MedSurg Notes: Nurse's Clinical Pocket Guide

Copyright © 2008 by F. A. Davis. Copyright © 2008 by F. A. Davis. 2nd Edition MedSurg Notes Nurse’s Clinical Pocket...

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Copyright © 2008 by F. A. Davis.


2nd Edition

MedSurg

Notes Nurse’s Clinical Pocket Guide

Tracey Hopkins, BSN, RN Ehren Myers, RN Purchase additional copies of this book at your health science bookstore or directly from F. A. Davis by shopping online at www.fadavis.com or by calling 800-323-3555 (US) or 800-665-1148 (CAN) A Davis’s Notes Book


F. A. Davis Company 1915 Arch Street Philadelphia, PA 19103 www.fadavis.com Copyright

©

2008 by F. A. Davis Company

All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Printed in China by Imago Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1 Publisher, Nursing: Robert G. Martone Director of Content Development: Darlene D. Pedersen Project Editor: Padraic J. Maroney Manager of Art & Design: Carolyn O’Brien: Consultants: Ellen Kliethermes, RN; Glynda Renee Sherrill, RN, MS; Fraces Swasey, RN, MN; Deborah Weaver, PhD, RN, MSN; Jessie Williams, BSN, MA; As new scientific information becomes available through basic and clinical research, recommended treatments and drug therapies undergo changes. The author(s) and publisher have done everything possible to make this book accurate, up to date, and in accord with accepted standards at the time of publication. The author(s), editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of the book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation. The reader is advised always to check product information (package inserts) for changes and new information regarding dose and contraindications before administering any drug. Caution is especially urged when using new or infrequently ordered drugs. Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by F. A. Davis Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the fee of $.10 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy license by CCC, a separate system of payment has been arranged. The fee code for users of the Transactional Reporting Service is: 80361868/08 0 ⫹ $.10.


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Look for our other Davis’s Notes titles RNotes®: Nurse's Clinical Pocket Guide, 2nd Edition ISBN-10: 0-8036-1335-0 / ISBN-13: 978-0-8036-1335-5

LPN Notes: Nurse's Clinical Pocket Guide, 2nd Edition ISBN-10: 0-8036-1767-4 / ISBN-13: 978-0-8036-1767-4

NCLEX-RN® Notes: Core Review & Exam Prep ISBN-10: 0-8036-1570-1 / ISBN-13: 978-0-8036-1570-0 MedNotes: Nurse's Pharmacology Pocket Guide, 2nd Edition ISBN-10: 0-8036-1531-0 / ISBN-13: 978-0-8036-1531-1

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For a complete list of Davis’s Notes and other titles for health care providers, visit www.fadavis.com.


1 Legal Issues in MedSurg Care Legal issues affect all aspects of nursing care. Urgent care situations, in which the patient’s life may be lost or potential quality of life compromised, require even more vigilant attention to nursing standards of care and best practices. The nurse practice law of each state defines the scope of nursing practice for that state. Advanced practice nurses, such as nurse midwives, nurse anesthetists, and clinical nurse specialists, function under a broader scope of practice. ■ Know your state’s nurse practice law; contact your state board of nursing for a copy. ■ Know your state’s requirements for licensure, and maintain your nursing license as required. ■ Keep informed of local, state, and national nursing issues; get involved as a lobbyist in your state; contact your state representatives regarding issues that affect nursing practice. ■ Know if and how a nursing union could affect your practice. Nurses have a duty of care of careful and continuous monitoring of the patient’s status. Nurses assess and directly intervene on patients more than any other healthcare professionals. ■ Monitor each patient’s vital signs, neurological status, intake and output, status per physician order, nursing care plan, hospital policy and procedure; increase frequency of vital signs if indicated, and notify the physician. ■ Evaluate family members’ concerns as soon as possible; the family often detects subtle changes in a patient’s status. Nurses have a duty to communicate the patient’s status to the medical staff, particularly on an immediate/STAT basis when the patient’s status warrants. The nurse is usually the first team member to detect an urgent care situation and has an obligation to report any changes in patient condition to the medical staff for timely intervention. ■ Notify the physician as soon as you detect any change in the patient’s condition that indicates deterioration in status. Document assessment, time of call to physician, and nursing interventions and patient’s response. ■ Use the hospital’s chain of command if the physician fails to respond within minutes. Notify the nursing supervisor if the physician does not respond immediately. (Continued on the following page)

BASICS

BASICS


■ The nurse must maintain accurate nursing notes, flow sheets, medical Kardexes, and nursing care plans that record the patient’s symptoms, time symptoms were present, time physician was notified, and time physician arrived. The medical chart should be a factual record of the patient’s medical treatment, responses thereto, vital signs, and all nursing interventions. Nurses have a duty to administer medications safely at all times, including urgent care situations. Medication errors are the most common source of nursing negligence. Procedural safeguards should be followed to prevent medication errors. The “five rights” of medication administration are minimum practice standards. ■ Give the right drug in the right dose to the right patient by the right route at the right time. ■ Document the five rights—which medication, to whom, in what dose, through which route, and at what time. ■ Document fully any suspected adverse drug reaction, time and nature of the reaction, time physician notified, interventions taken, and patient’s response. ■ Nurses have a duty to know about all the drugs they administer: drug names, drug categories, dosage, timing, technique of administration, expected therapeutic response, duration of drug use, and procedures to minimize the incidence or severity of adverse drug effects. Nurses have a duty to maintain safe patient care conditions. This is akin to the nurse’s duty to advocate for the patient at all times. ■ Report an unsafe staffing condition to the nursing supervisor as soon as it is apparent. The nurse-patient ratio in intensive care settings should not exceed 1:2; on general floors, 1:6. ■ Working beyond a 12-hour shift can create a substantial decline in performance. ■ Know the nurse practice limitations on nurses under your supervision; licensed practical nurses and student nurses cannot perform all the actions of the registered nurse. Nurses have a duty to keep the patient safe from self-harm. The nurse must be vigilant regarding any changes in the patient’s sensorium/ mental status. Any patient can experience a psychiatric crisis from a myriad of causes, including hypoxia, drug reaction, drug withdrawal, ICU psychosis, or underlying organic disease. ■ Assess the patient’s mental status with each nursing intervention; note subtle changes, and notify the physician. ■ Signs of impending psychiatric crisis include changes in orientation to person, place, and time; verbal abusiveness; restlessness; increased anxiety; and agitation.

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3 ■ If a patient is at risk of self-harm and/or of harming others, restraints can be applied. ■ Most states require a written physician order before restraining the patient, except in an emergency. The physician must be notified immediately of the use of restraints. ■ If restraints are applied, the patient must be monitored closely for changes in medical condition and mental status, for maintenance of adequate circulation, and for prevention of positional asphyxiation. Document all assessments and frequency of checks (no less frequent than every 15 minutes). ■ Know the hospital’s policy and procedure regarding use of restraints, and follow them at all times. Nurses have a duty to carry out physician orders as required by state law, hospital policy and procedure, and nursing practice standards. Concurrently, as patient advocate, the nurse must question an order he or she deems problematic, particularly when an urgent care situation is present or when one could arise from fulfillment of the order. ■ Contact the physician immediately for any order that is unclear, contrary to standard drug dosage/route/frequency of administration, or that does not address the acuity of the patient’s medical condition; e.g., an order for vital signs every shift for a postoperative patient recently transferred to a general surgical floor. ■ Question an order for a patient’s discharge from the hospital when the patient’s medical condition is not stable, when delay in treatment resulting from discharge could injure the patient, or when the patient is going to a potentially unsafe environment. Document interaction with the physician and health-care team. ■ Follow written physician orders; be particularly vigilant in carrying out an order that changes over time; e.g., tapering of medication or oxygen at specified time intervals. Informed consent is the process of informing the patient, not simply completing the form with the patient’s signature. ■ Informed consent involves providing the patient with adequate medical information so that he or she can make a reasonable decision as to treatment based upon that information. In urgent care situations it can be impossible to obtain a patient’s informed consent for an immediate intervention. ■ State laws differ regarding the informed consent standards; know your state’s informed consent law and the hospital’s policy and procedure for obtaining informed consent. (Continued on the following page)

BASICS

BASICS


■ Exceptions to informed consent include an emergency in which the patient is incompetent and cannot make an informed choice, there is not sufficient time to obtain an authorized person’s consent, and the patient’s medical condition is life-threatening. ■ If a patient is competent and refuses medical care, even when the condition is life-threatening, the patient’s choice supersedes the opinion of the health-care provider. ■ Ensure that each patient’s advance directive or living will (patient’s advance legal permission to the physician to withhold or discontinue treatment) is complied with and well documented in the medical chart per state law and hospital policy and procedure. Know if the patient has a do not resuscitate order, and ensure that it is well documented. Nurses are held to the standard of care of the profession. When nursing care falls below the standard of care, the care could be deemed to be negligent or deficient if that care (or lack of care) causes the patient some type of injury. This is the basis of a lawsuit against the healthcare professional, called medical malpractice. ■ Each nurse owes every patient the duty of “reasonable care.” This is implicit in the standard of care defined by what nursing professionals generally recognize on a national level as correct patient care. ■ Nationally recognized nursing textbooks, nursing journals, and nursing treatises that nurses generally regard as authoritative define the nursing standards of care. ■ Whether a nurse’s care of a patient met the applicable standards of nursing care in a medical malpractice case is determined by a nursing expert, a nurse who has the requisite experience and knowledge of the authoritative resources. As nursing practice, along with medical technology, continues to become more sophisticated and complex, the standards of nursing care will likewise increase.

Documentation Guidelines for Urgent Situations Documentation is critical in urgent situations. It enhances decision making and helps anyone who reads it understand what happened, how it was handled, and what the outcomes were. It is crucial in any legal analysis of care. Keep the following in mind as you document: ■ Always document your assessment findings, your interventions, and what triggered the situation. Did you observe a problem, did the patient call for help, or did you find the patient in distress? What were your immediate interventions?

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5 ■ Document as you go. It establishes a timeline for the incident as well as conveying the interventions and outcomes accurately. Time, date, and sign every individual entry. ■ Always note at what time, by what route, and how much medication you or another member of the team has administered. Always record response to the medication and the time the response(s) occurred or the time you observed for a response, whether there was a response or not. The same applies to any non-drug intervention. ■ Always note the time you called the physician or nurse practitioner and his or her response. ■ If you do not get the response from the physician or nurse practitioner you think is required for the patient’s best interests, call your administrative superior (nurse manager), and report the problems. Document your call and the supervisor’s response. Do not blame or complain about someone; just note that you called the supervisor to report the patient’s condition. ■ If you fail to document something, write another entry called “Addendum” to the note above, and give the time and date of the first note.

Delegation Guidelines The National Council of State Boards of Nursing defines delegation as “transferring to a competent individual the authority to perform a selected nursing task in a selected situation. The nurse retains accountability for the delegation.” Check your state’s nurse practice act for details about which nursing activities cannot be delegated. Sample of nursing tasks that cannot be delegated: ■ ■ ■ ■ ■ ■

Initial assessment or assessments of change in patient condition Formulating the nursing diagnosis; creating the nursing plan of care Administration of medications by direct IV bolus (IV push) Administration of blood products Programming a PCA pump Changing a tracheotomy tube

Before delegating, determine the following: ■ The complexity of the task and the potential for harm posed by the task (what psychomotor skills are required? what harm can occur if the procedure is done incorrectly?) ■ The predictability or unpredictability of the outcome (is this procedure new to the patient, or has the patient tolerated this procedure well before?) (Continued on the following page)

BASICS

BASICS


■ The problem-solving or critical thinking abilities required (problem-prone activities such as changing a new colostomy appliance, for example, may require the more in-depth knowledge and problem-solving skills only the RN can supply) Remember the Five Rights of Delegation: ■ Right Task—is the task within the caregiver’s scope of practice? ■ Right Person—does the assigned caregiver have the knowledge and skill required? ■ Right Circumstances—is the setting appropriate; are the right resources available? what is the current health status of the patient? ■ Right Direction—clear description of the activity to be performed, relevant patient conditions, limits, and expectations. ■ Right Supervision—monitoring performance, maintaining your availability to assist, receiving feedback about the procedure and patient’s tolerance, providing feedback. Remember: The RN delegates a task but retains responsibility and accountability. Specialized nursing skills and nursing judgment cannot be delegated.

Critical Thinking Guidelines Identifying ■ The first thing the nurse must do is identify that a problem exists. The triggering event is something unexpected. It may be as obvious as crushing chest pain or as subtle as a complaint of thirst. Big red flags are easy to see; do not ignore tiny red flags. ■ Listen and observe. Know recent trends in the patient’s status; understand normal and abnormal findings. Recognize differences and similarities. ■ Have you noticed or has the patient complained of something unexpected? ■ Follow up with questions any new complaint or unusual finding. ■ If you have any doubts, do not ignore them; ask a nurse who is senior to you, or notify the physician/NP. Assessing ■ Once a problem is identified, seek information; gather objective, subjective, historical, and current data. ■ Perform a focused physical examination; obtain relevant laboratory and diagnostic reports; read recent entries in the chart. ■ Order problems in importance; determine if the problem is urgent; if not, determine how important it is.

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7 Analyzing ■ Analysis involves breaking the whole into parts and discovering the relationships of the part to the whole. Is the problem hypotension? Think about the factors that influence blood pressure: What is the hemoglobin level, urinary output, recent blood loss? Can you assess cardiac output? Is the patient on medications that affect blood pressure? ■ Think about what you have discovered through assessment. Ask if the laboratory values or tests suggest a cause. ■ Consider if the data fit any of the known complications of the patient’s condition. Do the data suggest something is worsening? Link the data to the patient’s physical status. Do the data “fit”? ■ Ask yourself if you are making the data fit and if you have overlooked another cause. ■ Ask yourself what other information is needed. Do you need to assess another body system? Have you asked the patient about all recent related events? Should you check the medication record? ■ Other types of problems may require a different set of information (What other supplies are needed? Does the patient require referral to a religious leader? Does the family need to see a social worker?). ■ While you analyze, double-check that you are not making erroneous assumptions. Ask yourself if the data can be interpreted another way. Ask yourself what other issues or conditions could cause similar signs and symptoms. Diagnosing ■ The end result of analysis is a conclusion. For nurses who are thinking critically about a problem, this conclusion is a nursing diagnosis or a definition of the problem. ■ State the problem clearly, what the problem is related to, and what data support this conclusion. State the desired outcomes as well and in what time frame you expect them to be achieved. ■ Determine the significance of this problem. Ask yourself again: Is it urgent? Does it have the potential to cause a sudden and rapid deterioration in the patient’s health status? Is it imperative that you act immediately? Do you need help? Planning ■ Consider which intervention(s) will be most effective; predict the consequences of the intervention and if it will produce the desired outcome. ■ Urgent problems require that you immediately summon a physician or nurse practitioner. ■ Implement the plan; document all problems and interventions. (Continued on the following page)

BASICS


BASICS

Evaluating ■ Evaluation is the step that lets you know if the plan is working. ■ Assess the status of the problem at appropriate intervals; evaluate if the interventions are effective. ■ Determine if further intervention is required.

Enhance Your Clinical Reasoning Abilities ■ The link between a problem and a positive outcome is sound professional judgment. Pose new questions to yourself every day. Ask yourself why a certain complication occurs or why a medication helps. Find out the answers. Ask others; consult the literature. ■ Keep current. Read journals and other literature. ■ Learn about other specialty areas such as oncologic nursing, wound care, respiratory or physical therapy. ■ Know your real strengths, skills, and weaknesses. Correct weaknesses. ■ Be alert in your observations and assessments. Realize that everybody makes assumptions and that assumptions can be wrong. Ask yourself what else might be responsible for the signs and symptoms. ■ Work in other fields to gain experience. Challenge yourself. ■ Ask questions of other experts in medicine, surgery, nursing, and related fields. All practioners fundamentally are teachers. Learn from them.

Principles of Pain Management ■ Differentiate between acute and chronic pain. Patients in chronic pain may not exhibit signs of being in pain. ■ Do not assume that the patient’s pain is exaggerated because he or she asks for pain medicine frequently. Look for ways to better manage pain. ■ Assess each patient’s pain, and create an individualized treatment plan ■ Reassure patients in pain or who expect to have pain that pain can be relieved. ■ Assess any changes in pain pattern to ensure that new causes are not overlooked. ■ Try the least invasive route first in patients with cancer or chronic pain. Keep dosage schedules simple. ■ Monitor side effects. Use prevention strategies, especially for constipation when opiods are used.

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9 ■ Be careful switching from oral to IV, IM, IT, or other route. Dosages change, and different drugs may not provide as much pain relief. Use an equianalgesic dosing table for guidance. ■ Teach or arrange for instruction in biofeedback, relaxation exercises, and hypnosis. ■ All can reduce pain and stress and give a greater sense of control. ■ Do not avoid opioids because of fear the patient will become addicted. ■ Encourage patients to request pain medication before pain becomes severe. ■ Suggest administering medication on an around-the-clock schedule to maintain therapeutic blood levels. ■ Suggest time-released pain medications to avoid peaks and valleys in pain control. ■ Consult with a pain management clinical specialist, if available. ■ Include family in pain control plan.

Pain Management Numeric Scale 0 No pain

1 2 Mild pain

3

4 5 Moderate pain

6 7 Severe pain

8 9 Very severe pain

10 Worst possible pain

Visual Analog Scale

Text/image rights not available. 0 NO HURT

2 HURTS LITTLE BIT

4

6

HURTS LITTLE MORE

HURTS EVEN MORE

8 HURTS WHOLE LOT

10 HURTS WORST

Wong-Baker FACES Pain Rating Scale. Use for children over 3 years. (From Hockenberry MJ, Wilson D, Winkelstein ML: Wong’s Essentials of Pediatric Nursing, ed. 7, St. Louis, 2005, p. 1259. Used with permission. Copyright, Mosby.)

BASICS

BASICS


Using Pain Scales ■ Most patients can use the numerical scale. ■ Say: “On a scale of zero to ten, with zero meaning no pain and ten meaning the worst pain possible, tell me what level of pain you are feeling now.” ■ Ask how distressing the pain is, using a scale of 0–10. ■ Some patients report a moderate to high numerical score (5 or above) but are not distressed and do not want medication. ■ Some patients report a lower numerical value but are very distressed by the pain and may need medication or other intervention. ■ Always ask the patient directly if he or she would like medication. ■ Contact a pain care nurse, if available. ■ For patients who cannot use the numerical scale, use the Wong-Baker FACES Pain Rating Scale. Tailor questions accordingly. Mnemonics for Thorough Pain Assessment (PQRST and COLDERRA) Perform pain assessment quickly but thoroughly prior to medicating. Always find out if the pain is new and different; if it is consistent with the patient’s diagnosis, procedure, or surgery; or if it is typical and expected. New onset pain, or pain that is unusual for the diagnosis, procedure, or surgery, needs to be evaluated by the physician or nurse practitioner as soon as possible. Chest pain requires immediate assessment (see Chest Pain in CV tab).

PQRST P (provokes/point) ............What provokes the pain (exertion, spontaneous onset, stress, postprandial, etc.) Point to where the pain is. Q (quality) .........................Is it dull, achy, sharp, stabbing, pressing, deep, surface, etc.? Is it similar to pain you have had before? R (radiation/relief) ............Does it travel anywhere (to the jaw, back, arms, etc.)? What makes it better (position, being still)? What makes it worse (deep inspiration, movement)? S (severity/s/s) ..................Explain the 10/10 pain scale and have patient rate pain. Are there any signs or symptoms associated with this pain (n/v, dizziness, diaphoresis, pallor, SOB, dyspnea, abnormal vital signs, etc.)? T (time/onset) ...................When did it start? Is it constant or intermittent? How long does it last? Sudden or gradual onset? Does it start after you have eaten? Frequency?

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11 COLDERRA Characteristics..........................................Dull, achy, sharp, stabbing, pressure? Onset ..........................................................................................When did it start? Location ..................................................................................Where does it hurt? Duration .........................................................How long does it last? Frequency? Exacerbation ......................................................................What makes it worse? Radiation...........................................Does it travel to another part of the body? Relief.....................................................................................What provides relief? Associated s/s ......................................Nausea, anxiety, autonomic responses?

Nursing Interventions for Pain Management Provide comfort ..................................................positioning, rest and relaxation Validate patient’s response to pain .....................................offering reassurance Relieve anxiety and fears ....................................setting aside time with patient Teach relaxation techniques ......................rhythmic breathing, guided imagery Provide cutaneous stimulation ........................massage, heat and cold therapy Decrease irritating stimulation ....................................bright lights, noise, temp

Comparison of Routes of Analgesic Administration Route

Advantages

Disadvantages

Oral

Easiest, least invasive; consider oral first while taking into account patient status

Metabolized in the liver before reaching bloodstream—less drug available (40% to 60%) than with other routes; takes longer to act. Cannot be used if patient has difficulty taking oral medications.

IM

Quicker onset of action than oral route

Painful, potential nerve injury; difficulty finding sites in undernourished patients

Subcutaneous

No need for IV access; changing sites usually easy; 80% of drug available

Only small volumes of fluid can be injected each hour. Must use concentrated medications, which increases risk for drug error. (Continued on the following page)

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Comparison of Routes of Analgesic Administration (continued) Route

Advantages

Disadvantages

IV PCA

Immediate effect; can have a continuous rate and a bolus

IV sites are portal for infection. May not be appropriate for confused patient. NOTE: Never administer a dose for the patient—can lead to respiratory depression and death. Inform family also.

IT Epidural

Much lower doses, fewer side effects

Potential for infection or other complication

Transdermal

Easy to use. Slow buildup of drug, fewer side effects. Usually used for patients with cancer pain.

Not suitable for acute pain. Drug remains active for 14–25 hours after removal, which presents problems if patient overdosed.

Sublingual

Better absorption, quicker onset than oral route. Good for patients who cannot tolerate PO medications

Used primarily for break-through pain for cancer patients.

Cultural Sensitivity It is not possible for nurses to know intimately all other cultures different from his or her own. It is possible, however, to acknowledge that significant cultural variations exist and to adopt an attitude of sensitivity that includes a desire to learn about and respect the culture of the patients for whom you care. Potential for Stereotyping Books that list cultural characteristics of various groups have some value but can lead to stereotyping. Too often people make assumptions based on the

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13 color of someone’s skin or other overt characteristics. The challenge for nurses is to learn whether a person considers himself or herself to be a member of a group and to recognize that significant variation exists within groups. Cultural Assessment Cultural assessment covers many factors, too numerous for this book. Keep in mind that cultural variation is frequently expressed within domains applicable to any culture. Maintain a respectful and open attitude as you learn about each patient. Common domains of importance related to health care include: ■ Communication styles—eye contact, personal space, tone of voice, and more. Observe each patient, and follow his or her lead. If you are not sure, ask politely and respectfully. ■ Religion—you may ask how important religion is to the patient in daily life and if he or she consults with another member of that religion in healthcare matters. ■ Language—it is very important to use competent interpreters when obtaining and receiving health information. Do not automatically use a family member. Sensitive information may be embarrassing for the two people to discuss. Try to get someone of about the same age and gender as the patient. Always ask if the patient is willing to use the interpreter. In an emergency, communicate through the oldest family member present. ■ Family relationships—families may have a hierarchy that includes a spokesperson, so to speak. Show respect for that person’s role. As always, do not reveal confidential information about a person’s health without the express consent of the patient. ■ Food preferences—providing the patient’s preferred food can be instrumental in rate of recovery. Ask about any natural remedies the patient has or is using. ■ Health beliefs—What causes illness, how care is provided, how the patient handles being ill or in pain are powerful cultural beliefs. Ask the patient or family members about these issues and integrate the information into your plan of care. ■ Birth and death rituals—End-of-life beliefs can vary significantly within any culture. Suggest meeting with the family if the patient approves of you sharing or receiving information about personal preferences. Discuss issues such as organ donation, autopsy if applicable to the case, special care of the body, and what the family will want to do in the immediate time after death.

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Spiritual Care Providing spiritual care means different things to different people. Some nurses may be too intimidated to address this issue. Many do not feel competent to do so or that it is none of their business. You can always ask the patient how he or she feels spiritually. The answer will be very revealing in terms of willingness to discuss the topic. Follow the patient’s lead, and never impose your own beliefs. Often, the best spiritual intervention is to ask open-ended questions and then listen.

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15 Focused Assessment of the CV System ■ A focused assessment of CV status includes: ■ The core cardiovascular system—the heart, its rate and rhythm, the carotid arteries, blood pressure, and other hemodynamic measures. ■ The peripheral vascular system—the extremities, particularly the lower extremities. ■ The lungs—adventitious sounds, cough, and oxygenation status. ■ Mental status—level of alertness, restlessness, confusion, irritability, or stupor. ■ Vital signs: ■ Blood pressure, heart rate, respiratory rate, O2 saturation. ■ Mental status, head and neck: ■ Look for restlessness, ↓ LOC, circumoral cyanosis, color of conjunctiva, jugular venous distention. ■ Inspect the anterior chest: ■ Look for visible pulsations of the chest wall. ■ Palpate the anterior chest: ■ Locate apical beat, which is the point of maximum impulse (PMI). ■ Assess for heaves—a very forceful PMI. ■ Assess for thrills—a palpable murmur; feels like a cat purring. ■ Auscultate the heart and lungs: ■ Obtain rate and rhythm; assess for rhythm abnormalities. ■ Listen for normal heart sounds and possible murmurs. ■ Use the diaphragm of stethoscope first, then the bell. ■ Listen for carotid abdominal and femoral bruits. ■ Assess extremities: Check for: ■ Cyanosis, temperature, color, and amount of moisture. ■ Capillary refill time in hands and feet. ■ Changes in foot color, ulcers, varicose veins. ■ Edema of lower extremities (check sacrum if client is bedridden). ■ Presence and equality of pedal pulses. If pulses are not palpable, use a Doppler sonogram. ■ Assess current symptoms: ■ RED FLAG symptoms require immediate attention and intervention. Shortness of breath. Chest pain, possibly with neck, jaw, or left arm pain. Syncope possibly with palpitations and shortness of breath. Palpitations possibly with chest pain and dizziness. Cyanosis of lips, fingers, or nailbeds. Pain, coolness, pallor, or pulse changes in extremities. Sweating, nausea, vomiting, fatigue (especially in women).

CARDIAC


CARDIAC

Assessment Guides Circulation Scale

Pulse Scale

Capillary Refill

Pulse Strength

Normal

⫽ ⬍3 sec

Absent

⫽

0

Delayed

⫽ ⬎3 sec

Weak

⫽

⫹1

Normal

⫽

⫹2

Full

⫽

⫹3

Bounding ⫽

⫹4

Edema Scale Press thumb carefully into edematous area, usually on the shin (pretibial edema) or dorsum of foot (pedal edema): 0–1/4 inch; disappears in ⬍5 sec

⫽

⫹1

1/4–1/2 inch; disappears in 10–15 sec

⫽

⫹2

1/2–1 inch; disappears in 1–2 min

⫽

⫹3

⬎1 inch; disappears ⬎2 min

⫽

⫹4

Possible Causes of Shortness of Breath Source

Potential Causes

Cardiac

Coronary artery disease, angina, MI, heart failure, cardiomyopathy, valve disease, left ventricular hypertrophy, pericarditis, dysrhythmias

Pulmonary

COPD, asthma, pneumothorax, pulmonary embolus (PE), pulmonary edema

Combined cardiopulmonary

COPD with comorbid cardiac disorder, deconditioning, chronic pulmonary emboli, trauma

Other

Metabolic acidosis, pain, neuromuscular disorders, upper airway disorders, anxiety, panic, hyperventilation

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Cardiac auscultation sites.

Arterial Hematoma CLINICAL PICTURE The patient may have: ■ Pressure dressing to radial/brachial/femoral artery insertion site that is saturated with blood. ■ Cannulated artery that has been inadvertently decannulated and is hemorrhaging. ■ Hematoma, possibly pulsatile, around arterial puncture site.

IMMEDIATE INTERVENTIONS ■ Notify physician or NP. ■ Place patient in a supine position with affected limb extended. ■ Don sterile gloves and, using folded sterile gauze dressings, apply firm pressure 2 cm above puncture site, using the first three fingers of one hand. ■ Continue to apply pressure for 10 minutes or more, until bleeding has been controlled.

CARDIAC

CARDIAC


■ Once bleeding is controlled, apply sterile gauze dressing overlayed with a pressure dressing (Elastoplast). Depending on institution protocol, use a sandbag or other pressure device over the pressure dressing for added pressure. ■ Document patient’s status, phone call to physician or NP, and physician or NP response.

FOCUSED ASSESSMENT ■ Monitor distal pulses, skin color, temperature, and sensation of affected limb. ■ Assess VS, noting decrease in BP or increase in HR. ■ Assess LOC and patient’s ability to maintain extremity in immobile, neutral position. ■ Assess for pain.

STABILIZING AND MONITORING ■ ■ ■ ■ ■ ■

Instruct patient to maintain supine position a minimum of 6 hours. Frequently assess site for rebleeding. Monitor circulation, mobility, and sensation in affected extremity. Frequently monitor VS for changes in BP and HR. Reassess for pain. Assess for history of preexisting conditions such as clotting abnormalities or blood dyscrasias or for recent/current administration of antiplatelet or anticoagulant medications. ■ Chart patient status, and convey to physician or NP.

BE PREPARED TO ■ Assist physician or NP with cannulation of an alternate arterial site. ■ Obtain IV access for the administration of blood, clotting factors, or anticoagulant reversal agents such as protamine sulfate.

POSSIBLE ETIOLOGIES ■ Hemophilia, von Willebrand’s disease, thrombocytopenia, DIC, vascular trauma or iatrogenic arterial injury, anticoagulant therapy, antiplatelet therapy, thrombolytic therapy.

Arterial Occlusion CLINICAL PICTURE The patient may have: ■ Numbness, tingling, severe burning pain, or coolness in affected extremity. ■ Loss of sensation in the extremity.

18


19 ■ Pale, mottled, cyanotic, or ashen extremity. ■ Edematous, tight, shiny skin over affected extremity. ■ Capillary refill ⬎3 sec or absent.

IMMEDIATE INTERVENTIONS ■ Check all arterial pulses in the affected extremity. Compare with those in contralateral extremity. ■ Assess any sites of arterial puncture (e.g., arteriogram puncture site or A-line insertion site) for swelling or hematoma. ■ Assess mobility of affected extremity; compare with that of contralateral extremity. ■ Assess VS. ■ Notify physician or NP. ■ Document patient’s status, phone call to physician or NP, and physician or NP response.

FOCUSED ASSESSMENT ■ Assess for pallor, pain, paresthesias, paralysis, and pulselessness (5 Ps) by assessing circulation (skin color, capillary refill, pulses), movement (flexion, extension, rotation), and sensation (response to pinprick or light touch; pain level) of affected extremity. ■ Assess pulses with Doppler amplification. ■ Assess bandages or cast proximal to diminished pulses.

STABILIZING AND MONITORING ■ Continue to monitor condition of extremity. ■ Keep extremity at heart level to promote arterial flow without diminishing venous return. ■ Remove or do not use ice on the extremity. ■ Control and manage pain.

BE PREPARED TO ■ Remove any external fixtures (casts) on the extremity, or assist the physician or NP with fasciotomy for immediate relief of pressure. ■ Prepare the patient for surgery. ■ Initiate large-bore IV access.

POSSIBLE ETIOLOGIES ■ Compartment syndrome, major vascular injury, thrombus, ruptured aortic aneurysm, local or regional block anesthesia, cord injury, lymphedema, fracture, hypotension, hypothermia, dehydration, shock.

CARDIAC

CARDIAC


Bradycardia CLINICAL PICTURE The patient may have: ■ HR ⬍60 bpm. ■ Nausea and vomiting, dizziness or lightheadedness. ■ Signs of unstable bradycardia: ■ Altered LOC. ■ Chest pain, shortness of breath (SOB). ■ Hypotension, pulmonary congestion, and/or cyanosis.

IMMEDIATE INTERVENTIONS ■ ■ ■ ■ ■ ■ ■

Have patient sit or lie down in bed. Administer supplemental O2. Assess BP. Notify physician or NP. Obtain a 12-lead ECG. Check for patent IV access. Document patient’s status, phone call to physician or NP, and physician or NP response.

FOCUSED ASSESSMENT ■ ■ ■ ■

Assess LOC and orientation. Assess BP and HR. Assess respirations for rate and effort; assess SaO2 if readily available. Assess skin for color, moistness, and temperature. Assess for associated symptoms (chest pain, SOB, hypotension). ■ If patient on telemetry or cardiac monitor, assess ECG.

STABILIZING AND MONITORING ■ ■ ■ ■

Monitor VS. Set up cardiac monitoring, and monitor rate and rhythm. Assess recent laboratory results. Chart patient status, and convey to physician or NP.

BE PREPARED TO ■ ■ ■ ■ ■ ■

Administer oral or IV medications as ordered. Obtain or order laboratory tests. Titrate O2 to SaO2 ⬎90%. Obtain IV access if none available. Assist with external pacing. Transfer patient to ICU or telemetry unit.

20


21 POSSIBLE ETIOLOGIES ■ Medication toxicity, vasovagal response, hyperkalemia, hypothermia, hypothyroidism, sepsis, severe infection, hypoglycemia, hypothermia, excellent physical condition (athletes), myocardial infarction, shock.

Chest Pain CLINICAL PICTURE The patient may have (see table below on Possible Causes of Chest Pain): ■ Substernal or epigastric sensations of fullness, pressure, or tightness; pain may radiate to left neck, jaw, back, and/or arm. ■ Cool, pale, and/or diaphoretic skin. ■ Nausea, vomiting. ■ SOB, tachypnea. ■ Dizziness, fatigue, fainting. ■ Marked anxiety, expression of “impending doom.”

IMMEDIATE INTERVENTIONS ■ Elevate head of bed (HOB) to facilitate breathing. ■ Administer high-flow O2 by nonrebreather mask (10–15 L/min) or by nasal cannula (4–6 L/min). ■ Assess VS, character and quality of pain (PQRST), skin color. ■ Check for standing orders of nitrogylcerine (NTG) sublingual 0.4 mg q 5 min ⫻ 3 doses maximum (hold for BP ⬍90 mm Hg) and one 325 mg nonenteric-coated aspirin. Administer STAT. ■ Check for IV access. Prepare to initiate saline lock IV access. ■ Notify physician or NP. ■ Document patient’s status, phone call to physician or NP, and physician or NP response.

FOCUSED ASSESSMENT ■ ■ ■ ■ ■

Assess HR, rhythm, BP, respiratory rate (RR), and effort. Inspect skin for color, temperature, and moistness. Assess SaO2 with pulse oximetry. Assess rhythm strip. Auscultate lung fields.

STABILIZING AND MONITORING ■ Administer medications STAT for cardiac symptoms, if ordered: NTG 0.4 mg SL (hold for BP ⬍90 mm Hg); morphine (MS) 2 mg IV (hold for RR ⬍8, BP ⬍90 mm Hg); aspirin (ASA) 162–325 mg PO.

CARDIAC

CARDIAC

■ ■ ■ ■


Assess response to medications. Identify underlying rhythm. Obtain cardiac enzymes/troponin levels. Chart patient status, and convey to physician or NP.

BE PREPARED TO ■ ■ ■ ■ ■ ■ ■ ■

Assess need and eligibility for thrombolytic therapy. Set up cardiac monitoring. Set up or change the O2 delivery system. Administer oral or IV medications. Call for a STAT 12-lead ECG. Obtain laboratory tests (electrolytes, PT, PTT, cardiac markers). Transfer patient to ICU. Call a code; perform CPR.

POSSIBLE ETIOLOGIES

■ Angina, anxiety, MI, pulmonary embolism, pulmonary edema, chest trauma, endocarditis, pericarditis, indigestion, gastroesophageal reflux disorder, pleurisy, bronchitis.

22


Possible Causes of Chest Pain Provocation and Onset

Quality and Relief

Location and Radiation

Severity and Time (Duration)

No provocation; large, heavy meal; extreme exertion, stress, or fright. Sudden onset.

Pressure, squeezing. No relief.

Substernal anterior chest or epigastrium, → to left neck, jaw, arm, back

Severe, lasting longer than 20 min.

Angina

Provoked by exertion. Sudden onset.

Pressure, tightness. Rest or sl NTG provides relief

Same as MI

Mild to moderate, lasting ⬍2 min.

Pneumonia

No provocation or coughing. Gradual or sudden onset.

Ache with sharp, stabbing pain. No relief.

Anterior chest, shoulder, neck.

Moderate, lasting hours.

PE

No provocation. Sudden.

Dull, aching but may also have sharp pain. No relief.

Variable.

None, mild, or moderate of variable duration.

23

MI

(Continued on the following page)

CARDIAC

Etiology

Etiology

Provocation and Onset

Quality and Relief

Location and Radiation

Severity and Time (Duration)

Pericarditis

No provocation; deep breathing, coughing. Gradual or sudden onset.

Sharp.

Substernal anterior chest.

Moderate to severe, endures for hours to days.

Epigastric disorders

Gradual or sudden.

Sharp, burning when patient in upright position, antacids provide relief.

Chest, throat, RUQ, LUQ, back.

Moderate, lasting minutes or hours.

Musculoskeletal disorders

Gradual or sudden.

Dull ache; possible sharp pain. Rest and mild analgesics or NSAIDs provide relief.

Arm, shoulder, neck, back, sternum, ribs, abdomen.

Mild to moderate, lasting minutes to hours.

24


CARDIAC

Possible Causes of Chest Pain (continued)


25 Heart Failure CLINICAL PICTURE The patient may have: ■ Fatigue, weakness, anxiety. ■ SOB, orthopnea, dyspnea, adventitious breath sounds (rales or crackles), cyanosis. ■ Change in mental status anxiety, restlessness, confusion. ■ Edema, jugular vein distention, increased CVP, positive fluid balance.

IMMEDIATE INTERVENTIONS

■ ■ ■ ■ ■ ■

Assess VS; note if hypotensive. Elevate HOB, and lower legs if possible. Administer supplemental O2 (100% nonrebreather mask). Restrict fluids. Assess for patent IV. Notify physician or NP.

FOCUSED ASSESSMENT

■ ■ ■ ■ ■

Assess airway, RR and effort, BP, and HR. Auscultate lung fields for pulmonary congestion (crackles, wheezes). Assess SaO2 via pulse oximetry. Assess LOC and orientation. Assess cardiac rhythm.

STABILIZING AND MONITORING

■ Restrict fluids, and administer diuretics as ordered. ■ Closely monitor I&O. ■ Assess for improvement of LOC and oxygenation status.

BE PREPARED TO

■ ■ ■ ■

Titrate O2 to keep SaO2 ⬎90%. Obtain IV access. Set up cardiac monitoring. Administer oral or IV diuretics, NTG, morphine, and electrolytes as ordered. ■ Order a chest x-ray and ECG. ■ Order or obtain laboratory tests (BUN, creatinine, CBC, electrolytes). ■ Transfer patient to ICU or telemetry unit.

