Exam 1 Study Guide
Chapter 9 Pain
Quality and Safety Nursing Alert
Although accepting and responding to the report of pain may result in administering analgesic
agents to an occasional patient who does not have pain, doing so helps to ensure that everyone
who does have pain receives appropriate care. Health care professionals do not have the right to
deprive any patient of appropriate assessment and treatment simply because they believe a
patient is not being truthful. Pain is an extremely personal experience manifested uniquely by
each person. It is important to carefully assess and reassess pain when administering analgesic
medications.
Quality and Safety Nursing Alert
Staff, family, and other visitors should be instructed to contact the nurse if they have concerns
about pain control rather than activating the PCA device for the patient.
Quality and Safety Nursing Alert
Opioid-induced respiratory depression is dose related and preceded by increasing sedation.
Prevention of clinically significant opioid-induced respiratory depression begins with the
administration of the lowest effective opioid dose, careful titration, close monitoring of sedation
and respiratory function and status (i.e., rate, depth, regularity, excursion) throughout therapy,
and prompt dose reduction when advancing sedation is detected
Chapter 10 Fluid and Electrolytes
Electrolytes in body fluids are active chemicals (cations that carry positive charges and anions
that carry negative charges). The major cations in body fluid are sodium, potassium, calcium,
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magnesium, and hydrogen ions. The major anions are chloride, bicarbonate, phosphate, sulfate,
and negatively charged protein ions.
Quality and Safety Nursing Alert
When fluid balance is critical, all routes of systemic gain and loss must be recorded and all
volumes compared. Organs of fluid loss include the kidneys, skin, lungs, and GI tract.
Normal physiologic changes of aging include reduced cardiac, renal, and respiratory function.
Body fat changes, body water content decreases, and muscle mass decreases. These changes of
aging may alter the older adult’s responses to fluid and electrolyte changes and acid–base
disturbances. Decreased respiratory function and renal function can cause impaired acid–base
balance in older adults with major illness or trauma. Decreased renal function that occurs with
age can also cause slightly elevated serum creatinine. Decreased muscle mass that occurs with
aging leads to decreased daily breakdown of muscle, which reduces serum creatinine. Therefore,
high–normal and minimally elevated serum creatinine values may indicate substantially reduced
renal function in older adult
Fluid volume deficit (hypovolemia)
Loss of water and electrolytes, as in vomiting, diarrhea, fistulas, fever, excess sweating, burns,
blood loss, gastrointestinal suction, and third-space fluid shifts; and decreased intake, as in
anorexia, nausea, and inability to gain access to fluid. Diabetes insipidus and uncontrolled
diabetes both contribute to a depletion of extracellular fluid volume.
Acute weight loss, ↓ skin turgor, oliguria, concentrated urine, capillary filling time prolonged, low
CVP, ↓ BP, flattened neck veins, dizziness, weakness, thirst and confusion, ↑ pulse, muscle
cramps, sunken eyes, nausea, increased temperature; cool, clammy, pale skin
Labs indicate: ↑ hemoglobin and hematocrit, ↑ serum and urine osmolality and specific gravity, ↓
urine sodium, ↑ BUN and creatinine, ↑ urine specific gravity and osmolality
Fluid volume excess (hypervolemia)
Compromised regulatory mechanisms, such as kidney injury, heart failure, and cirrhosis;
overzealous administration of sodium-containing fluids; and fluid shifts (i.e., treatment of burns).
Prolonged corticosteroid therapy, severe stress, and hyperaldosteronism augment fluid volume
excess.
Acute weight gain, peripheral edema and ascites, distended jugular veins, crackles, elevated CVP,
shortness of breath, ↑ BP, bounding pulse and cough, ↑ respiratory rate, ↑ urine output
Labs indicate: ↓ hemoglobin and hematocrit, ↓ serum and urine osmolality, ↓ urine sodium and
specific gravity
Increased sensitivity to fluid and electrolyte changes in older patients requires careful physical
assessment, measurement of I&O of fluids from all sources, assessment of daily weight, careful
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monitoring of side effects and interactions of medications, and prompt reporting and
management of disturbances. In most adult patients, it is useful to monitor skin turgor to detect
subtle changes. However, assessment of skin turgor is not as valid in older adults because the
skin has lost elasticity; therefore, other assessment measures (e.g., slowness in filling of veins of
the hands and feet) become more useful in detecting FVD
The nurse observes for a weak, rapid pulse and orthostatic hypotension (i.e., a decrease in
systolic pressure exceeding 20 mm Hg when the patient moves from a lying to a sitting
position).
It is useful to monitor daily body weight when monitoring fluid volume; an acute loss of 0.5 kg
(1.1 lb) represents a fluid loss of approximately 500 mL. One liter (1000 mL) of fluid weighs
approximately 1 kg, or 2.2 lb. A weight loss or gain of 1–2 lb/day is mainly due to water loss or
gain.
An acute weight gain of 1 kg (2.2 lb) is equivalent to a gain of approximately 1 L of fluid.
In patients with hyponatremia, highly hypertonic sodium solutions (2–23% sodium chloride)
should be administered slowly. The patient needs close monitoring, because only small volumes
are needed to elevate the serum sodium concentration.
When administering fluids to patients with cardiovascular disease, the nurse assesses for
hemodynamic signs of circulatory overload (e.g., cough, dyspnea, jugular venous distention,
dependent edema, 1–2 lb weight gain in 24 h). The lungs should be auscultated for crackles as
this can indicate pulmonary edema.
