Test Bank for Introduction to Critical Care Nursing, 5th Edition: Mary Lou Sole
Product details:
- ISBN-10 : 1416056564
- ISBN-13 : 978-1416056560
- Author: Sole
Here’s the essential information you need to know in critical care nursing ― all in one concise text! Using a to-the-point, reader friendly approach, Introduction to Critical Care Nursing, 5th Edition, provides authoritative, real-world information on the important concepts of critical care nursing and the assessment and technical skills associated with the management of critically ill patients. The latest content on the technology makes it easy to learn and understand how to use the equipment you’ll use in the field. Nursing care chapters are organized according to the nursing process framework, and you’ll find detailed nursing care plans in every management chapter. Case studies and critical thinking questions challenge you to apply what you’ve learned, and user-friendly features throughout the text (updated pharmacology tables, clinical and laboratory alerts, and evidence-based practice boxes) help you bridge the gap between concepts and clinical practice.
Table contents:
- Part I Fundamental Concepts
- CHAPTER 1 Overview of Critical Care Nursing
- DEFINITION OF CRITICAL CARE NURSING
- EVOLUTION OF CRITICAL CARE
- PROFESSIONAL ORGANIZATIONS
- American Association of Critical-Care Nurses
- BOX 1-1 Role of the Critical Care Nurse as Patient Advocate
- BOX 1-2 Desired Competencies of Nurses Caring for the Critically Ill
- Society of Critical Care Medicine
- Other Professional Organizations
- CERTIFICATION
- STANDARDS
- BOX 1-3 Standards of Critical Care Professional Practice
- TRENDS AND ISSUES
- BOX 1-4 Examples of Patient Safety Goals
- BOX 1-5 Interventions to Reduce Harm and Prevent Injury
- BOX 1-6 Items to Consider in Daily Multidisciplinary Rounds
- SUMMARY
- CRITICAL THINKING QUESTIONS
- REFERENCES
- CHAPTER 2 The Critical Care Experience
- INTRODUCTION
- THE CRITICAL CARE ENVIRONMENT
- TABLE 2-1 Noise Levels Associated with Patient Care Devices and Activities
- Critical Care Culture
- Communication
- BOX 2-1 Elements of the Healthy Work Environment Initiative
- FIGURE 2-1 Interdependence of healthy work environment, clinical excellence, and optimal patient outcomes.
- BOX 2-2 Barriers to Effective Handoff Communication
- Communication Techniques from Industry: Crew Resource Management
- BOX 2-3 Situation, Background, Assessment, Recommendation (SBAR)
- Collaboration
- THE CRITICALLY ILL PATIENT
- BOX 2-4 Patients’ Recollection of the Critical Care Experience
- Cultural Considerations
- TABLE 2-2 Cultural Considerations
- Discharge from Critical Care and Quality of Life after Critical Care
- Geriatric Concerns
- FAMILY MEMBERS OF THE CRITICALLY ILL PATIENT
- EVIDENCE-BASED PRACTICE
- PROBLEM
- QUESTION
- REFERENCE
- EVIDENCE
- DECISION MAKING
- FAMILY COPING
- STAFF STRESS
- CULTURAL SUPPORT OF FAMILY
- SPIRITUAL AND RELIGIOUS SUPPORT
- FAMILY VISITATION
- FAMILY ENVIRONMENT OF CARE
- FAMILY PRESENCE DURING ROUNDS
- FAMILY PRESENCE DURING RESUSCITATION
- PALLIATIVE CARE
- IMPLICATIONS FOR NURSING
- Family Assessment
- Family Needs
- Visitation
- Family Presence during Procedures and Resuscitation
- BOX 2-5 Benefits of Family Presence
- THE CRITICAL CARE NURSE
- AACN SYNERGY MODEL FOR PATIENT CARE
- TABLE 2-3 American Association of Critical-Care Nurses Synergy Model Nurse Competencies
- BOX 2-6 American Association of Critical-Care Nurses Synergy Model Patient Characteristics
- SUMMARY
- CRITICAL THINKING QUESTIONS
- REFERENCES
- CHAPTER 3 Ethical and Legal Issues in Critical Care Nursing
- INTRODUCTION
- ETHICAL OBLIGATIONS AND NURSE ADVOCACY
- ETHICAL DECISION MAKING
- ETHICAL PRINCIPLES
- FIGURE 3-1 The process of ethical decision making.
- BOX 3-1 Ethical Principles
- Moral Theories
- INCREASING NURSES’ INVOLVEMENT IN ETHICAL DECISION MAKING
- TABLE 3-1 Moral Theories
- BOX 3-2 Situations Where Ethics Consultation May Be Considered
- BOX 3-3 Ethics Consultation Services
- BOX 3-4 Internet Resources for Bioethics
- LEGAL ACCOUNTABILITY IN NURSING
- Licensure and Mandatory Education
- Criminal Lawsuits
- Medical Malpractice
- Duty to Treat and Abandonment
- SELECTED ETHICAL AND LEGAL ISSUES
- Informed Consent
- Elements of Informed Consent
- Informed Consent of Adolescents
- Decisions Regarding Life-Sustaining Treatment
- TABLE 3-2 Landmark Legal Cases in the Right-to-Die Debate
- BOX 3-5 Definitions in Critical Care Decision Making
- Cardiopulmonary Resuscitation Decisions
- Withholding or Withdrawal of Life Support
- End-of-Life Issues
- Patient Self-Determination Act
- Advance Directives
- Organ and Tissue Transplantation
- TABLE 3-3 Organ and Tissue Transplantation
- BOX 3-6 Criteria Used to Determine Brain Death*
- Ethical Concerns Surrounding Transplantation
- CASE STUDY
- QUESTIONS
- SUMMARY
- CRITICAL THINKING QUESTIONS
- REFERENCES
- CHAPTER 4 End-of-Life Care in the Critical Care Unit
- INTRODUCTION
- ETHICAL AND LEGAL CONCERNS
- BOX 4-1 Definition of Medical Futility
- Effects on Nurses and the Health Care Team
- DIMENSIONS OF END-OF-LIFE CARE
- Palliative Care
- Communication and Conflict Resolution
- Withholding, Limiting, or Withdrawing Therapy
- BOX 4-2 Guidelines for Effective Communication to Facilitate End-of-Life Care
- BOX 4-3 Ethical Principles for Withholding and Withdrawing Life-Sustaining Treatment
- Ventilator Withdrawal
- CLINICAL ALERT
- Ventilator Withdrawal
- Other Commonly Withheld Therapies
- Emotional and Psychological Care of the Patient/Family
- FIGURE 4-1 Guidelines for pharmacological interventions during withdrawal of life support.
- EVIDENCE-BASED PRACTICE
- PROBLEM
- QUESTIONS
- REFERENCE
- EVIDENCE
- IMPLICATIONS FOR NURSING
- Caregiver Organizational Support
- BOX 4-4 Nursing Interventions to Support Care at the End of Life
- CULTURALLY COMPETENT END-OF-LIFE CARE
- BOX 4-5 End-of-Life Online Resources
- CASE STUDY
- QUESTIONS
- SUMMARY
- CRITICAL THINKING QUESTIONS
- REFERENCES
- Part II Tools for the Critical Care Nurse
- CHAPTER 5 Comfort and Sedation
- INTRODUCTION
- DEFINITIONS OF PAIN AND ANXIETY
- FIGURE 5-1 The anxiety-pain cycle.
- Box 5-1 Gate Control Theory of Pain
- PREDISPOSING FACTORS TO PAIN AND ANXIETY
- PHYSIOLOGY OF PAIN AND ANXIETY
- Pain
- TABLE 5-1 Physiological Responses to Pain and/or Anxiety
- FIGURE 5-2 Transmission of pain signals into the brainstem, thalamus, and cerebral cortex by way of the “fast” pain pathway and “slow” pain pathway.
- TABLE 5-2 Neuroimaging Studies
- Anxiety
- POSITIVE EFFECTS OF PAIN AND ANXIETY
- NEGATIVE EFFECTS OF PAIN AND ANXIETY
- Physical Effects
- Psychological Effects
- ASSESSMENT
- Pain Measurement Tools
- Pain Measurement Tools for Nonverbal Patients
- Adult Behavioral Pain Tools
- FIGURE 5-3 A version of the FACES scale.
- FIGURE 5-4 The Visual Analog Scale.
- TABLE 5-3 The Behavioral Pain Scale*
- Pediatric Pain Tools
- TABLE 5-4 Critical-Care Pain Observation Tool
- TABLE 5-5 The FLACC Scale
- Anxiety and Sedation Measurement Tools
- Sedation Scales
- Continuous Monitoring of Sedation
- TABLE 5-6 Richmond Agitation-Sedation Scale
- FIGURE 5-5 The Bispectral Index (BIS) monitor and electrode.
- TABLE 5-7 The Ramsay Sedation Scale
- TABLE 5-8 Sedation-Agitation Scale
- PAIN AND ANXIETY ASSESSMENT CHALLENGES
- Delirium
- TABLE 5-9 Clinical Subtypes of Delirium
- TABLE 5-10 Risk Factors for Delirium
- BOX 5-2 The Confusion Assessment Method for the Critical Care Unit
- Neuromuscular Blockade
- EVIDENCE-BASED PRACTICE
- PROBLEM
- QUESTIONS
- REFERENCE
- EVIDENCE
- IMPLICATIONS FOR NURSING
- FIGURE 5-6 A train-of-four peripheral nerve stimulator.
- BOX 5-3 Nursing Care of the Patient Receiving Neuromuscular Blockade
- MANAGEMENT OF PAIN AND ANXIETY
- Nonpharmacological Management
- Environmental Manipulation
- TABLE 5-11 PHARMACOLOGY Drugs Frequently Used in the Treatment of Anxiety, Pain, or for Neuromuscular Blockade*
- Guided Imagery
- Music Therapy
- Pharmacological Management
- Opioids
- CLINICAL ALERT
- Cautions in Use of Cyclooxygenase-2 (COX-2) Inhibitors and NSAIDs
- FIGURE 5-7 A patient-controlled analgesia infusion pump.
- Patient-Controlled Analgesia
- BOX 5-4 Typical Patient Criteria for Patient-Controlled Analgesia Therapy
- Epidural Analgesia
- BOX 5-5 Potential Benefits of Epidural Analgesia
- Nonsteroidal Antiinflammatory Drugs
- Sedative Agents
- Tolerance and Withdrawal
- MANAGEMENT CHALLENGES
- Invasive Procedures
- FIGURE 5-8 Sample algorithm of sedation guidelines.
- Substance Abuse
- FIGURE 5-9 The Cleveland Clinic Foundation Procedural Sedation Record: Nursing Assessment Page.
- Restraining Devices
- Effects of Aging
- TABLE 5-12 Common Restraining Devices
- GERIATRIC CONSIDERATIONS
- CASE STUDY
- QUESTIONS
- SUMMARY
- CRITICAL THINKING QUESTIONS
- REFERENCES
- CHAPTER 6 Nutritional Support
- INTRODUCTION
- GASTROINTESTINAL TRACT
- UTILIZATION OF NUTRIENTS
- ASSESSMENT OF NUTRITIONAL STATUS
- GERIATRIC CONSIDERATIONS
- OVERVIEW OF NUTRITIONAL SUPPORT
- Enteral Nutrition
- Parenteral Nutrition
- EVIDENCE-BASED PRACTICE
- PROBLEM
- QUESTION
- REFERENCE
- EVIDENCE
- IMPLICATIONS FOR NURSING
- Nutritional Additives
- NUTRITIONAL THERAPY GOAL
- TABLE 6-1 Components of Immune-Enhancing Formulas
- TABLE 6-2 Estimation of Nutrient Needs
- TABLE 6-3 Enteral Formulas
- PRACTICE GUIDELINES
- Enteral Nutrition
- Parenteral Nutrition
- Drug-Nutrient Interactions
- Monitoring Nutritional Status and Monitoring for Complications
- TABLE 6-4 Tube Feeding Complications and Nursing Interventions
- CLINICAL ALERT
- Assessment of Feeding Tube Placement
- LABORATORY ALERT
- MONITORING AND EVALUATING THE NUTRITION CARE PLAN
- CASE STUDY
- QUESTIONS
- SUMMARY
- CRITICAL THINKING QUESTIONS
- REFERENCES
- CHAPTER 7 Dysrhythmia Interpretation and Management
- INTRODUCTION
- BASIC ELECTROPHYSIOLOGY
- Automaticity
- The Cardiac Cycle
- Cardiac Action Potential
- FIGURE 7-1 Cardiac action potential with the electrocardiogram and movement of electrolytes. ATP, Adenosine triphosphate; Ca, calcium; K, potassium; Na, sodium.
- Relationship Between Electrical Activity and Muscular Contraction
- PHARMACOLOGY TABLE 7-1 Antidysrhythmic Drug Classifications
- CLINICAL ALERT
- Antidysrhythmic Drugs
- Normal Cardiac Conduction Pathway
- FIGURE 7-2 The electrical conduction system of the heart. Arrows indicate direction of electrical currents. The ECG represents the net sum of these currents. RA, Right atrium; RV, right ventricle; LA, left atrium; LV, left ventricle.
- THE 12-LEAD ELECTROCARDIOGRAPHY SYSTEM
- Standard Limb Leads
- Augmented Limb Leads
- FIGURE 7-3 Orientation of leads I, II, and III. Lead I records the difference in electrical potentials between the left arm and right arm. Lead II records it between the left leg and right arm. Lead III records it between the left leg and left arm.
- FIGURE 7-4 A, Einthoven’s triangle. B, The triangle is converted to a triaxial diagram by shifting leads I, II, III that they intersect at a common point.
- FIGURE 7-5 Triaxial lead diagram showing the relationship of the three augmented (unipolar) leads aVR, aVL, and aVF. Notice that each lead is represented by an axis with a positive and negative pole. The term unipolar was used to mean that the leads record the voltage in one location relative to about zero potential instead of relative to the voltage in one other extremity.
- Precordial Leads
- FIGURE 7-6 The precordial leads. The positive poles of the chest leads point anteriorly and the negative poles (dashed lines) point posteriorly.
- FIGURE 7-7 Limb leads and V1 electrode placement and their respective waveforms: A, Lead I; B, lead II; C, lead III; and D, lead V1.
- Continuous Cardiac Monitoring
- TABLE 7-2 Recommended Electrocardiographic Monitoring Leads for Specific Clinical Incidents
- FIGURE 7-8 Lead placement when using a five-lead cable. The chest lead is shown in the V1 position.
- TABLE 7-3 Indications for Cardiac Dysrhythmia Monitoring3
- ANALYZING THE BASIC ELECTROCARDIOGRAPHIC TRACING
- Measurements
- FIGURE 7-9 The ECG is usually recorded on a graph divided into millimeter squares, with darker lines marking 5-mm squares. Time is measured on the horizontal axis. With a paper speed of 25 mm/sec, each small (1-mm) box side equals 0.04 second and each larger (5-mm) box side equals 0.2 second. The amplitude of any wave is measured in millimeters on vertical axis.
- Waveforms and Intervals
- P Wave
- FIGURE 7-10 The P wave represents atrial depolarization. The PR interval is the time from initial stimulation of the atria to initial stimulation of the ventricles. The QRS represents ventricular depolarization. The ST segment, T wave, and U wave are produced by ventricular depolarization.
- PR Interval
- QRS Complex
- FIGURE 7-11 A, A positive complex is seen in any lead if the wave of depolarization spreads toward the positive pole of the lead. B, A negative complex is seen if the depolarization wave spreads toward the negative pole (away from the positive pole) of the lead. C, A biphasic (partly positive, partly negative) complex is seen if the mean direction of the wave is at right angles. These apply to the P wave, QRS, and T wave.
- FIGURE 7-12 Different types of QRS complexes. An R wave is a positive waveform. A negative deflection before the R wave is a Q wave. The S wave is a negative deflection after the R wave. If the waveform is tall or deep, the letter naming the waveform is a capital letter. If the waveform is small in either direction, the waveform is labeled with a lower case letter.
- QRS Interval
- FIGURE 7-13 Pathological Q wave (abnormal Q wave) 0.04 seconds wide and at least one fourth the height of the R wave.
