5D'S
The most direct means of evaluating the hematologic system is through laoratory
analysis and other diagnostic studies&
The complete lood count (C6C) involves several laoratory tests, each of ,hich serves
to assess the three ma#or lood cells formed in the one marro,&
*rythrocyte sedimentation rate (*B? or /sed rate0) measures the sedimentation or settling
of ?6Cs and is used as a nonspecific measure of many diseases, especially inflammatory
conditions&
The laoratory tests used in evaluating iron metaolism include serum iron, total iron+
inding capacity (T.6C), serum ferritin, and transferrin saturation&
?adiologic studies for the hematology system involve primarily the use of computed
tomography (CT) or magnetic resonance imaging (:?.) for evaluating the spleen, liver,
and lymph nodes&
6one marro, e)amination is important in the evaluation of many hematologic disorders&
The e)amination of the marro, may involve aspiration only or aspiration ,ith iopsy&
2ymph node iopsy involves otaining lymph tissue for histologic e)amination to
determine the diagnosis, and to help for planning therapy&
Testing for specific genetic or chromosomal variations in hematologic conditions is often
helpful in assisting in diagnosis and staging& These results also help to determine the
treatment options and prognosis&
Lewis et al: Medical-Surgical Nursing: Assessment and Management of
Clinical Problems, 7
th
edition
Key Points
Chapter $1: Nursing :anagement: >ematologic Prolems
ANM'A
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Key Points
Anemia is a deficiency in the numer of erythrocytes (red lood cells H?6CsI), the
<uantity of hemogloin, and1or the volume of pac'ed ?6Cs (hematocrit), ,hich can lead
to tissue hypo)ia&
>emogloin (>) levels are often used to determine the severity of anemia&
Correcting the cause of the anemia is ultimately the goal of therapy&
.nterventions may include lood or lood product transfusions, drug therapy, volume
replacement, o)ygen therapy, dietary modifications, and lifestyle changes&
Anemia Caused /. Decreased r.throc.te Production
Iron-Deficiency Anemia
'ron-deficienc. anemia may develop from inade<uate dietary inta'e, malasorption,
lood loss, or hemolysis& 5lso, pregnancy contriutes to iron deficiency ecause of the
diversion of iron to the fetus for erythropoiesis, lood loss at delivery, and lactation&
The main goal of collaorative care for iron+deficiency anemia is to treat the underlying
disease causing reduced inta'e (e&g&, malnutrition, alcoholism) or asorption of iron& .n
addition, efforts are directed to,ard replacing iron ,ith dietary changes or
supplementation&
.t is important for a nurse to recognize groups of individuals ,ho are at an increased ris'
for the development of iron+deficiency anemia& These include premenopausal and
pregnant ,omen, persons from lo,erclass socioeconomic ac'grounds, older adults,
and individuals e)periencing lood loss&
Thalassemia
,halassemia is a group of diseases that has an autosomal+recessive genetic asis that
involves inade<uate production of normal hemogloin&
5n individual ,ith thalassemia may have a heterozygous or homozygous form of the
disease, ased on the numer of thalassemic genes the individual has&
Thalassemia minor re<uires no treatment ecause the ody adapts to the reduced level of
normal hemogloin&
The symptoms of thalassemia ma#or are managed ,ith lood transfusions or e)change
transfusions in con#unction ,ith .3 defero)amine to reduce the iron overloading
(hemochromatosis) that occurs ,ith chronic transfusion therapy&
M4AL$/LAS,'C ANM'AS
Megaloblastic anemias are a group of disorders caused y impaired =N5 synthesis and
characterized y the presence of large ?6Cs&
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Key Points
:acrocytic (large) ?6Cs are easily destroyed ecause they have fragile cell memranes&
T,o common forms of megalolastic anemia are coalamin deficiency and folic acid
deficiency&
o Coalamin (vitamin 6
1"
) deficiency is most commonly caused y "ernicious
anemia, ,hich results in poor coalamin asorption through the A. tract&
Parenteral or intranasal administration of coalamin is the treatment of choice&
o @olic acid (folate) is re<uired for =N5 synthesis leading to ?6C formation
and maturation and therefore can lead to megalolastic anemia& @olic acid
deficiency is treated y replacement therapy&
Aplastic Anemia
A"lastic anemia is a disease in ,hich the patient has peripheral lood pancytopenia
(decrease of all lood cell types) and hypocellular one marro,&
:anagement of aplastic anemia is ased on identifying and removing the causative agent
(,hen possile) and providing supportive care until the pancytopenia reverses&
Anemia Caused /. /lood Loss
Acute Bloo !oss
5cute lood loss occurs as a result of sudden hemorrhage&
Causes of acute lood loss include trauma, complications of surgery, and conditions or
diseases that disrupt vascular integrity&
Collaorative care is initially concerned ,ith replacing lood volume to prevent shoc'
and identifying the source of the hemorrhage and stopping the lood loss&
"hronic Bloo !oss
The sources of chronic lood loss are similar to those of iron+deficiency anemia (e&g&,
leeding ulcer, hemorrhoids, menstrual and postmenopausal lood loss)&
:anagement of chronic lood loss anemia involves identifying the source and stopping
the leeding& Bupplemental iron may e re<uired&
Anemia Caused /. 'ncreased r.throc.te Destruction %)emol.tic Anemia&
S'C9L CLL D'SAS
Sic0le cell disease is a group of inherited, autosomal recessive disorders characterized y
the presence of an anormal form of hemogloin in the erythrocyte&
The ma#or pathophysiologic event of this disease is the sic'ling of ?6Cs& Bic'ling
episodes are most commonly triggered y lo, o)ygen tension in the lood&
-ith repeated episodes of sic'ling there is gradual involvement of all ody systems,
especially the spleen, lungs, 'idneys, and rain&
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Key Points
Collaorative care for a patient ,ith sic'le cell disease is directed to,ard alleviating the
symptoms from the complications of the disease and minimizing end target+organ
damage& There is no specific treatment for the disease&
Ac#uire Hemolytic Anemia
*)trinsic causes of hemolysis can e separated into three categories: (1) physical factors,
(") immune reactions, and ($) infectious agents and to)ins&
Physical destruction of ?6Cs results from the e)ertion of e)treme force on the cells&
5ntiodies may destroy ?6Cs y the mechanisms involved in antigen+antiody
reactions&
.nfectious agents foster hemolysis in four ,ays: (1) y invading the ?6C and destroying
its contents, (") y releasing hemolytic sustances, ($) y generating an antigen+antiody
reaction, and (%) y contriuting to splenomegaly as a means of increasing removal of
damaged ?6Cs from the circulation&
)M$C)-$MA,$S'S
)emochromatosis is an autosomal recessive disease characterized y increased intestinal
iron asorption and, as a result, increased tissue iron deposition&
The goal of treatment is to remove e)cess iron from the ody and minimize any
symptoms the patient may have&
P$L6C6,)M'A
Pol.c.themia is the production and presence of increased numers of ?6Cs& The
increase in ?6Cs can e so great that lood circulation is impaired as a result of the
increased lood viscosity and volume&
Treatment is directed to,ard reducing lood volume1viscosity and one marro, activity&
Phleotomy is the mainstay of treatment&
,)-$M/$C6,$PN'A
,hromboc.to"enia is a reduction of platelets elo, 1C8,8881Xl (1C8 Y 18
E
12)&
Platelet disorders can e inherited, ut the vast ma#ority of them are ac<uired& The causes
of ac<uired disorders include autoimmune diseases, increased platelet consumption,
splenomegaly, marro, suppression, and one marro, failure&
The most common ac<uired thromocytopenia is a syndrome of anormal destruction of
circulating platelets termed immune thrombocytopenic purpura (.TP)& :ultiple therapies
are used to manage the patient ,ith .TP, such as corticosteroids or splenectomy&
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Key Points
;ne of the ris's associated ,ith the road and increasing use of heparin is the
development of the life+threatening condition called heparin$induced thrombocytopenia
and thrombosis syndrome (>.TTB)& >eparin must e discontinued ,hen >.TTB is first
recognized, ,hich is usually if the patient(s platelet count has fallen C8K or more from its
aseline or if a thromus forms ,hile the patient is on heparin therapy&
@or the nurse, the overall goals are that the patient ,ith thromocytopenia ,ill (1) have
no gross or occult leeding, (") maintain vascular integrity, and ($) manage home care to
prevent any complications related to an increased ris' for leeding&
HEMOPHILIA AND VON WILLEBRAND DISEASE
)emo"hilia is a se)+lin'ed recessive genetic disorder caused y defective or deficient
coagulation factor& The t,o ma#or forms of hemophilia, ,hich can occur in mild to severe
forms, are hemophilia 5 and hemophilia 6&
3on -illerand disease is a related disorder involving a deficiency of the von -illerand
coagulation protein&
?eplacement of deficient clotting factors is the primary means of supporting a patient
,ith hemophilia& .n addition to treating acute crises, replacement therapy may e given
efore surgery and efore dental care as a prophylactic measure&
>ome management is a primary consideration for the patient ,ith hemophilia ecause the
disease follo,s a progressive, chronic course&
The patient ,ith hemophilia must e taught to recognize disease+related prolems and to
learn ,hich prolems can e resolved at home and ,hich re<uire hospitalization&
D'SSM'NA,D 'N,-A2ASC5LA- C$A45LA,'$N
Disseminated intra!ascular coagulation (=.C) is a serious leeding and thromotic
disorder&
.t results from anormally initiated and accelerated clotting& Buse<uent decreases in
clotting factors and platelets ensue, ,hich may lead to uncontrollale hemorrhage&
=.C is al,ays caused y an underlying disease or condition& The underlying prolem
must e treated for the =.C to resolve&
.t is important to diagnose =.C <uic'ly, stailize the patient if needed (e&g&, o)ygenation,
volume replacement), institute therapy that ,ill resolve the underlying causative disease
or prolem, and provide supportive care for the manifestations resulting from the
pathology of =.C itself&
N5,-$PN'A
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Key Points
Neutro"enia is a reduction in neutrophils, a type of granulocyte, and therefore is
sometime referred to as granulocytopenia& The neutrophilic granulocytes are closely
monitored in clinical practice as an indicator of a patient(s ris' for infection&
Neutropenia is a clinical conse<uence that occurs ,ith a variety of conditions or diseases&
.t can also e an e)pected effect, a side effect, or an unintentional effect of ta'ing certain
drugs&
;ccasionally the cause of the neutropenia can e easily treated (e&g&, nutritional
deficiencies)& >o,ever, neutropenia can also e a side effect that must e tolerated as a
necessary step in therapy (e&g&, chemotherapy, radiation therapy)& .n some situations the
neutropenia resolves ,hen the primary disease is treated (e&g&, tuerculosis)&
The nurse needs to monitor the neutropenic patient for signs and symptoms of infection
and early septic shoc'&
M6L$D6SPLAS,'C S6ND-$M
M.elod.s"lastic s.ndrome (:=B) is a group of related hematologic disorders
characterized y a change in the <uantity and <uality of one marro, elements& 5lthough
it can occur in all age groups, the highest prevalence is in people over D8 years of age&
Bupportive treatment consists of hematologic monitoring, antiiotic therapy, or
transfusions ,ith lood products& The overall goal is to improve hematopoiesis and
ensure age+related <uality of life&
L59M'A
Leu0emia is the general term used to descrie a group of malignant disorders affecting
the lood and lood+forming tissues of the one marro,, lymph system, and spleen&
Classification of leu'emia can e done ased on acute versus chronic and on the type of
-6C involved, ,hether it is of myelogenous origin or of lymphocytic origin&
o The onset of acute myelogenous leu'emia (5:2) is often arupt and dramatic&
5:2 is characterized y uncontrolled proliferation of myelolasts, the precursors
of granulocytes&
o 5cute lymphocytic leu'emia (522) is the most common type of leu'emia in
children&
o Chronic myelogenous leu'emia (C:2) is caused y e)cessive development of
mature neoplastic granuloctyes in the one marro,, ,hich move into the
peripheral lood in massive numers and ultimately infiltrate the liver and spleen&
The natural history of C:2 is a chronic stale phase, follo,ed y the
development of a more acute, aggressive phase referred to as the lastic phase#
o Chronic lymphocytic leu'emia (C22) is characterized y the production and
accumulation of functionally inactive ut long+lived, small, mature+appearing
lymphocytes& The lymphocytes infiltrate the one marro,, spleen, and liver, and
lymph node enlargement is present throughout the ody&
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Key Points
o >airy cell leu'emia is a chronic disease of lymphoproliferation predominantly
involving 6 lymphocytes that infiltrate the one marro, and spleen& Cells have a
/hairy0 appearance under the microscope&
;nce a diagnosis of leu'emia has een made, collaorative care is focused on the initial
goal of attaining remission& .n some cases, such as nonsymptomatic patients ,ith C22,
,atchful ,aiting ,ith active supportive care may e appropriate&
Cytoto)ic chemotherapy is the mainstay of the treatment for leu'emia& >ematopoietic
stem cell transplantation is another type of therapy used for patients ,ith different forms
of leu'emia&
The overall nursing goals are that the patient ,ith leu'emia ,ill (1) understand and
cooperate ,ith the treatment plan, (") e)perience minimal side effects and complications
associated ,ith oth the disease and its treatment, and ($) feel hopeful and supported
during the periods of treatment, relapse, or remission&
L6MP)$MAS
L.m"homas are malignant neoplasms originating in the one marro, and lymphatic
structures resulting in the proliferation of lymphocytes&
There are t,o ma#or types of lymphomasG>odg'in(s lymphoma and non+>odg'in(s
lymphoma (N>2)&
)odg0in<s L.m"homa
)odg0in<s l.m"homa, also called >odg'in(s disease, is a malignant condition
characterized y proliferation of anormal giant, multinucleated cells, called !eed$
Sternberg cells, ,hich are located in lymph nodes&
5lthough the cause of >odg'in(s lymphoma remains un'no,n, the main interacting
factors include infection ,ith *pstein+6arr virus, genetic predisposition, and e)posure to
occupational to)ins& The incidence of >odg'in(s lymphoma is increased in incidence
among human immunodeficiency virus infected patients&
The nursing care for >odg'in(s lymphoma is largely ased on managing prolems related
to the disease (e&g&, pain due to tumor), pancytopenia, and other side effects of therapy&
Non-)odg0in<s L.m"homas
Non-)odg0in<s l.m"homas (N>2s) are a heterogeneous group of malignant neoplasms
of primarily 6 or T cell origin affecting all ages& 5 variety of clinical presentations and
courses are recognized from indolent (slo,ly developing) to rapidly progressive disease&
N>2s can originate outside the lymph nodes, the method of spread can e unpredictale,
and the ma#ority of patients have ,idely disseminated disease at the time of diagnosis&
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Key Points
Treatment for N>2 involves chemotherapy and sometimes radiation therapy& Nursing
care is largely ased on managing prolems related to the disease (e&g&, pain due to the
tumor, spinal cord compression, tumor lysis syndrome), pancytopenia, and other side
effects of therapy&
MULTIPLE MYELOMA
Multi"le m.eloma, or plasma cell myeloma, is a condition in ,hich neoplastic plasma
cells infiltrate the one marro, and destroy one&
:ultiple myeloma develops slo,ly and insidiously& The patient often does not manifest
symptoms until the disease is advanced&
:ultiple myeloma is seldom cured, ut treatment can relieve symptoms, produce
remission, and prolong life& Chemotherapy is usually the first treatment recommended for
multiple myeloma&
:aintaining ade<uate hydration is a primary nursing consideration to minimize prolems
from hypercalcemia& 6ecause of the potential for pathologic fractures, the nurse must e
careful ,hen moving and amulating the patient&
/L$$D C$MP$NN, ,)-AP6
6lood component therapy is fre<uently used in managing hematologic diseases&
>o,ever, lood component therapy only temporarily supports the patient until the
underlying prolem is resolved&
-hen the lood or lood components have een otained from the lood an', positive
identification of the donor lood and recipient must e made& .mproper product+to+patient
identification causes E8K of hemolytic transfusion reactions&
The lood should e administered as soon as it is rought to the patient& .t should not e
refrigerated on the nursing unit&
5utotranfusion, or autologous transfusion, consists of removing ,hole lood from a
person and transfusing that lood ac' into the same person& The prolems of
incompatiility, allergic reactions, and transmission of disease can e avoided&
5 lood transfusion reaction is an adverse reaction to lood transfusion therapy that can
range in severity from mild symptoms to a life+threatening condition& 6lood transfusion
reactions can e classified as acute or delayed&
Acute ,ransfusion -eactions
The most common cause of hemolytic reactions is transfusion of 56;+incompatile
lood&
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Key Points
@erile reactions are most commonly caused y leu'ocyte incompatiility& :any
individuals ,ho receive five or more transfusions develop circulating antiodies to the
small amount of -6Cs in the lood product&
5llergic reactions result from the recipient(s sensitivity to plasma proteins of the donor(s
lood& These reactions are more common in an individual ,ith a history of allergies&
5n individual ,ith cardiac or renal insufficiency is at ris' for developing circulatory
overload& This is especially true if a large <uantity of lood is infused in a short period of
time, particularly in an elderly patient&
Transfusion+related lung in#ury is characterized y the sudden development of
noncardiogenic pulmonary edema (acute lung in#ury)&
5n acute complication of transfusing large volumes of lood products is termed massive
lood transfusion reaction# :assive lood transfusion reactions can occur ,hen
replacement of ?6Cs or lood e)ceeds the total lood volume ,ithin "% hours&
Dela.ed ,ransfusion -eactions
=elayed transfusion reactions include delayed hemolytic reactions, infections, iron
overload, and graft+versus+host disease&
.nfectious agents transmitted y lood transfusion include hepatitis 6 and C viruses, >.3,
human herpesvirus type D, *pstein+6arr virus, human T cell leu'emia, cytomegalovirus,
and malaria&
Lewis et al: Medical-Surgical Nursing: Assessment and Management of
Clinical Problems, 7
th
edition
Key Points
Chapter $": Nursing 5ssessment: Cardiovascular Bystem
S,-5C,5-S AND +5NC,'$NS
The heart is a four+chamered organ that lies in the mediastinal space in the thora)&
The heart is divided y the septum, forming the right and left atrium and the right and left
ventricle&
3alves separate the chamers of the heart:
o :itral valve separates the left atrium and the left ventricle&
o 5ortic valve separates the left ventricle and the aorta&
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Key Points
o Tricuspid valve separates the right atrium and the right ventricle&
o Pulmonic valve separates the right ventricle and the pulmonary artery&
The heart is:
o Composed of three layers: endocardium, myocardium, and epicardium&
o Burrounded y a firoserous sac called the pericardium&
The right side of the heart receives lood from the ody (via the vena cava) and pumps it
to the lungs ,here it is o)ygenated& 6lood returns to the left side of the heart (via the
pulmonary arteries) and is pumped to the ody via the aorta&
The coronary circulation provides lood to the myocardium& The right and left coronary
arteries are the first ranches of the aorta&
The conduction system consists of specialized cells that create and transport electrical
impulses& These electrical impulses initiate depolarization (contraction) of the
myocardium and ultimately a cardiac contraction&
*ach electrical impulse starts at the B5 node (located in the right atrium), travels to the
53 node (located at the atrioventricular #unction), through the undle of >is, do,n the
right and left undle ranches (located in the ventricular septum), terminating in the
Pur'in#e fiers&
The electrical activity of the heart is recorded on the electrocardiogram (*CA)&
S.stole, contraction of the myocardium, results in e#ection of lood from the ventricles&
?ela)ation of the myocardium, or diastole, allo,s for filling of the ventricles&
Cardiac out"ut (C;) is the amount of lood pumped y each ventricle in 1 minute& .t is
calculated y multiplying the amount of lood e#ected from the ventricle ,ith each
hearteat, the stro'e volume (B3), y the heart rate (>?) per minute: C; Z B3 >?&
@actors affecting B3 are preload, afterload, and contractility& Preload is the volume of
lood in the ventricles at the end of diastole, and afterload represents the peripheral
resistance against ,hich the left ventricle must pump&
Cardiac reser!e refers to the heart(s aility to alter the C; in response to an increase in
demand (e&g&, e)ercise, hypovolemia)&
Btimulation of the sympathetic nervous system increases >?, speed of conduction
through the 53 node, and force of atrial and ventricular contractions, ,hereas stimulation
of the parasympathetic nervous system decreases >?&
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Key Points
6aroreceptors, located in the aortic arch and carotid sinus, respond to stretch or pressure
,ithin the arterial system& Btimulation of these receptors results in temporary inhiition
of the sympathetic nervous system and an increase in parasympathetic influence&
Chemoreceptors, located in the aortic arch and carotid ody, can initiate changes in >?
and arterial pressure in response to decreased arterial ;
"
pressure, increased arterial C;
"
pressure, and decreased plasma p>&
Arterial blood "ressure (6P) measures the pressure e)erted y lood against the ,alls
of the arterial system&
The s.stolic blood "ressure (B6P) is the pea' pressure e)erted against the arteries ,hen
the heart contracts& The diastolic blood "ressure (=6P) is the residual pressure of the
arterial system during ventricular rela)ation (or filling)& Normal lood pressure is systolic
6P less than 1"8 mm >g and diastolic 6P less than F8 mm >g&
The t,o main factors influencing 6P are cardiac output (C;) and systemic vascular
resistance (B3?), ,hich is the force opposing the movement of lood&
6P can e measured y invasive (catheter inserted in an artery) and noninvasive
techni<ues (using a sphygmomanometer and a stethoscope)&
Pulse "ressure is the difference et,een the B6P and =6P and it is normally aout one
third of the B6P&
Mean arterial "ressure %MAP& is the perfusion pressure felt y organs in the ody, and
a :5P of greater than D8 is necessary to sustain the vital organs of an average person
under most conditions&
ASSSSMN,
Health History
-hen conducting a health assessment of the cardiovascular system, a thorough history should
include the follo,ing:
5ny past history of chest pain, shortness of reath, alcoholism and1or toacco use,
anemia, rheumatic fever, streptococcal sore throat, congenital heart disease, stro'e,
syncope, hypertension, thromophleitis, intermittent claudication, varicosities, and
edema
Current and past use of medications
.nformation aout specific treatments, past surgeries, or hospital admissions related to
cardiovascular prolems
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Key Points
.nformation aout cardiovascular ris' factors (i&e&, elevated serum lipids, hypertension)
@amily history ,ith cardiovascular illnesses of lood relatives
The patient(s current ,eight and ,eight history
5 typical day(s diet
Prolems ,ith urinary (e&g&, nocturia) or o,el elimination (e&g&, constipation)
The types of e)ercise performed and the occurrence of any un,anted effects
.dentification of paro)ysmal nocturnal dyspnea, sleep apnea, and the numer of pillo,s
needed for comfort
.nformation aout the patient(s gender, race, and age
5ny prolems in se)ual performance
.nformation aout stressful situations should e e)plored (e&g&, marital relationships)
.nformation aout a patient(s values and eliefs
Physical Examination
-hen conducting a health assessment of the cardiovascular system, a thorough physical
e)amination should include the follo,ing:
Aeneral appearance, vital signs, including orthostatic (postural) 6Ps and >?s
.nspection of the s'in, e)tremities, and the large veins of the nec'
6ilateral and simultaneous palpation of the upper and lo,er e)tremities
6ilateral and simultaneous palpation of the pulses in the e)tremities
Capillary refill
5uscultation of carotid arteries, adominal aorta, and femoral arteries
.nspection and palpation of the thora), epigastric area, and mitral valve area
5uscultation of the heart ,ith the ell and diaphragm of the stethoscope
5uscultation for e)tra heart sounds (B
$
or B
%
) ,ith the ell of the stethoscope
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Key Points
D'A4N$S,'C S,5D'S
The most common procedures used to diagnose cardiovascular disease include the follo,ing:
6lood studies
o Creatine 'inase (CK)+:6: levels increase ,ith myocardial infarction (:.)
o Cardiac+specific troponin: levels rise ,ith myocardial in#ury
o :yogloin: sensitive indicator of early myocardial in#ury
o Berum lipoproteins: including triglycerides, cholesterol, and phospholipids
o C+reactive protein (C?P): emerging as an independent ris' factor for C5= and a
predictor of cardiac events
o >omocysteine (>cy): elevated levels have een lin'ed to an increased ris' of a
first cardiac event and should e measured in patients ,ith a familial
predisposition for early cardiovascular disease
o Cardiac natriuretic peptide mar'ers: emerged as the mar'er of choice for
distinguishing a cardiac or respiratory cause of dyspnea
Chest )+ray
*lectrocardiogram
o =eviations from the normal sinus rhythm can indicate anormalities in heart
function&
o Continuous amulatory *CA (>olter monitoring): recorder is ,orn for "% to %F
hours, and the resulting *CA information is then stored until it is played ac' for
printing and evaluation&
o Transtelephonic event recorders: portale monitor uses electrodes to transmit a
limited *CA over the phone to a receiving device&
*)ercise or stress testing
o 4sed to evaluate the cardiovascular response to physical stress
D+:inute ,al' test
o 4sed for patients ,ith heart or peripheral arterial disease to measure response to
medical interventions and determine functional capacity for daily physical
activities
*chocardiogram
o 4ses ultrasound ,aves to record the movement of the structures of the heart&
o Provides information aout (1) valvular structure and motion, (") cardiac chamer
size and contents, ($) ventricular muscle and septal motion and thic'ness, (%)
pericardial sac, (C) ascending aorta, and (D) e*ection fraction (*@) (percentage of
end+diastolic lood volume that is e#ected during systole)&
Nuclear cardiology
o :ultigated ac<uisition (:4A5) or cardiac lood pool scan
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Key Points
Provides information on ,all motion during systole and diastole, cardiac
valves, and *@&
o Bingle+photon emission computed tomography (BP*CT)
4sed to evaluate the myocardium at ris' of infarction and to determine
infarction size&
o Positron emission tomography (P*T) scanning
4ses t,o isotopes to distinguish viale and nonviale myocardial tissue&
o Perfusion imaging ,ith e)ercise testing
=etermines ,hether the coronary lood flo, changes ,ith increased
activity&
4sed to diagnose C5=, determine the prognosis in already diagnosed
C5=, assess the physiologic significance of a 'no,n coronary lesion, and
assess the effectiveness of various therapeutic modalities such as coronary
artery ypass surgery, percutaneous coronary intervention, or thromolytic
therapy&
o :agnetic resonance imaging (:?.)
