A1. Care of Clients in Pain
From Davis NCLEX RN Success 3rd Edition
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Pain
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the “fifth vital sign” in the care of clients; a
complex subjective sensation.
Unpleasant sensory and emotional experience
associated with real or potential tissue damage.
Pain is considered to be whatever the person
experiencing it says it is, existing whenever he
or she says it does.
Classifications of Pain
● Acute pain: lasts typically less than 1 month;
characterized by: tachycardia, tachypnea,
increased BP, diaphoresis, dilated pupils.
Responsive to analgesics.
● Chronic pain: persists or is recurring for longer
than 3 months; often characterized by:
lassitude,
sleep disturbance, decreased
appetite, weight loss, diminished libido,
constipation, depression. Rarely responsive to
analgesics.
● Somatogenic (organic/physiological):
○ Nociceptive: somatic or visceral pain:
sensations, normal pain transmission,
such as aching or pressure (e.g., cancer
pain, chronic joint and bone pain).
○ Neuropathic: aberrant processes in
peripheral and/or central nervous
system; part of a defined neurological
problem; sensations such as sharp,
burning, shooting pain (e.g., nerve
compression, polyneuropathy, central
pain of stroke, phantom pain after
amputation).
● Psychogenic (without organic pathology
sufficient to explain pain).
Components of Pain Experience
● Stimuli - sources: chemical, ischemic,
mechanical trauma, extremes of heat/cold.
● Perception: viewed with fear by children, can be
altered by level of consciousness, interpreted
and influenced by previous and current
experience, is more severe when alone at night
or immobilized.
● Response: variations in physiological, cultural,
and learned responses; anxiety is created; pain
● seen as justified punishment; pain used as
means for attention-getting.
Assessment
Subjective data
● Site: medial, lateral, proximal, distal.
● Strength:
○ Certain tissues are more sensitive.
○ Change in intensity.
○ Based on expectations.
by
distraction
or
○ Affected
concentration, state of consciousness.
○ Described as: slight, medium, severe,
excruciating.
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●
Quality: aching, burning, crushing, dull, piercing,
shifting, throbbing, tingling.
Antecedent factors: physical exertion, eating,
extreme temperatures, physical and emotional
stressors (e.g., fear).
e. Previous experience: influences reaction to
pain.
Behavioral clues: demanding, worried, irritable,
restless, difficult to distract, sleepless.
Objective data:
● Verbal clues:moaning, groaning, crying.
● Nonverbal clues: clenching teeth, grimacing;
splinting of body parts, body position, knees
drawn up, involuntary reflex movements;
tossing/turning, rhythmic rubbing movements;
voice pitch and speed; eyes shut.
clues:
breathing
irregularities,
● Physical
abdominal distention; skin color changes, skin
temperature changes; excessive salivation,
perspiration.
● Time or duration: onset, duration, recurrence,
interval, last occurrence.
Analysis or Nursing Diagnosis
● Pain, acute or chronic, related to specific client
condition.
● Activity intolerance related to discomfort.
● Sleep pattern disturbance related to pain.
● Fatigue related to state of discomfort or
emotional stress.
● Ineffective individual coping related to chronic
pain.
Nursing Care Plan or Implementation
1. Goal: provide relief of pain.
● Assess level of pain; ask client to rate on scale of
0 to 10( 0 = no pain; 10 = worst pain) or
smiling/sad faces.
● Determine cause and try nursing comfort
measures before giving drugs:
○ Environmental factors: noise, light,
odors, motion.
needs:
elimination,
○ Physiological
hunger, thirst, fatigue, circulatory
impairment,
muscle
tension,
ventilation, pressure on nerves.
fear
of
unknown,
○ Emotional:
helplessness, loneliness (especially at
night).
● Relieve: anger, anxiety, boredom, loneliness.
● Report sudden, severe, new pain; pain not
relieved by medications or comfort measures;
pain associated with casts or traction.
● Remove pain stimulus:
pain
medication:
○ Administer
nonopioids:
NSAIDs—ketorolac
(Toradol);
○ Opioids: first-line analgesics include
morphine, hydromorphone, fentanyl,
oxycodone, hydrocodone
○ Adjuvants: local anesthetics, sedatives,
muscle relaxants; give at appropriate
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●
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time intervals; do not withhold due to
overestimated danger of addiction.
○ Avoid cold (to reduce immediate tissue
reaction to trauma).
○ Apply heat (to relieve ischemia).
○ Change activity (e.g., restrict activity in
cardiac pain).
○ Change, loosen dressing.
○ Comfort (e.g., smooth wrinkled sheets,
change wet dressing).
○ Give food (e.g., for ulcer).
○ Decrease stimulation (e.g., ↓ bright
lights, noise, temperature).
Reduce pain receptor reaction.
○ Ointment (use as coating).
○ Local anesthetics.
○ Padding (of bony prominences).
Assist with medical-surgical interventions to
block pain impulse transmission:
○ Injection of local anesthetic into nerve
(e.g., dental).
○ Cordotomy: sever anterolateral spinal
cord nerve tracts.
○ Electrical stimulation: transcutaneous
(skin surface), percutaneous (peripheral
nerve).
○ Peripheral nerve implant: electrode to
major sensory nerve.
○ Dorsal column stimulator: electrode to
dorsal column.
Minimize
barriers
to
effective
pain
management:
“balanced
analgesia”;
○ Achieve
around-the-clock administration of
NSAIDs or acetaminophen if possible,
continuous infusion, patient-controlled
analgesia (PCA); combination therapy
(opioids, nonopioids, adjuvants).
○ Accept client and family report of pain.
○ Discuss fear of addiction with client
family (incidence <1% when opioids
taken for pain relief).
○ Discuss fear of respiratory depression
with staff; preventable; related to
sedation.
Document response to pain relief measures.
2. Goal: use nonpharmacological methods to reduce
pain.
● Distraction, such as TV (cerebral cortical activity
blocks impulses from thalamus).
● Aromatherapy—assists in relaxation.
● Hypnosis—assess appropriateness for use for
psychogenic pain and for anesthesia; client
needs to be open to suggestion.
● Acupuncture—assess emotional readiness and
belief in it.
3. Goal: alter interpretation and response to pain.
● Administer narcotics - result: no longer sees
pain as disturbing.
● Administer hypnotics - result: changes
perception and decreases reaction.
●
Help client obtain interpersonal satisfaction
from ways other than attention received when
in pain.
4. Goal: promote client control of pain and analgesia:
patient-controlled analgesia (PCA).
● An analgesia administration system designed to
maintain optimal serum analgesia levels; safely
delivers intermittent bolus doses of a narcotic
analgesic; preset to maximum hourly dose.
● Advantages: decreased client anxiety; improved
pulmonary function; fewer side effects.
● Limitations: requires an indwelling intravenous
line; analgesia targets central pain, may not
relieve peripheral discomfort; cost of PCA unit.
5. Goal: health teaching.
● Explain causes of pain and how to describe pain.
● Explain that it is acceptable to admit existence
of pain.
● Relaxation exercises.
● Biofeedback methods of pain perception and
control.
● Proper medication administration (PCA,
continuous around-the-clock dosing), when
necessary, for self-care.
Evaluation or Outcome Criteria
● Verbalizes comfort; awareness of pain
decreased.
● Knows source of pain; how to reduce stimulus
and perception.
● Uses alternative measures for pain relief.
● Able to cope with pain (e.g., remains active,
relaxed appearance; verbal and nonverbal clues
of pain absent).
A2. Care of Clients Undergoing Perioperative Phase of
Care
From Davis NCLEX RN Success 3rd Edition
I. Preoperative Preparation
A. Assessment
● Subjective data
○ Understanding of proposed surgery:
site, type, extent of hospitalization.
experiences
with
○ Previous
hospitalization.
○ Age-related factors.
○ Allergies: iodine, latex, adhesive tape,
○ cleansing solutions, medications.
or
substance
use:
○ Medication
prescribed, OTC, smoking, alcohol,
recreational drugs.
○ Cultural and religious background.
○ Concerns or feelings about surgery:
■ Exaggerated ideas of surgical
risk (e.g., fear of colostomy
when
none
is
being
considered).
■ Nature of anesthesia (e.g., fears
of going to sleep and not
waking up, saying or revealing
things of a personal nature).
■
●
Degree of pain (e.g., may be
incapacitating).
Misunderstandings regarding
prognosis.
○ Identification of significant others as a
source of client support or care
responsibilities postdischarge.
Objective data
○ Speech patterns indicating anxiety:
repetition, changing topics, avoiding
talking about feelings.
○ Interactions with others: withdrawn or
involved.
○ Physical signs of anxiety (i.e., increased
pulse, respirations; clammy palms,
restlessness).
○ Baseline physiological status: vital signs;
breath sounds; peripheral circulation;
weight; hydration status (hematocrit,
skin turgor, urine output); degree of
mobility; muscle strength.
B. Analysis or Nursing Diagnosis
● Anxiety related to proposed surgery.
● Knowledge deficit (learning need) related to
incomplete teaching or lack of understanding.
● Fear related to threat of death or disfigurement.
● Risk for injury related to surgical complications.
● Ineffective individual coping related to
anticipatory stress.
C. Nursing Care Plan or Implementation
1. Goal: reduce preoperative and intraoperative anxiety
and prevent postoperative complications.
● Preoperative teaching:
○ Provide information about hospital
nursing routines and preoperative
procedures to reduce fear of the
unknown.
purpose
of
diagnostic
○ Explain
procedures to enhance ability to
cooperate and tolerate procedure.
○ Inform about what will occur and what
will be expected in the postoperative
period:
return
to
room,
■ Will
postanesthesia care unit, or
intensive care unit (ICU).
■ Special equipment—monitors,
tubes, suction equipment.
■ Pain control methods.
● Management of latex allergy if present. Three
forms:
○ Immediate reaction (most serious, life
threatening)—flushing,
diaphoresis,
pruritus, nausea, vomiting, cramping,
hypotension, dyspnea
○ Delayed response (most common,
discomfort)—localized symptoms 18 to
24 hours after contact.
○ Contact dermatitis.
● Exposure to latex through skin, mucous
membranes, inhalation, internal tissue, and
intravascular.
●
●
Sources include: gloves, anesthesia masks,
tourniquets, ECG electrodes, adhesive tape,
warming
blankets,
elastic
bandages,
tubes/catheters, irrigation syringes.
Nursing goal: provide latex-free environment.
2. Goal: instruct in exercises to reduce complications.
● Diaphragmatic breathing—refers to flattening of
diaphragm during inspiration, which results in
enlargement of upper abdomen; during
expiration the abdominal muscles are
contracted, along with the diaphragm.
○ The client should be in a flat, semiFowler’s, or side position, with knees
flexed and hands on the midabdomen.
○ Have the client take a deep breath
through nose and mouth, letting the
abdomen rise. Hold breath for 3 to 5
seconds.
○ Have client exhale through nose and
mouth, squeezing out all air by
contracting the abdominal muscles.
○ Repeat 10 to 15 times, with a short rest
after
each
5
to
prevent
hyperventilation.
○ Inform the client that this exercise will
be repeated 5 to 10 times every hour
postoperatively.
● Coughing: helps clear chest of secretions and,
although uncomfortable, will not harm incision
site.
○ (Have client lean forward slightly from a
sitting position, and place client’s hands
over incisional site; this acts as a splint
during coughing.
○ Have client inhale and exhale slowly
several times.
○ Have client inhale deeply, hold breath 3
seconds, and cough sharply three times
while exhaling—client’s mouth should
be slightly open.
○ Tell client to inhale again and to cough
deeply once or twice. If unable to cough
deeply, client should “huff” cough to
stimulate cough.
● Turning and leg exercises: help prevent
circulatory stasis, which may lead to thrombus
formation, and postoperative flatus or “gas
pains,” as well as respiratory problems.
○ Tell the client to turn on one side with
the uppermost leg flexed; use side rails
to facilitate the movement.
○ In a supine position, have client do five
repetitions every hour of: ankle pumps,
quadriceps-setting exercises, gluteal
tightenings, and straight-leg raises.
intermittent
pulsatile
○ Apply
compression device or sequential
compression device to promote venous
return.
3. Goal: reduce the number of bacteria on the skin to
eliminate incision contamination.
Skin preparation:
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●
Prepare area of skin wider and longer than
proposed incision in case a larger incision is
necessary.
Gently scrub with an antimicrobial agent.
○ Note possibility of allergy to iodine.
○ Hexachlorophene should be left on the
skin for 5 to 10 minutes.
○ If benzalkonium Cl (Zephiran) solution is
ordered, do not soap skin before use;
soap
reduces
effectiveness
of
benzalkonium by causing it to
precipitate.
Hair should remain unless it interferes with
surgical procedure.
○ Note any nicks, cuts, or irritations,
potential infection sites.
○ Depilatory creams or clipping of hair is
preferred to shaving with a razor; nick
may result in cancellation of surgery.
○ Skin prep may be done in surgery.
4. Goal: reduce the risk of vomiting and aspiration
during anesthesia; prevent contamination of abdominal
operative sites by fecal material.
Gastrointestinal tract preparation:
● No food or fluid at least 6 to 8 hours before
surgery.
● Remove food and water from bedside.
● Place NPO signs on bed or door.
● Inform kitchen and oncoming nursing staff that
client is NPO for surgery.
● Give IV infusions up to time of surgery if
dehydrated or malnourished.
● Enemas: two or three may be given the evening
before surgery with intestinal, colon, or pelvic
surgeries; 3 days of cleansing with large
intestine procedures.
● Possible antibiotic therapy to reduce colonic
flora with large bowel surgery.
● Gastric or intestinal intubation may be inserted
the evening before major abdominal surgery.
Types of tubes:
● Levin: single lumen; sufficient to remove fluids
and gas from stomach; suction may damage
mucosa.
● Salem sump: large lumen; prevents tissue-wall
adherence.
● Miller-Abbott: long single or double lumen;
required to remove the contents of jejunum or
ileum.
Pressures:
● Low setting with Levin and intestinal tubes; high
setting with Salem sump; excessive pressures
will result in injury to mucosal lining of intestine
or stomach.
5. Goal: promote rest and facilitate reduction of
apprehension.
● Medications as ordered: on evening before
surgery may give barbiturate—pentobarbital
(Nembutal), secobarbital (Seconal).
●
●
●
Quiet
environment:
eliminate
distractions.
Position: reduce muscle tension.
Back rub.
noises,
6. Goal: protect from injury; ensure final preparation for
surgery.
Day of surgery:
● Operative permit signed and on chart; physician
responsible for obtaining informed consent.
Possible blood products consent.
● Shower or bathe.
○ Dress: hospital pajamas.
○ Remove: hairpins (cover hair); nail
polish, to facilitate observation of
peripheral circulation; jewelry (or tape
wedding bands securely); pierced
earrings; contact lenses; dentures (store
and give mouth care); give valuable
personal items to family; chart
disposition of items.
● Proper identification—check band for secureness and legibility; surgical site (limb) may be
marked to prevent error.
● Vital signs—baseline data.
● Void, to prevent distention and possible injury
to bladder.
● Give preoperative medication to ensure smooth
induction and maintenance of anesthesia:
antianxiety (e.g., midazolam, diazepam,
lorazepam); narcotics (e.g., meperi- dine,
morphine, fentanyl); anticholinergics (e.g.,
atropine, glycopyrrolate).
○ Administered 45 to 75 minutes before
anesthetic induction.
○ Side rails up (client will begin to feel
drowsy and light-headed).
○ Expect complaint of dry mouth if
anticholinergics given.
○ Observe for side effects: narcotics may
cause
nausea
and
vomiting,
hypotension,
arrhythmias,
and/or
respiratory depression.
○ Quiet environment until transported to
operating room (OR).
○ Anticipate antibiotics to start “on call”
to OR.
● Note completeness of chart:
○ Surgical checklist completed.
○ Vital signs recorded.
○ Routine laboratory reports present.
○ Preoperative medications given.
○ Significant client observations.
● Assist client’s family in finding proper waiting
room.
○ Inform family members that the
surgeon will contact them after the
procedure is over.
○ Explain length of time client is expected
to be in recovery room.
○ Prepare family for any special
equipment or devices that may be
needed
to
care
for
client
postoperatively
(e.g.,
oxygen,
monitoring equipment, ventilator, blood
transfusions).
II. Intraoperative Preparation
Anesthesia:
● blocks transmission of nerve impulses,
suppresses
reflexes,
promotes
muscle
relaxation, and in some instances achieves
reversible unconsciousness.
1. Intravenous conscious sedation
● Produces sedation and amnesia in ambulatory
procedures, short surgical or diagnostic
procedures.
● Allays fear and anxiety, elevates pain threshold,
maintains consciousness and protective
reflexes, and returns clients quickly to normal
activities.
● Commonly used agents are benzodiazepines
(midazolam [Versed], diazepam) and narcotics
(fentanyl [Sublimaze], meperidine, morphine).
2. Regional anesthesia
● Purpose is to block pain reception and
transmission in a specified area. Commonly
used drugs are lidocaine HCl, tetracaine HCl,
cocaine HCl, and procaine HCl.
Types of Regional Anesthesia
1. Topical:
● Applied to mucous membranes or skin; drug
anesthetizes the nerves immediately below the
area.
● May be used for bronchoscopic or laryngoscopic
examinations.
● Side effects: rare anaphylaxis.
2. Local infiltration
● Used for minor procedures; anesthetic drug is
injected directly into the area to be incised,
manipulated, or sutured.
● Side effects: rare anaphylaxis.
3. Peripheral nerve block
● Regional anesthesia is achieved by injecting
drug into or around a nerve after it passes from
vertebral column; procedure is named for nerve
involved, such as brachial plexus block.
○ Requires a high degree of anatomical
knowledge.
○ Side effects: may be absorbed into
bloodstream.
○ Observe for: signs of excitability,
twitching, changes in vital signs, or
respiratory difficulties.
4. Field block
● A group of nerves is injected with anesthetic as
the nerves branch from a major or main nerve
trunk.
● May be used for dental procedures, plastic
surgery.
● Side effects: rare.
5. Epidural anesthesia
● Anesthetizing drug is injected into the epidural
space of vertebral canal; produces a bandlike
anesthesia around body.
○ Frequently used in obstetrics.
○ Rare complications.
○ Slower onset than spinal anesthesia; not
dependent on client position for level of
anesthesia; no postoperative headaches.
6. Spinal anesthesia
● Anesthetizing drug is injected into the
subarachnoid space and mixes with spinal fluid;
drug acts on the nerves as they emerge from
the spinal cord, thereby inhibiting conduction in
the autonomic, sensory, and motor systems.