POSSIBLE ETIOLOGIES

■ Atrial fibrillation, marked bradycardia, systemic infection, septic shock, pulmonary embolism; physical, environmental, and emotional excesses;

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CARDIAC


stress; cardiac infection and inflammation; excessive intake of water and/or sodium administration of cardiac depressants or drugs cause salt retention; cardiomyopathy, hypertension, severe aortic stenosis, ischemic myocardial disease, coronary artery disease, acute mitral or aortic regurgitation, infective endocarditis with acute valve incompetence, MI, anemia, hyperthyroidism, pregnancy, glomerulonephritis, cor pulmonale, polycythemia vera, carcinoid syndrome, obesity.

Hemorrhage/Wound Hemorrhage CLINICAL PICTURE The patient may have: ■ Saturated postoperative dressings. ■ Excessive amounts of blood in wound drainage system. ■ Peri-incisional swelling and hematoma. ■ Subtle changes in LOC, anxiety, irritability, restlessness, decreased alertness (early CNS signs of blood loss). ■ Confusion, combativeness, lethargy, coma (later CNS signs). ■ Increased HR to severe tachycardia. ■ Delayed capillary refill (⬎3 sec), diminished peripheral pulses (⬍⫹l2), cool extremities and pale, mottled, or cyanotic skin. ■ Slightly elevated RR to severe tachypnea. ■ Hypotension. ■ Narrowing of pulse pressure. ■ Thirst. ■ Bruising around umbilicus or retroperitoneally in flank areas (internal bleeding).

IMMEDIATE INTERVENTIONS ■ ■ ■ ■

■ ■ ■ ■ ■

Get help, and notify surgeon. Discontinue thrombolytics or anticoagulants. Control external bleeding with direct pressure. Do not remove saturated dressings, as this may also remove any clot formation. Instead, reinforce with additional dressing and pressure. Administer supplemental O2; maintain patent airway. If IV not in place, obtain large gauge (#18) IV access, and have IVF ready to hang. Monitor VS frequently. Document patient’s status, phone call to physician or NP, and physician or NP response.

26


27 FOCUSED ASSESSMENT

■ Assess LOC, orientation, and VS (HR, RR, BP). ■ Assess for orthostatic hypotension if possible. ■ Assess SaO2 via pulse oximetry if available (Note: may be unreliable due to decreased peripheral perfusion). ■ Assess skin for color, temperature, moistness, turgor, capillary refill.


■ Monitor VS and oxygenation status. ■ If patient previously typed and cross-matched, call blood bank to see if any blood available. ■ Monitor output from Hemovac, JP drains, NGT, and urinary catheter. ■ Check laboratory values. ■ Provide emotional support to patient/family. ■ Chart patient status, and convey to physician or NP.

BE PREPARED TO

■ Assist with insertion of a central line. ■ Obtain laboratory tests STAT (Hgb/Hct, ABGs, electrolytes, blood type and crossmatch). ■ Prepare the patient for surgery. ■ Administer colloidal infusions. ■ Insert Foley catheter. ■ Administer blood. ■ Mechanically ventilate.

POSSIBLE ETIOLOGIES

■ External bleeding: wounds (postsurgical and traumatic); internal bleeding: blunt trauma, cancer, ruptured aneurysm, postsurgical, GI perforation, thrombolytic therapy.

Hypertensive Urgency/Emergency Hypertensive urgency: systolic BP ⬎200 mm Hg or a diastolic BP ⬎120 mm Hg. Hypertensive emergency: diastolic BP ⬎140 mm Hg with evidence of acute end-organ damage.

CLINICAL PICTURE The patient may have: ■ Fatigue, headache, restlessness, confusion, visual disturbances, seizure. ■ Dyspnea, tachycardia, bradycardia, pedal edema, chest pain. ■ Lightheadedness, dizziness. ■ Nausea, vomiting.

CARDIAC

CARDIAC


IMMEDIATE INTERVENTIONS ■ ■ ■ ■ ■

Assess BP in both arms. Elevate HOB to 30⬚–45⬚. Administer supplemental O2. Notify physician or NP. Document patient’s status, phone call to physician or NP, and physician or NP response.

FOCUSED ASSESSMENT

■ ■ ■ ■ ■ ■

Assess LOC and orientation. Assess respiratory status. Assess for neurological deficits (hemiparesis, slurred speech). Assess baseline VS (temperature, HR, RR, BP). Assess SaO2 via pulse oximetry, if available. Assess for associated symptoms: visual disturbances, chest pain, peripheral edema, hematuria.


Maintain continuous monitoring of BP and HR. Assess for changes in cardiac rhythm if patient is on a monitor. Monitor I&O. Chart patient status, and convey to physician or NP.


Titrate O2 to SaO2 ⬎90%. Obtain a saline lock IV access. Administer ordered antihypertensive medications (oral or IV). Obtain or order laboratory tests (BUN, creatinine, electrolytes, UA). Assist with arterial line placement. Transfer patient to ICU.

POSSIBLE ETIOLOGIES

■ Atherosclerosis, primary hypertension, stress, anxiety, anger, medication, stroke, toxemia of pregnancy, diabetes, cardiac or renal disease, drugs (amphetamine, cocaine, corticosteroids, oral contraceptives).

Hypotension CLINICAL PICTURE The patient may have: ■ A systolic BP of ⬍90 mm Hg or systolic BP 40 mm Hg less than baseline. ■ Altered LOC or orientation. ■ Cool, pale, ashen, cyanotic, diaphoretic skin.

28


29 ■ ■ ■ ■

SOB, dyspnea. Nausea and vomiting. Tachycardia or bradycardia. Decreased urine output (⬍30 mL/hr).


■ Place patient in a supine position with legs elevated above heart level to increase circulation to vital organs. Note: This position is contraindicated if the airway is compromised; to maintain airway patency, place patient in supine or low Fowler’s position (HOB slightly elevated). ■ If respiratory effort inadequate (RR ⬍8, cyanosis, SaO2 ⬍90%), administer high-flow O2 via mask (10–15 L/min), or manually assist ventilations with an Ambu bag (mask-valve device). ■ Control bleeding, if any, with direct pressure. ■ Check for patent IV access. Note: IVF is not routinely administered until reason for hypotension is determined. Hypotension could be due to cardiac compromise, in which case fluids might be contraindicated. ■ Notify physician or NP. ■ Document patient’s status, phone call to physician or NP, and physician or NP response.

FOCUSED ASSESSMENT

■ Assess LOC, orientation, baseline VS (temperature, HR, RR, BP), and pulse quality and rhythm. ■ Assess respiratory effort and airway patency. ■ Assess skin for color, temperature, moistness, turgor, and capillary refill. ■ Assess for associated symptoms (chest pain, dyspnea, nausea). ■ Assess I&O; ask patient about recent history of vomiting, diarrhea, or urinary symptoms (burning, frequency, flank pain, hematuria). ■ Assess MAR for medications that can affect blood pressure.


Assess for cause. Continue to monitor VS. Review laboratory data (Hgb/Hct; BUN; urine specific gravity, electrolytes). Evaluate previous 24-hr I&O. Check MAR for possible medication-induced hypotension. Chart patient status, and convey to physician or NP.

BE PREPARED TO

■ ■ ■ ■ ■

Titrate O2 to SaO2 of 90%. Obtain IV access, and administer ordered IVF. Administer ordered vasoactive medications. Order specific laboratory tests to be drawn STAT. Transfer patient to a critical care unit.

CARDIAC

CARDIAC


POSSIBLE ETIOLOGIES

■ Medication; dehydration; hemorrhage; vasovagal response to anxiety; sepsis; shock; GI bleed or other internal bleeding; aneurysm; congestive heart failure; cardiac dyrsrhythmias; myxedema; adrenal crisis; hypoglycemia; completed stroke.

Palpitations CLINICAL PICTURE The patient may have or be: ■ Sensation of fluttering in chest, heart racing, or dizziness. ■ Tachycardia, bradycardia, irregular rate. ■ Cold and clammy skin, hypotensive (drop in BP ⱖ20 mm Hg from baseline). ■ SOB, dyspnea, nausea.


■ Place patient supine in bed. Apply O2 if available at bedside. ■ Stay with patient, and provide reassurance. ■ Take BP, and assess apical HR and rhythm. Compare apical rate to radial rate as one measure of perfusion. ■ Check for patent IV access. ■ Quickly assess perfusion by assessing mental status, peripheral pulses. ■ Observe cardiac monitor if patient is being monitored. Obtain rhythm strip to document event. ■ Notify physician or NP. ■ Document patient’s status, phone call to physician or NP, and physician or NP response.

FOCUSED ASSESSMENT ■ ■ ■ ■ ■ ■

Assess LOC, VS, and pulse quality and rhythm. Assess precipitating event, pain level, anxiety, hyperventilation. Assess breath sounds, O2 saturation Assess peripheral pulses, skin temperature and color, edema. Assess trends in pertinent laboratory data, e.g., Hg, Hct, electrolytes. Obtain and assess laboratory data such as ABG, cardiac enzymes, if appropriate. ■ Document assessment thoroughly.


■ Continue to monitor rhythm; obtain and analyze rhythm strip every 4 hours and when rate or rhythm changes. ■ Continue to monitor VS and O2 saturation.

30


31 ■ Keep IV line patent, and infuse IVF. ■ Review laboratory data such as Hgb/Hct; BUN and creatinine; electrolytes, other chemistries, blood glucose, liver and cardiac enzymes. ■ Check MAR for possible drug side effect or interactions. ■ Chart patient status, and convey to physician or NP.

BE PREPARED TO

■ Obtain a 12- or 15-lead ECG ■ Administer antiarrhythmic medication (e.g.: procainamide, quinidine, amiodarone). ■ Obtain IV access, administer ordered IVF and medications. ■ Transfer patient to a unit with cardiac monitoring. ■ Assist with placement of temporary transvenous or external pacemaker or cardioversion.

POSSIBLE ETIOLOGIES

■ Premature atrial or ventricular contractions (PACs or PVCs) or other cardiac dyrsrhythmia, mitral valve prolapse; stress, anxiety; medications; hyperthyroidism; dehydration; hemorrhage; heart failure; adrenal crisis; hypoglycemia.

Possible Causes of Palpitations Source

Conditions

Cardiac

Sinus tachycardia or bradycardia. PAC, PVC, PJC, SVT, VT. Bradycardia/tachycardia syndrome (sick sinus syndrome). Atrial fibrillation or flutter. Wolff-Parkinson-White syndrome. Heart failure, cardiomyopathy, pericarditis. Congenital heart disease. Pacemaker malfunction.

Drugs

Theophylline, digoxin, phenothiazine. Vasodilators, antiarrhythmics. Beta2 agonists (e.g., albuterol, terbutaline, salmeterol). Cocaine, alcohol, tobacco, caffeine.

Vascular

Vasovagal or postural hypotension. Transient ischemic attack, stroke.

Other

Hyperventilation, hypoxia, fever, hypoglycemia, thyrotoxicosis, anemia.

CARDIAC

CARDIAC


Syncope CLINICAL PICTURE The patient may have or be: ■ Lightheadedness, feeling faint. ■ Palpitations. ■ Tachypnea, hyperventilation. ■ Nausea, vomiting. ■ Cool, pale, diaphoretic skin.


■ ■ ■ ■ ■ ■

Assist patient to chair or bed, or floor (if necessary). Administer supplemental O2 via nasal cannula. Assess rate, ease of breathing. Assess BP. Assess HR, rhythm, and quality. If patient is hypotensive, keep supine, and elevate lower legs above heart level, using pillows. ■ Notify physician or NP. ■ Document patient’s status, phone call to physician or NP, and physician or NP response.

FOCUSED ASSESSMENT

■ Assess patency of airway and patient’s breathing. ■ Assess LOC and mental status; determine if patient had a sensation of spinning or movement. ■ Assess for associated neurological signs (slurred speech, numbness, weakness). ■ Assess skin for color, temperature, turgor, and moistness. ■ Ask if patient feels nauseated or is experiencing chest pain. ■ Check recent chemistry and hematology laboratory results. ■ Check if new medications have been administered. ■ Review I&O records from preceding days.


■ Assess orthostatic VS: take HR and BP in supine, sitting, and standing positions, each 2 min apart. Note if pulse increases by 20 or more bpm and the systolic BP drops by 20 mm Hg or more, which suggests hypovolemia or dehydration. ■ Assess mucous membranes and skin turgor for signs of dehydration. ■ Continue to assess VS as frequently as indicated. ■ Review history and all current medications.

32


33 ■ Test stool for occult blood. ■ Chart patient status and convey to physician or NP.

BE PREPARED TO ■ ■ ■ ■ ■

Obtain IV access. Administer IVF or a fluid challenge. Obtain a chemstick blood sugar level. Administer 50% dextrose IV. Order specific laboratory tests to be drawn STAT.

POSSIBLE ETIOLOGIES

■ Dysrhythmias, cardiac insufficiency, anemia, hypoxia, orthostatic/postural hypotension, hypovolemia/dehydration, hypertension, medication reaction, electrolyte imbalance, hypoglycemia, hyperglycemia, concussion, vasovagal response, stress/anxiety/fear.

Possible Causes of Syncope Source

Conditions

Cardiac

Bradycardia (HR ⬍60 bpm). Tachycardia (HR ⬎100 bpm). Decreased cardiac output, hemorrhage. Aortic or pulmonic stenosis. Pulmonary hypertension.

Neurological

Seizure, head trauma.

Vascular

Vasovagal or postural hypotension. Transient ischemic attack, stroke.

Other

Hyperventilation, hypoxia.

Tachycardia CLINICAL PICTURE The patient may have: ■ HR 100–150 bpm (sinus tachycardia—may be asymptomatic); HR ⬎150 bpm (supraventricular tachycardia). ■ Palpitations, dizziness or lightheadedness. ■ Chest discomfort, SOB. ■ Anxiety, restlessness.

CARDIAC

CARDIAC


■ Signs of unstable tachycardia: ■ Altered LOC. ■ Chest pain. ■ Hypotension. ■ Pulmonary congestion and/or cyanosis.

IMMEDIATE INTERVENTIONS ■ ■ ■ ■ ■ ■

Have patient sit or lie in bed. Assess blood pressure and respirations. Administer supplemental O2. Reduce or eliminate environmental stressors. Notify physician or NP. Document patient’s status, phone call to physician or NP, and physician or NP response.

FOCUSED ASSESSMENT

■ ■ ■ ■ ■

Assess LOC, orientation, and VS (temperature, HR, RR, BP). Assess SaO2 via pulse oximetry, if available. Assess heart rhythm. Assess skin for color, turgor, moistness, and temperature. Assess for associated symptoms (body pain, chest pain, SOB, hypotension, fever, dehydration). ■ If patient on telemetry or cardiac monitor, assess rhythm strip.


■ Assess HR, BP, and SaO2. ■ Assess 12-lead ECG (see ECG in Tools tab). ■ Assess recent history of emotional upset, medication use, infectious disease, diarrhea, vomiting, blood loss from menses, GI pain or nausea, melanotic stool. ■ Assess MAR for medications with potential to cause tachycardia. ■ Assess blood glucose level. ■ Assess recent I&O. ■ Chart patient status, and convey to physician or NP.

BE PREPARED TO

■ Set up cardiac monitoring; order 12-lead ECG. ■ Titrate O2 to keep SaO2 ⬎90%. ■ Obtain IV access.

34


35 ■ ■ ■ ■

Administer oral or IV medications as ordered. Order laboratory tests to be drawn STAT. Assist with cardioversion. Transfer patient to the cardiac care or telemetry unit.

POSSIBLE ETIOLOGIES

■ Hypoxia, exercise, caffeine, fever, medications, pain, anxiety, stress, atrial fibrillation, infection, hypoglycemia, hemorrhage, hypovolemia, dehydration, electrolyte imbalance.

A & P Snapshot

Brachiocephalic artery

Left common carotid artery Left subclavian artery

Superior vena cava

Aortic arch Left pulmonary artery

Right pulmonary artery

Left atrium Left pulmonary veins Mitral valve

Right pulmonary veins Pulmonary semilunar valve

Left ventricle Aortic semilunar valve

Right atrium Tricuspid valve

Interventricular septum

Inferior vena cava Chordae tendinea

Apex Right ventricle

Papillary muscles

Cardiac structure and blood flow.

CARDIAC


CARDIAC

Maxillary Facial External carotid Common carotid Subclavian Axillary Pulmonary

Occipital Internal carotid Vertebral Brachiocephalic Aortic arch

Intercostal Brachial Renal Gonadal Inferior mesenteric Radial Ulnar

Celiac Left gastric Hepatic Splenic Superior mesenteric Abdominal aorta Right common iliac Internal iliac

Deep palmar arch

External iliac Deep femoral

Superficial palmar arch

Femoral

Popliteal Anterior tibial

Posterior tibial

Arterial circulation.

36


37 Focused Respiratory System Assessment ■ A focused assessment of respiratory status includes: ■ Ease of breathing and respiratory rate ■ Lung sounds ■ Use of O2 and oxygenation ■ ABGs ■ Ventilator assessment, if applicable ■ Mental status level of alertness, restlessness, confusion, irritability, or stupor ■ Ease of breathing and respiratory rate: ■ Ask the patient how his breathing is; use his subjective terminology when documenting. Ask if SOB is triggered by activity and if rest relieves the feeling. Ask about energy levels and if the patient can eat and talk comfortably. ■ Assess rate—normal rate is 12–20; however, most adults have a respiratory rate in the lower end of the range. Rates ⬎20 respirations/min should be investigated. A rate ⬎26 is cause for alarm, unless it’s the patient’s baseline. ■ Assess use of accessory muscles or nasal flaring, both of which indicate respiratory distress. ■ Lung sounds: ■ Listen to lung sounds in all fields. Ask the patient to breathe deeply with his mouth open. ■ Note adventitious sounds, areas where air movement is not heard, or areas where breath sounds are diminished. ■ Use of O2 and oxygenation: ■ Note the amount of O2 ordered and the method of delivery (e.g., 3 L/min via nasal cannula). ■ Note if the patient is wearing the O2 all the time and if the device is correctly applied. ■ Check pulse oximetry to assess percentage of oxygen saturation (SaO2): 97% to 99% is normal, although 93% to 97% may be normal for some patients. Always look at the whole picture, not just a single reading. Also, pulse oximetry can be inaccurate in the presence of peripheral vascular disease. Reading of 90% or less indicates possible need for ventilation support. Compare trends in O2 saturation to determine if oxygen therapy is effective. ■ Analyze ABG results: ■ ABG allows for assessment of acid-base balance, ventilation, and oxygenation. It also tells how well the lungs and kidneys are compensating or responding to treatments.

RESP

RESP


■ pH, PaCO2, and HCO3 tell about acid-base balance. ■ PaO2 and SaO2 indicate oxygenation status. ■ Normal values (memorize): pH: 7.35–7.45 PaO2: 80–100 mm Hg PaCO2: 35–45 mm Hg O2 saturation: 95%–100% HCO3: 21–28 mEq/L Base excess: ⫺2 to ⫹2 mEq/L See detailed explanation of how to interpret ABGs on page 51 in this tab.

Aspiration CLINICAL PICTURE The patient may have: ■ Sudden onset of coughing and shortness of breath (SOB) associated with eating, drinking, or regurgitation. ■ Tachypnea, dyspnea, cyanosis, decreased breath sounds. ■ Tachycardia, bradycardia. ■ Crackles and rhonchi (usually on the right, but may be on the left or bilaterally). ■ Altered mental status. ■ Fever. ■ Chest pain (pleuritic).


Elevate head of bed (HOB) to upright position; help patient to expectorate. Provide supplemental oxygen. Suction oropharynx. Encourage coughing. If there is evidence of foreign body obstruction see Choking in the Emergency tab. ■ Notify physician or NP. ■ Document patient status, phone call to physician or NP, and physician or NP response.

FOCUSED ASSESSMENT

■ Assess patient’s ability to clear airway and effort to breathe. ■ Assess airway for secretions or foreign objects.

38


39 ■ Assess effectiveness of measures taken to clear airway. ■ Assess oxygenation status: level of consciousness (LOC), SaO2, presence of circumoral and nailbed cyanosis. ■ Assess HR, BP, respirations (rate, rhythm, and effort), and work of breathing. ■ Auscultate lung fields.


■ Continue to monitor airway and respiratory function. ■ Consider a speech pathology consultation to assess patient’s level of airway control and/or gag reflexes. ■ Monitor patient during oral intake, and assess patient for evidence of dysphagia.

BE PREPARED TO

■ Set up and assist with intubation, cricothyrotomy, tracheotomy, or bronchoscopy, if indicated. ■ Call a code.

POSSIBLE ETIOLOGIES

■ Emesis; disorders that affect normal swallowing and gag reflex (depression of the laryngeal reflexes, stroke); disorders of the esophagus (esophageal stricture, gastroesophageal reflux); use of sedative drugs; anesthesia; coma; excessive alcohol consumption; tracheitis; epiglottitis; foreign body aspiration.

Chest Tube Dislodgement CLINICAL PICTURE The patient may have: ■ Signs of respiratory distress: rapid, shallow, or increased work of breathing; cyanosis; decreased LOC; and SaO2, restlessness, or anxiety. ■ Partially or completely dislodged chest tube. ■ Visible chest tube drain pores. ■ Whistling sound as air enters or exits wound site or chest tube.


■ Immediately cover chest tube insertion site with sterile petroleum gauze (occlusive dressing) covered with several 4 ⫻ 4 pads. ■ Maintain constant pressure, but do not tape dressing in order to allow air to escape from chest cavity.

RESP


RESP

■ Administer supplemental O2. ■ Notify physician or NP and respiratory therapist STAT. ■ Document patient status, phone call to physician or NP, and physician or NP response.

FOCUSED ASSESSMENT

■ Assess respirations and quality of oxygenation including LOC, SaO2, skin color, and work of breathing. ■ Auscultate lung fields, and compare ventilation left to right. ■ Assess vital signs (VS) and pain level.


■ Assure chest x-ray (CXR) is obtained after reinsertion. ■ Continue to evaluate lung sounds and quality of oxygenation. ■ Make sure all chest tube connections are secure and that tubing is not tangled or encumbered. ■ Maintain drainage system in upright position below heart. ■ Place emergency equipment in patient’s room (sterile NS, 4 ⫻ 4 pads, petroleum gauze, tape and nontoothed padded clamps). ■ Assess drainage system for proper functioning. ■ Assure that extra drainage collection system is readily available on the unit. ■ Assist patient with movement and repositioning.

BE PREPARED TO

■ Set up and assist with reinsertion of chest tube. ■ Order portable CXR. ■ Administer supplemental O2.

POSSIBLE ETIOLOGIES

■ Excessive torque or tension on chest tube due to multiple possible causes (chest tubes not hanging freely during movement, improper transfer technique, patient confused).

Dyspnea/SOB CLINICAL PICTURE The patient may have or be: ■ Mild sensation of discomfort to feeling of suffocation. ■ Difficulty breathing; inability to take a deep breath. ■ Cyanotic, ashen or pale, and diaphoretic.

40


41 ■ Tachypneic, wheezing, poor air movement, use of accessory muscles. ■ Restless, confused, anxious, fearful, agitated. ■ Maintaining an upright position to facilitate breathing.


■ ■ ■ ■ ■ ■ ■ ■ ■

Place patient in a position that facilitates breathing. Administer supplemental O2 if no history of COPD. Assess VS. Auscultate lung fields for adventitious sounds and quality of air movement. Place on pulse oximetry and cardiac monitor if readily available; assess O2 saturation and cardiac rhythm. If patient is hyperventilating, encourage slower, deeper breathing or, if indicated, have the patient perform pursed-lipped breathing. Notify physician or NP and respiratory therapy. Stay with patient; maintain calm, reassuring demeanor. Document patient’s status, phone call to physician or NP, and physician or NP response.

FOCUSED ASSESSMENT

■ Assess VS and respiratory status. ■ Assess for chest pain, nausea, leg vein tenderness, other cardiovascular symptoms. ■ Assess for underlying respiratory conditions. ■ Assess oxygenation status by evaluating for changes in mental status, noting evidence of chest pain or tightness, measuring SaO2, and evaluating cardiac rhythm. ■ Ask patient about previous episodes of SOB, what provoked it, if onset was sudden or gradual, if SOB is made worse by lying flat. Assess cough. ■ Assess work of breathing as evidenced by flared nostrils, retraction of subclavicular and intercostal spaces, use of accessory muscles, and orthopnea. ■ Note tracheal alignment, symmetry of chest expansion, bulging interspaces, and presence of JVD. ■ Assess skin for color, circumoral and nailbed cyanosis, and moistness. ■ Auscultate lung fields, noting diminished breath sounds, crackles, wheezing, friction rubs or stridor. ■ Assess medication administration record for possible medication/anaphylactic reactions.


■ Continue to monitor respiratory status as detailed in Assessment, and support effort to breathe.

RESP

RESP


■ Continue to assess patient for contributing factors and underlying cause. ■ Administer medications as ordered. ■ Chart patient status, and convey to physician or NP.

BE PREPARED TO

■ ■ ■ ■ ■ ■ ■ ■ ■

Obtain IV access. Change or set up an O2 delivery system. Assist with diagnostic testing. Obtain ABGs. Place a nasal or oral airway. Suction the oropharynx/trachea. Administer medication. Assist with intubation or chest tube placement. Transfer to ICU.

POSSIBLE ETIOLOGIES

■ Allergic reaction, airway obstruction, anxiety/panic attack, aspiration, asthma, cardiac dysrhythmias or tamponade, emphysema, heart failure, cardiac ischemia, pleural effusion/pleuritis, pneumonia, pneumothorax, pulmonary edema, pulmonary embolism.

Possible Causes of Shortness of Breath Source

Potential Causes

Cardiac

Coronary artery disease, angina, MI, heart failure, cardiomyopathy, valve disease, left ventricular hypertrophy, pericarditis, dysrhythmias

Pulmonary

COPD, asthma, pneumothorax, pulmonary embolus (PE), pulmonary edema

Combined cardiopulmonary

COPD with comorbid cardiac disorder, deconditioning, chronic pulmonary emboli, trauma

Other

Metabolic acidosis, pain, neuromuscular disorders, upper airway disorders, anxiety, panic, hyperventilation

42


43 Hypoventilation/Ineffective Breathing Pattern CLINICAL PICTURE The patient may have or be: ■ Dyspnea at rest or on exertion. ■ Hypoxic and appear cyanotic, ashen, or pale. ■ Lethargic, stuporous, obtunded, or unconscious. ■ Rapid and shallow breathing pattern, periods of apnea as in CheyneStokes (neurological), or notably slow (narcotic) breathing. ■ Signs of right-sided heart failure (JVD, peripheral edema, and hepatomegaly).


Attempt to arouse patient with physical stimulation to enhance breathing. Assess airway for obstruction. Perform orotracheal suctioning to clear secretions. Administer supplemental O2. Manually ventilate patient with a BVM device if RR ⬍8 or O2 saturation ⬍90%. ■ Get help, notify RT, and call physician or NP. ■ Document patient status, phone call to physician or NP, and physician or NP response.


Assess LOC and orientation. Assess VS, noting RR, depth, and quality. Assess skin color and moistness. Auscultate lung fields for adventitious sounds and equality of breath sounds.


Insert oral or nasal airway, if necessary. Administer bronchodilators. For narcotic/opioid OD, administer Narcan 0.4 mg IV. For IM benzodiazepine OD, administer Romazicon 0.2 mg IV. Continue to monitor breathing and oxygenation closely. Chart patient status, and convey to physician or NP.

BE PREPARED TO

■ Assist with setup and application of various O2 delivery systems (mask, CPAP, BiPAP, intubation/ventilator). ■ Obtain IV access. ■ Obtain CXR, ABGs, other laboratory tests. ■ Administer medication as ordered. ■ Transfer to ICU.

RESP

RESP


POSSIBLE ETIOLOGIES

■ COPD, emphysema, chronic bronchitis, neuromuscular disorders, amyotrophic lateral sclerosis, muscular dystrophy, diaphragm paralysis, Guillain-Barré syndrome, myasthenia gravis, chest wall deformities, kyphoscoliosis, fibrothorax, thoracoplasty, central respiratory drive depression, drugs: narcotics, benzodiazepines, barbiturates; neurological disorders: encephalitis, brainstem disease, trauma; primary alveolar hypoventilation, obesity hypoventilation syndrome.

Pulmonary Embolism CLINICAL PICTURE The patient may have or be: ■ Dyspnea, pleuritic chest pain, tachycardia. ■ Anxiety, diaphoresis. ■ Syncope, hypotension. ■ Wheezing. ■ Lower extremity edema. ■ Signs and symptoms of thrombophlebitis.


Administer supplemental O2. Assess VS. Assess respiratory rate and work of breathing. Notify physician or NP. Place on pulse oximetry and cardiac monitor, if available. Document patient’s status, phone call to physician or NP, and physician or NP response.

FOCUSED ASSESSMENT

■ Auscultate lung fields for adventitious sounds and quality of air movement. ■ Assess O2 saturation, cardiac rhythm, VS. ■ Assess for chest pain, leg vein tenderness. ■ Assess for history of recent surgery, immobilization, recent DVT, malignancy.


■ Continue to assess VS, LOC, respiratory status. ■ Initiate anticoagulant therapy (heparin) as ordered. Have second practitioner independently calculate dilutions and infusion pump programming. ■ Chart patient status, and convey to physician or NP.

44


45 BE PREPARED TO

■ ■ ■ ■

Obtain IV access. Change or set up an O2 delivery system. Administer medications or fluids to maintain blood pressure. Assist with obtaining diagnostic studies (CXR, V/Q scan, spiral CT scan, pulmonary angiogram). ■ Obtain ABGs. ■ Obtain serial PTTs, and titrate heparin infusion. ■ Transfer to ICU for high acuity care or thrombolytic therapy.

POSSIBLE ETIOLOGIES

■ Embolization of thrombi from deep veins of the femur, pelvis, and lower extremities from multiple causes including venous stasis, hypercoagulable states, surgery and trauma, oral contraceptive and estrogen replacement therapy, pregnancy, malignancy.

Respiratory Distress/Failure CLINICAL PICTURE The patient may have: ■ Dyspnea, excessive work of breathing. ■ Cyanosis of skin and mucous membranes. ■ Anxiety, confusion, restlessness, or somnolence. ■ Tachycardia and dysrhythmias (due to hypoxemia and acidosis). ■ Decreased O2 saturation (SaO2 ⬍90% is considered abnormal, and levels below this can represent unstable respiratory status that requires immediate intervention; however, evaluate in context of patient baseline—some patients with COPD may never have SaO2 greater than 88% but are stable. ■ Abnormal ABG results: Hypoxemic respiratory failure, characterized by a PaO2 ⬍60 mm Hg and a normal or low PaCO2, is most common and is caused by any acute disease of the lung (pulmonary edema, pneumonia). Hypercapnic respiratory failure, characterized by a PaCO2 ⬎50 mm Hg, is associated with drug overdose, neuromuscular disease, chest wall abnormalities, and severe airway disorders such as asthma or emphysema. ■ Seizures (may occur with severe hypoxemia).


■ Notify physician or NP and respiratory therapist of decline in respiratory function. ■ Elevate HOB; position patient to facilitate breathing.

RESP

RESP


■ Assess if the airway is patent and if patient is alert enough to manage secretions and to protect airway. ■ Insert nasal or oral airway, and suction if patient unable to clear secretions. ■ Apply supplemental oxygen via nasal prongs or face mask to correct hypoxemia and keep oxygen saturation above 90%. (Use O2 cautiously in patients with severe COPD and chronic CO2 retention.) ■ Document patient’s status, phone call to physician or NP, and physician or NP response.

FOCUSED ASSESSMENT

■ Assess oxygenation, lung sounds, respiratory rate, and work of breathing; assess for circumoral or nailbed cyanosis. ■ Assess VS, LOC, orientation. ■ Assess for underlying cause of respiratory distress.


Assess cardiac monitor, BP, pulse oximetry, and ABG results. Continue to assess temperature, LOC, orientation. Administer medications to treat underlying cause. If hypoxemia is severe, intubation and mechanical ventilation to increase PaO2, lower PaCO2, and rest respiratory muscles may be required. ■ Assist with diagnostic and laboratory studies (portable CXR, ABGs, ECG, other diagnostic tests, sputum culture, bronchoscopy). ■ Insert IV access.

BE PREPARED TO

■ Call a code. ■ Assist with intubation. ■ Transfer to ICU.

POSSIBLE ETIOLOGIES

■ Hypoxemic respiratory failure: chronic bronchitis and emphysema (COPD), pneumonia, pulmonary edema, pulmonary fibrosis, asthma, pneumothorax, pulmonary embolism, pulmonary arterial hypertension, pneumoconiosis, granulomatous lung diseases, bronchiectasis, adult respiratory distress syndrome, fat embolism syndrome. ■ Hypercapnic respiratory failure: COPD, severe asthma, drug overdose, poisonings, myasthenia gravis, polyneuropathy, poliomyelitis, primary muscle disorders, head and cervical cord injury, primary alveolar hypoventilation, obesity hypoventilation syndrome, pulmonary edema, adult respiratory distress syndrome, myxedema.

46


47 Ventilators/Mechanical Ventilation Indications ■ Airway obstruction. ■ Inadequate oxygenation—O2 saturation (90% on hi-flow oxygen via nonrebreather mask). ■ Inadequate ventilation—hypoventilation (high pCO2, pH acidosis). ■ Increased work of breathing, ineffective breathing pattern. ■ Airway protection. Common Settings ■ AC (assist control)—patient triggers ventilator to deliver a breath. If apnea occurs, a minimum rate and volume will be delivered to the patient. ■ CPAP (continuous positive airway pressure)—continuous, nonstop positive pressure is applied throughout entire respiratory cycle. ■ BiPAP (bilevel positive airway pressure)—same as CPAP but with two preset pressure settings: one for inspiration and one for expiration. ■ CMV (continuous mandatory ventilation)—ventilator delivers a set tidal volume at a set rate regardless of patient’s own attempts to breathe. Expect patient to require sedation. ■ IMV (intermittent mandatory ventilation)—ventilator delivers a set tidal volume at a set rate, yet also allows the patient to initiate breaths. ■ PSV (pressure support ventilation)—for patients with spontaneous breathing. Ventilator delivers a preset positive pressure for the duration of inspiration when the patient initiates a breath. ■ SIMV (synchronized intermittent mandatory ventilation)—ventilator is triggered only by a patient-activated demand valve and, therefore, synchronizes with the patient’s own respiratory efforts. ■ PEEP (positive end-expiratory pressure)—maintains a preset positive airway pressure at the end of each expiration. PEEP is used to treat a PaO2 of 60 mm Hg on FiO2 of 50%.

Troubleshooting Ventilator Problems Patient in sudden, severe repiratory distress ■ Unhook the ventilator from the endotracheal (ET) tube, and manually ventilate patient with 100% oxygen using an Ambu bag. Get help after unhooking patient from ventilator. ■ If patient is easy to ventilate manually and is no longer in distress, the ventilator is the probable source of the problem. Notify respiratory therapy (RT). While you manually ventilate the patient, the respiratory therapist should assess the ventilator per manufacturer’s guidelines. The ventilator may need to be changed if the problem cannot be found.

RESP

RESP


■ If patient is difficult to ventilate manually: suction the ET tube to clear secretions. Notify RT. If unable to clear obstruction or pass suction catheter, extubate and manually ventilate with 100% oxygen using an Ambu bag and face mask. Suction the oropharynx to clear secretions. Notify RT/physician STAT, and assist with reintubation. ■ Assess for air leak. Listen for air around the cuff, and check cuff pressure with a manometer, if available. Notify RT for possible reintubation if air leak cannot be fixed. ■ Assess for dislodgement. If tube is dislodged, remove and manually ventilate patient with 100% oxygen using Ambu bag and face mask. Suction oropharynx to clear secretions. Notify RT/physician STAT, and assist with reintubation. ■ Assist with reintubation if needed or replacement of ventilator or ventilator components. ■ If ineffective ventilation continues, inspect and auscultate the patient’s chest for equal and adequate air entry. If there is unequal chest wall movement and/or decreased air entry on one side, it may be related to a malpositioned tube, atelectasis, or a tension pneumothorax. Notify physician and RT. ■ If ineffective ventilation continues and no physical or mechanical cause can be found, consider sedating the patient.

Ventilator Alarms: Implications and Interventions When the ventilator alarms, check the patient first. If patient is in no apparent distress, check vent to determine source of problem. If patient is showing signs of distress (“fighting the vent”), try to calm the patient. If unsuccessful, immediately disconnect patient from vent, and manually ventilate with 100% oxygen using an Ambu bag and call for help.

Alarm Low-Pressure Alarm Usually caused by system disconnections or leaks.

Interventions ■ Reconnect patient to ventilator. ■ Evaluate cuff, and reinflate if needed (if ruptured, ET tube will need to be replaced). ■ Evaluate connections, and tighten or replace as needed. ■ Check ET tube placement (auscultate lung fields, and assess for equal, bilateral breath sounds).

48


49 Alarm

Interventions

High-Pressure Alarm Usually caused by resistance within the system. Can be kink or water in ET tubing, patient biting the tube, copious secretions, or plugged tube.

■ Suction patient if secretions are suspected. ■ Insert bite block to prevent patient from biting ET tube. ■ Reposition patient’s head and neck, or reposition tube. ■ Sedation may be required to prevent a patient from fighting the vent, but only after careful assessment excludes a physical or mechanical cause.

High Respiratory Rate Can be caused by anxiety or pain, secretions in ET tube/airway, hypoxia

■ Suction patient. ■ Look for source of anxiety (e.g., pain). ■ Evaluate oxygenation.

Low Exhaled Volume Usually caused by ET tubing disconnection, inadequate seal

■ Evaluate/reinflate cuff; if ruptured, ET tube must be replaced. ■ Evaluate connections; tighten or replace as needed; check ET tube placement; reconnect to ventilator.

Tracheostomy Dislodgement CLINICAL PICTURE The patient: ■ Coughs out tracheostomy tube. ■ If on a ventilator, low pressure alarms may sound.


■ If the tracheostomy is less than 4 days old, STAT intervention is required as the tract can collapse suddenly. Page respiratory therapist and physician or NP STAT. Only trained personnel should replace a new tracheostomy tube.

RESP

RESP


■ Open the tracheostomy with a sterile hemostat, suction catheter, or sterile gloved finger to maintain airway patency, and prevent the edges of the tracheostomy from collapsing. ■ If patient cannot breathe, ventilate with bag-valve mask. ■ If you cannot be sure that someone clinically prepared to reinsert the tracheostomy tube will arrive within 1 minute, call a code. ■ If the tracheostomy is older than 4 days, the tract will be well formed and will not close quickly. ■ Notify physician or NP and respiratory therapist that tube needs to be replaced. ■ Obtain replacement tube, if not already at the bedside. ■ Stay with patient, and prepare for insertion of new tube. ■ Document patient’s status, phone call to physician or NP, and physician or NP response.

FOCUSED ASSESSMENT

■ Assess patient’s ability to breathe through stoma. Look, listen, and feel for signs of air movement through stoma. ■ Assess tracheostomy site for secretions (blood, mucus, etc.), swelling, or trauma. ■ Auscultate lungs, and assess patient’s ability to cough effectively and clear airway.


