Copyright © 2008 by F. A. Davis.
Copyright © 2008 by F. A. Davis.
2nd Edition
MedSurg
Notes
Nurse’s Clinical Pocket Guide
Tracey Hopkins, BSN, RN
Ehren Myers, RN
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1
Legal Issues in MedSurg Care
Legal issues affect all aspects of nursing care. Urgent care situations, in
which the patient’s life may be lost or potential quality of life compromised,
require even more vigilant attention to nursing standards of care and best
practices.
The nurse practice law of each state defines the scope of nursing
practice for that state.
Advanced practice nurses, such as nurse midwives, nurse anesthetists, and
clinical nurse specialists, function under a broader scope of practice.
■ Know your state’s nurse practice law; contact your state board of nursing
for a copy.
■ Know your state’s requirements for licensure, and maintain your nursing
license as required.
■ Keep informed of local, state, and national nursing issues; get involved as
a lobbyist in your state; contact your state representatives regarding
issues that affect nursing practice.
■ Know if and how a nursing union could affect your practice.
Nurses have a duty of care of careful and continuous monitoring
of the patient’s status.
Nurses assess and directly intervene on patients more than any other healthcare professionals.
■ Monitor each patient’s vital signs, neurological status, intake and output,
status per physician order, nursing care plan, hospital policy and
procedure; increase frequency of vital signs if indicated, and notify the
physician.
■ Evaluate family members’ concerns as soon as possible; the family often
detects subtle changes in a patient’s status.
Nurses have a duty to communicate the patient’s status to the
medical staff, particularly on an immediate/STAT basis when the
patient’s status warrants.
The nurse is usually the first team member to detect an urgent care situation
and has an obligation to report any changes in patient condition to the
medical staff for timely intervention.
■ Notify the physician as soon as you detect any change in the patient’s
condition that indicates deterioration in status. Document assessment,
time of call to physician, and nursing interventions and patient’s response.
■ Use the hospital’s chain of command if the physician fails to respond
within minutes. Notify the nursing supervisor if the physician does not
respond immediately.
(Continued on the following page)
BASICS
BASICS
Copyright © 2008 by F. A. Davis.
■ The nurse must maintain accurate nursing notes, flow sheets, medical
Kardexes, and nursing care plans that record the patient’s symptoms, time
symptoms were present, time physician was notified, and time physician
arrived. The medical chart should be a factual record of the patient’s
medical treatment, responses thereto, vital signs, and all nursing
interventions.
Nurses have a duty to administer medications safely at all times,
including urgent care situations.
Medication errors are the most common source of nursing negligence.
Procedural safeguards should be followed to prevent medication errors. The
“five rights” of medication administration are minimum practice standards.
■ Give the right drug in the right dose to the right patient by the right route
at the right time.
■ Document the five rights—which medication, to whom, in what dose,
through which route, and at what time.
■ Document fully any suspected adverse drug reaction, time and nature
of the reaction, time physician notified, interventions taken, and patient’s
response.
■ Nurses have a duty to know about all the drugs they administer: drug
names, drug categories, dosage, timing, technique of administration,
expected therapeutic response, duration of drug use, and procedures to
minimize the incidence or severity of adverse drug effects.
Nurses have a duty to maintain safe patient care conditions.
This is akin to the nurse’s duty to advocate for the patient at all times.
■ Report an unsafe staffing condition to the nursing supervisor as soon as
it is apparent. The nurse-patient ratio in intensive care settings should not
exceed 1:2; on general floors, 1:6.
■ Working beyond a 12-hour shift can create a substantial decline in
performance.
■ Know the nurse practice limitations on nurses under your supervision;
licensed practical nurses and student nurses cannot perform all the
actions of the registered nurse.
Nurses have a duty to keep the patient safe from self-harm.
The nurse must be vigilant regarding any changes in the patient’s sensorium/
mental status. Any patient can experience a psychiatric crisis from a myriad
of causes, including hypoxia, drug reaction, drug withdrawal, ICU psychosis,
or underlying organic disease.
■ Assess the patient’s mental status with each nursing intervention; note
subtle changes, and notify the physician.
■ Signs of impending psychiatric crisis include changes in orientation to
person, place, and time; verbal abusiveness; restlessness; increased
anxiety; and agitation.
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Copyright © 2008 by F. A. Davis.
3
■ If a patient is at risk of self-harm and/or of harming others, restraints can
be applied.