5llo,s detection and localization of areas of :. in a $+= vie,& .t is
sensitive enough to detect small :.s not apparent ,ith BP*CT imaging
and can assist in the final diagnosis of :.&
o :agnetic resonance angiography (:?5)
4sed for imaging vascular occlusive disease and adominal aortic
aneurysms&
Computed tomography (CT) ,ith spiral technology
o 5 noninvasive scan used to <uantify calcium deposits in coronary arteries&
*lectron eam computed tomography (*6CT), also 'no,n as ultrafast CT, uses a
scanning electron eam to <uantify the calcification in the coronary arteries and
the heart valves&
Cardiac catheterization and coronary angiography
o Contrast media (introduced via a catheter inserted in a large peripheral artery) and
fluoroscopy are used to otain information aout the coronary arteries, heart
chamers and valves, ventricular function, intracardiac pressures, ;
"
levels in
various parts of the heart, C;, and *@&
.ntracoronary ultrasound (.C4B) or intravascular ultrasound (.34B)
o Performed during coronary angiography& ;tains "+= or $+= ultrasound images to
provide a cross+sectional vie, of the arterial ,alls of the coronary arteries&
*lectrophysiology study (*PB)
o Btudies and manipulates the electrical activity of the heart using electrodes placed
inside the cardiac chamers& Provides information on B5 node function, 53 node
conduction, ventricular conduction, and source treatment dysrhythmias&
=uple) imaging
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Key Points
o 4ses contrast media, in#ected into arteries or veins (arteriography and
venography) to diagnose occlusive disease in the peripheral lood vessels and
thromophleitis&
>emodynamic monitoring
4ses intraarterial and pulmonary artery catheters to monitor arterial 6P, intracardiac pressures,
C;, and central venous pressure (C3P
Lewis et al: Medical-Surgical Nursing: Assessment and Management of
Clinical Problems, 7
th
edition
Key Points
Chapter $$: Nursing :anagement: >ypertension
)."ertension, or high blood "ressure (6P), is defined as a persistent systolic lood
pressure (B6P) greater than or e<ual to 1%8 mm >g, diastolic lood pressure (=6P)
greater than or e<ual to E8 mm >g, or current use of antihypertensive medication& There
is a direct relationship et,een hypertension and cardiovascular disease (C3=)&
Contriuting factors to the development of hypertension include cardiovascular ris'
factors comined ,ith socioeconomic conditions and ethnic differences&
>ypertension is generally an asymptomatic condition& .ndividuals ,ho remain
undiagnosed and untreated for hypertension present the greatest challenge and
opportunity for health care providers&
-45LA,'$N $+ /L$$D P-SS5-
6P is the force e)erted y the lood against the ,alls of the lood vessel& .t must e
ade<uate to maintain tissue perfusion during activity and rest&
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Key Points
?egulation of 6P involves nervous, cardiovascular, endothelial, renal, and endocrine
functions&
o Bympathetic nervous system (BNB) activation increases heart rate (>?) and
cardiac contractility, produces ,idespread vasoconstriction in the peripheral
arterioles, and promotes the release of renin from the 'idneys&
o 6aroreceptors, located in the carotid artery and the arch of the aorta, sense
changes in 6P& -hen 6P is increased, these receptors send inhiitory impulses to
the sympathetic vasomotor center in the rainstem resulting in decreased >?,
decreased force of contraction, and vasodilation in peripheral arterioles&
o 5 decrease in 6P leads to activation of the BNB resulting in constriction of the
peripheral arterioles, increased >?, and increased contractility of the heart&
o .n the presence of long+standing hypertension, the aroreceptors ecome ad#usted
to elevated levels of 6P and recognize this level as /normal&0
o Norepinephrine (N*), released from BNB nerve endings, activates receptors
located in the sinoatrial node, myocardium, and vascular smooth muscle&
o 3ascular endothelium produces vasoactive sustances and gro,th factors&
Nitric o)ide, an endothelium+derived rela)ing factor (*=?@), helps
maintain lo, arterial tone at rest, inhiits gro,th of the smooth muscle
layer, and inhiits platelet aggregation&
*ndothelin (*T), produced y the endothelial cells, is an e)tremely potent
vasoconstrictor&
o Kidneys contriute to 6P regulation y controlling sodium e)cretion and
e)tracellular fluid (*C@) volume&
Bodium retention results in ,ater retention, ,hich causes an increased
*C@ volume& This increases the venous return to the heart, increasing the
stro'e volume, ,hich elevates the 6P through an increase in C;&
o *ndocrine system:
The adrenal medulla releases epinephrine in response to BNB stimulation&
*pinephrine activates
"
+adrenergic receptors causing vasodilation& .n
peripheral arterioles ,ith only
1
+adrenergic receptors (s'in and 'idneys),
epinephrine causes vasoconstriction&
The adrenal corte) is stimulated y 5+.. to release aldosterone&
5ldosterone stimulates the 'idneys to retain sodium and ,ater& This
increases 6P y increasing C;&
5=> is released from the posterior pituitary gland in response to an
increased lood sodium and osmolarity level& 5=> increases the *C@
volume y promoting the reasorption of ,ater in the distal and collecting
tuules of the 'idneys resulting in an increase in lood volume and 6P&
CLASS'+'CA,'$N $+ )6P-,NS'$N
>ypertension is classified as follo,s:
o Preh."ertension: 6P 1"8 to 1$E 1 F8 to FE mm >g
o >ypertension, Btage 1: 6P 1%8 to 1CE 1 E8 to EE mm >g
o >ypertension, Btage ": systolic 6P greater than or e<ual to 1D8 or diastolic 6P
greater than or e<ual to 188 mm >g&
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Key Points
Butypes of hypertension:
o .solated systolic hypertension (.B>): average B6P greater than or e<ual to 1%8
mm >g coupled ,ith an average =6P less than E8 mm >g& .B> is more common
in older adults& Control of .B> decreases the incidence of stro'e, heart failure,
cardiovascular mortality, and total mortality&
o Pseudohypertension (false hypertension) occurs ,ith advanced arteriosclerosis&
Pseudohypertension is suspected if arteries feel rigid or ,hen fe, retinal or
cardiac signs are found relative to the pressures otained y cuff&
,'$L$46 $+ )6P-,NS'$N
Primar. %essential or idio"athic& h."ertension: elevated 6P ,ithout an identified
cause! accounts for E8K to ECK of all cases of hypertension&
Secondar. h."ertension: elevated 6P ,ith a specific cause! accounts for CK to 18K of
hypertension in adults&
PA,)$P)6S'$L$46 $+ P-'MA-6 )6P-,NS'$N
The hemodynamic hallmar' of hypertension is persistently increased B3?&
-ater and sodium retention:
o 5 high+sodium inta'e may activate a numer of pressor mechanisms and cause
,ater retention&
5ltered renin+angiotensin mechanism:
o >igh plasma renin activity (P?5) results in the increased conversion of
angiotensinogen to angiotensin . causing arteriolar constriction, vascular
hypertrophy, and aldosterone secretion&
Btress and increased BNB activity:
o 5rterial pressure is influenced y factors such as anger, fear, and pain&
o Physiologic responses to stress, ,hich are normally protective, may persist to a
pathologic degree, resulting in prolonged increase in BNB activity&
o .ncreased BNB stimulation produces increased vasoconstriction, increased >?,
and increased renin release&
.nsulin resistance and hyperinsulinemia:
o 5normalities of glucose, insulin, and lipoprotein metaolism are common in
primary hypertension&
o >igh insulin concentration in the lood stimulates BNB activity and impairs nitric
o)ideNmediated vasodilation&
o 5dditional pressor effects of insulin include vascular hypertrophy and increased
renal sodium reasorption&
*ndothelial cell dysfunction:
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Key Points
o Bome hypertensive people have a reduced vasodilator response to nitric o)ide&
o *ndothelin produces pronounced and prolonged vasoconstriction&
CL'N'CAL MAN'+S,A,'$NS $+ )6P-,NS'$N
;ften called the /silent 'iller0 ecause it is fre<uently asymptomatic until it ecomes
severe and target organ disease occurs&
Target organ diseases occur in the heart (hypertensive heart disease), rain
(cererovascular disease), peripheral vasculature (peripheral vascular disease), 'idney
(nephrosclerosis), and eyes (retinal damage)&
>ypertension is a ma#or ris' factor for coronary artery disease (C5=)&
Bustained high 6P increases the cardiac ,or'load and produces left ventricular
hypertrophy (23>)& Progressive 23>, especially in association ,ith C5=, is associated
,ith the development of heart failure&
>ypertension is a ma#or ris' factor for cereral atherosclerosis and stro'e&
>ypertension speeds up the process of atherosclerosis in the peripheral lood vessels,
leading to the development of peripheral vascular disease, aortic aneurysm, and aortic
dissection&
.ntermittent claudication (ischemic muscle pain precipitated y activity and relieved ,ith
rest) is a classic symptom of peripheral vascular disease involving the arteries&
>ypertension is one of the leading causes of end+stage renal disease, especially among
5frican 5mericans& The earliest manifestation of renal dysfunction is usually nocturia&
The retina provides important information aout the severity and duration of
hypertension& =amage to retinal vessels provides an indication of concurrent vessel
damage in the heart, rain, and 'idney& :anifestations of severe retinal damage include
lurring of vision, retinal hemorrhage, and loss of vision&
D'A4N$S,'C S,5D'S
6asic laoratory studies are performed to (1) identify or rule out causes of secondary
hypertension, (") evaluate target organ disease, ($) determine overall cardiovascular ris',
or (%) estalish aseline levels efore initiating therapy&
?outine urinalysis, 64N, serum creatinine, and creatinine clearance levels are used to
screen for renal involvement and to provide aseline information aout 'idney function&
:easurement of serum electrolytes, especially potassium levels, is done to detect
hyperaldosteronism, a cause of secondary hypertension&
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Key Points
6lood glucose levels assist in the diagnosis of diaetes mellitus&
2ipid profile provides information aout additional ris' factors that predispose to
atherosclerosis and cardiovascular disease&
4ric acid levels are determined to estalish a aseline, ecause the levels often rise ,ith
diuretic therapy&
*CA and echocardiography provide information aout the cardiac status&
5mulatory lood pressure monitoring (56P:) is a noninvasive, fully automated system
that measures 6P at preset intervals over a "%+hour period&
o Bome patients ,ith hypertension do not sho, a normal, nocturnal dip in 6P and
are referred to as /nondippers&0
o The asence of diurnal variaility has een associated ,ith more target organ
damage and an increased ris' for cardiovascular events& The presence or asence
of diurnal variaility can e determined y 56P:&
N5-S'N4 AND C$LLA/$-A,'2 MANA4MN,
Treatment goals are to lo,er 6P to less than 1%8 mm >g systolic and less than E8 mm >g
diastolic for most persons ,ith hypertension (less than 1$8 mm >g systolic and less than
F8 mm >g diastolic for those ,ith diaetes mellitus and chronic 'idney disease)&
2ifestyle modifications are indicated for all patients ,ith prehypertension and
hypertension and include the follo,ing:
o -eight reduction& 5 ,eight loss of 18 'g ("" l) may decrease B6P y
appro)imately C to "8 mm >g&
o =ietary 5pproaches to Btop >ypertension (=5B>) eating plan& .nvolves eating
several servings of fish each ,ee', eating plenty of fruits and vegetales,
increasing fier inta'e, and drin'ing a lot of ,ater& The =5B> diet significantly
lo,ers 6P&
o ?estriction of dietary sodium to less than D g of salt (NaCl) or less than "&% g of
sodium per day&
o This involves avoiding foods 'no,n to e high in sodium (e&g&, canned soups) and
not adding salt in the preparation of foods or at meals&
o There is evidence that greater levels of dietary potassium, calcium, vitamin =, and
omega+$ fatty acids are associated ,ith lo,er 6P in those ,ith hypertension&
o ?estriction of alcohol to no more than t,o drin's per day for men and no more
than one drin' per day for ,omen
o ?egular aeroic physical activity (e&g&, ris' ,al'ing) at least $8 minutes a day
most days of the ,ee'& :oderately intense activity such as ris' ,al'ing,
#ogging, and s,imming can lo,er 6P, promote rela)ation, and decrease or control
ody ,eight&
o .t is strongly recommended that toacco use e avoided&
o Btress can raise 6P on a short+term asis and has een implicated in the
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development of hypertension& ?ela)ation therapy, guided imagery, and
iofeedac' may e useful in helping patients manage stress, thus decreasing 6P&
Drug ,hera".
=rug therapy is not recommended for those persons ,ith prehypertension unless it is
re<uired y another condition, such as diaetes mellitus or chronic 'idney disease&
The overall goals for the patient ,ith hypertension include (1) achievement and
maintenance of the goal 6P! (") acceptance and implementation of the therapeutic plan!
($) minimal or no unpleasant side effects of therapy! and (%) aility to manage and cope
,ith illness&
=rugs currently availale for treating hypertension ,or' y (1) decreasing the volume of
circulating lood, and1or (") reducing B3?&
o =iuretics promote sodium and ,ater e)cretion, reduce plasma volume, decrease
sodium in the arteriolar ,alls, and reduce the vascular response to
catecholamines&
o 5drenergic+inhiiting agents act y diminishing the BNB effects that increase 6P&
5drenergic inhiitors include drugs that act centrally on the vasomotor center and
peripherally to inhiit norepinephrine release or to loc' the adrenergic receptors
on lood vessels&
o =irect vasodilators decrease the 6P y rela)ing vascular smooth muscle and
reducing B3?&
o Calcium channel loc'ers increase sodium e)cretion and cause arteriolar
vasodilation y preventing the movement of e)tracellular calcium into cells&
o 5ngiotensin+converting enzyme (5C*) inhiitors prevent the conversion of
angiotensin . to angiotensin .. and reduce angiotensin .. (5+..)Nmediated
vasoconstriction and sodium and ,ater retention&
o 5+.. receptor loc'ers (5?6s) prevent angiotensin .. from inding to its receptors
in the ,alls of the lood vessels&
o Thiazide+type diuretics are used as initial therapy for most patients ,ith
hypertension, either alone or in comination ,ith one of the other classes&
o -hen 6P is more than "8118 mm >g aove B6P and =6P goals, a second drug
should e considered& :ost patients ,ho are hypertensive ,ill re<uire t,o or
more antihypertensive medications to achieve their 6P goals&
o Bide effects and adverse effects of antihypertensive drugs may e so severe or
undesirale that the patient does not comply ,ith therapy&
>yperuricemia, hyperglycemia, and hypo'alemia are common side effects
,ith oth thiazide and loop diuretics&
5C* inhiitors lead to high levels of rady'inin, ,hich can cause
coughing& 5n individual ,ho develops a cough ,ith the use of 5C*
inhiitors may e s,itched to an 5?6&
>yper'alemia can e a serious side effect of the potassium+sparing
diuretics and 5C* inhiitors&
Be)ual dysfunction may occur ,ith some of the diuretics&
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;rthostatic hypotension and se)ual dysfunction are t,o undesirale
effects of adrenergic+inhiiting agents&
Tachycardia and orthostatic hypotension are potential adverse effects of
oth vasodilators and angiotensin inhiitors&
Patient and family teaching related to drug therapy is needed to identify
and minimize side effects and to cope ,ith therapeutic effects& Bide effects
may e an initial response to a drug and may decrease ,ith continued use
of the drug&
?esistant hypertension is the failure to reach goal 6P in patients ,ho are adhering to full
doses of an appropriate three+drug therapy regimen that includes a diuretic&
/lood Pressure Monitoring
The ma#ority of cases of hypertension are identified through routine screening procedures
such as insurance, preemployment, and military physical e)aminations&
The auscultatory method of 6P measurement is recommended& .nitially, the 6P is ta'en at
least t,ice, at least 1 minute apart, ,ith the average pressure recorded as the value for
that visit& Bize and placement of 6P cuff are important for accurate measurement& The
forearm is supported at heart level and Korot'off sounds are auscultated over the radial
artery&
6P measurements of oth arms should e performed initially to detect any differences
et,een arms& The arm ,ith the higher reading should e used for all suse<uent 6P
measurements&
;rthostatic (or postural) changes in 6P and pulse should e measured in older adults, in
people ta'ing antihypertensive drugs, and in patients ,ho report symptoms consistent
,ith reduced 6P upon standing (e&g&, light+headedness, dizziness, syncope)&
$rthostatic h."otension is defined as a decrease of "8 mm >g or more in B6P, a
decrease of 18 mm >g or more in =6P, and1or an increase of "8 eats1minute or more in
pulse from supine to standing&
6P monitoring should focus on controlling 6P in the person already identified as having
hypertension! identifying and controlling 6P in at+ris' groups such as 5frican 5mericans,
oese people, and lood relatives of people ,ith hypertension! and screening those ,ith
limited access to the health care system&
N5-S'N4 MANA4MN,
The primary nursing responsiilities for long+term management of hypertension are to
assist the patient in reducing 6P and complying ,ith the treatment plan& Nursing actions
include patient and family teaching, detection and reporting of adverse treatment effects,
compliance assessment and enhancement, and evaluation of therapeutic effectiveness&
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Patient and family teaching includes the follo,ing: (1) nutritional therapy, (") drug
therapy, ($) physical activity, (%) home monitoring of 6P (if appropriate), and (C) toacco
cessation (if applicale)&
o >ome monitoring of 6P should include daily 6P readings ,hen treatment is
initiated or medications are ad#usted and ,ee'ly once the 6P has stailized& 5 log
of the 6P measurements should e maintained y the patient& =evices that have
memory or printouts of the readings are recommended to facilitate accurate
reporting&
o 5 ma#or prolem in the long+term management of the patient ,ith hypertension is
poor compliance ,ith the prescried treatment plan& The reasons include
inade<uate patient teaching, unpleasant side effects of drugs, return of 6P to
normal range ,hile on medication, lac' of motivation, high cost of drugs, lac' of
insurance, and lac' of a trusting relationship et,een the patient and the health
care provider&
4-$N,$L$4'C C$NS'D-A,'$NS
The prevalence of hypertension increases ,ith age& The lifetime ris' of developing
hypertension is appro)imately E8K for middle+aged (age CC to DC) and older (age UDC)
normotensive men and ,omen&
5 numer of age+related physical changes contriute to the pathophysiology of
hypertension in the older adult&
.n some older people, there is a ,ide gap et,een the first Korot'off sound and
suse<uent eats (auscultatory gap)& @ailure to inflate the cuff high enough may result in
underestimating the B6P&
;lder adults are sensitive to 6P changes& ?educing B6P to less than 1"8 mm >g in a
person ,ith long+standing hypertension could lead to inade<uate cereral lood flo,&
;lder adults produce less renin and are more resistant to the effects of 5C* inhiitors and
angiotensin .. receptor loc'ers&
;rthostatic hypotension occurs often in older adults ecause of impaired aroreceptor
refle) mechanisms&
;rthostatic hypotension in older adults is often associated ,ith volume depletion or
chronic disease states, such as decreased renal and hepatic function or electrolyte
imalance&
To reduce the li'elihood of orthostatic hypotension, antihypertensive drugs should e
started at lo, doses and increased cautiously&
)6P-,NS'2 C-'S'S
)."ertensi!e crisis is a severe and arupt elevation in 6P, aritrarily defined as a =6P
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more than 1%8 mm >g&
o >ypertensive crisis occurs most often in patients ,ith a history of hypertension
,ho have failed to comply ,ith their prescried medications or ,ho have een
undermedicated&
o >ypertensive crisis related to cocaine or crac' use is ecoming a more fre<uent
prolem& ;ther drugs such as amphetamines, phencyclidine (PCP), and lysergic
acid diethylamide (2B=) may also precipitate hypertensive crisis that may e
complicated y drug+induced seizures, stro'e, :., or encephalopathy&
>ypertensive emergency develops over hours to days and is defined as 6P that is severely
elevated (more than 1F811"8 mm >g) ,ith evidence of acute target organ damage&
o >ypertensive emergencies can precipitate encephalopathy, intracranial or
suarachnoid hemorrhage, acute left ventricular failure ,ith pulmonary edema,
:., renal failure, dissecting aortic aneurysm, and retinopathy&
o >ypertensive emergencies re<uire hospitalization, intravenous (.3) administration
of antihypertensive drugs, and intensive care monitoring&
5ntihypertensive drugs include vasodilators, adrenergic inhiitors, and the 5C* inhiitor
enalaprilat& Bodium nitroprusside is the most effective .3 drug for the treatment of
hypertensive emergencies&
:ean arterial pressure (:5P) is generally used instead of systolic and diastolic readings
to guide therapy& :5P is calculated as follo,s: :5P Z (B6P O " =6P) $&
The use of an intraarterial line or an automated, noninvasive 6P machine to monitor the
:5P and 6P is re<uired& The rate of drug administration is titrated according to the level
of :5P or 6P&
The initial treatment goal is to decrease :5P y no more than "CK ,ithin minutes to 1
hour& .f the patient is stale, the target goal for 6P is 1D81188 to 118 mm >g over the ne)t
" to D hours&
2o,ering 6P e)cessively may decrease cereral, coronary, or renal perfusion and could
precipitate a stro'e, acute :., or renal failure&
5dditional gradual reductions to,ard a normal 6P should e implemented over the ne)t
"% to %F hours if the patient is clinically stale&
?egular, ongoing assessment (e&g&, *CA monitoring, vital signs, urinary output, level of
consciousness, visual changes) is essential to evaluate the patient ,ith severe
hypertension&
>ypertensive urgency develops over days to ,ee's and is defined as a 6P that is severely
elevated ut ,ith no clinical evidence of target organ damage&
o >ypertensive urgencies usually do not re<uire .3 medications ut can e managed
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,ith oral agents&
o .f a patient ,ith hypertensive urgency is not hospitalized, outpatient follo,+up
should e arranged ,ithin "% hours&
Lewis et al: Medical-Surgical Nursing: Assessment and Management of
Clinical Problems, 7
th
edition
Key Points
Chapter $%: Nursing :anagement: Coronary 5rtery =isease and 5cute Coronary
Byndrome
Coronar. arter. disease (C5=) is a type of lood vessel disorder included in the
general category of atherosclerosis&
Atherosclerosis is characterized y a focal deposit of cholesterol and lipids ,ithin the
intimal ,all of the artery& .nflammation and endothelial in#ury play a central role in the
development of atherosclerosis&
C5= is a progressive disease that develops in stages and ,hen it ecomes symptomatic,
the disease process is usually ,ell advanced&
Normally some arterial anastomoses or connections, termed collateral circulation, e)ist
,ithin the coronary circulation& The gro,th and e)tent of collateral circulation are
attriuted to t,o factors: (1) the inherited predisposition to develop ne, lood vessels
(angiogenesis), and (") the presence of chronic ischemia&
:any ris' factors have een associated ,ith C5=&
o Nonmodifiale ris' factors are age, gender, ethnicity, family history, and genetic
inheritance&
o :odifiale ris' factors include elevated serum lipids, hypertension, toacco use,
physical inactivity, oesity, diaetes, metaolic syndrome, psychologic states, and
homocysteine level&
*levated serum lipid levels are one of the four most firmly estalished ris'
factors for C5=&
2ipids comine ,ith proteins to form lipoproteins and are vehicles for fat
moilization and transport& The different types of lipoproteins are
classified as high+density lipoproteins (>=2s), lo,+density lipoproteins
(2=2s), and very+lo,+density lipoproteins (32=2s)&
>=2s carry lipids a,ay from arteries and to the liver for
metaolism& >igh serum >=2 levels are desirale&
>=2 levels are increased y physical activity, moderate alcohol
consumption, and estrogen administration&
*levated 2=2 levels correlate most closely ,ith an increased
incidence of atherosclerosis and C5=&
>ypertension, defined as a 6P greater than or e<ual to 1%81E8 mm >g, is a
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ma#or ris' factor in C5=&
Toacco use is also a ma#or ris' factor in C5=& The ris' of developing
C5= is t,o to si) times higher in those ,ho smo'e toacco than in those
,ho do not&
;esity is defined as a ody mass inde) (6:.) of less than $8 'g1m
"
& The
increased ris' for C5= is proportional to the degree of oesity&
o =iaetes, metaolic syndrome, and certain ehavioral states (i&e&, stress) have also
een found to e contriuting ris' factors for C5=&
C$-$NA-6 A-,-6 D'SAS
Prevention and early treatment of C5= must involve a multifactorial approach and needs
to e ongoing throughout the lifespan
5 complete lipid profile is recommended every C years eginning at age "8& Persons ,ith
a serum cholesterol level greater than "88 mg1dl are at high ris' for C5=&
:anagement of high+ris' persons starts ,ith controlling or changing the additive effects
of modifiale ris' factors&
o 5 regular physical activity program should e implemented&
o Therapeutic lifestyle changes to reduce the ris' of C5= include lo,ering 2=2
cholesterol y adopting a diet that limits saturated fats and cholesterol and
emphasizes comple) carohydrates (e&g&, ,hole grains, fruit, vegetales)&
o 2o,+dose aspirin is recommended for people at ris' for C5=& 5spirin therapy is
not recommended for ,omen ,ith lo, ris' for C5= efore age DC& Common side
effects of aspirin therapy include A. upset and leeding& @or people ,ho are
aspirin intolerant, clopidogrel (Plavi)) can e considered&
.f levels remain elevated despite modifiale changes, drug therapy is considered&
o Btatin drugs ,or' y inhiiting the synthesis of cholesterol in the liver& 2iver
enzymes must e regularly monitored&
o Niacin, a ,ater+solule 6 vitamin, is highly effective in lo,ering 2=2 and
triglyceride levels y interfering ,ith their synthesis& Niacin also increases >=2
levels etter than many other lipid+lo,ering drugs&
o @iric acid derivatives ,or' y accelerating the elimination of 32=2s and
increasing the production of apoproteins 5+. and 5+..&
o 6ile+acid se<uestrants increase conversion of cholesterol to ile acids and
decrease hepatic cholesterol content& The primary effect is a decrease in total
cholesterol and 2=2s&
o Certain drugs selectively inhiit the asorption of dietary and iliary cholesterol
across the intestinal ,all&
The incidence of cardiac disease is greatly increased in the elderly and is the leading
cause of death in older persons& Btrategies to reduce C5= ris' are effective in this age
group ut are often underprescried&
5ggressive treatment of hypertension and hyperlipidemia ,ill stailize pla<ues in the
coronary arteries of older adults, and cessation of toacco use helps decrease the ris' for
C5= at any age&
C)-$N'C S,A/L AN4'NA
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Chronic stable angina refers to chest pain that occurs intermittently over a long
period ,ith the same pattern of onset, duration, and intensity of symptoms&
o 5ngina is rarely sharp or staing, and it usually does not change ,ith
position or reathing& :any people ,ith angina complain of indigestion or a
urning sensation in the epigastric region&
o 5nginal pain usually lasts for only a fe, minutes ($ to C minutes) and
commonly susides ,hen the precipitating factor is relieved& Pain at rest is
unusual&
The treatment of chronic stale angina is aimed at decreasing o)ygen demand and1or
increasing o)ygen supply and reducing C5= ris' factors&
o .n addition to antiplatelet and cholesterol+lo,ering drug therapy, the most
common drugs used to manage chronic stale angina are nitrates&
Bhort+acting nitrates are first+line therapy for the treatment of angina&
Nitrates produce their principal effects y dilating peripheral lood
vessels, coronary arteries, and collateral vessels&
2ong acting nitrates are also used to reduce the incidence of anginal
attac's&
+5drenergic loc'ers are the preferred drugs for the management of
chronic stale angina&
Calcium channel loc'ers are used if +adrenergic loc'ers are
contraindicated, are poorly tolerated, or do not control anginal
symptoms& The primary effects of calcium channel loc'ers are (1)
systemic vasodilation ,ith decreased B3?, (") decreased myocardial
contractility, and ($) coronary vasodilation&
Certain high+ris' patients (e&g&, patients ,ith diaetes) ,ith chronic
stale angina may enefit from the addition of an angiotensin+
converting enzyme (5C*) inhiitor&
Common diagnostic tests for a patient ,ith a history of C5= or C5= include a chest
)+ray, a 1"+lead *CA, laoratory tests (e&g&, lipid profile)! nuclear imaging! e)ercise
stress testing, and coronary angiography&
AC5, C$-$NA-6 S6ND-$M
Acute coronar. s.ndrome (5CB) develops ,hen ischemia is prolonged and not
immediately reversile& 5CB encompasses the spectrum of unstale angina, nonNBT+
segment+elevation myocardial infarction (NBT*:.), and BT+segment+elevation
myocardial infarction (BT*:.)&
5CB is associated ,ith deterioration of a once stale atherosclerotic pla<ue& This
unstale lesion may e partially occluded y a thromus (manifesting as 45 or
NBT*:.) or totally occluded y a thromus (manifesting as BT*:.)&
5nstable angina (45) is chest pain that is ne, in onset, occurs at rest, or has a
,orsening pattern& 45 is unpredictale and represents an emergency&
M.ocardial infarction %M'& occurs as a result of sustained ischemia, causing
irreversile myocardial cell death& *ighty percent to E8K of all :.s are due to the
development of a thromus that halts perfusion to the myocardium distal to the
occlusion& Contractile function of the heart stops in the infracted area(s)&
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o Cardiac cells can ,ithstand ischemic conditions for appro)imately "8
minutes& .t ta'es appro)imately % to D hours for the entire thic'ness of the
heart muscle to infarct&
o .nfarctions are descried ased on the location of damage (e&g&, anterior,
inferior, lateral, or posterior ,all infarction)&
o Bevere, immoilizing chest pain not relieved y rest, position change, or
nitrate administration is the hallmar' of an :.& The pain is usually descried
as a heaviness, pressure, tightness, urning, constriction, or crushing&
o Complications after :.