■ After tube is reinserted and tracheostomy dressing is in place, check that ties are secure but not excessively tight. You should be able to easily insert 1 finger under the ties. ■ Administer humidified supplemental O2. ■ Assess oxygenation status by monitoring LOC and SaO2. ■ For future tracheostomy care, have another nurse hold tube in place while ties are changed. ■ Obtain sterile hemostat, sterile obturator, and replacement tracheostomy tube to be kept at bedside. ■ Chart patient status, and report to physician or NP.

BE PREPARED TO

■ Call a code. ■ Assist with the insertion of a new tracheostomy tube. ■ Perform tracheostomy care.

50


51 POSSIBLE ETIOLOGIES

■ Coughing, patient movement, poorly secured tracheostomy tube, accidental self-extubation, excessive torque or tension on a tracheostomy tube attached to a ventilator or other O2 administration device, deflated tracheostomy cuff.

Basic ABG Interpretation Commonly Used Terms ■ SaO2 is the oxygen saturation, frequently called O-2-”sats” ■ PaO2 is the partial pressure of oxygen in the blood and is referred to as P-O-2 ■ PaCO2 is the partial pressure of carbon dioxide. It can be called carbon dioxide or carbonic acid, but people generally call it C-O-2 ■ HCO3 is bicarbonate, usually called “bicarb” Step-by-Step Interpretation Determine the acid base balance: is it acidic, alkaline, or normal? ■ Evaluate pH. The range of 7.35–7.45 is very precise. ■ If the pH is between 7.35 and 7.40 it is considered normal, trending to acidic; a pH between 7.41 and 7.45 is considered normal, trending to alkalotic. 1. Determine the source of the imbalance. Is the problem primarily respiratory or metabolic? ■ Evaluate Paco2. This is the respiratory component. Carbon dioxide is an acid; therefore, an elevated CO2 ⫽ respiratory acidosis. A decreased CO2 ⫽ respiratory alkalosis. ■ Evaluate HCO3. This is the metabolic component. Bicarbonate is a base; therefore, if it is too low, it means metabolic acidosis. High bicarbonate ⫽ metabolic alkalosis. ■ Putting it together: to determine if the imbalance is primarily respir tory or metabolic, compare the pH with both the respiratory and the metabolic components. Whichever of the two is consistent with the pH result (acidosis or alkalosis) is the system that is dominating. For example: if the ABG results are pH ⫽ 7.50, PaCO2 ⫽ 28, and HCO3 ⫽ 23, the pH level is high: alkalosis. PaCO2, which is a respiratory acid, is low. Low acidity is another way of saying alkalosis, so they are consistent. HCO3, a metabolic buffer, is normal, neither acidosis or alkalosis. This means the respiratory system is causing the alkalosis, which is called respiratory alkalosis.

RESP

RESP


2. Determine the body’s response. Is it compensated or not? ■ The kidneys attempt to compensate for respiratory abnormalities, whereas the lungs try to correct metabolic disturbances. The extent of correction is referred to as compensation. ■ Compensated: Look at the pH. If it is normal, but the carbon dioxide or bicarbonate level is off, then the body has fully compensated. ■ If pH is not normal, determine if problem is partially compensated or uncompensated. ■ Partially compensated: Abnormal pH with either the PaCO2 or the HCO3 abnormal indicates partial compensation. ■ Abnormal pH with both the PaCO2 and the HCO3 abnormal indicates no compensation. 3. Determine how well the lungs are oygenating. ■ The two basic measures of oxygen in the blood are SaO2 and PaO2, although there may be others (hemoglobin and O2CT). ■ PaO2 is a measure of the amount of oxygen dissolved in the blood. It reflects how well the lungs are getting oxygen into the bloodstream from the atmosphere. Normal PaO2 ⫽ ⬎80 mm Hg. ■ PaO2 60–80 mm Hg ⫽ mild hypoxemia ■ PaO2 40–60 mm Hg ⫽ moderate hypoxemia ■ PaO2 ⬍40 mm Hg ⫽ severe hypoxemia ■ Decreased PaO2 levels are associated with ■ anemia ■ hypoventilation ■ heart failure ■ COPD and other restrictive pulmonary diseases. ■ SaO2 reflects to what degree oxygen is carried by hemoglobin. Hemoglobin has four oxygen-carrying sites. When all four sites have a molecule of oxygen attached, the hemoglobin is “saturated.” Normal SaO2 is 95%–100%. Some patients may have lower levels and not be in distress; the nurse must look at the whole picture and not just an isolated number. SaO2 less than 90% requires rapid intervention, unless it is within the patient’s baseline range. ■ You will sometimes see a PaO2 and a PaO2. These are different measures. PaO2 is the partial pressure of oxygen in the arteries. PaO2 is the partial pressure of oxygen in the alveoli. Both are used to calculate the A-a gradient, which indicates how well the lungs are getting oxygen from the air into the pulmonary circulation. If the A-a gradient is elevated, it means the lungs are not performing well.

52


53 Oxygen Delivery Systems Cannula (nasal prongs) ■ Indicated when low-flow, smallpercentage oxygen therapy is desired. ■ Flow rate of 1–6 L/min delivers 24%–44% oxygen. ■ Allows patient to eat, drink, and talk. ■ Extended use can dry the nose and nasopharynx; use with humidifier.

Cannula (nasal prongs).

Simple Mask ■ Indicated when desired FiO2 to be delivered is 40%–60%. ■ Flow rate of 6–10 L/min delivers 35%–60% oxygen. ■ Lateral perforations permit exhalation of CO2. ■ Permits humidification.

Exhalation ports

Elastic strap

To oxygen source

Simple mask.

Bag-Mask (nonrebreather) ■ Indicated when high concentrations of O2 are desired. ■ Flow rate of up to 15 L/min delivers up to 100% oxygen. ■ One-way flaps open and close with respiration, resulting in a high concentration of delivered oxygen and minimal to no CO2 rebreathed by the patient.

(one-way valves)

Exhalation port

Inhalation port

Bag-mask (nonrebreather).

RESP

RESP


Venturi Mask (Ventimask) ■ Indicated for precision titration of oxygen. ■ Accurate delivery of O2 is accomplished with a graduated dial that is set to the desired percentage of oxygen to be delivered. ■ Flow rate of 4–8 L/min delivers 24%–40% oxygen.

Venturi mask (Ventimask).

Ambu Bag, Bag-Valve-Mask ■ Indicated for resuscitation or to manually ventilate a patient during transport or ventilator failure or interruption. ■ Can deliver up to 100% oxygen. ■ Appropriate size and fit are essential, both to create a good seal and to prevent injury. ■ To create seal, hold mask with thumb and pointer finger (thumb toward nose), and grasp underneath the ridge of the jaw with remaining three fingers (see picture).

One-way valve

Reservoir

Mask Bag O2 supply

Ambu bag, bag-valve-mask.

Humidified Systems ■ Indicated for patients requiring longterm oxygen therapy to prevent drying of mucous membranes. ■ Setup may vary among brands. Fill canister with sterile water to recommended level, attach to oxygen source, and attach mask or cannula to humidifier. ■ Adjust flow rate.

To oxygen source

To patient

Maximum fill line

Sterile water in reservoir

Humidified systems.

54

Minimum water level line


55 Transtracheal Oxygenation ■ Indicated for patients with a tracheostomy who require longterm oxygen therapy and/or intermittent, transtracheal aerosol treatment. ■ Ensure proper placement (over stoma, tracheal tube). ■ Assess for and clear secretions as needed. ■ Assess skin for signs of irritation.

Chain necklace Tract Transtracheal catheter (connect to oxygen) Trachea

Transtracheal oxygenation.

Artificial Airways Oropharyngeal Airway ■ Indicated for unconscious patients who do not have a gag reflex. ■ Measure either from the corner of the mouth to the earlobe or from the center of the mouth to the angle of the jaw. ■ Rotate airway 180⬚ while inserting into oropharynx.

OROPHARYNGEAL AIRWAY TRACHEA TONGUE ESOPHAGUS

OROPHARYNGEAL AIRWAY PHARYNX

Oropharyngeal airway.

Nasopharyngeal Airway ■ Indicated for patients with a gag reflex, comatose with spontaneous respirations, lockjaw. ■ Measure from the tip of the patient’s nose to the earlobe. ■ The diameter should match that of the patient’s pinkie. ■ NEVER insert in the presence of facial trauma.

PHARYNX

NASOPHARYNGEAL AIRWAY

TRACHEA

ESOPHAGUS

Nasopharyngeal airway.

RESP

RESP


Endotracheal Tube ■ Indicated for apnea, airway obstruction, respiratory failure, risk of aspiration, combative patient (protect from further injury), or when goal of therapy is hyperventilation. ■ Can be inserted through the mouth or nose. ■ Inflated cuff protects patient from aspiration.

Endotracheal tube.

56


57 A & P Snapshot

Arteriole Pulmonary capillaries Alveolar duct

Frontal sinuses Sphenoidal sinuses Nasal cavity Nasopharynx Soft palate Epiglottis Larynx and vocal folds Trachea

Alveolus B

Superior lobe Right lung

Venule Left lung Left primary bronchus Superior lobe

Right primary bronchus Middle lobe

Bronchioles Inferior lobe Inferior lobe

Mediastinum Cardiac notch Diaphragm A Respiratory system.

RESP

Pleural membranes Pleural space


RESP

sp ac e

Pulmonary capillary

e Alv

ir ra ola

O2 pickup O2 Hb Hb O2 O2

O2

Systemic capillary

O2 delivery

Plasma Hb O2

Red blood cells

Hb

O2

s

O2

e

in su lls tis Ce ral

e iph per A

Oxygen pickup and delivery.

58

O2


59 sp ac

e

Pulmonary capillary

e Alv

ir ra ola

CO2 delivery

CO2

CO2 H2CO3 H 2O

CO2

Systemic capillary

Hb

Hb CO2

Hb

CO 2

H2CO3 H 2O

s

Hb

e

in su lls tis Ce ral

CO2

iph per

e

CO2

B

CO2 delivery and pickup.

RESP

CO2 pickup

NEURO


Neurological Assessment Mental Status ■ See Mini Mental Status Examination. ■ Assess affect, mood, appearance, grooming. ■ Assess speech for clarity and coherence. ■ Assess LOC—alert, lethargic, stuporous, obtunded. ■ Assess orientation—person, place, time. Cranial Nerves ■ See Cranial Nerve Assessment in this tab. Balance and Coordination ■ Gait/balance ■ Observe gait patterns while instructing patient to walk away from you and then back again. ■ Have patient hop in place on each foot. ■ Have patient stand from a sitting position. ■ Coordination ■ Instruct patient to tap the tip of the thumb with the tip of the index finger as fast as possible. ■ Instruct patient to touch nose and your index finger alternately several times. Continually change the position of your finger during the test. Sensation, Strength, Motion, Reflexes ■ Ask about altered sensations such as numbness and tingling. ■ Using your finger and a toothpick, instruct patient to distinguish between sharp and dull sensations. Compare left side of body with right, with patient’s eyes closed. ■ Assess motor strength of all four extremities. Muscle Strength Grading Scale 0 No muscle movement 1 Visible muscle movement, but no movement at the joint 2 Movement at the joint, but not against gravity 3 Movement against gravity, but not against added resistance 4 Movement against resistance, but less than normal 5 Normal strength ■ Assess reflexes using a reflex hammer Tendon Reflex Grading Scale 0 Absent 1⫹ Hypoactive 2⫹ Normal 3⫹ Hyperactive without clonus 4⫹ Hyperactive with clonus

60


61 ■ Assess plantar (Babinski’s) reflex by stroking the lateral aspect of the sole of each foot with the reflex hammer. Normal response is flexion (withdrawal) of the toes.

Glasgow Coma Scale (GCS) The GCS is an LOC assessment tool. Best Eye Response (E) Spontaneously 4 On command 3 To pain 2 No response 1 Score:_______ Best Verbal Response (V) Alert and oriented Confused Inappropriate Incomprehensible No response Score:_________

5 4 3 2 1

Best Motor Response (M) Follows direction Localizes pain Withdraws from pain Abnormal flexion Abnormal extension No response Score:________

6 5 4 3 2 1

Score may range from 3 (lowest neurological function) to 15 (highest function). However, a number of combinations of eye opening, verbal response, and motor response will give the same score. To provide a clearer picture of the patient’s neurological functioning, record the score in the following manner: GCS ⫽ 9/15 (E ⫽ 2, V ⫽ 3, M ⫽ 4) This is read as “Glasgow Coma Score ⫽ 9 out of a possible 15, eye opening score 2, verbal response score 3, motor response score 4.”

NEURO


NEURO

Cranial Nerve Assessment Nerve

Name

Function

Test

I

Olfactory

Smell

Identify familiar odors (e.g., coffee, peppermint).

II

Optic

Visual acuity

Assess visual acuity using eye chart.

Visual field

Assess peripheral vision.

III

Oculomotor

Pupillary reaction

Assess pupils for equality and reactivity to light.

IV

Trochlear

Eye movement

Patient follows finger without moving head.

V

Trigeminal

Facial sensation

Touch face, and assess for sharp and dull sensation.

Motor function

Have patient hold mouth open.

VI

Abducens

Motor function

Patient follows finger without moving head.

VII

Facial

Motor function

Have patient smile, wrinkle face, puff cheeks.

Sensory

Patient differentiates between sweet and salty taste.

Hearing

Snap fingers close to patient’s ears.

Balance

Feet together, arms at side, eyes closed for 5 sec.

VIII

Acoustic

IX

Glossopharyngeal

Swallowing and voice

Have patient swallow and then say “Ah.”

X

Vagus

Gag reflex

Use tongue depressor or swab to elicit gag reflex.

XI

Spinal accessory

Neck motion

Patient shrugs or turns head against resistance.

XII

Hypoglossal

Tongue movement

Patient sticks out tongue and moves it from side to side.

62


63 Mini Mental Status Examination Task

Instructions

Scoring

Date orientation

“Tell me the date.” Ask for omitted items.

1 point each for year, season, date, day of week, and month.

Place orientation

“Where are you?” Ask for omitted items.

1 point each for state, county, town, building, and floor or room.

Register three objects

Name three objects slowly and clearly. Ask patient to repeat them.

1 point for each item repeated correctly.

Serial 7s

Ask patient to count backward from 100 by 7. Stop after five answers (or ask patient to spell “world” backwards).

1 point for each correct answer (or letter).

Recall three objects

Ask patient to recall the objects mentioned above.

1 point for each item remembered correctly.

Naming

Point to your watch and ask patient “What is this?” Repeat with a pencil.

1 point for each correct answer.

Repeating a phrase

Ask patient to say “No ifs, ands, or buts.”

1 point if successful on first try.

Score


NEURO


NEURO

Mini Mental Status Examination (continued) Task

Instructions

Scoring

Verbal commands

Give patient a plain 1 point for each piece of paper and correct action. say “Take this paper in your right hand, fold it in half, and put it on the floor.”

Written commands

Show patient a piece 1 point if patient of paper with closes eyes. “Close your eyes” printed on it.

Writing

Ask patient to write a sentence.

Drawing

Ask patient to copy a 1 point if the pair of intersecting figure has pentagons onto a 10 corners and piece of paper. 2 intersecting lines.

Score

1 point if sentence has a subject and a verb and makes sense.

Scoring Total possible score: 30. Score of 24 or above is considered normal.

Altered Level of Consciousness CLINICAL PICTURE The patient may have or be: ■ Change in usual state of full consciousness. ■ Difficulty or inability to respond to verbal stimuli. ■ Inability to speak, obey commands, or open eyes in response to verbal or painful stimuli. ■ Confused, lethargic, obtunded, stuporous, or comatose (see following table for definitions).

64


65 IMMEDIATE INTERVENTIONS

■ Assess and protect airway. ■ Administer supplemental O2, or ventilate if patient is not breathing adequately (RR ⬍8 and/or cyanosis). ■ Suction the oropharynx, and clear secretions as needed. ■ Assess VS, O2 saturation, and pupillary reaction. ■ Notify physician or NP. ■ Document patient’s status, phone call to physician or NP, and physician or NP response.


Assess airway for patency and secretions/obstructions. Assess breathing and oxygenation. Assess HR for rate and regularity. Assess LOC (see GCS in this tab), pupil reactivity and size, best motor response, and orientation. ■ Assess responsiveness to verbal or painful stimuli. Note: Does patient respond to verbal stimuli? If not, does patient respond to gentle stimuli (shaking the arm) or only to painful stimuli (e.g., grasping the pectoralis muscle)? Is the motor response to stimuli purposeful (removing or withdrawing from stimuli or posturing)? ■ Assess for associated neurological deficits such as weakness or numbness on one side of the body. ■ Assess medication administration record (MAR) for drugs capable of causing altered LOC.


■ Collaborate with health-care team to treat underlying causes (such as drug overdose), if applicable. ■ Continue to monitor VS, breathing, and oxygenation closely. ■ Continue to monitor neurological status.


Assist with airway management or intubation if needed. Start an IV. Give medications. Order laboratory tests. Transfer patient to ICU.

NEURO


NEURO

POSSIBLE ETIOLOGIES

■ Brain lesions/interruptions in blood flow, metabolic disorders (hypoglycemia, hypoxia), psychiatric disorder, toxic medication levels/drug overdose, increasing intracranial pressure (ICP), dysrhythmia.

Levels of Consciousness LOC

Characteristics

Full consciousness

Awake, alert, and oriented. Understands written and spoken language, and responds reliably.

Confusion

Disoriented first to time, then place, then person. Memory deficits, difficulty following commands, restless, agitated.

Lethargy

Oriented to time, person, and place, but demonstrates slow mental processes, sluggish speech. Sleeps frequently, but wakens to spoken word or gentle shake. Maintains wakefulness with sufficient stimulation.

Obtundation

Extreme drowsiness, responds with one or two words, follows very simple commands, requires more vigorous stimulation to waken, and stays awake for only a few minutes at a time.

Stupor

Minimal movement, responds unintelligibly, and wakens briefly only to repeated vigorous stimulation.

Coma

Does not respond to verbal stimuli, does not speak. May have appropriate motor response (e.g., withdraws from noxious stimuli), nonpurposeful response, or no response.

66


67 Change in Mental Status/Delirium CLINICAL PICTURE The patient may have or be: ■ Confused, restless, agitated, disoriented to time and place. ■ Easily distracted, delusional, hallucinating. ■ Disturbed general appearance, motor activity, dress, and facial expression. ■ Agitated or obtunded with fluctuating LOC. ■ Rambling, disorganized speech. ■ Impaired cognitive function. ■ Reversal of sleep-wake cycle.


■ ■ ■ ■ ■ ■

Assist patient to safe area or back to bed. If LOC is diminished, position to maintain patent airway. Provide supplemental O2 if saturation in room air is 93%. Check MAR for recently given medications. Stay with patient, and notify physician or NP. Document patient status, phone call to physician or NP, and physician or NP response.

FOCUSED ASSESSMENT

■ Assess VS, oxygenation, and neurological status. ■ Assess mental status with Mini Mental Status Examination (see table in this tab). ■ Assess for associated neurological deficits, such as weakness or numbness on one side of the body or changes in consciousness. ■ Assess for history of alcohol abuse, medication use, psychiatric illness. ■ Assess for possible source of infection.

STABILIZING AND MONITORING ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Assess neurological status, motor function, and respiratory function. Auscultate lungs for adventitious sounds. Reorient as needed. Place calendar, clock, and family photos in room. Provide stable, quiet, and well-lighted environment. Keep staff consistent, if possible. Explain procedures before beginning care. Have patient wear eyeglasses and hearing aids, if applicable. Enhance safety of environment. Stay with patient, and offer support and reassurance. Avoid use of restraints.

NEURO


■ ■ ■ ■ ■ ■

NEURO

Assess nutritional status and ability to take foods and fluids. Monitor I&O/fluid status. Monitor laboratory results. Provide support. Collaborate with health-care team to treat identified cause(s). Document patient status, and communicate to physician.


Start a peripheral IV. Obtain laboratory work; prepare patient for diagnostic studies. Obtain blood, sputum, and urine cultures. Administer appropriate medications as ordered. Arrange for one-on-one care.

POSSIBLE ETIOLOGIES

■ Hypoglycemia, hypoxia, low blood pressure, compromise of cerebral blood supply (stroke), elevated ammonia levels (end-stage liver failure), toxic medication levels, drug-induced psychosis, urosepsis (especially in the elderly), structural lesions, metabolic disorders, psychiatric disorders, renal disease, compromise of cerebral blood flow.

Dizziness CLINICAL PICTURE The patient may have or be: ■ Sensation of spinning (vertigo), disequilibrium, or faintness. ■ Weakness, nausea. ■ Chest pain, tightness, squeezing, or pressure. ■ Shortness of breath, palpitations. ■ Tingling, pins-and-needles, weakness of extremities.


Assist patient to safe place to sit or lie down. Administer supplemental O2. Assess VS. Encourage slow deep breaths. Stay with patient, and provide reassurance. Document patient’s status, phone call to physician or NP, and physician or NP response.

68



■ Assess VS and respiratory status. ■ Assess cardiac rhythm and rate; assess for orthostasis (take blood pressure supine, sitting, and standing; note changes in systolic BP and HR). ■ Assess for circumoral cyanosis, skin temperature, and moistness. ■ Assess MAR for recently taken medications that can cause dizziness. ■ Assess history of similar episodes. ■ Assess for history of inner ear disease or migraine. ■ Assess recent laboratory values for electrolyte abnormality. ■ If patient is diabetic, obtain blood glucose level by fingerstick.

STABILIZING AND MONITORING ■ ■ ■ ■ ■

Administer medications for dizziness as ordered. Assess VS and subjective feeling of dizziness. Help patient with ambulation and self-care until dizziness resolves. Monitor I&O. Monitor laboratory values.

BE PREPARED TO

■ Start an IV. ■ Assist with diagnostic testing.

POSSIBLE ETIOLOGIES

■ Hypertension, hypotension, stroke, hypoglycemia, cardiac dysrhythmias, myocardial infarction, neuropathy, deconditioning, dehydration, arteriosclerosis, Ménière’s disease, medications, migraine, hyperventilation.

Head Trauma CLINICAL PICTURE The patient may have: ■ Scalp lacerations, hematoma, bilateral orbital ecchymosis. ■ Battle’s sign (bruising behind the ear at the mastoid process). ■ Altered mental status of LOC: agitated, semiconscious, consciousness or unconscious; may have seizures. ■ CSF leakage from ear or nose. ■ Signs of ICP: ■ Decreasing LOC, deterioration in GCS. ■ Cushing’s response (bradycardia, hypertension, bradypnea).

NEURO


NEURO


■ Assess airway, breathing, circulation; assess VS. ■ Call for assistance, and notify physician or NP. ■ If patient conscious, open airway, and inspect. Clear blood, vomitus, or secretions. ■ Immobilize cervical spine with collar or by holding head and neck in neutral alignment with body. ■ With proper assistance and C-spine aligned or in collar, transfer patient to bed or stretcher. ■ Treat bleeding lacerations. ■ Document patient status, phone call to physician or NP, and physician or NP response.

FOCUSED ASSESSMENT ■ ■ ■ ■ ■ ■ ■ ■

Examine for lacerations, depressions, swelling, Battle’s sign. Inspect mouth for blood, foreign bodies, and vomitus. Inspect pupils for equality and reactivity. Inspect ears and nose for leakage of clear fluid (CSF) suggestive of skull fracture. Assess for distal deficits such as numbness or paralysis in the arms or legs. Assess cause and underlying conditions. Assess for history of seizures. Assess recent laboratory values, if available.


■ Continue to assess for impaired consciousness, deterioration in LOC, unequal pupils/decrease in reactivity, severe tachycardia or bradycardia— report changes in condition immediately. ■ Assess for severe and persistent headache, nausea and vomiting, irritability or altered behavior. ■ Assist with diagnostic procedures (x-ray or CT scan).

BE PREPARED TO

■ ■ ■ ■ ■ ■ ■ ■

Set up and assist with intubation. Administer O2, and monitor oxygen saturation. Monitor cardiac rhythm and VS. Assist with diagnostic testing. Insert an indwelling urinary catheter. Start an IV; administer IVF and medications as ordered. Assist with immobilization of neck and back. Insert a nasogastric tube once skull fracture has been ruled out.

70


71 POSSIBLE ETIOLOGIES ■ Patient fall, trauma.

Increasing Intracranial Pressure (ICP) CLINICAL PICTURE The patient may have or be: ■ Subtle to dramatic changes in LOC; restlessness, confusion, drowsiness, stupor, coma. ■ Double or blurred vision, headache, nausea and vomiting, sensitivity to light. ■ Decreased motor function. ■ Late findings: changes in VS (widening pulse pressure, bradycardia, and increased respiratory rate).

IMMEDIATE INTERVENTIONS ■ ■ ■ ■ ■ ■ ■ ■ ■

Assess airway patency and breathing. Assess VS. Notify physician or NP of findings. Elevate head of bed to 15⬚–30⬚. Provide high-flow O2 with a non-rebreather mask. Keep head in neutral alignment. Avoid flexion of the neck or hips. Minimize environmental stimuli. Document patient’s status, phone call to physician or NP, and physician or NP response.

FOCUSED ASSESSMENT

■ Assess neurological status (see Neurological Assessment in this tab and GCS in this tab). ■ Assess cranial nerves as condition allows (see Cranial Nerve Assessment in this tab). ■ Asses oxygen saturation, cardiac rhythm. ■ Assess for signs of decreased oxygenation (LOC, desaturation, cyanosis, increase in respiratory rate).


■ Monitor neurological status and VS. ■ Keep systolic blood pressure between 100 and 160 mm Hg (check with physician for parameters).

NEURO


NEURO

■ Limit suctioning (increases ICP); suction for fewer than 10 seconds in duration, and administer 100% O2 beforehand; limit to two passes. ■ Maintain SaO2 at 100%. ■ Maintain and assess I&O. ■ Monitor ABGs, electrolytes. ■ If necessary, insert an oral or nasal airway. ■ Maintain quiet environment; protect patient from injury. ■ Provide education/reassurance/comfort measures. ■ Document all findings, and communicate to physician or NP. ■ Obtain or perform chest physiotherapy as needed. Perform skin assessment. Assess nutritional status; obtain consult if needed.

BE PREPARED TO

■ Assist with intubation if needed. ■ Establish IV access, and give medications (sedatives, osmotic diuretics, corticosteroids, anticonvulsants). ■ Insert nasogastric tube or urinary catheter. ■ Transfer to ICU.

POSSIBLE ETIOLOGIES

■ Tumor, cranial abcess, intracranial bleed, cerebral hypoxia, hypertension, hydrocephalus, head trauma.

Seizure CLINICAL PICTURE The patient may have: ■ Repetitive, jerking movements of the upper and lower extremities. ■ Extreme muscle rigidity. ■ LOC or disorientation. ■ Tongue or eye deviation. ■ Cyanosis or apnea. ■ Urinary or fecal incontinence. ■ Blinking or repetitive behaviors (e.g., playing with buttons). ■ Difficulty in arousing from stuporous state (postictal). ■ Aura (warning or recognition that seizure may occur).

72



■ Ascertain that airway is not compromised by secretions or emesis. Suction if necessary. Turn head/body to side, if able. ■ Protect patient from injury—clear immediate area of potentially harmful objects; e.g., overbed table or glasses. ■ Raise siderails; if patient is OOB, guide to floor. ■ Stay with patient, and call for help. ■ Do not insert objects into patient’s mouth.

FOCUSED ASSESSMENT

■ Assess VS, airway patency, and respiratory status. ■ Note length, onset, duration, progression, and location (i.e., body parts involved) of seizure activity. ■ Note tongue/eye deviation. ■ Note LOC, orientation, and responsiveness during seizure. ■ Assess pupil size, shape, and reactivity to light. ■ Assess for incontinence.


■ Suction the oropharynx, and clear secretions as needed. ■ Remove dentures. ■ Once seizure subsides (postictal phase), complete assessment, and document findings. Include seizure description: aura; onset; duration; body part in which seizure started; and progression of seizure activity; LOC before, during, and after seizure; pupils; respiratory status; and any precipitating factors. ■ Reorient patient if necessary. ■ Allow patient to sleep. ■ Provide reassurance and education.

BE PREPARED TO

■ Start an IV, and administer antiseizure medications. Check blood levels of antiseizure medications. ■ Prepare patient with new onset seizures for extensive evaluation, including CT scan, EEG, lumbar puncture, glucose level, Mg level, Ca level, CBC, electrolytes, BUN, and creatinine levels.

POSSIBLE ETIOLOGIES

■ Inadequate blood levels of a prescribed anticonvulsant, arteriovenous malformation, stroke, infection, trauma, tumor, metabolic disorders (severe electrolyte disorders, low blood glucose level, renal failure, hypoxia), drug or alcohol withdrawal.

NEURO


NEURO

Spinal Cord Trauma/Syndrome CLINICAL PICTURE The patient may have: ■ History of recent back trauma with varying amounts of weakness and sensory loss at and below the injury; pattern depends on whether cord injury is complete or partial (incomplete). ■ Arm and/or leg weakness, paralysis. ■ Breathing difficulties. ■ Spasticity (increased muscle tone). ■ Altered sensation, numbness, pain. ■ Loss of bowel and bladder control. ■ Constipation, incontinence, bladder spasms. ■ Rapid blood pressure fluctuations; abnormal sweating and thermoregulation (injuries to cervical or high thoracic cord). ■ Loss of sensation, reflexes, and mobility below level of injury. ■ Nausea and vomiting.


■ Immobilize cervical-spine (with light traction, hold head and neck in neutral alignment with body). ■ If immobilizing entire body on a backboard, legs and torso must be secured prior to securing head to board. ■ Assess airway, breathing, circulatory status. ■ Assess LOC, mental status. ■ Assess VS.

FOCUSED ASSESSMENT

■ Examine spine for lacerations, swelling, hematoma, deformity. ■ Assess mobility by asking patient to open and close fist, squeeze your hand, and move toes and turn feet (see Neurological Assessment in this tab). ■ Assess sensation by asking patient about numbness and altered sensation and by touching patient lightly, beginning at shoulder and working down arms and legs of both sides.


■ Frequently assess motor or sensory function—call physician or NP immediately if condition changes. ■ Assess VS, O2 saturation, temperature.

74


75 ■ Assess for potential complications: neurogenic shock (hypothermia and hypotension without tachycardia), spinal shock (urinary and bowel retention leading to abdominal distention, ileus, and delayed gastric emptying), autonomic hyperreflexia, respiratory compromise, nutritional decline, skin breakdown, urinary retention, constipation. ■ Maintain spinal stabilization and immobilization. Move the patient very carefully using logroll technique. Use a spine board with restraints or other items, such as head blocks and pillows, to maintain position. ■ Document findings, and communicate with physician or NP. ■ Assist with diagnostic studies (spine x-rays, CT, MRI).

BE PREPARED TO

■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Administer O2, and monitor O2 saturation. Set up and assist with intubation. Assist with placing patient in spinal traction. Monitor cardiac rhythm and VS. Assist with diagnostic testing. Insert an indwelling urinary catheter. Start an IV. Administer IVF and medications (e.g., methylprednisone). Assist with immobilization of neck and back. Insert a nasogastric tube.

POSSIBLE ETIOLOGIES

■ Blunt or penetrating trauma, auto versus pedestrian, motor vehicle accident, spinal lesion or abcess.

Sudden Neurological Deficit (Stroke/ Transient Ischemic Attack) CLINICAL PICTURE The patient may have: ■ Weakness or numbness of one side of the face or body. ■ Slurred speech, aphasia, difficulty finding words. ■ Difficulty swallowing. ■ Ataxia, clumsiness. ■ Double vision, severe headache. ■ Problems with respiratory function/gag reflex. ■ Tachycardia/bradycardia/hypertension.

NEURO


■ ■ ■ ■

NEURO

Changes in affect/memory/judgment. Altered LOC, confusion, agitation. Seizures. Nausea/vomiting.


■ Maintain patent airway. ■ If in bed, elevate head of bed 30⬚, and position head to one side to prevent aspiration of secretions (if no signs of shock present). ■ Administer supplemental O2. ■ Assess VS. ■ Do not give anything by mouth. ■ Call physician or NP. ■ Stay with patient. ■ Document patient status, phone call to physician or NP, and physician or NP response.

FOCUSED ASSESSMENT

■ Assess airway, ability to clear secretions, breathing pattern, heart rate and rhythm, oxygenation status, and blood pressure. ■ Assess LOC (see GCS in this tab). ■ If patient is conscious, assess level of orientation. ■ Assess pupillary response, vision, and facial symmetry. ■ Assess speech. ■ Assess motor strength and control (see Neurological Examination in Tools tab).


■ Continue to maintain patent airway. ■ Reassess airway, ability to clear secretions, breathing pattern, heart rate and rhythm, oxygenation status, and blood pressure every 15 minutes. ■ Initiate seizure precautions. ■ Suction the oropharynx as needed to clear secretions. ■ Assist with diagnostic testing (CT scan, MRI, ECG). ■ Monitor laboratory values, I&O. ■ Administer medications as ordered. ■ Stay with patient for continued monitoring and support. ■ Obtain nutrition assessment. ■ Perform skin assessment; initiate pressure ulcer prevention strategies. ■ Support patient, and provide safe environment. ■ Begin discharge/rehabilitation planning if stroke is confirmed.

76


77 BE PREPARED TO

■ ■ ■ ■ ■ ■ ■ ■

Aggressively manage airway. Start an IV. Administer O2. Draw laboratory tests. Accompany the patient to CT scan. Assess if patient meets thrombolytic criteria. Prepare patient for thrombolytic or anticoagulant therapy. Transfer patient to a higher level of care.

POSSIBLE ETIOLOGIES

■ Embolic, thrombotic, or hemorrhagic stroke, TIA.

A & P Snapshot

Premotor area

Motor area

Frontal lobe

General sensory area Sensory association area Parietal lobe Occipital lobe Visual association area Visual area

Motor speech area Auditory association area

Auditory area

Temporal lobe

Functional areas of the brain.

NEURO


NEURO

OLFACTORY 1 OCULOMOTOR 3 TROCHLEAR 4 ABDUCENS 6

OPTIC 2

TRIGEMINAL 5

FACIAL 7

GLOSSOPHARYNGEAL 9 VESTIBULOCOCHLEAR 8

HYPOGLOSSAL 12

VAGUS 10 ACCESSORY 11

Cranial nerves.

78


79 Central canal

Interneuron Synapse Dorsal root

Dorsal column Corticospinal tract Rubrospinal tract

Dorsal root ganglion Cell body of sensor neuron Dendrite of sensory neuron

Ventral root

Receptor

Axon of motor neuron Synaptic knobs

Spinothalamic tract

White matter Gray matter Effector muscle Cell body of motor neuron

Cross section of the spinal cord.

NEURO


RENAL/F&E

Focused Renal/GU Systems Assessment ■ A focused nursing assessment of renal function includes: ■ Assessing blood work: blood urea nitrogen (BUN) and creatinine values including BUN to creatinine ratio, electrolytes, other chemistries, hemoglobin, hematocrit level, ABGs. ■ Assessing urine laboratory tests: specific gravity, urine osmolality, creatinine clearance for renal function; urinalysis to screen for urinary system dysfunction; urine C&S to assess for infection. (Many more urine tests are available and are used to assess for diseases of systemic or other body systems diseases. This tab cites only the urine tests used specifically to assess the urinary system.) ■ Physical examination: vital signs; palpate for flank and CVA (costovertebral angle) tenderness; assess hydration status. ■ Blood work: ■ BUN is a by-product of protein metabolism and is excreted by the kidneys. A rise in BUN reflects a decrease in kidney function (kidneys are less able to filter and excrete the urea). BUN is affected by other variables (e.g., dehydration, upper GI bleed) and can remain within normal range even when kidney function is markedly impaired. Therefore, creatinine is a better measure of renal function, and creatinine clearance is preferred among the three blood tests. A rise in BUN without a rise in creatinine is most likely not related to a decline in renal functioning. ■ Normal value: Adults: 5–20 mg/dL ■ Critical Level: ⬎40 mg/dL (not dehydrated/no history of renal disease) ■ Critical Level: ⬎100 mg/dL (patient with history of renal disease) ■ Critical Level: ⬎20 mg/dL increase in 24 hr (indicates acute renal failure) Call physician or NP immediately with critical results. ■ Creatinine is a breakdown product of creatine phosphate in muscle. It is generally produced at a constant rate by the body and then is excreted by the kidney. It is used to estimate glomerular filtration rate. A rise in serum creatinine reflects a decrease in glomerular filtration rate (kidneys are less able to filter and excrete the creatinine, therefore, blood levels rise). ■ Normal values: Adult: Male: 0.6–1.2 mg/dL; Female: 0.5–1.1 mg/dL ■ Critical level: ⬎4 mg/dL

80


81 Call physician or NP immediately with critical results. ■ Creatinine clearance (CrCl) compares the level of creatinine in urine with the serum creatinine level. CrCl is used to determine safe dosing of nephrotoxic drugs. Urine creatinine is based on a 24-hour urine collection; blood for serum creatinine is collected at the end of the 24-hour period. However, CrCl is usually estimated by using a formula based on age, mass, and serum creatinine. Normal values: Male: 107–139 mL/min; Female: 85–105 mL/min. CrCl of 10–20 mL/min is indicative of renal failure and the need for dialysis. ■ Other urine tests include urinalysis for screening, urine osmolality and specific gravity for assessing renal concentrating ability, and urine culture and sensitivity for assessing urinary tract infection (UTI). ■ Assess urine for cloudiness, color, and volume. ■ Vital signs and ABGs: In coordination with other organs (lungs, adrenal glands, hypothalamus, endocrine system), the kidneys regulate acid-base balance, electrolyte concentrations, blood volume, and BP. The kidneys maintain BP through the renin-angiotensin system (RAS) and regulate hydration status by retaining sodium in response to aldosterone secretion. Therefore, kidney disorders may be reflected in changes in BP, fluids and electrolytes, and acid-base balance. When assessing BP, calculate the pulse pressure, which is the difference between the systolic and diastolic pressures. High pulse pressure (⬎40 mm Hg) is a risk factor for cardiac events. See Tab 3 for ABG interpretation. Briefly, the sodium bicarbonate value represents the metabolic componet of the ABG and is controlled by the kidneys. ■ Hydration status: Assess I&O, daily weights, mucous membranes, sodium levels, BUN to creatinine ratio, urine osmolality, specific gravity. ■ CVA tenderness: The angle created where the lowest ribs connect with the vertebral column. CVA pain and tenderness with other UTI symptoms suggests a kidney infection. ■ Focused assessment of the lower urinary tract includes: ■ Voiding patterns, including stress, urge, or overflow incontinence and difficulties initiating stream. ■ Residual urine volume (amount of urine left in the bladder after voiding). ■ Prostate examination in males.

RENAL/F&E


RENAL/F&E

Electrolyte Imbalances Electrolyte imbalances are encountered frequently in patients with all types of conditions. See p. 86 for hyperkalemia, p. 88 for hypokalemia, p. 87 for hypernatremia, and p. 89 for hyponatremia

Hypocalcemia: Ca ⬍8.4 mg/dL S&S

Treatment

Abdominal and muscle cramps, lethargy, ↑ BP, tetany, seizure, ECG changes.