● Advantages: rapid onset; produces excellent
muscle relaxation.
● Utilization: surgery on lower limbs, inguinal
region, perineum, and lower abdomen.
● Disadvantages:
● Loss of sensation below point of injection for 2
to 8 hours—watch for signs of bladder
distention; prevent injuries by main- taining
alignment, keeping bedclothes straightened.
● Client awake during surgical procedure— avoid
light or upsetting conversations.
● Leakage of spinal fluid from puncture site—keep
flat in bed for 24 to 48 hours to prevent
headache. Keep well hydrated to aid in spinal
fluid replacement.
○ Depression of vasomotor responses—
frequent checks of vital signs.
7. General anesthesia
● A reversible state in which the client loses
consciousness due to the inhibition of neuronal
impulses in the brain by a variety of chemical
agents; may be given intravenously, by
inhalation, or rectally.
● Side effects:
○ Respiratory depression.
○ Nausea, vomiting.
○ Excitement.
○ Restlessness.
○ Laryngospasm.
○ Hypotension.
Nursing Care Plan for General Anesthesia
1. Notify anesthesiologist if client is taking any of the
following drugs:
● Antidepressants, such as Prozac—long half-life;
monitor renal and liver function.
such
as
reserpine,
● Antihypertensives,
hydralazine, and methyldopa—potentiate the
hypotensive effects of anesthetic agents.
● Anticoagulants, such as heparin, warfarin
(Coumadin)—increase bleeding times, which
may result in excessive blood loss or
hemorrhage.
and
NSAIDs—decrease
platelet
● Aspirin
aggregation and may result in increased
bleeding.
●
Steroids, such as cortisone—anti- inflammatory
effect may delay wound healing.
●
Stages of inhalation anesthesia and nursing goals:
● Stage I—extends from beginning of induction to
loss of consciousness.
○ Nursing goal: reduce external stimuli,
because all movement and noises are
exaggerated for the client and can be
highly distressing.
● Stage II—extends from loss of consciousness to
relaxation; stage of delirium and excitement.
○ Nursing goal: prevent injury by assisting
anesthesiologist to restrain client if
necessary; maintain a quiet, nonstimulating environment.
● Stage III—extends from loss of lid reflex to
cessation of voluntary respirations.
○ Nursing goal: reduce risk of untoward
effects by preparing the operative site,
assisting
with
procedures,
and
observing for signs of complications.
● Stage IV—indicates overdose and consists of
respiratory arrest and vasomotor collapse due
to medullary paralysis.
○ Nursing goal: promote restoration of
ventilation and vasomotor tone by
assisting with cardiac arrest procedures
and by administering cardiac stimulants
or narcotic antagonists as ordered.
●
Intravenous Agents
● rapid and pleasant induction of anesthesia.
● Three categories: barbiturates (thiopental),
narcotics, and neuromuscular blocking agents
(succinylcholine, curare, pancuronium).
● Ketamine also used—may produce emergence
delirium.
● IV drugs require liver metabolism and renal
excretion.
Hypothermia
● A specialized procedure in which the client’s
body temperature is lowered to 28° to 30°C (82°
to 86°F).
● Reduces tissue metabolism and oxygen
requirements.
● Used in heart surgery, brain surgery, and surgery
on major blood vessels.
Nursing Care Plan or Implementation for Hypothermia
1. Goal: prevent complications.
● Monitor vital signs for shock.
● Note level of consciousness.
● Record intake and output accurately.
● Maintain good body alignment; reposition to
prevent edema, pressure, or discoloration of
skin.
● Maintain patent IV.
2. Goal: observe
hyperthermia
for
indications
of
malignant
●
●
●
Common during induction; may occur 24 to 72
hours postoperatively. Genetic defect of muscle
metabolism.
Early
sign
is
unexplained ventricular
dysrhythmia, tachypnea, cyanosis, skin mottling;
elevated temperature is not reliable indicator.
Administer 100% O2.
Cool with ice packs or cooling blankets.
Give dantrolene (muscle relaxant) per order.
3. Evaluation/outcome criteria: complete reversal of
anesthetic effects
● E.g., spontaneous respirations, pupils react to
light). No indication of intraoperative
complications—cardiac arrest, laryngospasm,
aspiration,
hypotension,
malignant
hyperthermia.
III. Postoperative Experience
Assessment
1. Subjective data
● Pain: location, onset, intensity.
● Nausea.
2. Objective data
● Operative summary:
○ Type of operation performed.
○ Pathological findings if known.
○ Anesthesia and medications received.
○ Problems during surgery that will affect
recovery (e.g., arrhythmias, bleeding
[estimated blood loss]).
○ Fluids received: type, amount.
○ Need for drainage or suction apparatus.
● Observations:
● Patency of airway.
● Vital signs.
● Skin color and dryness.
● Level of consciousness.
● Status of reflexes.
● Dressings.
● Type and rate of IV infusion and blood
transfusion.
● Tubes or drains: urinary, chest, Penrose,
Hemovac; note color and amount of
drainage.
Analysis or Nursing Diagnosis
● Ineffective breathing pattern related to general
anesthesia.
● Ineffective airway clearance related to absent or
weak cough.
● Risk for aspiration related to vomiting.
● Pain related to surgical incision.
● Altered tissue perfusion related to shock.
● Risk for fluid volume deficit related to blood
loss.
● Risk for injury related to disorientation.
● Risk for infection related to disruption of skin
integrity.
● Urinary retention related to anesthetic effects.
● Constipation related to decreased peristalsis.
Nursing Care Plan or Implementation
●
Immediate postanesthesia nursing care: refers
to time following surgery that is usually spent in
the recovery room (1 to 2 hours).
1.
Goal: promote a safe, quiet, nonstressful
environment.
● Side rails up at all times.
● Nurse in constant attendance.
2. Goal: promote lung expansion and gas exchange.
3. Goal: Prevent aspiration and atelectasis.
● Position: side or back, head of bed (HOB) 30
degrees, head turned to side to prevent
obstruction of airway by tongue; allows for
drainage from mouth.
Airway: leave the oropharyngeal or
●
nasopharyngeal airway in place until client
awakens and begins to eject; gagging and
vomiting may occur if not removed before
pharyngeal reflex returns.
● After removal of airway: turn on side in a lateral
position; support upper arm with pillow.
● Suction: remove excessive secretions from
mouth and pharynx.
● Encourage coughing and deep breathing: aids in
upward movement of secretions.
● Give humidified oxygen as necessary: reduces
respiratory irritation and keeps bronchotracheal
secretions soft and moist.
● Mechanical ventilation: respirators if needed.
4. Goal: promote and maintain cardiovascular function.
● Immediately report:
○ Systolic blood pressure that drops 20
mm Hg or more, a pressure below 80
mm Hg, or a pressure that continually
drops 5 to 10 mm Hg over several
readings.
○ Pulse rates under 60 or over 110
beats/min, or irregularities; respirations
over 30/min.
○ Becoming shallow, quiet, slow
○ Use of neck and diaphragm muscles
(symptoms of respiratory depression)
○ Stridorous breath sounds.
● Observe for other alterations in circulatory
function—pallor; thready pulse; cold, moist
skin; decreased urine output, restlessness.
○ Immediately report to
○ Initiate oxygen therapy.
○ Place client in shock position unless
contraindicated—feet elevated, legs
straight, head slightly elevated to
increase venous return.
● Intravenous infusions: time, rate, orders for
added medications.
● Monitor blood transfusions if ordered: observe
for signs of reaction (chills, elevated
temperature, urticaria, laryngeal edema, and
wheezing).
● If reaction occurs, immediately stop transfusion and notify physician. Send STAT urine to
laboratory.
5. Goal: promote psychological equilibrium.
● Reassure on awakening—orient frequently.
● Explain procedures even though client does not
appear alert.
● Answer client’s questions briefly and accurately.
● Maintain quiet, restful environment.
● Comfort measures:
○ Good body alignment.
○ Support dependent extremities to avoid
pressure areas and possible nerve
damage.
○ Check for constriction: dressings,
clothing, bedding.
○ Check IV sites frequently for patency
and signs of infiltration (swelling,
blanching, cool to touch).
General post-operative nursing care: refers to period of
time from admission to the general nursing unit until
anticipated recovery and discharge from the hospital.
1. Goal: promote lung expansion, gaseous exchange,
and elimination of bronchotracheal secretions.
● Turn, cough, and deep breathe q2h.
● Use incentive spirometer as ordered to enable
client to observe depth of ventilation.
● Administer nebulization as ordered to help
mobilize secretions.
● Encourage hydration to thin mucous secretions.
● Assist in ambulation as soon as allowed.
2. Goal: provide relief of pain.
● Assess type, location, intensity, and duration;
possible causative factors, such as poor body
alignment or restrictive bandages.
● Observe and evaluate reaction to discomfort.
Use scale: 1 to 10 numerical or pictorial.
● Use comfort measures, such as back rubs and
proper ventilation, staying with client and
encouraging verbalization.
● Reduce incidence of pain: change position
frequently; support dependent extremities with
pillows, sandbags, and footboards; keep
bedding dry and straight.
● Give analgesics or tranquilizers as ordered;
assure client that they will help.
● Observe for desired and untoward effects of
medication.
3. Goal: promote adequate nutrition and fluid and
electrolyte balance.
● Parenteral fluids, as ordered.
● Monitor blood pressure, I&O to assess
adequate, deficient, or excessive extracellular
fluid volume.
● Diet: liquid when nausea and vomiting stop and
bowel sounds are established; progress as
ordered.
4. Goal: assist client with elimination.
● Encourage voiding within 8 to 10 hours after
surgery.
○ Allow client to stand or use commode, if
not contraindicated.
○
●
●
Run tap water or soak feet in warm
water to promote micturition.
○ Catheterization if bladder is distended
and conservative treatments have
failed.
Maintain accurate I&O records.
Expect bowel function to return in 2 to 3 days.
5. Goal: facilitate wound healing and prevent infection.
● Incision care: avoid pressure to enhance venous
drainage and prevent edema.
● Elevate injured extremities to reduce swelling
and promote venous return.
● Support or splint incision when coughing.
● Check dressings q2h for drainage.
● Change dressings on draining wounds prn;
aseptic technique; protective ointments to
reduce skin irritation may be ordered.
● Carefully observe wound suction (e.g., Jackson
Pratt), if applied, for kinking or twisting of the
tubes.
6. Goal: promote comfort and rest.
● Recognize factors that may cause restlessness—
fear, anxiety, pain, oxygen lack, wet dressings.
● Comfort measures: analgesics or barbiturates;
apply oxygen as indicated; change positions;
encourage deep breathing; massage back to
reduce restlessness.
● Allow rest periods between care—group
activities.
● Give antiemetic for relief of nausea and
vomiting, as ordered.
● Vigorous oral hygiene (brushing) to prevent
“surgical mumps” or parotitis from preoperative
atropine or general anesthesia.
7. Goal: encourage early movement and ambulation to
prevent complications of immobilization.
● Turn or reposition q2h.
● Range of motion (ROM): passive and active
exercises.
● Encourage leg exercises.
preventive
treatments—antiembolic
● Use
stockings, graduated compression stockings, or
external pneumatic compression sleeves:
○ With compression stockings, highest
pressure (100%) at ankles, lowest
pressure (40%) at midthigh.
○ Compression sleeves, three chambers
sequentially
inflated-deflated
to
stimulate venous return.
● Assist with standing or use of commode if
allowed.
● Encourage resumption of personal care as soon
as possible.
● Assist with ambulation in room as soon as
allowed. Avoid prolonged chair sitting because it
enhances venous pooling and may predispose
to thrombophlebitis. Elevate legs when chair
sitting.
Evaluation or Outcome Criteria
● Incision heals without infection.
●
●
●
●
No complications (e.g., atelectasis, pneumonia,
thrombophlebitis).
Normal bowel and bladder functions resume.
Carries out activities of daily living, self-care.
Accepts possible limitations: dietary, activity,
body image (e.g., no depression, complies with
treatment regimen).
Postoperative Complications
Pulmonary Complications
1. Atelectasis
● s/s: Dyspnea; ↑ temperature; absent or
diminished breath sounds over affected area,
asymmetrical chest expansion, ↑ respirations
and pulse rate; tracheal shift to affected side
when severe; anxiety and restlessness.
● Nursing Care Plan:
○ Position: unaffected side
○ Turn, cough, and deep breathe;
encourage use of inspirometer hourly
while awake
○ Postural drainage
○ Nebulization
○ Force fluids if not contraindicated
2. Pneumonia
● S/s: Rapid, shallow, painful respirations;
crackles; diminished or absent breath sounds;
asymmetrical lung expansion; chills and fever,
productive cough, rust-colored sputum; and
circumoral and nailbed cyanosis.
● Nursing Care Plan:
○ Position of comfort— semi-Fowler’s to
high Fowler’s
○ Force fluids to 3,000 mL/day
○ Provide humidification of air and oxygen
therapy
○ Oropharyngeal suction prn
○ Assist during coughing
○ Administer antibiotics and analgesics as
ordered
○ Diet: high calorie, as tolerated
○ Cautious disposal of secretions; proper
oral hygiene
○ Respiratory treatments as ordered
3. Pleuritis
● S/s: Knifelike chest pain on inspiration; intercostal tenderness; splinting of chest by client;
rapid, shallow respirations; pleural friction rub;
↑ temperature; malaise.
● Nursing Care Plan:
○ Position: affected side to splint the
chest
○ Manually splint client’s chest during
cough
○ Administer analgesics as ordered
4. Hemothorax
● S/s: Chest pain; increased respiratory rate;
dyspnea, decreased or absent breath sounds;
decreased blood pressure; tachycardia, and
mediastinal shift may occur (heart, trachea and
●
esophagus, great vessels are pushed toward
unaffected side).
Nursing Care Plan
○ Observe vital signs closely for signs of
shock and respiratory distress
○ Assist with thoracentesis (needle
aspiration of fluid)
○ Assist with insertion of chest tube to
closed-chest drainage
5. Pneumothorax
● S/s: Marked dyspnea, sudden sharp chest pain,
subcutaneous emphysema (air in chest wall
tissue); cyanosis; tracheal shift to unaffected
side; hyperresonance on percussion, decreased
or absent breath sounds; increased respiratory
rate, tachycardia; asymmetrical chest expansion,
feeling of pressure within chest; mediastinal
shift—severe dyspnea and cyanosis, deviation
of larynx and trachea toward unaffected side,
deviation either medially or laterally of apex of
heart, decreased blood pressure; distended
neck veins; increased pulse and respirations.
● Nursing Care Plan:
○ Remain with client—keep as calm and
quiet as possible; STAT chest x-ray
○ Position: high Fowler’s (sitting)
○ Notify physician through another nurse,
and have thoracentesis equipment
brought to bedside
○ Administer oxygen as necessary
○ Take vital signs to evaluate respiratory
and cardiac function
○ Assist with thoracentesis
○ Assist with chest tube insertion and
maintenance of closed-chest drainage
Circulatory Complications
1. Shock
● S/s:
○ Dizziness; fainting; restlessness; anxiety;
↓ LOC
○ BP: ↓ or falling
○ Pulse: weak, thready
○ Respirations: ↑, shallow
○ Skin: pale, cool, clammy, cyanotic, ↓
temperature;
○ Oliguria
○ CVP <5 cm H2O;
○ Thirst
● Nursing Care Plan
○ Position: foot of bed raised 20 degrees,
knees straight, trunk horizontal, head
slightly elevated; avoid Trendelenburg’s
position
○ Administer blood transfu- sions, plasma
expanders, and intravenous infusions as
ordered; medications specific to type of
shock.
○ Check: vital signs, CVP, temperature
○ Insert urinary catheter to monitor
hourly urine output
○ Administer oxygen as ordered
2. Deep Vein Thrombosis
● S/s: Calf pain or cramping in affected extremity,
redness and swelling (the left leg is affected
more frequently than the right); slight fever,
chills; Homans’ sign and tenderness over the
anteromedial surface of thigh; decreased pulse
in affected extremity due to swelling and
venous congestion/
● Nursing Care Plan:
○ Maintain complete bedrest, avoiding
positions that restrict venous return.
○ Apply elastic stockings to prevent
swelling and pooling of venous blood.
○ Apply warm, moist soaks to area as
ordered.
○ Administer anticoagulants as ordered
○ Use bed cradle over affected limb
○ Provide active and passive ROM
exercises in unaffected limb
3. Pulmonary Embolism
● S/s: Sudden, severe stabbing chest pain; severe
dyspnea; cyanosis; rapid pulse; anxiety and
apprehension; pupillary dilation; profuse
diaphoresis; loss of consciousness.
● Nursing Care Plan:
○ Administer oxygen and inhalants while
client is sitting upright.
bedrest
and
frequent
○ Maintain
reassurance.
○ Administer heparin sodium, as ordered.
analgesics,
such
as
○ Administer
morphine SO4, to reduce pain and
apprehension.
Wound Complications
1. Wound Infection
● S/s: Redness, tenderness, and heat in area of
incision; wound drainage; ↑ temperature; ↑
pulse rate.
● Nursing Care Plan:
○ Assist in cleansing and irrigation of
wound and insertion of a drain
○ Give antibiotics as ordered; observe
responses
2. Wound Dehiscence and Evisceration
● S/s: slow parting of wound edges with a gush of
pinkish serous drainage; or rapid parting with
coils of intestines escaping onto the abdominal
wall; the latter accompanied by pain and often
by vomiting. Client reports “giving” sensation.
● Nursing Care Plan:
○ Position: bedrest, low Fowler’s or
horizontal position
○ Notify physician STAT
○ Cover exposed coils of intestines with
sterile towels or dressing and keep
moist with sterile normal saline
○ Monitor vital signs frequently
○
○
○
Remain with client; reassure that
physician is coming
Prepare for physician’s arrival; set up IV,
suction equipment, and nasogastric
tube; obtain sterile gown, mask, gloves,
towels, and warmed normal saline.
Notify surgery that client will be
returning to operating room
○
○
○
○
○
○
Urinary Complications
1. Urinary Retention
● S/s: Inability to void within 8 hours postsurgery, despite adequate fluid replacement;
palpable bladder, frequent voiding of small
amounts of urine or dribbling; suprapubic pain
● Nursing Care Plan:
○ Assist client to stand, or use bedside
commode if not contraindicated
○ Provide privacy
○ Reduce tension, provide support
○ Use warm bedpan
○ Run tap water
○ Place client’s feet in warm water
○ Pour warm water over perineum
○ Catheterize if conservative measures fail
2. Urinary Tract Infection
● Urinary: burning and frequency
● Pain: low back or flank
● Pyuria, hematuria; ↑ temperature, chills;
anorexia; positive urine culture
● Nursing Care Plan:
○ Push fluids to 3,000 mL daily, unless
contraindicated
○ Avoid stimulants such as caffeine
○ Give antibiotics, sulfon- amides, or
acidifying agents as ordered
○ Give perianal care after each bowel
movement
Gastrointestinal Complications
1. Gastric Distention
● S/s: Feeling of fullness, hiccups, overflow
vomiting of dark, foul-smelling liquid; severe
retention leads to decreased blood pressure
(due to pressure on vagus nerve) and other
symptoms of shock syndrome.