■ Most states require a written physician order before restraining the
patient, except in an emergency. The physician must be notified
immediately of the use of restraints.
■ If restraints are applied, the patient must be monitored closely for changes
in medical condition and mental status, for maintenance of adequate circulation, and for prevention of positional asphyxiation. Document all assessments and frequency of checks (no less frequent than every 15 minutes).
■ Know the hospital’s policy and procedure regarding use of restraints, and
follow them at all times.
Nurses have a duty to carry out physician orders as required by
state law, hospital policy and procedure, and nursing practice
standards.
Concurrently, as patient advocate, the nurse must question an order he or
she deems problematic, particularly when an urgent care situation is present
or when one could arise from fulfillment of the order.
■ Contact the physician immediately for any order that is unclear, contrary
to standard drug dosage/route/frequency of administration, or that does
not address the acuity of the patient’s medical condition; e.g., an order for
vital signs every shift for a postoperative patient recently transferred to a
general surgical floor.
■ Question an order for a patient’s discharge from the hospital when the
patient’s medical condition is not stable, when delay in treatment resulting
from discharge could injure the patient, or when the patient is going to a
potentially unsafe environment. Document interaction with the physician
and health-care team.
■ Follow written physician orders; be particularly vigilant in carrying out an
order that changes over time; e.g., tapering of medication or oxygen at
specified time intervals.
Informed consent is the process of informing the patient, not
simply completing the form with the patient’s signature.
■ Informed consent involves providing the patient with adequate medical
information so that he or she can make a reasonable decision as to
treatment based upon that information. In urgent care situations it can
be impossible to obtain a patient’s informed consent for an immediate
intervention.
■ State laws differ regarding the informed consent standards; know your
state’s informed consent law and the hospital’s policy and procedure for
obtaining informed consent.
(Continued on the following page)
BASICS
BASICS
Copyright © 2008 by F. A. Davis.
■ Exceptions to informed consent include an emergency in which the
patient is incompetent and cannot make an informed choice, there is not
sufficient time to obtain an authorized person’s consent, and the patient’s
medical condition is life-threatening.
■ If a patient is competent and refuses medical care, even when the
condition is life-threatening, the patient’s choice supersedes the opinion
of the health-care provider.
■ Ensure that each patient’s advance directive or living will (patient’s
advance legal permission to the physician to withhold or discontinue
treatment) is complied with and well documented in the medical chart
per state law and hospital policy and procedure. Know if the patient
has a do not resuscitate order, and ensure that it is well documented.
Nurses are held to the standard of care of the profession.
When nursing care falls below the standard of care, the care could be
deemed to be negligent or deficient if that care (or lack of care) causes the
patient some type of injury. This is the basis of a lawsuit against the healthcare professional, called medical malpractice.
■ Each nurse owes every patient the duty of “reasonable care.” This is
implicit in the standard of care defined by what nursing professionals
generally recognize on a national level as correct patient care.
■ Nationally recognized nursing textbooks, nursing journals, and nursing
treatises that nurses generally regard as authoritative define the nursing
standards of care.
■ Whether a nurse’s care of a patient met the applicable standards of
nursing care in a medical malpractice case is determined by a nursing
expert, a nurse who has the requisite experience and knowledge of the
authoritative resources.
As nursing practice, along with medical technology, continues to become
more sophisticated and complex, the standards of nursing care will likewise
increase.
Documentation Guidelines for Urgent Situations
Documentation is critical in urgent situations. It enhances decision making
and helps anyone who reads it understand what happened, how it was
handled, and what the outcomes were. It is crucial in any legal analysis of
care. Keep the following in mind as you document:
■ Always document your assessment findings, your interventions, and what
triggered the situation. Did you observe a problem, did the patient call for
help, or did you find the patient in distress? What were your immediate
interventions?
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Copyright © 2008 by F. A. Davis.
5
■ Document as you go. It establishes a timeline for the incident as well as
conveying the interventions and outcomes accurately. Time, date, and sign
every individual entry.
■ Always note at what time, by what route, and how much medication you
or another member of the team has administered. Always record
response to the medication and the time the response(s) occurred or the
time you observed for a response, whether there was a response or not.
The same applies to any non-drug intervention.
■ Always note the time you called the physician or nurse practitioner and
his or her response.
■ If you do not get the response from the physician or nurse practitioner
you think is required for the patient’s best interests, call your
administrative superior (nurse manager), and report the problems.