Calcium gluconate 10%*: 1 g in 50–100 mL of D5W over 1 hr, then infusion of 1–2 mg/kg/hr.

Nursing Given by physician or NP on general care units and by RNs in ICU. Do not infuse too rapidly—is cardiotoxic and can cause ↓ BP. Never given IM or subcutaneously—causes severe sloughing of tissue. Check calcium and magnesium levels. Antidote: IV magnesium sulfate.

*Do not confuse with calcium chloride.

Hypercalcemia: Ca ⬎10.2 mg/dL S&S

Treatment

Nursing

Dehydration, renal stones, confusion, severe thirst, constipation, polyuria, shortening of QT interval ↑ BP.

D5NS at 250–500 mL/hr; furosemide 20–80 mg IV over 2 min to bring Ca down with diuresis.

Monitor electrolyte levels. Encourage fluid intake, provide ↑ fiber diet and stool softeners. Potentiate digoxin toxicity; assess as indicated. Monitor ECG, if available, or assess pulse for irregular beats.

82


83 Hypomagnesemia Mg ⬍1.5 mEq/L S&S

Treatment

Nursing

Weakness, vertigo, muscle twitching, tachycardia, seizures, tetany, PVCs.

2 g magnesium sulfate in D5W over 10–20 min, then 1 g/hr for 3–4 hr.

Check other electrolyte levels; can have ↓ potassium, ↓ phosphate, ↓ calcium. Assess reflexes and monitor Mg levels.

Hypermagnesemia Mg ⬎2.1 mEq/L S&S

Treatment

Nursing

Nausea, vomiting, ↓ BP, weakness, drowsiness, hyperreflexia, ↓ HR, coma, respiratory failure.

Calcium gluconate 10%*: 1–10 mL in 50–100 mL of D5W over 10–20 minutes.

Assess for changes in LOC. Assess reflexes. Hold medications containing magnesium, especially in patients with renal failure.

*Do not confuse with calcium chloride.

Hypophosphatemia PO4 ⬍2.5 mg/dL S&S

Treatment

Nursing

Anorexia, weakness, muscle pain, confusion, rhabdomyolysis, hemolysis, cardiac and respiratory failure.

Potassium or sodium phosphate 2 mg/kg IV over 6 hr if PO4 level is ⬍1–5 mg/dL. Oral replacement with KPhos or Neutra-Phos if depletion is less severe.

Too rapid IV administration can cause severe hypocalcemia; assess for tetany.

RENAL/F&E


RENAL/F&E

Hyperphosphatemia PO4 ⬎4.5 mg/dL S&S Limited symptoms; possible tetany if calcium is low, which is a result of hyperphosphatemia.

Treatment

Nursing

Phosphate binders, possibly acetazolamide, low-phosphate diet

Teach patient about avoiding foods and OTC medications high in phosphorus

Dehydration CLINICAL PICTURE The patient may have: ■ Increased thirst, dry mouth, and swollen tongue (see table below of Signs and Symptoms of Progressive Dehydration). ■ Weakness, dizziness, palpitations. ■ Tachycardia, hypotension. ■ Confusion, sluggishness, fainting, seizure. ■ Decreased urine output.


Assess VS; check BP lying, sitting, and standing; note changes. Assess current urine output and recent intake and output (I&O). Make sure patient is comfortable and safe. Notify physician. Document patient’s status, phone call to physician or NP, and physician or NP response.


Assess VS including temperature. Assess skin for color, moistness, temperature, integrity. Assess mucous membranes. Assess LOC and orientation. Assess for patent IV access.


Administer oral or IVF. Closely monitor I&O. Monitor urine output for adequate hourly rate. Assess electrolytes, BUN, creatinine.

84


85 ■ Maintain safe environment. ■ Provide oral care. ■ Chart patient status and convey to physician or NP.

BE PREPARED TO

■ Obtain IV access. ■ Obtain a nutritional/dietary assessment. ■ Insert urinary catheter with a urometer to monitor hourly output.

Signs and Symptoms of Progressive Dehydration Symptom/ Sign

Mild Dehydration

Moderate Dehydration

Severe Dehydration

LOC

Alert

Lethargic

Obtunded

Capillary refill

2 sec

2–4 sec

Greater than 4 sec, cool limbs

Mucous membranes

Normal

Dry

Parched, cracked

HR

Slight increase

Increased

Very increased

RR

Normal

Increased

Increased and hyperpnea

BP

Normal

Normal, but orthostasis

Decreased

Pulse

Normal

Thready

Faint or impalpable

Skin turgor

Normal

Slow

Tenting

Urine output

Decreased

Oliguria

Oliguria/anuria

POSSIBLE ETIOLOGIES

■ Gastroenteritis, stomatitis, diabetic ketoacidosis, febrile illness, pharyngitis, burns, GI obstruction, heat stroke, diabetes insipidus, thyrotoxicosis.

RENAL/F&E


RENAL/F&E

Hyperkalemia CLINICAL PICTURE The patient may have: ■ Muscular weakness. ■ Cardiac dysrhythmias. ■ ECG abnormalities (tall, peaked T waves). ■ Nausea.


Assess VS; note cardiac rate and rhythm. Administer oxygen. Assess for patent IV access. Assess recent laboratory results (BUN, creatinine, electrolytes). Notify physician or NP. Document patient’s status, phone call to physician or NP, and physician or NP response.


Monitor VS, and assess cardiac rhythm if available. Assess LOC and orientation. Assess musculoskeletal function. Assess previous 2 days’ I&O.


■ Obtain IV access. ■ Administer potassium-binding resins (Kay-exalate) orally or rectally. ■ Monitor cardiac rhythm, I&O, serial potassium levels, and other laboratory tests. ■ Chart patient status and convey to physician or NP.

BE PREPARED TO

■ Set up cardiac monitoring. ■ Administer IV calcium, sodium bicarbonate, insulin and glucose, or furosemide per order. ■ Order or obtain laboratory tests. ■ Order a 12-lead ECG. ■ Transfer to telemetry unit.

86



■ Medication, chemotherapy, acute or chronic renal failure, hypoaldosteronism trauma, hemolysis, digitalis poisoning, acidosis, burns, insulin deficiency, uncontrolled hyperglycemia, excessive use of salt substitutes, metabolic acidosis.

Hypernatremia CLINICAL PICTURE The patient may have: ■ Sodium level ⬎ 144 mEq/L ■ Confusion, lethargy, seizures, coma (if imbalance is severe) ■ Restlessness, irritability, disorientation, hallucinations ■ Thirst (many older adults have an impaired sense of thirst and may not express thirst) of flushed skin, peripheral edema ■ Postural hypotension, tachycardia


■ Assess recent lab values. ■ Assess vital signs; obtain orthostatic BP if possible. ■ Notify physician or NP, and document findings and discussion with physician or NP in the chart.

FOCUSED ASSESSMENT

■ Assess total intake and output over previous several days. ■ Assess skin and mucous membranes; note dry cracked skin, sticky oral membranes. ■ Assess mental status (see Mini Mental Status Examination in Tab 4) ■ Assess for intact IV site.


■ Insert IV, if necessary. ■ Administer parenteral fluids as ordered using a volume control infusion device; make sure fluids do not infuse too quickly; doing so in the presence of elevated sodium levels causes fluid shifts that can result in cerebral edema and brain damage. ■ If patient is disoriented, move patient to a room near the nurse’s station or ask if a family member can stay with the patient. ■ Continue assessment outlined above as treatment progresses. ■ Provide mouth care and measures to protect skin integrity.

RENAL/F&E


RENAL/F&E

BE PREPARED TO

■ Change IVF as soon as a different concentration is ordered, depending on changes in patient’s status ■ Monitor changes in mental status, laboratory values, VS

POSSIBLE ETIOLOGIES

■ Poor water intake due to inability to express thirst or insensible water loss; diabetes insipidus, excess salt intake, near-drowning in salt water.

Hypokalemia CLINICAL PICTURE The patient may have: ■ Serum potassium ⬍3.5 mEq/L. ■ Palpitations, ventricular dysrhythmias, bradycardia or tachycardia, hypotension. ■ Malaise, fatigue, weakness, muscle cramps. ■ Nausea, vomiting, ileus, constipation. ■ Hypoventilation, respiratory distress.


Assess BP sitting and standing; note orthostasis. Assess HR; note rhythm. Assess LOC and muscle strength. Notify physician or NP. Document patient’s status, phone call to physician or NP, and physician or NP response.


Assess recent I&O. Assess cardiac rhythm if patient on telemetry. Assess for digitalis toxicity, if indicated. Assess recent laboratory results (BUN, creatinine, electrolytes, magnesium level). ■ Assess medication history, use of diuretics or laxatives. ■ Assess for patent IV access.

STABILIZING AND MONITORING ■ Obtain IV access.

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89 ■ Administer oral and/or IV potassium supplement. Oral supplementation is much safer; IV rate should not exceed 200–400 mEq/24 hr (based on serum potassium level of 2.0–2.5 mEq/L); never give as a bolus: may precipitate cardiac arrest. Patient should be on telemetry if receiving treatment level amounts of potassium. ■ Monitor potassium and other electrolyte levels. ■ Monitor HR and rhythm. ■ Maintain safety precautions due to muscle weakness. ■ Nutrition/dietary education, especially if taking diuretics. ■ Chart patient status, and convey to physician or NP.

BE PREPARED TO

■ Place patient on telemetry. ■ Order or obtain laboratory tests, urine sample for potassium, ECG.

POSSIBLE ETIOLOGIES

■ Deficient potassium intake, vomiting, diarrhea, fistulas, laxative abuse, metabolic alkalosis, diuretic therapy, aldosteronism, excess adrenocortical secretion, renal tubule disease, chronic respiratory acidosis.

Hyponatremia CLINICAL PICTURE The patient may have: ■ Mild: Na⫹ ⬎120 mEq/L: headache, nausea, vomiting, weakness, muscle cramps. ■ Moderate: Na⫹ 110–120 mEq/L: hallucinations, bizarre behavior, hyperventilation, gait disturbance. ■ Severe: Na⫹ ⬍110 mEq/L: coma, respiratory arrest, hypertension, dilated pupils, seizures. ■ Neurological symptoms usually reflect severe, sudden drop in serum sodium level, which causes intracerebral osmotic fluid shifts and cerebral edema. A gradual drop in serum sodium may be tolerated because of neuronal adaptation.


Assess VS, LOC, feelings of weakness. Make sure patient is comfortable and safe. Check if blood for laboratory was drawn above a running IV site. Notify physician or NP. Document patient’s status, phone call to physician or NP, and physician or NP response.

RENAL/F&E


RENAL/F&E

FOCUSED ASSESSMENT

■ Assess HR and BP lying, sitting, and standing (if possible); note changes in BP and HR. ■ Assess fluid status: examine mucous membranes and skin turgor, assess lung sounds, check for peripheral edema. ■ Assess recent I&O. ■ Assess for recent infusion of hypotonic IVF (common cause of ↓ Na⫹ in hospitalized patients) or use of continuous bladder irrigation (CBI). ■ Review medication and dietary history (salt and water intake).


■ Treament depends on patient’s volume status, duration and magnitude of hyponatremia, and severity of symptoms (see Table on p. 91, Treatment for Mild or Moderate Hyponatremia). ■ Monitor neurological status, laboratory values, I&O, VS. ■ Restrict fluids, and administer diuretics or IVF as ordered. ■ Chart patient status and convey to physician or NP.

BE PREPARED TO

■ Order or obtain laboratory tests (electrolyes, BUN, creatinine, urine and serum osmolality, urine sodium concentration). ■ Obtain IV access. ■ Administer oral or IV diuretics. ■ Administer hypertonic saline solution IV if CNS symptoms present. Caution: Must be administered slowly via an infusion pump. Too rapid correction can cause permanent neurological impairment.

POSSIBLE ETIOLOGIES

■ Vomiting, diarrhea, excessive sweating, GI fistulas or drainage tubes, pancreatitis, burns, acute or chronic renal insufficiency, medications (thiazide diuretics, chlorpropamide, cyclophosphamide, clofibrate, carbamazepine, oxcarbazepine, opiates, oxytocin, desmopressin, vincristine, selective serotonin reuptake inhibitors, trazodone, or tolbutamide), administration of hypotonic IV or irrigation fluids in the immediate postoperative period, prolonged exercise in a hot environment, hepatic cirrhosis, congestive heart failure, nephrotic syndrome, uncorrected hypothyroidism, cortisol deficiency, SIADH, use of the recreational drug MDMA (ecstasy).

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91 Hypotonic Hyponatremia Inability of the kidneys to excrete free water adequately. Categorized according to the associated intravascular volume: hypovolemic, hypervolemic, and euvolemic. Most common cause of hyponatremia in surgical patients is infusion of hypotonic fluids.

Treatment for Mild or Moderate Hyponatremia Cause

Intervention

Hypovolemic hyponatremia

Type

↑ sympathetic tone, ↓ renal perfusion due to intravascular volume depletion leading to ↑ renin and angiotensin excretion, ↑ sodium absorption and resultant impairment of renal free water excretion. Increase in serum ADH further impairs free water excretion.

Infuse 0.9% NS IV.

Euvolemic hyponatremia

Associated with SIADH arising from many clinical conditions including CNS disturbances, major surgery, trauma, pulmonary tumors, infection, stress, and certain medications (e.g., chlorpropamide, carbamazepine, cyclophosphamide, vincristine, vinblastine, amitriptyline, haloperidol, SSRI, and MAOI).

Treat underlying cause. Restrict free water.

Hypervolemic hyponatremia

↑ in total body water and sodium with paradoxical ↓ in circulating volume. Stimulates the same pathophysiological mechanism of impaired water excretion as is found in hypovolemic hypotonic hyponatremia. Also called dilutional hyponatremia.

Restrict free water. Possible diuretics.

RENAL/F&E


RENAL/F&E

Oliguria (Low Urine Output/Acute Renal Failure) CLINICAL PICTURE The patient may have: ■ Urine output ⬎500 mL in 24 hr. ■ Peripheral edema, neck vein distention, pulmonary crackles. ■ Orthostatic hypotension (if volume depleted), dry mucous membranes, hypotension. ■ Electrolyte imbalance. ■ Fatigue, nausea, vomiting, abdominal pain.


Assess vital signs, recent I&O, LOC. Assess for bladder distention. Assess for patent IV access. Notify physician or NP of low urine output. Document patient status, phone call to physician or NP, and physician or NP response.

FOCUSED ASSESSMENT

■ Assess recent laboratory chemistry tests, especially BUN/creatinine. ■ Assess for orthostatic hypotension, mucosal membrane moisture, and tissue turgor.


Insert IV access, and hang fluids to reverse hypovolemia. Monitor I&O; assess for fluid overload. Insert urinary catheter, and monitor urine output hourly. Monitor BP, HR, capillary refill time, mental status. Chart patient status, and convey to physician or NP.


Administer IVF challenge. Obtain urine samples for analysis, culture, other studies. Obtain or order laboratory tests including BUN/creatinine, chemistries, CBC. Administer diuretics. Transfer patient to ICU if invasive monitoring is required. Educate patient and family about dialysis.

POSSIBLE ETIOLOGIES

■ Renal hypoperfusion (hypovolemia, CHF, sepsis, blood loss); renal arterial disease; acute glomerulonephritis; acute tubular necrosis; tubular, ureteral, or urethral obstruction; drugs (aminoglycosides, radiocontrast medium).

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93 Urinary Retention CLINICAL PICTURE The patient may have: ■ Difficulty initiating stream, feeling of not emptying bladder. ■ Inability to void. ■ Lower abdominal pain, bladder distention and spasm. ■ Voiding in frequent small amounts.


■ Palpate bladder to assess distention and tenderness. ■ Assist patient to assume natural voiding position if possible (stand male patients, assist females to commode or raise HOB when using bedpan). ■ Implement triggers to help initiate stream (Credé’s maneuver, running water, pouring warm water over perineum). ■ If patient still unable to empty bladder, check for PRN order to catheterize patient. ■ If ordered, catheterize patient; note amount and characteristics of urine. Remove catheter. Note: Do not catheterize patient if suspected pelvic trauma or blood at meatus. ■ If patient does not have a straight catheter order or if residual volume is excessive (⬍500 mL), call physician or NP, and relate findings. ■ Document patient status, phone call to physician or NP, and physician or NP response.


Assess urine volume with a bladder scanner, if available. Inspect and palpate for distention or tenderness of the lower abdomen. Assess temperature; recent WBC count, if available. Assess voiding patterns, recent urological procedure or procedure requiring anesthesia, medications, history of BPH, urethral stricture, history of incontinence.


■ Monitor I&O. ■ Evaluate subsequent attempts to void and PVR. ■ Chart patient status, and convey to physician or NP.


Collect sterile urine sample. Initiate timed voiding and obtain postvoid residual (PVR) until PVR ⬎100 mL. Place indwelling urinary catheter. Teach self-intermittent catheterization. Instruct patient about urodynamic testing.

RENAL/F&E


RENAL/F&E

POSSIBLE ETIOLOGIES

■ Obstruction in the bladder or urethra, neurogenic bladder (secondary to CVA, spinal trauma/tumor, MS, neuropathy), long period of inactivity or bedrest, surgery, low fluid intake, benign prostatic hyperplasia (BPH), kidney stones, urinary tract infection (UTI), medications— antihypertensives, antihistamines (can be over-the-counter), anticholinergics, sedatives, spinal anesthesia.

Urinary Catheterization Straight Catheter Also called red rubber catheter or “straight cath.” Straight catheters have only a single lumen and do not have a balloon near the tip. Straight catheters are inserted for only as much time as required to drain the bladder or obtain a urine specimen. Indwelling Catheter Also called Foley or retention catheter. Indwelling catheters have two lumens, one for urine drainage and one for inflation of the balloon near the tip. Three-way Foley catheters are used for continuous or intermittent bladder irrigation. They have a third lumen for irrigation. Procedure 1. Prepare patient: explain procedure, and provide privacy. 2. Collect appropriate equipment. 3. Place patient in supine position (female: knees up, legs apart; male: legs flat, slightly apart). 4. Open and set up catheter kit using sterile technique. 5. Don sterile gloves, and set up sterile field. 6. If placing indwelling catheter, test patency of balloon by filling balloon with 5 mL sterile water. Check for leaks and proper inflation. Remove water. 7. Lubricate end of catheter; saturate cotton balls with cleansing solution. 8. With nondominant hand and using forceps to hold cotton balls: female— hold labia apart; swab from front to back, starting with the outer labia and working inward toward the meatus. Use one swab per swipe (total of five); male—retract foreskin; swab in a circular motion from the meatus outward. Repeat at least three times, using a different swab each time. 9. Gently insert catheter (about 2–3 inches for females and 6–9 inches for males) until return of urine is noted. Straight: collect specimen or drain bladder, and remove catheter. Indwelling: insert an additional inch, and inflate balloon. 10. Attach catheter to drainage bag, using sterile technique. 11. Secure catheter to patient’s leg according to hospital policy. 12. Hang drainage bag on bed frame below level of bladder.

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95 Patient Care ■ Wash hands with soap and water before and after handling catheter, tube, or bag. ■ Keep bag below level of patient’s bladder at all times. ■ Check frequently to be sure there are no kinks or loops in tubing and that patient is not lying on tubing. ■ Do not pull or tug on catheter. ■ Wash around catheter entry site with soap and water twice each day and after each bowel movement. ■ Do not use powder around catheter entry site. ■ Periodically check skin around catheter entry site for signs of irritation, redness, tenderness, swelling, or drainage. ■ Offer fluids frequently (if not contraindicated by health status), especially water or cranberry juice. ■ Record urine output according to physician orders. ■ Empty collection bag each shift; note color, clarity, and odor. ■ Notify physician for any of the following: ■ Blood, cloudiness, or foul odor. ■ Decreased urine output (⬍30 mL/hr). ■ Irritation or leaking around catheter entry site. ■ Fever, abdominal or flank pain. Removal ■ Don gloves. ■ Use a 10-mL syringe to withdraw all water from balloon. ■ Hold a clean 4 ⫻ 4 pad at meatus in the nondominant hand. With dominant hand, gently pull catheter. If you meet resistance, stop and reassess if balloon is completely deflated. If balloon appears to be deflated and catheter cannot be removed gently, notify physician or nursing supervisor for assistance. ■ Catheter should withdraw easily. Wrap tip in clean 4 ⫻ 4 pad as it is withdrawn to prevent leakage of urine. ■ Provide bedpan, urinal, or assist patient to toilet. Measure spontaneous void amount. Palpate bladder to ascertain it is empty. ■ Note time catheter discontinued.

Urinary Tract Infection (UTI) CLINICAL PICTURE The patient may have: ■ Lower UTI S&S (cystitis): ■ Dysuria, frequency, urgency, hesitancy. ■ Cloudy, foul-smelling, or bloody urine.

RENAL/F&E


RENAL/F&E

■ Suprapubic pain. ■ Fever ⬍101⬚F, chills, and malaise. ■ Upper UTI S&S (pyelonephritis): ■ Fever ⬍101⬚F, shaking chills. ■ Nausea, vomiting, flank pain. ■ Elderly: altered mental status, delerium, anorexia, abdominal pain, incontinence, or asymptomatic.


Assess VS. Notify physician or NP of symptoms. Obtain clean catheter urine specimen. Offer acetaminophen (if ordered) and heating pad or hot water bottle to relieve suprapubic pain. ■ Encourage patient to drink fluids to flush urinary system. ■ Document patient status, phone call to physician or NP, and physician or NP response.

FOCUSED ASSESSMENT

■ Assess history of UTI and usual voiding patterns. ■ Assess urine characteristics (odor, volume, color, cloudiness). ■ Assess for flank pain.


Administer antibiotics promptly and on schedule. Administer phenazopyridine PRN for dysuria. Monitor temperature. Encourage fluids. Monitor for relief of symptoms or complications (urosepsis, onset of upper UTI symptoms).

BE PREPARED TO ■ ■ ■ ■

Insert saline lock for IV antibiotics for upper UTI. Administer IVF. Obtain catheterized urine sample. Change or discontinue indwelling urinary catheter.

POSSIBLE ETIOLOGIES

■ Bacterial invasion of urinary tract (usually E. coli), factors that increase risk: incomplete emptying of bladder secondary to benign prostatic hyperplasia, prostatitis, and urethral strictures, neurogenic bladder; lack of adequate fluids, bowel incontinence, immobility or decreased mobility, indwelling urinary catheters.

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97 A & P Snapshot

Ribs Aorta Inferior vena cava Left adrenal gland Superior mesenteric artery Left renal artery and vein

Diaphragm

Left kidney Left ureter

Right kidney

Left common iliac artery and vein Lumbar vertebra Pelvis

Psoas major muscle lliacus muscle

Sacrum

Right ureter

Urinary bladder Urethra

Opening of ureter Trigone of bladder Symphysis pubis Urinary system.

RENAL/F&E


RENAL/F&E

Parietal peritoneum

Ureter

Detrusor muscle Openings of ureters Rugae

Ureter

B Trigone Prostate gland Prostatic urethra

Trigone

A

Internal urethral sphincter External urethral sphincter Urethra

Membranous urethra

Cavernous (spongy) urethra Cavernous (erectile) tissue of penis

Urethral orifice

Bladder and urethra. (A) Female. (B) Male.

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99 Focused GI Assessment ■ A focused nursing assessment of the GI system includes: ■ Investigation of abdominal pain, nausea, and vomiting. ■ Frequency and character of bowel sounds. ■ Amount of abdominal distention ■ Frequency and character of bowel movements (constipation or diarrhea). ■ Appetite, intake, swallowing, and tolerance of foods and fluids. ■ Abdominal pain, nausea, and vomiting: ■ Ask the patient about the nature of the abdominal pain. Use the PQRST guideline in the Basics tab. ■ Ask about nausea, and consider any recent procedures or new medication. ■ If the patient has vomited, assess quantity and characteristics of emesis. ■ Use a hemeoccult slide to test for blood in the emesis. ■ Fecal material in the emesis is rare but is an emergency if found. ■ Assess bowel sounds: ■ Assess bowel sounds before palpating the abdomen. Listen in all four quadrants; however, most clinicians think that it is difficult to pinpoint the origin of bowel sounds because they can be heard even when ausculatating the lungs. ■ Bowel sounds provide supporting information to the clinical picture for the patient with an evolving GI problem. ■ Normal bowel sounds are small gurgles heard every few seconds, although there is considerable variability that is still considered normal. ■ Absence of bowel sounds can indicate an inflammatory process such as peritonitis or a bowel obstruction. ■ High-pitched, frequent, tinkling bowel sounds can be heard in the initial stages of a bowel obstruction. ■ Bowel sounds are absent after abdominal surgery and may take a few days to return. Patients are not fed when bowel sounds are absent. ■ When bowel sounds return, which is usually accompanied with passing flatus, it indicates that the intestinal tract is beginning to function again. ■ Assess abdominal distention: ■ The abdomen can be distended in many bowel problems; such distention is frequently associated with abnormal or absent bowel sounds. The abdomen can be distended from constipation, excessive abdominal gas, severe bowel dysfunction, obstruction, or infection. ■ Ascites, the abnormal accumulation of fluid in the peritoneal cavity, can cause massive distention. For patients with ascites, mark the abdomen, and measure girth at the same level each day to assess if ascites is decreasing or increasing.

GI


GI

■ Bowel distention is usually observed; measurement as described above is not done routinely, especially when the distention is of acute onset as in a postoperative complication. Measurements only become meaningful once a baseline is established. ■ Palpate or precuss the abdomen after listening to bowel sounds. Both skills take practice to be helpful in an assessment. Refer to an assessment textbook for more information. ■ Frequency and character of bowel movements (constipation or diarrhea): ■ Monitor bowel movements, and ask the patient if he or she feels constipated. Ask about normal bowel habits. ■ If the patient has diarrhea, ascertain the frequency and amount of stool. Diarrhea, especially when accompanied by vomiting, can quickly cause electrolyte imbalances and dehydration. ■ If the patient is constipated, look to the recent history (procedures), medications that affect peristalsis (narcotics and many others), NPO status, or other possible causes. If constipation is chronic, discuss eating habits. ■ Assess for black, tarry stools (melena). Test the stool for blood when GI bleeding is suspected. ■ Appetite, intake, swallowing, and tolerance of foods and fluids: ■ Any impairment in swallowing is serious and should be evaluated by a speech pathologist. Suggest a consultation to the physician or NP. ■ If the patient complains of loss of appetite, find out more about the problem. How long has it been; is there early satiety (feeling full after eating small quantities); is there nausea, vomiting or weight loss? ■ If general food intake is low, especially in older adults, assess dentition, and ascertain if foods have lost their taste to the patient. ■ Does the patient tolerate the foods and fluids offered? If not, why not? Ask about allergies. ■ Decreased appetite is a symptom of many conditions, such as cancer, COPD, esophageal problems, decline in acuity of taste buds, and others and promptly needs to be evaluated.

Abdominal Pain and/or Distention CLINICAL PICTURE The patient may have: ■ Abdominal pain, tenderness, flank pain. ■ Nausea/vomiting/diarrhea. ■ Abdominal distention or rigidity. ■ High-pitched, hyperactive, hypoactive, or absent bowel sounds.

100



■ Place patient in position of comfort. ■ If patient has a nasogastric tube (NGT) but is unattached to suction, reconnect NGT to suction—note amount of immediate NGT drainage. ■ Assess vital signs (VS), including temperature.

FOCUSED ASSESSMENT ■ ■ ■ ■ ■ ■ ■ ■

Ask patient to describe pain; use the PQRST guidelines in the Basics tab. Assess recent bowel habits, recent laxative or enema use. Inspect abdomen; auscultate bowel sounds. Palpate abdomen for pulsations, tenderness, and rigidity. Assess from area of least tenderness to area of most tenderness. Assess hydration status and urine output (UO) by reviewing I&O record for previous 2 days. Check all recent laboratory values including WBC count. Test emesis for occult blood. Notify physician or NP of assessment findings. Document findings and phone call.


Administer antiemetic and pain medication, if ordered. Monitor VS as frequently as indicated. Assess output from NGT (if placed). Insert an IV and hang 0.9% NS (with order). Clarify with physician or NP on alternative route for administration of PO medications. ■ Obtain stool/emesis sample, and test for occult blood. ■ Monitor nutritional status.


Hang IVF. Administer pain medication, antiemetics, antibiotics. Insert an NGT, or set up suction. Insert indwelling urinary catheter. Order or obtain laboratory tests. Facilitate diagnostic tests such as abdominal x-ray, CT, endoscopy, ultrasound, and diagnostic imaging.

POSSIBLE ETIOLOGIES

■ Bowel obstruction, ileus, peritonitis, irritable bowel syndrome (IBS), ascites, gastroenteritis, malignancy, liver disease, ulcers, appendicitis, cholecystitis, pancreatitis.

GI


GI

NGT Insertion Indications ■ Aspirate blood or fluids and gas from stomach. ■ Control nausea and vomiting. Procedure 1. Explain procedure to the patient. 2. Position patient upright in high Fowler’s position. Instruct patient to keep chin-to-chest posture during insertion. This helps to prevent accidental insertion into the trachea. 3. Measure tube from tip of the nose to the ear lobe, then down to xyphoid. Mark this point on the tube with a piece of tape. 4. Lubricate tube by applying water-soluble lubricant to tube. Never use petroleum-based jelly. 5. Insert tube through nostril until the previously marked point on the tube is reached. Instruct patient to take small sips of water during insertion to help facilitate passing of the tube. Withdraw tube immediately if patient becomes cyanotic or develops breathing problems. 6. Secure tube to patient’s nose using tape. Be careful not to block the nostril. Tape tube 12–18 inches below insertion line. Then pin tape to patient’s gown, allowing slack for movement. 7. Confirm proper location of tube. ■ Checking the pH of aspirate is the preferred method for checking placement. ■ Pull back on plunger of a 20-mL syringe to aspirate stomach contents. Typically, gastric aspirates are cloudy and green, or tan, off-white, bloody, or brown in some cases. Gastric aspirate can look like respiratory secretions. ■ Dip litmus paper into gastric aspirate. A reading of 1–3 suggests placement in the stomach. ■ An alternate, but less reliable, method, is to inject 20 mL of air into tube while auscultating the abdomen. Hearing a loud gurgle of air suggest placement in the stomach. If no bubbling is heard, remove tube, and reattempt. Withdraw tube immediately if patient becomes cyanotic or develops breathing problems. ■ An inability to speak also suggests intubation of trachea instead of stomach. 8. Assemble suction canister, liner, and attachment for wall suction. If using portable suction, have ready at bedside. ■ Attach a connector to the end of tube. ■ Attach the extension tubing that comes with the suction canister to the connector.

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103 ■ Connect the other end of the tubing to suction canister where indicated. ■ Set suction as ordered. Patient Care ■ Reassess placement of tube. ■ Assess amount and character of drainage. ■ Replace collection liner before it is full (full or nearly full liner prevents thorough suction of GI material). ■ Flush tube with water after each feeding and after each medication. ■ Assess skin around nose for irritation and breakdown, and replace tape as needed. Change at least every other day. ■ Gently wash around the nose with soap and water, and dry before replacing tape. ■ Provide mouth care every 2 hours and PRN. ■ Mouthwash, water, toothettes: clean tongue, teeth, gums, cheeks, and mucous membranes. ■ If patient is performing oral hygiene, remind him or her not to swallow any water. Removal 1. Explain procedure to patient. Don gloves. 2. Remove tape from nose and face. Offer patient some tissues as he or she may gag slightly as the tube is withdrawn. 3. Clamp or plug tube (prevents fluid from entering lungs), and remove tube in one gentle, swift motion. 4. Assess for signs of aspiration.

Constipation CLINICAL PICTURE The patient may have: ■ Complaints of constipation. ■ Infrequent stools accompanied by discomfort, bloating, flatulence.

IMMEDIATE INTERVENTIONS/FOCUSED ASSESSMENT

■ Assess abdomen for bowel sounds. Bowel sounds may be infrequent; listen for a full minute before concluding that bowel sounds are absent. If no bowel sounds are heard, do not administer laxatives or PRN enemas; notify physician or nurse practitioner with findings. ■ Assess for abdominal distention and pain. ■ Ask about last bowel movement and recent dietary intake. ■ Check MAR for medications that can cause constipation; check MAR for PRN orders for laxatives and daily stool softener order.

GI


GI

■ If the patient has bowel sounds, is on a solid diet, and has a PRN order for a laxative, check how soon the laxative is designed to work, and administer it at the appropriate time (e.g., some magnesium-containing laxatives work very quickly; some are designed to work over 8 hrs). ■ If there is an order for a small-volume enema that can be selfadministered or an oral laxative, ask the patient which he or she would prefer. Explain how to use the enema if the patient chooses that option.


■ Assess effectiveness of laxative and return of usual bowel function. ■ Review diet and medications for possible changes that can prevent or treat constipation. ■ Assess need for daily stool softener or bulk-forming laxative. Stimulant laxatives should be used infrequently.

BE PREPARED TO Check for impaction; administer saline enemas.

POSSIBLE ETIOLOGIES Medications such as diuretics, loperamide, opioids, antidepressants, and medications containing iron, calcium, or aluminum; insufficient intake of dietary fiber; dehydration; hypothyroidism; hypokalemia; injury to the anal sphincter; diminished or absent peristalsis related to surgery, cancer, diverticula, irritable bowel syndrome, functional incapacity.

Diarrhea CLINICAL PICTURE The patient may have: ■ Frequent loose, watery, bowel movements. ■ Loose stools containing blood, pus, or mucus. ■ Abdominal pain, cramps, flatulence. ■ Nausea, vomiting, dehydration. ■ Fatigue, temperature elevation.


Assess VS and mental status. Provide comfort measures and perineal care. Obtain stool samples. Assess for patent IV access.

104


105 ■ Notify physician or NP of symptoms. ■ Document patient status, phone call to physician or NP, and physician or NP response.

FOCUSED ASSESSMENT

■ Assess hydration status (orthostasis, hypotension, and tachycardia; tissue turgor, mucous membrane moisture, mentation, UO). ■ Assess recent GI history (onset, frequency and nature of stools, presence or absence of blood and mucus, vomiting, cramps, and fever). ■ Assess recent antibiotic use, use of stool softeners and opiates (all associated with increased risk of psuedomembranous colitis [PMC] caused by Clostridium difficile). ■ Ask about recently eaten meals (raw eggs, contaminated food, raw seafood) and travel history. ■ Assess recent blood chemistries (electrolyte levels).


■ Insert IV, and administer IVF (D5 1/2 NS with KCl) if dehydrated or unable to tolerate oral fluids (with order). ■ Encourage fluids if able to tolerate. ■ Monitor I&O. ■ Administer appropriate antibiotic/anti-infective agent promptly and on schedule. ■ Avoid use of antimotility drugs (diphenoxalate, loperamide) or opiates if infectious diarrhea suspected. ■ Monitor for relief of symptoms or complications (toxic megacolon if PMC, dehydration, electrolyte imbalance, skin breakdown). ■ Document patient’s status in medical record, and communicate to physician or NP.

BE PREPARED TO

■ Insert IV access and administer IVF. ■ Obtain specimens. ■ Implement enteric precautions.

POSSIBLE ETIOLOGIES

■ Viral, bacterial, or parasitic gastroenteritis; food-borne diarrhea; ulcerative colitis; Crohn’s disease; AIDS; pseudomembranous colitis; drug side effect; inflammatory bowel disease.

GI


GI

Feeding Tube Complications CLINICAL PICTURE The patient may have: ■ Occluded tube. ■ Tube displacement. ■ Extubation. ■ Stomal infection. ■ Stomal leak.


■ Assess site for leak. ■ Assess for signs and symptoms of infection (elevated temperature, pain, redness, warmth, purulent discharge). ■ Assess for proper placement (is tube too far in tract, too far out, or completely out?). ■ If tube is occluded, attempt to dislodge using method described in table below. ■ Elevate HOB to minimize risk of aspiration. ■ For other complications or if attempt to dislodge tube is ineffective, notify physician or NP. ■ Document patient status, phone call to physician or NP, and physician or NP response.

FOCUSED ASSESSMENT

■ Assess for signs and symptoms of aspiration (temperature, RR, lung sounds). ■ Assess LOC/mental status. ■ Assess hydration status.


See table below for guide to ongoing interventions. Monitor nutritional status. Provide stomal care. Obtain nutrition consult if indicated. Chart patient status, and convey to physician or NP.

BE PREPARED TO

■ Obtain replacement tube, and assist with bedside reinsertion. ■ Obtain portable chest x-ray for placement if nasoenteric tube is inserted. ■ Resume tube feedings.

POSSIBLE ETIOLOGIES

■ Varies according to complication; see following table.

106


107 Feeding Tubes: Preventing and Managing Complications Complication/Cause

Interventions

Leakage of gastric secretions: Improper positioning of patient. Tube migration. Stomal erosion or widening.

■ Position patient upright for feeding. ■ Stabilize tube with gauze pads; adjust crosspiece. ■ Keep skin around stoma clean and dry; use protective ointments and gauze.

Tube migration: Internal balloon deflates or external tube suture, bumper, or disc falls out.

■ Reposition tube.

Extubation: Internal balloon deflates or suture, bumper, or disc falls out. Stomal infection: Leakage around tube. Inadequate stomal care. Allergic reaction to soap.

■ Tract can close within a few hours. Feeding tubes must be replaced within a few hours.

Gastroesophageal reflux/ large residuals: Delayed gastric emptying.

■ Elevate patient’s head 30⬚–45⬚ during feeding and for 1 hr after meal. ■ Check residuals before feeding. Hold feeding if greater than 100 mL, and call physician or NP. ■ Use gastric stimulant, if ordered, to promote gastric emptying. ■ Consider continuous feeds or smaller, more frequent boluses

■ Note length of tube outside of body, using either the external marks on the tube or a tape measure. ■ Document length in nursing record, and measure each shift. ■ Check that disc, suture, or attachment device is secure.

■ Correct cause of leakage. ■ Carefully clean and protect stoma per facility protocol. ■ If stoma site is irritated, use plain water or change type of soap used.


GI


GI

Feeding Tubes: Preventing and Managing Complications (continued) Complication/Cause

Interventions

Nausea, vomiting, cramps, bloating: Too rapid administration of feeding, lactose intolerance, fat malabsorption, contamination of food or feeding bag.

■ Change to a low-fat formula. ■ Administer feeding at room temperature. ■ Reduce rate of administration. ■ Check residuals before bolus feeding or every 4 hr for continuous feeding. Hold feeding if greater than 125 mL; call physician or NP. ■ Refrigerate open cans of formula, and keep only as long as manufacturer suggests. ■ Clean tops of formula cans before opening. ■ Hang only 4-hr amount of formula at a time. ■ Clean feeding sets well, and replace per facility policy.

Diarrhea: Too rapid increase in amount of feeding, too rapid administration, feeding too cold, lactose intolerance, tube migration from stomach to small intestine

■ Add fiber, or use a formula with fiber. ■ Reduce rate of administration. ■ Administer feeding at room temperature. ■ Do not add medication to formula. ■ Retract tube to reposition against stomach wall.