- T Wave
- ST Segment
- QT Interval
- FIGURE 7-14 A, Step-by-step sequence of ventricular depolarization in right bundle branch block. B, The sequence of ventricular depolarization in left bundle branch block produces a wide QS complex in lead V1 and a wide R wave in lead V6. LV, Left ventricle; RV, right ventricle.
- CLINICAL ALERT
- ST Segment Monitoring Practice for Ischemia2
- FIGURE 7-15 Abnormal QT interval prolongation in patient taking quinidine. The QT interval (0.6 seconds) is markedly prolonged for the heart rate (65/min) and the QT interval is greater than one half the R-R interval.
- CLINICAL ALERT
- QT Interval and ECG Monitoring for Detection of Proarrhythmias2
- Box 7-1 Systematic Approach for Rhythm Interpretation
- SYSTEMATIC INTERPRETATION OF DYSRHYTHMIAS
- Rhythmicity
- FIGURE 7-16 Establishing ventricular rhythmicity with calipers.
- FIGURE 7-17 Establishing ventricular rhythmicity with paper and pencil.
- Rate
- FIGURE 7-18 Calculating ventricular rate with the rule of 1500. Count the number of small boxes between QRS complexes. In this strip there are 15 small squares between QRS complexes; 1500 divided by 15 equals a heart rate of 100.
- Waveform Configuration and Location
- Configuration
- Location
- Intervals
- Basic Dysrhythmias
- Normal Sinus Rhythm
- FIGURE 7-19 Normal sinus rhythm. Rhythm strip generated by the AA-700 Rhythm Simulator.
- FIGURE 7-20 Sinus tachycardia.
- Critical Criteria for Diagnosis of Normal Sinus Rhythm
- Hemodynamic Effects.
- Dysrhythmias of the Sinoatrial Node
- Sinus Tachycardia
- Exercise.
- Stimulants.
- Increased Body Temperature.
- Alterations in Fluid Status.
- Critical Criteria for Diagnosis of Sinus Tachycardia
- Hemodynamic Effects.
- Sinus Bradycardia
- Bradycardia as a Normal Finding.
- Increased Vagal Stimulation.
- Drug Effects.
- SA Node Ischemia.
- Effects of Hypoxemia.
- Increased Intracranial Pressure.
- Critical Criteria for Diagnosis of Sinus Bradycardia
- Hemodynamic Effects.
- Box 7-2 Categories of Drugs
- Box 7-3 Symptoms of Decreased Cardiac Output
- FIGURE 7-21 Sinus bradycardia. Notice the negative P waves and QRS because this is lead aVR.
- Sinus Dysrhythmia
- Critical Criteria for Diagnosis of Sinus Dysrhythmia
- Hemodynamic Effects.
- Sinus Pauses and Sinus Arrest
- Enhanced Vagal Tone.
- FIGURE 7-22 Sinus dysrhythmia. Normally, the heart rate increases slightly with inspiration and decreases slightly with expiration.
- FIGURE 7-23 Sinus arrest/sinus exit block. Note the junctional escape beat at the end of the pause.
- Coronary Artery Disease.
- Effects of Drugs.
- Critical Criteria for Diagnosis of Sinus Arrest and Sinus Exit Block
- Hemodynamic Effects.
- Dysrhythmias of the Atria
- Stress.
- Electrolyte Imbalances.
- Hypoxemia.
- Injury to the Atria.
- Digitalis Toxicity.
- Hypothermia.
- Hyperthyroidism.
- Alcohol Intoxication.
- Pericarditis.
- Premature Atrial Contractions
- FIGURE 7-24 Premature atrial contractions shown in the fifth and seventh beats. The P wave occurs on the T wave for these premature atrial contractions.
- Critical Criteria for Diagnosis of Premature Atrial Contractions
- Critical Criteria for Diagnosis of Blocked Premature Atrial Contractions
- Hemodynamic Effects.
- Atrial Tachycardia
- FIGURE 7-25 Compensatory pause. PVC, Premature ventricular contraction.
- Box 7-4 Compensatory versus Noncompensatory Pause
- FIGURE 7-26 A, The fifth beat is an atrial premature contraction. B, Blocked premature atrial contraction (PAC).
- Box 7-5 Supraventricular Tachycardia
- FIGURE 7-27 Notice the marked regularity of rhythm in this paroxysmal supraventricular tachycardia (PSVT). The rate is 170 beats per minute.
- Critical Criteria for Diagnosis of Atrial Tachycardia
- Hemodynamic Effects.
- Wolff-Parkinson with Preexcitation Patterns (Figure 7-29)
- Wandering Atrial Pacemaker
- FIGURE 7-28 A, Normal sinus rhythm. B, With atrial tachycardia (AT), a focus (X) outside the sinoatrial (SA) node fires off automatically at a rapid rate. C, With atrioventricular (AV) nodal reentrant tachycardia (AVNRT), the cardiac stimulus originates as a wave of excitation that spins around the AV nodal (junctional) area. As a result, retrograde P waves may be buried in the QRS or appear immediately before or just after the QRS complex (arrows) because of nearly simultaneous activation of the atria and ventricles. D, A similar type of reentrant (circus movement) mechanism in Wolff-Parkinson-White syndrome. This mechanism is referred to as atrioventricular reentrant tachycardia (AVRT). Note the P wave in lead II somewhat after the QRS complex.
- Critical Criteria for Diagnosis of Wandering Atrial Pacemaker
- Hemodynamic Effects.
- Multifocal Atrial Tachycardia
- FIGURE 7-29 Preexcitation via the bypass tract in the Wolff-Parkinson White (WPW) pattern is associated with a triad finding.
- FIGURE 7-30 Wandering atrial pacemaker. Note the varying P-wave morphologies.
- Critical Criteria for Diagnosis of Multifocal Atrial Tachycardia
- Hemodynamic Effects.
- Atrial Flutter
- FIGURE 7-31 Multifocal atrial tachycardia.
- Critical Criteria for Diagnosis of Atrial Flutter
- Hemodynamic Effects.
- Atrial Fibrillation
- FIGURE 7-32 Atrial flutter with a fixed degree of block. Note the sawtooth configuration and the negative orientation of the flutter waves. Rhythm generated by the AA-700 Rhythm Simulator.
- FIGURE 7-33 Atrial flutter with varying degrees of block.
- FIGURE 7-34 Atrial fibrillation.
- FIGURE 7-35 Aberrancy is most likely to result when the right bundle branch blocks. The impulse must depolarize the left side of the heart first. The impulse then crosses the septum and abnormally depolarizes the right side of the heart. This results in a widened QRS complex.
- EVIDENCE-BASED PRACTICE
- PROBLEM
- REFERENCE
- QUESTION
- EVIDENCE
- IMPLICATIONS FOR NURSING
- Critical Criteria for Diagnosis of Atrial Fibrillation
- FIGURE 7-36 Atrial fibrillation. Note Ashman’s beat, following a long-short cycle.
- CLINICAL ALERT
- Hemodynamic Effects.
- Dysrhythmias of the Atrioventricular Node
- Junctional Rhythm
- P-Wave Changes.
- FIGURE 7-37 Junctional (nodal) rhythm. Note absence of P waves.
- FIGURE 7-38 Junctional (nodal) rhythm. Note the inverted P wave and the shortened PR interval.
- FIGURE 7-39 Junctional (nodal) rhythm. Note the P waves after the QRS complex.
- Critical Criteria for Diagnosis of Junctional Rhythm
- Hemodynamic Effects.
- Accelerated Junctional Rhythm and Junctional Tachycardia
- Critical Criteria for Diagnosis of Accelerated Junctional and Junctional Tachycardia
- Hemodynamic Effects.
- Premature Junctional Contractions
- FIGURE 7-40 Junctional tachycardia. Note the short PR interval and heart rate of 70 beats per minute. Rhythm generated by the AA-700 Rhythm Simulator.
- FIGURE 7-41 Premature junctional contractions. A, Third beat with a shortened PR interval and an inverted P wave. B, Fourth beat, no P waves visible. C, Third beat with a retrograde P wave.
- Critical Criteria for Diagnosis of Premature Junctional Contractions
- Hemodynamic Effects.
- Dysrhythmias of the Ventricle
- FIGURE 7-42 Unifocal premature ventricular contractions.
- Myocardial Ischemia, Injury, and Infarction.
- Hypokalemia.
- Hypomagnesemia.
- Hypoxemia.
- Acid-Base Imbalances.
- Premature Ventricular Contractions
- FIGURE 7-43 Multifocal premature ventricular contractions. Note the compensatory pause.
- FIGURE 7-44 Premature ventricular contractions in a bigeminal pattern. Rhythm strip generated by the AA-700 Rhythm Simulator.
- FIGURE 7-45 Two premature ventricular contractions in a row (pair).
- FIGURE 7-46 Three premature ventricular contractions in a row (triplet).
- FIGURE 7-47 A, R-on-T phenomenon in a patient with an acute myocardial infarction. B, In the same patient, the R-on-T phenomenon causes ventricular fibrillation.
- Critical Criteria for Diagnosis of Premature Ventricular Contractions
- Hemodynamic Effects.
- Ventricular Tachycardia
- FIGURE 7-48 Ventricular tachycardia. Rhythm strip generated by the AA-700 Rhythm Simulator.
- Critical Criteria for Diagnosis of Ventricular Tachycardia
- Hemodynamic Effects.
- Ventricular Fibrillation
- Critical Criteria for Diagnosis of Ventricular Fibrillation
- Hemodynamic Effects.
- Idioventricular Rhythm
- FIGURE 7-49 Fine ventricular fibrillation.
- FIGURE 7-50 Coarse ventricular fibrillation.
- FIGURE 7-51 Idioventricular rhythm.
- Critical Criteria for Diagnosis of Idioventricular Rhythm
- Hemodynamic Effects.
- Accelerated Idioventricular Rhythm
- Critical Criteria for Diagnosis of Accelerated Idioventricular Rhythm
- Hemodynamic Effects.
- FIGURE 7-52 Accelerated idioventricular rhythm.
- FIGURE 7-53 Ventricular standstill or asystole.
- Ventricular Standstill (Asystole)
- Critical Criteria for Diagnosis of Ventricular Standstill (Asystole)
- Hemodynamic Effects.
- Atrioventricular Blocks
- Coronary Artery Disease.
- Infectious and Inflammatory Processes.
- Enhanced Vagal Tone.
- Effects of Drugs.
- First-Degree Block
- Critical Criteria for the Diagnosis of First-Degree Block
- Hemodynamic Effects.
- Second-Degree Block
- GERIATRIC CONSIDERATIONS
- Second-Degree Block Type I: Mobitz I or Wenckebach’s Phenomenon
- Critical Criteria for Diagnosis of Second-Degree Block Type I
- Hemodynamic Effects.
- Second-Degree Block Type II: Mobitz II
- FIGURE 7-54 First-degree block. Rhythm strip generated by the AA-700 Rhythm Simulator.
- FIGURE 7-55 Second-degree block, Mobitz type I, or Wenckebach’s phenomenon. Note the steadily lengthening PR interval. Rhythm strip generated by the AA-700 Rhythm Simulator.
- FIGURE 7-56 Second-degree block, Mobitz type II. Note the fixed PR interval. Rhythm strip generated by the AA-700 Rhythm Simulator.
- Critical Criteria for Diagnosis of Second-Degree Block Type II
- Hemodynamic Effects.
- Third-Degree Block (Complete Heart Block)
- Critical Criteria for Diagnosis of Third-Degree Block (Complete Heart Block)
- FIGURE 7-57 Third-degree block with ventricular escape. Rhythm strip generated by the AA-700 Rhythm Simulator.
- Hemodynamic Effects.
- INTERVENTIONS FOR DYSRHYTHMIAS
- Tachydysrhythmias
- Bradydysrhythmias
- ELECTRICAL PACEMAKERS
- Rate.
- Mode.
- Electrical Output.
- Sensitivity.
- AV Internal.
- Pacemaker Rhythms.
- Pacemaker Malfunction.
- Failure to Pace.
- FIGURE 7-58 Paced rhythm: atrial. Note the spike in front of the P wave. Rhythm strip generated by the AA-700 Rhythm Simulator.
- FIGURE 7-59 Paced rhythm: ventricular. Note the spike in front of the QRS complex. Rhythm strip generated by the AA-700 Rhythm Simulator.
- FIGURE 7-60 Paced rhythm: dual chamber. Note the spikes before the P wave and the QRS complex. Rhythm strip generated by the AA-700 Rhythm Simulator.
- Failure to Capture.
- Failure to Sense.
- FIGURE 7-61 Paced rhythm with failure to capture.
- FIGURE 7-62 Paced rhythm with failure to capture (seventh spike) and failure to sense, note arrow (eighth spike).
- Biventricular Pacemaker
- FIGURE 7-63 Biventricular pacing with wires of the right atrium/ventricle and left ventricle.
- FIGURE 7-64 Patient’s actual rhythm (top strip, note the wide QRS). Biventricular pacing of right and left ventricle (bottom strip, note the QRS is not as wide as the top strip).
- NURSING CARE PLAN
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- Maintains optimal cardiac output
- CASE STUDY
- QUESTIONS
- SUMMARY
- CRITICAL THINKING QUESTIONS
- REFERENCES
- CHAPTER 8 Hemodynamic Monitoring
- INTRODUCTION
- REVIEW OF ANATOMY AND PHYSIOLOGY
- Cardiovascular System Structure
- Heart
- Arteries
- Capillaries
- FIGURE 8-1 Diagram of the cardiovascular system.
- Veins
- FIGURE 8-2 Cardiac cycle.
- Blood
- Principles of Physics
- FIGURE 8-3 Relationship between vessel diameter, flow, and resistance. A, Effect of lumen diameter on flow through vessel. d, Diameter. B, Blood flows with great speed in the large arteries. However, branching of arterial vessels increases the total cross-sectional areas of the arterioles and capillaries, thus reducing the flow rate.
- Components of Cardiac Output
- FIGURE 8-4 Cardiac output components. Cardiac output is determined by heart rate and stroke volume.
- FIGURE 8-5 Normal blood flow through the heart and intrachamber pressures; arrows indicate the normal direction of blood flow. This schematic representation of the heart shows all four chambers and valves visible in the anterior view to facilitate conceptualization of blood flow.
- Regulation of Cardiovascular Function
- Effects of Aging
- FIGURE 8-6 Factors regulating blood flow.
- HEMODYNAMIC MONITORING MODALITIES
- FIGURE 8-7 Impact of age-related changes on cardiac function.
- Noninvasive Monitoring
- Noninvasive Blood Pressure
- Jugular Venous Pressure
- Lactate
- TABLE 8-1 Normal Hemodynamic Values
- Invasive Hemodynamic Monitoring
- Indications
- BOX 8-1 Indications for Invasive Hemodynamic Monitoring
- Arterial Lines
- Central Venous Catheter
- Pulmonary Artery Catheter
- FIGURE 8-8 Assessment of jugular venous pressure:1.Place the patient in a supine position with the head of bed elevated 30 to 45 degrees.2.Position yourself at the patient’s right side.3.Have the patient turn head slightly to the left.4.If you cannot readily identify the jugular vein, place light pressure with your fingertips across the sternocleidomastoid muscle just superior and parallel to the clavicle. This pressure obstructs the external jugular vein and allows it to fill. Shine a pen light tangentially across the neck to accentuate the pulsations.5.Assess for jugular venous distention at end exhalation.6.Any fullness in the vein extending >3 cm above the sternal angle or angle of Louis is considered elevated jugular venous pressure. The higher the degree of elevation, the higher the central venous pressure.7.Observe the highest point of pulsation in the internal jugular vein at end exhalation.8.Measure the vertical distance between this pulsation and the angle of Louis in centimeters.9.Add 5 cm to this number for an estimation of central venous pressure.10.Normal is 7 to 9 cm.
- Equipment Common to All Intravascular Monitoring
- BOX 8-2 Complications of Invasive Hemodynamic Monitoring Devices
- FIGURE 8-9 Components of an invasive monitoring system connected to one flush solution. A, Invasive catheter. B, Noncompliant pressure tubing. C, Transducer and zeroing stopcock. D, Pressurized flush system. E, Bedside monitoring system. (Not to scale)
- Nursing Implications
- FIGURE 8-10 Example of a triple-lumen central line to measure central venous pressure and oxygen saturation.
- FIGURE 8-11 Example of a pulmonary artery catheter with capability of monitoring mixed venous oxygenation.