The most common complication after an :. is dysrhythmias, and
dysrhythmias are the most common cause of death in patients in the
prehospital period&
>@ is a complication that occurs ,hen the pumping po,er of the heart
has diminished&
Cardiogenic shoc' occurs ,hen inade<uate o)ygen and nutrients are
supplied to the tissues ecause of severe left ventricular failure& -hen
it occurs, it has a high mortality rate&
Papillary muscle dysfunction may occur if the infarcted area includes
or is ad#acent to the papillary muscle that attaches to the mitral valve&
Papillary muscle dysfunction causes mitral valve regurgitation and is
detected y a systolic murmur at the cardiac ape) radiating to,ard the
a)illa&
Papillary muscle rupture is a rare ut life+threatening complication that
causes massive mitral valve regurgitation, resulting in dyspnea,
pulmonary edema, and decreased C;&
3entricular aneurysm results ,hen the infarcted myocardial ,all
ecomes thinned and ulges out during contraction&
Pericarditis may occur " to $ days after an acute :. as a common
complication of the infarction&
Primary diagnostic studies used to determine ,hether a person has 45 or an :.
include an *CA and serum cardiac mar'ers&
Drug ,hera".
.nitial management of the patient ,ith chest pain includes aspirin, sulingual
nitroglycerin, morphine sulfate for pain unrelieved y nitroglycerin, and o)ygen&
.3 nitroglycerin, aspirin, +adrenergic loc'ers, and systemic anticoagulation ,ith
either lo, molecular ,eight heparin given sucutaneously or .3 unfractionated
heparin (4>) are the initial drug treatments of choice for 5CB&
.3 antiplatelet agents (e&g&, glycoprotein ..1...a inhiitor) may also e used if
percutaneous coronary intervention (PC.) is anticipated&
5C* inhiitors help prevent ventricular remodeling and prevent or slo, the
progression of >@& They are recommended follo,ing anterior ,all :.s or :.s that
result in decreased left ventricular function (e#ection fraction H*@I less than %8K) or
pulmonary congestion and should e continued indefinitely& @or patients ,ho cannot
tolerate 5C* inhiitors, angiotensin receptor loc'ers should e considered&
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Calcium channel loc'ers or long+acting nitrates can e added if the patient is already
on ade<uate doses of +adrenergic loc'ers or cannot tolerate +adrenergic loc'ers,
or has Prinzmetal(s angina&
Btool softeners are given to facilitate and promote the comfort of o,el evacuation&
This prevents straining and the resultant vagal stimulation from the 3alsalva
maneuver& 3agal stimulation produces radycardia and can provo'e dysrhythmias&
.nitially, patients may e NP; (nothing y mouth) e)cept for sips of ,ater until stale
(e&g&, pain free, nausea resolved)& =iet is advanced as tolerated to a lo,+salt, lo,+
saturated+fat, and lo,+cholesterol diet&
Surgical ,hera".
Coronar. re!asculari#ation ,ith coronary artery ypass graft (C56A) surgery is
recommended for patients ,ho (1) fail medical management, (") have left main
coronary artery or three+vessel disease, ($) are not candidates for PC. (e&g&, lesions
are long or difficult to access), or (%) have failed PC. ,ith ongoing chest pain&
:inimally invasive direct coronary artery ypass (:.=C56) surgery can e used for
patients ,ith single+vessel disease&
The off+pump coronary artery ypass (;PC56) procedure uses full or partial
sternotomy to enale access to all coronary vessels& ;PC56 is also performed on a
eating heart using mechanical stailizers and ,ithout cardiopulmonary ypass
(CP6)&
Transmyocardial laser revascularization (T:?) is an indirect revascularization
procedure used for patients ,ith advanced C5= ,ho are not candidates for traditional
ypass surgery and ,ho have persistent angina after ma)imum medical therapy&
Nursing Management: Chronic Stable Angina and Acute Coronar. S.ndrome
The follo,ing nursing measures should e instituted for a patient e)periencing
angina: (1) administration of supplemental o)ygen, (") determination of vital signs,
($) 1"+lead *CA, (%) prompt pain relief first ,ith a nitrate follo,ed y an opioid
analgesic if needed, (C) auscultation of heart sounds, and (D) comfortale positioning
of the patient&
.nitial treatment of a patient ,ith 5CB includes pain assessment and relief,
physiologic monitoring, promotion of rest and comfort, alleviation of stress and
an)iety, and understanding of the patient(s emotional and ehavioral reactions&
o Nitroglycerin, morphine sulfate, and supplemental o)ygen should e provided
as needed to eliminate or reduce chest pain&
o Continuous *CA monitoring is initiated and maintained throughout the
hospitalization&
o @re<uent vital signs, inta'e and output (at least once a shift), and physical
assessment should e done to detect deviations from the patient(s aseline
parameters& .ncluded is an assessment of lung sounds and heart sounds and
inspection for evidence of early >@ (e&g&, dyspnea, tachycardia, pulmonary
congestion, distended nec' veins)&
6ed rest may e ordered for the first fe, days after an :. involving a large portion of
the ventricle& 5 patient ,ith an uncomplicated :. (e&g&, angina resolved, no signs of
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complications) may rest in a chair ,ithin F to 1" hours after the event& The use of a
commode or edpan is ased on patient preference&
.t is important to plan nursing and therapeutic actions to ensure ade<uate rest periods
free from interruption& Comfort measures that can promote rest include fre<uent oral
care, ade<uate ,armth, a <uiet atmosphere, use of rela)ation therapy (e&g&, guided
imagery), and assurance that personnel are neary and responsive to the patient(s
needs&
Cardiac ,or'load is gradually increased through more demanding physical tas's so
that the patient can achieve a discharge activity level ade<uate for home care&
5n)iety is present in all patients ,ith 5CB to various degrees& The nurse(s role is to
identify the source of an)iety and assist the patient in reducing it&
The emotional and ehavioral reactions of a patient are varied and fre<uently follo, a
predictale response pattern& The role of the nurse is to understand ,hat the patient is
currently e)periencing, to assist the patient in testing reality, and to support the use of
constructive coping styles& =enial may e a positive coping style in the early phase of
recovery from 5CB&
The ma#or nursing responsiilities for the care of the patient follo,ing PC. involves
monitoring for signs of recurrent angina! fre<uent assessment of vital signs, including
>? and rhythm! evaluation of the groin site for signs of leeding! and maintenance of
ed rest per institution policy&
@or patients having C56A surgery, care is provided in the intensive care unit for the
first "% to $D hours, ,here ongoing monitoring of the patient(s *CA and
hemodynamic status is critical&
Cardiac rehailitation restores a person to an optimal state of function in si) areas:
physiologic, psychologic, mental, spiritual, economic, and vocational&
Patient teaching egins ,ith the *= nurse and progresses through the staff nurse to
the community health nurse& Careful assessment of the patient(s learning needs helps
the nurse set goals and o#ectives that are realistic&
Physical activity is necessary for optimal physiologic functioning and psychologic
,ell+eing& 5 regular schedule of physical activity, even after many years of
sedentary living, is eneficial&
o 5ctivity level is gradually increased so that y the time of discharge the
patient can tolerate moderate+energy activities of $ to D :*Ts&
o Patients ,ith 45 that has resolved or an uncomplicated :. are in the hospital
for appro)imately $ to % days and y day " can amulate in the hall,ay and
egin limited stair climing (e&g&, three to four steps)&
o 6ecause of the short hospital stay, it is critical to give the patient specific
guidelines for physical activity so that overe)ertion ,ill not occur& Patients
should /listen to ,hat the ody is saying&0
o Patients should e taught to chec' their pulse rate and the parameters ,ithin
,hich to e)ercise& The more important factor is the patient(s response to
physical activity in terms of symptoms rather than asolute >?, especially
since many patients are on +adrenergic loc'ers and may not e ale to reach
a target >?&
:any patients ,ill e referred to an outpatient or home+ased cardiac rehailitation
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Key Points
program& :aintaining contact ,ith the patient appears to e the 'ey to the success of
these programs&
;ne factor that has een lin'ed to poor adherence to a physical activity program after
:. is depression& 6oth men and ,omen e)perience mild to moderate depression post+
:. that should resolve in 1 to % months&
Be)ual counseling for cardiac patients and their partners should e provided& The
patient(s concern aout resumption of se)ual activity after hospitalization for 5CB
often produces more stress than the physiologic act itself&
o 6efore the nurse provides guidelines on resumption of se)ual activity, it is
important to 'no, the physiologic status of the patient, the physiologic effects
of se)ual activity, and the psychologic effects of having a heart attac'& Be)ual
activity for middle+aged men and ,omen ,ith their usual partners is no more
strenuous than climing t,o flights of stairs&
o The inaility to perform se)ually after :. is common and se)ual dysfunction
usually disappears after several attempts&
o Patients should 'no, that drugs used for erectile dysfunction should not e
used ,ith nitrates as severe hypotension and even death have een reported&
o Typically, it is safe to resume se)ual activity 9 to 18 days after an
uncomplicated :.&
S5DDN CA-D'AC DA,)
Sudden cardiac death (BC=) is une)pected death from cardiac causes&
C5= is the most common cause of BC= and accounts for F8K of all BC=s&
BC= involves an arupt disruption in cardiac function, producing an arupt loss of
cardiac output and cereral lood flo,& =eath usually occurs ,ithin 1 hour of the
onset of acute symptoms (e&g&, angina, palpitations)&
The ma#ority of cases of BC= are caused y acute ventricular dysrhythmias (e&g&,
ventricular tachycardia, ventricular firillation)&
Persons ,ho e)perience BC= as a result of C5= fall into t,o groups: (1) those ,ho
had an acute :. and (") those ,ho did not have an acute :.& The latter group
accounts for the ma#ority of cases of BC=& .n this instance, victims usually have no
,arning signs or symptoms&
Patients ,ho survive are at ris' for recurrent BC= due to the continued electrical
instaility of the myocardium that caused the initial event to occur&
?is' factors for BC= include left ventricular dysfunction (*@ less than $8K),
ventricular dysrhythmias follo,ing :., male gender (especially 5frican 5merican
men), family history of premature atherosclerosis, toacco use, diaetes mellitus,
hypercholesterolemia, hypertension, and cardiomyopathy&
:ost BC= patients have a lethal ventricular dysrhythmia and re<uire "%+hour >olter
monitoring or other type of event recorder, e)ercise stress testing, signal+averaged
*CA, and electrophysiologic study (*PB)&
The most common approach to preventing a recurrence and improving survival is the
use of an implantale cardioverter+defirillator (.C=)&
=rug therapy may e used in con#unction ,ith an .C= to decrease episodes of
ventricular dysrhythmias&
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Burvivors of BC= develop a /time om0 mentality, fearing the recurrence of
cardiopulmonary arrest& They and their families may ecome an)ious, angry, and
depressed&
Patients and families also may need to deal ,ith additional issues such as possile
driving restrictions and change in occupation& The grief response varies among BC=
survivors and their families&
Lewis et al: Medical-Surgical Nursing: Assessment and Management of
Clinical Problems, 7
th
edition
Key Points
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Key Points
Chapter $C: Nursing :anagement: >eart @ailure
,'$L$46 AND PA,)$P)6S'$L$46
)eart failure (>@) is an anormal clinical condition involving impaired cardiac pumping
that results in the characteristic pathophysiologic changes of vasoconstriction and fluid
retention&
>@ is characterized y ventricular dysfunction, reduced e)ercise tolerance, diminished
<uality of life, and shortened life e)pectancy&
?is' factors include coronary artery disease (C5=) and advancing age& >ypertension,
diaetes, cigarette smo'ing, oesity, and high serum cholesterol also contriute to the
development of >@&
CLASS'+'CA,'$N
>eart failure is classified as systolic or diastolic failure&
o S.stolic failure, the most common cause of >@, results from an inaility of the
heart to pump lood&
o Diastolic failure is an impaired aility of the ventricles to rela) and fill during
diastole& =ecreased filling of the ventricles ,ill result in decreased stro'e volume
and cardiac output (C;)&
CL'N'CAL MAN'+S,A,'$NS
>@ can have an arupt onset or it can e an insidious process resulting from slo,,
progressive changes& Compensatory mechanisms are activated to maintain ade<uate C;&
To maintain alance in >@, several counter regulatory processes are activated, including
the production of hormones from the heart muscle to promote vasodilation&
Cardiac compensation occurs ,hen compensatory mechanisms succeed in maintaining an
ade<uate C; that is needed for tissue perfusion&
Cardiac decompensation occurs ,hen these mechanisms can no longer maintain ade<uate
C; and inade<uate tissue perfusion results&
The most common form of >@ is left+sided failure from left ventricular dysfunction& 6lood
ac's up into the left atrium and into the pulmonary veins causing pulmonary congestion
and edema& >@ is usually manifested y iventricular failure&
5cute decompensated heart failure (5=>@) typically manifests as "ulmonar. edema, an
acute, life+threatening situation&
Clinical manifestations of chronic >@ depend on the patient(s age and the underlying type
and e)tent of heart disease& Common symptoms include fatigue, dyspnea, tachycardia,
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Key Points
edema, and unusual ehavior&
Pleural effusion, atrial firillation, thromus formation, renal insufficiency, and
hepatomegaly are all complications of >@&
D'A4N$S,'C S,5D'S
The primary goal in diagnosis of >@ is to determine the underlying etiology of >@&
o 5 thorough history, physical e)amination, chest )+ray, electrocardiogram (*CA),
laoratory data (cardiac enzymes, +type natriuretic protein (6NP), serum
chemistries, liver function studies, thyroid function studies, and complete lood
count), hemodynamic assessment, echocardiogram, stress testing, and cardiac
catheterization are performed&
N5-S'N4 AND C$LLA/$-A,'2 MANA4MN,: AD)+ AND P5LM$NA-6
DMA
The goals of therapy for oth 5=>@ and chronic >@ are to decrease patient symptoms,
reverse ventricular remodeling, improve <uality of life, and decrease mortality and
moridity&
Treatment strategies should include the follo,ing:
o =ecreasing intravascular volume ,ith the use of diuretics to reduce venous return
and preload&
o =ecreasing venous return (preload) to reduce the amount of volume returned to
the 23 during diastole&
o =ecreasing afterload (the resistance against ,hich the 23 must pump) improves
C; and decreases pulmonary congestion&
o Aas e)change is improved y the administration of .3 morphine sulfate and
supplemental o)ygen&
o .notropic therapy and hemodynamic monitoring may e needed in patients ,ho
do not respond to conventional pharmacotherapy (e&g&, diuretics, vasodilators,
morphine sulfate)&
o ?eduction of an)iety is an important nursing function, since an)iety may increase
the BNB response and further increase myocardial ,or'load&
C$LLA/$-A,'2 CA-: C)-$N'C )A-, +A'L5-
The main goal in the treatment of chronic >@ is to treat the underlying cause and
contriuting factors, ma)imize C;, provide treatment to alleviate symptoms, improve
ventricular function, improve <uality of life, preserve target organ function, and improve
mortality and moridity&
5dministration of o)ygen improves saturation and assists greatly in meeting tissue
o)ygen needs and helps relieve dyspnea and fatigue&
Physical and emotional rest allo,s the patient to conserve energy and decreases the need
for additional o)ygen& The degree of rest recommended depends on the severity of >@&
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Key Points
Nonpharmacologic therapies used in the management of >@ patients ,ho are receiving
ma)imum medical therapy, continue to have NW>5 @unctional Class ... or .3
symptoms, and have a ,idened P?B interval include the follo,ing:
o Cardiac resynchronization therapy (C?T) or iventricular pacing& .nvolves pacing
oth the right and left ventricles to achieve coordination of right and left ventricle
contractility&
o Cardiac transplantation& Btrict criteria are used to select the fe, patients ,ith
advanced >@ ,ho can even hope to receive a transplanted heart&
o .ntraaortic alloon pump (.56P) therapy& The .56P can e useful in the
hemodynamically unstale >@ patient ecause it decreases B3?, P5-P, and P5P
as much as "CK, leading to improved C;& >o,ever, the limitations of ed rest,
infection, and vascular complications preclude long+term use&
o 3entricular assist devices (35=s)& 35=s provide highly effective long+term
support for up to " years and have ecome standard care in many heart transplant
centers& 35=s are used as a ridge to transplantation&
o =estination therapy& The use of a permanent, implantale 35=, 'no,n as
destination therapy, is an option for patients ,ith advanced NW>5 @unctional
Class .3 >@ ,ho are not candidates for heart transplantation&
Aeneral therapeutic o#ectives for drug management of chronic >@ include: (1)
identification of the type of >@ and underlying causes, (") correction of sodium and
,ater retention and volume overload, ($) reduction of cardiac ,or'load, (%) improvement
of myocardial contractility, and (C) control of precipitating and complicating factors&
o =iuretics are used in >@ to moilize edematous fluid, reduce pulmonary venous
pressure, and reduce preload&
Thiazide diuretics may e the first choice in chronic >@ ecause of their
convenience, safety, lo, cost, and effectiveness& They are particularly
useful in treating edema secondary to >@ and in controlling hypertension&
2oop diuretics are potent diuretics& These drugs act on the ascending loop
of >enle to promote sodium, chloride, and ,ater e)cretion& Prolems in
using loop diuretics include reduction in serum potassium levels,
ototo)icity, and possile allergic reaction in the patient ,ho is sensitive to
sulfa+type drugs&
Bpironolactone (5ldactone) is an ine)pensive, potassium+sparing diuretic
that promotes sodium and ,ater e)cretion ut loc's potassium e)cretion&
This aldosterone receptor antagonist also loc's the harmful
neurohormonal effects of aldosterone on the heart lood vessels&
Bpironolactone adds to the enefits of angiotensin+converting
enzyme (5C*) inhiitors, and is appropriate to use ,hile renal
function is ade<uate&
Bpironolactone may also e used in con#unction ,ith other
diuretics, such as furosemide&
3asodilator drugs have een sho,n to improve survival in >@& The goals
of vasodilator therapy in the treatment of >@ include (1) increasing venous
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Key Points
capacity, (") improving *@ through improved ventricular contraction, ($)
slo,ing the process of ventricular dysfunction, (%) decreasing heart size,
(C) avoiding stimulation of the neurohormonal responses initiated y the
compensatory mechanisms of >@, and (D) enhancing neurohormonal
loc'ade&
5C* inhiitors (e&g&, captopril HCapotenI, enazepril H2otensinI,
enalapril H3asotecI) are useful in oth systolic and diastolic >@,
and they are the first+line therapy in the treatment of chronic >@&
5ngiotensin .. receptor loc'ers (e&g&, losartan HCozaarI, valsartan
H=iovanI) may e used in patients ,ho are 5C* inhiitor
intolerant&
Nitrates are used to treat >@ y acting directly on the smooth
muscle of the vessel ,all& :a#or effects include a decrease in
preload and vasodilation of coronary arteries&
Nesiritide, a synthetic form of human 6NP, eing studied for its
use in the ongoing treatment of patients ,ith chronic >@&
+5drenegic loc'ers, specifically carvedilol (Coreg) and
metoprolol (Toprol+M2), have improved survival of patients ,ith
>@&
Positive inotropic agents improve cardiac contractility and C;, decrease
23 diastolic pressure, and decrease B3?&
=igitalis glycosides He&g&, digo)in (2ano)in)I remain the mainstay
in the treatment of >@, ho,ever, they have not een sho,n to
prolong life&
Calcium sensitizers are novel positive inotropic agents in the
treatment of >@& They improve cardiac performance y interacting
directly ,ith contractile proteins ,ithout affecting intracellular
calcium concentrations or increasing myocardial o)ygen demand&
6i=il, a comination drug containing isosoride dinitrate and
hydralazine, approved only for the treatment of >@ in 5frican
5mericans ,ho are already eing treated ,ith standard therapy&
o =iet education and ,eight management are critical to the patient(s control of
chronic >@&
=iet and ,eight management recommendations must e individualized
and culturally sensitive if the necessary changes are to e realized&
5 detailed diet history should e otained and should include the
sociocultural value of food to the patient&
The =ietary 5pproaches to Btop >ypertension (=5B>) diet is effective as
a first+line therapy for many individuals ,ith hypertension, and this diet is
,idely used for the patient ,ith >@&
The edema of chronic >@ is often treated y dietary restriction of sodium&
@luid restrictions are not commonly prescried for the patient ,ith mild to
moderate >@& >o,ever, in moderate to severe >@ and renal insufficiency,
fluid restrictions are usually implemented&
Patients should ,eigh themselves daily to monitor fluid retention, as ,ell
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Key Points
as ,eight reduction& .f a patient e)periences a ,eight gain of $ l (1&% 'g)
over " days or a $+ to C+l ("&$ 'g) gain over a ,ee', the primary care
provider should e called&
N5-S'N4 MANA4MN,: C)-$N'C )A-, +A'L5-
The overall goals for the patient ,ith >@ include (1) a decrease in symptoms (e&g&,
shortness of reath, fatigue), (") a decrease in peripheral edema, ($) an increase in
e)ercise tolerance, (%) compliance ,ith the medical regimen, and (C) no complications
related to >@&
Treatment or control of underlying heart disease is 'ey to preventing >@ and episodes of
5=>@&
o @or e)ample, valve replacement should e planned efore lung congestion
develops, and early and continued treatment of C5= and hypertension is critical&
o The use of antidysrhythmic agents or pacema'ers is indicated for people ,ith
serious dysrhythmias or conduction disturances&
Patients ,ith >@ should e counseled to otain vaccinations against the flu and
pneumonia&
Preventive care should focus on slo,ing the progression of the disease&
o Patient teaching must include information on medications, diet, and e)ercise
regimens& *)ercise training (e&g&, cardiac rehailitation) does improve symptoms
of chronic >@ ut is often underprescried&
o >ome nursing care for follo,+up care and to monitor the patient(s response to
treatment may e re<uired&
Buccessful >@ management is dependent on the follo,ing principles: (1) >@ is a
progressive disease, and treatment plans are estalished ,ith <uality+of+life goals! (")
symptom management is controlled y the patient ,ith self+management tools (e&g&, daily
,eights, drug regimens, diet and e)ercise plans)! ($) salt and ,ater must e restricted! (%)
energy must e conserved! and (C) support systems are essential to the success of the
entire treatment plan&
.mportant nursing responsiilities in the care of a patient ,ith >@ include (1) teaching the
patient aout the physiologic changes that have occurred, (") assisting the patient to adapt
to oth the physiologic and psychologic changes, and ($) integrating the patient and the
patient(s family or support system in the overall care plan&
o :any patients ,ith >@ are at high ris' for an)iety and depression, and ma#or
depression is more prevalent in female patients and patients less than D8 years of
age&
o Patients ,ith >@ can live productive lives ,ith chronic >@&
o *ffective home health care can prevent or limit future hospitalization& :anaging
>@ patients out of the hospital is a priority of care&
o Patients ,ith >@ ,ill ta'e medication for the rest of their lives& This can ecome
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Key Points
difficult ecause a patient may e asymptomatic ,hen >@ is under control&
o Patients should e taught to evaluate the action of the prescried drugs and to
recognize the manifestations of drug to)icity&
Patients should e taught ho, to ta'e their pulse rate and to 'no, under
,hat circumstances drugs, especially digitalis and +adrenergic loc'ers,
should e ,ithheld and a health care provider consulted&
.t may e appropriate to instruct patients in home 6P monitoring,
especially for those >@ patients ,ith hypertension&
Patients should e taught the symptoms of hypo+ and hyper'alemia if
diuretics that deplete or spare potassium are eing ta'en& @re<uently the
patient ,ho is ta'ing thiazide or loop diuretics is given supplemental
potassium&
o The nurse, physical therapist, or occupational therapist should instruct the patient
in energy+conserving and energy+efficient ehaviors after an evaluation of daily
activities has een done&
Patients may need a prescription for rest after an activity& :any hard+
driving persons need the /permission0 to not feel /lazy&0
Bometimes an activity that the patient en#oys may need to e eliminated&
.n such situations the patient should e helped to e)plore alternative
activities that cause less physical and cardiac stress&
The physical environment may re<uire modification in situations in ,hich
there is an increased cardiac ,or'load demand (e&g&, fre<uent climing of
stairs)& The nurse can help the patient identify areas ,here outside
assistance can e otained&
o >ome health nursing is an essential component in the care of the >@ patient and
family&
>ome health nurses conduct fre<uent physical assessments, including vital
signs and ,eight&