● Nursing Care Plan
○ Report signs to physician immediately
○ Insert or assist in insertion of NG tube;
attach to intermittent suction
○ Irrigate NG tube with saline (water will
deplete electrolytes and result in
metabolic alkalosis)
○ Administer IV infusions with electrolytes
as ordered
2. Paralytic Ileus
● S/s: greatly decreased or absent bowel sounds,
failure of either gas or feces to be passed by
rectum; nausea and vomiting; abdominal
tenderness and distention; fever; dehydration.
● Nursing Care Plan:
○ Notify physician
Insert or assist with insertion of NG
tube; attach to low, intermittent suction
Insert rectal tube
Administer IV infusion with electrolytes
as ordered
Irrigate nasogastric tube with saline
Assist with insertion of Miller-Abbott
tube if indicated
Administer medications to increase
peristalsis as ordered
3. Intestinal Obstruction
● S/s: Severe, colicky abdominal pains, mild to
severe abdominal distention, nausea and
vomiting, anorexia and malaise; fever; lack of
bowel movement; electrolyte imbalance;
high-pitched tinkling bowel sounds
● Nursing Care Plan:
○ Assist with insertion of nasoenteric tube
and attach to intermittent suction
○ Maintain IV infusions with electrolytes
○ Encourage nasal breathing to avoid air
swallowing
○ Check abdomen for distention and
bowel sounds every 2 hours
○ Encourage verbalization
○ Plan rest periods for client
○ Administer oral hygiene frequently
Transfusion Reaction
1. Allergic or Febrile Reactions
● S/s: Fever to 103°F, may have sudden onset;
chills; itching; erythema; urticaria; nausea,
vomiting; dyspnea and wheezing, occasionally.
● Nursing Care Plans:
○ Stop transfusion and notify physician
○ Administer antihistamines, as ordered
○ Send STAT urine to labora- tory for
analysis
○ Institute cooling measures if indicated
○ Maintain strict input and output records
○ Send remaining blood to laboratory for
analysis, and order recipient blood
sample for analysis
2. Hemolytic Reaction
● S/s:
○ Early: chills and fever; throbbing
headache, feeling of burning in face;
hypotension; tachycardia; chest, back,
or flank pain; nausea, vomiting; feeling
of doom
spontaneous
and diffuse
○ Later:
bleeding; icterus; oliguria; anuria;
hemoglobinuria
● Nursing Care Plans:
○ Stop infusion immediately; take vital
signs and notify physician
○ Send client blood sample and unused
blood to laboratory for analysis
○ Send STAT urine to laboratory 4. Save all
urine for observation of discoloration
○ Administer parenteral infusions to
combat shock, as ordered
○
○
Administer
medications
as
ordered—diuretics,
sodium
bicarbonate,
hydrocortisone,
and
vasopressors
Emotional Complications
1. Emotional Disturbances
● S/s: Restlessness, insomnia, depression,
hallucinations, delusions, agitation, suicidal
thoughts.
● Nursing Care Plans:
○ Report symptoms to physician 2.
Encourage verbalization of feel- ings;
give realistic assurance
○ Orient to time and place as necessary
○ Provide safety measures, such as side
rails
○ Keep room lit, to reduce incidence of
visual hallucinations
○ Administer tranquilizers as ordered.
○ Use restraints as a last resort
A3. Care of Clients With Alterations in Oxygenation
From Davis NCLEX RN Success 3rd Edition
1. Pneumonia
● Acute inflammation of lungs with exudate
accumulation in alveoli and other respiratory
passages that interferes with ventilation
process.
Types of Pneumonia
● Typical/classic pneumonia: pneumococcal;
related to diminished defense mechanisms,
immunocompromised, critically ill, history of
smoking, general anesthesia/abdominal surgery,
exposure to airborne pathogens, hospitalization,
recent respiratory tract infection, viral influenza,
increased age, and chronic obstructive
pulmonary disease (COPD).
○ Lobar pneumonia—occurs abruptly
when an acute bacterial infection
affects a large portion of a lobe; causes
pleuritic
pain,
heavy
sputum
production.
○ Bronchopneumonia—involves patchy
infiltration over a general area.
○ Alveolar pneumonia—caused by virus;
diffuse bilateral infection without
patchy infiltrates.
● Atypical pneumonia: related to contact with
specific organisms.
○ Mycoplasma pneumoniae or Legionella
pneumophila, if untreated, can lead to
serious com- plications such as acute
respiratory distress syndrome (ARDS),
disseminated intravascular coagulation
(DIC), thrombocytopenic purpura, renal
failure, inflammation of the heart,
neurological disorders, or possible
death.
pneumonia
in
○ Pneumocystis
conjunction with AIDS.
● Aspiration pneumonia:
●
Noninfectious: aspiration of fluids
(gastric secretions, foods, liquids, tube
feedings) into the airways.
○ Bacterial aspiration pneumonia: related
to poor cough mechanisms due to
anesthesia, coma (mixed flora of upper
respiratory tract cause pneumonia).
Hematogenous pneumonia bacterial infections:
related to spread of bacteria from the
bloodstream.
Pathophysiology of Pneumonia
● Caused by infectious or noninfectious agents,
clotting of an exudate rich in fibrinogen,
consolidated lung tissue.
Assessment
Subjective data:
● Pain location: chest (affected side), referred to
abdomen, shoulder, flank.
● Irritability, restlessness.
● Apprehensiveness.
● Nausea, anorexia.
● History of exposure.
Objective data:
● Cough:
○ Productive, rust-colored (blood) or
yellowish sputum (greenish with
atypical pneumonia).
○ Splinting of affected side when
coughing.
● Sudden increased fever, chills.
● Nasal flaring, circumoral cyanosis.
● Respiratory distress: tachypnea.
● Auscultation:
○ Decreased breath sounds on affected
side.
breath
sounds
on
○ Exaggerated
unaffected side.
○ Crackles, bronchial breath sounds.
on
percussion
over
○ Dullness
consolidated area.
○ Possible pleural friction rub.
● Chest retraction (air hunger in infants).
● Vomiting.
● Facial herpes simplex.
Diagnostic Tests:
● Chest x-ray: haziness to consolidation.
● Sputum culture: Gram stain and culture; specific
organisms, usually pneumococcus.
if
sputum
results
are
● Bronchoscopy
inconclusive.
Laboratory Data:
● Blood culture: organism specific except when
viral.
● WBC count: leukocytosis.
● Sedimentation rate: elevated.
Factors Contributing to the Severity of Pneumonia
● Demographics:
○ Age—severity increased with age.
○
●
●
●
Gender.
Nursing home resident.
Comorbidities:
○ Congestive heart failure (CHF).
○ Active cancer.
○ Liver disease.
○ Renal insufficiency.
○ Stroke with residual symptoms.
Physical examination:
○ Systolic BP less than 90; mean arterial
pressure (MAP) less than 60.
○ Heart rate (HR) ≥125.
○ Respiratory rate ≥30.
○ Temperature (PO) ≥104°F or less than
95°F.
○ Altered level of consciousness (LOC).
Laboratory results:
○ Hematocrit (Hct) less than 30.
○ Na+ less than 130.
○ BUN ≥30.
○ Arterial pH less than 7.35.
○ Pleural effusion on chest x-ray.
○ Glucose greater than 250 mg/dL.
Nursing Diagnosis for Pneumonia
● Ineffective airway clearance related to retained
secretions.
● Activity intolerance related to inflammatory
process.
● Pain related to continued coughing.
● Knowledge deficit (learning need) related to
proper management of symptoms.
● Risk for fluid volume deficit related to
tachypnea.
Nursing Care Plan
1. Goal: promote adequate ventilation.
● Deep breathe, cough. Small-volume nebulizer
treatment.
● Remove respiratory secretions, suction prn.
● High humidity with or without oxygen therapy.
● Intermittent positive-pressure breathing (IPPB);
incentive spirometry, chest physiotherapy, as
ordered and needed to loosen secretions.
● Use of expectorants as ordered.
● Change position frequently.
● Percussion with postural drainage.
2. Goal: control infection.
● Monitor vital signs; hypothermia for elevated
temperature.
● Administer antibiotics as ordered to control
infection—broad spectrum (e.g. penicillin,
quinolones, aminoglycosides). Note: need
cultures before starting on antibiotics.
3. Goal: provide rest and comfort.
● Planned rest periods.
● Adequate hydration by mouth, I&O; IVs as
needed.
● Diet: high carbohydrate, high protein to meet
energy demands and assist in the healing
process.
● Mild analgesics for pain—no opioids.
4. Goal: prevent potential complications.
● Cross infection: use good hand-washing
technique.
● Sterile technique when tracheobronchial
suctioning to reduce risk of possible infection.
● Hyperthermia: tepid baths, hypothermia
blanket.
● Respiratory insufficiency and acidosis: clear
airway, promote expectoration of secretions.
● Assess cardiac and respiratory function.
● Keep ambulatory whenever possible.
5. Goal: health teaching.
● Proper disposal of tissues, cover mouth when
coughing.
● Expected side effects of prescribed medications.
● Need for rest, limited interactions, increased
caloric intake.
● Need to avoid future respiratory infections.
○ Immunization: influenza each year for
those at risk. Vaccine for pneumococcal
pneumonia every 5 years.
● Correct dosage of antibiotics and the
importance of taking entire prescription at prescribed times (times evenly distributed
throughout the 24-hour period to maintain
blood level of antibiotic) for increased
effectiveness.
Evaluation
● Adheres to medication regimen.
● Has improved gas exchange as shown by
improved pulmonary function tests.
● No acid-base or fluid imbalance: normal pH.
● Energy level: increased.
● Sputum production: decreased, normal color.
● Vital signs: stable.
● Breath sounds: clear.
● Cultures: negative.
● Reports comfort level increased.
2. Severe Acute Respiratory Syndrome (SARS)
● Viral respiratory illness caused by a coronavirus.
Incubation period: 2 to 7 days, maybe as long as
10 to 14 days. Recommend limiting contact
after infection until 10 days after fever has
gone.
Pathophysiology of SARS
● Little information is known about the
SARS-associated coronavirus.
● May survive in the environment for several days
- depends on temperature or humidity, and type
of material or body fluid.
● Spread generally by respiratory droplets—up to
3 feet.
● May spread through air; other ways not known.
● Progresses to hypoxia → pneumonia →
respiratory distress syndrome.
Risk Factors for SARS
● Weakened immune system.
● Close contact (within 3 feet)—kissing, hugging,
sharing utensils.
Assessment
Subjective data:
● Headache.
● Feeling of discomfort; body aches; chills.
● Dyspnea.
Objective data:
● Temperature greater than 100.4°F (38.0°C),
unless on antipyretics.
● Mild respiratory symptoms; dry cough.
● Diarrhea in 20%.
Laboratory data:
transcriptase–polymerase
chain
● Reverse
reaction (RT-PCR) of blood, stool, nasal
secretions; serologic test for antibodies; viral
culture (showing antibodies to virus more than
21 days after onset of illness).
● Leukopenia.
● Lymphopenia
● Thrombocytopenia.
● ↑ lactose dehydrogenase.
● ↑ aspartate aminotransferase.
● ↑ creatine kinase.
● Chest x-ray: focal interstitial infiltrates →
generalized patchy infiltrates → areas of
consolidation.
Nursing Diagnosis
● Ineffective breathing pattern related to hypoxia
and pneumonia.
● Risk for spread of infection related to droplet or
airborne transmission.
● Impaired gas exchange related to pneumonia.
Nursing Care Plan
1. Goal: infection control.
● Standard precautions (e.g., strict hand hygiene).
● Contact precautions (e.g., gown and gloves)
with eye protection.
● Airborne precautions (e.g., isolation room with
negative pressure; use of an N95 filtering
disposable respirator for those entering room,
or surgical mask).
● Identify or isolate suspected SARS cases
(quarantine).
2. Goal: supportive care.
● Empirical antibiotic therapy with broad
coverage.
● Isolation (i.e., those without symptoms) for 10
days after becoming afebrile.
3. H1N1 Influenza Virus (Swine Flu)
● Respiratory disease caused by a new strain of
the type A influenza virus (novel H1N1 or 2009
H1N1 flu).
● Described initially as a possible pandemic, a
technical term that refers to the geographical
(global) spread of the disease, not severity.
● Called swine flu because it resembled a strain
that circulates in pigs.
Pathophysiology of Swine Flu
● Influenza A virus with two proteins, hemagglutinin (H1) and neuraminidase (N1); humanto-human transmission through respiratory
secretions (droplets) from coughing or sneezing;
touching something with the virus on the
surface and then touching mouth, eyes, or nose.
Not spread by food.
● Incubation period: 1 day before symptoms
occur and up to 7 days following illness onset.
● Infectious (viral shedding): as long as symptomatic; a minimum of 7 days after onset up to 13
days. Young children may be contagious for
longer periods.
● Respiratory symptoms may progress to
pneumonia → respiratory failure → death.
Assessment
Subjective data:
● Fatigue
● Body aches; chills
● Sore throat
● Headache
● Emergency signs with swine flu:
○ Shortness of breath
○ Chest pain or abdominal pain
○ Sudden dizziness; confusion
Objective data:
● Fever above 100.4°F
● Cough
● Diarrhea; vomiting
● Runny nose
● Emergency signs with swine flu:
○ Severe or persistent vomiting
○ Difficulty breathing; rapid respiratory
rate
○ Bluish or gray skin color (particularly in
children)
Diagnostic Tests
● Viral culture, polymerase chain reaction (PCR),
rapid antigen testing, and immunofluorescence.
“Rapid influenza diagnostic test” - detects in 30
minutes, may not be conclusive.
Nursing Diagnosis
● Ineffective breathing pattern related to hypoxia
and pneumonia.
● Risk for spread of infection related to droplet or
airborne transmission.
● Risk for fluid volume deficit related to persistent
vomiting.
Nursing Care Plan
1. Goal: prevent spread of infection.
● Stay home from work or school at least 24 hours
after fever is gone without the use of a
fever-reducing medicine; limit contact with
others.
● Cover nose and mouth with tissue when
coughing or sneezing.
● Wash hands after every sneeze or cough.
●
Disinfect home surfaces to kill germs - virus can
survive 2 to 8 hours; use hydrogen peroxide,
iodophors, detergents, alcohol; heat.
2. Goal: reduce risk of complications, alleviate
symptoms.
Medications:
● Antipyretic: for fever 100°F or higher;
acetaminophen or ibuprofen; aspirin if over 18
years of age.
● Antiviral: treatment or prevention; stop spread
of virus:
○ oseltamivir (oral, Tamiflu)—take with
food, nausea and vomiting may occur
○ zanamivir (inhaled)—do not take with
history of asthma or lung disease; may
cause dizziness, stuffy nose, sinusitis
○ peramivir (IV, reserved for critically ill);
neuraminidase inhibitors; suspected or
confirmed cases. Most effective within
48 hours; 5 days of treatment.
● Fluids, lozenges; cough suppressant for dry
cough.
●
●
Fluids: clear liquids (water, broth, sports drinks,
ice chips, frozen popsicles); avoid alcohol and
caffeine.
Monitor for dehydration: urine color (dark
yellow with dehydration); frequency of trips to
bathroom. Look for tears with infants/ toddlers;
wet diapers.
3. Goal: prevent occupational exposure.
● Eliminate potential exposures: keep distance of
6 feet or more in community setting; restrict
visitors who are ill; keep sick workers at home.
● Respiratory hygiene and cough etiquette.
Encourage ill person to use tissues or wear a
disposable face mask (use only once) or
health-care provider should wear mask.
● Respiratory protection (personal protective
equipment) in occupational health-care
setting—N95 or higher filtering facepiece
respirator; fit-tested (not recommended for
children or people with facial hair); dispos- able,
single use, do not share. Remove gloves and
wash hands before and after touching
respirator. Extended use of N95 increases risk of
contact transmission. Usually reserved if
assisting with an aerosol- generating
procedure—intubation,
extubation,
bronchoscopy, nebulization.
● Isolation; standard (droplet) precautions—
private room preferred; if not available at least
3-foot separation between patient beds with
curtain between; share room with like diagnosis
(cohorting). Caregiver wears mask— respirator
not routinely necessary. Eye protec- tion if
within 6 feet of patient as treatments may cause
splashing of respiratory secretions.
● Limit transport of patient; client wears mask
outside of room.
● Vaccination of staff may be required; exempt:
with severe egg allergy; history of Guillain-Barré
syndrome; religion prohibits vaccinations. May
be required to wear mask if not vaccinated.
4. Goal: health teaching—methods to prevent
reinfection.
● Hand-washing technique—soap, water, and
friction for at least 20 seconds; alcohol-based
(antibacterial) hand rub may be used.
● Avoid touching eyes, nose, or mouth.
● Vaccination: one dose of swine flu and seasonal
flu vaccine for those 10 years of age and
older—may be given on same day; two doses of
swine flu vaccine (separated 4 weeks, 21 days
minimum) for children younger than 10 years.
● Pneumococcal vaccination if over 65 years,
smoker, or history of chronic health problem.
Evaluation
● No complications.
● Temperature normal for 24 hours without
medication.
● Breath sounds clear; respirations unlabored.
● Covers nose/mouth when coughing or sneezing.
● Performs hand hygiene frequently.
4. Atelectasis
● Collapsed alveoli in part or all of the lung.
Pathophysiology of Atelectasis
to compression (tumor), airway
● Due
obstruction, decreased surfactant production,
or progressive regional hypoventilation.
Assessment
Subjective data:
● Restlessness.
● Pain.
Objective data:
● Tachypnea.
● Tachycardia.
● Dullness on percussion.
● Absent bronchial breathing.
● Crackles at bases as alveoli “pop” open on
inspiration.
● Tactile fremitus in affected area.
● ↓ O2 saturation.
X-ray findings:
● Patches of consolidation.
● Elevated diaphragm.
● Mediastinal shift.
Nursing Diagnosis
● Impaired gas exchange related to shallow
breathing.
● Pain, acute, related to collapse of lung.
● Fear related to altered respiratory status.
Nursing Care Plan
1. Goal: relieve hypoxia.
● Frequent respiratory assessment.