- FIGURE 8-12 A schematic of a typical pressure transducer.
- Leveling the Air-Fluid Interface (Zeroing Stopcock)
- FIGURE 8-13 Locating the phlebostatic axis in the supine position.
- Patient Position
- CLINICAL ALERT
- Hemodynamic Monitoring
- FIGURE 8-14 A, Optimal Dynamic Response Test. B, Overdamped Dynamic Response Test. C, Underdamped Dynamic Response Test.
- Zero Referencing
- Dynamic Response Testing
- BOX 8-3 Abnormal Dynamic Response Test: Causes and Interventions
- Overdamped system
- Underdamped system
- Infection Control
- BOX 8-4 General Nursing Strategies for Managing Hemodynamic Monitoring Systems
- Arterial Pressure Monitoring
- BOX 8-5 Allen’s and Modified Allen’s Test Procedure
- Allen’s Test
- Modified Allen’s Test
- Complications
- FIGURE 8-15 A, Normal arterial pressure tracing; 1, peak systolic pressure; 2, dicrotic notch; 3, diastolic pressure; 4, anacrotic notch. B, Arterial pressure waveform obtained from arterial line.
- Clinical Considerations
- BOX 8-6 Causes of Higher Noninvasive versus Invasive Blood Pressure
- Nursing Implications
- Right Atrial Pressure/Central Venous Pressure Monitoring
- FIGURE 8-16 Position of central venous catheter in right atrium along with associated waveforms.
- Complications
- FIGURE 8-17 Identifying the a, c, and v waveforms to determine right atrial pressure.
- BOX 8-7 Methods for Determining Accurate Right Atrial Pressure
- Pre-c method
- Mean of the a waves
- Z-point method
- Clinical Considerations
- Nursing Implications
- Pulmonary Artery Pressure Monitoring
- FIGURE 8-18 A five-lumen pulmonary artery (PA) catheter containing the four-lumen components in addition to a second proximal lumen for infusion of fluid or medications.
- Hemodynamic Parameters Monitored via the PAC
- FIGURE 8-19 Position of pulmonary artery (PA) catheter and associated waveforms. (A) Dual-channel tracing of cardiac rhythm with pressure waveforms obtained as the PA catheter is inserted into the right atrium (RA) and right ventricle (RV); (B) dual-channel tracing of cardiac rhythm with RV, PA, and pulmonary artery occlusion pressure (PAOP) waveforms as the catheter is floated into proper position; (C), PA catheter in pulmonary artery; (D) PA catheter floating into pulmonary capillary with balloon inflated for PAOP measurements.
- Clinical Considerations
- FIGURE 8-20 Effect of respiration on pulmonary artery waveforms in patients with spontaneous breathing (A) and mechanical ventilation (B).
- Nursing Implications
- Controversy Surrounding the PAC
- Cardiac Output Monitoring
- Thermodilution Cardiac Output
- BOX 8-8 Interpretation of Abnormal Cardiac Output/Index Values
- Low Cardiac Output/Index
- High Cardiac Output/Index
- EVIDENCE-BASED PRACTICE
- PROBLEM
- QUESTION
- REFERENCES
- EVIDENCE
- Implications for Nursing
- Continuous Cardiac Output
- FIGURE 8-21 Illustration of the closed injectate delivery system (room temperature fluids) for thermodilution cardiac output measurement.
- FIGURE 8-22 Illustration of injection of fluid into the right atrium (RA) for cardiac output measurement.
- BOX 8-9 Steps to Ensure Accurate Thermodilution Cardiac Output Measurements
- Oxygen Delivery and Consumption
- FIGURE 8-23 A sample monitor interface displaying hemodynamic parameters and trends, including continuous cardiac output (CCO) and mixed venous oxygen saturation (SvO2).
- TABLE 8-2 Hemodynamic Calculations
- TABLE 8-3 Alterations in Mixed Venous Oxygen Saturation
- BOX 8-10 Esophageal Doppler Monitoring Indications and Contraindications
- Indications
- Contraindications
- EMERGING TECHNIQUES AND TECHNOLOGIES
- Esophageal Doppler Monitoring
- FIGURE 8-24 Esophageal Doppler probe placement.
- BOX 8-11 Nurse-Driven Protocol Using Esophageal Doppler Monitoring to Guide Therapy14
- FIGURE 8-25 A, CardioQ monitoring system for assessing cardiac output and function via the esophageal Doppler probe. B, Numeric and graphic data provided by the CardioQ device.
- TABLE 8-4 Interpretation Guidelines for Esophageal Doppler Monitoring
- Pulse Contour Cardiac Output Monitoring
- FIGURE 8-26 Schematic of the LiDCO system for assessing cardiac output via the pulse contour analysis method.
- FIGURE 8-27 Example of information provided by LiDCO device.
- Assessing Effect of Respiratory Variation on Hemodynamic Parameters
- Right Atrial Pressure Variation
- Systolic Pressure Variation
- Arterial Pulse Pressure Variation
- Stroke Volume Variation
- CASE STUDY
- QUESTIONS
- SUMMARY
- CRITICAL THINKING QUESTIONS
- REFERENCES
- CHAPTER 9 Ventilatory Assistance
- INTRODUCTION
- REVIEW OF RESPIRATORY ANATOMY AND PHYSIOLOGY
- Upper Airway
- Lower Airway
- FIGURE 9-1 Anatomy of the respiratory system. The lungs are located in the thoracic cavity. The diaphragm forms the floor of the thoracic cavity and separates it from the abdominal cavity. The internal view of one lung shows air passages.
- FIGURE 9-2 The vocal cords/glottis.
- Lungs
- FIGURE 9-3 Structure and function of the alveolus.
- PHYSIOLOGY OF BREATHING
- Gas Exchange
- FIGURE 9-4 Schematic view of the process of gas exchange. Hgb, Hemoglobin.
- Regulation of Breathing
- Respiratory Mechanics
- Work of Breathing
- FIGURE 9-5 Diffusion of oxygen and carbon dioxide at the alveolar-capillary membrane.
- Compliance
- Resistance
- LUNG VOLUMES AND CAPACITIES
- TABLE 9-1 Lung Volumes and Capacities
- FIGURE 9-6 Lung volumes and capacities.
- GERIATRIC CONSIDERATIONS
- PHYSIOLOGICAL CHANGES WITH AGING
- ASSESSMENT CHANGES
- NORMAL FINDINGS BECAUSE OF AGING PROCESS
- INCREASED RISK FOR
- RESPIRATORY ASSESSMENT
- Health History
- Physical Examination
- Inspection
- FIGURE 9-7 Breathing patterns.
- Palpation
- Percussion
- Auscultation
- FIGURE 9-8 Systematic method for palpation, percussion, and auscultation of the lungs in anterior (A), posterior (B), and lateral regions (C and D). The techniques should be performed systematically to compare right and left lung fields.
- TABLE 9-2 Percussion of the Chest Wall
- Breath Sounds
- TABLE 9-3 Normal Breath Sounds
- Arterial Blood Gas Interpretation
- Oxygenation
- Partial Pressure of Arterial Oxygen.
- Arterial Oxygen Saturation of Hemoglobin.
- TABLE 9-4 Adventitious Breath Sounds
- TABLE 9-5 Blood Gas Interpretation
- Ventilation and Acid-Base Status
- pH.
- Box 9-1 Signs and Symptoms of Hypoxemia
- Integumentary System
- Respiratory System
- Central Nervous System
- Partial Pressure of Arterial Carbon Dioxide.
- FIGURE 9-9 Oxyhemoglobin dissociation curve. A PaO2 of 60 mm Hg correlates with an oxygen saturation of 90%. When the PaO2 falls below 60 mm Hg, small changes in PaO2 are reflected in large changes in oxygen saturation. Shifts in the oxyhemoglobin curve. L, Left shift; N, normal; R, right shift.
- Sodium Bicarbonate.
- Buffer Systems.
- Box 9-2 Causes of Common Acid-Base Abnormalities
- Respiratory Acidosis: Retention of CO2
- Respiratory Alkalosis: Hyperventilation
- Metabolic Acidosis
- Increased Acids
- Loss of Base
- Metabolic Alkalosis
- Gain of Base
- Loss of Metabolic Acids
- Base Excess or Base Deficit.
- Compensation.
- Steps in Arterial Blood Gas Interpretation
- Step 1: Look at Each Number Individually and Label It.
- FIGURE 9-10 The kidneys and lungs work together to compensate for acid-base imbalances in the respiratory or metabolic systems. HCO3−, Bicarbonate; H2CO3, carbonic acid.
- LABORATORY ALERT
- Arterial Blood Gas Critical Values*
- Step 2: Evaluate Oxygenation.
- Step 3: Determine Acid-Base Status.
- Step 4: Determine Whether Primary Acid-Base Disorder Is Respiratory or Metabolic.
- Step 5: Determine Whether Any Form of Compensatory Response Has Taken Place.
- Box 9-3 Examples of Arterial Blood Gases and Compensation
- Noninvasive Assessment of Gas Exchange
- Assessment of Oxygenation
- Pulse Oximetry.
- Assessment of Ventilation
- End-Tidal Carbon Dioxide Monitoring.
- Colorimetric Carbon Dioxide Detector.
- FIGURE 9-11 Disposable colorimetric carbon dioxide (CO2) detector for confirming endotracheal tube placement. Detection of CO2 confirms tube placement in the lungs because the only source of CO2 is the alveoli.
- OXYGEN ADMINISTRATION
- Humidification
- Picking the Best Device
- Fit and Function
- Total Flow
- Oxygen Delivery Devices
- Nasal Cannula (Variable Performance)
- Simple Face Mask (Variable Performance)
- Face Masks with Reservoirs (Variable Performance)
- Venturi or Air-Entrainment Mask (Fixed Performance)
- FIGURE 9-12 Partial rebreathing and nonrebreathing oxygen masks.
- FIGURE 9-13 Air-entrainment (Venturi) mask with various jet orifices. Each orifice provides a specific delivered FiO2.
- Air Entrainment with Aerosol and Humidity Delivery (Variable or Fixed Performance)
- FIGURE 9-14 Devices used to apply high-flow, high-humidity oxygen therapy. A, Aerosol mask. B, Face tent. C, Tracheostomy collar. D, Briggs T-piece.
- Manual Resuscitation Bag (Variable Performance)
- AIRWAY MANAGEMENT
- Positioning
- Oral Airways
- FIGURE 9-15 Maintaining a patent airway with an oral airway.
- Box 9-4 Insertion of Oral Airway
- Nasopharyngeal Airways
- FIGURE 9-16 The nasopharyngeal airway is used to relieve upper airway obstruction and to facilitate passage of a suction catheter.
- Box 9-5 Insertion of Nasal Airway
- FIGURE 9-17 Endotracheal tube.
- Box 9-6 Oral versus Nasotracheal Intubation
- Oral Intubation
- Advantages
- Disadvantages
- Nasotracheal Intubation
- Advantages
- Disadvantages
- Endotracheal Intubation
- FIGURE 9-18 Equipment used for endotracheal intubation: A, stylet (disposable); B, endotracheal tube with 10-mL syringe for cuff inflation; C, laryngoscope handle with attached curved blade (left) and straight blade (right); D, water-soluble lubricant; E, colorimetric CO2 detector to check tube placement; F, tape or G, commercial device to secure tube; H, Yankauer disposable pharyngeal suction device; I, Magill forceps (optional). Additional equipment, not shown, includes suction source and stethoscope.
- Procedure for Oral Endotracheal Intubation
- FIGURE 9-19 Elevating the head with a blanket or folded towels places the patient in the „sniffing position” to facilitate endotracheal intubation.
- Procedure for Nasotracheal Intubation
- Verification of Endotracheal Tube Placement
- Tracheostomy
- FIGURE 9-20 Two methods for securing the endotracheal tube: tape (A) and harness device (B). Harness device shown is the SecureEasy Endotracheal Tube Holder. Nonelastic headgear reduces the risk of self-extubation. A soft bite block prevents tube occlusion.
- Tracheostomy Tube Designs
- Cuffed versus Uncuffed Tracheostomy Tubes.
- FIGURE 9-21 General design features of the tracheostomy tube.
- Single- versus Double-Cannula Tracheostomy Tubes.
- Fenestrated Tracheostomy Tube.
- Speaking Tracheostomy Valves.
- Endotracheal Suctioning
- Box 9-7 Key Points for Endotracheal Suctioning
- FIGURE 9-22 Closed tracheal suction device.
- EVIDENCE-BASED PRACTICE
- PROBLEM
- QUESTION
- REFERENCE
- EVIDENCE
- IMPLICATIONS FOR NURSING
- MECHANICAL VENTILATION
- Indications
- Positive-Pressure Ventilation
- Ventilator Settings
- Fraction of Inspired Oxygen
- FIGURE 9-23 Concept of positive-pressure ventilation.
- Tidal Volume
- FIGURE 9-24 Examples of mechanical ventilators, their control panels and graphic interface unit (GIU). A, Servo ventilator 300A control panel. B, Puritan Bennett 840 ventilator GIU.
- Exhaled Tidal Volume.
- Respiratory Rate
- Inspiratory-to-Expiratory Ratio
- Inverse Inspiratory-to-Expiratory Ratio
- Positive End-Expiratory Pressure
- FIGURE 9-25 Effect of application of positive end-expiratory pressure (PEEP) on the alveoli.
- Auto-PEEP.
- Sensitivity
- Sigh
- Patient Data
- Peak Inspiratory Pressure
- Total Respiratory Rate
- Modes of Mechanical Ventilation
- Volume-Controlled Ventilation
- Assist/Control Ventilation.
- FIGURE 9-26 Waveforms of volume-controlled ventilator modes. A, Volume assist control (A/C) ventilation. The patient may trigger additional breaths above the set rate. The ventilator delivers the same volume for ventilator-triggered and patient-triggered (assisted) breaths. B, Synchronized intermittent mandatory ventilation (SIMV). Both spontaneous and mandatory breaths are graphed. Mandatory breaths receive the set tidal volume (VT). VT of spontaneous breaths depends on work patient is capable of generating, lung compliance, and airway resistance.
- Synchronized Intermittent Mandatory Ventilation.
- Pressure-Controlled Ventilation
- Continuous Positive Airway Pressure.
- Pressure Support.
- FIGURE 9-27 Continuous positive airway pressure (CPAP) is a spontaneous breathing mode. Positive pressure at end expiration splints alveoli and supports oxygenation. I, Inspiration; E, Expiration.
- FIGURE 9-28 Pressure support ventilation requires the patient to trigger each breath, which is then supported by pressure on inspiration. Patient may vary amount of time in inspiration, respiratory rate, and tidal volume (VT).
- Pressure Assist/Control.
- FIGURE 9-29 Synchronized intermittent mandatory ventilation (SIMV) with pressure support (PS). SIMV breaths receive set tidal volume (VT). Pressure support is applied to the spontaneous, patient-triggered breaths.
- FIGURE 9-30 Pressure assist/control ventilation. Patient can trigger additional breaths above the set rate. Patient- and ventilator-triggered breaths receive the same inspiratory pressure.
- Pressure-Controlled Inverse-Ratio Ventilation.
- FIGURE 9-31 Airway pressure—release ventilation. See text below for description.
- Airway Pressure—Release Ventilation.
- Noninvasive Positive-Pressure Ventilation
- FIGURE 9-32 Masks used for noninvasive positive-pressure ventilation. A, Nasal. B, Oronasal. C, Total face mask.
- FIGURE 9-33 Noninvasive positive-pressure ventilation (NIPPV) may be administered through a mask with the BiPAP Vision ventilator. This ventilator is capable of operating in four modes: pressure support (PS); spontaneous/timed (S/T) mode, which is pressure support with back-up pressure control; timed (T), which is pressure control; and continuous positive airway pressure (CPAP). (Courtesy of Respironics, Murrysville, PA.)
- Advanced Methods and Modes of Mechanical Ventilation
- Respiratory Monitoring During Mechanical Ventilation
- Alarm Systems
- Volume Alarms.
- Pressure Alarms.
- Apnea Alarm.
- TABLE 9-6 Management of Common Ventilator Alarms
- Complications of Mechanical Ventilation
- Airway Problems
- Intubation of Right Mainstem Bronchus.
- CLINICAL ALERT
- Implementation of the Ventilator Bundle
- Endotracheal Tube Out of Position.