Feeding Tubes: Preventing and Managing Occlusions Prevention ■ Flush with 30 mL of water every 4–6 hr and before and after administering tube feedings, checking for residuals and administering medications. ■ Use a feeding pump with an automatic water flush feature. ■ Dilute liquid medications with 20–30 mL of water.

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109 ■ Obtain all medications in liquid form. If liquid form is not available, check with pharmacist to see if medication can be crushed. ■ Administer each medication separately, and flush with 5–10 mL of water between each medication. ■ Do not mix medications with feeding formula. Management ■ Check the feeding tube for kinks. ■ Inject a small amount of air into tube. ■ Change patient’s position. ■ If no obvious kink is found, place flushing syringe (30 mL) into the tube end, and gently pull back on the plunger to dislodge the occluding plug. ■ If tube still blocked, instill warm water into the tube. Gently depress, and withdraw syringe plunger to remove obstruction. If unsuccessful, leave instilled warm water in tube, clamp tube for 10–15 min, and try again. ■ Milk the tube with fingers from the insertion site out. ■ Do not instill meat tenderizer—can cause metabolic complications and allergic reactions. ■ Commercial products that use thin plastic devices for clearing feeding tubes or products that use a catheter and chemical declogging powder are available; however, a physician or NP usually must perform the procedure. ■ To prevent tube damage, do not use force to unclog, or use a syringe smaller than 30 mL.

Hematemesis/Upper GI Bleed CLINICAL PICTURE The patient may have: ■ Bright red or dark coffee ground–appearing emesis. ■ Distended, rigid, and/or tender abdomen. ■ Nausea, black stools. ■ Tachycardia, hypotension. ■ Dizziness, weakness, SOB. ■ Anxiety.


■ To prevent aspiration of blood and subsequent respiratory compromise, position patient to facilitate an open airway (upright or turned to one side), particularly in patients who have inadequate gag reflexes or altered LOC. ■ Provide emesis basin. ■ Assess BP, HR, RR, temperature.

GI


GI

■ Differentiate that patient has vomited, not expectorated, blood. ■ Suction oropharynx if patient vomiting copious amounts of blood and cannot clear vomitus/secretions. ■ Assess for patent IV. ■ Call physician or NP. ■ Document patient status, phone call to physician or NP, and physician or NP response.

FOCUSED ASSESSMENT

■ Assess BP, HR, and RR. Check blood pressure supine and standing (if feasible), and document difference. ■ Check oxygen saturation via pulse oximetry. Assess LOC. ■ Assess skin color and temperature, capillary refill. ■ Assess respiratory status and lung sounds. ■ Assess abdomen for distention, tenderness, guarding, peristalsis, and rigidity. ■ Hematest emesis; assess amount and characteristics. ■ Assess for use of anticoagulants, NSAIDs, or steroids. ■ Check if patient has been previously typed and cross-matched and if any blood products are available in the blood bank.


■ Insert a large-bore IV, and administer IVF per order. ■ Monitor VS frequently (every 5 min if unstable). ■ Place an NG tube (per level of practice and physician’s order). Connect to low intermittent suction. ■ Monitor laboratory studies (CBC, electrolytes, BUN, PT/PTT/INR, ABGs; type and cross-match). ■ Insert a urinary catheter, and monitor I&O. ■ Monitor serial Hgb/Hct. ■ Provide oral hygiene and other comfort measures after episodes of vomiting. ■ Chart patient status, and convey to physician or NP.

BE PREPARED TO

■ ■ ■ ■ ■ ■ ■

Start an IV (two large-bore IVs if vomiting copious amounts of blood). Assist with central line placement. Give IVF or blood products. Administer H2 blockers. Set up gastric suction, and perform room temperature saline lavage. Obtain ECG, laboratory and diagnositic studies (x-ray, endoscopy). Prepare for ICU transfer if hemodynamically unstable.

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■ Gastric ulcer, duodenal ulcer, gastric erosions, esophagitis, esophageal varices, Mallory-Weiss syndrome, carcinoma, peptic ulcer, polyps, salicylates, NSAIDs, corticosteroids, leukemia, uremia, blood dyscrasias, hemorrhagic gastritis.

Lower GI Bleed/Melena CLINICAL PICTURE The patient may have: ■ Frankly bloody or melanotic stool or stool tests positive for occult blood. ■ Abdominal cramping. ■ Signs and symptoms of hypovolemic shock (acute bleed): hr ⬍110 beats/min, SBP ⬎100 mm Hg, orthostatic drop in systolic BP of ⬍16 mm, oliguria, cold clammy extremities, mental status changes. ■ Anemia, fatigue, pallor, dizziness, chest pain (chronic bleed).


Assist patient to bed. Administer supplemental oxygen. Assess VS; check for orthostasis. Notify physician or NP. Document patient status, phone call to physician or NP, and physician or NP response.


Assess VS (HR, BP, RR, and temperature). Assess LOC and orientation; assess oxygen saturation. Assess skin color, moistness, and temperature; assess capillary refill. Assess abdomen (distention, tenderness, pain, bowel sounds). Obtain detailed GI history (history of tarry stools, use of NSAIDs, associated symptoms). ■ Check recent CBC. ■ Check if patient has been previously typed and cross-matched and if any blood products are available in blood bank. ■ Assess for patent IV access.


Monitor VS, hemodynamic status, and UO. Insert large-bore IV access. Record frequency and character of stools. Chart patient status, and convey to physician or NP.

GI


GI

BE PREPARED TO

■ Obtain or order laboratory tests including coagulation studies (platelet count, PT, PTT, INR), electrolytes, BUN, creatinine, serial Hb and Hct; type and cross-match. ■ Start an IV, and administer IVF or blood products. ■ Insert NGT, and check aspirate for blood; remove if negative. ■ Prepare patient for or assist with anoscopy or colonoscopy. ■ Insert a urinary catheter, and monitor UO.

POSSIBLE ETIOLOGIES

■ Diverticulitis, GI polyps, anal fissures, hemorrhoids, ulcerative colitis, Crohn’s disease, ischemic colitis, upper GI bleed.

Nausea CLINICAL PICTURE The patient may have: ■ Sensation/urge to vomit. ■ Tachycardia, bradycardia. ■ Diaphoresis, skin pallor. ■ Decreased or high-pitched bowel sounds. ■ Abdominal pain.


■ Elevate HOB to high Fowler’s position; provide emesis basin. ■ Place weak, confused, or debilitated patient in a side-lying position to reduce risk of aspiration. ■ Offer a cool compress to the forehead or nape of neck. ■ Keep NPO.


Assess patient’s ability to protect airway. Assess VS. Assess for chest pain, SOB, headache, visual disturbances. Assess onset of symptoms and associated events (e.g., eating, medication, activity). ■ Assess hydration status (orthostatic hypotension, skin turgor, mucous membranes, recent I&O). ■ Assess for patent IV access.

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113 STABILIZING AND MONITORING

■ Determine if nausea is an anticipated side effect of treatment (anesthesia, chemotherapy). ■ Check MAR for as-needed antiemetic; administer if clinically indicated. ■ If nausea is not expected given the patient’s clinical problem, notify physician or NP. ■ Clarify with physician or NP whether to withhold PO medication or give by alternate route. ■ Monitor and record I&O. ■ Document patient status, phone call to physician or NP, and physician or NP response.


Administer antinausea medication as ordered. Start an IV, and give IVF for hydration. Monitor serial electrolytes, nutritional status, and UO. Facilitate diagnostic studies. Insert NGT if bowel obstruction is present. Call for an ECG if associated with chest pain; SOB; slow, fast, or irregular HR.

POSSIBLE ETIOLOGIES

■ Gastroenteritis, appendicitis, bowel obstruction, other GI disorder, vascular headache, head injury, meningitis, other neurological cause, pregnancy, drug side effect, infection, pain, motion sickness, stress, chemotherapy.

Vomiting CLINICAL PICTURE The patient may have: ■ Small or large amounts of emesis. ■ Tachycardia, bradycardia, diaphoresis, skin pallor. ■ Abdominal pain, decreased or high-pitched bowel sounds.


■ Elevate HOB to high Fowler’s position; provide emesis basin. ■ Place weak, confused, or debilitated patient in a side-lying position to reduce risk of aspiration. ■ Offer a cool compress to the forehead or nape of neck. ■ Keep NPO.

GI


GI

FOCUSED ASSESSMENT

■ Assess patient’s ability to protect airway. ■ Assess VS. ■ Assess for chest pain, SOB or other symptoms (headache, dizziness, abdominal pain, diarrhea). ■ Assess onset of symptoms and associated events (e.g., eating, medication, activity). ■ Inspect emesis for color, odor, amount, and contents. ■ Assess abdomen for distention and tenderness. ■ Note if vomiting is projectile. ■ Assess hydration status (orthostatic hypotension, tissue turgor, mucous membranes, recent I&O). ■ Assess for patent IV access.


■ Determine if vomiting is an anticipated side effect of treatment (anesthesia, chemotherapy). ■ Check MAR for as-needed antiemetic; administer if clinically indicated. ■ If vomiting is not expected given the patient’s clinical problem, notify physician or NP. ■ Clarify with physician or NP whether to withhold PO medication or give by alternate route. ■ Monitor and record I&O. ■ Administer IVF if ordered. ■ Monitor laboratory tests for electrolyte imbalances (from loss of fluid) or metabolic alkalosis (from loss of gastric acid). ■ Document patient status, response to treatment, phone call to physician or NP, and physician or NP response.


Start an IV, and give IVF for hydration. Facilitate diagnostic studies. Insert NGT if bowel obstructed or vomiting continues. Administer antinausea medication as ordered. Monitor serial electrolytes, nutritional status, and UO. Call for an ECG if associated with chest pain; SOB; slow, fast, or irregular heart rate.

POSSIBLE ETIOLOGIES

■ Gastroenteritis, appendicitis, bowel obstruction, other GI disorders, vascular headache, head injury, meningitis, other neurological cause, pregnancy, drug side effect, infection, pain, motion sickness, stress, chemotherapy.

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115 A & P Snapshot Tongue Teeth Parotid gland Pharynx Sublingual gland

Esophagus

Submandibular gland

Liver

Left lobe

Stomach (cut)

Spleen Right lobe Gall bladder Bile duct

Duodenum Pancreas

Transverse colon (cut)

Descending colon Small intestine

Ascending colon Cecum

Rectum Anal canal

Vermiform appendix

Digestive system.

GI


ENDO

Focused Endocrine Assessment The endocrine system comprises hormone-secreting glands. These hormones are instrumental in all aspects of homeostasis. The glands and the hormones they secrete include: ■ Hypothalamus and pituitary: antidiuretic hormone (ADH), oxytocin, growth hormone (GH), thyroid-stimulating hormone (TSH), adrenocorticotropic hormone (ACTH), follicle-stimulating hormone (FSH), luteinizing hormone (LH), and prolactin (PRL) ■ Thyroid: thyroxine (T4), triiodothyronine (T3), and calcitonin ■ Parathyroids: parathyroid hormone (PH) ■ Adrenals: medulla: epinephrine and norepinephrine; cortex: glucocorticoids (cortisol), mineralocorticoids (aldosterone), and adrenal androgens ■ Endocrine pancreas: insulin; glucagon, somatostatin ■ Ovaries or testes: sex hormones Physical assessment of the endocrine system is difficult in that the thyroid gland is the only palpable gland, and signs and symptoms can be vague or attributable to other causes. Diagnostic testing is the cornerstone of endocrine assessment. Some physical signs and symptoms that may be the result of endocrine malfunction include: ■ Change in appearance of hair, nails, and skin ■ Increased or decreased energy, insomnia, fatigue ■ Heat or cold intolerance, hypothermia or fever ■ Tremors, tetany, muscle aches ■ Tachycardia, hypertension or hypotension ■ Kidney stones, pathological fractures, muscle weakness, memory loss ■ Polyuria, polydipsia, polyphagia (excessive eating and drinking, excessive urination) ■ Anorexia, weight gain or loss, constipation, dehydration ■ Change in thought processes, agitation, confusion Laboratory and diagnostic tests consist of radioimmunoassay of hormone levels, blood glucose levels, and other tests, 24-hour urine studies, and radiological scans.

Diabetic Ketoacidosis (DKA) CLINICAL PICTURE The patient may have: ■ Rapid onset excessive thirst, nearly constant urination. ■ Abdominal pain, N&V

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117 ■ ■ ■ ■

Lethargy progressing to coma (in later stages). Dehydration leading to hypotension and shock. Blood glucose level of 250–800 mg/dL. Abnormal ABGs indicating metabolic acidosis (pH ⬍7.3, bicarbonate ⬍15 mEq/L). ■ Multiple electrolyte abnormalities, including high potassium levels. ■ Hyperventilation (Kussmaul’s respirations), and fruity-smelling breath (somewhat like nail polish remover).


■ Assess VS, LOC, and ability to protect airway. ■ Assess for patent IV access. ■ Notify physician or NP of elevated glucose; decreased LOC, if present; and other findings. ■ Document findings, phone call to physician or NP, and the response. ■ Insert IV and hang IVF (NS, with order); administer medications (regular insulin) as ordered. ■ Stay with patient.


Assess electrolyte values, ketones, and osmolality. Continue to assess LOC and VS—hypotension can be severe. Assess ABG results. Assess for other complications of diabetes (e.g., skin infections, peripheral neuropathy, poor circulation to feet and toes).


■ Ongoing assessment of VS, LOC, and ability to protect airway. ■ Monitor blood glucose and electrolytes. ■ Monitor I&O.


Obtain blood work. Hang IVF. Administer IV insulin. Transfer patient to ICU.

POSSIBLE ETIOLOGIES

■ An infection in an otherwise well-controlled diabetic patient; too little insulin or failure to take any insulin; new onset of diabetes; underlying medical illness.

ENDO


ENDO

Hyperglycemia* CLINICAL PICTURE The patient may have: ■ Blood glucose level 180–300 mg/dL on routine fingerstick. ■ Usually there are few or no symptoms or signs other than blood glucose level ■ Can have: ■ Flushed, dry skin; poor skin turgor, and dry mucous membranes. ■ Fruity breath odor (like acetone). ■ Blurred vision, generalized weakness, and dizziness. ■ N&V, cramping, increased urination.


Obtain a blood glucose level if not already done. Check MAR for regular insulin sliding scale based on blood glucose level. Administer appropriate dose of regular insulin, based on sliding scale. If patient is symptomatic, if MAR does not contain a sliding scale, or if blood glucose level exceeds parameters of sliding scale, notify physician or NP.

FOCUSED ASSESSMENT

■ Assess HR, BP, RR; assess LOC if indicated. ■ Assess for signs of dehydration (dry mucous membranes, poor skin turgor, and dry scaly skin). ■ Ask patient about recent health changes, usual level of glucose control, and if there has been a recent change in diabetic management. ■ Assess if infusing IVF contains dextrose (if applicable).


Continue to assess LOC and orientation. Reassess blood glusose level at appropriate intervals. Discuss diabetic management with health-care team. Consider nutrition consult. Assess patient’s understanding of disease process and treatment; educate as needed. ■ Chart patient status, and convey to physician or NP.

BE PREPARED TO

■ Administer insulin as ordered. ■ Obtain serial blood glucose levels. ■ Dipstick urine for ketones. *This is a discussion of uncomplicated, moderately elevated blood glucose, not diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic nonketotic coma (HHNC).

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■ New-onset DM, infection, illness, stress, trauma, noncompliance with insulin and diet regimen, certain medications such as cortisone.

Hyperosmolar Hyperglycemic Nonketotic Coma (HHNC) CLINICAL PICTURE The patient may have: ■ Hyperglycemia (⬎600 mg/dL) ■ Polyuria, excessive thirst, weight loss. ■ Dehydration—dry mucous membranes, dry skin. ■ Confusion, delirium, lethargy to coma. ■ Visual changes. ■ Hypotension, tachycardia.


■ Call physician or NP as soon as the serum glucose level is known or if the patient’s LOC has changed. If patient’s LOC is declining from drowsiness to stupor or coma (which can happen rather quickly), assess ability to protect airway. ■ Check for a patent IV access; if none, gather needed supplies for IV insertion. Take NS to keep the vein open (with order) until treatment-level IV orders are written.

FOCUSED ASSESSMENT

■ Check ABGs as frequently as indicated, possibly every 15 min. Assess LOC at the same time. Note shallow, rapid respirations. ■ Monitor BP; shock can develop quickly. Assess for orthostasis (drop in systolic BP ⬎10 mm Hg when position changes from lying to standing or lying to sitting upright if standing is not possible). ■ Assess HR apically or with ECG monitoring, if available. Note dysrhythmias, tachycardia. ■ Check electrolytes for hypokalemia, ↑ BUN, ↑ serum osmolality (⬎350 mOsm/L). ■ Assess for focal neurological changes, including aphasia and hemiparesis, which can resemble signs of stroke. ■ Assess for history of type 2 diabetes (HHNC occurs almost exclusively in this group). ■ Assess for underlying illness, possibly infection, that triggered HHNC.


■ Continue all assessments as outlined above. ■ Hang IVF as ordered.

ENDO


ENDO

■ Begin insulin drip, and monitor glucose levels. ■ Monitor serum chemistries, and replace electrolytes as ordered. ■ Assess for signs or symptoms of venous thrombosis (due to dehydration, blood becomes hyperosmolic, meaning the blood is very thick. This predisposes the patient to thrombosis.). ■ Assess coagulation studies for signs of disseminated intravascular coagulation (DIC), a complication of HHNC. ■ Assess for other serious complications, such as adult respiratory distress syndrome (ARDS) and multiorgan dysfunction syndrome (MODS).

BE PREPARED TO ■ ■ ■ ■ ■ ■ ■

Obtain ABGs. Facilitate blood tests and other diagnostic tests. Assist with intubation. Assist with insertion of a central venous catheter. Insert a nasogastric tube. Transfer to ICU. Teach patient about process of HHNC to avoid recurrence.

POSSIBLE ETIOLOGIES

■ Preceding or concomitant illness that triggers dehydration (pneumonia and urinary tract infection are common triggers); stress response to illness that raises glucose levels; drugs that raise glucose levels, inhibit insulin, or cause dehydration.

Hypoglycemia CLINICAL PICTURE The patient may have: ■ Cool, pale, and diaphoretic skin. ■ Agitation, disorientation, slurred speech, blank stare. ■ Headache, palpitations/tachycardia, trembling, hunger. ■ ↓ LOC progressing to coma and/or seizures if not treated.


■ Obtain a blood glucose level by fingerstick. ■ Assess VS and LOC. ■ Give oral, rapidly absorbed carbohydrates (orange juice) if alert and no risk of aspiration. ■ Notify physician or NP. ■ If patient has ↓ LOC, position patient to protect airway.

120


121 ■ If patient has ↓ LOC, give 1 amp (25 g in 50 mL) of 50% dextrose IV push (with order). ■ Document patient status, phone call to physician or NP, and physician or NP response.


Assess time the insulin or oral hypoglycemic agent was taken and amount. Ascertain that dose/type of insulin/oral hypoglycemic given was accurate. Assess if patient has eaten. Assess other medications for potential to affect glucose control. Assess response to oral or IV administration of glucose.


■ Repeat serum glucose test, and reevaluate patient as needed. ■ Once symptoms improve, provide more slowly absorbed carbohydrates (e.g., milk, crackers). ■ Consult dietitian/nutrition support. ■ Monitor for hypokalemia. ■ Reassess insulin dosages with team. ■ Chart patient status, and convey to physician or NP.


Start a peripheral IV. Administer glucagon or other medications if necessary. Obtain serial blood glucose levels. Assist with airway management and intubation if needed. Manage seizure activity if needed.

POSSIBLE ETIOLOGIES

■ Diabetic patients: overdose of insulin or oral hypoglycemic agent, increased activity, too little food intake, alcohol, drugs, emotional stress, infections; nondiabetic patients: liver disease, excessive alcohol consumption, drug reaction (beta-adrenergic blockers and sulfonylureas are most common).

Myxedema Coma CLINICAL PICTURE The patient may have: ■ Low body temperature, cold intolerance. ■ Confusion, depression. ■ Hypoventilation. ■ Weakness. ■ Edema.

ENDO


ENDO


■ Assess LOC, VS, and ability to protect airway. ■ Assess patent IV access. ■ Provide blankets (not a warming blanket—can cause vasodilation and lower BP even further). ■ Call physician or NP; document phone call and response.

FOCUSED ASSESSMENT

■ Assess laboratory values—may have low sodium, low glucose, low calcium, high CPK and high creatinine. Will have high T4 and low TSH. ■ Assess respiratory pattern and ABGs; may have ↓ pH, ↓ oxygen saturation, with ↑ carbon dioxide (respiratory acidosis). ■ Assess for other signs and symptoms of hypothyroidism: ■ Altered mentation, such as apathy, confusion, psychosis, or coma. ■ Alopecia; coarse, sparse hair. ■ Dry, cool, skin. ■ Elevated diastolic BP in early stages; hypotension later. ■ Bradycardia. ■ Decreased GI motility, abdominal distention, myxedema megacolon (late). ■ Low temperature. ■ Generalized facial swelling, ptosis, periorbital edema.


■ Continued assessment of cardiac and respiratory status. ■ Administer IV thyroid hormone replacement, cortisol, or electrolytes as ordered. ■ Provide blankets.

BE PREPARED TO

■ Assist with obtaining laboratory studies, inserting and hanging IVF, administering medications as appropriate to the unit. ■ Transfer patient to ICU.

POSSIBLE ETIOLOGIES

■ New infection in an otherwise well-controlled hypothyroid patient; medications such as diuretics, opioids, beta blockers, tranquilizers, and others in a hypothyroid patient; GI bleed; stroke; surgery; trauma.

Thyroid Storm CLINICAL PICTURE The patient may have: ■ Tachycardia, palpitations, widened pulse pressure, atrial fibrillation.

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123 ■ ■ ■ ■

Anxiety, irritability, restlessness to unresponsiveness. Elevated free thyroxin level (T4), low TSH. SOB, chest pain. Warm, flushed skin, high fever (105⬚–106⬚F).


Assess VS, cardiac rhythm, LOC, and ability to protect airway. Check oxygen saturation by pulse oximetry. Assess patent IV access. Call physician or NP with findings. Document phone call and response.


Continued assessment of cardiac, respiratory, and neurological status. Assess for signs and symptoms of heart failure. Assess electrolyte levels, if recent ones are available. Assess for signs and symptoms consistent with hyperthyroidism: ■ Edematous legs and feet. ■ Intolerance to heat; increased sweating. ■ Labile mood, possible psychosis. ◆ Exophthalmia (bulging eyeballs). ◆ Weakness. ◆ Pretibial myxedema—itchy lesions on the legs and feet (not to be confused with myxedema as seen in hypothyroidism).


Continue frequent assessments. Insert IV if no access; hang IVF. Administer electrolytes as ordered. Administer medications as ordered, propylthiouracil (PTU) or methimazole (MMI) to control T4 production, hydrocortisone, and propranolol to control signs and symptoms. ■ Reduce fever with acetaminophen, cooling blanket, and/or tepid baths if needed.

BE PREPARED TO

■ Assess glucose level; obtain other laboratory values. ■ Transfer patient to ICU.

POSSIBLE ETIOLOGIES

■ Lung infections, discontinuing hyperthyroid medications, excessive dose of thyroid replacement medications, thyroid surgery in patients with overactive thyroid gland.

ENDO


ENDO

A & P Snapshot PITUITARY (HYPOPHYSIS) GLAND Anterior: GH, TSH, ACTH FSH, LH, Prolactin Posterior: ADH, Oxytocin

HYPOTHALAMUS Releasing hormones for anterior pituitary

PINEAL GLAND Melatonin THYROID GLAND Thyroxine and T3 Calcitonin

PARATHYROID GLANDS PTH

THYMUS GLAND Immune hormones

ADRENAL (SUPRARENAL) GLANDS Cortex: Aldosterone Cortisol Sex hormones Medulla: Epinephrine Norepinephrine

PANCREAS Insulin Glucagon

OVARIES Estrogen Progesterone Inhibin TESTES Testosterone Inhibin The endocrine system.

124


125 Focused Assessment of Musculoskeletal System ■ Assess the musculoskeletal system on all patients with an orthopedic problem or recent trauma, patients with arthritis or who have been on bedrest, and patients with neurological (e.g., stroke) or neuromuscular disease. ■ Clinicians usually assess the peripheral nervous system simultaneously. Assessment includes evaluation of dressings and wound drainage systems. ■ Assessment of musculoskeletal status includes: ■ Gait. ■ Joint mobility. ■ Neurovascular status (CMS: circulation, motion, sensation); an assessment of circulatory compromise and/or nerve damage. ■ Pain. ■ Fall risk. ■ Gait ■ Assess patient’s ability to ambulate independently. ■ Assess need for assistive devices. If the patient uses an assistive device, asses if he or she is using it safely. ■ Joint range of motion (ROM) ■ Ask patient to put shoulders, elbows, wrists and fingers, hips, knees, and ankles through full range of joint motion as indicated. Neck and back can be included if appropriate. ■ As a nursing assessment, joint ROM evaluation may be necessary only with initial assessment. If the patient is receiving physical therapy to increase that joint’s ROM, then the physical therapist will assess the extent to which the joint can move. ■ If the patient is not able to move or participate, passively move the joints to assess ROM. ■ Do not push a joint past its range, even if limited. ■ Do not push the joint if the patient has pain. ■ Neurovascular status (CMS: Circulation, Motion, Sensation) ■ Palpate peripheral pulse and check capillary refill. ■ Note skin color of extremity; compare with that of opposite extremity. ■ Have patient move hands and fingers, flex and extend feet. Focus on the extremity of interest, but initially compare with the contralateral arm, hand, leg, or foot. ■ Assess strength by having patient push or pull against resistance. ■ Ask about paresthesias (numbness and tingling, odd sensations); lightly trace your finger over different surfaces of the at-risk area

MSKEL/ INTEG


MSKEL/ INTEG

to assess sensation. Have the patient close his or her eyes while you do this. ■ Ask about pain. (See Pain Assessment in Basics tab.)

Focused Assessment of Skin Integrity ■ Assess skin integrity each shift for patients at risk for skin breakdown and patients with incisions, pressure ulcers, or wounds. ■ Assessment of skin integrity includes: ■ Skin condition. ■ Surgical or traumatic wounds. ■ Bandages, casts, wound dressings, and drainage systems. ■ Pressure points. ■ Pressure ulcers. ■ Skin condition ■ Note if skin is dry, moist, abraded, or fragile. ■ Assess for skin tears, which are common in older patients, and other disruptions in skin integrity such as surgical incisions. ■ Surgical or traumatic wounds ■ If dressings are not to be removed, assess for bleeding or drainage on dressings, intactness of dressings, and any tubes or drains exiting from the periwound area. ■ When changing the dressing, assess for intactness of sutures or staples, drainage, swelling, or signs of infection. ■ Assess for skin problems related to bandaging. For example, tape covering a postoperative dressing can cause skin maceration and blistering. The tape is secured to the surface of the skin, but as the skin stretches with swelling, the tape causes a shear injury by pulling the skin. This sometimes occurs in the total hip replacement dressing, especially in the older person who has fragile skin. ■ Bandages, casts, wound dressings, and drainage systems ■ Assess for signs of skin breakdown or pressure points from casts. Be extra vigilant if the patient is diabetic, as circulation to lower extremities is decreased. ■ Casts and circular dressings can abrade skin and impair circulation. Assess the tightness of these dressings, which can become irritating and quite injurious.

126


127 ■ Pressure points ■ Assess pressure points; do not massage reddened areas. ■ Use position changes, pillows, and preventive mattresses to alleviate pressure. ■ Pressure ulcers ■ Perform and document a thorough wound assessment and staging (see pressure ulcer later in this tab). ■ Assess healing. Note that ulcers may progress to a later stage but do not “regress” as they heal. The correct term, for example, is “healing stage 3 ulcer,” with a description of signs of healing (granulation tissue, decreased circumference).

Compartment Syndrome ■ Muscle groups are contained within a tough, inelastic tissue called fascia. This envelope of tissue creates a compartment that contains muscles, nerves, veins, and arteries. ■ After injury or surgery, swelling of the muscles in the fascial compartment causes increased pressure because the fascia cannot expand with the swelling. The increased pressure closes off capillaries, arterioles and, eventually, arteries, causing ischemia that will progress to necrosis if not treated. ■ Compartment syndrome is more common in the extremities, particularly the anterior or posterior compartments of the lower leg, but is possible at other sites of injury such as the abdomen. This discussion is focused on the arm or leg.

CLINICAL PICTURE

■ The patient may have or complain of the “5 Ps.” ■ Severe Pain not relieved by opioid analgesics and unusual for the injury. The pain worsens with stretching of the involved muscles. This pain is the first symptom to appear. Once the other Ps are evident, the process is well established, and tissue damage is probable. ■ Pallor—paleness of the involved extremity. ■ Pulselessness—loss of pulses or markedly diminished pulses of the affected extremity. ■ Paresthesia—numbness and tingling. ■ Paralysis—loss of ability to move the extremity. ■ Diminished capillary refill time (⬎3 seconds).

MSKEL/ INTEG


MSKEL/ INTEG


■ The extreme pain is the first warning sign. When pain is more severe than expected, immediately consider compartment syndrome, and notify physician or NP. ■ Although pain medication should not be delayed or withheld, do not simply medicate and return later to see if the medication is working. ■ Stay with the patient, and perform a focused assessment. ■ Elevate the extremity to the level of the heart to prevent further swelling and increase venous return. ■ Do not put ice bags on the extremity. ■ Document phone call to physician or NP and physician or NP response.


Palpate pulses. Use a Doppler if not palpable. Note skin color and if pallor is present. Blanch the skin, and check capillary refill time. Assess nerves in the affected extremity. Is there altered sensation or impaired mobility?


■ Continue to monitor vascular status. Pain indicates ischemia, but if pallor or pulselessness develops, tissue necrosis and permanent damage will occur. ■ Remain with patient until the physician or NP arrives. Loss of pulses and/or the extreme pain that accompanies compartment syndrome constitutes a surgical emergency. The physician or NP must rapidly determine the treatment plan and if immediate surgery is necessary.

BE PREPARED TO

■ Assist with pressure measurements of the affected compartment. ■ Get the patient ready for an emergency fasciotomy in the OR: draw blood, start an IV, etc. Make sure the time of the patient’s last meal or fluids is documented and easy to find.

POSSIBLE ETIOLOGIES

■ Severe muscle injury, burns, fractures.

128


129 Hip Fracture CLINICAL PICTURE The patient may have: ■ Groin, knee, or hip pain. ■ Inability to bear weight on affected extremity. ■ Shortened and externally rotated leg. ■ Inability to move affected leg.


■ Do not move leg; allow patient to maintain position of comfort. ■ Inspect and palpate for deformity, hematoma, laceration, and asymmetry. ■ Call 4–6 staff members to help transfer patient from stretcher to bed or, if patient has fallen, to lift patient into bed. ■ Assess vital signs (VS); assess for patent IV access. ■ Call physician or NP.

FOCUSED ASSESSMENT

■ If patient has experienced trauma, perform a primary survey and stabilize ABCs. Then perform a secondary survey to detect associated injuries. ■ Assess VS, and observe for signs and symptoms of shock such as cool, clammy skin; mental status changes; and decreased urine output (blood loss from hip fracture can be as much as 1500 mL). ■ Assess VS, level of consciousness (LOC), and orientation. ■ Inspect affected leg for shortening and rotation as compared with the opposite leg. ■ Do not assess ROM unless x-ray is negative. ■ Assess distal circulation, sensation, and ability to move toes.

ONGOING CARE AND ASSESSMENT

■ Administer pain medication (determine that there is no associated head injury first). ■ Avoid PO medications because patient may need surgery. ■ Monitor patient’s response to pain management. ■ Insert a urinary catheter, and monitor urinary output.

MSKEL/ INTEG


MSKEL/ INTEG

BE PREPARED TO

■ Start an IV. ■ Obtain laboratory work, x-rays, possible CT or MRI. ■ Assist with set-up and application of traction.

POSSIBLE ETIOLOGIES ■ Osteoporosis, trauma.

Necrotizing Fasciitis (NF) A very rapidly progressing infection by Streptococcus pyogenes of the deeper layers of skin and tissue, requiring immediate intervention. Very high mortality rate.

CLINICAL PICTURE The patient may have or be: ■ Minor skin disruption, no disruption at all, or major disruption (e.g., surgical incision). ■ Severe or worse than expected pain at site, which gets progressively worse. ■ Cellulitis-like appearance of affected area, which is hot and painful to the touch. ■ Swollen, purplish, blistered tissue with foul-smelling, watery discharge. ■ High fever with flu-like symptoms. ■ Dehydrated and hypotensive.


■ Take the patient’s vital signs. ■ Circle the affected area on the dressing, if present, or apply a dressing, and circle the area so that rapid spreading can be ascertained. ■ Call physician or NP, describe the affected area and patient’s condition. ■ Document your findings, phone call to physician or NP, and physician or NP response.

FOCUSED ASSESSMENT

■ Assess and document VS frequently, at least every half hour. ■ Assess area for rapid progression of swelling and erythema and crepitance. ■ Assess for changes in skin such as a grayish color beneath the skin, blackened areas (necrotic tissue), purple blisters, foul drainage. ■ Assess laboratory values; ↑ BUN and hematocrit level, and ↓ hemoglobin are characteristic of dehydration; ↓ sodium, ↓ albumin, ↑ WBCs, and ↑ bilirubin level are common with NF.

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■ Obtain wound cultures immediately so that antibiotics (penicillin and clindamycin) can be given. ■ Insert an IV, and hang ordered IV fluids. ■ Administer antibiotics immediately; delay in administration of the correct antibiotics is associated with a higher mortality rate. ■ Facilitate assessment of laboratory values. ■ Administer pain medication. ■ Insitute contact isolation or precautions. ■ Change dressings as ordered.


Assist with bedside débridement, or get the patient ready for the OR. Obtain x-rays or CT. Start a heparin drip (to decrease risk of vasculitis and thrombosis). Transfer the patient to ICU.

POSSIBLE ETIOLOGIES

■ Infection with Group A beta-hemolytic streptococcus alone or in combination with S aureus; infection with Clostridium, Peptococcus, E. coli, Pseudomonas, S. pyogrenes, S. aureus, or S. marcescens.

Pathological Fracture CLINICAL PICTURE The patient may have: ■ Sudden pain in leg/hip/back/shoulder/arm while moving in bed, transferring to wheelchair or stretcher, or ambulating. Audible crack may be heard. ■ Abnormal or limited motion of extremity. ■ Back pain (with spinal compression fracture). ■ Unexplained ecchymosis, edema over bone or joint. ■ Obvious deformity of extremity.


■ Immobilize extremity in its position. Do not attempt to realign bone. ■ Notify physician or NP. ■ Document patient’s status, phone call to physician or NP, and physician or NP response.

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FOCUSED ASSESSMENT

■ Assess VS. ■ Assess extremity for swelling or hematoma. ■ Assess sensation and mobility of fingers or toes distal to injury if extremity fracture is suspected. ■ Assess mobility and sensation of arms and legs if spinal fracture suspected. ■ Assess history of falls or fractures.


■ Medicate for pain as indicated. Monitor for signs of respiratory depression or excessive sedation. ■ Assist with diagnostic procedures (x-ray or bone scan). ■ Prepare patient for surgery, if applicable. ■ Assist with casting or immobilization with splint or traction. ■ Monitor foot or hand of affected extremity for peripheral neurovascular dysfunction. ■ Initiate rehabilitation consultation. ■ Initiate care to prevent complications of restricted mobility, such as foot and ankle exercises to decrease risk of deep venous thrombosis, early mobilization, and cough and deep-breathing exercises.


Initiate pressure ulcer prevention strategies. Manage pain so that patient is comfortable but not sedated. Protect patient from additional injury. Obtain assistive devices for ambulation or self-care activities. Initiate discharge planning and collaborate with home care nurse for follow-up care and prevention.

POSSIBLE ETIOLOGIES

■ Osteoporosis, osteomalacia, primary bone tumors, metastatic bone lesions, Paget’s disease.

Patient Fall CLINICAL PICTURE The patient may have or be: ■ Found on floor, unexplained abrasions, or reported falling.

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■ Do not move patient if he or she is unconscious, complains of severe pain, or has a deformity of an extremity (obvious fracture, internal rotation of hip or knee). ■ If unconscious, get help, assess ABCs, immobilize cervical spine (with light traction, hold head and neck in neutral alignment with body). ■ If conscious, have patient lie still while you call for help. ■ If the patient is alert with no obvious injuries, assist to bed or chair with help from another staff member. ■ Notify physician or NP. ■ Document patient’s status, phone call to physician or NP, and physician or NP response.

FOCUSED ASSESSMENT ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Assess LOC and orientation. Assess VS and pain level. Assess ability to move all extremities. Assess alignment and symmetry of extremities. Assess soft tissue and skin for abrasions, swelling, deformity. Assess for acute underlying condition, such as infection, transient ischemic attack, urinary tract infection, hypotension, or cardiac dysrhythmia. Assess for orthostasis, problems with gait, changes in mental status, and recent changes in functional status. Review records for preexisting conditions, medication use, and previous falls. Assess medication administration record for polypharmacy or medication that may have contributed to fall. Ask if patient felt dizzy or lightheaded before falling. Assess environment for potential cause of fall and safety hazards.


■ Treat minor injuries—clean and dress abrasions; apply ice to contusions or areas of swelling. ■ Assess for injuries. ■ Monitor patient closely for changes in condition, especially changes in mental status, which can suggest brain injury. ■ Assess distal circulation, sensory, and motor function of injured extremities. ■ Assess history of falls.

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Assist with x-rays or other diagnostic test. Modify environment to eliminate hazards. Arrange for one-on-one care if patient is confused. Administer oxygen. Order laboratory tests. Complete an incident report.

POSSIBLE ETIOLOGIES

■ Sedation, debilitation, unfamiliar surroundings, side rails left down, callbell malfunction or not left within easy reach, drug reaction, improper use of restraints, dysrhythmias, altered LOC, altered proprioception, spill on the floor.

Fall Risk Factor and Nursing Interventions Risk Factor

Nursing Intervention

Polypharmacy

Review medications with physician or NP. Eliminate medications if possible; reduce dosages if possible. Limit number of PRN medications. Assess drug interactions for additive CNS effects

Specific medications: benzodiazepines, antipsychotics, hypnotics, sedatives, antidepressants

Avoid medications known to cause adverse events in older patients.

Deconditioning

Start physical therapy for strengthening exercises, balance training.

Postural hypotension; change in proprioception

Tell patient to get out of bed or up from a chair slowly; avoid turning on heels quickly.

Uneven surfaces, poor lighting

Tell patient to consciously look around and evaluate the walking surface. Make sure to be aware of where one surface changes to another and the potential for thresholds in doorways. Make sure path from bed to bathroom is well lit and that objects the patient can use for support (cane, walker) are within reach

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135 Pressure Ulcer CLINICAL PICTURE The patient may have: ■ Reddened, blistered, open skin over pressure point such as sacrum, coccyx, scapula, trochanter, or heel. ■ History of immobility, decreased sensorium, incontinence.