Protocols enale the nurse and patient to identify prolems, such as
evidence of ,orsening >@, and institute interventions to prevent
hospitalization& This may include altering medications and initiating fluid
restrictions&
CA-D'AC ,-ANSPLAN,A,'$N
Cardiac trans"lantation has ecome the treatment of choice for patients ,ith refractory
end+stage >@, cardiomyopathy, and inoperale C5=&
;nce a patient meets the criteria for cardiac transplantation, the goal of the evaluation
process is to identify patients ,ho ,ould most enefit from a ne, heart&
o 5fter a complete physical e)amination and diagnostic ,or'up, the patient and
family then undergo a comprehensive psychologic profile&
o The comple)ity of the transplant process may e over,helming to a patient ,ith
inade<uate support systems and a poor understanding of the lifestyle changes
re<uired after transplant&
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Key Points
;nce a patient is accepted as a transplant candidate (this may happen rapidly during an
acute illness or over a longer period), he or she is placed on a transplant list&
o Btale patients ,ait at home and receive ongoing medical care&
o 4nstale patients may re<uire hospitalization for more intensive therapy&
o The overall ,aiting period for a transplant is long, and many patients die ,hile
,aiting for a transplant&
:ost donor hearts are otained at sites distant from the institution performing the
transplant& The ma)imum acceptale time from harvesting the donor heart to
transplantation is % to D hours&
The heart recipient is prepared for surgery, and cardiopulmonary ypass is used&
o The surgical procedure involves removing the recipient(s heart, e)cept for the
posterior right and left atrial ,alls and their venous connections&
o The recipient(s heart is then replaced ,ith the donor heart& Care is ta'en to
preserve the integrity of the donor sinoatrial (B5) node so that a sinus rhythm may
e achieved postoperatively&
o .mmunosuppressive therapy usually egins in the operating room&
*ndomyocardial iopsies are typically otained from the right ventricle (via the right
internal #ugular vein) on a ,ee'ly asis for the first month, monthly for the follo,ing D
months, and yearly thereafter to detect re#ection&
o The >eartsreath test is used along ,ith endomyocardial iopsy to assess organ
re#ection in heart transplant patients&
The test ,or's y measuring the amount of methylated al'anes (natural
chemicals found in the reath and air) in a patient[s reath& The value is
compared ,ith the results of a iopsy performed during the previous
month to measure the proaility of the transplanted heart eing re#ected&
The >eartsreath test is used in the first year follo,ing heart
transplantation and along ,ith the results of a heart iopsy to help guide
short+term and long+term medical care of heart transplant patients&
The test helps to separate less severe organ re#ection (grades 8, 1, and ")
from more severe re#ection (grade $)&
o Peripheral lood T lymphocyte monitoring is also done to assess the recipient(s
immune status&
Nursing management throughout the posttransplant period focuses on promoting patient
adaptation to the transplant process, monitoring cardiac function, managing lifestyle
changes, and providing ongoing teaching of the patient and family&
Beveral devices are availale as a ridge to transplantation
o The 56C888 Circulatory Bupport Bystem and the 63B C888 6iventricular
Bupport Bystem provide temporary support for one or oth sides of the heart in
circumstances in ,hich the heart has failed ut has the potential to recover (e&g&,
reversile >@, myocarditis, and acute :.)&
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o The Thoratec 3entricular 5ssist =evice (35=) system can support one or oth
ventricles, and it has een approved as a ridging device for transplantation and
for recovery of the heart after cardiac surgery&
A-,'+'C'AL )A-,
The lac' of availale transplant hearts and the increasing numer of patients in need have
triggered the movement to develop artificial hearts&
o T,o implantale artificial hearts, the Cardio-est Total 5rtificial >eart and the
5ioCor .mplantale ?eplacement >eart, have een developed&
o 6oth are designed ,ith materials that minimize coagulation and contain motor+
driven pumping systems (artificial ventricles) that operate on oth internal and
e)ternal atteries&
5n electronic pac'age in the adomen monitors the system, including
ad#usting the heart rate ased on the patient(s activity&
5n e)ternal attery pac' allo,s for periods of independence from the
console&
The total artificial heart re<uires no immunosuppression and may hold
promise for short+term survival in patients ,ith end+stage >@&
Lewis et al: Medical-Surgical Nursing: Assessment and Management of
Clinical Problems, 7
th
edition
Key Points
Chapter $D: Nursing :anagement: =ysrhythmias
The aility to recognize normal and anormal cardiac rhythms, called d.srh.thmias, is
an essential s'ill for the nurse&
@our properties of cardiac cells (automaticity, e)citaility, conductivity, and contractility)
enale the conduction system to initiate an electrical impulse, transmit it through the
cardiac tissue, and stimulate the myocardial tissue to contract&
o 5 normal cardiac impulse egins in the sinoatrial (B5) node in the upper right
atrium&
o The signal is transmitted over the atrial myocardium via 6achmann(s undle and
internodal path,ays, causing atrial contraction&
o The impulse then travels to the atrioventricular (53) node through the undle of
>is and do,n the left and right undle ranches, ending in the Pur'in#e fiers,
,hich transmit the impulse to the ventricles, resulting in ventricular contraction&
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The autonomic nervous system plays an important role in the rate of impulse formation,
the speed of conduction, and the strength of cardiac contraction&
o Components of the autonomic nervous system that affect the heart are the right
and left vagus nerve fiers of the parasympathetic nervous system and fiers of
the sympathetic nervous system&
C4 M$N',$-'N4
The electrocardiogram (*CA) is a graphic tracing of the electrical impulses produced in
the heart&
*CA ,aveforms are produced y the movement of charged ions across the
semipermeale memranes of myocardial cells&
There are 1" recording leads in the standard *CA&
o Bi) of the 1" *CA leads measure electrical forces in the frontal plane (leads ., ..,
..., a3?, a32, and a3@)&
o The remaining si) leads (3
1
through 3
D
) measure the electrical forces in the
horizontal plane (precordial leads)&
o The 1"+lead *CA may sho, changes that are indicative of structural changes,
damage such as ischemia or infarction, electrolyte imalance, dysrhythmias, or
drug to)icity&
Continuous *CA monitoring is done using leads .., 3
1
, and :C2
1
&
o :C2
1
is a modified chest lead that is similar to 3
1
and is used ,hen only three
leads are availale for monitoring&
o :onitoring leads should e selected ased on the patient(s clinical situation&
The *CA can e visualized continuously on a monitor oscilloscope, and a recording of
the *CA (i&e&, rhythm strip) can e otained on *CA paper attached to the monitor&
*CA leads are attached to the patient(s chest ,all via an electrode pad fi)ed ,ith
electrical conductive paste&
,elemetr. monitoring involves the oservation of a patient(s >? and rhythm to rapidly
diagnose dysrhythmias, ischemia, or infarction&
Normal sinus rhythm refers to a rhythm that originates in the B5 node and follo,s the
normal conduction pattern of the cardiac cycle&
o The P ,ave represents the depolarization of the atria (passage of an electrical
impulse through the atria), causing atrial contraction&
o The P? interval represents the time period for the impulse to spread through the
atria, 53 node, undle of >is, and Pur'in#e fiers&
o The P?B comple) represents depolarization of the ventricles (ventricular
contraction), and the P?B interval represents the time it ta'es for depolarization&
o The BT segment represents the time et,een ventricular depolarization and
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Key Points
repolarization& This segment should e flat or isoelectric and represents the
asence of any electrical activity et,een these t,o events&
o The T ,ave represents repolarization of the ventricles&
o The PT interval represents the total time for depolarization and repolarization of
the ventricles&
MC)AN'SMS $+ D6S-)6,)M'AS
Normally the main pacema'er of the heart is the B5 node, ,hich spontaneously
discharges D8 to 188 times per minute& =isorders of impulse formation can cause
dysrhythmias&
5 pacema'er from another site can lead to dysrhythmias and may e discharged in a
numer of ,ays&
o Becondary pacema'ers may originate from the 53 node or >is+Pur'in#e system&
o Becondary pacema'ers can originate ,hen they discharge more rapidly than the
normal pacema'er of the B5 node&
o Triggered eats (early or late) may come from an ectopic focus (area outside the
normal conduction path,ay) in the atria, 53 node, or ventricles&
2AL5A,'$N $+ D6S-)6,)M'AS
=ysrhythmias result from various anormalities and disease states, and the cause of a
dysrhythmia influences the treatment&
Beveral diagnostic tests are used to evaluate cardiac dysrhythmias and the effectiveness
of antidysrhythmia drug therapy&
o >olter monitoring records the *CA ,hile the patient is amulatory and
performing daily activities&
o *vent monitors have improved the evaluation of outpatient dysrhythmias&
o Bignal+averaged *CA (B5*CA) is a high+resolution *CA used to identify the
patient at ris' for developing comple) ventricular dysrhythmias&
o *)ercise treadmill testing is used for evaluation of cardiac rhythm response to
e)ercise&
o 5n electrophysiologic study (*PB) identifies different mechanisms of
tachydysrhythmias, heart loc's, radydysrhythmias, and causes of syncope&
,6PS $+ D6S-)6,)M'AS
$inus %raycaria has a normal sinus rhythm, ut the B5 node fires at a rate less than D8
eats1minute and is referred to as asolute radycardia&
o Clinical associations& Binus radycardia may e a normal sinus rhythm (e&g&, in
aeroically trained athletes), and it may occur in response to carotid sinus
massage, 3alsalva maneuver, hypothermia, and administration of
parasympathomimetic drugs&
o =isease states associated ,ith sinus radycardia are hypothyroidism, increased
intracranial pressure, ostructive #aundice, and inferior ,all myocardial infarction
(:.)&
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Key Points
o Treatment consists of administration of atropine (an anticholinergic drug) for the
patient ,ith symptoms& Pacema'er therapy may e re<uired&
$inus tachycaria has a normal sinus rhythm, ut the B5 node fires at a rate greater than
188 eats1minute as a result of vagal inhiition or sympathetic stimulation&
o Clinical associations& Binus tachycardia is associated ,ith physiologic and
psychologic stressors such as e)ercise, fever, pain, hypotension, hypovolemia,
anemia, hypo)ia, hypoglycemia, myocardial ischemia, heart failure (>@),
hyperthyroidism, an)iety, and fear& .t can also e an effect of certain drugs&
o 5ngina may result from sinus tachycardia due to the increased myocardial o)ygen
consumption that is associated ,ith an increased >?&
o Treatment is ased on the underlying cause& @or e)ample, if a patient is
e)periencing tachycardia from pain, tachycardia should resolve ,ith effective
pain management&
Premature atrial contraction (P5C) is a contraction originating from an ectopic focus in
the atrium in a location other than the sinus node& 5 P5C may e stopped (nonconducted
P5C), delayed (lengthened P? interval), or conducted normally through the 53 node&
o Clinical associations& P5Cs can result from emotional stress or physical fatigue!
from the use of caffeine, toacco, or alcohol! from hypo)ia or electrolyte
imalances! and from disease states such as hyperthyroidism, chronic ostructive
pulmonary disease (C;P=), and heart disease including coronary artery disease
(C5=) and valvular disease&
o .n healthy persons, isolated P5Cs are not significant& .n persons ,ith heart
disease, fre<uent P5Cs may indicate enhanced automaticit. of the atria or a
reentry mechanism and may ,arn of or initiate more serious dysrhythmias&
o Treatment depends on the patient(s symptoms& @or e)ample, ,ithdra,al of
sources of stimulation such as caffeine or sympathomimetic drugs may e
,arranted&
Paro&ysmal supra'entricular tachycaria (PB3T) is a dysrhythmia originating in an
ectopic focus any,here aove the ifurcation of the undle of >is&
o PB3T occurs ecause of a reentrant phenomenon (ree)citation of the atria ,hen
there is a one+,ay loc') and is usually triggered y a P5C&
o .n the normal heart, PB3T is associated ,ith overe)ertion, emotional stress, deep
inspiration, and stimulants such as caffeine and toacco& .t is also associated ,ith
rheumatic heart disease, digitalis to)icity, C5=, and cor pulmonale&
o Prolonged PB3T ,ith >? greater than 1F8 eats1minute may precipitate a
decreased C;, resulting in hypotension, dyspnea, and angina&
o Treatment for PB3T includes vagal stimulation and drug therapy (i&e&, .3
adenosine)&
Atrial flutter is an atrial tachydysrhythmia identified y recurring, regular, sa,tooth+
shaped flutter ,aves that originate from a single ectopic focus in the right atrium&
o 5trial flutter is associated ,ith C5=, hypertension, mitral valve disorders,
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pulmonary emolus, chronic lung disease, cor pulmonale, cardiomyopathy,
hyperthyroidism, and the use of drugs such as digo)in, <uinidine, and
epinephrine&
o >igh ventricular rates (over 1881minute) and the loss of the atrial /'ic'0 (atrial
contraction reflected y a sinus P ,ave) can decrease C; and cause serious
conse<uences such as chest pain and >@&
o Patients ,ith atrial flutter are at increased ris' of stro'e ecause of the ris' of
thromus formation in the atria from the stasis of lood&
o The primary goal in treatment of atrial flutter is to slo, the ventricular response
y increasing 53 loc'&
Atrial fi%rillation is characterized y a total disorganization of atrial electrical activity
due to multiple ectopic foci resulting in loss of effective atrial contraction&
o 5trial firillation usually occurs in the patient ,ith underlying heart disease, such
as C5=, rheumatic heart disease, cardiomyopathy, hypertensive heart disease, >@,
and pericarditis& .t can e caused y thyroto)icosis, alcohol into)ication, caffeine
use, electrolyte disturances, stress, and cardiac surgery&
o 5trial firillation can often result in a decrease in C;, and thromi may form in
the atria as a result of lood stasis& 5n emolized clot may develop and pass to the
rain, causing a stro'e&
o The goals of treatment include a decrease in ventricular response and prevention
of cereral emolic events&
(unctional ysrhythmias refer to dysrhythmias that originate in the area of the 53 node,
primarily ecause the B5 node has failed to fire or the signal has een loc'ed& .n this
situation, the 53 node ecomes the pacema'er of the heart&
o \unctional premature eats are treated in a manner similar to that for P5Cs&
o ;ther #unctional dysrhythmias include #unctional escape rhythm, accelerated
#unctional rhythm, and #unctional tachycardia& These dysrhythmias are treated
according to the patient(s tolerance of the rhythm and the patient(s clinical
condition&
o \unctional dysrhythmias are often associated ,ith C5=, >@, cardiomyopathy,
electrolyte imalances, inferior :., and rheumatic heart disease& Certain drugs
(e&g&, digo)in, amphetamines, caffeine, nicotine) can also cause #unctional
dysrhythmias&
o Treatment varies according to the type of #unctional dysrhythmia&
)irst-e*ree A+ %lock is a type of 53 loc' in ,hich every impulse is conducted to the
ventricles ut the duration of 53 conduction is prolonged&
o @irst+degree 53 loc' is associated ,ith :., C5=, rheumatic fever,
hyperthyroidism, vagal stimulation, and drugs such as digo)in, +adrenergic
loc'ers, calcium channel loc'ers, and flecainide&
o @irst+degree 53 loc' is usually not serious ut can e a precursor of higher
degrees of 53 loc'& Patients ,ith first+degree 53 loc' are asymptomatic&
o There is no treatment for first+degree 53 loc'& Patients should continue to e
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monitored for any ne, changes in heart rhythm&
$econ-e*ree A+ %lock, Type . (:oitz . or -enc'each heart loc') is a gradual
lengthening of the P? interval& .t occurs ecause of a prolonged 53 conduction time until
an atrial impulse is nonconducted and a P?B comple) is loc'ed (missing)&
o Type . 53 loc' may result from use of drugs such as digo)in or +adrenergic
loc'ers& .t may also e associated ,ith C5= and other diseases that can slo, 53
conduction&
o Type . 53 loc' is usually a result of myocardial ischemia or infarction& .t is
almost al,ays transient and is usually ,ell tolerated& >o,ever, it may e a
,arning signal of a more serious 53 conduction disturance&
o .f the patient is symptomatic, atropine is used to increase >?, or a temporary
pacema'er may e needed&
$econ-e*ree A+ %lock, Type .. (:oitz .. heart loc'), involves a P ,ave that is
nonconducted ,ithout progressive antecedent P? lengthening& This almost al,ays occurs
,hen a loc' in one of the undle ranches is present&
o Type .. second+degree 53 loc' is a more serious type of loc' in ,hich a certain
numer of impulses from the B5 node are not conducted to the ventricles&
o Type .. 53 loc' is associated ,ith rheumatic heart disease, C5=, anterior :.,
and digitalis to)icity&
o Type .. 53 loc' often progresses to third+degree 53 loc' and is associated ,ith
a poor prognosis& The reduced >? often results in decreased C; ,ith suse<uent
hypotension and myocardial ischemia&
o Temporary treatment efore the insertion of a permanent pacema'er may e
necessary if the patient ecomes symptomatic (e&g&, hypotension, angina) and
involves the use of a temporary transvenous or transcutaneous pacema'er&
Thir-e*ree A+ %lock, or complete heart loc', constitutes one form of 53 dissociation
in ,hich no impulses from the atria are conducted to the ventricles&
o Third+degree 53 loc' is associated ,ith severe heart disease, including C5=,
:., myocarditis, cardiomyopathy, and some systemic diseases such as
amyloidosis and progressive systemic sclerosis (scleroderma)&
o Third+degree 53 loc' almost al,ays results in reduced C; ,ith suse<uent
ischemia, >@, and shoc'& Byncope from third+degree 53 loc' may result from
severe radycardia or even periods of asystole&
o Treatment& @or symptomatic patients, a transcutaneous pacema'er is used until a
temporary transvenous pacema'er can e inserted&
Premature 'entricular contraction (P3C) is a contraction originating in an ectopic focus
in the ventricles& .t is the premature occurrence of a P?B comple), ,hich is ,ide and
distorted in shape compared ,ith a P?B comple) initiated from the normal conduction
path,ay&
o P3Cs are associated ,ith stimulants such as caffeine, alcohol, nicotine,
aminophylline, epinephrine, isoproterenol, and digo)in& They are also associated
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,ith electrolyte imalances, hypo)ia, fever, e)ercise, and emotional stress&
=isease states associated ,ith P3Cs include :., mitral valve prolapse, >@, and
C5=&
o P3Cs are usually a enign finding in the patient ,ith a normal heart& .n heart
disease, depending on fre<uency, P3Cs may reduce the C; and precipitate angina
and >@&
o Treatment is often ased on the cause of the P3Cs (e&g&, o)ygen therapy for
hypo)ia, electrolyte replacement)& =rugs that can e considered include +
adrenergic loc'ers, procainamide, amiodarone, or lidocaine (Mylocaine)&
+entricular tachycaria (3T) is a run of three or more P3Cs& .t occurs ,hen an ectopic
focus or foci fire repetitively and the ventricle ta'es control as the pacema'er&
o 3T is a life+threatening dysrhythmia ecause of decreased C; and the possiility
of deterioration to ventricular firillation, ,hich is a lethal dysrhythmia&
o 3T is associated ,ith :., C5=, significant electrolyte imalances,
cardiomyopathy, mitral valve prolapse, long PT syndrome, digitalis to)icity, and
central nervous system disorders&
o 3T can e stale (patient has a pulse) or unstale (patient is pulseless)&
o Treatment& Precipitating causes must e identified and treated (e&g&, electrolyte
imalances, ischemia)&
+entricular fi%rillation (3@) is a severe derangement of the heart rhythm characterized
on *CA y irregular undulations of varying shapes and amplitude& :echanically the
ventricle is simply /<uivering,0 and no effective contraction, and conse<uently no C;,
occurs&
o 3@ occurs in acute :. and myocardial ischemia and in chronic diseases such as
C5= and cardiomyopathy&
o 3@ results in an unresponsive, pulseless, and apneic state& .f not rapidly treated,
the patient ,ill die&
o Treatment consists of immediate initiation of CP? and advanced cardiac life
support (5C2B) measures ,ith the use of defirillation and definitive drug
therapy&
Asystole represents the total asence of ventricular electrical activity& No ventricular
contraction occurs ecause depolarization does not occur&
o 5systole is usually a result of advanced cardiac disease, a severe cardiac
conduction system disturance, or end+stage >@&
o Patients are unresponsive, pulseless, and apneic&
o 5systole is a lethal dysrhythmia that re<uires immediate treatment consisting of
CP? ,ith initiation of 5C2B measures (e&g&, intuation, transcutaneous pacing,
and .3 therapy ,ith epinephrine and atropine)&
Pulseless electrical acti'ity (P*5) descries a situation in ,hich electrical activity can e
oserved on the *CA, ut there is no mechanical activity of the ventricles and the patient
has no pulse&
o Prognosis is poor unless the underlying cause can e identified and <uic'ly
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Key Points
corrected&
o Treatment egins ,ith CP? follo,ed y intuation and .3 therapy ,ith
epinephrine&
S5DDN CA-D'AC DA,)
Sudden cardiac death (BC=) refers to death from a cardiac cause&
The ma#ority of BC=s result from ventricular dysrhythmias, specifically ventricular
tachycardia or firillation&
P-$D6S-)6,)M'A
5ntidysrhythmia drugs may cause life+threatening dysrhythmias similar to those for ,hich
they are administered& This concept is termed prodysrhythmia&
o The patient ,ho has severe left ventricular dysfunction is the most susceptile to
prodysrhythmias&
o =igo)in and some antidysrhythmia drugs can cause a prodysrhythmic response&
D+'/-'LLA,'$N
=efirillation is the most effective method of terminating 3@ and pulseless 3T&
=efirillation is accomplished y the passage of a =C electrical shoc' through the heart to
depolarize the cells of the myocardium& The intent is that suse<uent repolarization of
myocardial cells ,ill allo, the B5 node to resume the role of pacema'er&
?apid defirillation can e performed using a manual or automatic device&
o :anual defirillators re<uire health care providers to interpret cardiac rhythms,
determine the need for a shoc', and deliver a shoc'&
o Automatic e1ternal defibrillators (5*=s) are defirillators that have rhythm
detection capaility and the aility to advise the operator to deliver a shoc' using
hands+free defirillator pads&
S6NC)-$N'@D CA-D'$2-S'$N
Bynchronized cardioversion is the therapy of choice for the patient ,ith hemodynamically
unstale ventricular or supraventricular tachydysrhythmias&
o 5 synchronized circuit in the defirillator is used to deliver a countershoc' that is
programmed to occur on the ? ,ave of the P?B comple) of the *CA&
o The synchronizer s,itch must e turned on ,hen cardioversion is planned&
The procedure for synchronized cardioversion is the same as for defirillation, ,ith some
e)ceptions&
'MPLAN,A/L CA-D'$2-,--D+'/-'LLA,$- %'CD&
The .C= is used for patients ,ho (1) have survived BC=, (") have spontaneous sustained 3T,
($) have syncope ,ith inducile ventricular tachycardia1firillation during *PB, and (%) are at
high ris' for future life+threatening dysrhythmias (e&g&, have cardiomyopathy)&
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The .C= consists of a lead system placed via a suclavian vein to the endocardium&
5 attery+po,ered pulse generator is implanted sucutaneously, usually over the pectoral
muscle on the patient(s nondominant side&
o The .C= sensing system monitors the >? and rhythm and identifies 3T or 3@&
5ppro)imately "C seconds after the sensing system detects a lethal
dysrhythmia, the defirillating mechanism delivers a shoc' to the patient(s
heart&
.f the first shoc' is unsuccessful, the generator recycles and can continue to
deliver shoc's&
.n addition to defirillation capailities, .C=s are e<uipped ,ith antitachycardia and
antiradycardia pacema'ers&
*ducation of the patient ,ho is receiving an .C= is of e)treme importance&
PACMA9-S
The artificial cardiac "acema0er is an electronic device used to pace the heart ,hen the
normal conduction path,ay is damaged or diseased&
Pacema'ers ,ere initially indicated for symptomatic radydysrhythmias& They no,
provide antitachycardia and overdrive pacing&
5 permanent pacema'er is one that is implanted totally ,ithin the ody&
5 specialized type of cardiac pacing has een developed for the management of >@&
o Cardiac resynchronization therapy (C?T) is a pacing techni<ue that
resynchronizes the cardiac cycle y pacing oth ventricles, thus promoting
improvement in ventricular function&
o Beveral devices are availale that have comined C?T ,ith an .C= for ma)imum
therapy&
5 temporary pacema'er is one that has the po,er source outside the ody& There are three
types of temporary pacema'ers: transvenous, epicardial, and transcutaneous pacema'ers&
Patients ,ith temporary or permanent pacema'ers ,ill e *CA monitored to evaluate the
status of the pacema'er&
Complications of invasive temporary (i&e&, transvenous) or permanent pacema'er
insertion include infection and hematoma formation at the site of insertion of the
pacema'er po,er source or leads, pneumothora), failure to sense or capture ,ith possile
symptomatic radycardia, perforation of the atrial or ventricular septum y the pacing
lead, and appearance of /end+of+life0 attery parameters on testing the pacema'er&
-AD'$+-A5NC6 CA,),- A/LA,'$N ,)-AP6