- Unplanned Extubation.
- Laryngeal and Tracheal Injury.
- Damage to the Oral or Nasal Mucosa.
- FIGURE 9-34 Monitoring endotracheal tube cuff pressures.
- Box 9-8 Strategies for Unplanned or Self-Extubation
- Pulmonary System
- Trauma.
- Oxygen Toxicity.
- Respiratory Acidosis or Alkalosis.
- Infection.
- Cardiovascular System
- Gastrointestinal System
- Psychosocial Complications
- NURSING CARE
- Communication
- NURSING CARE PLAN for the Mechanically Ventilated Patient21
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- NURSING DIAGNOSIS
- PATIENT OUTCOME
- NURSING DIAGNOSIS
- PATIENT OUTCOME
- Medications
- WEANING PATIENTS FROM MECHANICAL VENTILATION
- Methods for Weaning
- Synchronized Intermittent Mandatory Ventilation
- Pressure Support
- T-Piece
- Continuous Positive Airway Pressure
- Approach to Weaning Using Best Evidence
- Assessment for Readiness to Wean (Wean Screen)
- Box 9-9 Evidence-Based Guidelines for Weaning from Mechanical Ventilation39,40
- Weaning Process (Weaning Trial)
- Box 9-10 Assessment Parameters Indicating Readiness to Wean
- Underlying Cause for Mechanical Ventilation Resolved
- Hemodynamic Stability; Adequate Cardiac Output
- Adequate Respiratory Muscle Strength
- Adequate Oxygenation Without a High FiO2 and/or a High PEEP
- Absence of Factors that Impair Weaning
- Box 9-11 Criteria for Discontinuing Weaning
- Respiratory
- Cardiovascular
- Neurological
- Extubation
- CASE STUDY
- QUESTIONS
- SUMMARY
- CRITICAL THINKING QUESTIONS
- REFERENCES
- CHAPTER 10 Code Management
- INTRODUCTION
- ROLES OF CAREGIVERS IN CODE MANAGEMENT
- Code Team
- Leader of the Code
- TABLE 10-1 Roles and Responsibilities of Code Team Members
- Code Nurses
- Primary Nurse.
- Second Nurse.
- Nursing Supervisor.
- Anesthesiologist or Nurse Anesthetist
- Respiratory Therapist
- Pharmacist or Pharmacy Technician
- Electrocardiogram Technician
- Chaplain
- Other Personnel
- EQUIPMENT USED IN CODES
- FIGURE 10-1 A typical crash cart.
- TABLE 10-2 Typical Contents of a Crash Cart
- RESUSCITATION EFFORTS
- TABLE 10-3 Flow of Events during a Code
- Basic Life Support
- Airway
- Breathing
- BOX 10-1 Steps in Basic Cardiac Life Support
- Airway
- Breathing
- Circulation
- Defibrillation
- FIGURE 10-2 Head-tilt/chin-lift technique for opening the airway. A, Obstruction by the tongue. B, Head-tilt/chin-lift maneuver lifts tongue relieving airway obstruction.
- FIGURE 10-3 Mouth-to-mask ventilation.
- FIGURE 10-4 Rescue breathing with bag-valve device.
- Circulation
- Advanced Cardiac Life Support
- Primary Survey
- Secondary Survey
- Airway
- Breathing
- FIGURE 10-5 Ventilation with a bag-valve device connected to endotracheal tube.
- Circulation
- FIGURE 10-6 End-tidal carbon dioxide detector connected to an endotracheal tube. Exhaled carbon dioxide reacts with the device to create a color change indicating correct endotracheal tube placement.
- Differential Diagnosis
- Recognition and Treatment of Dysrhythmias
- Ventricular Fibrillation and Pulseless Ventricular Tachycardia
- Critical Actions
- Pulseless Electrical Activity and Asystole
- Critical Actions
- Symptomatic Bradycardia
- Critical Actions
- BOX 10-2 Signs and Symptoms of Low Cardiac Output Associated with Bradycardia
- Unstable Tachycardia
- Critical Actions
- Electrical Therapy
- Defibrillation
- Definition.
- FIGURE 10-7 Defibrillator.
- Procedure.
- FIGURE 10-8 Paddle placement for defibrillation.
- FIGURE 10-9 Anteroposterior placement of adhesive electrode pads for defibrillation or transcutaneous pacing.
- BOX 10-3 Procedure for External Defibrillation
- Automated External Defibrillation
- Definition.
- Indications.
- Procedure.
- Cardioversion
- Definition.
- FIGURE 10-10 Automatic external defibrillator.
- BOX 10-4 Procedure for Automated External Defibrillator Operation
- Procedure.
- FIGURE 10-11 Approximate location of the vulnerable period.
- BOX 10-5 Procedure for Synchronous Cardioversion
- Special Situations
- FIGURE 10-12 Monitor/defibrillator demonstrating marked R waves for cardioversion.
- Transcutaneous Cardiac Pacing
- Definition.
- Procedure.
- FIGURE 10-13 Transcutaneous pacemaker-defibrillator.
- FIGURE 10-14 Electrical capture of transcutaneous pacemaker. Note the pacemaker spikes followed by a wide QRS complex and a tall T wave.
- BOX 10-6 Procedure for Transcutaneous Pacemaker
- PHARMACOLOGICAL INTERVENTION DURING A CODE
- Oxygen
- Epinephrine (Adrenalin)
- BOX 10-7 Effects of Adrenergic Receptor Stimulation
- Alpha
- Beta1
- Beta2
- Vasopressin
- Atropine
- PHARMACOLOGY TABLE 10-4 Drugs Frequently Used in Code Management
- Amiodarone (Cordarone)
- Lidocaine (Xylocaine)
- Procainamide (Pronestyl)
- Adenosine (Adenocard)
- Magnesium
- Sodium Bicarbonate
- FIGURE 10-15 Atrioventricular block after intravenous administration of adenosine.
- FIGURE 10-16 Torsades de pointes. The QRS complex seems to spiral around the isoelectric line.
- Dopamine (Intropin)
- Calcium Chloride
- SPECIAL PROBLEMS DURING A CODE
- GERIATRIC CONSIDERATIONS
- Tension Pneumothorax
- Pericardial Tamponade
- DOCUMENTATION OF CODE EVENTS
- FIGURE 10-17 Tension pneumothorax. On inspiration, air enters the pleural space. On expiration, air is unable to escape the pleural space. Pressure increases, causing the lung on the affected side to collapse and the trachea to shift to the opposite side.
- CARE OF THE PATIENT AFTER RESUSCITATION
- FIGURE 10-18 Sample of a code record used for documenting activities during a code.
- LABORATORY ALERTS
- Therapeutic Hypothermia After Cardiac Arrest
- EVIDENCE-BASED PRACTICE
- Therapeutic Hypothermia
- PROBLEM
- QUESTION
- REFERENCES
- EVIDENCE
- IMPLICATIONS FOR NURSING
- Family Presence during Resuscitation
- EVIDENCE-BASED PRACTICE
- Code Management
- PROBLEM
- QUESTION
- REFERENCES
- EVIDENCE
- NURSING IMPLICATIONS
- Rapid Response Teams
- SUMMARY
- CRITICAL THINKING QUESTIONS
- REFERENCES
- Part III Nursing Care during Critical Illness
- CHAPTER 11 Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
- INTRODUCTION
- REVIEW OF ANATOMY AND PHYSIOLOGY
- FIGURE 11-1 Microcirculation. AV, Arteriovenous.
- Pathophysiology
- TABLE 11-1 Classification of Shock
- Stages of Shock
- Stage I: Initiation
- Stage II: Compensatory Stage
- Neural Compensation.
- Endocrine Compensation.
- FIGURE 11-2 Impairment of cellular metabolism by shock. ATP, Adenosine triphosphate; Na, sodium; NH 4, ammonia; K, potassium.
- TABLE 11-2 Stages of Shock
- FIGURE 11-3 The renin-angiotensin-aldosterone system.
- Chemical Compensation.
- Stage III: Progressive Stage
- Stage IV: Refractory Stage
- Systemic Inflammatory Response Syndrome (SIRS)
- Effects of Aging
- ASSESSMENT
- Clinical Presentation
- Central Nervous System
- Cardiovascular System
- CLINICAL ALERT
- TABLE 11-3 Hemodynamic Alterations in Shock States
- Respiratory System
- Renal System
- Gastrointestinal System
- Hematological System
- Integumentary System
- Laboratory Studies
- LABORATORY ALERTS
- MANAGEMENT
- Maintenance of Circulating Blood Volume and Adequate Hemoglobin Level
- Intravenous Access
- Fluid Challenge
- Types of Fluids
- FIGURE 11-4 Fluid challenge algorithm. CVP, Central venous pressure; PAOP, pulmonary artery occlusion pressure.
- EVIDENCE-BASED PRACTICE
- PROBLEM
- QUESTION
- REFERENCES
- EVIDENCE
- IMPLICATIONS FOR NURSING
- Maintenance of Arterial Oxygen Saturation and Ventilation
- Pharmacological Support
- Cardiac Output
- FIGURE 11-5 Therapeutic manipulation of cardiac output and myocardial oxygen consumption. ACE, Angiotensin converting enzyme; ARB, angiotensin receptor blocker; CI, cardiac index; CO, cardiac output; CVP, central venous pressure; IABP, intra-aortic balloon pump; LR, lactated Ringer’s; LV, left ventricle; LVSWI, left ventricular stroke work index; NS, normal (0.9%) saline; NTG, nitroglycerin; PAOP, pulmonary artery occlusive pressure; PDE, phosphodiesterase; PVR, pulmonary vascular resistance; RAP, right atrial pressure; RV, right ventricle; RVSWI, right ventricular stroke work index; SVR, systemic vascular resistance.
- PHARMACOLOGY TABLE 11-4 Medications Commonly Used in Shock
- Preload
- Afterload
- Contractility
- Other Medications
- Maintenance of Body Temperature
- Nutritional Support
- Maintenance of Skin Integrity
- Psychological Support
- NURSING DIAGNOSIS
- NURSING CARE PLAN for the Patient in Shock
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- Adequate tissue perfusion
- SPECIFIC CLASSIFICATIONS OF SHOCK
- Hypovolemic Shock
- TABLE 11-5 Summary of Classifications of Shock
- FIGURE 11-6 Hypovolemic shock.
- TABLE 11-6 Severity of Hemorrhagic Shock
- Cardiogenic Shock
- FIGURE 11-7 Cardiogenic shock. ADH, Antidiuretic hormone; SVR, systemic vascular resistance.
- FIGURE 11-8 Cycle of cardiogenic shock.
- FIGURE 11-9 Intraaortic balloon pump. The balloon is deflated during systole (A) and inflated during diastole (B).
- Obstructive Shock
- FIGURE 11-10 Obstructive shock.
- Distributive Shock
- Neurogenic Shock
- FIGURE 11-11 Neurogenic shock. SVR, Systemic vascular resistance.
- Anaphylactic Shock
- FIGURE 11-12 Anaphylactic shock. IgE, Immunoglobulin E; SVR, systemic vascular resistance.
- Septic Shock
- TABLE 11-7 Clinical Condition, Diagnostic Criteria, and Management in the Continuum of Sepsis
- FIGURE 11-13 Sepsis and septic shock pathophysiology.
- TABLE 11-8 Stages of Septic Shock
- MULTIPLE ORGAN DYSFUNCTION SYNDROME
- FIGURE 11-14 Pathogenesis of multiple organ dysfunction syndrome. MODS, Multiple organ dysfunction syndrome; GI, gastrointestinal; PAF, platelet activating factor; WBCs, white blood cells; MDF, myocardial depressant factor.
- PATIENT OUTCOMES
- TABLE 11-9 Multiple Organ Dysfunction Syndrome
- CASE STUDY
- QUESTIONS
- SUMMARY
- CRITICAL THINKING QUESTIONS
- REFERENCES
- CHAPTER 12 Cardiovascular Alterations
- INTRODUCTION
- NORMAL STRUCTURE AND FUNCTION OF THE HEART
- FIGURE 12-1 The heart lies in the mediastinum, between the lungs. Its apex rests on the diaphragm. The heart is covered by the pericardium. The inset shows the layers of the heart muscle and the pericardium.
- FIGURE 12-2 Structure of the heart and course of blood flow through the heart chambers.
- Autonomic Control
- Coronary Circulation
- FIGURE 12-3 A, The atrioventricular (AV) valves in the open position and the semilunar (SL) valves in the closed position. B, The AV valves in the closed position and the SL valves in the open position.
- FIGURE 12-4 Autonomic control of circulation. AV, Atrioventricular; Pvv, pulmonary venules; Raa, renal arterioles; SA, sinoatrial.
- BOX 12-1 Coronary Artery Distribution
- Right Coronary Artery
- Left Anterior Descending Artery
- Circumflex Artery
- Other Cardiac Functions
- Heart Sounds
- FIGURE 12-5 The coronary vessels.
- FIGURE 12-6 Chest areas from which each valve sound is best heard.
- TABLE 12-1 Grading of Heart Murmurs
- Heart Murmur
- CORONARY ARTERY DISEASE
- Pathophysiology
- Assessment
- Patient Assessment
- FIGURE 12-7 Schematic of atherosclerotic plaque. 1. Accumulation of lipoprotein particles in the intima. 2. Oxidative stress. 3. Induction of the cytokines and movement into the intima. 4. Blood monocytes encounter stimuli that augment their expression of scavenger receptors. 5. Scavenger receptors mediate the uptake of modified lipoprotein particles and promote the development of foam cells. Cytokines and superoxide anion (O2−). 6. Smooth muscle cells divide and migrate into the intima from the media. 7. Smooth muscle cells promote extracellular atherosclerotic plaque growth. Fatty streaks evolve into fatty lesions. 8. Calcification can occur and fibrosis continues.
- BOX 12-2 Risk Factors for Coronary Artery Disease
- Gender
- Heredity
- Age
- Smoking
- Blood Cholesterol
- High Blood Pressure
- Physical Inactivity
- Overweight and Obesity
- Diabetes
- BOX 12-3 Questioning of Activities for Stress Reduction
- CLINICAL ALERT
- TABLE 12-2 Major Systems Assessment
- Diagnostic Studies
- 12-Lead Electrocardiography.
- Holter Monitor.
- Exercise Tolerance Test (ETT) or Stress Test.
- Chest X-ray.
- Echocardiography.
- Transesophageal Echocardiography.
- Diagnostic Heart Scans.
- Technetium-99m Stannous Pyrophosphate.
- Thallium-201.
- Multigated Blood Pool Study.
- Nitroglycerin MUGA.
- Sestamibi Exercise Testing and Scan.
- Single Photon Emission Computed Tomography.
- Cardiac Catheterization and Arteriography.
- Magnetic Resonance Imaging.
- FIGURE 12-8 FemoStop in correct position.
- BOX 12-4 Nursing Care after Cardiac Catheterization and Arteriography
- Electrophysiology Study.
- Laboratory Diagnostics
- Serum Electrolytes.
- Serum Enzymes.
- TABLE 12-3 ECG Changes Associated with Electrolyte Imbalances
- Nursing Diagnoses
- Interventions
- Nursing Interventions
- Medical Management
- Medications to Reduce Serum Lipid Levels.
- PHARMACOLOGY TABLE 12-4 Medications for Lowering Cholesterol and Triglycerides
- LABORATORY ALERT
- Medications to Prevent Platelet Adhesion and Aggregation.
- Patient Outcomes
- ANGINA
- Pathophysiology
- Types of Angina
- BOX 12-5 Factors That Influence Oxygen Demand and Supply
- Increased Oxygen Demand
- Reduced Oxygen Supply
- Assessment
- CLINICAL ALERT
- Diagnostic Studies
- Nursing Diagnoses
- Interventions
- Nursing Interventions
- Medical Interventions
- PHARMACOLOGY TABLE 12-5 Drugs for Acute Coronary Syndromes
- BOX 12-6 Instructions Regarding Nitroglycerin
- Outcomes
- ACUTE MYOCARDIAL INFARCTION
- Pathophysiology
- EVIDENCE-BASED PRACTICE
- PROBLEM
- QUESTION
- REFERENCE
- EVIDENCE
- IMPLICATIONS FOR NURSING
- FIGURE 12-9 Electrocardiographic alterations associated with the three zones of myocardial infarction.