Document your call and the supervisor’s response. Do not blame or
complain about someone; just note that you called the supervisor to
report the patient’s condition.
■ If you fail to document something, write another entry called “Addendum”
to the note above, and give the time and date of the first note.
Delegation Guidelines
The National Council of State Boards of Nursing defines delegation as
“transferring to a competent individual the authority to perform a selected
nursing task in a selected situation. The nurse retains accountability for the
delegation.” Check your state’s nurse practice act for details about which
nursing activities cannot be delegated.
Sample of nursing tasks that cannot be delegated:
■
■
■
■
■
■
Initial assessment or assessments of change in patient condition
Formulating the nursing diagnosis; creating the nursing plan of care
Administration of medications by direct IV bolus (IV push)
Administration of blood products
Programming a PCA pump
Changing a tracheotomy tube
Before delegating, determine the following:
■ The complexity of the task and the potential for harm posed by the task
(what psychomotor skills are required? what harm can occur if the procedure is done incorrectly?)
■ The predictability or unpredictability of the outcome (is this procedure
new to the patient, or has the patient tolerated this procedure well
before?)
(Continued on the following page)
BASICS
BASICS
Copyright © 2008 by F. A. Davis.
■ The problem-solving or critical thinking abilities required (problem-prone
activities such as changing a new colostomy appliance, for example, may
require the more in-depth knowledge and problem-solving skills only the
RN can supply)
Remember the Five Rights of Delegation:
■ Right Task—is the task within the caregiver’s scope of practice?
■ Right Person—does the assigned caregiver have the knowledge and skill
required?
■ Right Circumstances—is the setting appropriate; are the right resources
available? what is the current health status of the patient?
■ Right Direction—clear description of the activity to be performed, relevant
patient conditions, limits, and expectations.
■ Right Supervision—monitoring performance, maintaining your availability
to assist, receiving feedback about the procedure and patient’s tolerance,
providing feedback.
Remember: The RN delegates a task but retains responsibility and accountability. Specialized nursing skills and nursing judgment cannot be delegated.
Critical Thinking Guidelines
Identifying
■ The first thing the nurse must do is identify that a problem exists. The
triggering event is something unexpected. It may be as obvious as
crushing chest pain or as subtle as a complaint of thirst. Big red flags are
easy to see; do not ignore tiny red flags.
■ Listen and observe. Know recent trends in the patient’s status; understand
normal and abnormal findings. Recognize differences and similarities.
■ Have you noticed or has the patient complained of something
unexpected?
■ Follow up with questions any new complaint or unusual finding.
■ If you have any doubts, do not ignore them; ask a nurse who is senior
to you, or notify the physician/NP.
Assessing
■ Once a problem is identified, seek information; gather objective,
subjective, historical, and current data.
■ Perform a focused physical examination; obtain relevant laboratory and
diagnostic reports; read recent entries in the chart.
■ Order problems in importance; determine if the problem is urgent; if not,
determine how important it is.
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Copyright © 2008 by F. A. Davis.
7
Analyzing
■ Analysis involves breaking the whole into parts and discovering the
relationships of the part to the whole. Is the problem hypotension? Think
about the factors that influence blood pressure: What is the hemoglobin
level, urinary output, recent blood loss? Can you assess cardiac output?
Is the patient on medications that affect blood pressure?
■ Think about what you have discovered through assessment. Ask if the
laboratory values or tests suggest a cause.
■ Consider if the data fit any of the known complications of the patient’s
condition. Do the data suggest something is worsening? Link the data
to the patient’s physical status. Do the data “fit”?
■ Ask yourself if you are making the data fit and if you have overlooked
another cause.
■ Ask yourself what other information is needed. Do you need to assess
another body system? Have you asked the patient about all recent related
events? Should you check the medication record?
■ Other types of problems may require a different set of information (What
other supplies are needed? Does the patient require referral to a religious
leader? Does the family need to see a social worker?).
■ While you analyze, double-check that you are not making erroneous
assumptions. Ask yourself if the data can be interpreted another way.
Ask yourself what other issues or conditions could cause similar signs
and symptoms.
Diagnosing
■ The end result of analysis is a conclusion. For nurses who are thinking
critically about a problem, this conclusion is a nursing diagnosis or a
definition of the problem.
■ State the problem clearly, what the problem is related to, and what data
support this conclusion. State the desired outcomes as well and in what
time frame you expect them to be achieved.