Hypokalemia increases sensitivity to digitalis, predisposing the patient to digitalis toxicity at
lower digitalis levels.
Oral potassium supplements can produce small bowel lesions; therefore, the patient must be
assessed for and cautioned about abdominal distention, pain, or GI bleeding.
Potassium is never given by IV push or intramuscularly to avoid replacing potassium too quickly.
Potassium is extremely irritating to tissues. IV potassium must be given using an infusion pump.
Potassium supplements are extremely dangerous for patients who have impaired renal function
and thus decreased ability to excrete potassium. Even more dangerous is the IV administration
of potassium to such patients, because serum levels can rise very quickly. It is possible to exceed
the renal tolerance of any patient with rapid IV potassium administration, as well as when large
amounts of oral potassium supplements are ingested.
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Chvostek sign: a contraction of the
facial muscles elicited in response to light tap over the facial nerve in front of the ear. B.
Trousseau sign: a carpopedal spasm induced by inflating a blood pressure cuff above systolic
blood pressure.
Too rapid IV administration of calcium can cause cardiac arrest, preceded by bradycardia.
Therefore, calcium should be diluted in D5W and given as a slow IV bolus or a slow IV infusion
using an infusion pump. A 0.9% sodium chloride solution should not be used when
administering calcium.
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Inadvertent overdosage of IV magnesium can result in serious patient harm and death.
Whenever a patient is prescribed IV magnesium, a second nurse should independently double
check the IV magnesium prescription, including dose calculations, and check infusion pump
settings. Milligrams (mg) and grams (g) are not equivalent to milliequivalent (mEq) dosages.
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If the PaCO2 is chronically greater than 50 mm Hg, the respiratory center becomes relatively
insensitive to CO2 as a respiratory stimulant, leaving hypoxemia as the major drive for
respiration. Patients with long-term COPD breathe independently based on a hypoxic drive. High
oxygen concentration administration can remove the stimulus of hypoxemia. The patient can
lose the independent stimulus to breathe and incur respiratory failure. Therefore, oxygen is
given with extreme caution in patients with long-term COPD.
It is important for the nurse to recognize that in blood loss, 3 L of isotonic fluid (crystalloid
solution) is needed to replace 1 L of blood (colloidal solution).
The nurse must assess the patient for a history of allergic reactions to medications. Although
obtaining drug allergy information is important when administering any medication, it is
especially critical with IV administration, because the medication is delivered directly into the
bloodstream. This can trigger an immediate hypersensitivity reaction.
Chapter 14
The older adult is at a higher risk of cardiovascular complications. Of all the body systems, the
cardiovascular system exerts the most influence on anesthesia. The older adult patient usually
has decreased or slow circulation to the rest of the body. A preoperative assessment, including
blood tests, blood pressure, and EKG, can identify potential risks including anemia, hypertension,
and arrhythmias
Obesity increases the risk and severity of complications associated with surgery. Preoperative
assessment of the patient with obesity should pay careful attention to pulmonary,
cardiovascular, psychological, and integumentary systems.
Patients with obesity have more subcutaneous fat. The increase in adipose tissue can result in
difficult intravenous (IV) access and delayed wound healing at the incision site. Obesity is also
associated with increased SSIs and joint replacement failure. Patients with a body mass index
(BMI) of greater than 45 are at a significantly increased risk for total joint replacement failure
and postoperative infection.
The patient with obesity tends to have shallow respirations when supine, increasing the risk of
hypoventilation and postoperative pulmonary complications. Additionally, diagnosed and
undiagnosed obstructive sleep apnea (OSA) is common among patients with obesity. Since
these apnea and hypopnea events occur during sleep, most patients with OSA may not be
aware that they have the condition. It has been estimated that up to 80% of individuals with
moderate to severe OSA may remain undiagnosed and untreated. Positive identification of OSA
and OSA risks can dramatically reduce intubation and postoperative complications.
Special considerations for patients with mental or physical disability include the need for
appropriate assistive devices, modifications in preoperative education, and additional assistance
with and attention to positioning or transferring. Assistive devices include hearing aids,
eyeglasses, braces, prostheses, and other devices. People who are hearing impaired may need
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and are entitled by law to a sign interpreter or some alternative communication system
perioperatively. If the patient relies on signing or speech (lip) reading and their eyeglasses or
contact lenses are removed or the health care staff wears surgical masks, an alternative method
of communication will be needed. These needs must be identified in the preoperative evaluation
and clearly communicated to personnel. Specific strategies for accommodating the patient’s
needs must be identified in advance. Ensuring the security of assistive devices is important,
because these devices are expensive and require time to replace if lost.
Any signed form required for surgery is placed in a prominent place on the patient’s medical
record and accompanies the patient to the OR.
A latex allergy can manifest as a rash, asthma, or anaphylactic shock.
The possible adverse interactions of some medications require the nurse to assess and
document the patient’s use of prescription medications, OTC medications (especially aspirin),
herbal agents, and the frequency with which medications are used. The nurse must clearly
communicate this information to the intraoperative team.
Chapter 15
Older adult patients are at higher risk for complications from anesthesia and surgery compared
with younger adult patients due to several factors. One factor is age-related decline in
physiologic reserve that weakens the normal response to stressors, acute illness, anesthesia, and
surgery. Risks include delirium, hypothermia, positioning injury, deep vein thrombosis (DVT)
formation, electrolyte imbalance, and circulatory compromise.