●
●
●
●
●
Respiratory hygiene measures, cough, deep
breathe. Use bedside inspirometer q1h when
awake.
Oxygen as ordered.
Monitor effects of respiratory therapy,
ventilators, breathing assistance measures to
ensure proper gas exchange.
Position: on unaffected side to allow for lung
expansion.
Prepare for possible needle decompression or
chest tube insertion.
2. Goal: prevent complications.
● Antibiotics as ordered.
● Turn, cough, and deep breathe. Out of bed,
ambulation.
● Increase fluid intake to liquefy secretions.
3. Goal: health teaching.
● Need to report signs and symptoms listed in
assessment data for early recognition of
problem.
● Importance of coughing and deep breathing to
improve present condition and prevent further
problems.
Evaluation
● Lung expanded on x-ray.
● Acid-base balance obtained and maintained.
● No pain on respiration.
● Activity level increased.
5. Pulmonary Embolism
● Undissolved mass that travels in bloodstream
and occludes a blood vessel; can be
thromboembolus, fat, air, or catheter.
● Constitutes a critical medical emergency.
Pathophysiology of Pulmonary Embolism
● Obstructs blood flow to lung → increased
pressure on pulmonary artery and reflex
constriction of pulmonary blood vessels → poor
pulmonary circulation → pulmonary infarction.
Assessment
Subjective data:
● Chest pain: substernal, localized; type crushing, sharp, stabbing with respirations.
● Sudden onset of profound dyspnea.
● Restless, irritable, anxious.
● Sense of impending doom.
Objective data:
● Respirations: either rapid, shallow or deep,
gasping.
● Elevated temperature.
● Auscultation: friction rub, crackles; diminished
breath sounds.
● Shock:
○ Tachycardia.
○ Hypotension.
○ Skin: cold, clammy.
● Cough: hemoptysis.
Diagnostic tests:
● X-ray: area of density.
● ECG changes that reflect right-sided failure.
● Echocardiogram shows increased pulmonary
dynamics.
● Lung scan; pulmonary angiography.
Laboratory data:
● Decreased PaCO2.
● Elevated WBC count.
Nursing Diagnosis
● Ineffective breathing pattern related to shallow
respirations.
● Impaired gas exchange related to dyspnea.
● Pain related to decreased tissue perfusion.
● Altered peripheral tissue perfusion related to
occlusion of blood vessel.
● Fear related to emergency condition.
● Anxiety related to sense of impending doom.
Nursing Care Plan
1. Goal: monitor for signs of respiratory distress.
● Auscultate lungs for areas of decreased or
absent breath sounds.
● Elevate head of bed.
● Monitor arterial blood gases (ABGs).
● Monitor pulse oximetry; administer oxygen,
supplemental humidification as indicated.
● Monitor blood coagulation studies (e.g.,
activated partial thromboplastin time [aPTT]).
anticoagulation
therapy,
● Administer
thrombolytic agents, morphine for pain,
vasopressor medications.
● Fluids: IV/PO as indicated.
● Monitor signs: Homans’, acidosis.
● Ambulate as tolerated/indicated; change
position.
● Prepare for surgery if peripheral embolectomy is
indicated.
2. Goal: health teaching.
● Prevent further occurrence; importance of
antiembolism stockings, intermittent pneumatic
compression devices.
● Decrease stasis.
● If history of thrombophlebitis, avoid birth
control pills.
● Need to continue medication.
● Follow-up care.
Evaluation
● No complications; no further incidence of
emboli.
● Respiratory rate returns to normal.
● Respiratory System
● Reports comfort achieved.
6. Histoplasmosis
● Infection found mostly in central United States.
Not transmitted from human to human but
from dust and contaminated soil.
histoplasmosis,
seen
most
● Progressive
frequently in middle-aged white men who have
COPD, is characterized by cavity formation,
fibrosis, and emphysema.
Pathophysiology of Histoplasmosis
● Spores of Histoplasma capsulatum (from
droppings of infected birds and bats) are
inhaled, multiply, and cause fungal infections of
respiratory tract. Leads to necrosis and healing
by encapsulation.
Assessment
Subjective data
● Malaise
● Chest pain, dyspnea
Objective data:
● Weight loss.
● Nonproductive cough.
● Fever.
● Positive skin test for histoplasmosis. e. Benign
acute pneumonitis.
● Chest x-ray: nodular infiltrate.
● Sputum culture shows Histoplasma capsulatum.
● Hepatomegaly, splenomegaly.
Nursing Diagnosis
● Ineffective airway clearance related to
pneumonitis.
● Ineffective breathing pattern related to
dyspnea.
● Pain, acute, related to infectious process.
● Risk for infection related to repeated exposure
to fungal spores.
● Impaired gas exchange related to chronic
pulmonary disease.
● Knowledge deficit (learning need) related to
prevention of disease and potential side effects
of medications.
Nursing Care Plan
1. Goal: relieve symptoms of the disease.
Administer medications:
● Amphotericin B (IV) and ketoconazole.
○ Monitor for drug side effects: local
phlebitis, renal toxicity, hypokalemia,
anemia, anaphylaxis, bone marrow
depression.
○ Azotemia (presence of nitrogencontaining compounds in blood) is
monitored by biweekly BUN or
creatinine levels.
○ BUN greater than 40 mg/dL or
creatinine greater than 3.0 mg/dL
necessitates stopping amphotericin B
until values return to within normal
limits.
● Aspirin, diphenhydramine HCl (Benadryl),
promethazine HCl (Phenergan), prochlorperazine (Compazine): used to decrease
systemic toxicity of chills, fever, aching, nausea,
and vomiting.
2. Goal: health teaching.
● Desired effects and side effects of prescribed
medications; importance of taking medications
for entire course of therapy (usually from 2
weeks to 3 months).
● Importance of follow-up laboratory tests to
monitor toxic effects of drug.
● Identify source of contamination if possible and
avoid future contact if possible.
● Importance of deep breathing, pursed-lip
breathing, coughing.
● Signs and symptoms of chronic histoplasmosis,
COPD, drug toxicity, and drug side effects.
Evaluation
● Complies with treatment plan.
● Respiratory complications avoided.
● Symptoms of illness decreased.
● No further spread of disease.
● Source of contamination identified
removed.
and
7. Tuberculosis
● Inflammatory, communicable disease that
commonly attacks the lungs, although may
occur in other body parts.
Pathophysiology of Tuberculosis
to
causative
organism
● Exposure
(Mycobacterium tuberculosis) in the alveoli in
susceptible individual leads to inflammation.
● Infection spreads by lymphatics to hilus;
antibodies are released, leading to fibrosis,
calcification,
or
inflammation.
Exudate
formation leads to caseous necrosis, then
liquefication of caseous material leads to
cavitation.
Assessment
Subjective data:
● Loss of appetite, weight loss.
● Weakness, loss of energy.
● Pain: knifelike, chest.
● Though client may be symptom free, the
disease is found on screening.
Objective data:
● Night sweats, chills.
● Fever: low grade, late afternoon.
● Pulse: increased.
● Hoarseness.
● Unexplained weight loss.
● Respiratory assessment:
persistent
cough,
○ Productive,
hemoptysis.
○ Respiration normal; increased depth
○ Asymmetrical lung expansion.
○ Increased tactile fremitus
○ Dullness to percussion
○ Crackles following short cough
Diagnostic tests:
●
●
●
●
Positive tuberculin test (Mantoux)—reaction to
test begins approximately 12 hours after
administration with area of redness and a
central area of induration.
○ The peak time is 48 hours.
Determination of positive or negative is
made.
○ A reaction is positive when it measures
10 mm. Contacts reacting from 5 to 10
mm may need to be treated
prophylactically.
○ This test is referred to as purified
protein derivative (PPD) or intradermal
skin test.
(Sputum: three specimens tested positive for
acid-fast bacilli (AFB) (smear and culture).
Positive equals greater than 10 AFB per field.
X-ray: infiltration cavitation.
Laboratory data: decreased RBC count,
increased sedimentation rate.
Classification of Tuberculosis
● 0
○ No TB exposure, not infected
● 1
○ TB exposure, no evidence of infection
● 2
○ TB infection, no disease
● 3
○ TB: current disease (persons with
completed diagnostic evidence of
TB—both a significant reaction to
tuberculin skin test and clinical or x-ray
evidence of disease)
● 4
○ TB: no current disease (persons with
previous history of TB or with abnormal
x-ray films but no significant tuberculin
skin test reaction or clinical evidence)
● 5
○ TB: suspected (diagnosis pending) (used
during diagnostic testing period of
suspected persons, for no longer than 3
months)
Nursing Diagnosis
● Ineffective airway clearance related to
productive cough.
● Impaired gas exchange related to asymmetrical
lung expansion.
● Pain related to unresolved disease process.
● Body image disturbance related to feelings
about tuberculosis.
● Social isolation related to fear of spreading
infection.
● Knowledge deficit (learning need) related to
medication regimen.
Nursing Care Plan
1. Goal: reduce spread of disease.
● Administer medications: isoniazid (INH),
rifampin, pyrazinamide, ethambutol, or
streptomycin; or drug combinations such as
Rifadin or Rifamate.
○
●
●
●
●
Client will be treated as an outpatient;
may need to go to clinic for directly
observed therapy (DOT) to ensure
compliance with this long-term
medication regimen.
The following may need to take 300 mg of INH
daily for 1 year as prophylactic measure:
positive skin test reactors, including contacts;
persons who have diseases or are receiving
therapies that affect the immune system;
persons who have leukemia, lymphoma, or
uncontrolled diabetes or who have had a
gastrectomy.
Avoid direct contact with sputum.
○ Use good hand-washing technique after
contact with client, personal articles.
○ Have client cover mouth and nose when
coughing and sneezing, and use
disposable tissues to collect sputum.
Provide good circulation of fresh air. (Changes of
air dilute the number of organisms. This plus
chemotherapy provide protection needed to
prevent spread of disease.)
Implement airborne or droplet precautions
2. Goal: promote nutrition.
● Increased protein, calories to aid in tissue repair
and healing.
● Small, frequent feedings.
● Increased fluids, to liquefy secretions so they
can be expectorated.
3. Goal: promote increased self-esteem.
● Encourage client and family to express concerns
regarding long-term illness and treatment
protocol.
● Explain methods of disease prevention, and
encourage contacts to be tested and treated if
necessary.
● Encourage client to maintain role in family while
home treatment is ongoing and to return to
work and social contacts as soon as it is
determined safe for progress of treatment plan.
4. Goal: health teaching.
● Desired effects and side effects of medications:
○ INH may affect memory and ability to
concentrate. May result in peripheral
neuritis, hepatitis, rash, or fever.
○ Streptomycin may cause eighth cranial
nerve
damage
and
vestibular
ototoxicity, causing hearing loss; may
cause labyrinth damage, manifested by
vertigo and staggering; also may cause
skin rashes, itching, and fever.
○ Important for client to know that
medication regimen must be adhered to
for entire course of treatment.
○ Discontinuation of therapy may allow
organism to flourish and make the
disease more difficult to treat.
● Need for follow-up, long-term care, and contact
identification.
●
●
●
Importance of nutritious diet, rest, avoidance of
respiratory infections.
Identify community agencies for support and
follow-up.
Inform that this communicable disease must be
reported.
Evaluation
● Complies with medication regimen.
● Lists desired effects and side effects of
medications prescribed.
● Gains weight, eats food high in protein and
carbohydrates.
● Sputum culture becomes negative.
● Retains role in family.
● No complications (i.e., no hemorrhage, bacillus
not spread to others).
8. Emphysema
● Chronic disease with excessive inflation of the
air spaces distal to the terminal bronchioles,
alveolar ducts, and alveoli; characterized by
increased airway resistance and decreased
diffusing capacity. Emphysema and chronic
bronchitis
together
constitute
chronic
obstructive pulmonary disease (COPD).
Pathophysiology of Emphysema
● Imbalance between proteases, which break
down lung tissue, and α1-antitrypsin, which
inhibits the breakdown. Increased airway
resistance during expiration results in air
trapping and hyperinflation → increased
residual volumes. Increased dead space →
unequal ventilation → perfusion of poorly
ventilated alveoli → hypoxia and carbon dioxide
retention (hypercapnia).
● Chronic hypercapnia reduces sensitivity of
respiratory center; chemoreception in the aortic
arch and carotid sinus become principal
regulators of respiratory drive (respond to
hypoxia).
Assessment
Subjective data:
● Weakness, lethargy.
● History of repeated respiratory infections,
shortness of breath.
● Long-term smoking.
● Irritability.
● Inability to accept medical diagnosis and
treatment plan.
● Refusal to stop smoking.
● Dyspnea on exertion, dyspnea at rest
Objective data:
● Increased BP.
● Increased pulse. Decreased O2 saturation.
● Nostrils: flaring.
● Cough: chronic, productive.
● Episodes of wheezing, crackles.
● Increased anterior-posterior diameter of chest
(barrel chest).
●
●
●
●
●
●
●
●
●
●
Use of accessory respiratory muscles,
abdominal and neck.
Asymmetrical thoracic movements, decreased
diaphragmatic excursion.
Position: sits up, leans forward to compress
abdomen and push up diaphragm, increasing
intrathoracic pressure, producing more efficient
expiration.
Pursed lips for greater expiratory breathing
phase (“pink puffer”).
Weight loss due to hypoxia.
Skin: ruddy color, nail clubbing; when combined
with bronchitis: cyanosis (“blue bloater”).
Respiratory: early disease—alkalosis; late
disease—acidosis, respiratory failure.
Spontaneous pneumothorax.
Cor pulmonale (emergency cardiac condition
involving right ventricular failure due to
increased pressure within pulmonary artery).
X-ray: hyperinflation of lung, flattened
diaphragm; lung scan differentiates between
ventilation and perfusion.
Pulmonary Function Tests
● Prolonged rapid, forced exhalation.
● Decreased: vital capacity (<4,000 mL); forced
expiratory volume.
● Increased: residual volume (may be 200%); total
lung capacity.
Laboratory Tests:
● PaO2 less than 80 mm Hg, pH less than 7.35.
● PaCO2 greater than 45 mm Hg.
● Note: In clients whose compensatory mechanisms are functioning, laboratory values may be
out of the normal range, but if a 20:1 ratio of
bicarbonate to carbonic acid is maintained, then
appropriate acid-base balance also will be
maintained. (Carbonic acid value can be
obtained by multiplying the PCO2 value by
0.003.)
Nursing Diagnosis:
● Impaired gas exchange related to thick
pulmonary secretions.
● Ineffective breathing pattern related to hyperinflated alveoli.
● Ineffective airway clearance related to
pulmonary secretions.
● Altered nutrition, less than body requirements,
related to weight loss due to hypoxia.
● Infection related to chronic disease process and
decreased ciliary action.
● Activity intolerance related to increased energy
demands used for breathing.
● Sleep pattern disturbance related to changes in
body positions necessary for breathing.
● Anxiety related to disease progression.
● Knowledge deficit (learning need) related to
disease, treatment, and self-care needs.
Nursing Care Plan
1. Goal: promote optimal ventilation.
● Institute measures designed to decrease airway
resistance and enhance gas exchange.
● Position: Fowler’s or leaning forward to
encourage expiratory phase.
● Oxygen with humidification, as ordered—no
more than 2 L/min to prevent depression of
hypoxic respiratory drive. May need long-term
oxygen therapy as disease progresses, to
improve quality of life and reduce risk of
complications.
● Intermittent positive-pressure breathing (IPPB)
with nebulization as ordered. Small-volume
nebulizer treatment.
● Assisted ventilation.
● Postural drainage, chest physiotherapy.
● Immunotherapy: helps ward off life-threatening
influenza and pneumonia.
○ Flu vaccination every October or
November.
○ Pneumococcal vaccination routinely one
dose; revaccinate 5 years later if high
risk.
Medications, as ordered:
● Bronchodilators to increase airflow through
bronchial tree: inhaled: beta2-adrenergic
agonists (albuterol, metaproterenol); anticholinergic agent: ipratropium (Atrovent);
aminophylline,
theophylline,
terbutaline,
isoproterenol (Isuprel).
● Antimicrobials to treat infection (deter- mined
by
sputum
cultures
and
sensitivity):
trimethoprim and sulfamethoxazole (Bactrim,
Septra); doxycycline, erythromycin, amoxicillin,
cephalosporins, and macrolides (condition
deteriorates with respiratory infections).
● Corticosteroids to decrease inflammation,
mucosal edema, improve pulmonary function
during exacerbation; systemic: prednisone,
methylprednisolone
sodium
succinate
(Solu-Medrol); inhaled: triamcinolone acetonide
(Azmacort),
beclomethasone
(Beclovent,
Vanceril), flunisolide (AeroBid).
● Expectorants (increase water intake to achieve
desired effect): glyceryl guaiacolate (Robitussin).
detergents/liquefying
agents
● Bronchial
(Mucomyst).
2. Goal: employ comfort measures and support other
body systems.
● Oral hygiene prn; frequently client is mouth
breather.
● Skin care: waterbed, air mattress, foam pads to
prevent skin breakdown.
● Active and passive ROM exercises to prevent
thrombus formation; antiembolic stocking or
woven elastic (Ace) bandages may be applied.
● Increase activities to tolerance.
● Adequate rest and sleep periods to prevent
mental disturbances due to sleep deprivation
and to reduce metabolic rate.
3. Goal: improve nutritional intake.
● High-protein, high-calorie diet to prevent
negative nitrogen balance.
● Give small, frequent meals.
● Supplement diet with high-calorie drinks.
● Push fluids to 3,000 mL/day, unless
contraindicated—helps moisten secretions.
4. Goal: provide emotional support for client and family.
● Identify factors that increase anxiety:
○ Fears related to mechanical equipment.
○ Loss of body image.
○ Fear of dying.
● Assist family coping:
○ Do not reinforce denial or encourage
overconcern.
○ Give accurate, up-to-date information
on client’s condition.
○ Be open to questioning.
client–family
○ Encourage
communication.
appropriate
diversional
○ Provide
activities.
5. Goal: health teaching.
● Breathing exercises, such as pursed-lip
breathing and diaphragmatic breathing.
● Stress-management techniques.
● Methods to stop smoking.
● Importance of avoiding respiratory infections.
● Desired effects and side effects of prescribed
medications, possible interactions with overthe-counter drugs.
● Purposes and techniques for effective bronchial
hygiene therapy.
● Rest/activity schedule that increases with
ability.
● Food selection for high-protein, high-calorie
diet.
● Importance of taking 2,500 to 3,000 mL fluid per
day (unless contraindicated by another medical
problem).
● Importance of medical follow-up.