■ Relieve the pressure by turning patient or supporting extremity with pillows. ■ Do NOT massage the area; massage can cause tissue damage under the skin. ■ Do NOT use doughnut-shaped or ring-shaped cushions or sock-like heel booties; these items impede circulation. ■ Assess wound using Wound Assessment Guidelines and/or Pressure Ulcer Stage chart in this tab. ■ Assess patient for other areas of pressure and skin breakdown. ■ Notify physician or NP. ■ Document patient status, characteristics of wound, phone call to physician or NP, and physician or NP response.

FOCUSED ASSESSMENT

■ Assess temperature, VS. ■ Assess wound (size, depth, edges, undermining, type and amount of necrotic tissue [color, consistency adherence, and amount], exudate type and amount, color of skin surrounding wound, peripheral tissue edema, induration, granulation tissue, infection). See Wound Assessment Guide in this tab. ■ Assess patient’s pain level. ■ Assess for pressure ulcer risk.


■ Perform dressing changes as ordered. (See Wound Care Products for Pressure Ulcers in this tab.) ■ Turn and reposition patient at least every 2 hours. ■ Keep wound free of contamination from urine and stool. ■ Assess nutritional status; consult dietitian.

BE PREPARED TO

■ Clean, dress, pack the wound. ■ Obtain special wound care products. ■ Obtain specialized support surface for bed or wheelchair.

POSSIBLE ETIOLOGIES

■ Pressure or shearing forces, immobility.

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Pressure Ulcer Assessment and Intervention Guides Braden Scale Risk Assessment The Braden Scale assesses six domains or risk factors: ■ Activity—Amount of physical activity. ■ Nutrition—Usual food intake pattern. ■ Friction and Shear—Extent to which skin is subject to friction and shear forces. ■ Mobility—Ability to change or control body position. ■ Sensory perception—Ability to respond meaningfully to pressure-related discomfort. ■ Moisture—Extent to which skin is exposed to moisture. The patient is assigned a score of 1–4 (1–3 for Friction and Shear), depending on amount of impairment. The total possible score is 23. The lower the score, the greater the risk. There are other scales as well; find out which pressure risk assessment tool is used in your facility.

Pressure Ulcer Prevention Strategies ■ Inspect skin daily, document findings. ■ Effectively manage urinary and fecal incontinence. Clean skin promptly, using a mild, nonirritating, nondrying cleansing solution. Avoid friction during cleansing. ■ Use topical moisture barriers and moisture absorbing pad for incontinent patients. ■ Position patient to alleviate pressure and shearing forces. ■ Reposition patient every 2 hours when in bed and every hour when in a chair. ■ Teach the patient to shift his or her weight every 15 minutes while in a chair. ■ Use positioning devices and foam padding. Do not use doughnut-shaped devices. ■ Avoid placing the patient on his or her trochanters or directly on a wound. ■ Maintain the lowest head elevation possible to prevent sacral pressure. ■ Use lifting devices such as draw sheets or a trapeze. ■ Prevent contractures. ■ Provide adequate nutrition and hydration. ■ Do not massage reddened areas over bony prominences.

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137 Wound Assessment and Documentation Guide ■ Measure length, width, and depth using a centimeter ruler. ■ Assess characteristics of wound edges (i.e., attached, not attached, fibrotic). ■ Assess for undermining: Insert a cotton-tipped applicator under the wound edge; gently advance it until resistence is met. Using a felt-tipped pen, mark the skin where applicator is felt. Continue around the wound. ■ Describe necrotic tissue type: ■ White/gray. ■ Nonadherent yellow slough. ■ Loosely adherent yellow slough. ■ Adherent, soft black eschar. ■ Firmly adherent, hard black. ■ Describe exudate type: ■ Bloody. ■ Serosanguineous. ■ Serous. ■ Purulent. ■ Foul purulent. ■ Describe exudate amount: ■ None—wound tissues dry. ■ Scant—wound tissues moist; no measurable exudates. ■ Small—wound tissues wet; drainage involved 25% of dressing. ■ Moderate—wound tissues saturated; drainage involved 25%–75% of dressing. ■ Large—wound tissues bathed in fluid; drainage involves ⬎75% of dressing. ■ Assess and describe skin color surrounding wound: Assess tissues within 4 cm of wound edge. For light-skinned persons, note if skin is reddened. For dark-skinned persons, note if skin is reddened or darker or purplish around wound edges. ■ Assess wound edge for tissue edema: Note if edema is pitting or nonpitting and if wound is crepitant (crackly noises when tissue is palpated). Notify physician immediately if wound is crepitant: may indicate gas gangrene. ■ Assess amount of induration: Induration is abnormal firmness of tissues with margins. Assess by gently pinching the tissue distal to wound edge; if indurated, you will be unable to pinch a fold of skin. ■ Assess for granulation tissue: Granulation tissue is present in the healing wound. It is the regrowth of small blood vessels and connective tissue. Healthy granulation tissue is bright, beefy red, shiny, and granular. Poorly vascularized tissue supply appears pale pink, dull, or dusky red. ■ Stage the pressure ulcer: (see the following table).

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Stage

Ulcer Characteristics

Interventions

I

Intact skin. Nonblanchable erythema of intact skin. For patients with darker skin: discoloration, edema, redness, and warmth over a bony prominence.

No dressing. Prevent continued injury from pressure or shearing forces. Monitor frequently.

II

Clean wound base. Partial-thickness skin loss involving epidermis, dermis, or both. Ulcer is superficial and looks like an abrasion, blister, or shallow crater.

Use a dressing that will keep ulcer bed continuously moist. Keep surrounding intact skin dry. Fill wound dead space with loosely packed dressing material to absorb excess drainage and maintain a moist environment.

III

Eschar and necrosis. Full-thickness skin loss involving damage or necrosis of subcutaneous tissue. May extend down to fascia. The ulcer looks like a deep crater with or without undermining of adjacent tissue.

Same as stage II treatment plus débride eschar and necrotic tissue. (Heel ulcers with dry eschar and no edema, erythema, or drainage may not need to be débrided.) Débridement may be done surgically with enzymatic agents or mechanically with wet-to-dry dressings, water jets, or whirlpool. Do not use topical antiseptics.

IV

Extensive tissue damage. Fullthickness skin loss. Extensive destruction and necrosis or damage to muscle, bone, or supporting structures. Undermining and sinus tracts present.

Same as stages II and III plus remove all dead tissue, explore undermined areas, and remove the skin “roof.” Use clean, dry dressings for 8–24 hours after sharp débridement to control bleeding, then resume moist dressings.

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Pressure Ulcer Stages and Treatment


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Product

Characteristics

Transparent Films ■ Tegaderm ■ CarraFilm ■ OpSite ■ BIOCLUSIVE

■ Semipermeable membrane. ■ Waterproof. ■ Permeable to oxygen and water vapor. ■ Provide moist healing environment and prevent bacterial contamination.

Hydrogels ■ Hypergel ■ CarraSorb ■ Nu-gel ■ Curafil

■ Water- or glycerin-based gels, impregnated gauzes, or sheet dressings. ■ Provides moist wound environment. Helps clean and débride by supplying liquid to dry, sloughy wounds. ■ Occlusive and adhesive wafer dressings, or hydrocolloid powders and pastes. ■ Facilitate rehydration and autolytic débridement of dry, sloughy, or necrotic wounds.

Hydrocolloid dressings ■ Tegasorb ■ Comfeel ■ DuoDERM ■ Restore

Indications

Nursing Considerations

■ Stage I and II wounds. ■ Transparency allows visual inspection of wound. ■ Work best on ■ Can be a secondary dressuperficial wounds, sing over alginates or gels. blisters, and skin tears. ■ Dressing change up to three times per week. Do not absorb exudates; change when fluid collects underneath. ■ Reduce pain and promote ■ Stage II, III, and IV soothing effect. Easy to wounds. apply and remove. ■ Require secondary dressing. ■ Do not absorb large amounts of exudate due to large water content. ■ Change once daily. ■ Stage II and III wounds. ■ Conformable for easy application; help reduce ■ Granulating and pain at wound site. epithelizing wounds ■ Breakdown of product may with low to moderate produce residue and foul amounts of exudate. odor; do not confuse with infectious process. ■ Changed up to three times/ week. (Continued on the following page)

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Wound Care Products for Pressure Ulcers

Product Alginates ■ CURASORB ■ AlgiDERM ■ Sorbsan ■ Algosteril


Foam dressings ■ Flexzan ■ CURAFOAM ■ Mepilex

Enzymatic débriding agents ■ Panafil ■ Santyl ■ Accuzyme

Characteristics

Indications

■ Soft nonwoven fibers ■ Stage III and IV derived from seaweed. wounds with ■ Available in pads, ropes, moderate to heavy or ribbons. exudate, but not ■ Can absorb up to 20 wounds with eschar times their weight. or dry wound beds. ■ Highly absorbent ■ Stage III and IV dressings made from wounds. hydrophilic ■ Heavily exudating polyurethane foam. wounds, especially ■ Some have adhesive during inflammatory borders. phase following débridement and desloughing. ■ Deep cavity wounds and weeping ulcers such as venous stasis ulcers. ■ Agents selective in ■ Stage III and IV removing necrotic wounds. tissues from wound ■ Tunneling wounds bed. (may remove debris in areas that cannot be visualized).

Nursing Considerations ■ Highly absorbent, therefore good for packing exudating wounds. ■ Require secondary dressing. ■ Usually changed once daily. ■ Highly absorbent foam may allow less frequent dressing changes. ■ Can be left undisturbed for 3–4 days. ■ Decrease maceration of surrounding tissue. Comfortable and conformable. ■ Usually changed up to three times/week. ■ Surgical débridement may be avoided in some cases with use of enzymatic débriding agents. ■ Require prescription.

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Wound Care Products for Pressure Ulcers (continued)


141 Surgical Site Infection/Complication CLINICAL PICTURE The patient may have: ■ Warm, reddened, tender, swollen, painful wound. ■ Low-grade fever. ■ Separation of wound edges with serous-sanguineous or purulent drainage from wound. ■ Purulent discharge from wound drain. ■ Feeling of wound tearing or opening. ■ Exposure or protrusion of abdominal contents through open wound.


■ Examine wound for evisceration—total separation of deep wound layers (fascia and muscle) with protrusion of internal organs and viscera; dehiscence—partial or complete separation of deep wound layers; or superficial wound separation—separation of skin and subcutaneous tissue. ■ Abdominal wound: If there is evidence of dehiscence or evisceration, place the patient in semi-Fowler’s position, with knees bent to decrease tension on abdominal wall. Saturate a sterile dressing with normal saline, and cover the open wound. Place a large sterile dressing over top. Do not manipulate viscera or attempt to replace. Keep patient NPO and NOTIFY PHYSICIAN OR NP STAT. Stay with patient and offer support and reassurance. ■ For dehiscence of wounds elsewhere on the body, position patient to alleviate tension on suture line, then saturate a sterile dressing with normal saline, and cover the open wound. Place a large sterile dressing over top. Notify physician or NP immediately. ■ For superficial wound separation, cover wound with a sterile normal saline wet-to-dry dressing. Notify physician or NP. ■ If evidence of infection, obtain wound culture. ■ Assess for patent IV access. ■ Assess pain level, and medicate per order. ■ Document patient’s status, phone call to physician or NP, and physician or NP response.

FOCUSED ASSESSMENT

■ Assess temperature, VS. ■ Assess wound: determine or describe size, depth, edges, undermining, type and amount of necrotic tissue (color, consistency adherence, and amount), exudate type and amount, color of skin surrounding wound, peripheral tissue edema, induration, granulation tissue, infection. (See Wound Assessment Guide in this tab). ■ Assess patient’s pain level.

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Perform dressing changes as ordered. Administer antibiotics. Assess nutritional status; consult dietitian. Document assessment findings.

BE PREPARED TO

■ Prepare the patient for surgery. ■ Clean, dress, pack the wound. ■ Start an IV.

POSSIBLE ETIOLOGIES

■ Infection, excessive tension on suture line (vomiting or coughing), dehydration, long surgery time, hematoma, abdominal distention, obesity, poor nutritional status, diabetes, insufficient suturing, stretching or pulling at suture site (trauma), higher risk in geriatric patients.

Wound Vacuums Vacuum-assisted closure (VAC) units are negative pressure devices that help promote wound healing by removing exudate and other fluids with continuous and/or intermittent subatmospheric pressure; in other words, by suction. The suction, in conjunction with the system, also helps pull the wound edges together, stimulates granulation tissue, and improves blood flow to the wound bed. Setting up the wound VAC: ■ Wash your hands, don gloves, and clean the wound using aseptic technique. ■ Apply skin preparation to peri-wound area to help secure the dressing. ■ Cut foam to fit wound, and place in the wound; do not push it in, just place it on the wound. ■ Apply Tegaderm-like plastic sheet over foam and onto healthy skin; put it on in patches, if necessary. ■ Cut a small hole in the plastic sheet over the foam. This is essential for suction to reach wound bed. ■ Apply suction disc over the hole in the plastic dressing. ■ Connect suction tubing, remove kinks, and set suction as ordered. ■ Remove gloves, discard old dressing properly, wash hands.

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143

Dressing before suction is turned on.

Dressing appearance after suction is applied.

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A & P Snapshot Skull (cranium)

Zygomatic arch

Cervical vertebrae

Maxilla

Thoracic vertebrae

Mandible

Clavicle Scapula

Sternum Humerus

Ribs

Lumbar vertebrae Radius Ulna Ilium Sacrum

Carpals Metacarpals

Coccyx

Phalanges Pubis Ischium Femur

Patella

Tibia Fibula Tarsals Metatarsals Phalanges

Skeletal system.

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145

Receptor for touch (encapsulated)

Pore

Epidermis Papillary layer with capillaries Dermis Pilomotor muscle

Sebaceous gland

Hair follicle

Receptor for pressure (encapsulated) Nerve Arteriole Venule

Stratum germinativum Stratum corneum

Fascia of muscle Adipose tissue Subcutaneous Eccrine tissue sweat gland Free nerve ending Skin structure.

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Standard Precautions Use standard precautions for the care of all patients. Add contact, droplet, or airborne precautions, depending on the mode of transmission. Handwashing: ■ Wash hands. ■ After touching blood, body fluids, secretions, excretions, and contaminated items. ■ Immediately after gloves are removed. ■ Between patient contacts. ■ To avoid transfer of microorganisms to other patients or environments. ■ Between tasks and procedures on the same patient to prevent cross contamination of different body sites. Gloves: ■ Wear clean, nonsterile gloves: ■ When touching blood, body fluids, secretions, excretions, and contaminated items. ■ Before touching mucous membranes and nonintact skin. ■ Change gloves between procedures on the same patient after contact with contaminated material. ■ Remove gloves promptly after use and before touching noncontaminated items and environmental surfaces. Wash hands immediately. Mask, Eye Protection, Face Shield: ■ Wear mask and eye protection or face shield when patient-care activities are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions. Gown: ■ Wear a clean, nonsterile gown when patient-care activities are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions. Patient-Care Equipment: ■ Prevent skin, mucous membrane, and clothing exposure to contaminated equipment. ■ Do not use reusable equipment for another patient until cleaned appropriately. ■ Discard single-use items properly. Linen: ■ Prevent skin, mucous membrane, and clothing exposure to contaminated linen.

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147 Preventing Needle and Sharps Injuries Never recap used needles or manipulate them using both hands. ■ Do not direct needle point toward self. ■ Use one-handed “scoop” technique. ■ Do not remove used needles from disposable syringes by hand; do not bend, break, or manipulate used needles by hand. ■ Place used disposable syringes and needles, scalpel blades, and other sharp items in appropriate puncture-resistant containers.

Airborne Precautions For patients who are or may be infected with microorganisms transmitted by airborne droplet nuclei. ■ Private room with: ■ Monitored negative air pressure in relation to the surrounding area. ■ 6 to 12 air changes per hour. ■ Monitored high-efficiency filtration of room air. ■ Door closed. ■ Keep patient in room.

Droplet Precautions For patients who are or may be infected with microorganisms transmitted by large-particle droplets that occur with coughing, sneezing, talking. ■ Private room or in room with patient who has active infection with same microorganism but no other infection. ■ If private room not possible, maintain at least 3 ft of space between infected patient and other patients and visitors. ■ Door may be open. ■ Wear a mask when working within 3 ft of patient. ■ Place mask on patient when leaving the room, if possible.

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Contact Precautions For patients who are or may be infected or colonized with microorganisms transmitted by direct contact with the patient or indirect contact with environmental surfaces or patient-care items. ■ Private room or in room with patient who has active infection with same microorganism but with no other infection. ■ Wear clean, nonsterile gloves when entering the room. ■ Remove gloves before leaving patient room, and immediately wash hands with antimicrobial or waterless antiseptic agent. ■ Do not touch potentially contaminated surfaces once gloves are removed and hands washed. ■ Wear clean, nonsterile gown when entering room if clothing will have contact with patient, surfaces, or items in the room or if patient is incontinent, has diarrhea, an ileostomy, a colostomy, or wound drainage not contained by a dressing. ■ Remove the gown before leaving room.

Clostridium-Associated Diarrhea (CDAD, Psuedomembranous Colitis) CLINICAL PICTURE The patient may have: ■ Frequent, watery diarrhea, possibly with blood. ■ Fever. ■ Loss of appetite, nausea. ■ Abdominal cramping, pain, and tenderness.


■ Assess hydration status, electrolyte balance, and recent I&O records (to assess hydration). ■ Note trends in recent VS assessment; reassess as needed. ■ Assess for recent antibiotic use; if patient is still on antibiotics, withhold until you speak with the physician or NP. Clostridium difficile infection is usually caused by antibiotic-induced derangement of normal intestinal flora, and discontinuation of the antibiotic is part of the treatment. ■ Call physician or NP about the character and frequency of the stool. ■ Document findings, phone call, and physician or NP response. ■ Move patient to a private room, and initiate contact precautions. ■ Obtain stool sample for laboratory testing.

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■ Assess for IV access as rehydration may be necessary. ■ Assess stool for blood or pus, which can occur with severe infection. ■ Auscultate bowel sounds, and palpate abdomen for tenderness.


■ Make sure all visitors wear gloves when touching the patient, and wash their hands with soap and water each time before they leave the room. ■ Administer oral metronidazole or Vancomycin as ordered. ■ Collect stools for testing as ordered—usually three stools from three separate bowel movements on consecutive days. ■ Provide incontinence care, if needed, and monitor perianal skin for breakdown. ■ Monitor hydration status and food intake ■ Monitor electrolytes, albumin, WBC count. ■ Assess for complications of severe infection including anasarca, dehydration, toxic megacolon, and colonic perforation.

BE PREPARED TO

■ Transfer patient to high-acuity unit if infection is severe with complications. ■ Insert an IV, and hang IV fluids.

POSSIBLE ETIOLOGIES

■ C. difficile, which produces two toxins that cause tissue damage; inflammation of colonic tissues.

Fever CLINICAL PICTURE The patient may have: ■ Temperature elevation (low-grade fever: T ⬍101⬚F; high-grade ⬎101⬚F). ■ Fatigue, weakness. ■ Flushed, dry skin.


■ Assess VS. ■ Offer cool compress for forehead.

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FOCUSED ASSESSMENT

■ Auscultate lungs for diminshed breath sounds, crackles, rhonchi. ■ Assess for stiff neck, headache, photophobia, irritability, confusion. ■ Assess IV sites, surgical incisions for redness, warmth, tenderness, swelling. ■ Assess legs for swelling, warmth, pain (do not massage calves). ■ Assess for urinary symptoms. ■ Assess for GI symptoms. ■ Evaluate medications for possible drug fever; note any rashes. ■ Assess mucous membranes, I&O. ■ Ask about prosthetic implants (heart valve, artificial joint). ■ Check recent laboratory test for ↑WBC count. ■ Notify physician or NP. ■ Document patient’s status, phone call to physician or NP, and physician or NP response.


■ Encourage patient to cough, breathe deeply, and use incentive spirometer. ■ Encourage fluids (unless contraindicated by renal or cardiac disease). ■ Check medication administration record for order for PRN antipyretic. Administer if patient feels uncomfortable. ■ Obtain cooling blanket, or give tepid bath, if ordered.

BE PREPARED TO

■ Obtain sputum, blood, or urine sample for Gram stain, culture, and sensitivity. ■ Obtain or change IV access. ■ Order a chest x-ray. ■ Order or obtain laboratory tests.

POSSIBLE ETIOLOGIES

■ Numerous potential causes include bacterial, viral, or fungal infection; deep venous thrombosis; medications; tumor; neutropenia.

Fever With SIRS/Sepsis Terms: ■ Infection: Inflammatory response to microorganisms, or the invasion of normally sterile host tissue by those organisms.

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151 ■ Systemic Inflammatory Response Syndrome (SIRS): Systemic inflammatory response to severe clinical insults, including infection, pancreatitis, trauma, and burns. This response is manifested by two or more of the following conditions: ■ Core temperature ⬎38⬚C (100.4⬚F) or ⬍36⬚C (96.8⬚F). ■ HR ⬎90 beats/min. ■ RR ⬎20 breaths/min or PaCO2 ⬍32 mm Hg. ■ WBC count ⬎12,000/mm3, ⬍4000/mm3, or the presence of ⬎10% immature neutrophils. ■ Sepsis: A systemic inflammatory response to infection that initiates a cascade of biochemical events resulting in hypotension, coagulopathy, suppression of fibrinolysis, and multisystem organ dysfunction. Sepsis is diagnosed when there is a documented infection with at least two of the four systemic inflammatory response criteria. ■ Severe sepsis: Sepsis with dysfunction of one or more organ systems, hypoperfusion, or hypotension. ■ Septic shock: Sepsis with hypotension (systolic BP ⬍90 mm Hg or a reduction of 40 mm Hg from baseline) despite adequate fluid resuscitation and with perfusion abnormalities that include lactic acidosis, oliguria, or change in mental status. ■ Multiple organ dysfunction syndrome: Altered organ function in an acutely ill patient such that homeostasis cannot be maintained without intervention.

CLINICAL PICTURE The patient may have: ■ Temperature ⬎38⬚C (100.4⬚F) or ⬍36⬚C (96.8⬚F). ■ Chills, sweating. ■ Tachypnea, respiratory alkalosis. ■ Tachycardia. ■ Elevated or depressed WBC count. ■ Change in mental status. ■ Abdominal or flank pain. ■ Rash; warm, dry, flushed skin. Progressive Indications: ■ Restlessness, confusion, altered LOC. ■ Hypotension, widening pulse pressure. ■ Oliguria. ■ Rapid thready pulse, delayed capillary refill. ■ Decreased urinary output.

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■ Hypoactive bowel sounds. ■ Rapid shallow breathing. ■ Cold, clammy, mottled skin.


■ ■ ■ ■ ■ ■ ■ ■ ■

Assess HR, BP, RR, and temperature (rectally). Administer supplemental oxygen. Assess for patent IV access. Obtain SaO2 via pulse oximetry. Review recent WBC count if available. Notify physician or NP. Obtain large-bore IV access if needed. Obtain IV fluids (NS) for administration. Document patient’s status, phone call to physician or NP, and physician or NP response.

FOCUSED ASSESSMENT

■ ■ ■ ■ ■

Assess airway status, LOC, and VS (HR, RR, BP) frequently. Assess SaO2 via pulse oximetry. Assess VS and capillary refill. Assess onset, recent history of fever. Assess for possible source of infection.


■ Obtain and administer prescribed antibiotic STAT. ■ Administer isotonic IV fluids to correct hypovolemia (due to vasodilation and capillary leak) and restore blood pressure and tissue perfusion. ■ Monitor for signs of volume overload: dyspnea, pulmonary crackles, jugular vein distention. ■ Monitor mental status, HR, BP, capillary refill, and urinary output. ■ Monitor coagulation studies, BUN, and creatinine.

BE PREPARED TO ■ ■ ■ ■ ■ ■ ■

Obtain urine, blood, wound, and sputum samples for culture. Assist with line placement. Assist with central line placement. Order or obtain laboratory tests. Facilitate diagnostic testing such as x-rays or CT scan. Insert indwelling urinary catheter. Administer vasoactive drugs to treat hypotension.

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153 ■ Assist with intubation and airway management. ■ Call a code. ■ Transfer patient to ICU or monitored unit.

POSSIBLE ETIOLOGIES

■ Head and neck infections; chest and pulmonary infections; GI infections; pelvic/genitourinary infections; bone, soft-tissue, and skin infections.

Hepatitis Inflammation of liver cells that results in necrosis and obstruction of bile. There are many forms of hepatitis, including viral, bacterial, alcoholic, and drug-induced hepatitis. The various forms of viral hepatitis are named with a letter of the alphabet, using A through G.

CLINICAL PICTURE The patient may have: ■ Fever, loss of appetite, nausea, and vomiting ■ Fatigue, headache. ■ Tea-colored urine, clay-colored stools, jaundice. ■ Right upper quadrant abdominal pain.

IMMEDIATE INTERVENTIONS/FOCUSED ASSESSMENT ■ ■ ■ ■ ■

Assess laboratory values for positive hepatitis test. Institute contact precautions if needed (see following table). Assess pain, activity tolerance, appetite. Assess for jaundice. Observe urine for characteristic tea color and stools for the absence of bile, which renders them clay-colored. ■ Document findings.


■ Continue ongoing assessment. ■ Implement energy-conserving routines for self-care. ■ Teach patient about self-care during recovery and how to prevent transmission to others.

POSSIBLE ETIOLOGIES ■ Viral infection.

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Precautions for Major Types of Viral Hepatitis Type

Route of Transmission

HAV

Fecal-oral route; exposure to contaminated food or water

HBV

Parenteral: bloodto-blood contact

HCV

Parenteral: blood-to-blood contact

HDV

Parenteral: bloodto-blood contact Fecal-oral: possible person-toperson contact

HEV

Precautions Standard precautions plus contact precautions. Found in feces; spread under poor sanitary conditions and poor personal hygiene. Can also be transmitted through oral and anal sexual activity, drinking contaminated water, eating raw shellfish taken from contaminated water, or eating fruits and vegetables contaminated during handling. Standard precautions. Spread by blood-to blood contact via punctures of the skin with bloodcontaminated needles or scalpels, blood splashes to open skin or mucous membranes, or indirectly when dried blood on a surface or instrument gets transferred to open skin or mucous membranes. Saliva can contain very low concentrations of hepatitis B virus, thus disease can be spread by a bite. Spread by sharing needles and through unprotected sexual contact. Feces, nasal secretions, sputum, sweat, tears, urine, and emesis do not spread hepatitis B unless visibly contaminated with blood. Not transmitted by casual contact. Standard precautions. Spread by blood-to-blood contact or exposure of contaminated blood to open skin or mucous membranes. People may get hepatitis C by sharing needles to inject drugs or through exposure to blood in the workplace. Can be sexually transmitted. Not spread by casual contact or through food or water. Standard precautions. See Hepatitis B. Standard precautions plus contact precautions. See Hepatitis A.

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155 Meningitis Inflammation of the meninges, which cover the brain and spinal cord. May be septic meningitis, which is caused by bacteria, or aseptic, which is viral or secondary to a lymphoma, leukemia, or a brain abscess. Bacterial meningitis is much more severe than viral meningitis and will be fatal if not treated promptly.

CLINICAL PICTURE The patient may have: ■ Fever, headache, nausea and vomiting. ■ Confusion, delirium, seizure. ■ Neck stiffness, lethargy, rash. ■ Photophobia, sore throat, weakness.


■ Assess VS, LOC, SaO2. ■ Start antibiotics immediately. ■ Institute droplet precautions for meningococcal meningitis; maintain until 48 hours after antibiotics are started. ■ Discuss diagnosis with physician or NP for information about causative organism. ■ Document findings.

FOCUSED ASSESSMENT

■ Assess cranial nerves for possible complication (hearing loss, visual impairment, nerve palsy). See cranial nerve assessment in Neurological tab. ■ Assess for Brudzinski’s sign (hip and knee flexion in response to forced flexion of the neck). ■ Assess for Kernig’s sign (inability to completely extend the legs). ■ Initiate seizure precautions.


■ Record I&O, and observe patient for signs of dehydration. ■ Administer IV fluids and medications, as ordered by the physician. ■ Monitor patient’s vital signs and neurological status and record. Use Glasgow Coma Scale in this tab for accuracy and consistency.

BE PREPARED TO

■ Assist with lumbar puncture. ■ Obtain blood for CBC, blood cultures, protein. ■ Send patient for CT scan or MRI.

POSSIBLE ETIOLOGIES

■ Bacterial, viral, fungal, amoebic, neonatal, or TB infection.

INFECT


INFECT

Pneumonia Acute infection of the lungs. Alveoli become inflamed and fluid-filled. The patient may have: ■ Cough, chest pain, fever, tachycardia. ■ Shortness of breath, cyanosis, tachypnea, hemoptysis. ■ Joint pain, muscle aches. ■ Loss of appetite, fatigue.


■ Assess VS, and determine if patient has SOB. ■ Apply O2 if already ordered. ■ Assess HR and RR; note if patient is short of breath or struggling to breathe. ■ Listen to lung sounds, assess use of accessory muscles. ■ Notify physician or NP of assessment findings. ■ Document phone call and physician or NP response.

FOCUSED ASSESSMENT ■ ■ ■ ■ ■ ■ ■

Assess Assess Assess Assess Assess Assess Assess

sputum quantity and character. oxygen saturation by pulse oximetry. LOC and orientation. for pleuritic chest pain, chills. for cyanosis. appetite. for patent IV line.


Administer antibiotics as soon as they are available. Maintain O2, and check oxygen saturation frequently. Keep patient well hydrated. Provide diet high in protein. Assess for complications such as empyema, respiratory distress, or superinfection (worsening signs and symptoms despite treatment).

BE PREPARED TO

■ Obtain sputum culture and sensitivity, blood cultures, ABGs, or other laboratory work. ■ Assist with thoracentesis, and monitor for complications (pneumothorax). ■ Obtain chest x-ray STAT. ■ Suction the patient; assist with bronchoscopy.

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■ Viral, fungal, bacterial infection; prolonged bedrest; mechanical ventilation; TB; aspiration; smoking; malnutrition; upper respiratory tract disorder.

MRSA and Vancomycin-Resistant Staph Infection Methicillin-resistant Staphylococcus aureus (MRSA) infection is caused by S. aureus bacteria, which are often found in hospitals. S. aureus is resistant to the broad-spectrum antibiotics commonly used to treat it. A patient or health-care worker can be colonized with MRSA, which means the bacterium lives on the skin and nares but does not cause infection. The danger with colonization is that the patient or health-care worker can transmit the bacteria to others, who may develop the hard-to-treat infection. CA-MRSA is community-acquired MRSA. MRSA can be fatal. Vancomycin is one of the few antibiotics that effectively treat MRSA; however, vancomycin-resistant staph has begun to emerge.

CLINICAL PICTURE The patient may have: ■ Small red pimple-like bumps that may look like boils or spider bites. ■ Erythema, swelling, and warmth around bumps; purulent drainage. ■ Fever, SOB, chest pain, muscle aches. ■ Painful skin abscesses. ■ Infection of bone, joints, incisions, blood, cardiac valves, lungs.


■ Using gloves, cover the wound(s), abscesses, or bumps with a clean, dry, dressing; wash hands thoroughly. ■ Assess VS. ■ Notify physician or NP of possible staph infection. ■ Document phone call and physician or NP response.

FOCUSED ASSESSMENT

■ Assess for signs and symptoms of internal infection: auscultate lungs for adventitious sounds; take apical pulse, and listen for murmurs; assess urine for cloudiness; check BUN and creatinine for signs of renal impairment. ■ Ask patient about general aches and pains, chills, headache, feeling unwell (malaise).

INFECT


INFECT

■ ■ ■ ■

Obtain culture of wound and drainage. Obtain blood cultures. If pneumonia is suspected, obtain sputum culture. If urinary tract infection is suspected, obtain urine culture.


Initiate contact precautions (See Contact Precautions in this tab). Move patient to private room. Wear a mask if patient has a productive cough. Start antibiotics promptly. Do not discontinue contact precautions until two sets of cultures, taken 24 hours apart and 48 hours after all antibiotics are discontinued, are negative for MRSA.

BE PREPARED TO

■ Transfer patient to ICU if septic. ■ Teach family about preventing spread of MRSA. ■ Assist with incision and drainage of skin abscesses.

POSSIBLE ETIOLOGIES

■ S. aureus colonization or infection.

Tuberculosis CLINICAL PICTURE The patient may have: ■ Productive cough, worse in the morning. ■ Hemoptysis. ■ Chest pain, SOB. ■ Fever, night sweats. ■ Extreme weight loss if disease is advanced.

IMMEDIATE INTERVENTIONS/FOCUSED ASSESSMENT

■ Institute airborne precautions (see Airborne Precautions in this tab). ■ Auscultate lungs for possible diminished breath sounds, bronchial breathing, coarse crackles. ■ Assess findings of chest x-ray: cavitation, calcification (indicates healed disease), and nodes in the upper lobes suggest pulmonary TB. ■ Assess sputum production and patient’s ability to clear airway.

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■ Obtain early morning sputum specimens for 3 consecutive days for culture and acid-fast bacilli (AFB). Obtain proper medium for AFB specimen. ■ Administer standard therapy, and teach patient that it is critical that he or she take medications as prescribed for the duration of therapy (6 to 18 months). A combination of the following drugs is standard treatment: ■ Isoniazid (INH). ■ Rifampin (RM). ■ Pyrazinamide (PZA). ■ Ethambutol (EMB). ■ Vitamin B6 for neuropathy of hands/feet. ■ Assess for signs and symptoms of tuberculosis outside the lungs (meningitis, peritonitis, renal or bone involvement, pericarditis).

BE PREPARED TO

■ Assist with bronchoscopy. ■ Assist with chest tube placement (ruptured TB granuloma, empyema).

POSSIBLE ETIOLOGIES

■ Mycobacterium tuberculosis.

INFECT


EMERG

Assessment in an Emergency This assessment guideline was developed for the multiple trauma patient brought into the emergency department (ED). However, the basic primary survey—the ABCs (airway, breathing, circulation)—take precedent in any emergency situation, whether in the ED, ICU, or general care floor. The primary survey should be accomplished within the first few minutes. ■ Put on gloves and face mask with visor. ■ Check that needed equipment is readily available. ■ Ensure that needed staff is available.

Primary Survey: Airway, Breathing, Circulation The primary survey is a crucial, rapid (less than 5 minutes) assessment. The highest priorities are to establish an airway, supplement breathing or provide ventilation, and support circulation. These are the ABCs and must always be addressed first in any situation in which a patient’s status is deteriorating. The order of assessment is critical (a blunt clinical saying: “If you do not have A and B, you can forget about C.”). If the team encounters a problem with the ABCs, an intervention to correct or improve the problem is initiated immediately, and its efficacy is assessed before proceeding. Once ABC is established, proceed to D (disability) and E (expose) and then to the seconday survey. Throughout, the team ALWAYS reassesses ABCs—if problems arise in ABCs, all attention is directed to the problem. ■ During the primary survey all patients are ■ Given high-flow O2. ■ Assessed multiple times by cardiac monitoring, pulse oximetry, and BP measurement ■ Penetrating objects are NOT removed. This should be done only in the OR. Otherwise, catastrophic bleeding or additional injury can occur.

A: Airway Assessment (with cervical spine immobilized): ■ Ask “are you all right?” Can the patient speak? If so, ABC is functional to some extent. If there is no answer, rapidly begin more in-depth airway and breathing assessment. ■ Look in the oropharynx for foreign objects, blood, teeth, vomitus, etc. You may hear abnormal sounds such as wheezing or stridor.

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161 Interventions: ■ Immobilize cervical spine. ■ Establish patent airway with: ■ Jaw thrust/chin lift maneuver. ■ Consider a nasal airway. Do not use an oral airway in a conscious patient as it may induce vomiting and aspiration. ■ Suction fluid from oropharynx. ■ If patient is not breathing or the airway cannot be cleared, endotracheal intubation will be attempted. This will help: ■ Protect airway and ensure patency. ■ Correct hypoxemia. ■ Provide access for some medications. ■ If the patient cannot be intubated, a tracheotomy will be performed.

B: Breathing Assessment: ■ Some patients are not breathing in an emergency (see CPR Quick Reference in this tab). In a hospital, the code team will take over, and an anesthesiologist, respiratory therapist, or other highly skilled individual will assess the airway. ■ If the patient is breathing and you hear any noises with breathing, open the mouth, and inspect the airway. Remove any obstructing material by sweeping with a gloved finger. ■ Assess rate and ease of breathing. Check nailbed and circumoral area for cyanosis. ■ Is the patient restless, thrashing about, extremely anxious? You will see this in an emergency unless the patient has had a head injury and is unconscious. ■ Feel trachea, examine the chest, and auscultate lungs. ■ Evaluate ABG results. Interventions: ■ Provide high-flow supplemental O2; manually ventilate if necessary. ■ Identify and treat major thoracic injuries: ■ Pneumothorax (simple, open, or tension). ■ Hemo-pneumothorax. ■ Rib fractures. ■ Flail chest.

EMERG


EMERG

C: Circulation Assessment: ■ Check cardiac rate and rhythm and BP. Recheck every few minutes. ■ Check peripheral perfusion. Interventions: ■ Control external bleeding. ■ Insert two large-bore IV accesses. ■ Send blood for laboratory tests, and type and crossmatch. ■ Infuse a warmed crystalloid.

D: Disability Assessment: ■ Initial neurological assessment is limited to checking pupils and assessing LOC (responsiveness) using the AVPU scale: ■ A ⫽ Alert ■ V ⫽ responds to Voice ■ P ⫽ responds to Pain ■ U ⫽ Unresponsive ■ Any change in AVPU requires reassessment of ABC. E: Exposure ■ Remove clothing (expose), and inspect for obvious injuries. ■ Cover patient to reduce heat loss.

Secondary Survey ■ Follows primary survey and resuscitation. ■ Involves head-to-toe systematic assessment to detect injuries. ■ Includes AMPLE history (allergies, medications, past medical history, last meal eaten, events prior). ■ Includes continuous reassessment of primary survey. ■ Provides for assessment of each body area for signs of deformity, contusion, abrasion, hemorrhage, penetrating injury, altered perfusion, and altered function.

Head and Face

■ Inspect and palpate head and face for lacerations, contusions, fractures, or other injury. ■ Eyes (injury, hemorrhage, contact lens, dislocation of lens). ■ Ears and nose for CSF. ■ Mouth. ■ Cranial nerves.

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163 Cervical Spine and Neck

■ Inspect for signs of injury, tracheal deviation. ■ Palpate for tenderness, deformity, swelling, subcutaneous emphysema. ■ Auscultate for carotid bruits.

Chest ■ ■ ■ ■

Inspect for injury, use of accessory muscles. Auscultate lungs, and compare left with right. Palpate entire chest for tenderness, crepitation, and injury. Percuss.

Abdomen ■ ■ ■ ■

Inspect for distention, skin condition. Auscultate for bowel sounds. Percuss. Palpate; soft or rigid, tender or nontender?

Extremities

■ Inspect for signs of injury or deformity. ■ Palpate for sensation, tenderness, crepitation, abnormal movement. ■ Check all pulses.

Perineum

■ Inspect for rectal blood, sphincter tone. ■ Assess for bleeding or other injury to genitalia.