Biologic variations of particular importance include age-related cardiovascular and pulmonary
changes. The aging heart and blood vessels have decreased ability to respond to stress. Cardiac
output and pulmonary capacity diminish with age, with a decline in maximal oxygen uptake.
Slow circulation and hypotension predispose the patient to thrombus formation and emboli.
Excessive or rapid administration of intravenous (IV) solutions can cause pulmonary edema. A
sudden or prolonged decline in blood pressure may lead to cerebral ischemia, thrombosis,
embolism, infarction, and anoxia. Reduced gas exchange can result in cerebral hypoxia.
It is imperative that the correct patient identity, surgical procedure, and surgical site be verified
prior to surgery. The surgical site should be marked by the physician and confirmed by the
patient prior to coming to the OR suite during the consent process. The marking should be
visible after the sterile drapes are applied and verified by the surgical team members during the
time-out.
The movements of the surgical team are from sterile-to-sterile areas and from unsterile-tounsterile areas. Scrubbed people and sterile items contact only sterile areas; circulating nurses
and unsterile items contact only unsterile areas.
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Movement around a sterile field must not cause contamination of the field. Sterile areas must be
kept in view during movement around the area. At least a 1-ft distance from the sterile field
must be maintained to prevent inadvertent contamination.
Whenever a sterile barrier is breached, the area must be considered contaminated. A tear or
puncture of the drape permitting access to an unsterile surface underneath renders the area
unsterile. Such a drape must be replaced.
Every sterile field is constantly monitored and maintained. Items of doubtful sterility are
considered unsterile. Sterile fields are prepared as close as possible to the time of use.
The routine administration of hyperoxia (high levels of oxygen) is not recommended to reduce
SSIs.
Stage I: beginning anesthesia. Dizziness and a feeling of detachment may be experienced
during induction. The patient may have a ringing, roaring, or buzzing in the ears and, although
still conscious, may sense an inability to move the extremities easily. These sensations can result
in agitation. During this stage, noises are exaggerated; even low voices or minor sounds seem
loud and unreal. For these reasons, unnecessary noises and motions are avoided when
anesthesia begins.
Stage II: excitement. The excitement stage, characterized variously by struggling, shouting,
talking, singing, laughing, or crying, is often avoided if IV anesthetic agents are given smoothly
and quickly. The pupils dilate, but they constrict if exposed to light; the pulse rate is rapid; and
respirations may be irregular. Because of the possibility of uncontrolled movements of the
patient during this stage, the anesthesiologist or CRNA must always be assisted by someone
ready to help restrain the patient or to apply cricoid pressure in the case of vomiting to prevent
aspiration. Manipulation increases circulation to the operative site and thereby increases the
potential for bleeding.
Stage III: surgical anesthesia. Surgical anesthesia is reached by administration of anesthetic
vapor or gas and supported by IV agents as necessary. The patient is unconscious and lies
quietly on the table. The pupils are small but constrict when exposed to light. Respirations are
regular, the pulse rate and volume are normal, and the skin is pink or slightly flushed. With
proper administration of the anesthetic agent, this stage may be maintained for hours in one of
several planes, ranging from light (1) to deep (4), depending on the depth of anesthesia needed.
Stage IV: medullary depression. This stage is reached if too much anesthesia has been given.
Respirations become shallow, the pulse is weak and thready, and the pupils become widely
dilated and no longer constrict when exposed to light. Cyanosis develops and, without prompt
intervention, death rapidly follows. If this stage develops, the anesthetic agent is discontinued
immediately and respiratory and circulatory support is initiated to prevent death. Stimulants,
although rarely used, may be given; narcotic antagonists can be used if the overdose is due to
opioids. It is not a planned stage of surgical anesthesia.
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It is the responsibility of all nurses, and particularly peri anesthesia and perioperative nurses, to
be aware of latex allergies, necessary precautions, and products that are latex free. Hospital staff
are also at risk for development of a latex allergy secondary to repeated exposure to latex
products.
Chapter 16
The primary objective in the immediate postoperative period is to maintain ventilation and thus
prevent hypoxemia (reduced oxygen in the blood) and hypercapnia (excess carbon dioxide in
the blood). Both can occur if the airway is obstructed and ventilation is reduced
(hypoventilation). Besides administering supplemental oxygen as prescribed, the nurse assesses
respiratory rate and depth, ease of respirations, oxygen saturation, and breath sounds.
A hypopharyngeal obstruction occurs when neck flexion permits the chin to drop toward the
chest; obstruction almost always occurs when the head is in the misposition. B. Tilting the head
back to stretch the anterior neck structure lifts the base of the tongue off the posterior
pharyngeal wall. The direction of the arrows indicates the pressure of the hands. C. Opening the
mouth is necessary to correct a valvelike obstruction of the nasal passage during expiration,
which occurs in about 30% of unconscious patients. Open the patient’s mouth (separate lips and
teeth) and move the lower jaw forward so that the lower teeth are in front of the upper teeth. To
regain backward tilt of the neck, lift with both hands at the ascending rami of the mandible.
Patients who have experienced prolonged anesthesia usually are unconscious, with all muscles
relaxed. This relaxation extends to the muscles of the pharynx. When the patient lies on the
back, the lower jaw and the tongue fall backward and the air passages become obstructed
(Fig. 16-1A). This is called hypopharyngeal obstruction. Signs of occlusion include choking; noisy
and irregular respirations; decreased oxygen saturation scores; and, within minutes, a blue,
dusky color (cyanosis) of the skin. Because movement of the thorax and the diaphragm does not
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necessarily indicate that the patient is breathing, the nurse needs to place the palm of the hand
at the patient’s nose and mouth to feel the exhaled breath.