Evaluation
● Takes prescribed medication.
● Participates in rest/activity schedule.
● Improves nutritional intake, gains appropriate
weight for body size.
● No complications of respiratory failure, cor
pulmonale.
● No respiratory infections.
balance
maintained
through
● Acid-base
compensatory mechanisms, acidosis prevented.
9. Asthma
● Sometimes called reactive airway disease (RAD)
or reversible obstructive airway disease (ROAD);
● S complex inflammatory process that causes
increased airway resistance and, over time,
airway tissue damage.
● Characterized by airway inflammation and
hyperresponsiveness to a variety of stimuli such
as allergens, cold air, dust, smoke, exercise,
medications (e.g., aspirin), some food additives,
and viral infections.
● Immunologic asthma occurs in childhood and
follows other allergic disease.
● Nonimmunologic asthma occurs in adulthood
and is associated with a history of recurrent
respiratory tract infections.
Pathophysiology of Asthma
● Triggers initiate the release of inflammatory
mediators such as histamine, which produce
airway obstruction through smooth muscle
constriction, microvascular leakage, mucus
plugging, and swelling.
● This process involves six sequential steps:
○ (1) triggering—the allergic or antigenic
stimuli activate the inflammatory (mast)
cells;
○ (2) these mast cells signal the systemic
immune
system
to
release
proinflammatory substances;
migration
of
circulating
○ (3)
inflammatory cells to regions of
inflammation in the respiratory tract;
○ (4) migrating cells are activated by the
proinflammatory mediators;
○ (5) this results in tissue damage; and
○ (6) resolution. The airways of many
clients with asthma are chronically
inflamed.
Types of Asthma
● Immunologic, or allergic asthma in persons who
are atopic (hypersensitivity state that is subject
to hereditary influences); immunoglobulin E
(IgE) usually elevated.
● Nonimmunologic, or nonallergic asthma in persons who have a history of repeated respiratory
tract infections; age usually more than 35 years.
combined
immunologic
and
● Mixed,
nonimmunologic; any age, allergen or
nonspecific stimuli.
Assessment
Subjective data:
● History: upper respiratory infection (URI),
rhinitis, allergies, family history of asthma.
● Increasing tightness of the chest → dyspnea
(see Table 6.14).
● Anxiety, restlessness.
● Attack history:
○ Immunologic: contact with allergen to
which person is sensitive; seen most
often in children and young adults.
○
Nonimmunologic: develops in adults
older than 35 years; aggravated by
infections of the sinuses and respiratory
tract.
Objective data:
● Peak flowmeter level drops.
● Respiratory assessment: increased rate, audible
expiratory wheeze (also inspiratory when
severe) on auscultation, hyperresonance on
percussion, rib retractions, use of accessory
muscles on inspiration.
● Tachycardia, tachypnea.
● Cough: dry, hacking, persistent.
appearance:
pallor,
cyanosis,
● General
diaphoresis, chronic barrel chest, elevated
shoulders, flattened malar bones, narrow nose,
prominent upper teeth, dark circles under eyes,
distended neck veins, orthopnea.
● Expectoration of tenacious mucoid sputum.
Diagnostic tests:
● Forced vital capacity (FVC): decreased.
● Forced expiratory volume in 1 second (FEV1):
decreased.
● Peak expiratory flow rate: decreased.
● Residual volume: increased.
● Laboratory data: blood gases—elevated PCO2;
decreased PO2, pH.
● Emergency note: Persons severely affected may
develop status asthmaticus, a life-threatening
asthmatic attack in which symptoms of asthma
continue and do not respond to usual treatment. Could lead to respiratory failure and
hypoxemia.
Nursing Diagnosis
● Ineffective airway clearance related to
tachypnea.
● Impaired gas exchange related to constricted
bronchioles.
● Anxiety related to breathlessness.
● Activity intolerance related to persistent cough.
● Knowledge deficit (learning need) related to
causal factors and self-care measures.
Nursing Care Plan
1. Goal: promote pulmonary ventilation.
● Position: high-Fowler’s for comfort.
● Oxygen therapy with increased humidity as
ordered.
● Frequent monitoring for respiratory distress.
● Rest periods and gradual increase in activity.
Medications as ordered:
● Rescue medications: corticosteroids (e.g.,
prednisone, methylprednisolone [Medrol];
beta-adrenergic agonists, such as albuterol
[Proventil, Ventolin], metaproterenol [Alupent,
Metaprel]).
medications:
nonsteroidal
● Maintenance
anti-inflammatory drugs: cromolyn (Intal),
nedocromil
(Tilade);
corticosteroids:
beclomethasone
(Vanceril),
triamcinolone
●
(Azmacort); leukotriene inhibitors/receptor
antagonists: zafirlukast (Accolate), zileuton
(Zyflo); theophylline (Theo-Dur, Slo-Bid, Uni-Dur,
theophylline ethylenediamino [Aminophylline]);
anticholinergic: ipratropium (Atrovent); beta
agonists: salmeterol (Serevent); mast cell
stabilizers: nedocromil sodium (Tilade).
Antibiotics to control infection.
2. Goal: facilitate expectoration.
● High humidity.
● Increase fluid intake.
● Monitor for dehydration.
● Respiratory therapy: IPPB.
3. Goal: health teaching to prevent further attacks.
● Identify and avoid all asthma triggers.
● Teach importance of peak flowmeter readings.
● Medications—when to use, how to use, side
effects, withdrawals.
● Using a metered-dose inhaler:
○ Shake vigorously.
○ Position inhaler about 1 inch in front of
mouth. Use 2 fingers to measure the
1-inch distance.
○ A spacer is recommended: connect
spacer device, shake, press down the
canister; place lips on the mouthpiece
and take a slow deep breath through
mouth. Without spacer: breathe out all
the way, open mouth wide, and take a
slow deep breath through mouth. Press
down the canister and continue to
breathe in.
○ Once lungs are full, hold breath for 10
seconds if possible.
○ Exhale normally through pursed lips.
○ Wait 1 to 2 minutes between puffs.
Depending
on
the
particular
medication, may need to rinse mouth
with water or mouthwash after each
treatment.
● Methods to facilitate expectoration—increase
humidity, postural drainage when appropriate,
percussion techniques.
● Breathing techniques to increase expiratory
phase.
● Stress-management techniques.
● Importance of recognizing early signs of asthma
attack and beginning treatment immediately.
● Steps to take during an attack.
Evaluation
● No complications.
● Has fewer attacks.
● Takes prescribed medications, avoids infections.
● Adjusts lifestyle.
● Pulmonary function tests return to normal.
10. Bronchitis
● Acute or chronic inflammation of bronchus
resulting as a complication from colds and flu.
● Acute bronchitis is caused by an extension of
upper respiratory infection, such as a cold, and
●
can be given to others. It can also result from an
irritation from physical or chemical agents.
Chronic bronchitis is characterized by
hypersecretion of mucus and chronic cough for
3 months per year for 2 consecutive years.
Pathophysiology of Bronchitis
● Bronchial walls are infiltrated with lymphocytes
and macrophages; lumen becomes obstructed
due to decreased ciliary action and repeated
bronchospasms.
● Hyperventilation of alveolar sacs occurs.
● Long-term condition results in respiratory
acidosis, recurrent pneumonitis, emphysema, or
cor pulmonale.
Risk Factors:
● Smoking.
● Repeated respiratory infections.
● History of living in area where there is much air
pollution.
Assessment
Subjective data:
● History: recurrent, chronic cough, especially
when arising in the morning.
● Anorexia.
Objective data:
● Respiratory:
○ Shortness of breath.
○ Use of accessory muscles.
○ Cyanosis, dusky complexion: “blue
bloater.”
○ Sputum: excessive, nonpurulent.
○ Vesicular and bronchovesicular breath
sounds; wheezing.
● Weight loss.
● Fever.
● Pulmonary function tests:
○ Decreased forced expiratory volume.
○ PaO2 less than 90 mm Hg; PaCO2
greater than 40 mm Hg.
● Laboratory data:
○ RBC count: elevated to compensate for
hypoxia (polycythemia).
○ WBC count: elevated to fight infection.
Nursing Diagnosis
● Ineffective airway clearance related to excessive
sputum.
● Ineffective breathing pattern related to need to
use accessory muscles for breathing.
● Impaired gas exchange related to shortness of
breath.
● Activity intolerance related to increased energy
used for breathing.
Nursing Care Plan
1. Goal: assist in optimal respirations.
● Increase fluid intake.
● IPPB, chest physiotherapy.
● Administer medications as ordered:
○ Bronchodilators.
○
○
Antibiotics.
Bronchial detergents, liquefying agents.
2. Goal: minimize bronchial irritation.
● Avoid respiratory irritants (e.g., smoke, dust,
cold air, allergens).
air-conditioned,
increased
● Environment:
humidity.
● Encourage nostril breathing rather than mouth
breathing.
3. Goal: improve nutritional status.
● Diet: soft, high calorie.
● Small, frequent feedings.
4. Goal: prevent secondary infections.
● Administer antibiotics as ordered.
● Avoid exposure to infections, crowds.
5. Goal: health teaching.
● Avoid respiratory infections.
● Medications: desired effects and side effects.
● Methods to stop smoking.
● Rest and activity balance.
● Stress management.
Evaluation
● Stops smoking.
● Acid-base balance maintained.
● Respiratory infections less frequent.
11. Acute Adult Respiratory Distress Syndrome (ARDS)
● (formerly called by other names, including
shock lung).
● Noncardiogenic pulmonary infiltrations resulting
in stiff, wet lungs and refractory hypoxemia in
an adult who was previously healthy.
● Acute hypoxemic respiratory failure without
hypercapnea.
Pathophysiology of ARDS
● Damage to alveolar capillary membrane,
increased vascular permeability creating
noncardiac pulmonary edema, and impaired gas
exchange; decreased surfactant production →
atelectasis; severe hypoxia; refractory to ↑ FiO2
→ possible death.
Risk Factors
● Primary:
○ Shock, multiple trauma.
○ Infections.
○ Aspiration, inhalation of chemical
toxins.
○ Drug overdose.
○ Disseminated intravascular coagulation
(DIC).
○ Emboli, especially fat emboli.
● Secondary:
○ Overaggressive fluid administration.
○ Oxygen toxicity.
○ Mechanical ventilation.
Assessment
Subjective data:
● Restlessness, anxiety.
● History of risk factors.
● Severe dyspnea
Objective data:
● Cyanosis.
● Tachycardia.
● Hypotension.
● Hypoxemia, acidosis.
● Crackles.
● X-ray—bilateral patchy infiltrates.
● Death if untreated.
Nursing Diagnosis
● Anxiety related to serious physical condition.
● Ineffective breathing pattern related to severe
dyspnea.
● Impaired gas exchange related to alveolar
damage.
● Altered tissue perfusion related to hypoxia.
Nursing Care Plan
1. Goal: assist in respirations.
● May require mechanical ventilatory support to
maintain respirations.
● May need to be transferred to ICU.
● May need oxygen to combat hypoxia.
● Suction prn.
● Monitor blood gas results to detect early signs
of acidosis/alkalosis.
● If not on ventilator, assess vital signs and
respiratory status every 15 minutes.
● Cough, deep breathe every hour.
● May need:
○ Rotation therapy and/or prone position.
○ Postural drainage, suction.
○ Bronchodilator medications.
2. Goal: prevent complications.
● Decrease anxiety and provide psychological
care:
○ Maintain a calm atmosphere.
○ Encourage rest to conserve energy.
○ Emotional support.
● Obtain fluid balance:
○ Slow IV flow rate.
○ Diuretics: rapid acting, low dose.
● Monitor:
○ Pulmonary artery and capillary wedge
pressure cardiac output.
venous
pressure
(CVP),
○ Central
peripheral perfusion, arterial line BP.
○ I&O.
○ Assess for bleeding tendencies,
potential for disseminated intravascular
coagulation.
● Protect from infection:
○ Strict aseptic technique.
○ Antibiotic therapy.
○ Deep vein thrombosis prophylaxis.
● Provide physiological support:
● Maintain nutrition.
●
Skin care.
3. Goal: health teaching.
● Briefly explain procedures as they are
happening (emergency situation can frighten
client).
● Give rationale for follow-up care.
● Identify risk factors as appropriate for
prevention of recurrence.
Evaluation
● Client survives and is alert.
● Skin warm to touch.
● Respiratory rate within normal limits.
● Laboratory values and pressures within normal
limits.
● Urinary output greater than 30 mL/hr.
12. Pneumothorax
● Presence of air within the pleural cavity; occurs
spontaneously or as a result of trauma.
Types of Pneumothorax
● Closed (spontaneous): rupture of a subpleural
bulla, tuberculous focus, carcinoma, lung
abscess, pulmonary infarction, severe coughing
attack, or blunt trauma.
● 2. Open (traumatic): communication between
atmosphere and pleural space because of
opening in chest wall.
● 3. Tension: one-way leak; may occur during
mechanical ventilation or cardiopulmonary
resuscitation (CPR), or as a complication of any
type
of
spontaneous
or
traumatic
pneumothorax. Positive pressure within chest
cavity resulting from accumulated air that
cannot escape during expiration. Leads to
collapse of lung, mediastinal shift, and
compression of the heart and great vessels.
Pathophysiology
● Pressure builds up in the pleural space, lung on
the affected side collapses, and the heart and
mediastinum shift toward the unaffected lung.
Assessment
Subjective data:
● Pain:
○ Sharp, aggravated by activity.
○ Location—chest; may be referred to
shoulder, arm on affected side.
● Restlessness, anxiety.
● Dyspnea
Subjective data:
● Cough.
● Cessation of normal movements on affected
side.
● Absence of breath sounds on affected side.
● Pallor, cyanosis.
● Shock.
● Tracheal deviation to unaffected side.
● X-ray: air in pleural space.
Nursing Diagnosis
● Ineffective breathing pattern related to collapse
of lung.
● Impaired gas exchange related to abnormal
thoracic movement.
● Pain related to trauma to chest area.
● Fear related to emergency situation.
Nursing Care Plan
1. Goal: prevent damage until medical intervention
available.
● Place sterile occlusive gauze dressing over
wound.
● Tape dressing on three sides to allow air to
escape during expiration.
● Place client on affected side to diminish
possibility of tension pneumothorax.
2. Goal: protect against injury during thoracentesis.
● Provide sterile equipment.
● Explain procedure.
● Monitor vital signs for shock.
● Monitor for respiratory distress, mediastinal
shift.
3. Goal: promote respirations.
● Position: Fowler’s.
● Oxygen therapy as ordered.
● Encourage slow breathing to improve gas
exchange.
● Careful administration of narcotics to prevent
respiratory depression (avoid morphine).
4. Goal: prepare client for closed chest drainage,
physically and psychologically.
● Explain purpose of the procedure—to provide
means for evacuation of air and fluid from
pleural cavity; to reestablish negative pressure
in pleural space; to promote lung reexpansion.
● b. Explain procedure and apparatus.
● Cleanse skin at tube insertion site; place client
in sitting position, ensuring safety by having
locked over-the-bed table for client to lean on,
or have a nurse stay with client so appropriate
position is maintained throughout the
procedure.
5. Goal: prevent complications with chest tubes.
● Observe for and immediately report:
crepitations (air under skin, also called
subcutaneous emphysema), labored or shallow
breathing, tachypnea, cyanosis, tracheal
deviation, or signs of hemorrhage.
● Monitor for signs of infection.
● Ensure that tubing stays intact.
● Monitor proper tube function.
● Change position every 1 to 2 hours.
● Arm and shoulder ROM.
6. Goal: health teaching.
● How to prevent recurrence by avoiding
overexertion; avoid holding breath.
● Signs and symptoms of condition.
● Methods to stop smoking.
●
○
○
○
Encourage follow-up care.
Evaluation
● No complications noted.
● Closed system remains intact until chest tubes
are removed.
● Lung reexpands, breath sounds heard, pain
diminished, symmetrical thoracic movements.
●
●
13. Hemothorax
● presence of blood in the pleural cavity related
to trauma or ruptured aortic aneurysm.
Hemothorax vs. Pneumothorax
Pneumothorax
● Cause:
enters
without
○ Spontaneous—air
trauma; rupture of bleb (vesicle) on
pleura; non–life threatening.
○ Traumatic—open chest wound: life
threatening;
closed
chest
wound—usually non–life threatening
unless untreated Tension—air cannot
escape via route of entry; causes
atelectasis.
● Assessment findings:
○ Minimal to sudden onset; sharp chest
pain; dyspnea; cough; hypotension;
tachypnea; tachycardia; mediastinal
shift (tracheal deviation)
Hemothorax
● Cause:
○ Blunt trauma (assaults, falls)
○ Penetrating trauma (knives, gunshot
wounds)
● Assessment findings
○ Asymptomatic or pleuritic pain and
dyspnea; decreased or absent breath
sounds; often discovered during chest
x-ray; in severe cases: shock
14. Chest Trauma
Types:
● Flail chest: multiple rib fractures resulting in
instability of the chest wall, with subsequent
paradoxical breathing (portion of lung under
injured chest wall moves in on inspiration while
remaining lung expands; on expiration, the
injured portion of the chest wall expands while
unaffected lung tissue contracts).
● Sucking chest wound: penetrating wound of
chest wall with hemothorax and pneumothorax,
resulting in lung collapse and mediastinal shift
toward unaffected lung.
Assessment
Subjective data:
● Severe, sudden, sharp pain.
● Dyspnea.
● Anxiety, restlessness, fear, weakness.
Objective data:
● Vital signs:
●
●
●
●
●
Pulse: tachycardia, weak.
BP: hypotension.
Respirations:
shallow,
decreased
expiratory force, tachypnea, stridor,
accessory muscle breathing.
Skin color: cyanosis, pallor.
Chest:
chest
expansion
○ Asymmetrical
(paradoxical movement).
○ Chest wound, rush of air through
trauma site.
○ Crepitus over trauma site (from air
escaping into surrounding tissues).
○ Lateral deviation of trachea, mediastinal
shift.
Pneumothorax: documented by absence of
breath sounds, x-ray examination.
Hemothorax: documented by needle aspiration
by physician, x-ray examination.
Shock; blood and fluid loss.
Hemoptysis.
Distended neck veins.
Nursing Diagnosis
● Ineffective airway clearance related to shallow
respirations.
● Impaired gas exchange related to asymmetrical
chest expansion.
● Pain related to chest trauma.
● Fear related to emergency situation.
● Risk for trauma related to fractured ribs.
● Risk for infection related to open chest wound.
Nursing Care Plan
1. Goal: restore adequate ventilation and prevent
further air from entering pleural cavity: MEDICAL
EMERGENCY.