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?adiofre<uency catheter alation therapy is a relatively ne, development in the area of
antidysrhythmia therapy& 5lation therapy is done after *PB has identified the source of
the dysrhythmia&
5n electrode+tipped alation catheter is used to /urn0 or alate accessory path,ays or
ectopic sites in the atria, 53 node, and ventricles&
Catheter alation is considered the nonpharmacologic treatment of choice for 53 nodal
reentrant tachycardia or for reentrant tachycardia related to accessory ypass tracts, and
to control the ventricular response of certain tachydysrhythmias&
The alation procedure is a successful therapy ,ith a lo, complication rate& Care of the
patient follo,ing alation therapy is similar to that of a patient undergoing cardiac
catheterization&
C4 C)AN4S ASS$C'A,D 7',) AC5, C$-$NA-6 S6ND-$M
The 1"+lead *CA is the primary diagnostic tool used to evaluate patients presenting ,ith
5CB&
There are definitive *CA changes that occur in response to ischemia, in#ury, or infarction
of myocardial cells and ,ill e seen in the leads that face the area of involvement&
Typical *CA changes seen in myocardial ischemia include BT+segment depression and1or
T ,ave inversion&
The typical *CA change seen during myocardial in#ury is BT+segment elevation&
5n BT+segment elevation and a pathologic P ,ave may e seen on the *CA ,ith
myocardial infarction&
Patient monitoring guidelines for patients ,ith suspected 5CB include continuous,
multilead *CA and BT+segment monitoring& The leads selected for monitoring should
minimally include the leads that reflect the area of ischemia, in#ury, or infarction&
S6NC$P
Byncope, a rief lapse in consciousness accompanied y a loss in postural tone (fainting),
is a common diagnosis of patients coming into the emergency department&
The causes of syncope can e categorized as cardiovascular or noncardiovascular&
o Common cardiovascular causes of syncope include (1) neurocardiogenic syncope
or /vasovagal0 syncope (e&g&, carotid sinus sensitivity) and (") primary cardiac
dysrhythmias (e&g&, tachycardias, radycardias)&
o Noncardiovascular causes can include hypoglycemia, hysteria, un,itnessed
seizure, and verteroasilar transient ischemic attac'&
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The diagnostic ,or'up for a patient ,ith syncope from a suspected cardiac cause egins
,ith ruling out structural and1or ischemic heart disease&
o *chocardiography and stress testing are performed&
o .n the older patient, ,ho is more li'ely to have ischemic and structural heart disease,
*PB is used to diagnose atrial and ventricular tachydysrhythmias, as ,ell as
conduction system disease causing radydysrhythmias&
o .n patients ,ithout structural heart disease or in ,hom *PB testing is not diagnostic,
head+upright tilt tale testing may e performed&
o ;ther diagnostic tests for syncope include various recording devices&
>olter monitors and event monitors can e used&
5 sucutaneously implanted loop recording device can also e used to record
the *CA during presyncopal and syncopal events&
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Lewis et al: Medical-Surgical Nursing: Assessment and Management of
Clinical Problems, 7
th
edition
Key Points
Chapter $9: Nursing :anagement: .nflammatory and Btructural >eart =isorders
'N+C,'2 ND$CA-D','S
'nfecti!e endocarditis (.*) is an infection of the endocardial surface of the heart that
affects the cardiac valves& .t is treated ,ith penicillin&
T,o forms of .* include the suacute form (typically affecting those ,ith pree)isting
valve disease) and the acute form (typically affecting those ,ith healthy valves)&
The most common causative organisms of .* are Staphylococcus aureus and
Streptococcus viridans#
The principal ris' factors for .* are prior endocarditis, prosthetic valves, ac<uired
valvular disease, and cardiac lesions&
3egetations, the primary lesions of .*, adhere to the valve surface or endocardium and
can emolize to various organs (particularly the lungs, rain, 'idneys, and spleen) and to
the e)tremities, causing lim infarction&
The infection may spread locally to cause damage to the valves or to their supporting
structures resulting in dysrhythmias, valvular incompetence, and eventual invasion of the
myocardium, leading to heart failure (>@), sepsis, and heart loc'&
Clinical findings in .* are nonspecific and can include the follo,ing:
o 2o,+grade fever, chills, ,ea'ness, malaise, fatigue, and anore)ia
o 5rthralgias, myalgias, ac' pain, adominal discomfort, ,eight loss, headache,
and cluing of fingers
o Bplinter hemorrhages (lac' longitudinal strea's) in the nail eds
o Petechiae (a result of fragmentation and microemolization of vegetative lesions)
in the con#unctivae, the lips, the uccal mucosa, and the palate and over the
an'les, the feet, and the antecuital and popliteal areas
o $sler<s nodes (painful, tender, red or purple, pea+size lesions) on the fingertips or
toes and Banewa.<s lesions (flat, painless, small, red spots) on the palms and
soles
o >emorrhagic retinal lesions called ?oth(s spots
o 5 ne, or changing murmur in the aortic or mitral valve
o >@
=efinitive diagnosis of .* e)ists if t,o of the follo,ing ma#or criteria are present:
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positive lood cultures, ne, or changed cardiac murmur, or intracardiac mass or
vegetation noted on echocardiography&
Collaorative care consists of antiiotic prophyla)is for patients ,ith specific cardiac
conditions efore dental, respiratory tract, gastrointestinal (A.), and genitourinary (A4)
procedures and for high+ris' patients ,ho (1) are to undergo removal or drainage of
infected tissue, (") receive renal dialysis, or ($) have ventriculoatrial shunts for
management of hydrocephalus&
=rug therapy consists of long+term treatment ,ith .3 antiiotic therapy ,ith suse<uent
lood cultures to evaluate the effectiveness of antiiotic therapy&
*arly valve replacement follo,ed y prolonged (D ,ee's or longer) drug therapy is
recommended for patients ,ith fungal infection and prosthetic valve endocarditis&
@ever is treated ,ith aspirin, acetaminophen (Tylenol), iuprofen (:otrin), fluids, and
rest&
Complete ed rest is usually not indicated unless the temperature remains elevated or
there are signs of >@&
;verall goals for the patient ,ith .* include (1) normal or aseline cardiac function, (")
performance of activities of daily living (5=2s) ,ithout fatigue, and ($) 'no,ledge of
the therapeutic regimen to prevent recurrence of endocarditis&
Patients and families must e taught to recognize signs and symptoms of life+threatening
complications of .*, such as cereral emoli (e&g&, change in mental status), pulmonary
edema (e&g&, dyspnea), and >@ (e&g&, chest pain)&
o @ever (chronic or intermittent) is a common early sign that the drug therapy is
ineffective&
2aoratory data and lood cultures are monitored to determine the effectiveness of the
antiiotic therapy&
AC5, P-'CA-D','S
Pericarditis is caused y inflammation of the pericardial sac (the pericardium)&
5cute pericarditis most often is idiopathic ut can e caused y uremia, viral or acterial
infection, acute myocardial infarction (:.), tuerculosis, neoplasm, and trauma&
Pericarditis in the acute :. patient may e descried as t,o distinct syndromes: (1) acute
pericarditis (occurs ,ithin the initial %F to 9" hours after an :.), and (") =ressler
syndrome (late pericarditis ,hich appears % to D ,ee's after an :.)&
Clinical manifestations include the follo,ing:
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o Progressive, fre<uently severe chest pain that is sharp and pleuritic in nature and
,orse ,ith deep inspiration and ,hen lying supine& The pain is relieved y
sitting&
o Pain can e referred to the trapezius muscle (shoulder, upper ac')&
o The hallmar' finding in acute pericarditis is the "ericardial friction rub(
Complications include "ericardial effusion and cardiac tam"onade(
Collaorative care includes the follo,ing:
o 5ntiiotics
o Corticosteroids for pericarditis secondary to systemic lupus erythematosus,
patients already ta'ing corticosteroids for a rheumatologic or other immune
system condition, or patients ,ho do not respond to nonsteroidal
antiinflammatory drugs (NB5.=s)
o Pain and inflammation are usually treated ,ith NB5.=s or high+dose salicylates
(e&g&, aspirin)&
o Colchicine, an antiinflammatory agent used for gout, may e considered for
patients ,ho have recurrent pericarditis&
o Pericardiocentesis is usually performed for pericardial effusion ,ith acute
cardiac tamponade, purulent pericarditis, and a high suspicion of a neoplasm&
Complications from pericardiocentesis include dysrhythmias, further
cardiac tamponade, pneumomediastinum, pneumothora), myocardial
laceration, and coronary artery laceration&
The management of the patient(s pain and an)iety during acute pericarditis is a primary
nursing consideration&
*CA monitoring can aid in distinguishing ischemic pain from pericardial pain as
ischemia involves localized BT+segment changes, as compared to the diffuse BT+segment
changes present in acute pericarditis&
Pain relief measures include maintaining ed rest ,ith the head of the ed elevated to %C
degrees and providing an overed tale for support, and antiinflammatory medications&
C)-$N'C C$NS,-'C,'2 P-'CA-D','S
Chronic constricti!e "ericarditis results from scarring ,ith conse<uent loss of elasticity
of the pericardial sac and egins ,ith an initial episode of acute pericarditis follo,ed y
firous scarring, thic'ening of the pericardium from calcium deposition, and eventual
oliteration of the pericardial space&
The end result is that the firotic, thic'ened, and adherent pericardium impairs the aility
of the atria and ventricles to stretch ade<uately during diastole&
Clinical manifestations mimic >@ and cor pulmonale and include dyspnea on e)ertion,
peripheral edema, ascites, fatigue, anore)ia, and ,eight loss&
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The most prominent finding is #ugular venous distention&
5uscultation reveals a pericardial 'noc', ,hich is a loud early diastolic sound often heard
along the left sternal order&
Treatment of choice for chronic constrictive pericarditis is a pericardiectomy&
Pericardiectomy involves complete resection of the pericardium through a median
sternotomy ,ith the use of cardiopulmonary ypass&
M6$CA-D','S
M.ocarditis is a focal or diffuse inflammation of the myocardium caused y viruses,
acteria, fungi, radiation therapy, and pharmacologic and chemical factors&
:yocarditis is fre<uently associated ,ith acute pericarditis, particularly ,hen it is caused
y co)sac'ievirus 6 strains&
:yocarditis results in cardiac dysfunction and has een lin'ed to the development of
dilated cardiomyopathy&
Clinical manifestations include the follo,ing:
o @ever, fatigue, malaise, myalgias, pharyngitis, dyspnea, lymphadenopathy, and
nausea and vomiting are early systemic manifestations of the viral illness&
o *arly cardiac manifestations appear 9 to 18 days after viral infection and include
pleuritic chest pain ,ith a pericardial friction ru and effusion&
o 2ate cardiac signs relate to the development of >@ and may include an B
$
heart
sound, crac'les, #ugular venous distention, syncope, peripheral edema, and
angina&
Collaorative care includes the follo,ing:
o :anaging associated cardiac decompensation ,ith:
=igo)in (2ano)in) to treat ventricular failure
=iuretics to reduce fluid volume and decrease preload
Nitroprusside (Nitropress), inamrinone (.nocor), and milrinone (Primacor)
to reduce afterload and improve cardiac output
The use of anticoagulation therapy may e considered in patients ,ith a
lo, e#ection fraction ,ho are at ris' for thromus formation from lood
stasis in the cardiac chamers&
o .mmunosuppressive therapy to reduce myocardial inflammation and to prevent
irreversile myocardial damage&
o ;)ygen therapy, ed rest, and restricted activity&
o .ntraaortic alloon pump therapy and ventricular assist devices&
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Nursing interventions focus on assessment for the signs and symptoms of >@ and include
assessing the level of an)iety, instituting measures to decrease an)iety, and 'eeping the
patient and family informed aout therapeutic measures&
:ost patients ,ith myocarditis recover spontaneously, although some may develop
dilated cardiomyopathy& .f severe >@ occurs, the patient may re<uire heart
transplantation&
-)5MA,'C +2- AND )A-, D'SAS
-heumatic fe!er is an inflammatory disease of the heart potentially involving all layers
of the heart&
-heumatic heart disease is a chronic condition resulting from rheumatic fever that is
characterized y scarring and deformity of the heart valves&
Acute rheumatic fe!er (5?@) is a complication that occurs as a delayed se<uela of a
group 5 streptococcal pharyngitis and affects the heart, #oints, central nervous system
(CNB), and s'in&
5out %8K of 5?@ episodes are mar'ed y carditis, meaning that all layers of the heart
are involved, and this is referred to as rheumatic pancarditis&
o ?heumatic endocarditis is found primarily in the valves& 3egetation forms and
valve leaflets may fuse and ecome thic'ened or even calcified, resulting in
stenosis or regurgitation&
o :yocardial involvement is characterized y Aschoff<s bodies(
o ?heumatic pericarditis affects the pericardium, ,hich ecomes thic'ened and
covered ,ith a firinous e)udate, and often involves pericardial effusion&
o The lesions of rheumatic fever are systemic, especially involving the connective
tissue, as ,ell as the #oints, s'in, and CNB&
Clinical manifestations of 5?@ include the follo,ing:
o The presence of t,o ma#or criteria or one ma#or and t,o minor criteria plus
evidence of a preceding group 5 streptococcal infection&
:a#or criteria:
Carditis results in three signs: (1) murmurs of mitral or aortic
regurgitation, or mitral stenosis! (") cardiac enlargement and >@! ($)
pericarditis&
:ono+ or polyarthritis causes s,elling, heat, redness, tenderness, and
limitation of motion&
Chorea (Bydenham(s chorea) involves involuntary movements,
especially of the face and lims, muscle ,ea'ness, and disturances of
speech and gait&
*rythema marginatum lesions are right pin', nonpruritic, mapli'e
macular lesions that occur mainly on the trun' and pro)imal
e)tremities&
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Key Points
Bucutaneous nodules are firm, small, hard, painless s,ellings
located over e)tensor surfaces of the #oints&
:inor criteria:
Clinical findings: fever, polyarthralgia
2aoratory findings: elevated *B?, elevated -6C, elevated C?P
Complications of 5?@ include chronic rheumatic carditis&
B'in should e assessed for sucutaneous nodules and erythema marginatum&
The overall goals for a patient ,ith rheumatic fever include (1) normal or aseline heart
function, (") resumption of daily activities ,ithout #oint pain, and ($) veralization of the
aility to manage the disease&
>ealth promotion emphasizes prevention of rheumatic fever y early detection and
treatment of group 5 streptococcal pharyngitis ,ith antiiotics, specifically penicillin&
o The success of treatment re<uires strict adherence to the full course of antiiotic
therapy&
o The primary goals of managing a patient ,ith 5?@ are to control and eradicate
the infecting organism! prevent cardiac complications! and relieve #oint pain,
fever, and other symptoms ,ith antiiotics! optimal rest! and antipyretics,
NB5.=s, and corticosteroids&
o Becondary prevention aims at preventing the recurrence of rheumatic fever ,ith
monthly in#ections of long+acting penicillin& 5dditional prophyla)is is necessary if
a patient ,ith 'no,n rheumatic heart disease has dental or surgical procedures
involving the upper respiratory, A. (e&g&, endoscopy), or A4 tract&
The e)pected outcomes for the patient ,ith rheumatic fever and heart disease include (1)
aility to perform 5=2s ,ith minimal fatigue and pain, (") adherence to treatment
regimen, and ($) e)pression of confidence in managing disease&
2AL25LA- )A-, D'SAS
3alvular stenosis refers to a constriction or narro,ing of the valve opening&
3alvular regurgitation (also called valvular incompetence or insufficiency) occurs ,ith
incomplete closure of the valve leaflets and results in the ac',ard flo, of lood&
Mitral 2al!e Stenosis
5dult mitral valve stenosis results from rheumatic heart disease& 2ess commonly, it
can occur congenitally, from rheumatoid arthritis and from systemic lupus
erythematosus&
Clinical manifestations of mitral stenosis include e)ertional dyspnea, fatigue, palpitations
from atrial firillation, and a loud first heart sound and a lo,+pitched, rumling diastolic
murmur&
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Key Points
Mitral -egurgitation
:itral regurgitation (:?) is caused y :., chronic rheumatic heart disease, mitral valve
prolapse, ischemic papillary muscle dysfunction, and .*&
.n chronic :?, the additional volume load results in atrial enlargement, ventricular
dilation, and eventual ventricular hypertrophy&
.n acute :?, there is a sudden increase in pressure and volume that is transmitted to the
pulmonary ed, resulting in pulmonary edema and life+threatening shoc'&
Clinical manifestations of acute :? include thready, peripheral pulses and cool, clammy
e)tremities! and a ne, systolic murmur&
Patients ,ith asymptomatic :? should e monitored carefully, and surgery considered
efore significant left ventricular failure or pulmonary hypertension develops&
Mitral 2al!e Prola"se
Mitral !al!e "rola"se (:3P) is an anormality of the mitral valve leaflets and the
papillary muscles or chordae that allo,s the leaflets to prolapse, or uc'le, ac' into the
left atrium during systole& The etiology of :3P is un'no,n ut is related to diverse
pathogenic mechanisms of the mitral valve apparatus&
.n many patients :3P found y echocardiography is not accompanied y any other
clinical manifestations of cardiac disease, and the significance of the finding is unclear&
Clinical manifestations of :3P can include a murmur from regurgitation that gets more
intense through systole, chest pain, dyspnea, palpitations, and syncope&
Aortic 2al!e Stenosis
.n older patients, aortic stenosis is a result of rheumatic fever or senile firocalcific
degeneration that may have an etiology similar to coronary artery disease&
5ortic stenosis results in left ventricular hypertrophy and increased myocardial o)ygen
consumption, and eventually, reduced cardiac output leading to pulmonary hypertension
and >@&
Clinical manifestations include a systolic, crescendo+decrescendo murmur and the classic
triad of angina, syncope, and e)ertional dyspnea&
Aortic 2al!e -egurgitation
Acute aortic regurgitation (5?) is caused y .*, trauma, or aortic dissection&
Chronic 5? is generally the result of rheumatic heart disease, a congenital icuspid aortic
valve, syphilis, or chronic rheumatic conditions&
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Clinical manifestations of acute 5? include severe dyspnea, chest pain, and hypotension
indicating left ventricular failure and shoc' that constitute a medical emergency&
Clinical manifestations of chronic 5? include e)ertional dyspnea, orthopnea, and
paro)ysmal nocturnal dyspnea after considerale myocardial dysfunction has occurred&
,ricus"id and Pulmonic 2al!e Disease
=iseases of the tricuspid and pulmonic valves are uncommon, ,ith stenosis occurring
more fre<uently than regurgitation&
Tricuspid valve stenosis occurs almost e)clusively in patients ,ith rheumatic mitral
stenosis, in .3 drug ausers, or in patients treated ,ith a dopamine agonist&
Pulmonary stenosis is almost al,ays congenital&
Tricuspid and pulmonic stenosis oth result in the ac',ard flo, of lood to the right
atrium and right ventricle, respectively&
Tricuspid stenosis results in right atrial enlargement and elevated systemic venous
pressures& Pulmonic stenosis results in right ventricular hypertension and hypertrophy&
Collaborati!e Care of 2al!ular )eart Disease
Collaorative care of valvular heart disease includes the prevention of recurrent
rheumatic fever and .* and the prevention of e)acerations of >@, acute pulmonary
edema, and thromoemolism&
5nticoagulant therapy is used to prevent and treat systemic or pulmonary emolization
and is used prophylactically in patients ,ith atrial firillation&
5n alternative treatment for valvular heart disease is percutaneous transluminal alloon
valvuloplasty (PT63) to split open the fused commissures& .t is used for mitral, tricuspid,
and pulmonic stenosis, and less often for aortic stenosis&
Burgical intervention is ased on the clinical state of the patient and depends on the
valves involved, the valvular pathology, the severity of the disease, and the patient(s
clinical condition&
3alve repair (e&g&, mitral commissurotomy HvalvulotomyI, is typically the surgical
procedure of choice&
;pen surgical valvuloplasty involves repair of the valve y suturing the torn leaflets,
chordae tendineae, or papillary muscles and is used to treat mitral or tricuspid
regurgitation&
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5nnuloplasty entails reconstruction of the annulus, ,ith or ,ithout the aid of prosthetic
rings (e&g&, a Carpentier ring)&
Prosthetic mechanical valves are made from manmade materials&
Prosthetic iologic valves are constructed from ovine, porcine, and human cardiac tissue
and usually contain some human+made materials&
:echanical prosthetic valves are more durale and last longer than iologic valves ut
have an increased ris' of thromoemolism, necessitating long+term anticoagulation
therapy&
6iologic valves do not re<uire anticoagulation therapy due to their lo, thromogenicity&
>o,ever, they are less durale due to the tendency for early calcification, tissue
degeneration, and stiffening of the leaflets&
5uscultation of the heart should e performed to monitor the effectiveness of digo)in, +
adrenergic loc'ers, and antidysrhythmic drugs&
Prophylactic antiiotic therapy is necessary to prevent .* and, if the valve disease ,as
caused y rheumatic fever, ongoing prophyla)is is necessary&
Patients on anticoagulation therapy after valve replacement surgery must have the
international normalized ratio (.N?) chec'ed regularly (usually monthly) to assess the
ade<uacy of therapy& Therapeutic values are "&C to $&C&
The nurse must teach the patient to see' medical care if any manifestations of infection or
>@, any signs of leeding, and any planned invasive or dental procedures are planned&
Patients on anticoagulation therapy should e encouraged to ,ear a medical alert
racelet&
CA-D'$M6$PA,)6
Cardiom.o"ath. (C:P) constitutes a group of diseases that directly affect the structural
or functional aility of the myocardium&
C:P is classified as primary (refers to those conditions in ,hich the etiology of the heart
disease is un'no,n) or secondary (the cause of the myocardial disease is 'no,n and is
secondary to another disease process)&
Cardiomyopathies can lead to cardiomegaly and >@, and are the leading cause for heart
transplantation&
Dilated Cardiom.o"ath.
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Key Points
Dilated cardiom.o"ath. is characterized y a diffuse inflammation and rapid
degeneration of myocardial fiers that results in ventricular dilation, impairment of
systolic function, atrial enlargement, and stasis of lood in the left ventricle&
Clinical manifestations develop acutely after an infectious process or insidiously over a
period of time&
o Bymptoms include decreased e)ercise capacity, fatigue, dyspnea at rest,
paro)ysmal nocturnal dyspnea, orthopnea, palpitations, adominal loating,
nausea, vomiting, and anore)ia&
o Bigns include an irregular heart rate ,ith an anormal B
$
and1or B
%
, tachycardia or
radycardia, pulmonary crac'les, edema, ,ea' peripheral pulses, pallor,
hepatomegaly, and #ugular venous distention&
o >eart murmurs and dysrhythmias are common&
.nterventions focus on controlling >@ y enhancing myocardial contractility and
decreasing afterload ,ith drug therapy&
Nutritional therapy and cardiac rehailitation may help alleviate symptoms of >@ and
improve C; and <uality of life&
=ilated C:P does not respond ,ell to therapy, and patients may enefit from a
ventricular assist device (35=) to allo, the heart to rest and recover from acute >@ or as
a ridge to heart transplantation&
Cardiac resynchronization therapy and an implantale cardioverter+defirillator may e
considered in appropriate patients& The patient(s family must learn cardiopulmonary
resuscitation (CP?) and ho, to access emergency care&
The goal of therapy is to 'eep the patient at an optimal level of function and out of the
hospital&
)."ertro"hic Cardiom.o"ath.
)."ertro"hic cardiom.o"ath. (>C:) is asymmetric left ventricular hypertrophy
,ithout ventricular dilation&
The four main characteristics of >C: are: (1) massive ventricular hypertrophy! (") rapid,
forceful contraction of the left ventricle! ($) impaired rela)ation (diastole)! and (%)
ostruction to aortic outflo, (not present in all patients)& The end result is impaired
ventricular filling as the ventricle ecomes noncompliant and unale to rela)&
>C: is the most common cause of BC= in other,ise healthy young people&
Patients ,ith >C: may e asymptomatic or may have e)ertional dyspnea, fatigue,
angina, syncope, and dysrhythmias&
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Aoals of intervention are to improve ventricular filling y reducing ventricular
contractility and relieving left ventricular outflo, ostruction&
=rug therapy for >C: includes +adrenergic loc'ers or calcium channel loc'ers&
=igitalis preparations are contraindicated unless they are used to treat atrial firillation,
and antidysrhythmics are used as needed&
@or patients at ris' for BC=, the implantation of a cardioverter+defirillator is
recommended&
5trioventricular pacing can e eneficial for patients ,ith >C: and outflo, ostruction&
Bome patients may e candidates for a surgical procedure called ventriculomyotomy and
myectomy, ,hich involves incision of the hypertrophied septal muscle and resection of
some of the hypertrophied ventricular muscle&
Nursing interventions for >C: focus on relieving symptoms, oserving for and
preventing complications, and providing emotional and psychologic support&
-estricti!e Cardiom.o"ath.