The treatment of hypopharyngeal obstruction involves tilting the head back and pushing
forward on the angle of the lower jaw, as if to push the lower teeth in front of the upper teeth.
This maneuver pulls the tongue forward and opens the air passages.
A systolic blood pressure of less than 90 mm Hg is usually considered immediately reportable.
However, the patient’s preoperative or baseline blood pressure is used to make informed
postoperative comparisons. A previously stable blood pressure that shows a downward trend of
5 mm Hg at each 15-minute reading should also be reported.
Types of shock are classified as hypovolemic, cardiogenic, neurogenic, anaphylactic, and septic.
The most common type of shock in the postoperative setting is hypovolemic and is associated
with hemorrhage from the surgical site (Odom-Forren, 2018). The classic signs of hypovolemic
shock are pallor; cool, moist skin; rapid breathing; cyanosis of the lips, gums, and tongue; rapid,
weak, thready pulse; narrowing pulse pressure; low blood pressure; and concentrated urine (see
Chapter 11 for a detailed discussion of shock).
Hypovolemic shock can be avoided largely by the timely administration of IV fluids, blood,
blood products, and medications that elevate blood pressure. The primary intervention for
hypovolemic shock is volume replacement, with an infusion of lactated Ringer solution, 0.9%
sodium chloride solution, colloids, or blood component therapy (see Chapter 11, Table 11-3).
Oxygen is given by nasal cannula, facemask, or mechanical ventilation. If fluid administration
fails to reverse hypovolemic shock, then various cardiac, vasodilator, and corticosteroid
medications may be prescribed to improve cardiac function and reduce peripheral vascular
resistance.
The PACU bed can readily be positioned to facilitate the use of measures to counteract shock.
The patient is placed flat with the legs elevated, usually with a pillow. Respiratory rate, pulse rate,
blood pressure, blood oxygen concentration, urinary output, and level of consciousness are
monitored to provide information on the patient’s respiratory and cardiovascular status. Vital
signs are monitored continuously until the patient’s condition has stabilized.
Other factors can contribute to hemodynamic instability, such as body temperature and pain.
The PACU nurse implements measures to manage these factors. The nurse keeps the patient
warm (while avoiding overheating to prevent cutaneous vessels from dilating and depriving vital
organs of blood), avoids exposure, and maintains normothermia (to prevent vasodilation).
At the slightest indication of nausea, the patient is turned completely to one side to promote
mouth drainage and prevent aspiration of vomitus, which can cause pneumonia, asphyxiation,
and death.
The older patient, like all patients, is transferred from the OR table to the bed or stretcher slowly
and gently. The effects of this action on blood pressure and ventilation are monitored. Special
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attention is given to keeping the patient warm, because older adults are more susceptible to
hypothermia. The patient’s position is changed frequently to stimulate respirations as well as
promote circulation and comfort.
A patient remains in the PACU until fully recovered from the anesthetic agent. Indicators of
recovery include stable blood pressure, adequate respiratory function, and adequate oxygen
saturation level compared with baseline.
The Aldrete score is used to determine the patient’s general condition and readiness for transfer
from the PACU. Throughout the recovery period, the patient’s physical signs are observed and
evaluated by means of a scoring system based on a set of objective criteria. This evaluation
guide allows an objective assessment of the patient’s condition in the PACU. The patient is
assessed at regular intervals, and a total score is calculated and recorded on the assessment
record. The Aldrete score is usually between 7 and 10 before discharge from the PACU. The unit
policy and the established PACU discharge criteria determine appropriate post anesthesia
recovery score parameters. Scores or conditions lower than the preestablished level necessitate
evaluation by the anesthesia provider or surgeon and can result in an extension of the PACU
stay or possible disposition to a special care or critical care unit.
11
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Nursing interventions to promote wound healing also include management of surgical
drains. Drains are tubes that exit the peri-incisional area, either into a portable wound suction
device (closed) or into the dressings (open). The principle involved is to allow the escape of
fluids that could otherwise serve as a culture medium for bacteria. In portable wound suction,
the use of gentle, constant suction enhances drainage of these fluids and collapses the skin flaps
against the underlying tissue, thus removing “dead space.” Types of wound drains include the
Penrose, Jackson-Pratt, and Hemovac drains (see Fig. 16-5). Output (drainage) from wound
systems is recorded.
Any condition that is persistent or considered intractable, such as hiccups, should be reported to
the primary provider so that appropriate measures can be implemented.
If disruption of a wound occurs, the patient is placed in the low Fowler position and instructed
to lie as still as possible. These actions minimize protrusion of body tissues. The protruding coils
of intestine are covered with sterile dressings moistened with sterile saline solution, and the
surgeon is notified at once.
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Chapter 17
Causes of Increased Airway Resistance
Common phenomena that may alter bronchial diameter, which affects airway resistance, include
the following:
•Contraction of bronchial smooth muscle—as in asthma
•Thickening of bronchial mucosa—as in chronic bronchitis
•Obstruction of the airway—by mucus, a tumor, or a foreign body
•Loss of lung elasticity—as in emphysema, which is characterized by connective tissue encircling
the airways, thereby keeping them open during both inspiration and expiration
gradual decline in respiratory function begins in early to middle adulthood and affects the
structure and function of the respiratory system. The vital capacity of the lungs and the strength
of the respiratory muscles peak between 20 and 25 years of age and decrease thereafter. With
aging (40 years and older), changes occur in the alveoli that reduce the surface area available for
the exchange of oxygen and carbon dioxide. At approximately 50 years of age, the alveoli begin
to lose elasticity. A decrease in vital capacity occurs with the loss of chest wall mobility, which
restricts the tidal flow of air. The amount of respiratory dead space increases with age. These
changes result in a decreased diffusion capacity for oxygen with increasing age, producing lower
oxygen levels in the arterial circulation. Older adults have a decreased ability to rapidly move air
in and out of the lungs.