■ Determine the significance of this problem. Ask yourself again: Is it urgent?
Does it have the potential to cause a sudden and rapid deterioration in the
patient’s health status? Is it imperative that you act immediately? Do you
need help?
Planning
■ Consider which intervention(s) will be most effective; predict the consequences of the intervention and if it will produce the desired outcome.
■ Urgent problems require that you immediately summon a
physician or nurse practitioner.
■ Implement the plan; document all problems and interventions.
(Continued on the following page)
BASICS
Copyright © 2008 by F. A. Davis.
BASICS
Evaluating
■ Evaluation is the step that lets you know if the plan is working.
■ Assess the status of the problem at appropriate intervals; evaluate if the
interventions are effective.
■ Determine if further intervention is required.
Enhance Your Clinical Reasoning Abilities
■ The link between a problem and a positive outcome is sound professional
judgment. Pose new questions to yourself every day. Ask yourself why a
certain complication occurs or why a medication helps. Find out the
answers. Ask others; consult the literature.
■ Keep current. Read journals and other literature.
■ Learn about other specialty areas such as oncologic nursing, wound care,
respiratory or physical therapy.
■ Know your real strengths, skills, and weaknesses. Correct weaknesses.
■ Be alert in your observations and assessments. Realize that everybody
makes assumptions and that assumptions can be wrong. Ask yourself
what else might be responsible for the signs and symptoms.
■ Work in other fields to gain experience. Challenge yourself.
■ Ask questions of other experts in medicine, surgery, nursing, and related
fields. All practioners fundamentally are teachers. Learn from them.
Principles of Pain Management
■ Differentiate between acute and chronic pain. Patients in chronic pain may
not exhibit signs of being in pain.
■ Do not assume that the patient’s pain is exaggerated because he or she
asks for pain medicine frequently. Look for ways to better manage pain.
■ Assess each patient’s pain, and create an individualized treatment plan
■ Reassure patients in pain or who expect to have pain that pain can be
relieved.
■ Assess any changes in pain pattern to ensure that new causes are not
overlooked.
■ Try the least invasive route first in patients with cancer or chronic pain.
Keep dosage schedules simple.
■ Monitor side effects. Use prevention strategies, especially for constipation
when opiods are used.
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Copyright © 2008 by F. A. Davis.
9
■ Be careful switching from oral to IV, IM, IT, or other route. Dosages
change, and different drugs may not provide as much pain relief. Use an
equianalgesic dosing table for guidance.
■ Teach or arrange for instruction in biofeedback, relaxation exercises, and
hypnosis.
■ All can reduce pain and stress and give a greater sense of control.
■ Do not avoid opioids because of fear the patient will become addicted.
■ Encourage patients to request pain medication before pain becomes
severe.
■ Suggest administering medication on an around-the-clock schedule to
maintain therapeutic blood levels.
■ Suggest time-released pain medications to avoid peaks and valleys in
pain control.
■ Consult with a pain management clinical specialist, if available.
■ Include family in pain control plan.
Pain Management
Numeric Scale
0
No
pain
1
2
Mild
pain
3
4
5
Moderate
pain
6
7
Severe
pain
8
9
Very severe
pain
10
Worst
possible
pain
Visual Analog Scale
Text/image rights not available.
0
NO HURT
2
HURTS
LITTLE BIT
4
6
HURTS
LITTLE MORE
HURTS
EVEN MORE
8
HURTS
WHOLE LOT
10
HURTS
WORST
Wong-Baker FACES Pain Rating Scale. Use for children over 3 years. (From Hockenberry
MJ, Wilson D, Winkelstein ML: Wong’s Essentials of Pediatric Nursing, ed. 7, St. Louis,
2005, p. 1259. Used with permission. Copyright, Mosby.)
BASICS
BASICS
Copyright © 2008 by F. A. Davis.
Using Pain Scales
■ Most patients can use the numerical scale.
■ Say: “On a scale of zero to ten, with zero meaning no pain and ten
meaning the worst pain possible, tell me what level of pain you are
feeling now.”
■ Ask how distressing the pain is, using a scale of 0–10.
■ Some patients report a moderate to high numerical score (5 or above)
but are not distressed and do not want medication.
■ Some patients report a lower numerical value but are very distressed
by the pain and may need medication or other intervention.
■ Always ask the patient directly if he or she would like medication.
■ Contact a pain care nurse, if available.