- Assessment
- Patient Assessment
- Diagnosis
- Nursing Diagnoses
- Complications
- Medical Interventions
- TABLE 12-6 Myocardial Infarction by Site, Electrocardiographic Changes, and Complications
- Pain Relief.
- Oxygen.
- Antidysrhythmics.
- Prevention of Platelet Aggregation.
- Thrombolytic Therapy.
- TABLE 12-7 Criteria for Diagnosis of Acute Coronary Syndrome
- Percutaneous Coronary Intervention.
- NURSING CARE PLAN for the Patient with Acute Myocardial Infarction
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- PHARMACOLOGY TABLE 12-8 Thrombolytics
- Facilitated Percutaneous Coronary Intervention.
- Medications.
- Nitrates.
- Beta-Blockers.
- Angiotensin-Converting Enzyme Inhibitors.
- Outcomes
- INTERVENTIONAL CARDIOLOGY
- Percutaneous Transluminal Coronary Angioplasty
- FIGURE 12-10 Coronary angioplasty procedure. A-D, Order of procedure.
- Complications
- Intracoronary Stent
- FIGURE 12-11 Radiographs of patients with triple-vessel disease with images before (A and B) and after (C and D) angioplasty.
- SURGICAL REVASCULARIZATION
- Coronary Artery Bypass Graft
- FIGURE 12-12 Coronary artery bypass graft surgery. Saphenous vein is harvested from the leg using either a traditional long incision or less-invasive videoscopic harvesting (A). The vein is then anastomosed to the coronary artery (B).
- Minimally Invasive Coronary Artery Surgery
- Transmyocardial Revascularization
- BOX 12-7 Key Points for Maintaining Chest and Mediastinal Tubes
- Definitions
- Baseline Assessment
- Maintaining the Chest Drainage System
- Assisting with Removal
- Autotransfusion
- Management after Cardiac Surgery
- Complications of Cardiac Surgery
- CARDIAC DYSRHYTHMIAS
- BOX 12-8 Nursing Interventions after Cardiac Surgery
- Radiofrequency Catheter Ablation
- PHARMACOLOGY TABLE 12-9 Medications Used to Treat Dysrhythmias
- Permanent Pacemakers
- Implantable Cardioverter-Defibrillator
- TABLE 12-10 Modified Generic Code for Pacemakers
- BOX 12-9 Indications for an Implantable Cardioverter-Defibrillator
- BOX 12-10 Patient and Family Teaching for an Implantable Cardioverter-Defibrillator
- Preprocedural Teaching
- Postprocedural Teaching
- HEART FAILURE
- Pathophysiology
- TABLE 12-11 Heart Failure Stages and Descriptions
- BOX 12-11 Causes of Heart Failure
- Left Heart Systolic Failure
- Left Heart Diastolic Failure
- Right Heart Systolic Failure
- Right Heart Diastolic Failure
- BOX 12-12 Signs and Symptoms of Heart Failure
- Left-Sided Heart Failure: Poor Pump
- Right Sided Hearty Failure: Excess Volume
- Assessment
- Nursing Diagnoses
- Interventions
- NURSING CARE PLAN for the Patient with Heart Failure
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- NURSING DIAGNOSIS
- PATIENT OUTCOME
- PHARMACOLOGY TABLE 12-13 Specific Medications for Heart Failure
- TABLE 12-12 Medication Subsets for Heart Failure
- Complications
- Pulmonary Edema
- TRANSPLANTATION Cardiac
- INDICATIONS
- CRITERIA FOR TRANSPLANT RECIPIENT
- CRITERIA FOR DONOR
- PATIENT MANAGEMENT
- COMPLICATIONS
- PREVENTING REJECTION
- REFERENCES
- Cardiogenic Shock
- PERICARDIAL DISEASE
- Pericarditis
- ENDOCARDITIS
- VASCULAR ALTERATIONS
- FIGURE 12-13 Anatomy of the aorta and its major branches.
- Aortic Aneurysms
- FIGURE 12-14 The four types of aneurysms.
- Aortic Dissection
- Nursing Assessment
- Diagnostic Studies
- GENETICS
- MARFAN SYNDROME
- REFERENCES
- Treatment
- FIGURE 12-15 Surgical repair of an abdominal aortic aneurysm. The aneuysmal sac is incised (A). The synthetic graft is inserted (B), and the native aortic wall is sutured over the synthetic graft (C).
- BOX 12-13 Nursing Interventions after Aortic Surgery
- CASE STUDY
- QUESTIONS
- SUMMARY
- GERIATRIC CONSIDERATIONS
- MEDICATIONS
- PROCEDURES
- SURGERY
- POSTOPERATIVE
- FAMILY
- REHABILITATION
- CRITICAL THINKING QUESTIONS
- REFERENCES
- CHAPTER 13 Nervous System Alterations
- INTRODUCTION
- ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEM
- Cells of the Nervous System
- FIGURE 13-1 A neuron, the basic element of the nervous system.
- Transmission of Nerve Impulses
- Synapses
- Neurotransmitters
- Cerebral Circulation
- TABLE 13-1 Common Neurotransmitters and Their Actions
- Brain Metabolism
- FIGURE 13-2 Arteries at the base of the brain. The arteries that compose the circle of Willis are the two anterior cerebral arteries, joined to each other by the anterior communicating two short segments of the internal carotids, off of which the posterior communicating arteries connect to the posterior cerebral arteries.
- Brain Barrier System
- Ventricular System and Cerebrospinal Fluid
- FUNCTIONAL AND STRUCTURAL DIVISIONS OF THE CENTRAL NERVOUS SYSTEM
- Meninges
- FIGURE 13-3 Cerebrospinal fluid (CSF) circulation. Arrows represent the route of CSF. CSF is produced in the ventricles and returns to the venous circulation in the superior sagittal sinus.
- Brain (Encephalon)
- Cerebrum
- FIGURE 13-4 Frontal section of the skull and brain showing the relationships of the meninges.
- FIGURE 13-5 Major divisions of the central nervous system.
- FIGURE 13-6 The structures of the brain (midsagittal section).
- FIGURE 13-7 Cerebral hemispheres.
- Diencephalon
- Brainstem
- Cerebellum
- Specialized Systems within the Central Nervous System
- Spinal Cord
- FIGURE 13-8 Each of the 31 pairs of spinal nerves exit the spinal cavity from the vertebrae. The names of the vertebrae are listed on the left, and the corresponding spinal nerves are listed on the right.
- Plexuses
- Peripheral Nervous System
- Autonomic Nervous System
- FIGURE 13-9 Dermatome distribution of spinal nerves. A, Anterior view. B, Posterior view. C, Side view.
- Effects of Aging
- TABLE 13-2 The Cranial Nerves and Assessment in the Critically Ill Patient
- GERIATRIC CONSIDERATIONS
- Assessment
- CLINICAL ALERT
- Neurological Assessment
- Mental Status.
- FIGURE 13-10 The Glasgow Coma Scale is based on eye opening, movement, and verbal responses. Each response is given a number, and the three scores are summed. Scores range from 3 to 15.
- Language Skills.
- Memory.
- Cranial Nerve Functioning.
- Motor Status.
- Spontaneous Movement.
- Muscle Strength.
- Muscle Tone.
- Deep Tendon Reflexes.
- Babinski’s Reflex.
- Coordination.
- Abnormal Posture.
- Sensory Assessment.
- FIGURE 13-11 Deep tendon reflexes. A, Biceps. B, Triceps. C, Brachioradialis. D, Patellar. E, Achilles.
- Respiratory Assessment.
- Hourly Assessment.
- INCREASED INTRACRANIAL PRESSURE
- FIGURE 13-12 Babinski’s reflex. A, Light pressure is applied with a hard object to the lateral surface of the sole, starting at the heel and going over the ball of the foot ending beneath the great toe. B, Normal response is flexion of all toes. C, Positive Babinski’s response is dorsiflexion of the great toe and fanning of the other toes.
- FIGURE 13-13 Abnormal motor responses. A, Flexion posturing. B, Extensor posturing. C, Flexion posturing on right side and extensor posturing on left side.
- TABLE 13-3 Spinal Nerve Innervation of Major Muscle Groups
- Pathophysiology
- TABLE 13-4 Respiratory Patterns in Neurological Disorders
- FIGURE 13-14 Intracranial pressure–volume curve. Between points A and B, intracranial compliance is present. Intracranial pressure (ICP) is normal, and increases in intracranial volume are tolerated without large increases in ICP. As compliance is lost, small increases in volume result in large and dangerous increases in ICP (points C and D).
- FIGURE 13-15 Pathophysiology flow diagram for increased intracranial pressure.
- TABLE 13-5 Components of the Hourly Neurological Assessment for Patients with Increased Intracranial Pressure, Head Injury, or Acute Stroke
- TABLE 13-6 Herniation Syndromes
- Causes of Increased Intracranial Pressure
- Increased Brain Volume
- BOX 13-1 Risk Factors for Increased Intracranial Pressure
- Increased Brain Volume
- Increased Cerebral Blood Flow
- Increased Cerebrospinal Fluid
- Increased Cerebral Blood Volume
- Loss of Autoregulation.
- Decreased Cerebral Oxygenation.
- Increased Metabolic Demands.
- Obstructed Venous Outflow.
- FIGURE 13-16 Herniation syndromes. A, Normal intracranial structures. B, Supratentorial herniation syndromes. C, Cerebellar tonsil herniation.
- CLINICAL ALERT
- Optimal Positioning
- Increased Cerebrospinal Fluid
- Assessment
- Monitoring Techniques
- Intracranial Pressure Monitoring.
- FIGURE 13-17 Intracranial pressure monitoring sites.
- Intracranial Pressure Waveform Monitoring.
- FIGURE 13-18 Intracranial pressure (ICP) waveforms. A, Normal ICP waveform. B, Abnormal waveform.
- TABLE 13-7 Intracranial Pressure Monitoring Devices3
- Ventriculostomy.
- Hemodynamic Monitoring.
- Cerebral Oxygenation Monitoring.
- FIGURE 13-19 Becker external drainage and monitoring system. (Courtesy of Medtronic, Minneapolis, MN.)
- Respiratory Monitoring.
- Bedside Electroencephalographic Monitoring.
- Diagnostic Testing
- Nursing Diagnoses
- Management
- Medical and Nursing Interventions (Nonsurgical)
- Nursing Actions to Manage Intracranial Pressure.
- NURSING CARE PLAN for the Patient with Traumatic Brain Injury, Increased Intracranial Pressure, or Acute Stroke
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- Optimal cerebral perfusion
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- Improved cerebral tissue perfusion
- NURSING DIAGNOSIS
- Optimal gas exchange
- Optimal gas exchange
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- Optimal fluid balance
- NURSING DIAGNOSIS
- Optimal nutrition
- Optimal nutrition
- NURSING DIAGNOSES
- PATIENT OUTCOMES
- Free of infection
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- Optimal thought processes
- NURSING DIAGNOSIS
- PATIENT OUTCOME
- Family demonstrates effective adaptation to the situation
- Medical Management.
- Adequate Oxygenation.
- Management of Carbon Dioxide.
- Diuretics.
- Optimal Fluid Administration.
- Blood Pressure Management.
- Reducing Metabolic Demands.
- Temperature Control.
- Sedation.
- PHARMACOLOGY TABLE 13-8 Frequently Used Drugs in Nervous System Alterations
- EVIDENCE-BASED PRACTICE
- PROBLEM
- QUESTION
- REFERENCE
- EVIDENCE
- IMPLICATIONS FOR NURSING
- Seizure Prophylaxis.
- Neuromuscular Blockade and Barbiturate Therapy.
- Surgical Interventions
- Psychosocial Support
- TRAUMATIC BRAIN INJURY
- Pathophysiology
- FIGURE 13-20 Pathophysiology flow diagram for traumatic brain injury. CSF, Cerebrospinal fluid; Ca++, calcium; ICP, intracranial pressure.
- TABLE 13-9 Types of Traumatic Injury with Associated Signs and Symptoms
- Scalp Lacerations
- FIGURE 13-21 Coup and contrecoup head injury after blunt trauma. A, Coup injury: impact against object. a, Site of impact and direct trauma to the brain. b, Shearing of the subdural veins. c, Trauma to the base of the brain. B, Contrecoup injury: impact within skull. a, Site of impact from brain hitting opposite side of skull. b, Shearing forces throughout the brain. These injuries occur in one continuous motion—the head strikes the wall (coup), then rebounds (contrecoup).
- Skull Fractures
- Linear Skull Fracture.
- FIGURE 13-22 Skull fractures. A, Linear; open, depressed; basilar and comminuted fractures. B, View of base of skull with fractures.
- Depressed Skull Fracture.
- FIGURE 13-23 A, Raccoon eyes, rhinorrhea. B, Battle’s sign with otorrhea. C, Halo or ring sign.
- Comminuted Skull Fracture.
- Brain Injury
- Primary Brain Injury.
- Concussion.
- Contusion.
- Diffuse Axonal Injury.
- Penetrating Injury.
- FIGURE 13-24 Types of hematomas. A, Subdural (takes on contour of brain). B, Epidural. C, Intracerebral.
- Hematoma.
- Epidural Hematoma.
- Subdural Hematoma.
- Intracerebral Hematoma.
- Secondary Brain Injury.
- Assessment
- Nursing Diagnoses
- Management
- Medical (Nonsurgical) Interventions
- Surgical Interventions
- ACUTE STROKE
- GENETICS
- APOLIPOPROTEIN E AND COGNITIVE RECOVERY AFTER BRAIN INJURY
- REFERENCES
- Pathophysiology
- Ischemic Stroke
- Large Artery Atherosclerosis.
- FIGURE 13-25 Proximal occlusion of left middle cerebral artery with infarction. Ischemic penumbra represents regional blood flow at about 25 mL/100 g/min. Ischemic penumbra is the area where acute therapies for stroke are targeted.
- Cardioembolic Stroke.
- Lacunar Stroke.
- FIGURE 13-26 Common arterial and cardiac abnormalities causing ischemic stroke.
- Cryptogenic Stroke.
- Hemorrhagic Stroke
- Intraparenchymal Hemorrhage.
- Ruptured Cerebral Aneurysm with Subarachnoid Hemorrhage.
- Arteriovenous Malformation.
- Assessment
- BOX 13-2 Signs and Symptoms of Stroke
- TABLE 13-10 National Institutes of Health Stroke Scale
- Diagnostic Tests
- Management
- Nursing Diagnoses
- Ischemic Stroke
- Thrombolytic Candidates.
- BOX 13-3 Diagnostic Testing for Stroke
- Initial Diagnostic Testing
- Additional Diagnostic Testing1
- Nonthrombolytic Candidates.
- BOX 13-4 Administration of Tissue Plasminogen Activator for Acute Ischemic Stroke
- Inclusion Criteria
- Exclusion Criteria
- Administration
- Other Ischemic Events
- Transient Ischemic Attacks.
- Hemorrhagic Stroke
- Intraparenchymal Stroke.
- Subarachnoid Hemorrhage
- Arteriovenous Malformation
- Postoperative Neurosurgical Care
- SEIZURES AND STATUS EPILEPTICUS
- TABLE 13-11 Classification of Seizures
- Pathophysiology of Status Epilepticus
- Assessment
- Diagnostic Tests
- Management
- Nursing Diagnoses
- Nursing and Medical Interventions
- CENTRAL NERVOUS SYSTEM INFECTIONS
- Bacterial Meningitis
- Pathophysiology
- BOX 13-5 Causes of Meningitis
- Bacterial
- Viruses
- Fungal
- Assessment
- Diagnostic Tests
- Management
- Nursing Diagnoses.
- TABLE 13-12 Manifestations of Cranial Nerve Inflammation in Bacterial Meningitis
- Nursing and Medical Management.
- SPINAL CORD INJURY
- Pathophysiology
- Assessment
- Airway and Respiratory Assessment
- Neurological Assessment
- Hemodynamic Assessment
- FIGURE 13-27 Pathophysiology flow diagram for spinal cord injury. ANS, Autonomic nervous system; K+, potassium; Na+, sodium; Ca2+, calcium; O2, oxygen; PaO2, partial pressure of oxygen in arterial blood; PaCO2, partial pressure of carbon dioxide in arterial blood.
- Bowel and Bladder Function
- FIGURE 13-28 Common spinal cord syndromes.