There are subtle differences between Cheyne–Stokes and Biot’s respiration patterns. Between
regularly cycled periods of apnea, Cheyne–Stokes respirations demonstrate a regular pattern
with the rate and depth of breathing increasing and then decreasing. In Biot’s respiration,
irregularly cycled periods of apnea are interspersed with cycles of normal rate and depth.
Quality and Safety Nursing Alert
The nurse should not rely only on visual inspection of the rate and depth of a patient’s
respiratory excursions to determine the adequacy of ventilation. Respiratory excursions may
appear normal or exaggerated due to an increased work of breathing, but the patient may
actually be moving only enough air to ventilate the dead space. If there is any question
regarding adequacy of ventilation, the nurse should use auscultation or pulse oximetry (or both)
for additional assessment of respiratory status.
Quality and Safety Nursing Alert
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Most patients can generate a vital capacity twice the volume they normally breathe in and out
(tidal volume). If the vital capacity is less than 10 mL/kg, the patient will be unable to sustain
spontaneous ventilation and will require respiratory assistance.
Quality and Safety Nursing Alert
Sedation given to patients with respiratory insufficiency may precipitate respiratory arrest.
Chapter 18
Upper Respiratory Tract Disorders in Older Adults
•Upper respiratory infections in older adults may have more serious consequences if patients
have concurrent medical problems that compromise their respiratory or immune status.
•Influenza causes exacerbations of chronic obstructive pulmonary disease and reduced
pulmonary function.
•Antihistamines and decongestants used to treat upper respiratory disorders must be used
cautiously in older adults because of their side effects and potential interactions with other
medications.
•The prevalence of nonallergic rhinosinusitis is greater among older adults than among adults of
other age groups. Rhinosinusitis is the sixth most common chronic disease among older adults.
With anticipated future growth in the older adult population, the need for endoscopic sinus
surgery will increase. Older patients with nonallergic rhinosinusitis present with symptoms
similar to those of younger adults and experience a similar degree of improvement and quality
of life after endoscopic sinus surgery.
•The structure of the nose changes with aging; it lengthens and the tip droops from loss of
cartilage. This can cause restriction in airflow and predispose older adult patients to geriatric
rhinitis, characterized by increased thin, watery sinus drainage. These structural changes may
also adversely affect the sense of smell.
•Laryngitis in older adults is common and may be secondary to gastroesophageal reflux disease
(GERD). Older adults are more likely to have impaired esophageal peristalsis and a weaker
esophageal sphincter. Treatment measures include sleeping with the head of the bed elevated
and the use of medications such as histamine-2 receptor blockers (e.g., famotidine) or proton
pump inhibitors (e.g., omeprazole).
•Age-related loss of muscle mass and thinning of the mucous membranes can cause structural
changes in the larynx that may change characteristics of the voice. In general, the pitch of voice
becomes higher in older adult men and lower in older adult women. The voice also “thins”
(decreased projection) and may sound tremulous. These changes should be discriminated from
signs that could indicate pathologic conditions.
Quality and Safety Nursing Alert
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Patients with nasotracheal and nasogastric tubes in place are at the risk for development of
sinus infections (Brook, 2018a; Brook, 2018b). Thus, accurate assessment of patients with these
tubes is critical. Removal of the nasotracheal or nasogastric tube as soon as the patient’s
condition permits allows the sinuses to drain, possibly avoiding septic complications.
Quality and Safety Nursing Alert
URIs, specifically CRS and recurrent acute rhinosinusitis, may be linked to primary or secondary
immune deficiency or treatment with immunosuppressive therapy (e.g., for cancer or organ
transplantation). Typical symptoms may be blunted or absent due to immunosuppression.
Immunocompromised patients are at the increased risk for acute or chronic fungal infections;
these infections can progress rapidly and become life-threatening (Brook, 2018a; Brook, 2018b).
Thus, assessment, early reporting of symptoms to the patient’s primary provider, and immediate
initiation of treatment are essential.
Assessing for Obstructive Sleep Apnea
Be alert for the following signs and symptoms of obstructive sleep apnea:
•Excessive daytime sleepiness
•Frequent nocturnal awakening
•Insomnia
•Loud snoring
•Morning headaches
•Intellectual deterioration
•Personality changes, irritability
•Impotence
•Systemic hypertension
•Arrhythmias
•Pulmonary hypertension, cor pulmonale
•Polycythemia
•Enuresis
Epistaxis
•Local infections (vestibulitis, rhinitis, rhinosinusitis)
•Systemic infections (scarlet fever, malaria)
•Drying of nasal mucous membranes
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•Nasal inhalation of corticosteroids (e.g., beclomethasone) or illicit drugs (e.g., cocaine)
•Trauma (digital trauma, blunt trauma, fracture, forceful nose blowing)
•Arteriosclerosis
•Hypertension
•Tumor (sinus or nasopharynx)
•Thrombocytopenia
•Use of aspirin
•Liver disease
•Rendu–Osler–Weber syndrome (hereditary hemorrhagic telangiectasia)
Laryngeal Cancer
Carcinogens
•Tobacco (smoke, smokeless, e-cigarettes, hookahs, secondhand smoke)
•Heavy alcohol consumption (defined as more than one drink daily)
•Combined effects of alcohol and tobacco
•Asbestos
•Paint fumes
•Wood dust
•Chemicals used in metalworking, petroleum, plastics, and textiles
Other factors
•Nutritional deficiencies (vitamins)
•Genetic predisposition
•Age (higher incidence after 65 years of age)
•Gender (more common in men)
•Race (more prevalent in African Americans and Whites)
•Weakened immune system
Chapter 19
Quality and Safety Nursing Alert
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Tachypnea, dyspnea, and mild-to-moderate hypoxemia are hallmarks of the severity of
atelectasis.