■ For patients who cannot use the numerical scale, use the Wong-Baker
FACES Pain Rating Scale. Tailor questions accordingly.
Mnemonics for Thorough Pain Assessment (PQRST and COLDERRA)
Perform pain assessment quickly but thoroughly prior to medicating. Always
find out if the pain is new and different; if it is consistent with the patient’s
diagnosis, procedure, or surgery; or if it is typical and expected. New onset
pain, or pain that is unusual for the diagnosis, procedure, or surgery, needs
to be evaluated by the physician or nurse practitioner as soon as possible.
Chest pain requires immediate assessment (see Chest Pain in CV tab).
PQRST
P (provokes/point) ............What provokes the pain (exertion, spontaneous
onset, stress, postprandial, etc.)
Point to where the pain is.
Q (quality) .........................Is it dull, achy, sharp, stabbing, pressing, deep,
surface, etc.? Is it similar to pain you have had
before?
R (radiation/relief) ............Does it travel anywhere (to the jaw, back, arms,
etc.)? What makes it better (position, being still)?
What makes it worse (deep inspiration,
movement)?
S (severity/s/s) ..................Explain the 10/10 pain scale and have patient rate
pain. Are there any signs or symptoms associated
with this pain (n/v, dizziness, diaphoresis, pallor,
SOB, dyspnea, abnormal vital signs, etc.)?
T (time/onset) ...................When did it start? Is it constant or intermittent?
How long does it last? Sudden or gradual onset?
Does it start after you have eaten? Frequency?
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Copyright © 2008 by F. A. Davis.
11
COLDERRA
Characteristics..........................................Dull, achy, sharp, stabbing, pressure?
Onset ..........................................................................................When did it start?
Location ..................................................................................Where does it hurt?
Duration .........................................................How long does it last? Frequency?
Exacerbation ......................................................................What makes it worse?
Radiation...........................................Does it travel to another part of the body?
Relief.....................................................................................What provides relief?
Associated s/s ......................................Nausea, anxiety, autonomic responses?
Nursing Interventions for Pain Management
Provide comfort ..................................................positioning, rest and relaxation
Validate patient’s response to pain .....................................offering reassurance
Relieve anxiety and fears ....................................setting aside time with patient
Teach relaxation techniques ......................rhythmic breathing, guided imagery
Provide cutaneous stimulation ........................massage, heat and cold therapy
Decrease irritating stimulation ....................................bright lights, noise, temp
Comparison of Routes of Analgesic Administration
Route
Advantages
Disadvantages
Oral
Easiest, least invasive;
consider oral first
while taking into
account patient status
Metabolized in the liver before
reaching bloodstream—less
drug available (40% to 60%)
than with other routes; takes
longer to act. Cannot be used
if patient has difficulty taking
oral medications.
IM
Quicker onset of action
than oral route
Painful, potential nerve injury;
difficulty finding sites in
undernourished patients
Subcutaneous
No need for IV access;
changing sites usually
easy; 80% of drug
available
Only small volumes of fluid can
be injected each hour. Must
use concentrated medications, which increases risk for
drug error.
(Continued on the following page)
BASICS
BASICS
Copyright © 2008 by F. A. Davis.
Comparison of Routes of Analgesic Administration (continued)
Route
Advantages
Disadvantages
IV PCA
Immediate effect; can have
a continuous rate and a
bolus
IV sites are portal for
infection.
May not be appropriate
for confused patient.
NOTE: Never administer a dose for the
patient—can lead to
respiratory depression and death.
Inform family also.
IT Epidural
Much lower doses, fewer
side effects
Potential for infection or
other complication
Transdermal
Easy to use. Slow buildup
of drug, fewer side
effects.
Usually used for patients
with cancer pain.
Not suitable for acute
pain. Drug remains
active for 14–25 hours
after removal, which
presents problems if
patient overdosed.
Sublingual
Better absorption, quicker
onset than oral route.
Good for patients who
cannot tolerate PO
medications
Used primarily for
break-through pain
for cancer patients.
Cultural Sensitivity
It is not possible for nurses to know intimately all other cultures different
from his or her own. It is possible, however, to acknowledge that significant
cultural variations exist and to adopt an attitude of sensitivity that includes
a desire to learn about and respect the culture of the patients for whom you
care.
Potential for Stereotyping
Books that list cultural characteristics of various groups have some value but
can lead to stereotyping. Too often people make assumptions based on the
12
Copyright © 2008 by F. A. Davis.