- Skin Assessment
- TABLE 13-13 Components of the Hourly Neurological Assessment for Patients with Spinal Cord Injury*
- Psychological Assessment
- Diagnostic Studies
- BOX 13-6 Autonomic Dysreflexia
- Medical Emergency; Can Result in Stroke, Seizures, or Other Complications
- Triggered by a Variety of Stimuli
- Common Signs and Symptoms
- Treatment
- Management
- Nursing Interventions
- NURSING CARE PLAN for the Patient with Spinal Cord Injury
- NURSING DIAGNOSIS
- PATIENT OUTCOMES Risk for injury minimized
- NURSING DIAGNOSIS
- PATIENT OUTCOMES Adequate gas exchange
- NURSING DIAGNOSIS
- PATIENT OUTCOME
- Within 24-48 hours, airway clear
- NURSING DIAGNOSIS
- PATIENT OUTCOME
- NURSING DIAGNOSIS
- PATIENT OUTCOMES Adequate CO
- NURSING DIAGNOSIS
- PATIENT OUTCOMES Adequate nutrition
- NURSING DIAGNOSIS
- PATIENT OUTCOME
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- Free of infection
- NURSING DIAGNOSIS
- PATIENT OUTCOME
- NURSING DIAGNOSIS
- PATIENT OUTCOME
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- Reduced fear and anxiety
- NURSING DIAGNOSIS
- PATIENT OUTCOME
- Nursing and Medical Interventions
- FIGURE 13-29 Halo vest.
- Surgical Intervention
- CASE STUDY
- QUESTIONS
- SUMMARY
- CRITICAL THINKING QUESTIONS
- REFERENCES
- CHAPTER 14 Acute Respiratory Failure
- INTRODUCTION
- ACUTE RESPIRATORY FAILURE
- Definition
- Pathophysiology
- Failure of Oxygenation
- Hypoventilation.
- Intrapulmonary Shunting.
- FIGURE 14-1 Pulmonary causes of hypoxemia. A, Normal alveolar-capillary unit. B, Hypoventilation causes an increased PaCO2 and decreased PaO2. C, Shunt. D, Ventilation-perfusion mismatch resulting from pulmonary embolus. E, Diffusion defect due to increased interstitial fluid.
- Ventilation-Perfusion Mismatch.
- Diffusion Defects.
- Low Cardiac Output.
- Low Hemoglobin Level.
- Tissue Hypoxia.
- Failure of Ventilation
- Hypoventilation.
- Ventilation-Perfusion Mismatch.
- Assessment
- Effects of Aging
- GERIATRIC CONSIDERATIONS
- Interventions
- CLINICAL ALERT
- Nursing Diagnoses
- RESPIRATORY FAILURE IN ACUTE RESPIRATORY DISTRESS SYNDROME
- Definition
- NURSING CARE PLAN for a Patient with Acute Respiratory Failure*
- NURSING DIAGNOSIS
- PATIENT OUTCOMEs
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- Absence of infection
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- Anxiety decreased or absent
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- Family integrity maintained
- Etiology
- TABLE 14-1 Mechanical Ventilation Protocol for Acute Respiratory Distress Syndrome (NHLBI, NIH)
- BOX 14-1 Possible Causes for Acute Respiratory Distress Syndrome
- Direct Causes
- Indirect Causes
- Pathophysiology
- Assessment
- FIGURE 14-2 Pathogenesis of acute respiratory distress syndrome (ARDS). TNF, Tumor necrosis factor; IL-1, interleukin-1; PAF, platelet-activating factor; RBCs, red blood cells.
- Interventions
- Oxygenation
- EVIDENCE-BASED PRACTICE
- PROBLEM
- QUESTION
- REFERENCE
- EVIDENCE
- IMPLICATIONS FOR NURSING
- Sedation/Comfort
- Prone Positioning
- Fluid and Electrolytes
- Nutrition
- Pharmacological Treatment
- Psychosocial Support
- ACUTE RESPIRATORY FAILURE IN CHRONIC OBSTRUCTIVE PULMONARY DISEASE
- Pathophysiology
- TABLE 14-2 Pathological and Physiological Changes in Chronic Obstructive Pulmonary Disease
- Assessment
- CLINICAL ALERT
- Interventions
- Oxygen
- BOX 14-2 Treatment of Stable Chronic Obstructive Pulmonary Disease
- Bronchodilator Therapy
- TABLE 14-3 Bronchodilators
- Corticosteroids
- Antibiotics
- Ventilatory Assistance
- ACUTE RESPIRATORY FAILURE IN ASTHMA
- Pathophysiology
- Assessment
- FIGURE 14-3 Airway obstruction caused by asthma. A, Normal lung. B, Bronchial asthma: thick mucus, mucosal edema, and smooth muscle spasm causing obstruction of small airways.
- Interventions
- BOX 14-3 Asthma Triggers
- Inhalant Allergens
- Occupational Exposure
- Irritants
- Other Factors Influencing Asthma Severity
- CLINICAL ALERT
- TABLE 14-4 Emergency Treatment of Severe Asthma
- ACUTE RESPIRATORY FAILURE RESULTING FROM VENTILATOR-ASSOCIATED PNEUMONIA
- Definition and Etiology
- FIGURE 14-4 Role of airway management in the pathogenesis of ventilator-associated pneumonia.
- Pathophysiology
- Assessment
- TABLE 14-5 Modified Clinical Pulmonary Infection Score
- Interventions
- Prevention
- Hand Hygiene and Universal Precautions.
- Respiratory Equipment.
- BOX 14-4 Prevention of Ventilator-Associated Pneumonia
- Patient Position and Mobility.
- Oral Care.
- Gastric Tubes, Nutrition, and Peptic Ulcer Prophylaxis.
- BOX 14-5 Example of a Comprehensive Oral Care Protocol
- Interventions
- Equipment
- Sedation Interruption and Daily Assessment of Readiness to Extubate.
- Treatment
- ACUTE RESPIRATORY FAILURE RESULTING FROM PULMONARY EMBOLISM
- Definition/Classification
- Etiology
- Pathophysiology
- BOX 14-6 Risk Factors for Venous Thromboembolism
- Venous Stasis
- Vessel Wall Injury
- Hypercoagulability
- Assessment
- Diagnosis
- Arterial Blood Gases.
- Electrocardiogram.
- Chest X-ray.
- D-dimer Assay.
- Ventilation-Perfusion Scan.
- Duplex Ultrasonography.
- Echocardiogram.
- High-Resolution Multidetector Computed Tomography Angiography.
- Magnetic Resonance Imaging.
- Pulmonary Angiogram.
- Prevention
- Treatment
- BOX 14-7 Nursing Measures to Prevent Venous Thromboembolism
- GENETICS
- CYSTIC FIBROSIS: A HERITABLE DISORDER WITH PULMONARY AND GASTROINTESTINAL COMPLICATIONS
- REFERENCES
- TRANSPLANTATION Lung
- INTRODUCTION
- CRITERIA FOR TRANSPLANT RECIPIENTS
- CRITERIA FOR DONORS
- PATIENT MANAGEMENT
- COMPLICATIONS
- PREVENTING REJECTION
- REFERENCES
- ACUTE RESPIRATORY FAILURE IN ADULT PATIENTS WITH CYSTIC FIBROSIS
- Definition
- Etiology
- Interventions
- CASE STUDY
- QUESTIONS
- SUMMARY
- CRITICAL THINKING QUESTIONS
- REFERENCES
- CHAPTER 15 Acute Renal Failure
- INTRODUCTION
- REVIEW OF ANATOMY AND PHYSIOLOGY
- FIGURE 15-1 Anatomy of the nephron, the functional unit of the kidney.
- BOX 15-1 Functions of the Kidney
- Regulation of Fluid and Electrolytes and Excretion of Waste Products
- Regulation of Acid-Base Balance
- FIGURE 15-2 Average pressures involved in filtration from the glomerular capillaries.
- Regulation of Blood Pressure
- FIGURE 15-3 Renin-angiotensin mechanism.
- Effects of Aging
- PATHOPHYSIOLOGY OF ACUTE RENAL FAILURE
- Definition
- Etiology
- Prerenal Causes of Acute Renal Failure
- Postrenal Causes of Acute Renal Failure
- Intrarenal Causes of Acute Renal Failure
- BOX 15-2 Prerenal Causes of Acute Renal Failure
- Volume Depletion
- Vasodilation
- Impaired Cardiac Performance
- Miscellaneous
- BOX 15-3 Postrenal Causes of Acute Renal Failure
- Acute Tubular Necrosis.
- FIGURE 15-4 Schematic of loss of glomerular filtration seen in ischemic and nephrotoxic acute tubular necrosis.
- BOX 15-4 Intrarenal Causes of Acute Renal Failure
- Glomerular, Vascular, or Hematological Problems
- Tubular Problem (Acute Tubular Necrosis or Acute Interstitial Nephritis)
- Contrast-Induced Nephropathy.
- EVIDENCE-BASED PRACTICE
- Acute Renal Failure
- PROBLEM
- QUESTION
- REFERENCE
- EVIDENCE
- IMPLICATIONS FOR NURSING
- Course of Acute Renal Failure
- Initiation (Onset) Phase.
- Maintenance (Oliguric/Anuric) Phase.
- Recovery (Diuretic) Phase.
- ASSESSMENT
- Patient History
- BOX 15-5 Common Nephrotoxic Medications
- Vital Signs
- Physical Assessment
- TABLE 15-1 Systemic Manifestations of Acute Renal Failure
- Evaluation of Laboratory Values
- CLINICAL ALERT
- Serum Creatinine
- TABLE 15-2 Laboratory Findings Useful in Differentiating Causes of Acute Renal Failure
- Diagnostic Procedures
- GERIATRIC CONSIDERATIONS
- Management of Acute Renal Failure
- NURSING DIAGNOSES
- NURSING INTERVENTIONS
- TABLE 15-3 Invasive Diagnostic Procedures for Assessing the Renal System
- NURSING CARE PLAN for the Patient with Acute Renal Failure
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- Stable fluid balance
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- Absence of infection
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- Adequate nutritional and caloric intake
- NURSING DIAGNOSIS
- PATIENT OUTCOME Anxiety levels reduced
- NURSING DIAGNOSIS
- PATIENT OUTCOME
- CLINICAL ALERT
- Fluid Volume Overload
- MEDICAL MANAGEMENT OF ACUTE RENAL FAILURE
- Prerenal Causes
- Postrenal Causes
- Intrarenal Causes: Acute Tubular Necrosis
- Pharmacological Management
- Diuretics.
- BOX 15-6 Measures to Prevent Acute Renal Failure
- Avoid Nephrotoxins
- Optimize Volume Status Before Surgery or Invasive Procedures
- Reduce Incidence of Nosocomial Infections
- Implement Tight Glycemic Control in the Critically Ill
- Aggressively Investigate and Treat Sepsis
- Dopamine.
- Acetylcysteine.
- Fenoldopam.
- Theophylline.
- Miscellaneous Agents.
- Epoetin Alfa (Epogen).
- Pharmacological Management Considerations.
- Dietary Management
- BOX 15-7 Common Drugs Removed by Hemodialysis*
- Management of Fluid, Electrolyte, and Acid-Base Imbalances
- Fluid Imbalance.
- Electrolyte Imbalance.
- LABORATORY ALERT
- Acute Renal Failure
- FIGURE 15-5 Electrocardiographic (ECG) changes seen in hyperkalemia.
- Acid-Base Imbalance.
- PHARMACOLOGY TABLE 15-4 Medications to Treat Hyperkalemia
- BOX 15-8 Metabolic Acidosis in Acute Renal Failure
- Etiology
- Signs and Symptoms
- Renal Replacement Therapy
- Definition.
- Indications for Dialysis.
- Principles and Mechanisms.
- Vascular Access.
- FIGURE 15-6 Central venous catheter used for hemodialysis.
- FIGURE 15-7 Hemodialysis access devices.
- Nursing Care of Arteriovenous Fistula or Graft.
- Nursing Care of Percutaneous Catheters.
- Hemodialysis.
- Complications.
- Nursing Care of the Patient.
- BOX 15-9 Complications of Dialysis
- Continuous Renal Replacement Therapy.
- TABLE 15-5 Continuous Renal Replacement Therapies
- Indications.
- Principles.
- Complications.
- Nursing Care.
- Peritoneal Dialysis.
- FIGURE 15-8 Schematic of A, continuous venovenous hemofiltration (CVVH) and B, continuous venovenous hemofiltration dialysis (CVVHD).
- Indications.
- Complications.
- FIGURE 15-9 Prismaflex continuous renal replacement therapy system.
- Contraindications.
- TRANSPLANTATION Renal
- INDICATIONS
- CRITERIA FOR TRANSPLANT RECIPIENT
- CRITERIA FOR DONORS
- PATIENT MANAGEMENT
- COMPLICATIONS
- PREVENTING REJECTION
- REFERENCES
- OUTCOMES
- CASE STUDY
- QUESTIONS
- SUMMARY
- CRITICAL THINKING QUESTIONS
- REFERENCES
- CHAPTER 16 Hematological and Immune Disorders
- INTRODUCTION
- REVIEW OF ANATOMY AND PHYSIOLOGY
- Hematopoiesis
- Effects of Aging
- Components and Characteristics of Blood
- TABLE 16-1 Hematology-Immunology Key Terms
- Hematopoietic Cells
- Erythrocytes
- FIGURE 16-1 Hematopoietic stem cell and lineage.
- FIGURE 16-2 Hematopoietic organs and their function.
- GERIATRIC CONSIDERATIONS
- Platelets
- TABLE 16-2 Characteristics of Blood
- Leukocytes
- Granular Leukocytes
- Neutrophils.
- TABLE 16-3 Overview of Leukocytes
- Eosinophils.
- Basophils.
- Nongranular Leukocytes (Agranulocytes)
- Monocytes.
- Lymphocytes.
- Immune Anatomy
- Immune Physiology
- Nonspecific Defenses
- Epithelial Surfaces.
- Inflammation and Phagocytosis.
- Other Nonspecific Defenses.
- Specific Defenses
- Humoral Immunity.
- Cell-Mediated Immunity.
- TABLE 16-4 Immunoglobulins
- Hemostasis
- FIGURE 16-3 Coagulation physiology.
- Coagulation Pathway
- Coagulation Antagonists and Clot Lysis
- FIGURE 16-4 Coagulation cascade.
- NURSING ASSESSMENT OF HEMATOLOGICAL AND IMMUNOLOGICAL FUNCTION
- TRANSPLANTATION Hematopoietic Stem Cell Transplantation
- INDICATIONS
- CATEGORIES
- TISSUE TYPING
- COMPLICATIONS
- REFERENCES
- Past Medical History
- Evaluation of Patient Complaints and Physical Examination
- FIGURE 16-5 Fibrinolysis.
- Diagnostic Tests
- BOX 16-1 Conditions that may Indicate Hematological and Immunological Problems*
- SELECTED ERYTHROCYTE DISORDERS
- TABLE 16-5 Physical Assessment for Hemotological and Immune Disorders
- Anemia
- Pathophysiology
- TABLE 16-6 Functions and Normal Values of Blood Cells
- Assessment and Clinical Manifestations
- TABLE 16-7 Coagulation Profile Studies
- Nursing Diagnoses
- TABLE 16-8 Anemias
- Medical Interventions
- Nursing Interventions
- WHITE BLOOD CELL AND IMMUNE DISORDERS
- The Immunocompromised Patient
- Pathophysiology
- Assessment and Clinical Manifestations
- Nursing Diagnoses
- Medical Interventions
- TABLE 16-9 Risk Factors for Infections in the Immunocompromised Patient
- CLINICAL ALERT
- Infection in Immunocompromised Patients
- Nursing Interventions
- Neutropenia
- Pathophysiology
- Assessment and Clinical Manifestations
- NURSING CARE PLAN for the Immunocompromised Patient
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- Patient will remain free of infection
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- Skin and mucous membranes intact
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- Optimal nutritional status maintained
- EVIDENCE-BASED PRACTICE
- PROBLEM
- QUESTION
- REFERENCE
- EVIDENCE
- IMPLICATIONS FOR NURSING
- Nursing Diagnoses
- Medical Interventions
- BOX 16-2 Causes of Neutropenia
- Malnutrition
- Health States
- Medications
- Nursing Interventions
- Malignant White Blood Cell Disorders: Leukemia, Lymphoma, and Multiple Myeloma
- Pathophysiology
- Assessment and Clinical Manifestations
- TABLE 16-10 Malignant White Blood Cell Disorders
- Nursing Diagnoses
- Medical Interventions
- Nursing Interventions
- SELECTED IMMUNOLOGICAL DISORDERS
- Primary Immunodeficiency
- Secondary Immunodeficiency
- Acquired Immunodeficiency Syndrome
- Pathophysiology.