Pneumonia Based upon Pathogen Type
Risk Factors for Infection with Penicillin-Resistant and Drug-Resistant Pneumococci
•Age >65 years
•Alcoholism
•Beta-lactam therapy (e.g., cephalosporins) in past 3 months
•Immunosuppressive disorders
•Multiple medical comorbidities
•Exposure to a child in a day care facility
Risk Factors for Infection with Enteric Gram-Negative Bacteria
•Residency in a long-term care facility
•Underlying cardiopulmonary disease
•Multiple medical comorbidities
•Recent antibiotic therapy
Risk Factors for Infection with Pseudomonas aeruginosa
•Structural lung disease (e.g., bronchiectasis)
•Corticosteroid therapy
•Broad-spectrum antibiotic therapy (>7 days in the past month)
•Malnutrition
Pneumonia in older adult patients may occur as a primary diagnosis or as a complication of a
chronic disease. Pulmonary infections in older adults frequently are difficult to treat and result in
a higher mortality rate than in younger people (Ramirez, 2019). General deterioration, weakness,
abdominal symptoms, anorexia, confusion, tachycardia, and tachypnea may signal the onset of
pneumonia. The diagnosis of pneumonia may be missed because the classic symptoms of
cough, chest pain, sputum production, and fever may be absent or masked in older adult
patients. In addition, the presence of some signs may be misleading. Abnormal breath sounds,
for example, may be caused by micro atelectasis that occurs as a result of decreased mobility,
decreased lung volumes, or other respiratory function changes. Chest x-rays may be needed to
differentiate chronic heart failure, which is often seen in older adults, from pneumonia as the
cause of clinical signs and symptoms.
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Aspiration
•Seizure activity
•Brain injury
•Decreased level of consciousness from trauma, drug or alcohol intoxication, excessive sedation,
or general anesthesia
•Flat body positioning
•Stroke
•Swallowing disorders
•Cardiac arrest
Quality and Safety Nursing Alert
When a nonfunctioning nasogastric tube allows the gastric contents to accumulate in the
stomach, a condition known as silent aspiration may result. Silent aspiration often occurs
unobserved and may be more common than suspected. If untreated, massive inhalation of
gastric contents develops in a period of several hours.
Clinical Practices That Prevent Aspiration
•Maintain head-of-bed elevation at an angle of 30 to 45 degrees, unless contraindicated
•Use sedatives as sparingly as possible
•Before initiating enteral tube feeding, confirm the tip location
•For patients receiving tube feedings, assess placement of the feeding tube at 4-hour intervals,
assess for gastrointestinal residuals (<150 mL before next feeding) to the feedings at 4-hour
intervals
•For patients receiving tube feedings, avoid bolus feedings in those at risk for aspiration
•Consult with primary provider about obtaining a swallowing evaluation before oral feedings are
started for patients who were recently extubated but were previously intubated for >2 days
•Maintain endotracheal cuff pressures at an appropriate level, and ensure that secretions are
cleared from above the cuff before it is deflated.
Tuberculosis
•Close contact with someone who has active TB. Inhalation of airborne nuclei from a person who
is infected is proportional to the amount of time spent in the same air space, the proximity of
the person, and the degree of ventilation.
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•Immunocompromised status (e.g., those with HIV infection, cancer, transplanted organs, and
prolonged high-dose corticosteroid therapy).
•Substance use disorder (individuals who use IV/injection drug or abuse alcohol).
•Any person without adequate health care (those experiencing homelessness; those who are
impoverished; and racial–ethnic minorities, particularly children <15 years and young adults
between ages 15 and 44 years).
•Preexisting medical conditions or special treatment (e.g., diabetes, chronic kidney disease,
malnourishment, select malignancies, hemodialysis, transplanted organ, gastrectomy, and
jejunoileal bypass).
•Immigration from or recent travel to countries with a high prevalence of TB (southeastern Asia,
Africa, Latin America, Caribbean).
•Institutionalization (e.g., long-term care facilities, psychiatric institutions, prisons).
•Living in overcrowded, substandard housing.
•Being a health care worker performing high-risk activities: administration of aerosolized
pentamidine and other medications, sputum induction procedures, bronchoscopy, suctioning,
coughing procedures, caring for patients who are immune suppressed, home care with the highrisk population, and administering anesthesia and related procedures (e.g., intubation,
suctioning).
TB may have atypical manifestations in older adult patients, whose symptoms may include
unusual behavior and altered mental status, fever, anorexia, and weight loss. In many older adult
patients, the tuberculin skin test produces no reaction (loss of immunologic memory) or delayed
reactivity for up to 1 week (recall phenomenon). A second skin test is performed in 1 to 2 weeks.