13
color of someone’s skin or other overt characteristics. The challenge for
nurses is to learn whether a person considers himself or herself to be a
member of a group and to recognize that significant variation exists within
groups.
Cultural Assessment
Cultural assessment covers many factors, too numerous for this book. Keep
in mind that cultural variation is frequently expressed within domains
applicable to any culture. Maintain a respectful and open attitude as you
learn about each patient. Common domains of importance related to health
care include:
■ Communication styles—eye contact, personal space, tone of voice, and
more. Observe each patient, and follow his or her lead. If you are not sure,
ask politely and respectfully.
■ Religion—you may ask how important religion is to the patient in daily life
and if he or she consults with another member of that religion in healthcare matters.
■ Language—it is very important to use competent interpreters when
obtaining and receiving health information. Do not automatically use
a family member. Sensitive information may be embarrassing for the
two people to discuss. Try to get someone of about the same age and
gender as the patient. Always ask if the patient is willing to use the
interpreter. In an emergency, communicate through the oldest family
member present.
■ Family relationships—families may have a hierarchy that includes a
spokesperson, so to speak. Show respect for that person’s role. As always,
do not reveal confidential information about a person’s health without the
express consent of the patient.
■ Food preferences—providing the patient’s preferred food can be
instrumental in rate of recovery. Ask about any natural remedies the
patient has or is using.
■ Health beliefs—What causes illness, how care is provided, how the patient
handles being ill or in pain are powerful cultural beliefs. Ask the patient or
family members about these issues and integrate the information into
your plan of care.
■ Birth and death rituals—End-of-life beliefs can vary significantly within
any culture. Suggest meeting with the family if the patient approves of
you sharing or receiving information about personal preferences. Discuss
issues such as organ donation, autopsy if applicable to the case, special
care of the body, and what the family will want to do in the immediate
time after death.
BASICS
BASICS
Copyright © 2008 by F. A. Davis.
Spiritual Care
Providing spiritual care means different things to different people. Some
nurses may be too intimidated to address this issue. Many do not feel
competent to do so or that it is none of their business. You can always ask
the patient how he or she feels spiritually. The answer will be very revealing
in terms of willingness to discuss the topic. Follow the patient’s lead, and
never impose your own beliefs. Often, the best spiritual intervention is to
ask open-ended questions and then listen.
14
Copyright © 2008 by F. A. Davis.
15
Focused Assessment of the CV System
■ A focused assessment of CV status includes:
■ The core cardiovascular system—the heart, its rate and rhythm, the
carotid arteries, blood pressure, and other hemodynamic measures.
■ The peripheral vascular system—the extremities, particularly the
lower extremities.
■ The lungs—adventitious sounds, cough, and oxygenation status.
■ Mental status—level of alertness, restlessness, confusion, irritability,
or stupor.
■ Vital signs:
■ Blood pressure, heart rate, respiratory rate, O2 saturation.
■ Mental status, head and neck:
■ Look for restlessness, ↓ LOC, circumoral cyanosis, color of conjunctiva,
jugular venous distention.
■ Inspect the anterior chest:
■ Look for visible pulsations of the chest wall.
■ Palpate the anterior chest:
■ Locate apical beat, which is the point of maximum impulse (PMI).
■ Assess for heaves—a very forceful PMI.
■ Assess for thrills—a palpable murmur; feels like a cat purring.
■ Auscultate the heart and lungs:
■ Obtain rate and rhythm; assess for rhythm abnormalities.
■ Listen for normal heart sounds and possible murmurs.
■ Use the diaphragm of stethoscope first, then the bell.
■ Listen for carotid abdominal and femoral bruits.
■ Assess extremities: Check for:
■ Cyanosis, temperature, color, and amount of moisture.
■ Capillary refill time in hands and feet.
■ Changes in foot color, ulcers, varicose veins.
■ Edema of lower extremities (check sacrum if client is bedridden).
■ Presence and equality of pedal pulses. If pulses are not palpable,
use a Doppler sonogram.
■ Assess current symptoms:
■ RED FLAG symptoms require immediate attention and intervention.
Shortness of breath.
Chest pain, possibly with neck, jaw, or left arm pain.
Syncope possibly with palpitations and shortness of breath.
Palpitations possibly with chest pain and dizziness.
Cyanosis of lips, fingers, or nailbeds.
Pain, coolness, pallor, or pulse changes in extremities.