- Assessment and Clinical Manifestations.
- FIGURE 16-6 Human immunodeficiency virus (HIV) pathophysiology. CMV, Cytomegalovirus; CNS, central nervous system; ELISA, enzyme-linked immunosorbent assay; TB, tuberculosis.
- Nursing Diagnoses.
- Medical Interventions.
- Nursing Interventions.
- BLEEDING DISORDERS
- The Bleeding Patient
- Pathophysiology
- Assessment and Clinical Manifestations
- Nursing Diagnoses
- Medical Interventions
- NURSING CARE PLAN for the Patient with a Bleeding Disorder
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- Adequate perfusion maintained and damage to vital organs prevented
- NURSING DIAGNOSIS
- PATIENT OUTCOMES Free of bleeding and normovolemic
- Nursing Interventions
- TABLE 16-11 Summary of Blood Products and Administration
- Thrombocytopenia
- Pathophysiology
- Assessment and Clinical Manifestations
- Box 16-3 Causes of Thrombocytopenia
- Bone Marrow Suppression
- Interference with Platelet Production (Other than Nonspecific Marrow Suppression)
- Platelet Destruction Outside the Bone Marrow
- Immune Response Against Platelets
- Interference with Platelet Function
- Nursing Diagnoses
- Medical Interventions
- Box 16-4 Heparin-Induced Thrombocytopenia11,15,22
- Definition
- Risks
- Complications
- Diagnosis
- Treatment
- CLINICAL ALERT
- Bleeding Disorders
- Nursing Interventions
- Disseminated Intravascular Coagulation
- Pathophysiology
- Assessment and Clinical Manifestations
- FIGURE 16-7 Pathophysiology of disseminated intravascular coagulopathy.
- Nursing Diagnoses
- Medical Interventions
- TABLE 16-12 Causes of Disseminated Intravascular Coagulation
- GENETICS
- FACTOR V LEIDEN: AN INHERITED CLOTTING DISORDER
- REFERENCES
- LABORATORY FINDINGS
- Disseminated Intravascular Coagulation
- Nursing Interventions
- CASE STUDY
- QUESTIONS
- SUMMARY
- CRITICAL THINKING QUESTIONS
- REFERENCES
- CHAPTER 17 Gastrointestinal Alterations
- INTRODUCTION
- REVIEW OF ANATOMY AND PHYSIOLOGY
- Gastrointestinal Tract
- Gut Wall
- Mucosa.
- Gastric Mucosal Barrier.
- FIGURE 17-1 The gastrointestinal system.
- Submucosa.
- Oropharyngeal Cavity
- Mouth.
- BOX 17-1 Swallowing Stages
- Oral: Voluntary
- Pharyngeal: Involuntary
- Esophageal: Involuntary
- Salivary Glands.
- Pharynx.
- Esophagus
- FIGURE 17-2 The stomach.
- Stomach
- TABLE 17-1 Gastric Secretions
- Small Intestine
- TABLE 17-2 Electrolyte and Acid-Base Disturbances Associated with the Gastrointestinal Tract
- TABLE 17-3 Pancreatic Enzymes and Their Actions
- Large Intestine
- Accessory Organs
- Pancreas
- FIGURE 17-3 The intestinal system.
- FIGURE 17-4 The pancreas.
- Liver
- FIGURE 17-5 The normal liver lobule.
- Vascular Functions
- Blood Storage.
- Blood Filtration.
- BOX 17-2 Functions of the Liver
- Vascular Functions
- Secretory Functions
- Metabolic Functions
- Storage Functions
- Secretory Functions
- Bile Production.
- Bilirubin Metabolism.
- Metabolic Functions
- Carbohydrate Metabolism.
- Fat Metabolism.
- Protein Metabolism.
- Production and Removal of Blood Clotting Factors.
- Detoxification.
- Storage, Synthesis, and Transport of Vitamins and Minerals.
- Gallbladder
- Neural Innervation of the Gastrointestinal System
- Hormonal Control of the Gastrointestinal System
- Blood Supply of the Gastrointestinal System
- Geriatric Concerns
- TABLE 17-4 Actions of Gastrointestinal Hormones
- GENERAL ASSESSMENT OF THE GASTROINTESTINAL SYSTEM
- History
- Inspection
- GERIATRIC CONSIDERATIONS
- Skin Color and Texture
- Symmetry and Contour of Abdomen
- Masses and Pulsations
- Peristalsis and Movement
- Auscultation
- BOX 17-3 Causes of Increased and Decreased Bowel Sounds
- Causes of Decreased Bowel Sounds
- Causes of Increased Bowel Sounds
- Percussion
- Palpation
- ACUTE GASTROINTESTINAL BLEEDING
- Pathophysiology
- Peptic Ulcer Disease
- FIGURE 17-6 Duodenal ulcer. A, Deep ulceration in the duodenal wall extending as a crater through the entire mucosa and into the muscle layers. B, Duodenal ulcer.
- BOX 17-4 Causes of Gastrointestinal Bleeding
- Causes of Upper Gastrointestinal Bleeding
- Causes of Lower Gastrointestinal Bleeding8
- Stress Ulcers
- BOX 17-6 Contributing Factors to Ulcer Formation8
- BOX 17-5 Risk Factors for Peptic Ulcer Disease
- Mallory-Weiss Tear
- TABLE 17-5 Selected Studies of Gastrointestinal Function14
- TABLE 17-6 Characteristics of Gastric and Duodenal Ulcers
- Esophageal Varices
- FIGURE 17-7 The liver and collateral circulation.
- Assessment
- Clinical Presentation
- CLINICAL ALERT
- Clinical Signs and Symptoms of Upper Gastrointestinal Bleeding9
- Nursing Assessment
- FIGURE 17-8 Pathophysiology flow diagram of acute upper gastrointestinal (GI) bleeding. BP, Blood pressure.
- Medical Assessment
- Laboratory Studies.
- LABORATORY ALERTS
- Upper Gastrointestinal Bleeding5
- Complete Blood Count
- Serum Electrolyte Panel
- Hematology Profile
- Arterial Blood Gases
- Gastric Aspirate for pH and Guaiac
- Endoscopy and Barium Study.
- Nursing Diagnoses
- Collaborative Management: Nursing and Medical Considerations
- NURSING CARE PLAN for the Patient with Acute Gastrointestinal Bleeding
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- Adequate circulating blood volume
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- Adequate tissue perfusion
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- BOX 17-7 Management of Upper Gastrointestinal Bleeding
- Hemodynamic Stabilization
- Definitive and Supportive Therapies
- Hemodynamic Stabilization
- Gastric Lavage
- Pharmacological Therapy
- Antibiotics.
- Endoscopic Therapy
- PHARMACOLOGY TABLE 17-7 Pharmacological Treatments to Decrease Gastric Acid Secretion and/or Reduce Acid Effects on Gastric Mucosa10
- Surgical Therapy
- GENETICS
- Cytochrome P450 Enzymes and the Patient’s Response to Drugs
- REFERENCES
- FIGURE 17-9 Billroth I and II procedures.
- Nursing Diagnoses
- Recognition of Potential Complications
- CLINICAL ALERT
- Acute Gastric Perforation9
- Treatment of Variceal Bleeding
- Somatostatin or Octreotide
- Vasopressin
- Endoscopic Procedures
- 17-8 Vasopressin (Pitressin) Therapy10
- Mechanism of Action
- Dose
- Side Effects
- Nursing Considerations
- Transjugular Intrahepatic Portosystemic Shunt
- FIGURE 17-10 Sengstaken-Blakemore tube.
- Esophagogastric Tamponade
- Surgical Interventions
- FIGURE 17-11 Types of portacaval shunts. A, Normal portal circulation. B, End-to-side shunt. C, Side-to-side shunt.
- Patient Outcomes
- ACUTE PANCREATITIS
- Pathophysiology
- BOX 17-9 Systemic Complications of Acute Pancreatitis
- Pulmonary
- Cardiovascular
- Hematological
- Gastrointestinal
- Renal
- Metabolic
- Assessment
- History and Physical Examination
- BOX 17-10 Causes of Acute Pancreatitis
- LABORATORY ALERTS
- Pancreatitis5
- CLINICAL ALERT
- Signs and Symptoms of Acute Pancreatitis9
- Diagnostic Tests
- BOX 17-11 Other Conditions Associated with Increased Serum Amylase Levels
- Predicting the Severity of Acute Pancreatitis
- BOX 17-12 Ranson Criteria for Predicting Severity of Acute Pancreatitis*
- At Admission or on Diagnosis
- During Initial 48 Hours
- Nursing Diagnoses
- Medical and Nursing Interventions
- Fluid Replacement
- EVIDENCE-BASED PRACTICE
- PROBLEM
- QUESTION
- REFERENCES
- EVIDENCE
- IMPLICATIONS FOR NURSING
- NURSING CARE PLAN
- for the Patient with Acute Pancreatitis
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- Adequate fluid volume
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- Adequate nutrition
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- Adequate gas exchange
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- Electrolyte Replacement
- Nutrition Support
- Comfort Management
- Pharmacological Intervention
- Treatment of Systemic Complications
- Surgical Therapy
- Patient Outcomes
- HEPATIC FAILURE
- Pathophysiology
- Hepatitis
- Assessment.
- Nursing Diagnoses.
- Medical and Nursing Interventions.
- BOX 17-13 Modes of Transmission for Hepatitis
- CLINICAL ALERT
- Signs and Symptoms of Fulminant Hepatic Failure9
- TABLE 17-8 Characteristics of Hepatitis
- TRANSPLANTATION Liver
- INDICATIONS
- CRITERIA FOR TRANSPLANT RECIPIENTS
- CRITERIA FOR DONORS
- PATIENT MANAGEMENT
- COMPLICATIONS
- PREVENTING REJECTION
- REFERENCES
- BOX 17-14 Common Hepatotoxic Drugs
- Analgesics
- Anesthetics
- Anticonvulsants
- Antidepressants
- Antimicrobial Agents
- Antipsychotic Drugs
- Cardiovascular Drugs
- Hormonal Agents
- Sedatives
- Others
- Cirrhosis
- Fatty Liver
- Assessment of Hepatic Failure
- Presenting Clinical Signs
- Portal Hypertension.
- TABLE 17-9 Characteristics of Types of Cirrhosis
- BOX 17-15 Clinical Signs and Symptoms of Liver Disease
- Cardiac
- Dermatological
- Electrolytes
- Endocrine
- Fluid Alterations
- Gastrointestinal
- Hematological
- Immune System
- Neurological
- Pulmonary
- Renal
- Impaired Metabolic Processes.
- Impaired Bile Formation and Flow.
- Nursing Diagnoses
- NURSING CARE PLAN for the Patient with Hepatic Failure
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- Adequate fluid volume
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- Adequate nutrition
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- Effective breathing
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- Normal thought processes
- Medical and Nursing Interventions
- Diagnostic Tests
- Supportive Therapy
- LABORATORY ALERTS
- Liver Failure5
- From Chernecky, C. C., & Berger, B. J. (2008). Laboratory tests and diagnostic procedures (5th ed.). Philadelphia: Saunders.
- Support for the Failing Liver
- Treatment of Complications
- Ascites.
- BOX 17-16 Physiological Effects of Abdominal Compartment Syndrome
- Cardiovascular
- Respiratory
- Hepatic and Renal
- Gastrointestinal
- Neurological
- Portal Systemic Encephalopathy.
- FIGURE 17-12 The Denver shunt. Percutaneous placement of both the venous and peritoneal catheters of a Denver Ascites Shunt. Venous catheter placement into the (A) subclavian and (B) internal jugular vein.
- BOX 17-17 Stages of Portal Systemic Encephalopathy
- Stage 1
- Stage 2
- Stage 3
- Stage 4
- Hepatorenal Syndrome.
- Patient Outcomes
- CASE STUDY
- QUESTIONS
- SUMMARY
- CRITICAL THINKING QUESTIONS
- REFERENCES
- CHAPTER 18 Endocrine Alterations
- INTRODUCTION
- Changes in the Endocrine System in Critical Illness
- Disease States of the Endocrine System
- HYPERGLYCEMIA IN THE CRITICALLY ILL PATIENT
- FIGURE 18-1 Feedback system for cortisol regulation.
- Achieving Glycemic Control
- Hypoglycemia as a Preventable Adverse Effect of Glucose Management
- GERIATRIC CONSIDERATIONS
- PANCREAS
- ADRENAL
- THYROID
- PITUITARY
- The Diabetic Patient in the Critical Care Unit
- Box 18-1 Risk Factors for the Development of Hyperglycemia in the Critically Ill Patient16,19
- Box 18-2 Key Components of a Glucose Management Protocol
- PANCREATIC ENDOCRINE EMERGENCIES
- Review of Physiology
- TABLE 18-1 Types of Insulin
- Box 18-3 Physiological Activity of Insulin
- Carbohydrate Metabolism
- Fat Metabolism
- Protein Metabolism
- Effects of Aging
- Hyperglycemic Crises
- Pathogenesis
- CLINICAL ALERT
- Metabolic Syndrome
- GENETICS
- Type 2 Diabetes Mellitus: A Complex Disease with Complex Genetics
- REFERENCES
- FIGURE 18-2 Pathophysiology of diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS).
- Etiology of Diabetic Ketoacidosis.
- Box 18-4 Factors Leading to Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State
- Common Factors
- Medications
- DKA-Specific Factors
- HHS-Specific Factors
- Etiology of Hyperosmolar Hyperglycemic State.
- Pathophysiology of Diabetic Ketoacidosis
- FIGURE 18-3 Intracellular/extracellular shifts in hyperglycemic crises. DKA, Diabetic ketoacidosis.
- Box 18-5 Calculation for Anion Gap
- Pathophysiology of Hyperosmotic Hyperglycemic State
- Box 18-6 HHS and Other Synonymous Acronyms
- Assessment
- Clinical Presentation.
- TABLE 18-2 Manifestations of Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State
- Laboratory Evaluation.
- LABORATORY ALERTS
- Pancreatic Endocrine Disorders
- Nursing and Medical Interventions
- EVIDENCE-BASED PRACTICE
- PROBLEM
- QUESTION
- REFERENCES
- EVIDENCE
- IMPLICATIONS FOR NURSING
- Respiratory Support.
- Fluid Replacement.
- Insulin Therapy.
- Box 18-7 Signs and Symptoms of Fluid Overload
- Electrolyte Management.
- Treatment of Acidosis.
- Patient and Family Education.
- Patient Outcomes
- NURSING CARE PLAN for the Patient with Hyperglycemic Crisis
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- Normal respiratory rate and pattern
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- Adequate fluid volume status
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- Effective therapeutic management of diabetes
- Hypoglycemia
- Pathophysiology
- Etiology
- FIGURE 18-4 Pathophysiology of hypoglycemia.
- Assessment
- Clinical Presentation.
- Box 18-8 Causes of Hypoglycemia
- Excess Insulin or Oral Hypoglycemics
- Decreased Oral, Enteral, or Parenteral Intake
- Underproduction of Glucose
- Too Rapid Utilization of Glucose
- TABLE 18-3 Signs and Symptoms of Hypoglycemia
- Laboratory Evaluation.
- Nursing Diagnoses
- Box 18-9 Treatment of Hypoglycemia
- Mild Hypoglycemia
- Moderate Hypoglycemia
- Severe Hypoglycemia
- Nursing and Medical Interventions
- Box 18-10 Sources of 15 Grams of Carbohydrates
- Patient Outcomes
- ACUTE AND RELATIVE ADRENAL INSUFFICIENCY
- Etiology
- Box 18-11 Causes of Adrenal Insufficiency
- Primary
- Secondary
- Box 18-12 Therapeutic Uses of Corticosteroids
- Replacement Therapy in Patients with Primary or Secondary Adrenal Cortical Insufficiency
- Review of Physiology
- Box 18-13 Physiological Effects of Glucocorticoids (Cortisol)
- Pathophysiology
- FIGURE 18-5 Physiology of aldosterone release.