-estricti!e cardiom.o"ath., the least common C:P, impairs diastolic filling and
stretch though systolic function remains unaffected&
The specific etiology of restrictive C:P is un'no,n&
Clinical manifestations include fatigue, e)ercise intolerance, and dyspnea ecause the
heart cannot increase C; y increasing the heart rate ,ithout further compromising
ventricular filling&
Currently no specific treatment for restrictive C:P e)ists and interventions are aimed at
improving diastolic filling and the underlying disease process&
o Treatment includes conventional therapy for >@ and dysrhythmias&
o >eart transplant may also e a consideration&
o Nursing care is similar to the care of a patient ,ith >@&
Lewis et al: Medical-Surgical Nursing: Assessment and Management of
Clinical Problems, 7
th
edition
Key Points
Chapter $F: Nursing :anagement: 3ascular =isorders
P-'P)-AL A-,-'AL D'SAS
Peri"heral arterial disease (P5=) is a progressive narro,ing and degeneration of the
arteries of the nec', adomen, and e)tremities& .n most cases, it is a result of
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Key Points
atherosclerosis&
P5= typically appears in the si)th to eighth decades of life& .t occurs at an earlier age in
persons ,ith diaetes mellitus and more fre<uently in 5frican 5mericans&
The four most significant ris' factors for P5= are cigarette smo'ing (most important),
hyperlipidemia, hypertension, and diaetes mellitus&
The most common locations for P5= are the coronary arteries, carotid arteries, aortic
ifurcation, iliac and common femoral arteries, profunda femoris artery, superficial
femoral artery, and distal popliteal artery&
AN5-6SMS
5ortic aneur.sms are outpouchings or dilations of the arterial ,all&
The primary causes of aortic aneurysms can e classified as degenerative, congenital,
mechanical, inflammatory, or infectious&
5ortic aneurysms may involve the aortic arch, thoracic aorta, and1or adominal aorta, ut
most are found in the adominal aorta elo, the level of the renal arteries&
Thoracic aorta aneurysms are often asymptomatic, ut the most common manifestations
are deep, diffuse chest pain that may e)tend to the interscapular area! hoarseness as a
result of pressure on the recurrent laryngeal nerve! and dysphagia from pressure on the
esophagus&
5dominal aortic aneurysms (555s) are often asymptomatic ut symptoms may mimic
pain associated ,ith adominal or ac' disorders&
The most serious complication related to an untreated aneurysm is rupture and leeding&
=iagnostic tests for 555s include chest )+ray, electrocardiogram (to rule out myocardial
infarction), echocardiography, CT scan, and magnetic resonance imaging scan&
The goal of management is to prevent the aneurysm from rupturing&
Burgical repair of 555 involves (1) incising the diseased segment of the aorta, (")
removing intraluminal thromus or pla<ue, ($) inserting a synthetic graft, and (%) suturing
the native aortic ,all around the graft&
:inimally invasive endovascular grafting is an alternative to conventional surgical repair
of 555 and involves the placement of a sutureless aortic graft into the adominal aorta
inside the aneurysm via a femoral artery cutdo,n&
Preoperatively, the patient is monitored for indications of aneurysm rupture&
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Preoperative teaching should include a rief e)planation of the disease process, the
planned surgical procedure(s), preoperative routines, and ,hat to e)pect immediately
after surgery&
The overall goals for a patient undergoing aortic surgery include (1) normal tissue
perfusion, (") intact motor and sensory function, and ($) no complications related to
surgical repair, such as thromosis or infection&
Postoperatively, the patient ,ill have an endotracheal tue for mechanical ventilation, an
arterial line, a central venous pressure or pulmonary artery catheter, peripheral
intravenous lines, an ind,elling urinary catheter, a nasogastric tue, and continuous *CA
and pulse o)imetry monitoring&
o :onitoring for graft patency and ade<uate renal perfusion are priorities!
maintenance of an ade<uate 6P is e)tremely important&
o 5ntiiotics are given to prevent infection&
o Peripheral pulses, s'in temperature and color, capillary refill time, and sensation
and movement of the e)tremities are assessed and recorded per hospital policy&
o >ourly urine outputs and daily ,eights are recorded&
;n discharge, the patient should e instructed to gradually increase activities ut to avoid
heavy lifting for at least % to D ,ee's&
*)pected outcomes for the patient ,ho undergoes aortic surgery include (1) patent
arterial graft ,ith ade<uate distal perfusion, (") ade<uate urine output, ($) normal ody
temperature, and (%) no signs of infection&
A$-,'C D'SSC,'$N
Aortic dissection occurs most commonly in the thoracic aorta and is the result of a tear
in the intimal (innermost) lining of the arterial ,all allo,ing lood to /trac'0 et,een the
intima and media and creates a false lumen of lood flo,&
The e)act cause of aortic dissection is uncertain, and most people ,ith dissection are
older and have chronic hypertension&
Clinical manifestations include a sudden, severe pain in the anterior part of the chest or
intrascapular pain radiating do,n the spine into the adomen or legs that is descried as
/tearing0 or /ripping&0
=iagnostic studies used to assess aortic dissection are similar to those performed for
555&
The initial goal of therapy for aortic dissection ,ithout complications is to lo,er the 6P
and myocardial contractility ,ith drug therapy&
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Burgery is indicated ,hen drug therapy is ineffective or ,hen complications of aortic
dissection are present&
P-'P)-AL A-,-'AL D'SAS $+ ,) L$7- 8,-M','S
P5= of the lo,er e)tremities affects the aortoiliac, femoral, popliteal, tiial, or peroneal
arteries&
The classic symptom of P5= of the lo,er e)tremities is intermittent claudication,
,hich is defined as ischemic muscle ache or pain that is precipitated y a consistent level
of e)ercise, resolves ,ithin 18 minutes or less ,ith rest, and is reproducile&
Paresthesia, manifested as numness or tingling in the toes or feet, may result from nerve
tissue ischemia& Aradually diminishing perfusion to neurons produces loss of oth
pressure and deep pain sensations&
Physical findings include thin, shiny, and taut s'in! loss of hair on the lo,er legs!
diminished or asent pedal, popliteal, or femoral pulses! pallor or lanching of the foot in
response to leg elevation (elevation pallor)! and reactive hyperemia (redness of the foot)
,hen the lim is in a dependent position (dependent ruor)&
?est pain most often occurs in the forefoot or toes, is aggravated y lim elevation, and
occurs ,hen there is insufficient lood flo, to maintain asic metaolic re<uirements of
the tissues and nerves of the distal e)tremity&
Complications of P5= include nonhealing ulcers over ony prominences on the toes,
feet, and lo,er leg, and gangrene& 5mputation may e re<uired if lood flo, is not
restored&
Tests used to diagnose P5= include =oppler ultrasound ,ith segmental lood pressures
at the thigh, elo, the 'nee, and at an'le level& 5 falloff in segmental 6P of more than $8
mm >g indicates P5=&
5ngiography is used to delineate the location and e)tent of the disease process&
The first treatment goal is to aggressively modify all cardiovascular ris' factors in all
patients ,ith P5=, ,ith smo'ing cessation a priority&
=rug therapy includes antiplatelet agents and 5C* inhiitors& T,o drugs are approved to
treat intermittent claudication, pento)ifylline (Trental) and cilostazol (Pletal)&
The primary nonpharmacologic treatment for claudication is a formal e)ercise+training
program ,ith ,al'ing eing the most effective e)ercise&
Ain'go iloa has een found to increase ,al'ing distance for patients ,ith intermittent
claudication&
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Critical limb ischemia is a chronic condition characterized y ischemic rest pain, arterial
leg ulcers, and1or gangrene of the leg due to advanced P5=&
.nterventional radiologic procedures for P5= include percutaneous transluminal alloon
angioplasty& There is a relatively high rate of restenosis after alloon angioplasty&
The most common surgical procedure for P5= is a peripheral arterial ypass operation
,ith autogenous vein or synthetic graft material to ypass or carry lood around the
lesion&
The overall goals for the patient ,ith lo,er e)tremity P5= include (1) ade<uate tissue
perfusion, (") relief of pain, ($) increased e)ercise tolerance, and (%) intact, healthy s'in
on e)tremities&
5fter surgical or radiologic intervention, the operative e)tremity should e chec'ed every
1C minutes initially and then hourly for s'in color and temperature, capillary refill,
presence of peripheral pulses, and sensation and movement of the e)tremity&
5ll patients ,ith P5= should e taught the importance of meticulous foot care to prevent
in#ury&
Acute arterial ischemia is a sudden interruption in the arterial lood supply to tissue, an
organ, or an e)tremity that, if left untreated, can result in tissue death&
Bigns and symptoms of an acute arterial ischemia usually have an arupt onset and
include the /si) Ps:0 pain, pallor, pulselessness, paresthesia, paralysis, and poi'ilothermia
(adaptation of the ischemic lim to its environmental temperature, most often cool)&
Treatment options include anticoagulation, thromolysis, emolectomy, surgical
revascularization, or amputation&
,)-$M/$AN4'','S $/L',-ANS %/5-4-<S D'SAS&
,hromboangiitis obliterans is a some,hat rare nonatherosclerotic, segmental, recurrent
inflammatory vaso+occlusive disorder of the small and medium+sized arteries, veins, and
nerves of the upper and lo,er e)tremities&
Patients may have intermittent claudication of the feet, hands, or arms&
5s the disease progresses, rest pain and ischemic ulcerations develop&
There are no laoratory or diagnostic tests specific to 6uerger(s disease&
Treatment includes complete cessation of toacco use in any form (including secondhand
smo'e)& ;ther therapies can e considered ut have had limited success&
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Burgical options include revascularization and sympathectomy, ,ith the most common
eing sympathectomy (transection of a nerve, ganglion, and1or ple)us of the sympathetic
nervous system)&
-A6NA5D<S P)N$MN$N
-a.naud<s "henomenon is an episodic vasospastic disorder of small cutaneous arteries,
most fre<uently involving the fingers and toes& The e)act etiology of ?aynaud(s
phenomenon remains un'no,n&
Clinical symptoms include vasospasm+induced color changes of the fingers, toes, ears,
and nose (,hite, lue, and red)& 5n episode usually lasts only minutes ut in severe cases
may persist for several hours&
Bymptoms usually are precipitated y e)posure to cold, emotional upsets, caffeine, and
toacco use&
There is no simple diagnostic test for ?aynaud(s phenomenon, and diagnosis is ased on
persistent symptoms for at least " years&
Patient teaching should e directed to,ard prevention of recurrent episodes: temperature
e)tremes and all toacco products should e avoided&
Calcium channel loc'ers are the first+line drug therapy&
2N$5S ,)-$M/$S'S
2enous thrombosis is the most common disorder of the veins and involves the formation
of a thromus (clot) in association ,ith inflammation of the vein&
Su"erficial thrombo"hlebitis occurs in aout DCK of all patients receiving .3 therapy
and is of minor significance&
Dee" !ein thrombosis (=3T) involves a thromus in a deep vein, most commonly the
iliac and femoral veins, and can result in emolization of thromi to the lungs&
Three important factors (called 2irchow<s triad) in the etiology of venous thromosis
are (1) venous stasis, (") damage of the endothelium, and ($) hypercoagulaility of the
lood&
Buperficial thromophleitis presents as a palpale, firm, sucutaneous cordli'e vein&
The area surrounding the vein may e tender to the touch, reddened, and ,arm& 5 mild
systemic temperature elevation and leu'ocytosis may e present&
o Treatment of superficial thromophleitis includes elevating the affected
e)tremity to promote venous return and decrease the edema and applying ,arm,
moist heat&
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Key Points
o :ild oral analgesics such as acetaminophen or aspirin are used to relieve pain&
The patient ,ith =3T may or may not have unilateral leg edema, e)tremity pain, ,arm
s'in, erythema, and a systemic temperature greater than 188&% @ ($F C)&
The most serious complications of =3T are pulmonary emolism (P*) and chronic
venous insufficiency& Chronic venous insufficiency (C3.) results from valvular
destruction, allo,ing retrograde flo, of venous lood&
.nterventions for patients at ris' for =3T include early moilization of surgical patients&
Patients on ed rest need to e instructed to change position, dorsifle) their feet, and
rotate their an'les every " to % hours&
The usual treatment of =3T in hospitalized patients involves ed rest, elevation of the
e)tremity, and anticoagulation&
Patients ,ith hyperhomocysteinemia are treated ,ith vitamins 6
D
, 6
1"
, and folic acid to
reduce homocysteine levels&
The goal of anticoagulation therapy for =3T prophyla)is is to prevent =3T formation!
the goals in the treatment of =3T are to prevent propagation of the clot, development of
any ne, thromi, and emolization&
.ndirect thromin inhiitors include unfractionated heparin (4>) and lo,+molecular+
,eight heparin (2:->)&
o 4> affects oth the intrinsic and common path,ays of lood coagulation y ,ay
of the plasma cofactor antithromin&
o 2:-> is derived from heparin and also acts via antithromin, ut has an
increased affinity for inhiiting factor Ma&
=irect thromin inhiitors can e classified as hirudin derivatives or synthetic thromin
inhiitors& >irudin inds specifically ,ith thromin, therey directly inhiiting its
function ,ithout causing plasma protein and platelet interactions&
@actor Ma inhiitors inhiit factor Ma directly or indirectly, producing rapid
anticoagulation&
o @ondaparinu) (5ri)tra) is administered sucutaneously and is approved for =3T
prevention in orthopedic patients and treatment of =3T and P* in hospitalized
patients ,hen administered in con#unction ,ith ,arfarin&
o 6oth direct thromin inhiitors and factor Ma inhiitors have no antidote&
@or =3T prophyla)is, lo,+dose 4>, 2:->, fondaparinu), or ,arfarin can e
prescried&
o 2:-> has replaced heparin as the anticoagulant of choice to prevent =3T for
most surgical patients&
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Key Points
o =3T prophyla)is typically lasts the duration of the hospitalization&
o Patients undergoing ma#or orthopedic surgery may e prescried prophyla)is for
up to 1 month postdischarge&
3ena cava interruption devices, such as the Areenfield filter, can e inserted
percutaneously through right femoral or right internal #ugular vein to filter clots ,ithout
interrupting lood flo,&
Nursing diagnoses and collaorative prolems for the patient ,ith venous thromosis can
include the follo,ing:
o 5cute pain related to venous congestion, impaired venous return, and
inflammation
o .neffective health maintenance related to lac' of 'no,ledge aout the disorder
and its treatment
o ?is' for impaired s'in integrity related to altered peripheral tissue perfusion
o Potential complication: leeding related to anticoagulant therapy
o Potential complication: pulmonary emolism related to emolization of thromus,
dehydration, and immoility
The overall goals for the patient ,ith venous thromosis include (1) relief of pain, (")
decreased edema, ($) no s'in ulceration, (%) no complications from anticoagulant therapy,
and (C) no evidence of pulmonary emoli&
o =epending on the anticoagulant prescried, 5CT, aPTT, .N?, hemogloin,
hematocrit, platelet levels, and1or liver enzymes are monitored&
o Platelet counts are monitored for patients receiving 4> or 2:-> to assess for
>.T&
o 4>, ,arfarin, and direct thromin inhiitors are titrated according to the results of
clotting studies&
o The nurse oserves for signs of leeding, including epista)is, gingival leeding,
hematuria, and melena&
=ischarge teaching should focus on elimination of modifiale ris' factors for =3T, the
importance of compression stoc'ings and monitoring of laoratory values, medication
instructions, and guidelines for follo,+up&
o The patient and family should e taught aout signs and symptoms of P* such as
sudden onset of dyspnea, tachypnea, and pleuritic chest pain&
o .f the patient is on anticoagulant therapy, the patient and family need information
on dosage, actions, and side effects, as ,ell as the importance of routine lood
tests and ,hat symptoms to report to the health care provider&
o >ome monitoring devices are no, availale for testing of PT1.N?&
o Patients on 2:-> ,ill need to learn ho, to self+administer the drug or have a
friend or family memer administer it&
o Patients on ,arfarin should e instructed to follo, a consistent diet of foods
containing vitamin K and to avoid any additional supplements that contain
vitamin K&
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1+1%%
Key Points
o Proper hydration is recommended to prevent additional hypercoagulaility&
o *)ercise programs should e developed ,ith an emphasis on ,al'ing, s,imming,
and ,ading&
The e)pected outcomes for the patient ,ith venous thromosis include (1) minimal to no
pain, (") intact s'in, ($) no signs of hemorrhage or occult leeding, and (%) no signs of
respiratory distress&
2A-'C$S 2'NS
2aricose !eins, or varicosities, are dilated, tortuous sucutaneous veins most fre<uently
found in the saphenous system&
o Primary varicose veins are more common in ,omen and patients ,ith a strong
family history and are proaly caused y congenital ,ea'ness of the veins&
o Becondary varicose veins typically result from a previous =3T&
o Becondary varicose veins also may occur in the esophagus, in the anorectal area,
and as anormal arteriovenous connections&
o ?eticular veins are smaller varicose veins that appear flat, less tortuous, and lue+
green in color&
o Telangiectasias ('no,n as spider veins) are very small visile vessels that appear
luish+lac', purple, or red&
The etiology of varicose veins is un'no,n and ris' factors include congenital
,ea'ness of the vein structure, female gender, use of hormones (oral contraceptives
or >?T), increasing age, oesity, pregnancy, venous ostruction resulting from
thromosis or e)trinsic pressure y tumors, or occupations that re<uire prolonged
standing&
The most common symptom of varicose veins is an ache or pain after prolonged
standing, ,hich is relieved y ,al'ing or y elevating the lim& Nocturnal leg cramps
in the calf may occur&
Treatment usually is not indicated if varicose veins are only a cosmetic prolem&
Collaorative care involves rest ,ith the affected lim elevated, compression
stoc'ings, and e)ercise, such as ,al'ing&
5n heral therapy used for the treatment of varicose veins is horse chestnut seed
e)tract&
Bclerotherapy involves the in#ection of a sustance that oliterates venous
telangiectasias, reticular veins, and small, superficial varicose veins&
Ne,er, more costly, noninvasive options for the treatment of venous telangiectasias
include laser therapy and high+intensity pulsed+light therapy&
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Key Points
Burgical intervention is indicated for recurrent thromophleitis or ,hen chronic
venous insufficiency cannot e controlled ,ith conservative therapy&
o Burgical intervention involves ligation of the entire vein (usually the greater
saphenous) and dissection and removal of its incompetent triutaries&
o 5n alternative techni<ue is amulatory phleectomy, ,hich involves pulling
the varicosity through a /sta0 incision, follo,ed y e)cision of the vein&
o Ne,er, less invasive procedures include endovenous occlusion using
radiofre<uency closure or laser, or transilluminated po,ered phleectomy&
Prevention is a 'ey factor related to varicose veins and the patient should avoid sitting
or standing for long periods of time, maintain ideal ody ,eight, ta'e precautions
against in#ury to the e)tremities, avoid ,earing constrictive clothing, and participate
in a daily ,al'ing program&
C)-$N'C 2N$5S 'NS5++'C'NC6 AND L4 5LC-S
Chronic !enous insufficienc. (C3.) is a condition in ,hich the valves in the veins are
damaged, ,hich results in retrograde venous lood flo,, pooling of lood in the legs, and
s,elling&
C3. often occurs as a result of previous episodes of =3T and can lead to venous leg
ulcers&
Causes of C3. include vein incompetence, deep vein ostruction, congenital venous
malformation, 53 fistula, and calf muscle failure&
o ;ver time, the s'in and sucutaneous tissue around the an'le are replaced y
firous tissue, resulting in thic', hardened, contracted s'in&
o The s'in of the lo,er leg is leathery, ,ith a characteristic ro,nish or /ra,ny0
appearance from the hemosiderin deposition&
o *dema and eczema, or /stasis dermatitis,0 are often present, and pruritus is a
common complaint&
3enous ulcers classically are located aove the medial malleolus&
o The ,ound margins are irregularly shaped, and the tissue is typically a ruddy
color&
o 4lcer drainage may e e)tensive, especially ,hen the leg is edematous&
o Pain is present and may e ,orse ,hen the leg is in a dependent position&
Compression is essential to the management of C3., venous ulcer healing, and
prevention of ulcer recurrence&
o ;ptions include elastic ,raps, custom+fitted compression stoc'ings, elastic
tuular support andages, a 3elcro ,rap, intermittent compression devices, a
paste andage ,ith an elastic ,rap, and multilayer (three or four) andage
systems&
o :oist environment dressings are the mainstay of ,ound care and include
transparent film dressings, hydrocolloids, hydrogels, foams, calcium alginates,
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Key Points
impregnated gauze, gauze moistened ,ith saline, and comination dressings&
o Nutritional status and inta'e should e evaluated in a patient ,ith a venous leg
ulcer&
o ?outine prophylactic antiiotic therapy typically is not indicated&
o Clinical signs of infection in a venous ulcer include change in <uantity, color, or
odor of the drainage! presence of pus! erythema of the ,ound edges! change in
sensation around the ,ound! ,armth around the ,ound! increased local pain,
edema, or oth! dar'+colored granulation tissue! induration around the ,ound!
delayed healing! and cellulitis&
The usual treatment for infection is sharp deridement, ,ound e)cision,
and systemic antiiotics&
.f the ulcer fails to respond to conservative therapy, alternative treatments
may include use of a radiant heat andage, vacuum+assisted closure
therapy, and coverage ,ith a split+thic'ness s'in graft, cultured epithelial
autograft, allograft, or ioengineered s'in&
o 5n heral therapy used for the treatment of C3. is horse chestnut seed e)tract&
2ong+term management of venous leg ulcers should focus on teaching the patient aout
self+care measures ecause the incidence of recurrence is high&
o Proper foot and leg care is essential to avoid additional trauma to the s'in&
o The patient ,ith C3. ,ith or ,ithout a venous ulcer is instructed to avoid
standing or sitting ,ith the feet dependent for long periods&
o 3enous ulcer patients are instructed to elevate their legs aove the level of the
heart to reduce edema&
;nce an ulcer is healed, a daily ,al'ing program is encouraged&
Prescription compression stoc'ings should e ,orn daily and replaced
every % to D months to reduce the occurrence of C3.&
Lewis et al: Medical-Surgical Nursing: Assessment and Management of
Clinical Problems, 7
th
edition
Key Points
Chapter $E: Nursing 5ssessment: Aastrointestinal Bystem
S,-5C,5-S AND +5NC,'$NS
The main function of the gastrointestinal (A.) system is to supply nutrients to ody cells&
The A. tract is innervated y the autonomic nervous system& The parasympathetic system
is mainly e)citatory, and the sympathetic system is mainly inhiitory&
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Key Points
The t,o types of movement of the A. tract are mi)ing %segmentation& and propulsion
%peristalsis&#
The secretions of the A. system consist of enzymes and hormones for digestion, mucus
to provide protection and lurication, ,ater, and electrolytes&
:outh:
o The mouth consists of the lips and oral (uccal) cavity&
o The main function of saliva is to luricate and soften the food mass, thus
facilitating s,allo,ing&
Pharyn): a musculomemranous tue that is divided into the nasopharyn), oropharyn),
and laryngeal pharyn)&
*sophagus:
o 5 hollo,, muscular tue that receives food from the pharyn) and moves it to the
stomach y peristaltic contractions&
o 2o,er esophageal sphincter (2*B) at the distal end remains contracted e)cept
during s,allo,ing, elching, or vomiting&
Btomach:
o The functions are to store food, mi) the food ,ith gastric secretions, and empty
contents into the small intestine at a rate at ,hich digestion can occur&
o The secretion of >Cl acid ma'es gastric #uice acidic&
o .ntrinsic factor promotes coalamin asorption in the small intestine&
Bmall intestine: t,o primary functions are digestion and absor"tion(
2arge intestine:
o The four parts are (1) the cecum and appendi)! (") the colon (ascending,
transverse, descending, sigmoid colon)! ($) the rectum! and (%) the anus&
o The most important function of the large intestine is the asorption of ,ater and
electrolytes&
2iver:
o >epatocytes are the functional unit of the liver&
o .s essential for life& .t functions in the manufacture, storage, transformation, and
e)cretion of a numer of sustances involved in metaolism&
6iliary tract:
o Consists of the gallladder and the duct system&
o 6ile is produced in the liver and stored in the gallladder& 6ile consists of
bilirubin, ,ater, cholesterol, ile salts, electrolytes, and phospholipids&
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Key Points
Pancreas:
o The e)ocrine function of the pancreas contriutes to digestion&
o The endocrine function occurs in the islets of 2angerhans, ,hose eta cells
secrete insulin! alpha cells secrete glucagon! and delta cells secrete somatostatin&
4-$N,$L$4'C C$NS'D-A,'$NS
5ging causes changes in the functional aility of the A. system&
Merostomia (decreased saliva production) or dry mouth is common&
Taste uds decrease, the sense of smell diminishes, and salivary secretions diminish,
,hich can lead to a decrease in appetite&
5lthough constipation is a common complaint of elderly patients, age+related changes in
colonic secretion or motility have not een consistently sho,n&
The liver size decreases after C8 years of age, ut liver function tests remain ,ithin
normal ranges& There is decreased aility to metaolize drugs and hormones&
ASSSSMN,
Bu#ective data:
o .mportant health information: the patient is as'ed aout adominal pain, nausea
and vomiting, diarrhea, constipation, adominal distention, #aundice, anemia,
hearturn, dyspepsia, changes in appetite, hematemesis, food intolerance or
allergies, e)cessive gas, loating, melena, hemorrhoids, or rectal leeding&
o The patient is as'ed aout (1) history or e)istence of diseases such as gastritis,
hepatitis, colitis, gallladder disease, peptic ulcer, cancer, or hernias! (") ,eight
history! ($) past and current use of medications and prior hospitalizations for A.
prolems&
o :any chemicals and drugs are potentially hepatoto)ic and result in significant
patient harm unless monitored closely&
;#ective data:
o 5nthropometric measurements (height, ,eight, s'infold thic'ness) and lood
studies (e&g&, serum protein, alumin, hemogloin) may e performed&
o Physical e)amination
:outh& The lips are inspected for symmetry, color, and size& The lips,
tongue, and uccal mucosa are oserved for lesions, ulcers, fissures, and
pigmentation&
5domen& The s'in is assessed for changes (color, te)ture, scars, striae,
dilated veins, rashes, lesions), symmetry, contour, oservale masses, and
movement&
5uscultation of the four <uadrants of the adomen includes listening for
increased or decreased o,el sounds and vascular sounds&
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Key Points
Percussion of the adomen is done to determine the presence of distention,
fluid, and masses& The nurse lightly percusses all four <uadrants of the
adomen&
2ight palpation is used to detect tenderness or cutaneous hypersensitivity,
muscular resistance, masses, and s,elling&
=eep palpation is used to delineate adominal organs and masses&
?eound tenderness indicates peritoneal inflammation&
=uring inspiration the liver edge should feel firm, sharp, and smooth& The
surface and contour and any tenderness are descried&
The spleen is normally not palpale& .f palpale, manual compression of
an enlarged spleen may cause it to rupture&
The perianal and anal areas should e inspected for color, te)ture, lumps,
rashes, scars, erythema, fissures, and e)ternal hemorrhoids&
D'A4N$S,'C S,5D'S
:any of the diagnostic procedures of the A. system re<uire measures to cleanse the A.