● In emergency situation: place air-occlusive
dressing or hand over open wound as client
exhales forcefully against glottis (Valsalva
maneuver helps expand collapsed lung by
creating positive intrapulmonary pressures); or
place client’s weight onto affected side.
Administer oxygen.
● Assist with endotracheal tube insertion; client
will be placed on volume-controlled ventilator.
● Assist with thoracentesis and insertion of chest
tubes with connection to water-seal drainage as
ordered.
● Monitor vital signs to determine early shock.
● Monitor blood gases to determine early
acid-base imbalances.
● Pain medications given with caution, so as not
to depress respiratory center.
Evaluation
● Respiratory status stabilizes, lung reexpands.
● Shock and hemorrhage are prevented.
● No further damage done to surrounding tissues.
● Pain is controlled.
15. Thoracic Surgery
● Used for bronchogenic and lung carcinomas,
lung abscesses, tuberculosis, bronchiectasis,
emphysematous blebs, and benign tumors.
Types
● Thoracotomy—incision in the chest wall, pleura
is entered, lung tissue examined, biopsy
secured. Chest tube is needed postoperatively.
● Lobectomy—removal of a lobe of the lung.
Chest tube is needed postoperatively.
● Pneumonectomy—removal of an entire lung.
No chest tube is needed postoperatively.
Nursing Diagnosis
● Risk for injury related to chest wound.
● Impaired gas exchange related to pain from
surgical procedure.
● Ineffective airway clearance related to
decreased willingness to cough due to pain.
● Pain related to surgical incision.
● Impaired physical mobility related to large
surgical incision and chest tube drainage
apparatus.
● Knowledge deficit (learning need) related to
importance of coughing and deep breathing to
prevent complications.
Nursing Care Plan
Preoperative care
1. Goal: minimize pulmonary secretions.
● Humidify air to moisten secretions.
● Use IPPB, as ordered, to improve ventilation.
● Administer bronchodilators, expectorants, and
antibiotics as ordered.
● Use postural drainage, cupping, and vibration to
mobilize secretions.
2. Goal: preoperative teaching.
● Teach client to cough against a closed glottis to
increase intrapulmonary pressure for improved
expiratory phase.
● Instruct in diaphragmatic breathing and
coughing.
● Encourage to stop smoking.
● Instruct and supervise practice of postoperative
arm exercises—flexion, abduction, and rotation
of shoulder—to prevent ankylosis.
● Explain postoperative use of chest tubes, IV, and
oxygen therapy.
Postoperative care:
1. Goal: maintain patent airway.
● Auscultate chest for breath sounds; report
diminished or absent breath sounds on
unaffected side (indicates decreased ventilation → respiratory embarrassment).
● Turn, cough, and deep breathe, every 15
minutes to 1 hour for first 24 hours and prn
according to pulmonary conges- tion heard on
auscultation.
2. Goal: promote gas exchange.
● Splint chest during coughing—support incision
to help cough up sputum (most important
activity postoperatively).
● Position: high-Fowler’s.
○ Turn client who has had a
pneumonectomy to operative side
(avoid extreme lateral positioning and
mediastinal shift) to allow unaffected
lung expan- sion and drainage of
secretions; can also be turned onto
back.
○ Client who has had a lobectomy or
thoracotomy can be turned on either
side or back because chest tubes will be
in place.
3. Goal: reduce incisional stress and discomfort
● Pad area around chest tube when turning on
operative side to maintain tube patency and
promote comfort.
4. Goal: prevent complications related to respiratory
function.
● Maintain chest tubes to water-seal drainage
system.
● Observe for mediastinal shift (trachea should
always be midline; movement toward either
side indicates shift).
○ Move client onto back or toward
opposite side.
○ MEDICAL EMERGENCY: Notify physician
immediately.
5. Goal: maintain fluid and electrolyte balance.
● Administer parenteral infusion slowly (risk of
pulmonary edema due to decrease in
pulmonary vasculature with removal of lung
lobe or whole lung).
6. Goal: postoperative teaching.
● Prevent ankylosis of shoulder—teach passive
and active ROM exercises of operative arm.
● Importance of early ambulation, as condition
permits.
● Importance of stopping smoking.
● Dietary instructions—nutritious diet to aid in
healing process.
● Importance of deep breathing, coughing
exercises, to prevent stasis of respiratory
secretions.
● Importance of increased fluids in diet to liquefy
secretions.
● Desired and side effects of prescribed
medications.
● Importance of rest, avoidance of heavy lifting
and work during healing process.
● Importance of follow-up care; give names of
referral agencies where client and family can
obtain assistance.
● Signs and symptoms of complications.
Evaluation
● Client or significant other or both will be able
to:
○ Give rationale for activity restriction and
demonstrate prescribed exercises.
○ Identify name, dosage, side effects, and
schedule of prescribed medications.
○ State plans for necessary modifications
in lifestyle, home.
○ Identify support systems.
● Wound heals without complications.
● Obtains ROM in affected shoulder.
● No complications of thoracotomy, such as:
○ Respiratory: pulmonary insufficiency,
respiratory
acidosis,
pneumonitis,
atelectasis, pulmonary edema.
○ Circulatory: hemorrhage, hypovolemia,
shock, myocardial infarction.
○ Mediastinal shift.
○ Renal failure.
○ Gastric distention.
16. Tracheostomy
● Opening into trachea, temporary or permanent.
● Rationale: airway obstruction due to foreign
body, edema, tumor, excessive tracheobronchial
secretions, respiratory depression, decreased
gaseous diffusion at alveolar membrane,
increased dead space (e.g., severe emphysema),
or failure to wean from mechanical ventilator.
Nursing Diagnosis
● Ineffective airway clearance related to increased
secretions and decreased ability to cough
effectively.
● Ineffective breathing pattern related to physical
condition that necessitated tracheostomy.
● Impaired verbal communication related to
inability to speak when tracheostomy tube cuff
inflated.
● Fear related to need for specialized equipment
to breathe.
Nursing Care Plan
Preoperative care:
1. Goal: relieve anxiety and fear.
● Explain purpose of procedure and equipment.
● Demonstrate suctioning procedure.
means
of
postoperative
● Establish
communication (e.g., paper and pencil, “magic
slate,” picture cards, and call bell). Specialized
tubes such as a fenestrated tracheostomy tube
or a tracheostomy button allow the individual to
talk when the external opening is plugged.
● Remain with client as much as possible.
Postoperative care:
1. Goal: maintain patent airway
2. Goal: alleviate apprehension.
● Remain with client as much as possible.
● Encourage client to communicate feelings using
preestablished communication system.
3. Goal: improve nutritional status.
● Provide nutritious foods/liquids the client can
swallow.
● Give supplemental drinks to maintain necessary
calories.
4. Goal: health teaching.
● Explain all procedures.
● Teach alternative methods of communication
(best if done before the tracheostomy if it is not
an emergency situation).
● Teach self-care of tracheostomy as soon as
possible.
Evaluation
● Airway patent.
● Acid-base balance maintained.
● No respiratory infection/obstruction.
A4. Care of Clients with Alterations in Endocrine &
Metabolism
From Davis NCLEX RN Success 3rd Edition
1. Diabetes Mellitus
● Heterogeneous group of diseases involving the
disruption of the metabolism of carbohydrates,
fats, and protein. If uncontrolled, serious
vascular and neurological changes occur.
Types
● Type 1: formerly called insulin-dependent diabetes mellitus (IDDM); and also formerly called
“juvenile-onset diabetes.”
○ Insulin is needed to prevent ketosis;
onset usually in youth but may occur in
adulthood; prone to ketosis, unstable
diabetes.
● Type 2: formerly called non–insulin-dependent
diabetes mellitus (NIDDM); and also formerly
called “maturity-onset diabetes” or “adult-onset
diabetes.”
○ May be controlled with diet and oral
hypoglycemics or insulin; client less apt
to have ketosis, except in presence of
infection. May be further classified as
obese type 2 or nonobese type 2.
● Type 3: gestational diabetes mellitus (GDM):
glucose intolerance during pregnancy in women
who were not known to have diabetes before
pregnancy; will be reclassified after birth; may
need to be treated or may return to
prepregnancy state and need no treatment.
● Type 4: diabetes secondary to another
condition, such as pancreatic disease, other
hormonal imbalances, or drug therapy such as
receiving glucocorticoids.
Pathophysiology
● Type 1: absolute deficiency of insulin due to
destruction of pancreatic beta cells by the interaction of genetic, immunological, hereditary, or
environmental factors.
● Type 2: relative deficiency of insulin due to: a.
An islet cell defect resulting in a slowed or
delayed response in the release of insulin to a
glucose load; or
○ Reduction in the number of insulin
receptors from continuously elevated
insulin levels; or
○ A postreceptor defect; or
○ A major peripheral resistance to insulin
induced by hyperglycemia. These
factors lead to deprivation of
insulin-dependent cells → a marked
decrease in the cellular rate of glucose
uptake, and therefore elevated blood
glucose.
Risk Factors
● Obesity.
● Family history of diabetes.
● Age 45 or older.
● Women whose babies at birth weighed more
than 9 lb.
● History of autoimmune disease.
● Members of high-risk ethnic group (African
American, Latino, or Native American).
● History of gestational diabetes mellitus.
● Hypertension.
● Elevated high-density lipoprotein (HDL).
Assessment
Subjective data:
● Eyes: blurry vision.
● Skin: pruritus vulvae.
paresthesia,
peripheral
● Neuromuscular:
neuropathy, lethargy, weakness, fatigue,
increased irritability.
● GI: polydipsia (increased thirst).
● Reproductive: impotence.
Objective data:
● Genitourinary: polyuria, glycosuria, nocturia
(nocturnal enuresis in children).
● Vital signs:
○ Pulse and temperature: normal or
elevated.
○ BP: normal or decreased, unless
complications present.
○ Respirations: increased rate and depth
(Kussmaul’s respirations).
● GI:
○ Polyphagia, dehydration.
○ Weight loss, failure to gain weight.
○ Acetone breath.
● Skin: cuts heal slowly; frequent infections, foot
ulcers, vaginitis.
● Neuromuscular: loss of strength, peripheral
neuropathy.
Laboratory data:
● Elevated:
○ Blood sugar greater than 126 mg/dL
fasting or 200 mg/dL 1 to 2 hours after
eating.
○ Glucose tolerance test.
○ Glycosuria (>170 mg/100 mL).
○
●
Potassium (>5 mg/dL) and chloride
(>145 mg/dL).
○ Hemoglobin A1c greater than 7%.
Decreased:
○ pH (<7.4).
○ PaCO2 (<32).
Long term pathological considerations:
● Cataract formation and retinopathy: thickened
capillary basement membrane, changes in
vascularization and hemorrhage, due to chronic
hyperglycemia.
● Nephropathy: due to glomerulosclerosis,
arteriosclerosis
of
renal
artery
and
pyelonephritis, progressive uremia.
● Neuropathy: due to reduced tissue perfu- sion;
affecting motor, sensory, voluntary, and
autonomic functions.
● Arteriosclerosis: due to lesions of the intimal
wall.
angina,
coronary
insufficiency,
● Cardiac:
myocardial infarction.
● Vascular changes: occlusions, intermittent
claudication, loss of peripheral pulses,
arteriosclerosis.
Nursing Diagnosis
● Altered nutrition, less than body requirements,
related to inability to metabolize nutrients and
weight loss.
nutrition,
more
than
body
● Altered
requirements, related to excessive glucose
intake.
● Risk for injury related to complications of
uncontrolled diabetes.
● Body image disturbance related to long-term
illness.
● Knowledge deficit (learning need) related to
management of long-term illness and potential
complications.
● Ineffective individual coping related to inability
to follow diet/medication regimen.
● Sexual dysfunction related to impotence from
diabetes and treatment.
Nursing Care Plan
1. Goal: obtain and maintain normal sugar balance.
● Monitor: vital signs; blood glucose before meals,
at bedtime, and as symptoms demand (urine
testing for glucose levels is not as accurate as
capillary blood testing).
● Diet, as ordered.
○ Carbohydrate, 50% to 60%; protein,
20%; fats, 30% (saturated fats limited to
10%, unsaturated fats, 90%).
○ Calorie reduction in adults who are
obese; enough calories to promote
normal growth and development for
children or adults who are not obese.
○ Limit refined sugars.
○ Add vitamins, minerals as needed for
well-balanced diet.
● Monitor for signs of acute (hypoglycemia,
ketoacidosis)
or
chronic
(circulatory
compromise,
neuropathy,
retinopathy) complications.
nephropathy,
●
●
Medications:
● Oral hypoglycemics:
○ Sulfonylureas; tolbutamide (Orinase),
chlorpropamide
(Diabenese),
tolazamide (Tolinase), acetohexamide
(Dymelor),
glimepiride
(Amaryl),
glyburide (DiaBeta and Micronase), and
glipizide (Glucocotrol).
metformin
(Glucophage)
○ Others:
increases body’s sensitivity to insulin.
Acarbose (Precose) inhibits cells of the
small intestine from absorbing complex
carbohydrates.
● Insulin (biosynthetic human insulin): bolus
insulin—released in response to meals; basal
insulin—released between meals, at nighttime.
○ Rapid-acting bolus analogue of human
insulin (Lispro, Aspart).
○ Short-acting bolus (crystalline, regular)
(Humulin R).
○ Intermediate-acting basal (Lente and
NPH).
○ Slow acting (protamine zinc). (e) Long,
extended-acting basal (Ultralente).
○ Long-acting basal analogue (Glargine).
● Methods of administration:
○ Subcutaneous injection. (b)Prefilled
injectable insulin pens (Novopen and
Novolin).
subcutaneous
insulin
○ Continuous
infusion therapy (insulin pumps).
2. Goal: health teaching
● Diet: foods allowed, restricted, substitutions.
administration
techniques,
● Medications:
importance of using room-temperature insulin
and rotating injection sites to prevent tissue
damage.
● Desired and side effects of prescribed insulin
type; onset, peak, and duration of action of
prescribed insulin.
● Blood glucose testing techniques.
● Signs of complications.
● Importance of health maintenance:
○ Infection prevention, especially foot and
nail care.
○ Routine checkups.
○ Maintain stable balance of glucose by
carefully monitoring glucose level and
making necessary adjustments in diet
and activity level; seeking medical
attention when unable to maintain
balance; regular exercise program.
Evaluation
● Optimal blood-glucose levels achieved.
● Ideal weight maintained.
● Adequate hydration.
● Carries out self-care activities: blood testing,
foot care, exchange diets, medication
administration, exercise.
Recognizes and treats hyperglycemic
hypoglycemic reactions.
Seeks medical assistance appropriately.
or
Complications of Diabetes Mellitus
1. Hypoglycemia
Pathophysiology
● Major metabolic complication when too little
food or too-large dose of insulin or
hypoglycemic agents administered; interferes
with oxygen consumption of nervous tissue.
Risk Factors
● Too little food
● Emotional or added stress
● Vomiting or diarrhea Added exercise
Assessment
● Behavioral change:
○ Subjective data—nervous, irritable,
anxious,
confused,
disoriented
Objective data—abrupt mood changes,
psychosis
● Visual:
data—blurred
vision,
○ Subjective
diplopia Objective data—dilated pupils
● Skin:
○ Objective data—diaphoresis, pale, cool,
clammy, goosebumps (piloerection),
tenting
● Vitals:
○ Subjective data—palpitations
● Gastrointestinal:
○ Subjective data—hunger, nausea
○ Objective data—diarrhea, vomiting
● Neurological:
data—headache;
○ Subjective
lips/tongue: tingling, numbness
○ Objective data—fainting, yawning;
speech: incoherent; convulsions; coma
● Musculoskeletal:
○ Subjective data—weak, fatigue
○ Objective data—trembling
● Blood sugar: <80 mg/dL
Nursing Diagnosis
● Risk for injury related to deficit of needed
glucose
● Knowledge deficit (learning need) related to
proper dietary intake or proper insulin dosage
● Altered nutrition, less than body requirements,
related to glucose deficiency
Nursing Care Plan
● Goal: provide adequate glucose to reverse
hypoglycemia: administer simple sugar STAT, PO
or IV, glucose paste absorbed in mucous
membrane; monitor blood sugar levels; identify
events leading to complication
● Goal: health teaching: how to prevent further
episodes; importance of careful monitoring of
balance between glucose levels and insulin
dosage.
Evaluation
● Adheres to diet and correct insulin criteria
dosage
● Adjusts dosage when activity is increased
● Glucose level: 80–120 mg/dL
2. Ketoacidosis
Pathophysiology
● Major metabolic complication in which there is
insufficient insulin for metabolism of
carbohydrates, fats, and proteins; seen most
frequently with clients who are insulin
dependent; precipitated in the person with
known diabetes by stressors (such as infection,
trauma, major illness) that increase insulin
needs.
Risk factors
● Insufficient insulin or oral hypoglycemics
● Noncompliance with dietary instructions
● Major illness/infections
● Therapy with steroid administration
● Trauma, surgery
● Elevated blood sugar: >200 mg/dL
Assessment
● Behavioral change:
○ Subjective data—irritable, confused
Objective data—drowsy
● Visual:
○ Objective data—eyeballs: soft, sunken
● Skin:
○ Objective data—loss of turgor, flushed
face, pruritus vulvae
● Vitals:
○ Objective data— tachycardia; thready;
respirations:
Kussmaul’s;
BP:
hypovolemic shock
● Gastrointestinal:
○ Subjective data—increased thirst and
hunger, abdominal pain, nausea
○ Objective data—vomiting, diarrhea, dry
mucous membrane; lips, tongue: red,
parched; breath: fruity
● Neurological:
○ Subjective data—headache; irritability;
confusion; lethargy, weakness
● Musculoskeletal
data—fatigue;
general
○ Subjective
malaise
● Renal:
○ Objective data—polyuria
● Blood sugar: >130 mg/dL
Nursing DIagnosis
● Risk for injury related to glucose imbalance
● Knowledge deficit (learning need) related to
proper balance of diet and insulin dosage
Nursing Care Plan
● Goal: promote normal balance of food and
insulin: regular insulin as ordered; IV saline, as
ordered;
bicarbonate
and
electrolyte
replacements,
as
ordered;
potassium
●
replacements once therapy begins and urine
output is adequate
Goal: health teaching: diet instructions, desired
effects and side effects of prescribed insulin or
hypoglycemic agent (onset, peak, and duration
of action); importance of recognizing signs of
imbalance
Evaluation
● Accepts prescribed diet
● Takes medication (correct dose and time)
● Serious complications avoided
● Glucose level: 80–120 mg/dL
2. Nonketotic Hyperglycemic Hyperosmolar Coma
● Profound hyperglycemia and dehydration
without ketosis or ketoacidosis; seen in type 2
diabetes; brought on by infection or illness.