- Assessment
- Clinical Presentation
- Box 18-14 Risk Factor Analysis for Adrenal Crisis
- Cardiovascular System.
- Neurological System.
- FIGURE 18-6 Pathophysiological effects of adrenal insufficiency. BUN, Blood urea nitrogen; ECG, electrocardiogram; MSH, melanocyte-stimulating hormone.
- Gastrointestinal System.
- Genitourinary System.
- Box 18-15 Progressive Signs of Chronic Adrenal Insufficiency
- Laboratory Evaluation
- LABORATORY ALERTS
- Adrenal Disorders
- Nursing Diagnoses
- Box 18-16 Cosyntropin Stimulation Test
- Standard Method
- Test Response
- Nursing and Medical Interventions
- Fluid and Electrolyte Replacement
- Hormonal Replacement
- PHARMACOLOGY TABLE 18-4 Medications Used to Treat Adrenal Crisis
- Box 18-17 Treatment of Adrenal Crisis
- Identify and Treat Precipitating Event
- Replace Fluid and Electrolytes
- Hormonal Replacement
- Patient Education
- Patient and Family Education
- THYROID GLAND IN CRITICAL CARE
- Review of Physiology
- Box 18-18 Physiological Effect of Thyroid Hormones
- Major Effects
- Other Effects
- FIGURE 18-7 Feedback systems for thyroid hormone regulation.
- Box 18-19 Causes of Blockage of Conversion from Thyroxine to Triiodothyronine
- Effects of Aging
- Thyroid Function in the Critically Ill
- THYROID CRISES
- Etiology
- Box 18-20 Causes of Hyperthyroidism
- Most Common
- Other Causes
- Rare Causes
- Associated with Other Disorders*
- Thyrotoxic Crisis (Thyroid Storm)
- Pathophysiology
- Box 18-21 Causes of Hypothyroidism
- Primary Thyroid Disease
- Secondary (Pituitary) or Tertiary (Hypothalamus) Disease
- Assessment
- Clinical Presentation
- Thermoregulation Disturbances.
- Neurological Disturbances.
- Cardiovascular Disturbances.
- Box 18-22 Progressive Signs of Hyperthyroidism
- Pulmonary Disturbances.
- Gastrointestinal Disturbances.
- Musculoskeletal Disturbances.
- Laboratory Evaluation.
- Nursing Diagnoses
- TABLE 18-5 Thyroid Crises
- Nursing and Medical Interventions
- Box 18-23 Treatment of Thyroid Storm
- Antagonize Peripheral Effects of Thyroid Hormone
- Inhibit Hormone Biosynthesis
- Block Thyroid Hormone Release
- Give 1-2 Hours after Proplylthiouracil or Methimazole Loading Dose
- Secondary Options
- Supportive Therapy
- Identify and Treat Precipitating Cause
- Patient and Family Education
- LABORATORY ALERTS
- Thyroid Disorders
- Antagonism of Peripheral Effects of Thyroid Hormones.
- Inhibition of Thyroid Hormone Biosynthesis.
- Blockage of Thyroid Hormone Release.
- Supportive Care.
- Patient and Family Education.
- Patient Outcomes
- Myxedema Coma
- Pathophysiology
- Etiology
- Assessment
- Clinical Presentation.
- Cardiovascular Disturbances.
- Box 18-24 Progressive Signs of Hypothyroidism
- Pulmonary Disturbances.
- Neurological Disturbances.
- Skeletal Muscle Disturbances.
- Laboratory Evaluation.
- Nursing Diagnoses
- Nursing and Medical Interventions
- Box 18-25 Treatment of Myxedema Coma
- Thyroid Replacement.
- Fluid and Electrolyte Restoration.
- Supportive Care.
- Patient and Family Education.
- Patient Outcomes
- ANTIDIURETIC HORMONE DISORDERS
- Review of Physiology
- FIGURE 18-8 Hypothalamic–posterior pituitary system.
- Diabetes Insipidus
- Etiology
- Box 18-26 Causes of Diabetes Insipidus
- Antidiuretic Hormone Deficiency (Neurogenic Diabetes Insipidus)
- Antidiuretic Hormone Insensitivity (Nephrogenic Diabetes Insipidus)
- Secondary Diabetes Insipidus
- Pathophysiology
- FIGURE 18-9 Physiology of antidiuretic hormone (ADH) release. BP, Blood pressure.
- TABLE 18-6 Electrolyte and Fluid Findings in ADH Disorders
- Assessment
- Clinical Presentation.
- Laboratory Evaluation.
- Nursing Diagnoses
- Nursing and Medical Interventions
- Volume Replacement.
- Hormone Replacement.
- LABORATORY ALERTS
- Pituitary Disorders
- Nephrogenic Diabetes Insipidus.
- Patient and Family Education.
- Patient Outcomes
- Syndrome of Inappropriate Antidiuretic Hormone
- Etiology
- Pathophysiology
- Assessment
- Clinical Presentation.
- Box 18-27 Causes of Syndrome of Inappropriate Antidiuretic Hormone
- Ectopic Antidiuretic Hormone Production
- Central Nervous System Disorders
- Drugs
- Positive-Pressure Ventilation
- Central Nervous System.
- Gastrointestinal System.
- Cardiovascular System.
- Pulmonary System.
- Laboratory Evaluation.
- Nursing Diagnoses
- Nursing and Medical Interventions
- Fluid Balance.
- Box 18-28 Treatments for Chronic or Resistant Syndrome of Inappropriate Antidiuretic Hormone
- Nursing.
- Patient and Family Education.
- Patient Outcomes
- CASE STUDY
- QUESTIONS
- SUMMARY
- CRITICAL THINKING QUESTIONS
- REFERENCES
- CHAPTER 19 Trauma and Surgical Management
- INTRODUCTION
- TRAUMA DEMOGRAPHICS
- SYSTEMS APPROACH TO TRAUMA CARE
- Trauma System
- Levels of Trauma Care
- Trauma Continuum
- Injury Prevention
- Trauma Team Concept
- Box 19-1 Multidisciplinary Trauma Team
- Prehospital Care and Transport
- Trauma Triage
- Disaster and Mass Casualty Management
- MECHANISMS OF INJURY
- Blunt Trauma
- Penetrating Trauma
- FIGURE 19-1 Potential sites of blunt trauma injury in unrestrained passenger and driver in a motor vehicle crash. A, Unrestrained passenger in front seat. B, Unrestained driver. C, Lateral impact collision.
- Blast Injuries
- EMERGENCY CARE PHASE
- Initial Patient Assessment
- Primary and Secondary Survey
- TABLE 19-1 Primary Survey: ABCDE
- RESUSCITATION PHASE
- Establishing Airway Patency
- TABLE 19-2 Secondary Survey
- Maintaining Effective Breathing
- Maintaining Circulation
- TABLE 19-3 Specific Interventions for Ineffective Breathing Patterns
- Diagnostic Testing
- Adequacy of Resuscitation
- Fluid Resuscitation
- TABLE 19-4 Responses to Initial Fluid Resuscitation*
- EVIDENCE-BASED PRACTICE
- PROBLEM
- Question
- REFERENCE
- EVIDENCE
- IMPLICATIONS FOR NURSING
- Assessment of Neurological Disabilities
- Exposure and Environmental Considerations
- FIGURE 19-2 Medi-Temp Blood and Fluid Warmer.
- TABLE 19-5 Rewarming Strategies
- ASSESSMENT AND MANAGEMENT OF SPECIFIC ORGAN INJURIES
- Thoracic Injuries
- Cardiac Tamponade
- Cardiac Contusion
- Aortic Disruption
- Tension Pneumothorax
- Hemothorax
- Open Pneumothorax
- Pulmonary Contusion
- Rib Fractures and Flail Chest
- Abdominal Injuries
- Musculoskeletal Injuries
- FIGURE 19-3 Common types of fractures.
- Complications
- Compartment Syndrome.
- Rhabdomyolysis.
- Deep Vein Thrombosis.
- Fat Embolism Syndrome.
- CRITICAL CARE PHASE
- Damage-Control Surgery
- Postoperative Management
- GERIATRIC CONSIDERATIONS
- SPECIAL CONSIDERATIONS AND POPULATIONS
- Effects of Aging
- Alcohol and Drug Abuse
- Box 19-2 Signs and Symptoms of Alcohol Withdrawal
- Family and Patient Coping
- REHABILITATION
- CASE STUDY
- QUESTIONS
- SUMMARY
- CRITICAL THINKING QUESTIONS
- REFERENCES
- CHAPTER 20 Burns
- INTRODUCTION
- REVIEW OF ANATOMY AND PHYSIOLOGY OF THE SKIN
- Effects of Aging
- FIGURE 20-1 Anatomy of the skin.
- MECHANISMS OF INJURY
- Thermal Injury
- Chemical Injury
- Electrical Injury
- TABLE 20-1 Types of Smoke Inhalation Injury
- Inhalation Injury
- Carbon Monoxide Poisoning
- TABLE 20-2 Carboxyhemoglobin
- Injury Above the Glottis
- CLINICAL ALERT
- Clinical Indicators of Inhalation Injury
- Injury Below the Glottis
- BURN CLASSIFICATION AND SEVERITY
- CLINICAL ALERT
- Guidelines for Burn Center Referral
- Depth of Injury
- TABLE 20-3 Depth of Burn Injury
- Extent of Injury
- PHYSIOLOGICAL RESPONSES TO BURN INJURY
- FIGURE 20-2 Zones of thermal injury.
- FIGURE 20-3 The rule of nines. TBSA, Total body surface area. EXAMPLE: An adult with superficial burns to the face and partial-thickness burns to the lower half of the right arm, entire left arm, and chest: 4.5% (lower right arm) + 9% (entire left arm) + 9% (chest or upper anterior trunk) = 22.5% TBSA (the superficial burns to the face are not included in the %TBSA calculation).
- FIGURE 20-4 Burn estimate and diagram. Ant, Anterior; post, posterior; L, left; R, right; R. U., right upper; R. L., right lower; L. U., left upper; L. L., left lower.
- FIGURE 20-5 Overview of physiological changes that occur after acute burn injury. TBSA, Total body surface area; TNF, tumor necrosis factor.
- FIGURE 20-6 Pathophysiology of extensive burn injury. *A response associated with burn injury greater than 20% to 25% total body surface area (%TBSA). CO, Cardiac output; H2O, water; Hct, hematocrit; SVR, systemic vascular resistance; UO, urinary output.
- FIGURE 20-7 Burn edema and shock development. H2O, Water; K, potassium; Na, sodium.
- Cardiovascular Response
- Host Defense Mechanisms
- Pulmonary Response
- Renal Response
- Gastrointestinal Response
- Metabolic Response
- PHASES OF BURN CARE ASSESSMENT AND COLLABORATIVE INTERVENTIONS
- Resuscitative Phase: Prehospital
- Primary Survey
- NURSING CARE PLAN for Resuscitative and Acute Care Phases of Major Burn Injury
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- Adequate airway clearance and gas exchange
- NURSING DIAGNOSIS
- Adequate fluid volume
- PATIENT OUTCOMES
- NURSING DIAGNOSIS
- PATIENT OUTCOME
- Normothermia
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- Adequate tissue perfusion
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- Relief of pain
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- Absence of infection
- NURSING DIAGNOSES
- PATIENT OUTCOMES
- Absence of injury and adequate nutrition
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- Physical mobility
- NURSING DIAGNOSIS
- PATIENT OUTCOMES
- Effective coping
- Stopping the Burning Process.
- FIGURE 20-8 Major burn injury: primary survey. BP, Blood pressure; CPR, cardiopulmonary resuscitation.
- Airway (with Cervical Spine Precautions).
- Breathing.
- Circulation.
- Secondary Survey
- FIGURE 20-9 Major burn injury: secondary survey. ABG, Arterial blood gas; ECG, electrocardiogram; IV, intravenous; LR, lactated Ringer’s solution.
- Resuscitative Phase: Emergency Department and Critical Care Burn Center
- Transfer to a Burn Center
- Primary Survey
- Airway.
- Breathing.
- FIGURE 20-10 Burn center transfer form. ABG, Arterial blood gas; CIRC, circulatory; CO, carbon monoxide; ET, endotracheal tube; GI/GU, gastrointestinal/genitourinary; HEENT, head, eyes, ears, nose, throat; NG, nasogastric tube; O2, oxygen.
- FIGURE 20-11 Facial edema.
- FIGURE 20-12 Escharotomy.
- Circulation
- Fluid Resuscitation.
- BOX 20-1 Burn Fluid Resuscitation Formula
- First 24 Hours Administer
- ABLS Consensus Formula (Based on the Parkland Formula)
- Second 24 Hours Administer
- Parkland Formula
- End Point Monitoring.
- EVIDENCE-BASED PRACTICE
- PROBLEM
- REFERENCES
- EVIDENCE
- IMPLICATIONS FOR NURSING
- Peripheral Circulation.
- Secondary Survey
- Cardiovascular System.
- Neurological Status.
- Renal Status.
- Gastrointestinal System.
- Integumentary System.
- Blood and Electrolytes.
- Acute Care Phase: Critical Care Burn Center
- LABORATORY ALERTS
- Respiratory System
- Cardiovascular System
- Neurological Status
- Renal Status
- Gastrointestinal System
- Integumentary System
- Blood and Electrolytes
- SPECIAL CONSIDERATIONS AND AREAS OF CONCERN
- Burns of the Face
- Burns of the Ears
- Burns of the Eyes
- Burns of the Hands, Feet, or Major Joints
- Burns of the Genitalia and Perineum
- Electrical Injury
- Chemical Injury
- BOX 20-2 Manifestations and Complications of Electrical Injury
- Abuse and Neglect
- FIGURE 20-13 Child abuse by hot water immersion. The thigh burn wound edges have a clear demarcation line (are in a straight line), and there are no splash marks. The parents delayed seeking medical treatment for the child’s burns until 3 days after injury (note the dry, crusty appearance of the wounds). The child also had a forearm fracture and multiple areas of bruising on the body.
- PAIN CONTROL
- INFECTION CONTROL
- WOUND MANAGEMENT
- Wound Care
- Topical Agents and Dressings
- PHARMACOLOGY TABLE 20-4 Topical Antimicrobial Agents for Burn Wound Management
- TABLE 20-5 Biological and Biosynthetic Dressings
- Surgical Excision and Grafting
- FIGURE 20-14 A, Vacuum-assisted closure (VAC) device. B, The device creates a negative-pressure dressing to decompress edematous interstitial spaces and to increase local perfusion, help draw wound edges closed uniformly, remove wound fluid, and provide a closed, moist healing environment.
- FIGURE 20-15 Excision and autografting. A, Surgical debridement (excision) with meshed autograft placement in the operating room. B, Meshed autograft postoperative day 2. C, Comparison of sheet autograft (on hand) versus meshed autograft (on forearm) 3 weeks postoperatively. Use of meshed autograft allows larger body surface area coverage, but it also typically leads to more scarring and a less cosmetically pleasing appearance.
- TABLE 20-6 Autograft Skin: Nursing Implications
- NUTRITIONAL CONSIDERATIONS
- TABLE 20-7 Types of Donor Site Dressings
- PSYCHOSOCIAL CONSIDERATIONS
- GERIATRIC CONCERNS
- BOX 20-3 Stages of Postburn Psychological Adaptation
- Survival Anxiety
- Search for Meaning
- Investment in Recuperation
- Investment in Rehabilitation
- Reintegration of Identity
- GERIATRIC CONSIDERATIONS
- NONBURN INJURY
- Severe Exfoliative Disorders
- Toxic Epidermal Necrolysis, Stevens-Johnson Syndrome, Erythema Multiforme
- Staphylococcal Scalded Skin Syndrome
- Necrotizing Soft Tissue Infections
- DISCHARGE PLANNING
- BURN PREVENTION
- BOX 20-4 Strategies for Preventing Burn Injuries
- Cook with Care
- Hot Liquids Cause Scalds
- Home Precautions
- Fire Extinguishers and Smoke Detectors
- Occupation-Related Precautions
- CASE STUDY
- QUESTIONS
- SUMMARY
- CRITICAL THINKING QUESTIONS
- REFERENCES
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