tract, as ,ell as the use of a contrast medium or a radiopa<ue tracer&
5n upper A. series ,ith small o,el follo,+through provides visualization of the
esophagus, stomach, and small intestine&
5 lo,er A. series (arium enema) )+ray e)amination is done to detect anormalities in
the colon&
4ltrasonography is used to sho, the size and configuration of organs&
3irtual colonoscopy comines computed tomography (CT) scanning or magnetic
resonance imaging (:?.)&
ndosco". refers to the direct visualization of a ody structure through a lighted
fieroptic instrument&
?etrograde cholangiopancreatography (*?CP) is an endoscopic procedure that visualizes
the pancreatic, hepatic, and common ile ducts&
*ndoscopy of the A. tract is often done ,ith iopsy and cytologic studies& 5 complication
of A. endoscopy is perforation&
Capsule endoscopy is a noninvasive approach to visualize the A. tract&
2iver iopsy is performed to otain tissue for diagnosis of firosis, cirrhosis, and
neoplasms&
2iver function tests reflect hepatic disease and function&
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Key Points
Lewis et al: Medical-Surgical Nursing: Assessment and Management of
Clinical Problems, 7
th
edition
Key Points
Chapter %8: Nursing :anagement: Nutritional Prolems
Aood nutrition in the asence of any underlying disease process results from the
ingestion of a alanced diet&
The :yPyramid (formerly the @ood Auide Pyramid) consists of food groups that are
presented in proportions appropriate for a healthy diet, including grains, vegetales,
fruits, oils, mil', and meat and eans&
The National ?esearch Council recommends that at least half of the ody(s energy needs
should come from carohydrates, especially comple) carohydrates&
The =ietary Auidelines for 5mericans "88C from Healthy People '()( recommends that
people reduce their fat inta'e to "8K to $CK of their total daily caloric inta'e&
5n average adult re<uires an estimated "8 to $C calories per 'ilogram of ody ,eight per
day, leaning to,ard the higher end if the person is critically ill or very active and the
lo,er end if the person is sedentary&
The recommended daily protein inta'e is 8&F to 1 g1'g of ody ,eight&
3egetarians can have vitamin or protein deficiencies unless their diets are ,ell planned&
Culture, personal preferences, socioeconomic status, and religious preferences can
influence food choices&
The nurse should include cultural and ethnic considerations ,hen assessing the patient(s
diet history and implementing interventions that re<uire dietary changes&
MALN5,-','$N
Malnutrition is common in hospitalized patients&
-ith starvation, the ody initially uses carohydrates (glycogen) rather than fat and
protein to meet metaolic needs& ;nce carohydrate stores are depleted, protein egins to
e converted to glucose for energy&
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Key Points
@actors that contriute to malnutrition include socioeconomic status, cultural influences,
psychologic disorders, medical conditions, and medical treatments&
?egardless of the cause of the illness, most sic' persons have increased nutritional needs&
*ach degree of temperature increase on the @ahrenheit scale raises the asal metaolic
rate (6:?) y aout 9K&
Prolonged illness, ma#or surgery, sepsis, draining ,ounds, urns, hemorrhage, fractures,
and immoilization can all contriute to malnutrition&
;n physical e)amination, the most ovious clinical signs of inade<uate protein and
calorie inta'e are apparent in the s'in, eyes, mouth, muscles, and the central nervous
system&
The malnourished person is more susceptile to all types of infection&
5cross all settings of care delivery, the nurse must e a,are of the nutritional status of
the patient&
The protein and calorie inta'e re<uired in the malnourished patient depends on the cause
of the malnutrition, the treatment eing employed, and other stressors affecting the
patient&
The older patient is at ris' for nutritional prolems due to the follo,ing factors:
o Changes in the oral cavity
o Changes in digestion and motility
o Changes in the endocrine system
o Changes in the musculos'eletal system
o =ecreases in vision and hearing
>igh+calorie oral supplements may e used in the patient ,hose nutritional inta'e is
deficient&
,5/ +D'N4S
,ube feeding (also 'no,n as enteral nutrition) may e ordered for the patient ,ho has a
functioning A. tract ut is unale to ta'e any or enough oral nourishment&
5 gastrostomy tue may e used for a patient ,ho re<uires tue feedings over an
e)tended time&
The most accurate assessment for correct tue placement is y )+ray visualization&
PA-N,-AL N5,-','$N
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Key Points
Parenteral nutrition (PN) is used to meet the patient(s nutritional needs and to allo,
gro,th of ne, ody tissue&
5ll parenteral nutrition solutions should e prepared y a pharmacist or a trained
technician using strict aseptic techni<ues under a laminar flo, hood&
Complications of parenteral nutrition include infectious, metaolic, and mechanical
prolems&
&
Lewis et al: Medical-Surgical Nursing: Assessment and Management of
Clinical Problems, 7
th
edition
Key Points
C>5PT*? %1: N4?B.NA :5N5A*:*NT: ;6*B.TW
$/S',6
$besit. is the most common nutritional prolem, affecting almost one third of the
population&
5ppro)imately 1$K of 5mericans have a bod. mass inde1 (6:.) greater than $C 'g1m
"
&
;esity is the second leading cause of preventale disease in the 4nited Btates, after
smo'ing&
The cause of oesity involves significant genetic1iologic susceptiility factors that are
highly influenced y environmental and psychosocial factors&
The degree to ,hich a patient is classified as under,eight, healthy (normal) ,eight,
o!erweight, or obese is assessed y using a 6:. chart&
.ndividuals ,ith fat located primarily in the adominal area (apple+shaped ody) are at a
greater ris' for oesity+related complications than those ,hose fat is primarily located in
the upper legs (pear+shaped ody)&
Complications or ris' factors related to oesity include the follo,ing:
o Cardiovascular disease in oth men and ,omen
o Bevere oesity may e associated ,ith sleep apnea and oesity1hypoventilation
syndrome&
o Type " diaetes mellitus! as many as F8K of patients ,ith type " diaetes are
oese
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Key Points
o ;steoarthritis, proaly ecause of the trauma to the ,eight+earing #oints and
gout
o Aastroesophageal reflu) disease (A*?=), gallstones, and nonalcoholic
steatohepatitis (N5B>)
o 6reast, endometrial, ovarian, and cervical cancer is increased in oese ,omen
-hen patients ,ho are oese have surgery, they are li'ely to suffer from other
comoridities, including diaetes, altered cardiorespiratory function, anormal metaolic
function, hemostasis, and atherosclerosis that place them at ris' for complications related
to surgery&
:easurements used ,ith the oese person may include s'infold thic'ness, height, ,eight,
and 6:.&
The overall goals for the oese patient include the follo,ing:
o :odifying eating patterns
o Participating in a regular physical activity program
o 5chieving ,eight loss to a specified level
o :aintaining ,eight loss at a specified level
o :inimizing or preventing health prolems related to oesity
;esity is considered a chronic condition that necessitates day+to+day attention to lose
,eight and maintain ,eight loss&
Persons on lo,+calorie and very+lo,+calorie diets need fre<uent professional monitoring
ecause the severe energy restriction places them at ris' for multiple nutrient
deficiencies&
?estricted food inta'e is a cornerstone for any ,eight loss or maintenance program&
:otivation is an essential ingredient for successful achievement of ,eight loss&
*)ercise is an important part of a ,eight control program& *)ercise should e done daily,
preferaly $8 minutes to an hour a day&
4seful asic techni<ues for ehavioral modification include self+monitoring, stimulus
control, and re,ards&
=rugs approved for ,eight loss can e classified into t,o categories, including those that
decrease the follo,ing:
o @ood inta'e y reducing appetite or increasing satiety (sense of feeling full after
eating)
o Nutrient asorption
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Key Points
/ariatric surger. is currently the only treatment that has een found to have a successful
and lasting impact for sustained ,eight loss for severely oese individuals&
o -ound infection is one of the most common complications after surgery&
o *arly amulation follo,ing surgery is important for the oese patient&
o 2ate complications follo,ing ariatric surgery include anemia, vitamin
deficiencies, diarrhea, and psychiatric prolems&
;esity in older adults can e)acerate age+related declines in physical function and lead
to frailty and disaility&
M,A/$L'C S6ND-$M
Metabolic s.ndrome is a collection of ris' factors that increase an individual(s chance of
developing cardiovascular disease and diaetes mellitus&
2ifestyle therapies are the first+line interventions to reduce the ris' factors for metaolic
syndrome&
Lewis et al: Medical-Surgical Nursing: Assessment and Management of
Clinical Problems, 7
th
edition
Key Points
Chapter %": Nursing :anagement: 4pper Aastrointestinal Prolems
NA5SA AND 2$M','N4
Nausea and !omiting are found in a ,ide variety of gastrointestinal (A.) disorders&
They are also found in conditions that are unrelated to A. disease, including pregnancy,
infectious diseases, central nervous system (CNB) disorders (e&g&, meningitis),
cardiovascular prolems (e&g&, myocardial infarction), metaolic disorders (e&g&, diaetes
mellitus), side effects of drugs (e&g&, chemotherapy, opioids), and psychologic factors
(e&g&, fear)&
3omiting can occur ,hen the A. tract ecomes overly irritated, e)cited, or distended&
o .t can e a protective mechanism to rid the ody of spoiled or irritating foods and
li<uids&
o Pulmonary aspiration is a concern ,hen vomiting occurs in the patient ,ho is
elderly, is unconscious, or has other conditions that impair the gag refle)&
o The color of the emesis aids in identifying the presence and source of leeding&
=rugs that control nausea and vomiting include anticholinergics (e&g&, scopolamine),
antihistamines (e&g&, promethazine HPhenerganI), phenothiazines (e&g&, chlorpromazine
Copyright 7 "889 y :osy, .nc&, an affiliate of *lsevier .nc&
1+1CC
Key Points
HThorazineI, prochlorperazine HCompazineI), and utyrophenones (e&g&, droperidol
H.napsineI)&
The patient ,ith severe or prolonged vomiting is at ris' for dehydration and acid+ase
and electrolyte imalances& The patient may re<uire intravenous (.3) fluid therapy ,ith
electrolyte and glucose replacement until ale to tolerate oral inta'e&
5""er 4astrointestinal /leeding
The mortality rate for upper A. leeding remains at DK to 18K despite advances in
intensive care, hemodynamic monitoring, and endoscopy&
The severity of leeding depends on ,hether the origin is venous, capillary, or arterial&
6leeding ulcers account for C8K of the cases of upper A. leeding&
=rugs such as aspirin, nonsteroidal antiinflammatory agents, and corticosteroids are a
ma#or cause of upper A. leeding&
5lthough appro)imately F8K to FCK of patients ,ho have massive hemorrhage
spontaneously stop leeding, the cause must e identified and treatment initiated
immediately&
The immediate physical e)amination includes a systemic evaluation of the patient(s
condition ,ith emphasis on lood pressure, rate and character of pulse, peripheral
perfusion ,ith capillary refill, and oservation for the presence or asence of nec' vein
distention& 3ital signs are monitored every 1C to $8 minutes&
The goal of endoscopic hemostasis is to coagulate or thromose the leeding artery&
Beveral techni<ues are used including thermal (heat) proe, multipolar and ipolar
electrocoagulation proe, argon plasma coagulation, and neodymium:yttrium+aluminum+
garnet (Nd:W5A) laser&
The patient undergoing vasopressin therapy is closely monitored for its myocardial,
visceral, and peripheral ischemic side effects&
The nursing assessment for the patient ,ith upper A. leeding includes the patient(s level
of consciousness, vital signs, appearance of nec' veins, s'in color, and capillary refill&
The adomen is chec'ed for distention, guarding, and peristalsis&
The patient ,ho re<uires regular administration of ulcerogenic drugs, such as aspirin,
corticosteroids, or NB5.=s, needs instruction regarding the potential adverse effects
related to A. leeding&
=uring the acute leeding phase an accurate inta'e and output record is essential so that
the patient(s hydration status can e assessed&
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Key Points
;nce fluid replacement has een initiated, the older adult or the patient ,ith a history of
cardiovascular prolems is oserved closely for signs of fluid overload&
The ma#ority of upper A. leeding episodes cease spontaneously, even ,ithout
intervention&
:onitoring the patient(s laoratory studies enales the nurse to estimate the effectiveness
of therapy&
The patient and family are taught ho, to avoid future leeding episodes& 4lcer disease,
drug or alcohol ause, and liver and respiratory diseases can all result in upper A.
leeding&
$ral 'nfections and 'nflammations
:ay e specific mouth diseases, or they may occur in the presence of systemic disorders
such as leu'emia or vitamin deficiency&
The patient ,ho is immunosuppressed (e&g&, patient ,ith ac<uired immunodeficiency
syndrome or receiving chemotherapy) is most susceptile to oral infections& The patient
on oral corticosteroid inhaler treatment for asthma is also at ris'&
:anagement of oral infections and inflammation is focused on identification of the
cause, elimination of infection, provision of comfort measures, and maintenance of
nutritional inta'e&
$ral %or $ro"har.ngeal& Cancer
:ay occur on the lips or any,here ,ithin the mouth (e&g&, tongue, floor of the mouth,
uccal mucosa, hard palate, soft palate, pharyngeal ,alls, tonsils)&
>ead and nec' s<uamous cell carcinoma is an umrella term for cancers of the oral
cavity, pharyn), and laryn)& 5ccounts for E8K of malignant oral tumors&
The overall goals are that the patient ,ith carcinoma of the oral cavity ,ill (1) have a
patent air,ay, (") e ale to communicate, ($) have ade<uate nutritional inta'e to
promote ,ound healing, and (%) have relief of pain and discomfort&
4AS,-$S$P)A4AL -+L58 D'SAS %4-D&
There is no one single cause of gastroeso"hageal reflu1 disease (A*?=)& .t can occur
,hen there is reflu) of acidic gastric contents into the esophagus&
Predisposing conditions include hiatal hernia, incompetent lo,er esophageal sphincter,
decreased esophageal clearance (aility to clear li<uids or food from the esophagus into
the stomach) resulting from impaired esophageal motility, and decreased gastric
emptying&
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1+1C9
Key Points
5 complication of A*?= is /arrett<s eso"hagus (esophageal metaplasia), ,hich is
considered a precancerous lesion that increases the patient(s ris' for esophageal cancer&
:ost patients ,ith A*?= can e successfully managed y lifestyle modifications and
drug therapy&
=rug therapy for A*?= is focused on improving 2*B function, increasing esophageal
clearance, decreasing volume and acidity of reflu), and protecting the esophageal
mucosa&
6ecause of the lin' et,een A*?= and 6arrett(s esophagus, patients are instructed to see
their health care provider if symptoms persist&
)'A,AL )-N'A
The t,o most common types of hiatal hernia are sliding and paraesophageal (rolling)&
@actors that predispose to hiatal hernia development include increased intraadominal
pressure, including oesity, pregnancy, ascites, tumors, tight girdles, intense physical
e)ertion, and heavy lifting on a continual asis& ;ther factors are increased age, trauma,
poor nutrition, and a forced recument position (e&g&, prolonged ed rest)&
so"hageal Cancer
T,o important ris' factors for eso"hageal cancer are smo'ing and e)cessive alcohol
inta'e&
4astritis
4astritis occurs as the result of a rea'do,n in the normal gastric mucosal arrier&
=rugs such as aspirin, nonsteroidal antiinflammatory drugs (NB5.=s), digitalis, and
alendronate (@osama)) have direct irritating effects on the gastric mucosa& =ietary
indiscretions can also result in acute gastritis&
The symptoms of acute gastritis include anore)ia, nausea and vomiting, epigastric
tenderness, and a feeling of fullness&
Pe"tic 5lcer Disease
Aastric and duodenal ulcers, although defined as "e"tic ulcer disease (P4=), are
different in their etiology and incidence&
=uodenal ulcers are more common than gastric ulcers&
The organism Helicobacter pylori is found in the ma#ority of patients ,ith P4=&
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5lcohol, nicotine, and drugs such as aspirin and nonsteroidal antiinflammatory drugs
play a role in gastric ulcer development&
The three ma#or complications of chronic P4= are hemorrhage, perforation, and gastric
outlet ostruction& 5ll are considered emergency situations and are initially treated
conservatively&
*ndoscopy is the most commonly used procedure for diagnosis of P4=&
Treatment of P4= includes ade<uate rest, dietary modifications, drug therapy,
elimination of smo'ing, and long+term follo,+up care& The aim is to decrease gastric
acidity, enhance mucosal defense mechanisms, and minimize the harmful effects on the
mucosa&
The drugs most commonly used to treat P4= are histamine (>
"
)+receptor loc'ers,
proton pump inhiitors, and antacids& 5ntiiotics are employed to eradicate H# pylori
infection&
The immediate focus of management of a patient ,ith a perforation is to stop the spillage
of gastric or duodenal contents into the peritoneal cavity and restore lood volume&
The aim of therapy for gastric outlet ostruction is to decompress the stomach, correct
any e)isting fluid and electrolyte imalances, and improve the patient(s general state of
health&
;verall goals for the patient ,ith P4= include compliance ,ith the prescried
therapeutic regimen, reduction or asence of discomfort, no signs of A. complications,
healing of the ulcer, and appropriate lifestyle changes to prevent recurrence&
Burgical procedures for P4= include partial gastrectomy, vagotomy, and1or pyloroplasty&
S,$MAC) Cancer
Btomach (gastric) cancers often spread to ad#acent organs efore any distressing
symptoms occur&
The nursing role in the early detection of stomach cancer is focused on identification of
the patient at ris' ecause of specific disorders such as pernicious anemia and
achlorhydria&
-. coli $?C7:)7$?C7:)7
.t is the organism most commonly associated ,ith food+orne illness&
.t is found primarily in undercoo'ed meats, such as hamurger, roast eef, ham, and
tur'ey&
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Key Points
Lewis et al: Medical-Surgical Nursing: Assessment and Management of
Clinical Problems, 7
th
edition
Key Points
Chapter %$: Nursing :anagement: 2o,er Aastrointestinal Prolems
Diarrhea
Diarrhea is most commonly defined as an increase in stool fre<uency or volume, and an increase in the
looseness of stool&
=iarrhea can result from alterations in gastrointestinal motility, increased secretion, and
decreased asorption&
5ll cases of acute diarrhea should e considered infectious until the cause is 'no,n&
Patients receiving antiiotics (e&g&, clindamycin HCleocinI, ampicillin, amo)icillin,
cephalosporin) are susceptile to Clostridium difficile %C# difficile&, ,hich is a serious
acterial infection&
+ecal 'ncontinence
+ecal incontinence, the involuntary passage of stool, occurs ,hen the normal structures
that maintain continence are disrupted&
?is' factors include constipation, diarrhea, ostetric trauma, and fecal impaction&
Prevention and treatment of fecal incontinence may e managed y implementing a
o,el training program&
C$NS,'PA,'$N
Consti"ation can e defined as a decrease in the fre<uency of o,el movements from
,hat is /normal0 for the individual! hard, difficult+to+pass stools! a decrease in stool
volume! and1or retention of feces in the rectum&
The overall goals are that the patient ,ith constipation is to increase dietary inta'e of
fier and fluids! increase physical activity! have the passage of soft, formed stools! and
not have any complications, such as leeding hemorrhoids&
5n important role of the nurse is teaching the patient the importance of dietary measures
to prevent constipation&
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Abdominal Pain, ,rauma, and 'nflammator. Disorders
5cute adominal pain is a symptom of many different types of tissue in#ury and can arise
from damage to adominal or pelvic organs and lood vessels&
Pain is the most common symptom of an acute adominal prolem&
The goal of management of the patient ,ith acute adominal pain is to identify and treat
the cause and monitor and treat complications, especially shoc'&
6o,el sounds that are diminished or asent in a <uadrant may indicate a complete o,el
ostruction, acute peritonitis, or paralytic ileus&
*)pected outcomes for the patient ,ith acute adominal pain include resolution of the
cause of the acute adominal pain! relief of adominal pain and discomfort! freedom
from complications (especially hypovolemic shoc' and septicemia)! and normal fluid,
electrolyte, and nutritional status&
Common causes of chronic adominal pain include irritable bowel s.ndrome (.6B),
diverticulitis, peptic ulcer disease, chronic pancreatitis, hepatitis, cholecystitis, pelvic
inflammatory disease, and vascular insufficiency&
The adominal pain or discomfort associated ,ith .6B is most li'ely due to increased
visceral sensitivity&
Abdominal ,rauma
6lunt trauma commonly occurs ,ith motor vehicle accidents and falls and may not e
ovious ecause it does not leave an open ,ound&
Common in#uries of the adomen include lacerated liver, ruptured spleen, pancreatic
trauma, mesenteric artery tears, diaphragm rupture, urinary ladder rupture, great vessel
tears, renal in#ury, and stomach or intestine rupture&
A""endicitis
A""endicitis results in distention, venous engorgement, and the accumulation of mucus
and acteria, ,hich can lead to gangrene and perforation&
5ppendicitis typically egins ,ith periumilical pain, follo,ed y anore)ia, nausea, and
vomiting& The pain is persistent and continuous, eventually shifting to the right lo,er
<uadrant and localizing at :c6urney(s point&
4ntil a health care provider sees the patient, nothing should e ta'en y mouth (NP;) to
ensure that the stomach is empty in the event that surgery is needed&
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Peritonitis
Peritonitis results from a localized or generalized inflammatory process of the
peritoneum&
5ssessment of the patient(s adominal pain, including the location, is important and may
help in determining the cause of peritonitis&
4astroenteritis
4astroenteritis is an inflammation of the mucosa of the stomach and small intestine&
Clinical manifestations include nausea, vomiting, diarrhea, adominal cramping, and distention& :ost cases
are self+limiting and do not re<uire hospitalization&
.f the causative agent is identified, appropriate antiiotic and antimicroial drugs are given&
Bymptomatic nursing care is given for nausea, vomiting, and diarrhea&
'nflammator. /owel Disease
Crohn<s disease and ulcerati!e colitis are immunologically related disorders that are
referred to as inflammator. bowel disease (.6=)&
.6= is characterized y mild to severe acute e)acerations that occur at unpredictale intervals over many
years&
4lcerative colitis usually starts in the rectum and moves in a continual fashion to,ard the
cecum& 5lthough there is sometimes mild inflammation in the terminal ileum, ulcerative
colitis is a disease of the colon and rectum&
Crohn(s disease can occur any,here in the A. tract from the mouth to the anus, ut
occurs most commonly in the terminal ileum and colon& The inflammation involves all
layers of the o,el ,all ,ith segments of normal o,el occurring et,een diseased
portions, the so+called /s'ip lesions&0
-ith Crohn(s disease, diarrhea and colic'y adominal pain are common symptoms& .f the small intestine is
involved, ,eight loss occurs due to malasorption& .n addition, patients may have systemic symptoms such
as fever& The primary symptoms of ulcerative colitis are loody diarrhea and adominal pain&
The goals of treatment for .6= include rest the o,el, control the inflammation, comat infection, correct
malnutrition, alleviate stress, provide symptomatic relief, and improve <uality of life&
Nutritional prolems are especially common ,ith Crohn(s disease ,hen the terminal
ileum is involved&
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The follo,ing five ma#or classes of medications are used to treat .6=:
o 5minosalicylates
o 5ntimicroials
o Corticosteroids
o .mmunosuppressants
o 6iologic therapy
Burgery is indicated if the patient ,ith .6= fails to respond to treatment! e)acerations
are fre<uent and deilitating! massive leeding, perforation, strictures, and1or ostruction
occur! tissue changes suggest that dysplasia is occurring! or carcinoma develops&
=uring an acute e)aceration of .6=, nursing care is focused on hemodynamic staility,
pain control, fluid and electrolyte alance, and nutritional support&
Nurses and other team memers can assist patients to accept the chronicity of .6= and
learn strategies to cope ,ith its recurrent, unpredictale nature&
'ntestinal $bstruction
The causes of intestinal obstruction can e classified as mechanical or nonmechanical&
.ntestinal ostruction can e a life+threatening prolem&
Cancer is the most common cause of large o,el ostruction, follo,ed y volvulus and
diverticular disease&
*mergency surgery is performed if the o,el is strangulated, ut many o,el
ostructions resolve ,ith conservative treatment&
-ith a o,el ostruction, there is retention of fluid in the intestine and peritoneal cavity,
,hich can result in a severe reduction in circulating lood volume and lead to
hypotension and hypovolemic shoc'&
Pol."s
5denomatous polyps are characterized y neoplastic changes in the epithelium and are
closely lin'ed to colorectal adenocarcinoma&
@amilial adenomatous polyposis (@5P) is the most common hereditary polyp disease&
Colorectal Cancer
Colorectal cancer is the third most common form of cancer and the second leading cause
of cancer+related deaths in the 4nited Btates&
:ost people ,ith colorectal cancer have hematochezia (passage of lood through rectum)
or melena (lac', tarry stools), adominal pain, and1or changes in o,el haits&
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Key Points
The 5merican Cancer Bociety recommends that a person ,ho has no estalished ris'
factors should have a fecal occult lood test (@;6T) or a fecal immunochemical test
(@.T) yearly, a doule+contrast enema every C years, a sigmoidoscopy every C years, or a
colonoscopy every 18 years starting at age C8&
Colonoscopy is the gold standard for colorectal cancer screening&
Burgery for a rectal cancer may include an adominal+perineal resection& Potential
complications of adominal+perineal resection include delayed ,ound healing,
hemorrhage, persistent perineal sinus tracts, infections, and urinary tract and se)ual
dysfunctions&
Chemotherapy is used oth as an ad#uvant therapy follo,ing colon resection and as
primary treatment for nonresectale colorectal cancer&
The goals for the patient ,ith colorectal cancer include normal o,el elimination
patterns, <uality of life appropriate to disease progression, relief of pain, and feelings of
comfort and ,ell+eing&
Psychologic support for the patient ,ith colorectal cancer and family is important& The
recovery period is long, and the cancer could return&
5n ostom. is used ,hen the normal elimination route is no longer possile&
The t,o ma#or aspects of nursing care for the patient undergoing ostomy surgery are (1)
emotional support as the patient copes ,ith a radical change in ody image, and (")
patient teaching aout the many aspects of stoma care and the ostomy&
6o,el preparations are used to empty the intestines efore surgery to decrease the chance
of a postoperative infection caused y acteria in the feces&
Postoperative nursing care includes assessment of the stoma and provision of an
appropriate pouching system that protects the s'in and contains drainage and odor&
The patient should e ale to perform a pouch change, provide appropriate s'in care,
control odor, care for the stoma, and identify signs and symptoms of complications&