Back

■ Inspect for injuries, swelling. ■ Assess for flank pain, hematoma.

Fractures

■ Assess for bone/joint deformity. ■ Assess for loss of function.

Neurological

■ Reevaluate pupils and LOC. ■ Determine GCS. ■ Evaluate for paralysis, paresis, motor and sensory responses of extremities.

EMERG


EMERG

Diagnostic Studies ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Type and crossmatch for blood. Hemoglobin and hematocrit levels. WBC count. Glucose. Urinalysis. Amylase. Cardiac and liver enzymes. Arterial blood gas. Cervical-spine radiographic series. Chest x-ray. Head CT. Abdominal CT.

Advance Directives and Do Not Resuscitate Orders First, make sure you know the patient’s wishes (or family’s, if the patient is unable to make decisions) regarding “heroic measures.” Ideally, all patients should have advance directives in the medical record indicating whether they wish to be resuscitated and to what extent resuscitative efforts should be carried out. Admission personnel often ask this of the patient when he or she is admitted. However, sometimes this is not possible, and if there is any doubt as to the interpretation or whereabouts of a patient’s advance directives a code must be called and resuscitative efforts initiated. Therefore, make sure this document is always available in the record. ■ Help patients and families address end-of-life care issues. ■ Suggest discussing with a religious leader of their faith. ■ Keep in mind the role of culture, ethnicity, and religion in end-of-life questions. ■ Always treat the patient as an individual. ■ Tell patients that they will not be abandoned or given substandard care if they or their advance directive limit medical interventions.

Rapid Response Teams Patients typically go through several hours of subtle changes in condition before a respiratory or cardiac arrest. HR and BP changes, changes in mentation, breathing difficulties, and other signs precede a full-blown code. Intervening earlier in the downward spiral of events vastly increases the

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165 patient’s chance of survival. The nurse’s role is critical in getting the right help for the patient. Many hospitals have rapid response teams that can be and should be called when the patient’s condition changes, even if you cannot say for sure what it is (“something’s different/wrong”). The rapid response team may consist of: ■ Resident, NP, or physician’s assistant. ■ ICU nurse. ■ Nurse anesthetist or respiratory therapist. The staff nurse is usually responsible for: ■ Calling the rapid response team. ■ Calling the attending physician. ■ Providing the recent history and background information. ■ Continuing to assess the patient. ■ Obtaining and administering medications. ■ Providing other noncritical care. If your facility does not have a rapid response team, notify the nurse manager or nursing supervisor, who can help you get the resources needed.

What to Do If Your Patient Codes If you are by yourself: ■ Establish unresponsiveness, call for help, and check ABC; clear airway by sweeping your fingers in the patient’s mouth or by suctioning. ■ If you have no help, call the code before proceeding. As you do this, pull the call bell out so that the light flashes continually, ask any visitors to wait outside the room, and pull the curtain if another patient is present. ■ Note if the patient has a running IV or an IV access device. ■ Place the patient in a supine position in bed, if possible. ■ Place the arrest board under the patient’s back, if you have help. If not, proceed until a second person arrives. ■ Next, assess breathing for 5 seconds, using the head-tilt/chin-lift maneuver (see first figure below). If the patient is not breathing, initiate ventilations, preferably with a bag-valve-mask device. If one is not available, quickly apply a barrier, and give two breaths of 11/2–2 seconds each.

EMERG


EMERG

■ Check for a pulse. If the patient has no pulse, begin one-person CPR until another person or the code team arrives (see CPR Quick Reference in this tab). When another nurse arrives to help: ■ Bring the crash cart into the room. ■ Get an IV of NS running. ■ Switch to bag-valve-mask ventilations by: ■ Inserting an oral airway. ■ Connecting the bag-valve-mask to oxygen tubing. ■ Setting up the flowmeter. ■ Turning on the oxygen to 12–15 L/min. ■ Make sure the seal around the patient’s airway is tight, and resume CPR. ■ Once the code team arrives, someone will relieve you and begin other resuscitative interventions. ■ Once you are relieved: ■ Make sure one nurse is documenting and another nurse is retrieving medications and supplies as needed from the code cart. ■ Stay in the room to be available to the team. ■ Many other tasks may be required of you in a code situation, including obtaining laboratory tests and transporting them to the laboratory, inserting an IV or Foley catheter, suctioning the airway, administering medications, calling the attending physician, arranging for a bed in the ICU, etc. Do not practice beyond your level of expertise. ■ Offer support to any visitors who are present. ■ Document all events up to and including time code was called. Document after time the code ended. Check that the code record is complete and on the chart. ■ If the patient survives, write a transfer note, and give report to receiving unit. If you work in an ICU and the patient is not being moved, detail the events in your end-of-shift report, and document on the ICU flowsheet. ■ If the patient does not survive, leave all tubes in place, and check with your supervisor to determine what can be removed. If an autopsy will be performed, you will not remove anything. ■ Clean and cover the patient, and straighten the room before the family views the body. If family members were present at the time the patient coded, sensitively ask them if they would like you to do this first. It may be unbearable for them to wait. ALWAYS consider the family’s needs first.

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167 Adult/Child CPR, Hemlich, and Recovery Positions

Head—tilt, chin—lift.

Jaw thrust maneuver.

Hand placement.

Heimlich maneuver.

Heimlich maneuver: abdominal thrusts if unresponsive.

EMERG

Recovery position.


EMERG

Infant CPR and Heimlich Positions

Head—tilt, chin—lift.

Heimlich maneuver: back blows; support head.

CPR hand placement.

Heimlich maneuver: chest thrusts; support head.

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169 CPR Quick Reference Determine unresponsiveness

■ Adult: Call 911: get help—obtain AED if available. ■ Child or infant: Call 911 after 2 min (5 cycles) of CPR.

Open airway

■ All ages: head—tilt, chin—lift ■ If trauma suspected, use jaw-thrust method.

Assess for breathing

■ If not breathing, give two slow breaths at 1 sec/breath. ■ If unsuccessful, reposition airway, and reattempt to ventilate. If still unsuccessful, refer to Choking Quick Reference below.

Check for a pulse for 10 seconds

■ If pulse is present but patient is not breathing, begin rescue breathing (see table below). ■ If no pulse after 10 seconds, start chest compressions.

CPR Parameters for Adults, Children, Infants, and Neonates Adult

Child and Infant

Newborn

Ventilations

10–12/min

12–20/min

40–60/min

Pulse check location

Carotid

Child: Carotid Infant: Brachial

Brachial Umbilicus

Compression rate

100/min

100/min

120/min

Ratio of compressions to breaths

30:2 (1 or 2 rescuers)

30:2 (15:2 if 2 rescuers)

3:1 (1 or 2 rescuers)

Compression depth

11/2–2 inches

1/2–1/3

1/3

the depth of the chest

the depth of the chest

If a defibrillator is available Power on, and follow voice prompts (AED) ■ Perform 2 minutes of CPR between each shock. ■ Adults: Do not use pediatric pads. ■ Child: Use after 2 min (5 cycles) of CPR (may use adult pads if pediatric pads are unavailable). Note: Recheck pulse every 2 minutes and after each shock. Check without interrupting chest compressions.

EMERG


EMERG

Choking Quick Reference Conscious Patient

1. Assess for airway obstruction

■ Adult or child: Ask victim if he/she is choking; can he/she speak or make any sounds? ■ Infant: Cannot cry or ineffective cough.

2. Attempt to relieve obstruction

■ Adult or child: Abdominal thrusts until the obstruction is relieved or victim becomes unresponsive (see step 3 below). ■ Pregnant or obese patients: Chest thrusts until the obstruction is relieved or the patient becomes unresponsive (see step 3 below). ■ Infant: 5 back blows and 5 chest thrusts until the obstruction is relieved or victim becomes unresponsive (see step 3 below).

Unresponsive Patient

3. Determine unresponsiveness

■ Adult: Get help or call 911 prior to any intervention. ■ Child or infant: Get help or call 911 after 1 min.

4. Open airway

■ Head—tilt, chin—lift. ■ If trauma suspected, use the jaw-thrust method.

5. Assess breathing and attempt to ventilate

■ If unsuccessful, reposition airway, and reattempt ventilation. ■ If still unsuccessful, begin CPR (for all ages).

6. Inspect mouth and remove obstruction

■ Adult, child, and infant: Use a tongue-jaw lift while opening the airway during CPR. ■ Perform a finger sweep only to remove a visible foreign body.

7. Repeat manuevers

■ Inspect, sweep, ventilate. ■ Perform CPR until obstruction relieved. Note: If patient resumes breathing, place into recovery position, and reassess ABCs every minute.

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171 Automatic External Defibrillators (AEDs) ■ Assessment: Determine unresponsiveness and assess ABCs. ■ Children 1–8 years: get help/AED after 2 min of CPR. ■ Adults ≥8 years: get help/AED immediately. ■ Perform CPR until AED arrives. ■ Power: Turn on the AED, and follow voice prompts. ■ Attach pads: Stop CPR, attach appropriate-size pads to patient, and plug pad cable into the AED unit if needed. ■ Upper right sternal border and cardiac apex. ■ Analyze: Press the “Analyze” button, and wait for instructions (do not make contact with patient while AED is analyzing rhythm). ■ Shock: Announce “Shock indicated, stand clear,” and assure that no one is in contact with the patient. ■ Fully automatic units analyze rhythm and shock if indicated. ■ Semiautomatic units analyze rhythm, and then instruct the operator to press the “shock” button if indicated.

Transcutaneous Pacing (TCP) INDICATIONS ■ ■ ■ ■

Symptomatic 2nd-degree AV block type II or 3rd-degree AV block. Symptomatic bradycardia unresponsive to atropine. Bradycardia with ventricular escape rhythms. Overdrive pacing of tachycardia refractory to drug therapy or electrical cardioversion (to be performed by physician only).

PACING MODES

■ Demand (synchronous) mode senses the patient’s heart rate and paces only when the HR falls below the clinician-set rate. ■ Fixed (asynchronous) mode does not sense the HR, but rather paces at the rate set by the clinician.

PROCEDURE ■ ■ ■ ■

Pads: Apply pacing electrodes to patient per package instructions. Power: Turn on pacemaker, and assure all cables are connected. Rate: Set demand rate to approximately 80 bpm. Current: Output ranges 0–200 mA ■ Bradycardia: Increase mA from minimum setting until a consistent capture is achieved, then increase by 2 mA. ■ Asystole: Begin at full output. If capture occurs, slowly decrease until capture is lost, then increase by 2 mA.

EMERG


EMERG

Emergency Conditions INJURY AND ILLNESS

■ Appendicitis (leading to peritonitis) ■ Chest pain or sudden severe abdominal pain ■ Cholecystitis ■ Compound fracture ■ Drug overdose or withdrawal ■ Gangrene ■ Head trauma ■ Hypothermia or hyperthermia ■ Intestinal obstruction ■ Malignant hyperthermia ■ Necrotizing faciitis ■ Pancreatitis ■ Peritonitis ■ Septicemia blood infection ■ Severe burn ■ Spreading wound infection ■ Spinal injury

CARDIAC AND CIRCULATORY ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Air embolism Aortic aneurysm (ruptured) Aortic dissection Cardiac arrest Cardiac arrhythmia Cardiac tamponade Hemorrhage Hypertensive emergency Myocardial infarction Subarachnoid hemorrhage Subdural hematoma, acute Ventricular fibrillation

METABOLIC ■ ■ ■ ■ ■ ■ ■

Acute renal failure Addisonian crisis Dehydration, advanced Diabetic ketoacidosis Electrolyte disturbance, severe Hepatic encephalopathy Hypoglycemic coma

■ Lactic acidosis ■ Thyroid storm

NEUROLOGICAL ■ ■ ■ ■

Cerebrovascular accident (stroke) Meningitis Seizure Syncope (fainting)

OPHTHALMOLOGICAL

■ Acute angle–closure glaucoma ■ Orbital perforation/penetration ■ Retinal detachment

RESPIRATORY

■ Acute asthma ■ Agonal breathing ■ Asphyxia secondary to angioedema, choking. drowning, smoke inhalation ■ Epiglottitis or severe croup ■ Pneumothorax ■ Pulmonary embolism ■ Respiratory failure

SHOCK ■ ■ ■ ■ ■

Anaphylaxis Cardiogenic shock Hypovolemic or hemorrhagic shock Neurogenic shock Septic shock

UROLOGICAL, GYNECOLOGICAL, AND OBSTETRIC ■ ■ ■ ■ ■ ■ ■ ■

Eclampsia Ectopic pregnancy Gynecological hemorrhage Obstetrical hemorrhage Paraphimosis Priapism Testicular torsion Urinary retention

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173 Anaphylaxis CLINICAL PICTURE The patient may have: ■ Angioedema, hives, itching. ■ Feelings of impending doom, anxiety, restlessness. ■ Bronchospasm, laryngeal edema, respiratory distress. ■ Hypotension, dysrhythmia. ■ Nausea, vomiting, diarrhea.


■ Call physician and respiratory therapist or anesthesiologist STAT. Get help. Have someone bring code cart or emergency medications box to room. ■ Establish patent airway. Administer high concentrations of supplemental O2, or manually assist ventilations with an Ambu-bag. ■ Initiate continuous cardiac and VS monitoring. ■ Obtain IV access. ■ Anticipate need for mechanical ventilation. ■ Assess recent exposure to allergen (food, insect sting, medication, blood product, contrast medium, latex). ■ Document patient’s status, phone call to physician, and physician response.

FOCUSED ASSESSMENT

■ Assess airway status, LOC, and VS (HR, RR, BP) on a continuous basis. ■ Assess SaO2 via pulse oximetry. ■ Assess skin for color, temperature, turgor, moistness, and capillary refill.


Monitor VS every 5 min. or more frequently. Administer medications, IV fluids as ordered. Provide emotional support to family/patient. Record patient’s status in chart, and communicate to physician.


Administer epinephrine subcutaneously. Call a code. Assist with intubation and airway management. Assist with obtaining central venous access. Administer IV fluids and medications (vasopressors, diphenhydramine, steroids, volume expanders). ■ Transfer patient to ICU.

POSSIBLE ETIOLOGIES ■ Exposure to antigen.

EMERG


EMERG

Transfusion Reaction CLINICAL PICTURE The patient may have: ■ Fever, chills, tachycardia, hypotension. ■ Chest pain, SOB. ■ Apprehension, restlessness. ■ Burning at infusion site. ■ Nausea, vomiting, diarrhea. ■ Urticaria, pruritus, skin erythema. ■ Flank, back, or joint pain. ■ Hematuria.


■ Stop the transfusion. Run normal saline through the IV to maintain IV access. ■ Assess airway, breathing, and circulation. Get help. ■ Check VS. ■ Administer supplemental O2. ■ Notify physician or NP. ■ Recheck patient ID and blood labels for error. Notify blood bank of reaction. ■ Document patient’s status, phone call to physician or NP, and physician or NP response.

FOCUSED ASSESSMENT

■ ■ ■ ■

Assess LOC, orientation, and VS (temperature, HR, RR, BP). Assess SaO2 via pulse oximetry if available. If patient on telemetry or cardiac monitor, assess rhythm strip. Assess skin for color, turgor, moistness, and temperature.


Return unused portion of blood product to blood bank for analysis. Administer prescribed medications and O2. Document specific reaction. Continue to monitor VS, temperature, respiratory status, LOC, and urine output. ■ Chart patient status, and convey to physician or NP.

BE PREPARED TO

■ Administer epinephrine, treat shock, initiate CPR if necessary. ■ Administer IV fluids.

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175 ■ Insert indwelling catheter to monitor hourly urine output. ■ Administer medications such as: ■ Antihistamine, antipyretic, steroids, and furosemide (Lasix) IV. ■ Acute hemolytic reaction: IV normal saline with diuretics to maintain urine output of 100 mL/hr. ■ Allergic response: corticosteroids such as Solu-Medrol. ■ Urticaria: diphenhydramine 25–50 mg IV, deep IM. ■ Fever: acetaminophen. ■ Septicemia: antibiotics, IV fluids, vasopressors. ■ Kidney failure and shock: IV fluids and vasopressors. ■ Obtain or order STAT laboratory tests. ■ Titrate O2 to keep SaO2 ⬎90%. ■ Obtain two large-bore IV accessories.

POSSIBLE ETIOLOGIES

■ ABO incompatibility, blood contamination, allergic response.

Types of Reactions Type

Cause

Signs and Symptoms

Acute hemolytic

ABO incompatibility reaction to RBC antigens.

Fever, chills, low back pain, flushing, tachycardia, hypotension, vascular collapse, cardiac arrest.

Febrile nonhemolytic

Sensitization to donor WBCs, platelets, or plasma proteins.

Fever, chills, headache, flushing, muscle aches, respiratory distress, cardiac dysrhythmias.

Anaphylactic

Administration of donor’s IgA proteins to recipient with anti-IgA antibodies.

Restlessness, urticaria, wheezing, shock, cardiac arrest.

Allergic

Sensitivity to foreign proteins.

Hives, urticaria, fever, flushing, itching.

Bacteremia

Infusion of bacteriacontaminated blood.

Chills, fever, hypotension, vomiting, diarrhea, septic shock.

EMERG


EMERG

Shock CLINICAL PICTURE The patient may have: ■ Anxiety (early), lethargy and coma (later). ■ Hypotension. ■ Decreased urine ouput. ■ Tachycardia (bradycardia in neurogenic shock). ■ Delayed capillary refill (⬎3 sec), diminished peripheral pulses (⬍⫹2). ■ Cool, pale, mottled, or cyanotic skin (hypovolemic shock). ■ Tachypnea. ■ Diaphoresis. ■ Throat tightness, stridor, flushing, urticaria (anaphylactic shock).


■ ■ ■ ■

■ ■

Call physician or NP STAT. Get help from other staff. Establish patent airway. Insert nasal or oral airway, and suction oropharynx if needed. Administer high-flow O2 via nonrebreather mask (10–15 L/min), or manually assist ventilations with an Ambu-bag (mask-valve device). Anticipate need for mechanical ventilation. Obtain IV access. Set up cardiac monitoring. Place patient in a supine position with legs elevated above heart level to increase circulation to vital organs. Note: This position is contraindicated if the airway is compromised; to maintain airway patency, place patient in supine or low Fowler’s position (HOB slightly elevated). Control bleeding with direct pressure if patient hemorrhaging. Document patient’s status, phone call to physician or NP, and physician or NP response.

FOCUSED ASSESSMENT

■ Assess LOC, orientation, and VS (HR, RR, BP). ■ Assess SaO2 via pulse oximetry if available (may be unreliable due to decreased peripheral perfusion). ■ Assess skin for color, temperature, turgor, moistness, and capillary refill. ■ Evaluate previous 2-hour I&O.


■ Monitor VS every 5 minutes or more frequently. ■ Manage various types of shock accordingly: ■ Hypovolemic: O2; IVF; volume replacement with crystalloids, colloids, plasma volume expanders, and/or blood; elevate lower limbs (if not contraindicated); control bleeding; arterial line placement.

176


177 ■ Cardiogenic: O2; IVF; vasopressors, cardiotonics, antidysrhythmics (i.e., dopamine, dobutamine, lidocaine); correct dysrhythmias; arterial line placement and hemodynamic monitoring. ■ Septic: O2; IVF; volume replacement; antibiotics, vasopressors, antipyretics; arterial line placement. ■ Anaphylactic: O2; IVF; epinephrine, antihistamines (Benadryl/Atarax), steroids; intubation and airway management; arterial line placement. ■ Neurogenic: O2; IVF; spinal stabilization; vasopressors; intubation and airway management; arterial line placement; insert Foley’s catheter. ■ Provide emotional support to family/patient. ■ Record patient’s status in chart, and communicate to physician or NP.


Call a code. Assist with intubation and airway management. Assist with obtaining central venous access. Administer fluids, blood products, and medications as ordered. Order or obtain specific laboratory tests to be drawn STAT (Hgb, Hct, WBC, cardiac markers, electrolytes, ABG, UA). ■ Transfer to ICU.

POSSIBLE ETIOLOGIES

■ Blood loss, vomiting, dehydration (hypovolemic shock), MI, profound brady/tachycardia, pump failure (cardiogenic shock), infection, endo/ exotoxin release (septic shock), exposure to antigen (anaphylactic), spinal cord injury, anesthesia (neurogenic shock), pharmacological overdose.

Comparison of Different Types of Shock States Type

Pathophysiology

Anaphylactic: Acute, lifethreatening allergic reaction to a specific antigen.

Massive vasodilation; fluid shifts out of intravascular space; ↓ tissue perfusion; peripheral and laryngeal edema; bronchospasm.

Signs and Symptoms Respiratory distress (stridor); ↓ BP; edema; rash, hives; cool, pale skin; possible seizure activity, tight chest.

Interventions O2, airway management, epinephrine, antihistamines, steroids, IV fliuds.


EMERG


EMERG

Comparison of Different Types of Shock States (continued) Type

Signs and Symptoms

Pathophysiology

Cardiogenic: Pump failure due to MI, PE, cardiac tamponade, heart failure, aneurysm.

Inadequate cardiac output due to lack of contractile force to create BP; decreased tissue perfusion. Hypovolemic: ↓ Decrease in intracirculating volume vascular due to hemorvolume with rhage, burns, which to create dehydration, a BP; third spacing decreased of fluids. tissue perfusion. Neurogenic: Profound vasodiSpinal shock lation that secondary to results in lack spinal cord injury, of peripheral anesthesia. vascular resistance sufficient to sustain BP; decreased tissue perfusion. Septic: Septicemia Circulatory secondary to failure due to endo/exotoxin systemic release, most inflammatory commonly Gramresponse; negative bacteria. capillary leak syndrome; decreased tissue perfusion.

Interventions

Hypotension, weak pulse, tachycardia, clammy skin, altered LOC; dysrhythmias.

O2, IV fliuds, vasopressors, cardiotonics, antidysrhythmics.

Hypotension; tachycardia; weak pulse; ↓ capillary refill; cyanosis; dysrhythmias; altered LOC; cool, clammy, pale skin. Hypotension, bradycardia, or tachycardia; tachypnea; possible flaccid paralysis and absent reflexes.

O2, control bleeding, fluid replacement with crystalloids, colloids, volume expanders, blood. O2, IV fluids, airway management, spinal stabilization, possible vasopressors.

Fever or low temperature; bounding pulse; ↓ urine output; flushed, warm, moist to diaphoretic skin; increased HR/RR.

O2, IV fluids, blood cultures, UA, sputum C&S antibiotics, vasopressors.

178


179 Cardiogenic Shock Ineffective Pump Ventricular Emptying

Stroke Volume

End-diastolic Volume

Cardiac Output

Filling Pressures

Tissue Perfusion

Cardiogenic shock.

Hypovolemic Shock Volume

Venous Return

Filling Pressures

Stroke Volume

Cardiac Output

Tissue Perfusion

Hypovolemic shock.

EMERG


EMERG

Neurogenic Shock Massive Vasodilation Venodilation

Arteriolar Dilation

Venous Return

Peripheral Resistance

Filling Pressures Stroke Volume

Cardiac Output

Blood Pressure

Tissue Perfusion

Neurogenic shock.

180


181 High-Alert Medications High-alert medications are those medications that have a high risk of causing injury or death when improperly handled or administered. Many of these drugs are used commonly in the general population or are used frequently in urgent clinical situations. The Joint Commission monitors the five most often prescribed high-alert medications: insulin, opiates and narcotics, injectable potassium chloride (or phosphate) concentrate, IV anticoagulants (heparin); and sodium chloride solutions above 0.9%. Exercise extreme caution when administering these medications: ■ Adrenergic agonists (e.g., epinephrine, isoproterenol, norepinephrine). ■ Cardioplegic solutions. ■ Chemotherapeutic agents. ■ Chloral hydrate (in pediatric patients). ■ Colchicine injection. ■ High-concentration dextrose (greater than 10% dextrose). ■ Hypoglycemic agents (oral). ■ Hypertonic sodium chloride injection (⬎0. 9% concentration). ■ Insulin. ■ IV adrenergic antagonists (propranolol, esmolol, metoprolol). ■ IV calcium. ■ IV digoxin. ■ IV magnesium sulfate. ■ IV potassium (phosphate and chloride). ■ Lidocaine/benzocaine; other topical anesthetics. ■ Midazolam. ■ Neuromuscular blocking agents. ■ Opiates (opioids). ■ Thrombolytics, heparin, warfarin.

Safe Medication Administration ■ Carefully read product packaging to note strength of solution, dosage, and/or route of administration. ■ Double-check with a pharmacist about dose range. ■ Have a colleague double-check dosage calculations and infusion pump programming. ■ Use the Five Rights (right drug, right dose, right patient, right route, right time) as a guide.

MEDS/LABS


MEDS/LABS

■ Clarify any order that is incomplete, contains abbreviations, is confusing or hard to read, or raises a question. ■ Suspect a missed decimal point, and clarify any order if the dose requires more than 3 dosing units. ■ If taking a verbal order, ask prescriber to spell out the drug name and dosage to avoid sound-alike confusion (e.g., hearing Cerebyx for Celebrex, or fifty for fifteen). ■ Read back the order to the prescriber after you have written it in the chart. ■ Do not borrow medications from other patients or begin new medications before the order has been received in the pharmacy; to do so circumvents the built-in checks that can detect a prescribing error. ■ Review each patient’s medications for: ■ Medication use without an indication. ■ Contraindications. ■ Improper drug selection. ■ Overdose/subtherapeutic dose (consider age, renal/hepatic impairment). ■ Medication duplication. ■ Efficacy. ■ Adverse drug reactions/toxicity. ■ Potential drug or food interactions. ■ Weight changes requiring dosage adjustments. ■ Appropriate duration of therapy. ■ Adherence with prescribed medication therapy.

Patient Education and Medication Use Educating patients about their medications is a critical nursing function that promotes proper medication use and improved outcomes. It also can prevent adverse drug reactions or early or improper discontinuation of a medication. Many issues related to medication errors, such as ambiguous directions, unfamiliarity with a drug, and confusing packaging, affect the patient as well as the health-care providers, thereby emphasizing the need for careful education. Patient education also enhances compliance, which is a factor in proper medication use. ■ All patients need clear written and verbal instruction for all medications. ■ Present information in a format the patient can understand. ■ Use an interpreter if provider and patient speak different languages. ■ Do not rush. ■ Include family members. ■ Have the patient repeat the information you provide.

182


183 ■ Make sure to tell the patient: ■ The brand and generic names of the medication. ■ The purpose of the medication. ■ The strength and dose and when to take the medication. ■ Possible side effects and what to do if they occur. ■ How long to take the medication. ■ What medications or foods to avoid and why they should be avoided. ■ How to store the medication. ■ What to do if a dose is missed. ■ What activities, if any, should be avoided while on the medication. ■ Signs and symptoms of adverse drug reactions.

Error-Prone Abbreviations and Symbols Abbreviations ■ ␮g ■ AD, AS, AU ■ OD, OS, OU ■ BT ■ cc ■ D/C ■ IJ ■ IN ■ HS, hs ■ IU ■ o.d., OD ■ OJ ■ per os ■ q.d., QD ■ q1d ■ q6PM, etc. ■ SC, SQ, sub q ■ ss ■ SSRI, SSI ■ 1/d ■ TIW, tiw ■ U, u

Symbols ■ (dram) ■ (minim) ■ @ (at) ■ & (and) ■ ⬚ (hour) ■ / (slash) ■ ⫹ (plus) ■ ⫺ (minus) ■ ⬎ (greater than) ■ ⬍ (less than) ■ Apothecary symbols Drug Names ■ ARA A ■ AZT ■ CPZ ■ DPT ■ DTO ■ HCl ■ HCT ■ HCTZ ■ IV Vanc ■ MgSO4

MEDS/LABS

■ MTX ■ Nitro drip ■ Norflox ■ PCA ■ PTU ■ T3 ■ TAC ■ TNK ■ ZnSO4 General Tips ■ Avoid using a zero after a decimal point. ■ Use a zero before a decimal point. ■ Use commas for dosing units at or above 1,000. ■ Place adequate space between a drug name, dose, and the unit of measure.


MEDS/LABS

IV Fluid Drip Rate Table (drops/min) Rate: mL/ hr →

TKO

50

75

100

125

200

250

10 gtt/ mL set

5

8

13

17

21

150 175 25

29

33

42

12 gtt/ mL set

6

10

15

20

25

30

35

40

50

15 gtt/ mL set

8

13

19

25

31

37

44

50

62

20 gtt/ mL set

10

17

25

33

42

50

58

67

83

60 gtt/ mL set

30

50

75

100

125

150

175

200

250

Note: TKO is 30 mL/hr.

Emergency Medications (62 Medications) Note: This list is a reference only. It is not meant to be exhaustive. Always consult an authoritative, current reference about dose, dilution, interactions, and route and rate of administration before administering medications, especially IV medications. Have a second licensed person independently check dose calculations, preparation, original orders, and infusion pump programming for high-alert medications.

ACE Inhibitors (Antihypertensive) Common Agents: Captopril, Enalapril, Lisinopril. Indications: MI, heart failure without hypotension, ST elevation. Dose: See individual order and drug for route and dosage. Contraindications: Hypotension, pregnancy, angioedema. Side Effects: Dizziness, HA, fatigue, hypotension, altered LOC. Precautions: Lower doses in renal failure.

Activated Charcoal (Absorbent) Indications: Overdose and poisoning. Dose: 25–100 g PO, NG tube. Contraindications: Concurrent use with syrup of ipecac. Side Effects: Constipation, N&V, diarrhea. Precautions: Ineffective in iron (heavy metals) OD.

184


185 Adenosine (Adenocard®) (Antidysrhythmic) Indications: Narrow complex PSVT. Dose: 6 mg IV. Repeat with 12 mg IV in1–2 min if needed. A third dose of 12 mg may be given in 1–2 min. Max: 30 mg. Contraindications: Drug- or poison-induced tachycardia. Side Effects: Flushing, chest pain, tightness, bradycardia, heart block, asystole, ventricular ectopy, VF. Precautions: Ineffective in treating atrial fibrillation, atrial flutter, or VT. Avoid in patients on dipyridamole or with a history of MI or cerebral hemorrhage.

Albuterol (Ventolin®) (Bronchodilator) Indications: Reversible airway restriction due to acute bronchospasm, asthma, or COPD. Dose: 1.25–5 mg nebulized in 3-mL saline. Contraindications: Hypersensitivity to adrenergic amines. Side Effects: Nervousness, restlessness, tremor, tachycardia, anxiety, N&V, diarrhea, HA, HTN, hyperglycemia. Precautions: Tachydysrhythmias, cardiac disease, elderly, hypersensitivity.

Alteplase (Activase®, t-PA) (Thrombolytic, Fibrinolytic) Indications: Within 4–6 hr of acute MI and 3 hr from onset of symptoms in acute ischemic stroke, pulmonary embolus. Dose: Per order. Contraindications: Active internal bleeding within 10 days (except menses), history of neurovascular event within 2 months, major surgery or trauma within 2 weeks, aortic dissection, severe (uncontrolled) HTN, bleeding disorder, prolonged CPR, lumbar puncture within 1 week. Side Effects: Hypotension, reperfusion dysrhythmias, heart failure, HA, increased bleeding time, deep or superficial hemorrhage, flushing, urticaria, anaphylaxis. Precautions: Patients with severe renal or hepatic disease.

Alupent (Metaproterenol®) (Adrenergic Agonist [Bronchodilator]) Indications: Reversible airway restriction due to asthma or COPD. Dose: 10–15 mg nebulized in 3-mL saline. Contraindications: Hypersensitivity to adrenergic amines. Side Effects: Nervousness, restlessness, tremor, tachycardia, anxiety, N&V, diarrhea, HA, HTN, hyperglycemia. Precautions: Tachydysrhythmias, cardiac disease, elderly, hypersensitivity.

Aminophylline (Truphylline®) (Bronchodilator) Indications: Long-term control of reversible airway obstruction due to asthma or COPD. Dose: Per order.

MEDS/LABS


MEDS/LABS

Contraindications: Uncontrolled dysrhythmias, hyperthyroidism. Side Effects: Seizures, dysrhythmias, anxiety, N&V, tremors. Precautions: Geriatric patients, patients with CHF or liver failure, obesity; multiple drug interactions.

Amiodarone (Cordarone®) (Antidysrhythmic) Indications: Wide- and narrow-complex tachycardia, VF, and pulseless VT. Dose: 150 mg over first 10 min (15 mg/min), 360 mg over next 6 hr (1 mg/ min), 540 mg over next 18 hr (0.5 mg/min). Contraindications: Sinus bradycardia, cardiogenic shock, 2nd- or 3rddegree heart block. Side Effects: Hypotension, prolonged QT interval, ARDS, CHF, PSVT. Precautions: Avoid concurrent use with procainamide.

Amyl Nitrate (Antidote to Cyanide Poisoning) Indications: Cyanide poisoning. Dose: Inhale vapors from crushed ampules for 30 sec of every min continuously. Contraindications: Cerebral hemorrhage, head trauma, hypotension, glaucoma, recent MI, hypersensitivity to nitrates or nitrites. Side Effects: HA, hypotension, tachycardia, N&V. Precautions: Increased hypotension with alcohol consumption.

Aspirin (Acetylsalicylic Acid) (Antiplatelet, Analgesic) Indications: Analgesic, acute coronary syndrome. Dose: 160–325 mg PO nonenteric-coated for antiplatelet effect. Contraindications: Known allergy to aspirin, pregnancy. Side Effects: Anorexia, nausea, epigastric pain, anaphylaxis. Precautions: Active ulcers and asthma, blood dyscrasias.

Ativan® (Lorazepam) (Anticonvulsant, Anxiolytic, Sedative, Hypnotic) Indications: Status epilepticus, acute ETOH withdrawal. Dose: 50 ␮g (0.05 mg)/kg, maximum 4 mg each dose; may be repeated after 10–15 min, not to exceed 8 mg/12 hr or 2 mg/min IV infusion. Contraindications: Allergy to benzodiazepines, narrow-angle glaucoma. Side Effects: Dizziness, drowsiness, lethargy, apnea, cardiac arrest, paradoxical excitation, N&V, diarrhea. Precautions: Severe hepatic, renal, pulmonary impairment.

Atracurium (Tracrium®) (Neuromuscular Blocking Agent [Nondepolarizing]) Indications: Paralysis to facilitate endotracheal intubation.

186


187 Dose: 0.4–0.5 mg/kg IV bolus, may repeat subsequent boluses of 0.1 ␮g/kg q 15–20 min or an infusion of 5–9 ␮g/kg/min. Contraindications: Myasthenia gravis, asthma, Eaton-Lambert syndrome, severe electrolyte imbalances. Side Effects: Bronchospasm, flushed skin, hypotension, tachycardia, urticaria, hypersensitivity. Precautions: Ensure intubation and suction equipment available, set up, and in working order; multiple drug interactions. Time Action Profile: Onset 2–2.5 min; peak 1–2 min; duration 30–40 min.

Atropine (Anticholinergic)

Indications: Sinus bradycardia, asystole, PEA with rate ⬍60, organophosphate and neurotoxin (nerve gas) exposure, antidote to cholinergic drug toxicity and mushroom poisoning. Dose: Bradycardia: 0.5–1 mg IV (may give via ET tube at double the dose) q 3–5 min, maximum 0.04 mg/kg; cardiac arrest: 1 mg q 3–5 min, maximum 0.04 mg/kg; nerve gas and organophosphate exposure: 2–6 mg IV or IM depending on severity of symptoms, may repeat in 2-mg increments q 3 min titrated to relief of symptoms. Contraindications: Atrial fibrillation, atrial flutter, glaucoma. Side Effects: Tachycardia, HA, dry mouth, dilated pupils, VF/VT. Precautions: Use caution in hypoxia. Avoid in hypothermic bradycardia and 2nd-degree (Mobitz) type-II HB.

Beta Blockers (Antihypertensive) Common Agents: Atenolol, Labetalol, Metoprolol, Propranolol. Indications: MI, unstable angina, PSVT, atrial fibrillation, atrial flutter, HTN. Dose: See individual order and drug for route and dosage. Contraindications: HR ⬍50, SBP ⬍100, 2nd- or 3rd-degree HB, left ventricular failure. Side Effects: Hypotension, dizziness, bradycardia, HA, N&V. Precautions: Concurrent use with calcium channel blockers can cause hypotension; use caution in patients with a history of bronchospasm; multiple drug interactions.

Benadryl® (Diphenhydramine) (Antihistamine) Indications: Anaphylactic reaction, extrapyramidal symptoms. Dose: 10–50 mg IV or deep IM up to 100 mg; not to exceed 400 mg/24 hr. Contraindications: Asthma, pregnant, lactating. Side Effects: Dry mouth, drowsiness, hypotension. Precautions: Elderly, severe liver disease, narrow angle glaucoma, pregnancy.

MEDS/LABS


MEDS/LABS

Bretylium (Bretylol®) (Antidysrhythmic) Indications: Ventricular dysrhythmias. Dose: VF, pulseless VT 5 mg/kg IVP, repeat 10 mg/kg q 15 min, maximum 30 mg/kg in 24 hr; VT w/pulse 5–10 mg/kg in 50–100 mL over 10 min; maintenance drip 1–2 mg/min. Contraindications: Severe aortic stenosis, severe pulmonary hypertension. Side Effects: Hypotension, N&V, CP, bradycardia. Precautions: Digoxin toxicity, renal failure.

Calcium Chloride (Minerals/Electrolytes/Calcium Salt) Indications: Hyperkalemia, hypocalcemia, hypermagnesemia, antidote to calcium channel blockers and beta blockers, given prophylactically with calcium channel blockers to prevent hypotension. Dose: Antidote to calcium channel blocker: 2–4 mg/kg IV, may be repeated as needed; given prophylactically prior to IV calcium channel blockers 8–16 mg/kg IV; hyperkalemia: 2.25–14 mEq; may repeat in 1–2 min; give amount sufficient to return ECG to normal; hypocalcemia: 2.3–9.3 mEq as needed or 7–14 mEq if emergent need elevates Ca⫹⫹; hypermagnesemia: 2–7 mEq slows IVP, may be repeated in 10 min, then observe for response before any additional dose administered. Contraindications: Hypercalcemia, VF, digoxin toxicity. Side Effects: Bradycardia, asystole, hypotension, VF, N&V. Precautions: Incompatible with sodium bicarbonate; administered undiluted IVP.

Calcium Gluconate (Minerals/Electrolytes/Calcium Salt) Indications: Hypocalcemia, hypocalcemic tetany, hyperkalemia with cardiac toxicity, hypermagnesemia. Dose: Hypocalcemia: 7–14 mEq IV; hypocalcemic tetany: 4.5–16 mEq IV, repeat until symptoms are controlled; hyperkalemia with cardiac toxicity: 2.25–14 mEq IV, may repeat in 1–2 min; hypermagnesemia: 4.5–9 mEq IV. Contraindications: Hypercalcemia, renal calculi, VF. Side Effects: Cardiac arrest, dysrhythmias, phlebitis, N&V, bradycardia, tingling, syncope. Precautions: Monitor blood pressure, pulse, and ECG; do not administer IM due to potential for tissue necrosis.