Older adults who live in long-term care facilities are at increased risk for primary and reactivated
TB as compared to those in the community
Care of the Patient with an Endotracheal Tube
Immediately After Intubation
1.Check symmetry of chest expansion.
2.Auscultate breath sounds of anterior and lateral chest bilaterally.
3.Obtain capnography or end-tidal CO2 as indicated.
4.Ensure chest x-ray obtained to verify proper tube placement.
5.Check cuff pressure every 6 to 8 hours.
6.Monitor for signs and symptoms of aspiration.
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7.Ensure high humidity; a visible mist should appear in the T-piece or ventilator tubing.
8.Administer oxygen concentration as prescribed by the primary provider.
9.Secure the tube to the patient’s face with tape, and mark the proximal end for position
maintenance.
a. Cut proximal end of tube if it is longer than 7.5 cm (3 inches) to prevent kinking.
b. Insert an oral airway or mouth device if orally intubated to prevent the patient from biting
and obstructing the tube.
10.Use sterile suction technique and airway care to prevent iatrogenic contamination and
infection.
11.Continue to reposition patient every 2 hours and as needed to prevent atelectasis and to
optimize lung expansion.
12.Provide oral hygiene and suction the oropharynx whenever necessary.
Extubation (Removal of Endotracheal Tube)
1.Explain procedure.
2.Have self-inflating bag and mask ready in case ventilatory assistance is required immediately
after extubation.
3.Suction the tracheobronchial tree and oropharynx, remove tape, and then deflate the cuff.
4.Give 100% oxygen for a few breaths, then insert a new, sterile suction catheter inside tube.
5.Have the patient inhale. At peak inspiration, remove the tube, suctioning the airway through
the tube as it is pulled out.
Note: In some hospitals, this procedure can be performed by respiratory therapists; in others, by
nurses. Check hospital policy.
Care of Patient Following Extubation
1.Give heated humidity and oxygen by facemask and maintain the patient in a sitting or highFowler position.
2.Monitor respiratory rate and quality of chest excursions. Note stridor, color change, and
change in mental alertness or behavior.
3.Monitor the patient’s oxygen level using a pulse oximeter.
4.Keep patient NPO (nothing by mouth), or give only ice chips for next few hours.
5.Provide mouth care.
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6.Educate the patient about how to perform coughing and deep-breathing exercises.
Quality and Safety Nursing Alert
To prevent alarm fatigue associated with mechanical ventilators, nurses can manage the physical
layout of the critical care unit (e.g., avoid locating patients on mechanical ventilators in close
proximity); devise protocols for setting of alarms based upon best practices; and educate staff
on how to set alarms and when and how to respond to them.
Quality and Safety Nursing Alert
Inadvertent removal of an endotracheal tube can cause laryngeal swelling, hypoxemia,
bradycardia, hypotension, and even death. Measures must be taken to prevent premature or
inadvertent removal.
Acute Respiratory Distress Syndrome
•Aspiration (gastric secretions, drowning, hydrocarbons)
•COVID-19 pneumonia
•Drug ingestion and overdose
•Fat or air embolism
•Hematologic disorders (disseminated intravascular coagulation, massive transfusions,
cardiopulmonary bypass)
•Localized infection (bacterial, fungal, viral pneumonia)
•Major surgery
•Metabolic disorders (pancreatitis, uremia)
•Prolonged inhalation of high concentrations of oxygen, smoke, or corrosive substances
•Sepsis
•Shock (any cause)
•Trauma (pulmonary contusion, multiple fractures, head injury)
Quality and Safety Nursing Alert
Be alert for the development of acute lung injury in the patient population using e-cigarettes,
also known as vaping. This syndrome is called e-cigarette or vaping associated acute lung injury
(EVALI). According to the CDC (2019c), patients diagnosed with EVALI have been identified in
most states.
Quality and Safety Nursing Alert
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Nursing assessment is essential to minimize the complications related to neuromuscular
blockade. The patient may have discomfort or pain but cannot communicate these sensations. In
addition, frequent oral care and suctioning may be needed
Quality and Safety Nursing Alert
A cough that changes in character should arouse suspicion of lung cancer.
At the time of diagnosis of lung cancer, most patients are older than 65 years and have stage III
or IV disease (Midthun, 2019). In older patients, the management of a cancer is complex and
challenging. Although age is not a significant prognostic factor for overall survival and response
to treatment of either NSCLC or SCLC, older patients have specific needs. The presence of
comorbidities and the patient’s cognitive, functional, nutritional, and social status are important
issues to consider with the patient of advanced age. Depending on the comorbidities and
functional status of older adult patients, chemotherapy agents, doses, and cycles may need to
be adjusted to maintain quality of life.
Quality and Safety Nursing Alert
Traumatic open pneumothorax calls for emergency interventions. Stopping the flow of air
through the opening in the chest wall is a lifesaving measure.
Quality and Safety Nursing Alert
When the wall vacuum is turned off, the drainage system must be open to the atmosphere so
that intrapleural air can escape from the system. This can be done by detaching the tubing from
the suction port to provide a vent.
Quality and Safety Nursing Alert
If the chest tube and drainage system become disconnected, air can enter the pleural space,
producing a pneumothorax. To prevent pneumothorax if the chest tube is inadvertently
disconnected from the drainage system, a temporary water seal can be established by
immersing the chest tube’s open end in a bottle of sterile water.