Colostomy irrigations are used to stimulate emptying of the colon in order to achieve a
regular o,el pattern& .f control is achieved, there should e little or no spillage et,een
irrigations&
The patient ,ith an ileostom. should e oserved for signs and symptoms of fluid and
electrolyte imalance, particularly potassium, sodium, and fluid deficits&
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6o,el surgery can disrupt nerve and vascular supply to the genitals& ?adiation therapy,
chemotherapy, and medications can also alter se)ual function&
Concerns of people ,ith stomas include the aility to resume se)ual activity, altering
clothing styles, the effect on daily activities, sleeping ,hile ,earing a pouch, passing gas,
the presence of odor, cleanliness, and deciding ,hen or if to tell others aout the stoma&
Di!erticular Disease
=iverticular disease covers a spectrum from asymptomatic, uncomplicated diverticulosis
to diverticulitis ,ith complications such as perforation, ascess, fistula, and leeding&
=iverticular disease is a common disorder that affects CK of the 4&B& population y age
%8 years and C8K y age F8 years&
The ma#ority of patients ,ith diverticular disease are asymptomatic&
Bymptomatic diverticular disease can e further ro'en do,n into the follo,ing:
o Painful diverticular disease
o =iverticulitis (inflammation of the diverticuli)
Complications of diverticulitis include perforation ,ith peritonitis&
5 high+fier diet, mainly from fruits and vegetales, and decreased inta'e of fat and red
meat are recommended for preventing diverticular disease&
)-N'A
5 hernia is a protrusion of a viscus through an anormal opening or a ,ea'ened area in
the ,all of the cavity in ,hich it is normally contained&
.f the hernia ecomes strangulated, the patient ,ill e)perience severe pain and symptoms
of a o,el ostruction, such as vomiting, cramping adominal pain, and distention&
MALA/S$-P,'$N S6ND-$M
:alasorption results from impaired asorption of fats, carohydrates, proteins, minerals,
and vitamins&
Causes of malasorption include the follo,ing:
o 6iochemical or enzyme deficiencies
o 6acterial proliferation
o =isruption of small intestine mucosa
o =istured lymphatic and vascular circulation
o Burface area loss
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Key Points
Celiac Disease
Three factors necessary for the development of celiac disease (gluten intolerance) are
genetic predisposition, gluten ingestion, and an immune+mediated response&
*arly diagnosis and treatment of celiac disease can prevent complications such as cancer
(e&g&, intestinal lymphoma), osteoporosis, and possily other autoimmune diseases&
Celiac disease is treated ,ith lifelong avoidance of dietary gluten& -heat, arley, oats,
and rye products must e avoided&
LAC,AS D+'C'NC6
The symptoms of lactose intolerance include loating, flatulence, cramping adominal
pain, and diarrhea& They usually occur ,ithin $8 minutes to several hours after drin'ing a
glass of mil' or ingesting a mil' product&
Treatment consists of eliminating lactose from the diet y avoiding mil' and mil'
products and1or replacement of lactase ,ith commercially availale preparations&
$ther Lower 4' Disorders
Short bowel s.ndrome (B6B) results from surgical resection, congenital defect, or disease+related loss of
asorption&
o B6B is characterized y failure to maintain protein+energy, fluid, electrolyte and micronutrient
alances on a standard diet&
o The length and portions of small o,el resected are associated ,ith the numer and severity
of symptoms& Bhort o,el syndrome is characterized y failure to maintain protein+energy,
fluid, electrolyte, and micronutrient alances on a standard diet&
)emorrhoids are dilated hemorrhoidal veins& They may e internal (occurring aove the
internal sphincter) or e"ternal (occurring outside the e)ternal sphincter)& Nursing
management for the patient ,ith hemorrhoids includes teaching measures to prevent
constipation, avoidance of prolonged standing or sitting, proper use of over+the+counter
(;TC) drugs, and the need to see' medical care for severe symptoms of hemorrhoids
(e&g&, e)cessive pain and leeding, prolapsed hemorrhoids) ,hen necessary&
5n anal fissure is a s'in ulcer or a crac' in the lining of the anal ,all that is caused y
trauma, local infection, or inflammation&
5 "ilonidal sinus is a small tract under the s'in et,een the uttoc's in the
sacrococcygeal area& Nursing care for the patient ,ith a pilonidal cyst or ascess includes
,arm, moist heat applications&
Lewis et al: Medical-Surgical Nursing: Assessment and Management of
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Key Points
Clinical Problems, 7
th
edition
Key Points
Chapter %%: Nursing :anagement: 2iver, Pancreas, and 6iliary Tract Prolems
BA5ND'C
Baundice, a yello,ish discoloration of ody tissues, results from an alteration in normal
iliruin metaolism or flo, of ile into the hepatic or iliary duct systems&
The three types of #aundice are hemolytic, hepatocellular, and ostructive&
o >emolytic (prehepatic) #aundice is due to an increased rea'do,n of red lood
cells (?6Cs), ,hich produces an increased amount of uncon#ugated iliruin in
the lood&
o >epatocellular (hepatic) #aundice results from the liver(s altered aility to ta'e up
iliruin from the lood or to con#ugate or e)crete it&
o ;structive (posthepatic) #aundice is due to decreased or ostructed flo, of ile
through the liver or iliary duct system&
)PA,','S
)e"atitis is an inflammation of the liver& 3iral hepatitis is the most common cause of
hepatitis& The types of viral hepatitis are 5, 6, C, =, *, and A&
Hepatitis A
o >53 is an ?N5 virus that is transmitted through the fecal+oral route&
o The mode of transmission of >53 is mainly transmitted y ingestion of food or
li<uid infected ,ith the virus and rarely parenteral&
Hepatitis B
o >63 is a =N5 virus that is transmitted perinatally y mothers infected ,ith
>63! percutaneously (e&g&, .3 drug use)! or horizontally y mucosal e)posure to
infectious lood, lood products, or other ody fluids&
o >63 is a comple) structure ,ith three distinct antigens: the surface antigen
(>6s5g), the core antigen (>6c5g), and the e antigen (>6e5g)&
o 5ppro)imately DK of those infected ,hen older than age C develop chronic >63&
Hepatitis "
o >C3 is an ?N5 virus that is primarily transmitted percutaneously&
o The most common mode of >C3 transmission is the sharing of contaminated
needles and paraphernalia among .3 drug users&
o There are D genotypes and more than C8 sutypes of >C3&
Hepatitis D, -, /
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Key Points
o >epatitis = virus (>=3) is an ?N5 virus that cannot survive on its o,n& .t
re<uires >63 to replicate&
o >epatitis * virus (>*3) is an ?N5 virus that is transmitted y the fecal+oral
route&
o >epatitis A virus (>A3) is a se)ually transmitted virus& >A3 coe)ists ,ith other
viral infections, including >63, >C3, and >.3&
Clinical manifestations:
o :any patients ,ith hepatitis have no symptoms&
o Bymptoms of the acute phase include malaise, anore)ia, fatigue, nausea,
occasional vomiting, and adominal (right upper <uadrant) discomfort& Physical
e)amination may reveal hepatomegaly, lymphadenopathy, and sometimes
splenomegaly&
:any >63 infections and the ma#ority of >C3 infections result in chronic (lifelong)
viral infection&
:ost patients ,ith acute viral hepatitis recover completely ,ith no complications&
5ppro)imately 9CK to FCK of patients ,ho ac<uire >C3 ,ill go on to develop chronic
infection&
@ulminant viral hepatitis results in severe impairment or necrosis of liver cells and
potential liver failure&
There is no specific treatment or therapy for acute viral hepatitis&
=rug therapy for chronic >63 and >6C is focused on decreasing the viral load, aspartate
aminotransferase (5BT) and aspartate aminotransferase (52T) levels, and the rate of
disease progression&
o Chronic >63 drugs include interferon, lamivudine (*pivir), adefovir (>epsera),
entecavir (6araclude), and telivudine (Tyze'a)&
o Treatment for >C3 includes pegylated +interferon (Peg+.ntron, Pegasys) given
,ith riavirin (?eetol, Copegus)&
6oth hepatitis 5 vaccine and immune gloulin (.A) are used for prevention of hepatitis 5&
.mmunization ,ith >63 vaccine is the most effective method of preventing >63
infection& @or poste)posure prophyla)is, the vaccine and hepatitis 6 immune gloulin
(>6.A) are used&
Currently there is no vaccine to prevent >C3&
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:ost patients ,ith viral hepatitis ,ill e cared for at home, so the nurse must assess the
patient(s 'no,ledge of nutrition and provide the necessary dietary teaching&
A5,$'MM5N )PA,','S
5utoimmune hepatitis is a chronic inflammatory disorder of un'no,n cause& .t is
characterized y the presence of autoantiodies, high levels of serum immunogloulins,
and fre<uent association ,ith other autoimmune diseases&
5utoimmune hepatitis (in ,hich there is evidence of necrosis and cirrhosis) is treated
,ith corticosteroids or other immunosuppressive agents&
7'LS$N<S D'SAS
7ilson<s disease is a progressive, familial, terminal neurologic disease accompanied y
chronic liver disease leading to cirrhosis&
.t is associated ,ith increased storage of copper&
P-'MA-6 /'L'A-6 C'--)$S'S
Primary iliary cirrhosis (P6C) is characterized y generalized pruritus, hepatomegaly,
and hyperpigmentation of the s'in&
N$NALC$)$L'C +A,,6 L'2- D'SAS
Nonalcoholic fatt. li!er disease (N5@2=) is a group of disorders that is characterized
y hepatic steatosis (accumulation of fat in the liver) that is not associated ,ith other
causes such as hepatitis, autoimmune disease, or alcohol&
The ris' for developing N5@2= is a ma#or complication of oesity& N5@2= can progress
to liver cirrhosis&
N5@2= should e considered in patients ,ith ris' factors such as oesity, diaetes,
hypertriglyceridemia, severe ,eight loss (especially in those ,hose ,eight loss ,as
recent), and syndromes associated ,ith insulin resistance&
C'--)$S'S
Cirrhosis is a chronic progressive disease characterized y e)tensive degeneration and
destruction of the liver parenchymal cells&
Common causes of cirrhosis include alcohol, malnutrition, hepatitis, iliary ostruction,
and right+sided heart failure& *)cessive alcohol ingestion is the single most common
cause of cirrhosis follo,ed y chronic hepatitis (6 and C)&
:anifestations of cirrhosis include #aundice, s'in lesions (s"ider angiomas),
hematologic prolems (thromocytopenia, leucopenia, anemia, coagulation disorders),
endocrine prolems, and peripheral neuropathy&
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:a#or complications of cirrhosis include "ortal h."ertension, eso"hageal and gastric
!arices, peripheral edema and ascites, hepatic encephalopathy, and he"atorenal
s.ndrome(
o )e"atic ence"halo"ath. is a neuropsychiatric manifestation of liver damage& .t
is considered a terminal complication in liver disease&
o 5 characteristic symptom of hepatic encephalopathy is asteri1is (flapping
tremors)&
=iagnostic tests for cirrhosis include elevations in liver enzymes, decreased total protein,
fat metaolism anormalities, and liver iopsy&
There is no specific therapy for cirrhosis& :anagement of ascites is focused on sodium
restriction, diuretics, and fluid removal&
o Peritoneovenous shunt is a surgical procedure that provides continuous reinfusion
of ascitic fluid into the venous system&
o The main therapeutic goal for esophageal and gastric varices is avoidance of
leeding and hemorrhage&
o Trans#ugular intrahepatic portosystemic shunt (T.PB) is a nonsurgical procedure
in ,hich a tract (shunt) et,een the systemic and portal venous systems is created
to redirect portal lood flo,&
o :anagement of hepatic encephalopathy is focused on reducing ammonia
formation and treating precipitating causes&
5n important nursing focus is the prevention and early treatment of cirrhosis&
.f the patient has esophageal and1or gastric varices in addition to cirrhosis, the nurse
oserves for any signs of leeding from the varices (e&g&, hematemesis, melena)&
The focus of nursing care of the patient ,ith hepatic encephalopathy is on maintaining a
safe environment, sustaining life, and assisting ,ith measures to reduce the formation of
ammonia&
+ulminant he"atic failure, or acute liver failure, is a clinical syndrome characterized y
severe impairment of liver function associated ,ith hepatic encephalopathy&
L'2- ,-ANSPLAN,A,'$N
.ndications for liver transplant include chronic viral hepatitis, congenital iliary
anormalities (iliary atresia), inorn errors of metaolism, hepatic malignancy (confined
to the liver), sclerosing cholangitis, fulminant hepatic failure, and chronic end+stage liver
disease&
Postoperative complications of liver transplant include re#ection and infection&
The patient ,ho has had a liver transplant re<uires highly s'illed nursing care&
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AC5, PANC-A,','S
Acute "ancreatitis is an acute inflammatory process of the pancreas& The primary
etiologic factors are iliary tract disease (most common cause in ,omen) and alcoholism
(most common cause in men)&
5dominal pain usually located in the left upper <uadrant is the predominant symptom of
acute pancreatitis& ;ther manifestations include nausea, vomiting, hypotension,
tachycardia, and #aundice&
T,o significant local complications of acute pancreatitis are pseudocyst and ascess& 5
pancreatic "seudoc.st is a cavity continuous ,ith or surrounding the outside of the
pancreas&
The primary diagnostic tests for acute pancreatitis are serum amylase and lipase&
;#ectives of collaorative care for acute pancreatitis include relief of pain! prevention or
alleviation of shoc'! reduction of pancreatic secretions! control of fluid and electrolyte
imalances! prevention or treatment of infections! and removal of the precipitating cause&
6ecause hypocalcemia can also occur, the nurse must oserve for symptoms of tetany,
such as #er'ing, irritaility, and muscular t,itching&
C)-$N'C PANC-A,','S
Chronic "ancreatitis is a continuous, prolonged, inflammatory, and firosing process of
the pancreas& The pancreas ecomes progressively destroyed as it is replaced ,ith firotic
tissue& Btrictures and calcifications may also occur in the pancreas&
Clinical manifestations of chronic pancreatitis include adominal pain, symptoms of
pancreatic insufficiency, including malasorption ,ith ,eight loss, constipation, mild
#aundice ,ith dar' urine, steatorrhea, and diaetes mellitus&
:easures used to control the pancreatic insufficiency include diet, pancreatic enzyme
replacement, and control of the diaetes&
PANC-A,'C CANC-
The ma#ority of pancreatic cancers have metastasized at the time of diagnosis& The signs
and symptoms of pancreatic cancer are often similar to those of chronic pancreatitis&
Transadominal ultrasound and CT scan are the most commonly used diagnostic imaging
techni<ues for pancreatic diseases, including cancer&
Burgery provides the most effective treatment of cancer of the pancreas! ho,ever, only
1CK to "8K of patients have resectale tumors&
4ALL/LADD- D'S$-D-S
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The most common disorder of the iliary system is cholelithiasis (stones in the
gallladder)& Cholec.stitis (inflammation of the gallladder) is usually associated ,ith
cholelithiasis&
4ltrasonography is commonly used to diagnose gallstones&
:edical dissolution therapy is recommended for patients ,ith small radiolucent stones
,ho are mildly symptomatic and are poor surgical ris's&
Cholelithiasis develops ,hen the alance that 'eeps cholesterol, ile salts, and calcium in
solution is altered and precipitation occurs& 4ltrasonography is commonly used to
diagnose gallstones&
.nitial symptoms of acute cholecystitis include indigestion and pain and tenderness in the
right upper <uadrant&
Complications of cholecystitis include gangrenous cholecystitis, suphrenic ascess,
pancreatitis, cholangitis (inflammation of iliary ducts), iliary cirrhosis, fistulas, and
rupture of the gallladder, ,hich can produce ile peritonitis&
Postoperative nursing care follo,ing a laparoscopic cholecystectomy includes monitoring
for complications such as leeding, ma'ing the patient comfortale, and preparing the
patient for discharge&
The nurse should assume responsiility for recognition of predisposing factors of
gallladder disease in general health screening&
Lewis et al: Medical-Surgical Nursing: Assessment and Management of
Clinical Problems, 7
th
edition
Key Points
Chapter %C: Nursing 5ssessment: 4rinary Bystem
S,-5C,5-S AND +5NC,'$NS
The urinary system consists of t,o 'idneys, t,o ureters, a urinary ladder, and a urethra&
The ladder provides storage, and the ureters and urethra are the drainage channels for
the urine after it is formed y the 'idneys&
9idne.s
The primary functions of the 'idneys are (1) to regulate the volume and composition of
e)tracellular fluid (*C@), and (") to e)crete ,aste products from the ody&
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Key Points
The 'idneys function to control lood pressure, produce erythropoietin, activate vitamin
=, and regulate acid+ase alance&
The outer layer of the 'idney is termed the corte", and the inner layer is called the
medulla#
The ne"hron is the functional unit of the 'idney& *ach 'idney contains F88,888 to 1&"
million nephrons&
5 nephron is composed of a glomerulus, 6o,man(s capsule, and a tuular system& The
tuular system consists of the pro)imal convoluted tuule, the loop of >enle, the distal
convoluted tuule, and a collecting tuule&
The 'idneys receive "8K to "CK of cardiac output&
The primary function of the 'idneys is to filter the lood and maintain the ody(s internal
homeostasis&
4rine formation is the result of a multistep process of filtration, reasorption, secretion,
and e)cretion of ,ater, electrolytes, and metaolic ,aste products&
/lomerular )unction
6lood is filtered in the glomerulus(
The hydrostatic pressure of the lood ,ithin the glomerular capillaries causes a portion of
lood to e filtered across the semipermeale memrane into 6o,man(s capsule&
The ultrafiltrate is similar in composition to lood e)cept that it lac's lood cells,
platelets, and large plasma proteins&
The amount of lood filtered y the glomeruli in a given time is termed the glomerular
filtration rate (A@?)& The normal A@? is aout 1"C ml1min&
Tu%ular )unction
The functions of the tuules and collecting ducts include reasorption and secretion&
!eabsorption is the passage of a sustance from the lumen of the tuules through the
tuule cells and into the capillaries& *ubular secretion is the passage of a sustance from
the capillaries through the tuular cells into the lumen of the tuule&
o The loop of >enle is important in conserving ,ater and thus concentrating the
filtrate& .n the loop of >enle, reasorption continues&
o T,o important functions of the distal convoluted tuules are final regulation of
,ater alance and acid+ase alance&
5ntidiuretic hormone (5=>) is re<uired for ,ater reasorption in the
'idney&
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Key Points
5ldosterone acts on the distal tuule to cause reasorption of sodium ions
(Na
O
) and ,ater& .n e)change for Na
O
, potassium ions (K
O
) are e)creted&
o 5cid+ase regulation involves reasoring and conserving most of the icaronate
(>C;
$
Contraindications to charcoal administration are diminished o,el sounds,
ileus, or ingestion of a sustance poorly asored y charcoal&
Charcoal can asor and neutralize antidotes, and these should not e given
immediately efore, ,ith, or shortly after, charcoal&
B'in and ocular decontamination involves removal of to)ins from eyes and s'in using copious
amounts of ,ater or saline& -ith the e)ception of mustard gas, most to)ins can e safely
removed ,ith ,ater or saline&
-ater mi)es ,ith mustard gas and releases chlorine gas&
=econtamination ta'es priority over all interventions e)cept asic life support
techni<ues&
*limination of poisons is increased through administration of cathartics, ,hole+o,el
irrigation, hemodialysis, hemoperfusion, urine al'alinization, chelating agents, and antidotes&
5 cathartic such as soritol is given ,ith the first dose of activated charcoal to
stimulate intestinal motility and increase elimination&
>emodialysis and hemoperfusion are reserved for patients ,ho develop severe
acidosis from ingestion of to)ic sustances&
2'$LNC
2iolence is the acting out of the emotions of fear or anger to cause harm to someone or something&
.t may e the result of organic disease, psychosis, or antisocial ehavior&
3iolence can ta'e place in a variety of settings, including the home, community, and ,or'place&
*=s have een identified as high+ris' areas for wor7place violence#
Domestic !iolence is a pattern of coercive ehavior in a relationship that involves fear, humiliation,
intimidation, neglect, and1or intentional physical, emotional, financial, or se)ual in#ury&
.t is found in all professions, cultures, socioeconomic groups, ages, and oth genders! although
men can e victims of domestic violence, most victims are ,omen, children, and the elderly&
.t has een reported that 1&C million ,omen and F$%,888 men treated at *=s have een battered
(assaulted) y spouses, significant others, or individuals 'no,n to them&
Bcreening for domestic violence is re<uired for any patient ,ho is found to e a victim of ause&
5ppropriate interventions should e initiated, including ma'ing referrals, providing emotional support, and
informing victims aout their options&
A4N,S $+ ,--$-'SM
Terrorism involves overt actions such as the dispensing of disease pathogens (bioterrorism) or other agents
(e&g&, chemical, radiologic1nuclear, e)plosive devices) as ,eapons for the e)pressed purpose of causing
harm&
The pathogens most li'ely to e used in a ioterrorist attac' are anthra), smallpo), otulism,
plague, tularemia, and hemorrhagic fever&
Those agents that cause anthra), plague, and tularemia can e treated effectively ,ith
commercially availale antiiotics if sufficient supplies are availale and the organisms
are not resistant&
Bmallpo) can e prevented or ameliorated y vaccination even ,hen first given after
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Key Points
e)posure&
6otulism can e treated ,ith antito)in&
There is no estalished treatment for viruses that cause hemorrhagic fever&
Chemicals used as agents of terrorism are categorized according to their target organ or effect&
Barin is a highly to)ic nerve gas that can cause death ,ithin minutes of e)posure& Barin
enters the ody through the eyes and s'in and acts y paralyzing the respiratory muscles!
antidotes for nerve agent poisoning include atropine and pralido)ime chloride&
Phosgene is a colorless gas normally used in chemical manufacturing& .f inhaled at high
concentrations for a long enough period, it causes severe respiratory distress, pulmonary
edema, and death&
:ustard gas is yello, to ro,n in color and has a garlic+li'e odor& The gas irritates the
eyes and causes s'in urns and listers&
?adiologic1nuclear agents represent another category of agents of terrorism&
!adiologic dispersal devices, %!!D& also 'no,n as /dirty oms,0 consist of a mi) of
e)plosives and radioactive material&
-hen the device is detonated, the last scatters radioactive dust, smo'e, and other
material into the surrounding environment resulting in radioactive contamination&
The main danger from an ??= results from the e)plosion& The radioactive materials used
in an ??= do not usually generate enough radiation to cause immediate serious illness,
e)cept to those casualties ,ho are in close pro)imity to the e)plosion&
Bince radiation cannot e seen, smelled, felt, or tasted, measures to limit contamination
and decontamination should e initiated&
-oni2ing radiation (e&g&, nuclear om, damage to a nuclear reactor) represents a serious threat to
the safety of the casualties and the environment&
*)posure to ionizing radiation may or may not include s'in contamination ,ith
radioactive material! if e)ternal radioactive contaminants are present, decontamination
procedures must e initiated immediately&
5cute radiation syndrome develops after a sustantial e)posure to ionizing radiation and
follo,s a predictale pattern&
*)plosive devices used as agents of terrorism result in one or more of the follo,ing types of
in#uries: last, crush, or penetrating&
6last in#uries result from the supersonic over+pressurization shoc' ,ave that occurs
follo,ing the e)plosion, causing damage to the lungs, middle ear, and gastrointestinal
tract&
Crush in#uries often result from e)plosions that occur in confined spaces and result from
structural collapse&
Bome e)plosive devices contain materials that are pro#ected during the e)plosion, leading
to penetrating in#uries&
M-4NC6 AND MASS CAS5AL,6 'NC'DN, P-PA-DNSS
The term emergenc. usually refers to any e)traordinary event that re<uires a rapid and s'illed response and that
can e managed y a community(s e)isting resources&
5n emergency is differentiated from a mass casualt. incident (:C.) in that an :C. is a manmade (e&g&,
iologic ,arfare) or natural (e&g&, hurricane) event or disaster that over,helms a community(s aility to
respond ,ith e)isting resources&
:C.s usually involve large numers of casualties, involve physical and emotional suffering,
and result in permanent changes ,ithin a community&
:C.s al,ays re<uire assistance from people and resources outside the affected community
(e&g&, 5merican ?ed Cross, @ederal *mergency :anagement 5gency H@*:5I)&
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-hen an emergency or :C. occurs, first responders (i&e&, police, emergency medical personnel) are dispatched
to the scene&
Triage of casualties of an emergency or :C. differs from the usual triage that occurs in the *=
and must e conducted in less than 1C seconds&
5 system of colored tags is used to designate oth the seriousness of the in#ury and the li'elihood
of survival&
5 green (minor in#ury) or .ellow (nonNlife+threatening in#ury) tag is used to indicate a
non+critical in#ury&
5 red tag indicates a life+threatening in#ury re<uiring immediate intervention&
5 blac0 tag is used to identify those casualties ,ho are deceased or ,ho are e)pected to
die&
Casualties need to e treated and stailized, and if there is 'no,n or suspected contamination,
decontaminated at the scene, and then transported to hospitals&
:any casualties ,ill arrive at hospitals on their o,n (i&e&, ,al'ing ,ounded)&
The total numer of casualties a hospital can e)pect is estimated y douling the numer of
casualties that arrive in the first hour&
Aenerally, $8K of casualties ,ill re<uire admission to the hospital, and C8K of these ,ill need
surgery ,ithin F hours&
:any communities have initiated programs to develop community emergency response teams (C*?Ts)&
C*?Ts have een recognized y @*:5 as important partners in emergency preparedness, and the
training helps citizens to understand their personal responsiility in preparing for a natural or
manmade disaster&
Citizens are taught ,hat to e)pect follo,ing a disaster and ho, to safely help themselves, their
family, and their neighors&
Training includes the teaching of life+saving s'ills, ,ith an emphasis on decision+ma'ing and
rescuer safety&
5ll health care providers have a role in emergency and :C. preparedness, and 'no,ledge of the hospital(s
emergency response plan and participation in emergency1:C. preparedness drills are re<uired&
?esponse to :C.s often re<uires the aid of a federal agency such as the National =isaster :edical Bystem
(N=:B), ,hich is a division ,ithin the 4&B& =epartment of >omeland Becurity that is responsile for the
coordination of the federal medical response to :C.s&
;ne component of the N=:B is to organize and train volunteer disaster medical assistance
teams (=:5Ts)&
=:5Ts are categorized according to their aility to respond to an :C.& 5 2evel+1 =:5T
can e deployed ,ithin F hours of notification and remain self+sufficient for 9" hours
,ith enough food, ,ater, shelter, and medical supplies to treat aout "C8 patients per day&
2evel+" =:5Ts lac' enough e<uipment to e self+sufficient ut are used to replace a
2evel+1 team, using and supplementing the e<uipment left on site&
:any hospitals and =:5Ts have a critical incident stress management unit that arranges
group discussions to allo, participants to veralize and validate their feelings and
emotions aout the e)perience to facilitate psychologic recovery&
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