● This condition may lead to impaired
consciousness and seizures. The client is
critically ill. Mortality rate is over 50%.
Pathophysiology
● Hyperglycemia greater than 1,000 mg/dL causes
osmotic diuresis, depletion of extracellular fluid,
and hyperosmolarity related to infection or
another stressor as the precipitating factor.
● Client unable to replace fluid deficits with oral
intake.
Risk factors
● Old age.
● History of non–insulin-dependent diabetes.
pneumonia,
pyelonephritis,
● Infections:
pancreatitis, gram-negative infections.
● Kidney failure: uremia and peritoneal dialysis or
hemodialysis.
● Shock:
○ Lactic acidosis related to bicarbonate
deficit.
○ Myocardial infarction.
● Hemorrhage:
○ GI.
○ Subdural.
○ Arterial thrombosis.
● Medications:
○ Diuretics.
○ Glucocorticoids.
● Tube feedings.
Assessment
Subjective data:
● Confusion.
● Lethargy.
Objective data:
● Nystagmus.
● Dehydration.
● Aphasia.
● Nuchal rigidity.
● Hyperreflexia.
Laboratory data
● Blood glucose level greater than 1,000 mg/dL.
●
●
●
Serum sodium and chloride—normal to
elevated.
BUN greater than 60 mg/dL (higher than in
ketoacidosis because of more severe
gluconeogenesis and dehydration).
Arterial pH—slightly depressed.
Nursing Diagnosis
● Risk for injury related to hyperglycemia.
● Altered renal peripheral tissue perfusion related
to vascular collapse.
● Ineffective airway clearance related to coma.
Nursing Care Plan
1. Goal: promote fluid and electrolyte balance.
● IVs: fluids and electrolytes, sodium chloride
solution used initially to combat dehydra- tion.
Rate of infusion will be determined by: BP
assessment, cardiovascular status, balance
between fluid input and output, and laboratory
values.
● Monitor I&O because of the high volume of
fluid replaced in the critical stage of this
condition.
● Administer nursing care for the problem that
precipitated this serious condition.
● Diet: Food by mouth when client is able.
2. Goal: prevent complications.
● Administer regular insulin (initial dose usually 5
to 15 units) and food, as ordered.
Uncontrolled condition leads to: cardiovascular
disease, renal failure, blindness, and diabetic
gangrene.
Evaluation
● Blood sugar returns to normal level of 80 to 120
mg/dL.
● Client is alert to time, place, and person.
● Primary medical problem resolved.
● Client recognizes and reports signs of
imbalance.
3. Hyperthyroidism
● Also called thyrotoxicosis; Graves’ disease
● Spectrum of symptoms of accelerated
metabolism caused by excessive amounts of
circulating thyroid hormone.
● Graves’ disease is most common cause of
hyperthyroidism.
● The three components of Graves’ disease are:
(1) hyperthyroidism, (2) ophthalmopathy
(protrusion of the eyes), and (3) skin lesions
(dermopathy).
● Graves’ disease is triggered by: stress, smoking,
radiation of the neck, some medications
(interleukin-2), and infections.
● Treatment of hyperthyroidism is accomplished
by antithyroid medications, radioactive iodine
administration (capsule given once), or surgery.
● Clients may need to take supplemental thyroid
hormone (levothyroxine) after treatment.
Pathophysiology
● Diffuse hyperplasia of thyroid gland →
overproduction of thyroid hormone and
increased blood serum levels.
● Hormone stimulates mitochondria to increase
energy for cellular activities and heat
production.
● As metabolic rate increases, fat reserves are
utilized, despite increased appetite and food
intake.
● Cardiac output is increased to meet increased
tissue metabolic needs, and peripheral
vasodilation occurs in response to increased
heat production.
● Neuromuscular hyperactivity → accentuation of
reflexes, anxiety, and increased alimentary tract
mobility.
● Graves’ disease is caused by stimulation of the
gland by immunoglobulins of the IgG class.
Risk Factors
● Possible autoimmune response resulting in
increase of a gamma globulin called long-acting
thyroid stimulator (LATS).
● Occurs in third and fourth decade.
● Affects women more than men.
● Emotional trauma, infection, increased stress.
● Overdose of medications used to treat
hypothyroidism.
● Use of certain weight-loss products.
● Radiation of neck.
Assessment
Subjective data:
● Nervousness, mood swings.
● Palpitations.
● Heat intolerance.
● Dyspnea.
● Weakness.
Objective data:
● Eyes: exophthalmos, characteristic stare, lid lag.
● Skin:
○ Warm, moist, velvety.
○ Increased sweating; increased melanin
pigmentation.
○ Pretibial edema with thickened skin and
hyperpigmentation.
● Weight: loss of weight despite increased
appetite.
● Muscle: weakness, tremors, hyperkinesia.
● Vital signs: BP—increased systolic pressure,
widened pulse pressure; tachycardia.
● Goiter: thyroid gland noticeable and palpable.
● Gynecological: abnormal menstruation.
● GI: frequent bowel movements.
● Activity pattern: overactivity leads to fatigue,
which leads to depression, which stimulates
client into overactivity, and pattern continues.
Danger: total exhaustion.
Laboratory data:
● Elevated: serum thyroxine (T4) (>11 mcg/100
mL), free T4 or free T4 index, triiodothyronine
(T3) level (>35%) and free T3 level.
● Elevated: radioactive iodine uptake (RAIU) by
thyroid.
● Elevated: basal metabolic rate (BMR).
● Decreased: WBC count caused by decreased
granulocytosis (<4,500).
Nursing Diagnosis
● Altered nutrition, less than body requirements,
related to elevated basal metabolic rate.
● Risk for injury related to exophthalmos and
tremors.
● Activity intolerance related to fatigue from
overactivity.
● Fatigue related to overactivity.
● Anxiety related to tachycardia.
● Sleep pattern disturbance related to excessive
amounts of circulating thyroid hormone.
Nursing Care Plan
1. Goal: protect from stress: private room, restrict
visitors, quiet environment.
2. Goal: promote physical and emotional equilibrium.
● Environment: quiet, cool, well ventilated.
● Eye care:
to
protect
from
○ Sunglasses
photophobia, dust, wind.
○ Protective drops (methylcellulose) to
soothe exposed cornea.
● Diet:
○ High: calorie, protein, vitamin B.
○ 6 meals/day, as needed.
○ Weigh daily.
○ Avoid stimulants (coffee, tea, colas,
tobacco).
3. Goal: prevent complications.
● Medications as ordered:
○ Propylthiouracil to block thyroid
synthesis; hyperthyroidism returns
when therapy is stopped.
○ Methimazole (Tapazole) to inhibit
synthesis of thyroid hormone.
preparations:
used
in
○ Iodine
combination with other medications
when hyperthyroidism not well
controlled; saturated solution of
potassium iodide (SSKI) or Lugol’s
solution; more palatable if diluted with
water, milk, or juice; give through a
straw to prevent staining teeth. Takes 2
to 4 weeks before results are evident.
(Inderal),
atenolol
○ Propranolol
(Tenormin), metoprolol (Lopressor)
given to counteract the increased
metabolic effect of thyroid hormones,
but do not alter their levels. Relieve the
symptoms of tachycardia, tremors, and
anxiety.
●
Monitor for thyroid storm (crisis)—medical
emergency: acute episode of thyroid
overactivity caused when increased amounts of
thyroid hormone are released into the
bloodstream and metabolism is markedly
increased.
Risk factors for thyroid storm: client with uncontrolled
hyperthyroidism (usually Graves’ disease) who
undergoes severe sudden stress, such as:
● Infection.
● Surgery.
● Beginning labor to give birth.
● Taking inadequate antithyroid medications
before thyroidectomy.
Assessment for thyroid storm:
● Subjective data—thyroid storm:
○ Apprehension.
○ Restlessness.
● Objective data—thyroid storm:
○ Vital signs: elevated temperature
(106°F),
hypotension,
extreme
tachycardia.
○ Marked respiratory distress, pulmonary
edema.
○ Weakness and delirium.
○ If untreated, client could die of heart
failure.
Medications for thyroid storm:
● Propylthiouracil or methimazole (Tapazole) to
decrease synthesis of thyroid hormone.
● Sodium iodide IV; Lugol’s solution orally to
facilitate thyroid hormone synthesis.
● Propranolol (Inderal) to slow heart rate.
● Aspirin to decrease temperature.
● Steroids to combat crisis.
● Diuretics, digitalis to treat heart failure.
4. Goal: health teaching.
● Stress-reduction techniques.
● Importance of medications, their desired effects
and side effects.
● Methods to protect eyes from environmental
damage.
● Signs and symptoms of thyroid storm
5. Goal: prepare for additional treatment as needed.
● Radioactive iodine therapy: 131I, a radioactive
isotope of iodine to decrease thyroid activity.
○ 131I dissolved in water and given by
mouth.
○ Hospitalization necessary only when
dose is administered.
○ Minimal precautions needed for usual
dose.
■ Sleep alone for several nights.
■ Flush toilet several times after
use.
○ Effectiveness of therapy seen in 2 to 3
weeks; single dose controls 90% of
clients.
○ Monitor for signs of hypothyroidism.
●
Surgery (see IV. THYROIDECTOMY following).
crowing voice sound indicates laryngeal nerves
on both sides have been injured; respiratory
distress possible from swelling.
○ Avoid unnecessary talking to lessen
hoarseness.
alternative
means
of
○ Provide
communication.
Evaluation
● Complications avoided.
● Compliance with medical regimen.
● No further weight loss.
● Able to obtain adequate sleep.
4. Thyroidectomy
● Partial removal of
hyperthyroidism) or
malignancy of thyroid).
thyroid gland
total removal
Risk Factors
medical
● Unsuccessful
hyperthyroidism.
treatment
(for
(for
of
Nursing Diagnosis
● Risk for injury related to possible trauma to
parathyroid gland during surgery.
● Ineffective breathing pattern related to neck
incision.
● Pain related to surgical incision.
● Altered nutrition, less than body requirements,
related to difficulty in swallowing because of
neck incision.
● Impaired verbal communication related to
possible trauma to nerve during surgery.
● Risk for altered body temperature related to
thyroid storm.
Nursing Care Plan
Postoperative:
1. Goal: promote physical and emotional equilibrium.
● Position: semi-Fowler’s to reduce edema.
● Immobilize head with pillows or sandbags.
● Support head during position changes to avoid
stress on sutures, prevent flexion or
hyperextension of neck.
2. Goal: prevent complications of hypocalcemia and
tetany, due to accidental trauma to parathyroid gland
during surgery; signs of tetany indicate necessity of
calcium gluconate IV.
● Check Chvostek’s sign—tapping face in front of
ear produces spasm of facial muscles.
● Check Trousseau’s sign—compression of upper
arm (usually with BP cuff) elicits carpal (wrist)
spasm.
● Monitor for respiratory distress (due to
laryngeal nerve injury, edema, bleeding); keep
tracheostomy set or suction equipment at
bedside.
● Monitor for elevated temperature, indicative of
thyroid storm.
● Monitor vital signs, check dressing and beneath
head, shoulders for bleeding q1h and prn for 24
hours; hemorrhage is possible complication; if
swallowing is difficult, loosen dressing. If client
still complains of tightness when dressing is
loosened, look for further signs of hemorrhage.
● Check voice postoperatively as soon as
responsive after anesthesia and every hour
(assess for possible laryngeal nerve damage);
3. Goal: promote comfort measures.
● Narcotics as ordered.
● Offer iced fluids.
● Ambulation and soft diet, as tolerated.
4. Goal: health teaching.
● How to support neck to prevent pressure on
suture line: place both hands behind neck when
moving head or coughing.
● Signs of hypothyroidism; needs supplemental
thyroid hormone if total thyroidectomy.
● Signs and symptoms of hemorrhage and
respiratory distress.
● Importance of adequate rest and nutritious diet.
● Importance of voice rest in early recuperative
period.
Evaluation
● No respiratory distress, hemorrhage, laryngeal
damage, tetany.
● Preoperative symptoms relieved.
● Normal range of neck motion obtained.
● States signs and symptoms of possible
complications.
5. Hypothyroidism
● Deficiency of circulating thyroid hormone; often
a final consequence of Hashimoto’s thyroiditis
and Graves’ disease.
Pathophysiology
● Atrophy, destruction of gland by endogenous
antibodies or inadequate pituitary thyrotropin
production → insidious slowing of body
processes, personality changes, and generalized,
interstitial nonpitting (mucinous) edema—
myxedema; pronounced involvement in systems
with high protein turnover (e.g., cardiac, GI,
reproductive, hematopoietic).
Risk Factors
● Total thyroidectomy; inadequate replacement
therapy.
● Inherited autosomal recessive gene coding for
disorder.
● Hypophyseal failure.
● Dietary iodine deficiencies.
● Irradiation of thyroid gland.
● Overtreatment of hyperthyroidism.
● Chronic lymphocytic thyroiditis.
● Postpartum thyroiditis.
● Viral thyroiditis.
● Medications, such as amiodarone HCl
(Cordarone), used to treat abnormal heart
rhythms.
Assessment
Subjective data:
● Weakness, fatigue, lethargy.
● Headache.
● Slow memory, psychotic behavior.
● Loss of interest in sexual activity.
Objective data:
● Depressed basal metabolic rate (BMR).
bradycardia,
hypotension,
● Cardiomegaly,
anemia.
● Menorrhagia, amenorrhea, infertility.
● Dry skin, brittle nails, coarse hair, hair loss.
● Slow speech, hoarseness, thickened tongue.
● Weight gain: edema, generalized interstitial;
peripheral nonpitting; periorbital puffiness.
● Intolerance to cold.
● Hypersensitive to narcotics and barbiturates.
Laboratory data:
● Elevated: thyroid-releasing hormone (TRH),
thyroid-stimulating hormone (TSH), cholesterol
(>220 mg/dL), lipids (>850 mg/dL), protein (>8
gm/dL).
● Normal-low: serum thyroxine (T4), serum
triiodothyronine (T3).
● Decreased: radioactive iodine uptake (RAIU).
Nursing Diagnosis
● Risk for injury related to hypersensitivity to
drugs.
nutrition,
more
than
body
● Altered
requirements, related to decreased BMR.
● Activity intolerance related to fatigue.
● Constipation related to decreased peristalsis.
cardiac
output related to
● Decreased
hypotension and bradycardia.
● Risk for impaired skin integrity related to dry
skin and edema.
● Social isolation related to lethargy.
Nursing Care Plan
1. Goal: provide for comfort and safety.
● Monitor for infection or trauma; may precipitate
myxedema coma, which is manifested by:
unresponsiveness, bradycardia, hypoventilation,
hypothermia, and hypotension.
● Provide warmth; prevent heat loss and vascular
collapse.
● Administer thyroid medications as ordered:
levothyroxine (Synthroid)—most common drug
used; liothyronine sodium (Cytomel); dosage
adjusted according to symptoms.
2. Goal: health teaching.
● Diet: low calorie, high protein.
● Signs and symptoms of hypothyroidism and
hyperthyroidism.
● Lifelong medications, dosage, desired effects
and side effects.
● Medication dosage adjustment: take one third
to one half the usual dose of narcotics and
barbiturates.
●
Stress-management
program.
techniques.
f. Exercise
Evaluation
● No complications noted. Most common
complications: atherosclerotic coronary heart
disease, acute organic psychosis, and myxedema
coma.
● Dietary instructions followed.
● Medication regimen followed.
● Thyroid hormone balance obtained and
maintained.
6. Cushing’s Disease
endogenous
overproduction
of
● An
adrenocorticotropic hormone (ACTH) that can
be caused by pituitary-dependent adenomas.
● Cushing’s syndrome: condition marked by
chronic excessive circulating cortisol with or
without pituitary involvement.
● One of the most common causes of Cushing’s
syndrome is the administration of cortisone-like
medications for treatment of a variety of
conditions.
Pathophysiology
● Excess glucocorticoid production, leading to:
○ Increased gluconeogenesis → raised
serum glucose levels → glucose in
urine, increased fat deposits in face and
trunk.
○ Decreased amino acids → protein
deficiencies, muscle wasting, poor
antibody response, and lack of collagen.
Risk Factors
● Adrenal hyperplasia.
● Excessive hypothalamic stimulation.
● Tumors: adrenal, hypophyseal,
bronchogenic, or gallbladder.
● Excessive steroid therapy.
pituitary,
Assessment
Subjective data:
● Headache, backache.
● Weakness, decreased work capacity.
● Mood swings.
Objective data:
● Hypertension, weight gain, pitting edema.
● Characteristic fat deposits, truncal and cervical
obesity (buffalo hump).
● Pendulous abdomen, purple striae, easy
bruising.
● Moon facies, acne.
● Hyperpigmentation.
● Impotence.
● Virilization in women: hirsutism, breast atrophy,
and amenorrhea.
● Pathological fractures, reduced height.
● Slow wound healing.
Laboratory data:
●
●
●
●
Urine: elevated 17-ketosteroids (>12 mg/24 hr)
and glucose (>120 mg/dL).
Plasma: elevated 17-hydroxycorticosteroids,
cortisol (>10 mcg/dL). Cortisol does not
decrease during the day as it should.
Serum: elevated—glucose, RBC, WBC counts;
diminished—potassium, chlorides, eosinophils,
lymphocytes.
X-rays and scans to determine tumors
metastasis.
Nursing Diagnosis
● Body image disturbance related to changes in
physical appearance.
● Activity intolerance related to backache and
weakness.
● Risk for injury related to infection and bleeding.
● Knowledge deficit (learning need) related to
management of disease.
● Pain related to headache.
Nursing Care Plan
1. Goal: promote comfort.
● Assist with preparation of diagnostic work-up.
● Explain procedures.
● Protect from trauma.
2. Goal: prevent complications; monitor for:
● Fluid balance—I&O, daily weights.
● Glucose metabolism—blood, urine for sugar and
acetone.
● Hypertension—vital signs.
● Infection—skin care, urinary tract; check
temperature.
● Mood swings—observe behavior.
3. Goal: health teaching.
● Diet: increased protein, potassium; decreased
calories, sodium.
● Medications:
○ Cytotoxic agents: aminoglutethimide
(Cytadren), trilostane (Modrastane),
mitotane
(Lysodren)—to decrease
cortisol production.
○ Replacement hormones as needed.
● Signs and symptoms of progression of disease
as noted in assessment.
● Preparation for adrenalectomy if medical
regimen unsuccessful.
Evaluation
● Symptoms controlled by medication.
● No complications—adrenal steroids within
normal limits.