Cardizem® (Diltiazem) (Calcium Channel Blocker) Indications: Atrial fibrillation, atrial flutter, PSVT refractory to adenosine. Dose: 15–20 mg IVP over 2 min (0.25 mg/kg). May repeat in 15 min at 20–25 mg IVP over 2 min (0.35 mg/kg); maintenance drip: start at 5–15 mg/hr, and titrate to HR.

188


189 Contraindications: Drug or poison induced tachycardia, wide-complex tachycardia of uncertain type, WPW syndrome, cardiogenic shock, pulmonary edema. Side Effects: Hypotension, BBB, ventricular extrasystoles. Precautions: Severe hypotension in patients on beta blockers; do not withdraw abruptly.

Dantrolene (Dantrium®) (Skeletal Muscle Relaxant) Indications: Emergency treatment of malignant hyperthermia. Dose: 1–3 mg/kg IVP, may repeat as needed, maximum 10 mg/kg. Contraindications: Pregnancy. Side Effects: Drowsiness, muscle weakness, confusion, HA. Precautions: Cardiac, pulmonary, or liver disease.

Decadron® (Dexamethasone) (Glucocorticoid, Anti-inflammatory) Indications: Anaphylaxis, cerebral edema, spinal trauma, shock. Dose: 10 mg IVP. Contraindications: Ulcer, infection, alcohol intolerance. Side Effects: Peptic ulceration, HTN, N&V. Precautions: Tissue necrosis with infiltration.

Demerol® (Meperidine) (Opioid-Narcotic Analgesic [Agonist]) Indications: Moderate to severe pain. Dose: 25–100 mg IM or 15 to 35 mg/hr continuous IV infusion. Contraindications: Concurrent or recent use of MAO inhibitors, pregnancy, respiratory depression, epilepsy or convulsive states, increased ICP, asthma. Side Effects: Respiratory depression, confusion, sedation, seizure, CNS toxicity, hypotension, N&V. Precautions: Head trauma, elderly.

Dextrose 50% (Caloric Agent) Indications: Hypoglycemic coma/altered LOC. Dose: 25 g slow IVP. Contraindications: CNS bleed, allergy to corn, hyperglycemia. Side Effects: Hyperglycemia, fluid overload. Precautions: Tissue necrosis with infiltration.

Digibind® (Digoxin Immune fab) (Antidote to Digoxin, Digitoxin) Indications: Symptomatic digoxin toxicity or acute ingestion of unknown amount of digoxin. Dose: Dependent on serum digoxin levels. One 40 mg vial binds to approximately 0.6 mg of digoxin. Contraindications: Allergy only, otherwise, none known.

MEDS/LABS


MEDS/LABS

Side Effects: Worsening of CHF, atrial fibrillation, hypokalemia, increased serum digoxin levels. Precautions: Patients with allergies to sheep proteins.

Digoxin (Lanoxin®) (Inotropic, Antidysrhythmic) Indications: Atrial fibrillation and atrial flutter, CHF, pulmonary edema. May be used as an alternative treatment for PSVT. Dose: Loading dose of 10–15 ␮g/kg. Contraindications: Uncontrolled atrial dysrhythmias, AV block, idiopathic hypertrophic subaortic stenosis (IHSS), constrictive pericarditis. Side Effects: Dysrhythmias, particularly VF, AV block, atrial fibrillation, fatigue, bradycardia, N&V, blurred or yellow vision, HA, hypersensitivity, hypokalemia. Precautions: Avoid electrical cardioversion of stable patients. If unstable, use lower current settings such as 10–20 joules; elderly; pregnancy.

Dobutamine (Dobutrex®) (Inotropic) Indications: Short-term treatment of cardiac decompensation in organic heart disease or cardiac surgical procedures. Dose: Per order. Contraindications: Idiopathic hypertrophic subaortic stenosis. Side Effects: Ventricular ectopy, chest pain, hypersensitivity, bronchospasm. Precautions: Safe use in acute MI not established. Ensure adequate hydration prior to infusion.

Dopamine (Intropin®) (Vasopressor, Inotropic) Indications: Cardiogenic shock d/t MI, trauma, endotoxic septicemia, open heart surgery, renal failure, and chronic cardiac decompensation. Dose: Per order. Contraindications: Pheochromocytoma, uncorrected tachycardia, VF, and pediatric clients. Side Effects: Tachycardia, angina, hypo- and hypertension, palpitations, vasoconstriction, dyspnea, N&V. Precautions: Adjust dosage in elderly patients and in those with occlusive vascular disease. Extravasation may result in sloughing of tissue. Ensure adequate hydration prior to infusion.

Epinephrine (Adrenalin®) (Adrenergic Agonist) Indications: All cardiac arrest, anaphylaxis. Also used for symptomatic bradycardia refractory to atropine, dopamine, and TCP; severe hypotension, acute asthma attack, and vasopressor shock.

190


191 Dose: Cardiac arrest: 1 mg IV of 1:10,000 solution q 3–5 min; double the dose if administering via ET tube; anaphylaxis: 0.1–1 mg SQ or IM of 1:1000 solution; asthma: 0.1–0.3 mg SQ or IM of 1:10,000 solution; refractory bradycardia and hypotension: 2–10 ␮g/min (1 mg of 1:1,000 solution in 500 mL of saline and start at 1–5 mL/min). Contraindications: Hypersensitivity to adrenergic amines, narrow-angle glaucoma. Side Effects: Angina, HTN, tachycardia, VT, VF, nervousness, restlessness, tremors, pallor, cerebral or subarachnoid hemorrhage and aortic rupture, suicidal/homicidal tendencies. Precautions: Use caution in HTN, tachydysrhythmias, cardiac disease, hyperthyroidism, glaucoma, DM, elderly, pregnancy, multiple drug interactions.

Esmolol (Brevibloc) (Selective Beta Blocker, Antidysrhythmic) Indications: SVT in those with atrial fibrillation or atrial flutter, noncompensatory ST, tachycardia and HTN during induction or emergence from anesthesia. Dose: 80 mg over 30 sec followed by 150 ␮g/kg/min. May repeat dose. Contraindications: Dosage has not been established in children. Side Effects: Flushing, pallor, induration, burning and/or edema at site of infusion, urinary retention, midscapular pain, asthenia. Precautions: Avoid use in children.

Glucagon (Hormone) Indications: Antidote to beta-blocker and calcium channel blocker overdose; hypoglycemia when IV access unavailable and patient cannot protect airway (cannot take oral glucose); used to decrease GI motility during GI procedures. Dose: Antidote to calcium channel blocker: 2 mg IV; antidote to beta blocker: 50–150 ␮g/kg IVP followed by a 1–5 mg/hr infusion; hypoglycemia: 0.5–1 mg IV, IM, SC; to decrease GI motility: 0.25–1 mg slow IVP or up to 2 mg IM. Contraindications: Known allergy to beef or pork protein. Side Effects: N&V. Precautions: Use caution in patients with insulinoma or pheochromocytoma.

Glycoprotein IIb and IIIa Inhibitors (Platelet Aggregation Inhibitor) Common Agents: Abciximab (ReoPro®), Eptifibatide (Integrilin®), Tirofiban HCl (Aggrastat®). Indications: Acute coronary syndrome without ST-segment elevation, adjunct to percutaneous coronary intervention in patients with high risk of abrupt closure of treated coronary vessel.

MEDS/LABS


MEDS/LABS

Dose: See individual order and drug for route and dosages. Contraindications: Active internal bleeding within 30 days, history of neurovascular event within 1 month (within 2 years of surgery or trauma within 1 month) aortic dissection, severe (uncontrolled) HTN, within 6 weeks of a known GI or GU bleed, known bleeding disorder. Side Effects: Increased bleeding and bruising, GI irritation. Precautions: Increased chance of bleeding; use with caution in elderly, in patients with history of GI disease, or those receiving thrombolytics; multiple herb interactions.

Heparin (Anticoagulant) Indications: Acute pulmonary/peripheral embolism, atrial fibrillation with emoblization, treatment of DIC. Dose: Per order. Contraindications: Active bleeding, blood dyscrasias, thrombocytopenia, liver disease, suspected intracranial hemorrhage, ulceration of the GI tract, subendocarditis, shock, threatened abortion, severe HTN, hypersensitivity. Side Effects: Minor to major hemorrhage, thrombocytopenia, anaphylaxis. Precautions: Use with caution in menstruating women, post-partally, following CVA, and in the elderly; multiple herb interactions.

Histamine Blockers (H2-Receptor Antagonists) Common Agents: Cimetidine (Tagament®), famotidine (Pepcid®), nizatidine (Axid®), ranitidine (Zantac®). Indications: Duodenal and gastric ulcers; management of gastroesophageal reflux disease (GERD); upper GI bleed. Dose: See individual order and drug for route and dosages. Contraindications: Hypersensitivity, impaired renal or hepatic function. Side Effects: Confusion, dizziness, agitation, drowsiness, HA, site pain, N&V, constipation, bradycardia, tachycardia, PVCs, cardiac arrest, bronchospasm, anaphylaxis. Precautions: Assess elderly and severely ill patients for confusion routinely.

Ibutilide Fumarate (Corvert®) (Antidysrhythmic) Indications: SVT, including atrial fibrillation and atrial flutter. Dose: Patients ⴝ 60 kg: 1 mg slow IVP over 10 min, may repeat same dose in 10 min; Patients ⬍60 kg: 0.01 mg/kg slow IVP over 10 min, may repeat in 10 min. Contraindications: Known allergy, concomitantly with other antidysrhythmics such as quinidine, procainamide, amiodarone. Side Effects: Severe ventricular dysrhythmias such as torsades de pointes, HA, N&V, hypotension, bundle branch block, HTN, nodal dysrhythmias. Precautions: CHF, LV dysfunction, pregnancy, multiple drug interactions.

192


193 Inamrinone (Inocor®) (Inotropic) Indications: Short-term treatment of CHF unresponsive to traditional therapies. Dose: Per order. Contraindications: Hypersensitivity to bisulfates, IHSS. Side Effects: Dyspnea, dysrhythmias, hypotension, N&V, diarrhea, hepatotoxicity, hypersensitivity, tachyphylaxis. Precautions: Use cautiously in atrial fibrillation or atrial flutter, electrolyte imbalances, renal impairment, and geriatric patients.

Ipecac Syrup (Emetic) Indications: OD/poisoning of noncaustic substance. Dose: 15–30 mL PO followed by 240 mL of water, may repeat 15 mL in 30 min if ineffective. Contraindications: Altered LOC, ingestion of caustic substance, severe inebriation, shock, TCA OD, seizures. Side Effects: Diarrhea, dysrhythmias, atrial fibrillation, sedation, coughing or choking with emesis. Precautions: Pregnancy, abuse in bulemic or anorexic patients.

Isuprel® (Isoproterenol) (Inotropic) Indications: Symptomatic bradycardia, torsades de pointes refractory to magnesium, bradycardia in heart transplant patients, beta-blocker OD, bronchospasm. Dose: 2–10 ␮g/min titrated to desired heart rate. Contraindications: Cardiac arrest, concurrent use with epinephrine, high dosages (except in beta-blocker OD), heart block caused by digitalis intoxication, angina, tachydysrhythmias. Side Effects: Hypotension, HA, VT, VF, tachycardia, pulmonary edema, cardiac arrest. Precautions: Increase cardiac ischemia, consider Isuprel last, cautious use in persons with tuberculosis.

Kayexalate® (Sodium Polystyrene Sulfonate) (Cation Exchange Resin) Indications: Mild to moderate hyperkalemia. Dose: 15 g PO or 25–100 g rectally as a retention enema 1–4 times daily in water or sorbitol (if severe, more immediate measures such as sodium bicarbonate IV, calcium, or glucose/insulin infusion should be instituted). Contraindications: Life-threatening hyperkalemia, ileus, known alcohol intolerance, hypersensitivity to saccharin or parabens. Side Effects: Constipation, N&V, fecal impaction, gastric irritation, hypocalcemia, hypokalemia, sodium retention. Precautions: Monitor ECG and electrolytes during therapy, use cautiously in the elderly, CHF, hypertension, constipation.

MEDS/LABS


MEDS/LABS

Lasix® (Furosemide) (Diuretic, Distal Loop) Indications: CHF with acute pulmonary edema, hypertensive crisis, increased ICP, nephrotic syndrome, hepatic cirrhosis. Dose: 0.5–1 mg/kg slow IVP over 1–2 min, may repeat once at 2 mg/kg slow IVP over 1–2 min. Contraindications: Never use with ethacrinic acid, anuria, hypotension, hepatic coma, dehydration, hypokalemia, hypersensitivity to sulfonamides. Side Effects: Severe dehydration/hypovolemia, hypotension, hypokalemia, hyponatremia, hypochloremia, azotemia, vertigo, dizziness. Precautions: Monitor urine output and electrolytes during therapy and injection site for thrombophlebitis, cardiac arrest following IV administration.

Lidocaine (Xylocaine®) (Antidysrhythmic, Anesthetic) Indications: Pulseless VF/VT, wide-complex tachycardia of uncertain type. Dose: 1–1.5 mg/kg IVP or ET tube (double dose if giving via ET tube), may repeat q 5–10 min, maximum 3 mg/kg. If conversion successful, start an infusion of 2–4 mg/min. Contraindications: 2nd- or 3rd-degree HB, Stokes-Adams and WPW syndromes, hypotension, hypersensitivity to amide-type local anesthetics. Side Effects: Altered LOC, seizure, slurred speech, malignant hyperthermia, hypotension, bradycardia, cardiovascular collapse, respiratory arrest. Precautions: Reduce infusion dose by 50% if ⬎70 yr, CHF, shock, liver disease, marked hypoxia, digitalis toxicity, severe respiratory depression.

Magnesium Sulfate (Electrolyte, Anticonvulsant) Indications: Seizures associated with toxemia of pregnancy, hypomagnesemia or hypothyroidism, torsades de pointes, severe asthma, VF refractory to lidocaine, digoxin-induced VT/VF. Dose: Hypomagnesemia: 0.5–1 g/hr IV; cardiac arrest 1–2 g IVP; torsades de pointes (noncardiac arrest): load with 1–2 g infused over 5–60 min, then infuse 0.5–1 g /hr; digoxin-induced VT/VF: 1–2 g IVP; toxemia of pregnancy: 1–4 g slow IVP (4–5 g IV followed by an infusion of 1–2 g/hr) continuous infusion not to exceed 40 g/24 hr. Contraindications: Hypermagnesemia, hypocalcemia, renal disease, heart block, toxemia of pregnancy 2 hr prior to delivery. Side Effects: Hypotension, cardiac arrest, respiratory depression, altered LOC, flushed skin, diaphoresis, hypocalcemia. Precautions: Renal insufficiency.

Mannitol (Osmitrol®) (Diuretic [Osmotic]) Indications: Increased ICP, the oliguric phase of acute renal failure, severe intraocular pressure, diuresis of toxic substances. Dose: 1.5–2 g/kg IV over 30–60 min. Contraindications: Intracranial bleeding, pulmonary edema, anuria, dehydration.

194


195 Side Effects: Altered LOC, HA, blurred vision, N&V, tachycardia, hypotension or HTN, chest pain, CHF, seizures. Precautions: Elderly, cardiovascular and renal disease.

Milrinone (Primacor®) (Inotropic) Indications: Short-term treatment of CHF in patients receiving digoxin and diuretics. Dose: Per order. Contraindications: Obstructive pulmonic or aortic valvular disease, hypersensitivity. Side Effects: VT, SVT, hypotension, abnormal digoxin levels, angina, HA, hypokalemia, tremors. Precautions: Use cautiously in patients with a history of dysrhythmias, electrolyte imbalances, renal impairment, pregnancy.

Morphine Sulfate (Opioid-Narcotic Analgesic [Agonist]) Indications: Moderate to severe pain, chest pain unrelieved with NTG, CHF and dyspnea associated with pulmonary edema. Dose: 4–15 mg IVP q 3–4 hr or as a loading dose titrated to respiratory status followed by an infusion of 0.2–1 mg/mL. Contraindications: Heart failure due to chronic lung disease, respiratory depression, hypotension, undiagnosed acute abdominal pain, head injury, altered LOC, acute alcoholism, DTs. Side Effects: Respiratory depression, hypotension, N&V, bradycardia, altered LOC, seizures. Precautions: Reverse with Narcan, multiple drug interactions.

Narcan (Naloxone®) (Opioid-Narcotic Antagonist) Indications: Narcotic-induced respiratory depression. Dose: 0.4–2 mg IV, IM, SC, ET (double the dose when administered via ET tube) q 2–3 min intervals, maximum 10 mg. Contraindications: Known allergy to Narcan, narcotic addicts. Side Effects: Acute withdrawal symptoms in addicted patients, VT, VF, hypotension or hypertension, seizures. Precautions: Avoid total narcotic reversal in addicted patients, half-life may not be as long as narcotic half-life. May cause severe HTN in hypertensive patient during labor.

Nipride® (Nitroprusside, Nitropress®) (Vasodilator) Indications: Hypertensive crisis, acute CHF. Dose: Per order. Contraindications: Aortic coarctation or AV shunting, high output failure in endotoxic sepsis. Side Effects: Dizziness, restlessness, nausea, HA, palpitations, bradycardia, tachycardia, flushing, seizures, increased ICP, thiocyanate toxicity.

MEDS/LABS


MEDS/LABS

Precautions: Use with caution in hypothyroidism, liver or renal impairment, increased ICP, and the elderly.

Nitroglycerin (Nitrostat®) (Antianginal, Nitrate) Indications: Angina, CHF associated with acute MI, cardiac load-reducing agent, hypertensive crisis. Dose: 0.3–0.4 mg SL q 5 min, maximum 3 doses. Contraindications: SBP ⬍90 mm Hg, severe bradycardia, severe tachycardia, Viagra® within 24 hr, RV infarction. Side Effects: Hypotension with secondary tachycardia, syncope, HA, flushed skin. Precautions: Do not mix with other medications, titrate IV form to maintain SBP ⬎90 mm Hg.

Pitocin® (Oxytocin) (Hormone) Indications: Postpartum hemorrhage. Dose: 10 units IM or 10–40 units in 1000 mL saline, LR, or D5W, and infuse at 0.02–0.1 units/min (titrate to effect). Contraindications: Known allergy, incomplete delivery. Side Effects: Anaphylaxis, dysrhythmias, HTN, seizure, coma, hypotension, postpartum hemorrhage, uterine rupture. Precautions: Evaluate for multiple births.

Potassium Chloride (Mineral/Electrolyte) Indications: Hypokalemia. Dose: Hypokalemia (⬎2.5) up to 200 mEq/day as an infusion (not to exceed 20 mEq/hr or a concentration of 40 mEq/L via peripheral line) (up to 80 mEq/L has been used via central line [unlabeled]). Hypokalemia (⬍2) up to 400 mEq/day as an infusion (rate should generally not exceed 20 mEq/hr). Contraindications: Hyperkalemia, severe renal impairment, untreated Addison’s disease, severe tissue trauma. Side Effects: Dysrhythmias including heart block, abdominal pain, N&V, diarrhea, confusion, restlessness, weakness, respiratory paralysis, irritation at IV site. Precautions: Monitor HR, BP, RR, and ECG throughout infusion. Severe pain and tissue necrosis with extravasation. Use with caution in the elderly with cardiac or renal disease.

Procainamide (Pronestyl®) (Antidysrhythmic) Indications: VT, PSVT refractory to adenosine and vagal stimulation, rapid atrial fibrillation in WPW, paroxysmal atrial tachycardia, stable wide-complex tachycardia of uncertain type, maintenance after conversion. Dose: 20 mg/min, maximum 17 mg/kg; maintenance of 1–4 mg/min. Contraindications: 2nd- or 3rd-degree HB, torsades de pointes, lupus, myasthenia gravis, digoxin toxicity, hypersensitivity.

196


197 Side Effects: Hypotension, widening QT, asystole, HA, N&V, flushed skin, seizure, ventricular dysrhythmias, partial or complete HB. Precautions: Stop administration for hypotension or when QT interval begins to widen. Use cautiously in patients with CHF, cardiomyopathy, or acute ischemic heart disease, and in patients with liver or renal disease. Multiple drug interactions.

Propofol (Diprivan®) (Sedative, Anesthetic) Indication: Sedation, anesthesia. Dose: Initial dose 2–2.5 mg/kg; maintenance 100–200 ␮g/kg/min or may be given in 25–50-mg increments; use half the dose for elderly and debilitated patients. Contraindications: Allergy to egg, soy, or glycerol products; labor and delivery. Side Effects: Apnea, HTN, bradycardia, dizziness, HA, N&V, flushed skin, burning at the site. Precautions: Lipid metabolism disorders, increased ICP, cardiovascular disease, the elderly.

Proton Pump Inhibitors Common Agents: Lansoprozole (Prevacid®), omprazole (Prilosec®), pantroprazole (Protonix®), esomeprazole (Nexium®), rabeprazole (Aciphex®). Indications: Duodenal and gastric ulcers; management of GERD; upper GI bleed. Dose: See individual order and drug for route and dosages. Contraindications: Hypersensitivity. Side Effects: Confusion, dizziness, drowsiness, HA, site pain, N&V, hypotension or HTN, CVA, MI, shock. Precautions: Assess elderly and severely ill patients for confusion routinely, reduce dosage in impaired hepatic function.

Romazicon® (Flumazenil) (Antagonist [Benzodiazepines]) Indication: Antidote to benzodiazepines. Dose: 0.2 mg IVP, may repeat 0.3 mg in 30 sec, followed with 0.5 mg q min, maximum 3 mg/hr (0.2 mg given over 15 sec, followed by 0.2 mg if no patient response after 45 sec). May be repeated at 60-sec intervals, up to a maximum of 1 mg. Contraindications: TCA OD, known history of seizures, increased ICP, allergy to benzodiazepine. Side Effects: Withdrawal symptoms, dizziness, seizures, N&V. Precautions: Avoid using in multiple drug OD; use associated with high risk of seizures in certain patients, especially those with head injury or alcoholism.

Sodium Bicarbonate (Alkalizing Agent, Buffer) Indications: Hyperkalemia, tricyclic antidepressant OD, cocaine or diphenhydramine or ASA OD, metabolic acidosis, shock associated with severe diarrhea, dehydration, uncontrolled DM.

MEDS/LABS


MEDS/LABS

Dose: 1 mEq/kg IVP, may repeat 0.5 mEq/kg q 10 min. Contraindications: Metabolic or hypochloremic alkalosis, hypocalcemia, renal failure, as an antidote to ingestion of strong mineral acid, HTN, convulsions. Side Effects: Hypokalemia, metabolic alkalosis, seizures, N&V, tetany. Precautions: CHF, renal disease, concurrent use with glucocorticoids, multiple drug interactions.

Succinylcholine chloride (Sucostrin®) (Neuromuscular Blocking Agent [Depolarizing]) Indications: Paralysis to facilitate endotracheal intubation. Dose: Initial dose: 1–2 mg/kg IVP (0.3–1.1 mg/kg IVP; maintenance: 0.5–10 mg/min continuous infusion). Contraindications: Cannot use with lactated Ringer’s solution or in patients with a family history of malignant hyperthermia, myopathies with elevated CPK, acute narrow-angle glaucoma. Side Effects: Hypotension, bradycardia, apnea, bronchospasm, hyperkalemia, malignant hyperthermia, severe persistent respiratory depression or apnea, anaphylaxis. Precautions: Ensure intubation and suction equipment available, set up, and in working order. Use with caution in clients with CV, pulmonary, or metabolic disorders. Patients with myasthenia gravis may show resistance. Time Action Profile: Onset 0.5–1 min; peak 1–2 min; duration 4–10 min.

Thrombolytics Common Agents: Activase® (Alteplase, recombinant; t-PA); Retavase® (Reteplase), Streptase® (Streptokinase) Indication: Acute MI ⬍12 hr from onset of symptoms and acute ischemic stroke. Dose: See individual order and drug for route and dosages. Contraindications: Active internal bleeding within 21 days (except menses), history of neurovascular event within 3 months, major surgery or trauma within 2 weeks, aortic dissection, severe (uncontrolled) HTN, bleeding disorder, prolonged CPR, LP within 1 week. Side Effects: Hypotension, reperfusion arrhythmias, HA, increased bleeding time, hemorrhage, flushing, urticaria. Precautions: Patients with severe renal or hepatic disease.

Toradol® (Ketorolac) (NSAID, Nonopioid Analgesic) Indication: Short-term management of moderate acute pain. Dose: 15–30 mg IV or 30–60 mg IM; use half the dose for patients over 65 yr, ⬍50 kg, or have renal impairment. Contraindications: Allergy, prior to and during surgery, known alcohol intolerance, active peptic ulcer disease or GI bleeding, renal impairment, pregnancy, lactation.

198


199 Side Effects: Drowsiness, GI bleed or perforation, nausea, HA, increased bleeding time, anaphylaxis, bronchospasm. Precautions: GI bleed; renal, hepatic, or CV disease.

Vasopressin (Pitressin®) (Vasopressor, Hormone) Indication: Cardiac arrest as an alternative to epinephrine, GI hemorrhage, neurogenic diabetes insipidus. Dose: Cardiac arrest: 40 units IVP one-time dose; GI hemorrhage: 0.1–0.4 units/min; IV diabetes insipidus: 5–10 units IM/SC. Contraindications: Pregnancy, epilepsy, heart failure, asthma, CAD, migraine, allergy to beef or pork protein, renal failure with BUN. Side Effects: Dizziness, HA, N&V, MI, chest pain, abdominal cramps, diaphoresis, heartburn, diarrhea, bronchoconstriction, anaphylaxis, coma, convulsions. Precautions: Monitor ECG throughout therapy, never give the tannate IV, multiple drug interactions.

Vecuronium (Norcuron®) (Neuromuscular Blocking Agent [Nondepolarizing]) Indications: Paralysis to facilitate endotracheal intubation. Dose: Initial dose: 80–100 ␮g/kg; maintenance 10–15 ␮g/kg 25–40 min after initial dose, repeat every 12–15 min as needed or as a continuous infusion at 1 ␮g/kg/min Contraindications: Cannot use with lactated Ringer’s solution, sensitivity to bromides. Side Effects: Hypotension, tachycardia, bradycardia, dyspnea, flushed skin, urticaria, malignant hyperthermia. Precautions: Ensure intubation and suction equipment available, set up, and in working order; avoid use in patients with myasthenia gravis or EatonLambert syndrome. Time Action Profile: Onset 1 min; peak 3–5 min; duration 15–25 min.

Verapamil (Calan®, Isoptin®) (Calcium Channel Blocker) Indications: PSVT refractory to adenosine, atrial fibrillation, atrial flutter. Dose: 2.5–5 mg (5–10 mg slow IVP over 2 min, may repeat 5–10 mg q 10 min, maximum 30 mg/min); may give prophylactic calcium chloride (8–16 mg/kg IV) to counteract hypotension. Contraindications: Atrial fibrillation/flutter with WPW, VT, or wide-complex tachycardia of uncertain type, 2nd or 3rd degree heartburn, hypotension, severe CHF. Side Effects: Hypotension, exacerbation of CHF, asystole, bradycardia, AV heart block, MI, CVA. Precautions: Patients on oral beta blockers, hypertrophic cardiomyopathy, impaired hepatic or renal function. Multiple drug interactions.

MEDS/LABS


MEDS/LABS

Medications Compatible With IV KCl acyclovir alatrovafloxacin aldesleukin allopurinol amifostine aminophylline amiodarone ampicillin amrinone atropine aztreonam betamethasone calcium gluconate chlordiazepoxide chlorpromazine cimetidine ciprofloxacin cisatracurium cladribine cyanocobalamin dexamethasone digoxin diltiazem diphenhydramine dobutamine docetaxel dopamine doxorubicin liposome droperidol droperidol/fentanyl edrophonium enalaprilat epinephrine

esmolol conjugated estrogens ethacrynate sodium etoposide famotidine fentanyl filgrastim fludarabine fluorouracil furosemide gatifloxacin gemcitabine granisetron heparin hydralazine idarubicin potassium indomethacin insulin isoproterenol kanamycin labetalol lidocaine linezolid lorazepam magnesium sulfate melphalan menadiol meperidine methoxamine methylergonovine midazolam minocycline

morphine neostigmine norepinephrine ondansetron oxacillin oxytocin paclitaxel penicillin G potassium pentazocine phytonadione piperacillin/tazobactam procainamide prochlorperazine edisylate propofol propranolol pyridostigmine ranitidine remifentanil sargramostim scopolamine sodium bicarbonate succinylcholine tacrolimus teniposide theophylline thiotepa tirofiban trimethaphan trimethobenzamide vinorelbine warfarin zidovudine

Medications Incompatible With IV KCl adrenaline HCl amphotericin B cholesteryl sulfate complex atropine sulfate cephalothin sodium

chloramphenicol sodium succinate chlorpromazine HCl diazepam ergotamine tartrate methicillin sodium

200

phenytoin phenytoin sodium sulphadiazine sodium suxamethonium chloride thiopentone sodium


201 Reference Ranges for Common Laboratory Tests Arterial Blood Gases (ABGs) Normal ABG Results (U.S. System of Measurements) pH

PaO2

PaCO2

7.35–7.45

80–100 35–45 mm Hg mm Hg Normal ABG Results (SI Units)

O2 sat

HCO3

Base Excess

95%–100%

21–28 mEq/L

⫺2 to ⫹2 mEq/L

pH

PaO2

PaCO2

O2 sat

HCO3

7.35–7.45

10.6–12.6 kPa

4.66–5.98 kPa

95%–100%

21–28 mmol/L

Base Excess ⫺2 to ⫹2 mmol/L

Critical Levels: pH: ⬍7.25 or ⬎7.55 PaO2: ⬍45 PaCO2: ⬍20 or ⬎60 HCO3: ⬍15 or ⬎40 Base Excess: ⫾ 3 mEq/L

Chemistries Test

Conventional

Albumin Alkaline phosphatase ALT AST BUN Bilirubin, direct Bilirubin, total Calcium Chloride Cholesterol, total CO2 Creatinine Gamma-GT Glucose Lactic acid

3.9–5.0 g/dL 44–147 units/L 6–59 units/L 10–34 units/L 7–20 mg/dL 0.0–0.3 mg/dL 0.2–1.9 mg/dL 8.5–10.9 mg/dL 101–111 mmol/L 100–240 mg/dL 20–29 mEq/L 0.8–1.4 mg/dL 0–51 units/L 64–128 mg/dL 0.5–1.5 mEq/L or 8.1–15.3 mg/dL

SI Units 35–50 g/L 40–120 U/L 20–65 U/L 15–45 U/L 2.9–8.9 mmol/L 0–8 ␮mol/L 0–20 ␮mol/L 2.15–2.5 mmol/L 98–106 mmol/L 2–5.19 mmol/L 20–29 mmol/L 70–120 ␮mol/L 10–58 U/L 3.3–11 mmol/L SI units: 0.5–1.5 mmol/L (Continued on the following page)

MEDS/LABS


MEDS/LABS

Chemistries (continued) Test LDH Magnesium Phosphorus Potassium Protein, total Sodium Uric acid, serum

Conventional 105–333 units/L 1.5–2 mEq/L 2.4–4.1 mg/dL 3.5–5 mEq/L 6.3–7.9 g/dL 136–144 mEq/L Male: 4.0–8.5 mg/dL Female: 2.8–7.3 mg/dL

SI Units 300–600 mmol/L 0.7–1.05 mmol/L 0.8–1.4 mmol/L 3.5–5 mmol/L 60–80 g/L 136–144 mmol/L 0.24–0.51 mmol/L 0.16–0.43 mmol/L

Coagulation Profile Test INR PT PTT/aPTT D-dimer FDP (fibrin degradation products) Fibrinogen

Conventional

SI Units

0.9–1.2 10–14 sec 21–37 sec ⬍0.5 ␮g/mL ⬍5 ␮g/mL

0.9–1.2 10–14 sec 21–37 sec

150–400 mg/dL

1.7–4.1 g/L

Cardiac Markers Test

Conventional

SI Units

Albumin cobalt binding test

⬍85 U/mL

⬍85 U/mL

B-type natriuretic peptide

0–100 pg/mL

Ø–100 ng/L

Creatinine phosphokinase, creatine kinase

Male: 55–170 U/L Female: 30–135 U/L

Male: 55–170 U/L Female: 30–135 U/L

CK isoenzymes

CK-MB: 0%–3%

0–0.03

Troponins (TnI, TnT)

Cardiac troponin T: ⬍0.2 ng/mL Cardiac troponin I: ⬍0.03 ng/mL

Cardiac troponin T: ⬍0.2 ng/mL Cardiac troponin I: ⬍0.03 ng/mL

202


203 Cardiac Markers (continued) Test

Conventional

SI Units

Myoglobin, serum Lactate dehydrogenase (LD, LDH), LDH isoenzymes Aspartate aminotransferase

⬍90 ␮g/L 100–190 U/L

⬍90 ␮g/L 100–190 U/L

0–35 U/L

0-0.58 ␮kat/L

Hematology Test

Conventional

8.5–9.0% of body weight in kg Male: 4.6–6.2 million/mm3 Red blood cell (RBC) Female: 4.2–5.9 million/mm3 Male: 13–18 g/100 mL Female: 12–16 g/100 mL Hemoglobin (Hgb) Male: 45%–52% Hematocrit (Hct) Female: 37%–48% 4.300–10.800/mm3 Leukocytes (WBC) 0%–5% ■ Bands 0%–1% ■ Basophils 1%–4% ■ Eosinophils 25%–40% ■ Lymphocytes 10%–20% ■ B lymphocytes 60%–80% ■ T lymphocytes 2%–8% ■ Monocytes 54%–75% ■ Neutrophils 150,000–350,000/mm3 Platelets Male: 1–13 mm/hr Erythrocyte sediFemale: 1–20 mm/hr mentation rate 150,000–450,000 mm3 Platelets Males under 50 yr: ⬍15 mm/hr; Sedimentation rate males over 50 yr: ⬍20 mm/hr; females under 50 yr: ⬍20 mm/ hr; females over 50 yr: ⬍30 mm/ hr (Westergren method) Blood volume

MEDS/LABS

SI Units 80–85 mL/kg 4.6–6.2 ⫻ 1012/L 4.2–5.9 ⫻ 1012/L 8.1–11.2 mmol/L 7.4–9.9 mmol/L 0.45–0.52 0.37–0.48 4.3–10.8 ⫻ 109/L 0.03–0.08 0–0.01 0.01–0.04 0.25–0.40 0.10–0.20 0.60–0.80 0.02–0.08 0.54–0.75 150–350 ⫻ 109/L 1–13 mm/hr 1–20 mm/hr 150–450 ⫻ 109/L


MEDS/LABS

A & P Snapshot

IM injection sites.

204


205

Two inches away from the umbilicus

SC injection sites, technique, and variations.

MEDS/LABS

Copyright © 2008 by F. A. Davis. TOOLS/

INDEX

Electrical Conduction of the Heart

SA node

Left bundle branch

Intra-atrial pathways AV Node

Purkinje fibers

Bundle of His Right bundle branch

Electrical conduction of the heart.

Standard Placement: Lead-II & 7-Channel White's

G

on the right (negative)

and...

Smoke (Ground) Over

Fire Chest lead and Right leg lead Included for seven channel monitoring

(positive)

+

Standard placement: Lead II and 7-channel.

Normal Cardiac Rhythm Parameters NSR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Between 60 and 100 bpm SB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Fewer than 60 bpm ST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Over 100 bpm QRS width . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Between 0.08 and 0.12 sec P-R interval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Between 0.12 and 0.20 sec Q-T interval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .0.30–0.40 sec Atrial rate, inherent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60–100 bpm Junctional rate, inherent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40–60 bpm Ventricular rate, inherent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20–40 bpm

206


207 Lead Placement and Normal Deflection of PQRST Waves Midclavicular line Anterior axillary line Midaxillary line

V6 V5 V 1 V2 V3

V4

Right lung

Left lung V6 V5 V4 V1

V2

V3

Lead placement and normal deflection of PQRST waves.

TOOLS/ INDEX


TOOLS/ INDEX

ECG Waveform of the Cardiac Cycle R

P

PR

T

Q S Atrial Ventricular Ventricular depolarization depolarization repolarization

ECG waveform of the cardiac cycle.

208


209 Heart Sounds QRS P

QRS T

S1

P

S2

T

S1

S2

Aortic valve Pulmonic valve

S1

S2 S2

S1

Tricuspid valve Heart sounds.

TOOLS/ INDEX

Mitral valve


TOOLS/ INDEX

Figuring Rate and Measurement To figure out rate (regular rhythms only), you can do one of the following: Count the number of QRS complexes (regular rhythms only) in a 6-sec strip and multiply by 10.

Irregular rhythms should be counted for an entire minute.

Divide the number of large boxes between two R waves into 300.

Remember the number sequence below and find an R wave that falls on a heavy line. Starting from the next heavy line, count 300, 150, 100, and so forth, and whatever line the next R wave falls on is the heart rate (see below for example).

1st R wave

300 150 100 75

Next R wave here would be 150 bpm.

60

50

43

Next R wave here would be 60 bpm.

Inherent rates of different cardiac regions:

SA Node ..................... 60–100 bpm AV Node ....................... 40–60 bpm Ventricles..................... 20–40 bpm

One small box represents 0.04 sec and is 1 mm2.

One big box represents 0.20 sec and is 5 mm2.

210


211 Normal Cardiac Cycle and Measurements

P

QRS

P

R

T

Q

S

P-R interval Normal Rate bpm 60–100 bpm Normal Rate → 60–100 Normal P-RNormal → 0.12–0.20 0.12–0.20 sec P-R sec Normal QRS → 0.08–0.12 sec P wave → atrial depolarization; QRS → ventricular depolarization; T wave → ventricular repolarization

0.04 sec 0.20 sec

Normal Sinus Rhythms P waves before every QRS, P-R

MedSurg Notes: Nurse's Clinical Pocket Guide

Neuro Notes: Clinical Pocket Guide

Critical Care Notes: Clinical Pocket Guide

Critical Care Notes: Clinical Pocket Guide

LPN Notes: Nurse's Clinical Pocket Guide

Derm notes Dermatology Clinical Pocket Guide

PsychNotes: Clinical Pocket Guide

IV Med Notes: Nurse's Clinical Pocket Guide (Davis Notes)

LPN Notes: Nurse's Clinical Pocket Guide, 2nd Edition

OB Peds Women's Health Notes: Nurse's Clinical Pocket Guide

Clinical Supervision for Nurses

Rnotes: Nurse's Clinical Pocket Guide, Third Edition

Clinical Pocket Guide to Women and Cancer

Iv Therapy Notes: Nurse's Pharmacology Pocket Guide (Nurse's Clinical Pocket Guides)

DocuNotes - Clinical Pocket Guide to Effective Charting

PsychNotes: Clinical Pocket Guide, 2nd Edition

Nurse's Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales 11th Edition (Nurses Pocket Guide)

Respiratory Notes: Respiratory Therapist's Pocket Guide (Davis's Notes)

Mobilization Notes: A Rehabilitation Specialist's Pocket Guide (Davis's Notes)

Provider's Coding Notes: Billiing and Coding Pocket Guide (Davis's Notes)

Screening Notes: Rehabilitation Specialist's Pocket Guide (Davis Notes S.)

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