Quality and Safety Nursing Alert
The manual vent should not be used to lower the water level in the water seal when the patient
is on gravity drainage (no suction) because intrathoracic pressure is equal to the pressure in the
water seal.
Chapter 20
Chronic Obstructive Pulmonary Disease
•Exposure to tobacco smoke accounts for an estimated 80–90% of cases of chronic obstructive
pulmonary disease
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•Secondhand smoke
•Increased age
•Occupational exposure—dust, chemicals
•Indoor and outdoor air pollution
•Genetic abnormalities, including a deficiency of alpha1-antitrypsin, an enzyme inhibitor that
normally counteracts the destruction of lung tissue by certain other enzymes
The respiratory system changes throughout the aging process, and it is important for nurses to
be aware of these changes when assessing older adult patients who are receiving oxygen
therapy. As the respiratory muscles weaken and the large bronchi and alveoli become enlarged,
the available surface area of the lungs decreases, resulting in reduced ventilation and respiratory
gas exchange. The number of functional cilia is also reduced, decreasing ciliary action and the
cough reflex. As a result of osteoporosis and calcification of the costal cartilages, chest wall
compliance is decreased. Patients may display increased chest rigidity and respiratory rate and
decreased PaO2 and lung expansion. The older adult is at risk for aspiration and infection
related to these changes. In addition, patient education regarding adequate nutrition is essential
because appropriate dietary intake can help diminish the excess buildup of carbon dioxide and
maintain optimal respiratory functioning
Oxygen delivery systems are classified as either low- or high-flow systems. Whereas a low-flow
oxygen delivery system may imprecisely deliver high concentrations of oxygen (e.g., up to 100%
via a nonrebreathing mask), the Venturi mask, which is a high-flow system, is specifically
designed to deliver precise but lower concentrations of oxygen (less than 30% oxygen).
Quality and Safety Nursing Alert
Oxygen therapy is variable in patients with COPD; its aim in COPD is to achieve an acceptable
oxygen level without a fall in the pH (increasing hypercapnia).
Use of Pressurized Metered-Dose Inhaler (pMDI)
The nurse instructs the patient to:
Remove the cap and hold the inhaler upright.
•Shake the inhaler.
•Sit upright or stand upright. Breathe out slowly and all the way.
•Use one of two techniques: open- or closed-mouth technique.
•Open-mouth technique
•Place the pMDI 2 finger widths away from lips.
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•With mouth open and tongue flat, tilt outlet of the pMDI so that it is pointed toward the upper
back of the mouth.
•Actuate the pMDI and begin to breathe in slowly. Breathe slowly and deeply through the
mouth and try to hold breath for 10 s.
•Closed-mouth technique
•Place the pMDI between the teeth and make sure the tongue is flat under the mouthpiece and
does not block pMDI.
•Seal lips around mouthpiece and actuate the pMDI. Breathe in slowly through the mouth and
try to hold breath for 10 s.
•Repeat puffs as directed, allowing 1 min between puffs. There is no need to wait for other
medications.
•Apply the cap to the pMDI for storage.
•After inhalation, rinse mouth with water when using a corticosteroid-containing pMDI.
The pMDI mouthpiece should be cleaned on a regular basis as should the nozzle of the canister
based on the manufacturer’s recommendations. As there are many types of inhalers, it is
important to follow the manufacturer’s instructions for use and care of the inhaler.
Quality and Safety Nursing Alert
Normal PaCO2 during an asthma attack may be a signal of impending respiratory failure.
Quality and Safety Nursing Alert
In status asthmaticus, increasing PaCO2 (to normal levels or levels indicating respiratory
acidosis) is a danger sign signifying impending respiratory failure.
Chapter 1
Skills needed in critical thinking include interpretation, analysis, evaluation, inference,
explanation, and self-regulation. Independence is not part of the critical thinking process.
The collaborative practice model involves all care providers, including nurses, physicians, and
ancillary health personnel as well as the patient functioning within a decentralized organizational
structure to collaboratively make clinical decisions. The collaborative model promotes shared
participation, responsibility, and accountability in a health care environment that strives to meet
the complex health care needs of the public.
Two broad goals of the Healthy People initiative are to increase the quality and years of
healthy life and to eliminate health disparities.
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The healthcare team includes nurses, physicians, pharmacists, psychologists, social workers,
healthcare administrators, and various other health professionals, such as physical therapists
One classic theory in ethics is teleologic theory or consequentialism, which focuses on the ends
or consequences of actions. The best-known form of this theory, utilitarianism, is based on the
concept of “the greatest good for the greatest number.” The choice of action is clear under this
theory, because the action that maximizes good over bad is the correct one. The theory poses
difficulty when one must judge intrinsic values and determine who’s good is the greatest. In
addition, it is important to ask whether good consequences can justify any amoral actions that
might be used to achieve them.
Critical thinking includes metacognition, the examination of one's own reasoning or thought
processes, to help refine thinking skills. Metacognition is not characterized by eliciting input
from others or evaluating previous responses.
Nursing Process
-assessment
-Diagnosis
-Planning
-Implementation
-evaluation
Critical Thinking skills
-interpretation
-analysis
-inference
-explanation
-evaluation
-self-reflection
-self-regulation
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1.
2.
3.
4.
5.
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Self-actualization-achieving one’s full potential, including creative activities
Esteem and self-respect-Prestige and feelings of accomplishment, recognition
Belongingness and affection-Intimate relationships, friendships
Safety and security-personal security, employment, resources, shelter, stability
Physiologic needs- food, water, warmth, rest, pain relief