● If adrenalectomy necessary, see VIII.
ADRENALECTOMY.
7. Pheochromocytoma
● A rare, typically benign neuroendocrine tumor
of the adrenal medulla. Appears to have a
familial basis; common in middle age—rare
after 60 years.
Pathophysiology
●
Catecholamine-secreting tumor → increased
epinephrine and norepinephrine (paroxysm) →
hypertensive retinopathy and nephropathy,
myocarditis → cerebral hemorrhage and cardiac
failure.
Risk Factors for Paroxysms
● Voiding.
● Smoking.
● Drugs (i.e., histamine, anesthesia, atropine,
steroids, fentanyl).
● Bending, straining, exercising (displacing
abdominal organs) → increased abdominal
pressure.
Assessment
Subjective data:
● Apprehension.
● Pounding headache.
● Nausea.
● Pain with vomiting.
● Visual disturbances.
● Palpitations.
● Heat intolerance.
Objective data:
● Hypertension: rapid onset, abrupt cessation;
postural hypotension.
● Profuse diaphoresis with acute attack.
● Pulse: rapid, dysrhythmia.
● Pupils: dilated.
● Extremities: cold, tremors.
Laboratory Data:
● Hyperglycemia, glycosuria.
● ↑ Urinary catecholamines: single-voided, 2- to
4-hour specimen and 24-hour urine, greater
than 14 mg/100 mL.
● Direct assay of catecholamines— epinephrine
greater than 0.2 mg/L; norepinephrine 0.5
mg/L. (4)↑ BMR.
● X-ray, CT, and MRI—used to localize tumor
before surgery.
Nursing Diagnosis
● Anxiety related to excessive physiological
stimulation of sympathetic nervous system.
● Fluid volume deficit related to excessive gastric
losses, hypermetabolic state, diaphoresis.
● Risk for decreased cardiac output related to
excessive secretion of catecholamines as
evidenced by hypertension.
● Risk for injury related to excessive release of
epinephrine and norepinephrine.
nutrition,
greater than body
● Altered
requirements, related to elevated glucose.
Nursing Care Plan
1. Goal: prevent paroxysmal hypertension.
● Rest: reduce stress, ↓ environmental
stimulation.
● Give sedatives, alpha-adrenergic blocker
(phenoxybenzamine) for hypertension and
antidysrhythmics as ordered.
●
●
Diet: high vitamin, high calorie, mineral,
calcium; restrict caffeine.
Monitor vital signs (especially BP in sitting and
supine positions).
2. Goal: prepare for surgical removal of tumor (see VIII.
ADRENALECTOMY, following).
Evaluation
● No paroxysmal hypertension.
● See VIII. ADRENALECTOMY.
8. Adrenalectomy
● Surgical removal of adrenal glands because of
tumors or uncontrolled overactivity; also
bilateral adrenalectomy may be performed to
control metastatic breast or prostate cancer.
Risk Factors
● Pheochromocytoma.
● Adrenal hyperplasia.
● Cushing’s syndrome.
● Metastasis of prostate or breast cancer.
● Adrenal cortex or medulla tumors.
Assessment
Objective data: validated evidence of:
● Benign lesion (unilateral adrenalectomy) or
malignant tumor (bilateral adrenalectomy).
● Adrenal hyperfunction that cannot be managed
medically.
● Bilateral excision for metastasis of breast and
sometimes metastasis of prostate cancer.
Nursing Diagnosis
● Knowledge deficit (learning need) related to
planned surgery.
● Risk for physical injury related to hormone
imbalance.
● Risk for decreased cardiac output related to
possible hypotensive state resulting from
surgery.
● Risk for infection related to decreased normal
resistance.
● Altered health maintenance related to need for
self-administration of steroid medications, orally
or by injection.
Nursing Care Plan
1. Goal: preoperative: reduce risk of postoperative
complications.
● Prescribed steroid therapy, given 1 week before
surgery, is gradually decreased; will be given
again postoperatively.
● Antihypertensive drugs are discontinued
because surgery may result in severe
hypotension.
● Sedation as ordered.
● General preoperative measures.
2. Goal: postoperative: promote hormonal balance.
● Administer hydrocortisone parenteral therapy
as ordered; rate indicated by fluid and
electrolyte balance, blood sugar, and blood
pressure.
● Monitor for signs of addisonian (adrenal) crisis.
3. Goal: prevent postoperative complications.
● Monitor vital signs until stability is regained; if
on vasopressor drugs such as metaraminol
(Aramine):
○ Maintain flow rate as ordered.
○ Monitor BP q5–15 min, notify physician
of significant elevations in BP (dose
needs to be decreased) or drop in BP
(dose needs to be increased). Note:
readings that are normotensive for
some may be hypotensive for clients
who have been hypertensive.
● NPO—attach nasogastric tube to intermittent
suction; abdominal distention is common side
effect of this surgery.
● Respiratory care:
○ Turn, cough, and deep breathe.
○ Splint flank incision when coughing.
○ Administer narcotics to reduce pain and
○ allow client to cough; flank incision is
close to diaphragm, making coughing
very painful.
breath
sounds
q2h;
○ Auscultate
decreased or absent sounds could
indicate pneumothorax.
○ Sudden chest pain and dyspnea should
be reported immediately (spontaneous
pneumothorax).
● Position: flat or semi-Fowler’s. e. Mouth care.
● Monitor dressings for bleeding; reinforce prn.
● Ambulation, as ordered.
○ Check BP q15 min when ambulation is
first attempted.
○ Place elastic stockings on lower
extremities to enhance stability of
vascular system.
● Diet—once NG tube removed, diet as tolerated.
4. Goal: health teaching.
● Signs and symptoms of adrenal crisis:
○ Pulse: rapid, weak, or thready.
○ Temperature: elevated.
○ Severe weakness and hypotension.
○ Headache.
○ Convulsions, coma.
● Importance of maintaining steroid therapy
schedule to ensure therapeutic serum level.
● Weigh daily.
● Monitor blood glucose levels daily.
● Report undesirable side effects of steroid
therapy or adrenal crisis to physician.
● Avoid persons with infections, due to decreased
resistance.
● Daily schedule: include adequate rest, moderate
exercise, good nutrition.
Evaluation
● Adrenal crisis avoided.
○ Vital signs within normal limits.
○ No neurological deficits noted.
●
●
Healing progresses: no signs of infection or
wound complications.
Adjusts to alterations in physical status.
○ Complies with medication regimen.
○ Avoids infections.
○ Incorporates good nutrition, periods of
rest and activity into daily schedule.
9. Addison’s Disease
primary
adrenal
corticotropic
● Chronic
insufficiency.
● A hormonal (endocrine) disorder involving
destruction of the adrenal glands, which then
are unable to produce sufficient adrenal
hormones (cortisol) necessary for the normal
body functions.
Pathophysiology
● Atrophy of adrenal gland is most common cause
of adrenal insufficiency; manifested by
decreased adrenal cortical secretions.
in
mineralocorticoid
○ Deficiency
secretion (aldosterone) → increased
sodium excretion → dehydration →
hypotension → decreased cardiac
output and resulting decrease in heart
size.
○ Deficiency in glucocorticoid secretion
(cortisol)
decrease
in
→
gluconeogenesis → hypoglycemia and
liver glycogen deficiency, emotional
disturbances, diminished resist- ance to
stress. Cortisol deficiency → failure to
inhibit anterior pituitary secretion of
ACTH and melanocyte-stimulating hormone → increased levels of ACTH and
hyperpigmentation.
○ Deficiency in androgen hormone → less
axillary and pubic hair in women (testes
supply adequate sex hormone in men,
so no symptoms are produced).
Risk Factors
● Autoimmune processes.
● Infection.
● Malignancy.
● Vascular obstruction.
● Bleeding.
● Environmental hazards.
● Congenital defects.
● Bilateral adrenalectomy.
● Tuberculosis.
Assessment
Subjective data:
● Muscle weakness, fatigue, lethargy.
● Dizziness, fainting.
● Nausea, food idiosyncrasies, anorexia.
● Abdominal pain/cramps.
Objective data:
● Vital signs: decreased BP, orthostatic
hypotension, widened pulse pressure.
● Pulse—increased, collapsing, irregular.
●
●
●
●
Temperature—subnormal.
Vomiting, diarrhea, and weight loss.
Tremors.
Skin: poor turgor, excessive pigmentation
(bronze tone).
Laboratory Data:
● Blood:
○ Decreased: sodium (<135 mEq/L);
glucose (<60 mg/dL), chloride (<98
mEq/L), bicarbonate (<23 mEq/L).
○ Increased: hematocrit, potassium (>5
mEq/L).
● Urine: decreased (or absent) 17-ketosteroids,
17-hydroxycorticosteroids (<5 mg/24 hr).
Diagnostic tests:
● CT scan, MRI.
● ACTH stimulation test (cortisol levels are
measured before and after administration of
synthetic ACTH).
Nursing Diagnosis
● Fluid volume deficit related to decreased
sodium.
● Altered renal tissue perfusion related to
hypotension.
● Decreased cardiac output related to aldosterone
deficiency.
● Risk for infection related to cortisol deficiency.
● Activity intolerance related to muscle weakness
and fatigue.
● Altered nutrition, less than body requirements,
related to nausea, anorexia, and vomiting.
Nursing Care Plan
1. Goal: decrease stress.
● Environment: quiet, nondemanding schedule.
● Anticipate events for which extra resources will
be necessary.
2. Goal: promote adequate nutrition.
● Diet: acute phase—high sodium, low potassium;
nonacute phase—increase carbohydrates and
protein.
● Fluids: force, to balance fluid losses; monitor
I&O, daily weights.
● Administer lifelong exogenous replacement
therapy as ordered:
○ Glucocorticoids—prednisone,
hydrocortisone.
○ Mineralocorticoids—fludrocortisone
(Florinef ).
3. Goal: health teaching.
● Take medications with food or milk.
● May need antacid therapy to prevent GI
disturbances.
● Side effects of steroid therapy.
● Avoid stress; may need adjustment in
medication dosage when stress is increased.
● Signs and symptoms of addisonian (adrenal)
crisis: very serious condition characterized by
severe hypotension, shock, coma, and
vasomotor collapse related to strenuous
activity, infection, stress, omission of prescribed
medications. If untreated, could quickly lead to
death.
4. Goal: prevent serious complications if addisonian
crisis evident.
● Complete bedrest; avoid stimuli.
● High dose of hydrocortisone IV or cortisone IM.
● Treat shock—IV saline.
● I&O, vital signs q15 min to 1 hour or prn until
crisis passes.
Evaluation
● No complications occur.
● Medication regimen followed, is adequate for
client’s needs.
● Adequate nutrition and fluid balance obtained.
A4. Care of Clients with Alterations in Endocrine &
Metabolism (continuation)
From Delmar’s Complete Review for the NCLEX-RN
1. Growth Hormone Deficiency or Short Stature
● Short stature caused by decreased production
of GH by the pituitary gland.
● Occurs equally in boys and girls, but more
psychologically devastating for boys.
● Causes include injury and destruction of the
anterior pituitary gland by a tumor, an infection,
or radiation, but most commonly idiopathic.
Assessment
● Decreased velocity of height and weight on
growth charts (height and weight usually
proportional, or weight somewhat above
height); height is 2–3 standard deviations below
mean for age.
Diagnostic Tests
● Blood tests: measurement of GH—random
testing is not useful because growth hormone is
released in intermittent spurts.
● Provocative GH testing: given medication
(arginine, clonidine, glucagons, insulin, or
L-dopa) to stimulate release of GH, which is
then measured.
● Bone age x-ray: determines bone age and
potential for growth; once the epiphyses are
closed, growth potential is minimal; bone
growth is often delayed when compared to
age-related norms.
● Need to rule out familial short stature (short
parents),
constitutional
growth
delay
(nutritional), or skeletal dysplasia.
Nursing Interventions
● Instruct the parents on subcutaneous injections
of GH—given 6–7 days weekly or as
intramuscular depot shot (slowly absorbed)
every 2–4 weeks.
● Accurately monitor growth over time and plot
on growth curves at least every 6 months.
●
●
●
Instruct the family about the disorder and
treatment and instruct the parents to give shots
if appropriate.
Evaluate the need for help with financial
coverage for treatment— not covered by many
insurance plans.
Offer support to the child because short stature
may be emotionally difficult, especially for boys,
who are expected to be tall.
2. Diabetes Insipidus
● Disorder of the posterior lobe of the pituitary
gland involving absence of vasopressin (ADH)
● ADH increases reabsorption of H2O from the
renal tubules, and, when absent, large amounts
of urine are excreted, leading to fluid and
electrolyte imbalance.
● If fluids are withheld, client continues to excrete
large volumes of urine, leading to severe
dehydration.
Assessment
● Insatiable thirst (polydipsia)
● Large volume of dilute urinary output (polyuria)
● Urine specific gravity between 1.001 and 1.005
Diagnostic Tests
● Fluid deprivation test
● Plasma osmolality
● Urine osmolality
● Plasma levels of vasopressin
● Stimulating test with administration
desmopressin (synthetic vasopressin)
monitor response.
of
to
3. Syndrome of Inappropriate Secretion of Antidiuretic
Hormone (SIADH)
● Excessive ADH secretion from the posterior
pituitary resulting in low urinary output and
high urine osmolality, hyponatremia, and high
urine Na􏰃 concentration.
Assessment
● Abrupt weight gain without edema
● Neurological clinical manifestations such as
muscle twitching, headaches, and seizures
● Hyponatremia, causing muscle cramps and
weakness
● Low urinary output
manifestations such as
● Gastrointestinal
abdominal cramps, anorexia, and vomiting.
Diagnostic Tests
● Serum sodium
● Urinary sodium
Nursing Interventions
● Frequent neurological checks (observe for
clinical manifestations of hyponatremia)
● Monitor daily weights.
● Accurate intake and output
● Restrict fluid intake to 1000 ml per day.
● Measure specific gravity.
● Monitor vital signs.
●
●
Administer hypertonic saline.
Administer furosemide (Lasix) if the serum
sodium level is above 125 mEq/L.
Medical Management
● Treat the underlying cause (central nervous
system [CNS] disorders, cancer, body response
to some drugs, such as those that stimulate the
release of the antidiuretic hormone).
4. Myxedema
● Severest form of hypothyroidism noted by
nonpitting edema from accumulations of
mucopolysaccharides in tissues.
● Myxedema coma, often preceded by infection,
progresses to decreased blood flow to brain,
hypotension,
hypoglycemia,
bradycardia,
hypothermia, hypoventilation, and death.
Assessment
● Periorbital edema
● Puffy hands and feet
● Profound lethargy and apathy 4) Slowed body
metabolism
5. Hyperparathyroidism
● Caused by overproduction of parathormone by
the parathyroid gland
● Characterized by bone decalcification, elevated
serum calcium levels, decreased serum
phosphate levels, increased calcium and
phosphorus in the urine, and decreased
neuromuscular irritability
● Renal calculi, obstruction, pyelonephritis, and
renal failure are complications due to increased
renal calcium and phosphorus levels in the renal
pelvis and parenchyma.
Assessment
● Nausea and vomiting
● Weakness and fatigue
● Bone pain
● Polyuria
● Polydipsia
● Increased emotional irritability
● Neuromuscular irritability
Diagnostic Tests
● Serum calcium (elevated)
● Serum phosphates (low)
● Urinary calcium and phosphates (elevated)
● Radioimmunoassays for parathormone
Nursing Interventions
● Encourage fluids to prevent renal calculi.
● Encourage ambulation.
● Measures to prevent falls (osteoporosis can lead
to pathologic fractures)
● Instruct the client on a diet low in calcium and
high in phosphorus.
Surgical Management
● Surgery usually performed, with part or all of
the gland removed
●
●
Prior to surgery, electrolyte imbalance treated
with oral phosphorus, fluids forced to 2000 ml
per day, IV saline and Lasix to aid in the renal
clearance of calcium, and cranberry and prune
juice to prevent stone formation
Postoperative goals related to prevention of
complications
of
hemorrhage,
airway
obstruction, injury to recurrent laryngeal nerve,
and tetany
6. Hypoparathyroidism
● Disorder in which there is insufficient secretion
of parathormone caused by inadequate blood
supply to the parathyroid gland, mechanical
injury, or inadvertent removal of all or some of
parathyroid glands during thyroid or neck
surgery
● Clinical manifestations related to imbalance of
calcium and phosphorus, increased calcification
of bone, and increased neuromuscular activity
that may progress to tetany
Assessment
● Numbness and tingling in extremities and
around the neck (mild tetany)
● Painful muscle spasms, seizures, carpal spasm,
marked
anxiety
and
apprehension,
bronchospasm, laryngeal stridor, and cardiac
dysrhythmias (severe tetany)
Diagnostic Tests
● Serum phosphate (elevated)
● Serum calcium (low)
● Bone density (increased)
● Urinary calcium and phosphorus (low)
Nursing Intervention
● Place the tracheostomy set at the bedside.
● Place calcium gluconate at the bedside.
● Perform Trousseau’s sign (constrict blood flow
to the wrist) or Chvostek’s sign (tap facial
muscle) to assess for tetany.
● Instruct the client on a diet high in calcium and
low in phosphorus.
● Instruct the client to take large daily doses of
vitamin D orally, calcium salts, and aluminum
hydroxide gel or aluminum carbonate (Gelusil
Ampojel) after meals.
Medical Management
● Treatment goals are to raise serum calcium
levels,
eliminate
symptoms
of
hypoparathyroidism and hypocalcemia, and
correct state of tetany if present.
● Calcium gluconate in saline is given parenterally
to treat tetany (should be kept at bedside for
emergency use).
● Parathormone is given in severe cases but many
clients exhibit allergic response.
7. Primary Aldosteronism
● Condition in which there is excessive secretion
of aldosterone from the adrenal cortex; usually
due to tumor
●
●
●
●
●
Client exhibits signs and symptoms of
hypokalemia and alkalosis and has normal or
elevated serum sodium levels
Adrenalectomy performed if caused by a tumor
Postoperative
care
includes
temporary
(unilateral)
or
permanent
(bilateral)
replacement
of
corticosteroids,
fluid
management, and insulin for hyperglycemia.
If not treated early, advances to hypertension,
cardiovascular disease, and renal insufficiency
Spironolactone, an aldosterone antagonist,
given if the client is unable to have surgery.
Assessment
● Hypertension
● Muscle weakness
● Leg cramps
● Generalized fatigue
● Polyuria
● Polydipsia
● Tetany
● Paresthesia
Nursing Intervention
● Observe for changes in vital signs.
● Assess for clinical manifestations of adrenal
insufficiency, adrenal crisis, or hemorrhage.