Sweating, nausea, vomiting, fatigue (especially in women).
CARDIAC
Copyright © 2008 by F. A. Davis.
CARDIAC
Assessment Guides
Circulation Scale
Pulse Scale
Capillary Refill
Pulse Strength
Normal
⫽ ⬍3 sec
Absent
⫽
0
Delayed
⫽ ⬎3 sec
Weak
⫽
⫹1
Normal
⫽
⫹2
Full
⫽
⫹3
Bounding ⫽
⫹4
Edema Scale
Press thumb carefully into edematous area, usually on the shin
(pretibial edema) or dorsum of foot (pedal edema):
0–1/4 inch; disappears in ⬍5 sec
⫽
⫹1
1/4–1/2 inch; disappears in 10–15 sec
⫽
⫹2
1/2–1 inch; disappears in 1–2 min
⫽
⫹3
⬎1 inch; disappears ⬎2 min
⫽
⫹4
Possible Causes of Shortness of Breath
Source
Potential Causes
Cardiac
Coronary artery disease, angina, MI, heart failure,
cardiomyopathy, valve disease, left ventricular
hypertrophy, pericarditis, dysrhythmias
Pulmonary
COPD, asthma, pneumothorax, pulmonary embolus
(PE), pulmonary edema
Combined cardiopulmonary
COPD with comorbid cardiac disorder, deconditioning,
chronic pulmonary emboli, trauma
Other
Metabolic acidosis, pain, neuromuscular disorders,
upper airway disorders, anxiety, panic,
hyperventilation
16
Copyright © 2008 by F. A. Davis.
17
Cardiac auscultation sites.
Arterial Hematoma
CLINICAL PICTURE
The patient may have:
■ Pressure dressing to radial/brachial/femoral artery insertion site that is
saturated with blood.
■ Cannulated artery that has been inadvertently decannulated and is
hemorrhaging.
■ Hematoma, possibly pulsatile, around arterial puncture site.
IMMEDIATE INTERVENTIONS
■ Notify physician or NP.
■ Place patient in a supine position with affected limb extended.
■ Don sterile gloves and, using folded sterile gauze dressings, apply
firm pressure 2 cm above puncture site, using the first three fingers
of one hand.
■ Continue to apply pressure for 10 minutes or more, until bleeding has
been controlled.
CARDIAC
CARDIAC
Copyright © 2008 by F. A. Davis.
■ Once bleeding is controlled, apply sterile gauze dressing overlayed with
a pressure dressing (Elastoplast). Depending on institution protocol, use
a sandbag or other pressure device over the pressure dressing for added
pressure.
■ Document patient’s status, phone call to physician or NP, and physician or
NP response.
FOCUSED ASSESSMENT
■ Monitor distal pulses, skin color, temperature, and sensation of affected
limb.
■ Assess VS, noting decrease in BP or increase in HR.
■ Assess LOC and patient’s ability to maintain extremity in immobile,
neutral position.
■ Assess for pain.
STABILIZING AND MONITORING
■
■
■
■
■
■
Instruct patient to maintain supine position a minimum of 6 hours.
Frequently assess site for rebleeding.
Monitor circulation, mobility, and sensation in affected extremity.
Frequently monitor VS for changes in BP and HR.
Reassess for pain.
Assess for history of preexisting conditions such as clotting abnormalities
or blood dyscrasias or for recent/current administration of antiplatelet or
anticoagulant medications.
■ Chart patient status, and convey to physician or NP.
BE PREPARED TO
■ Assist physician or NP with cannulation of an alternate arterial site.
■ Obtain IV access for the administration of blood, clotting factors, or
anticoagulant reversal agents such as protamine sulfate.
POSSIBLE ETIOLOGIES
■ Hemophilia, von Willebrand’s disease, thrombocytopenia, DIC, vascular
trauma or iatrogenic arterial injury, anticoagulant therapy, antiplatelet
therapy, thrombolytic therapy.
Arterial Occlusion
CLINICAL PICTURE
The patient may have:
■ Numbness, tingling, severe burning pain, or coolness in affected extremity.
■ Loss of sensation in the extremity.
18
Copyright © 2008 by F. A. Davis.
19
■ Pale, mottled, cyanotic, or ashen extremity.
■ Edematous, tight, shiny skin over affected extremity.
■ Capillary refill ⬎3 sec or absent.
IMMEDIATE INTERVENTIONS
■ Check all arterial pulses in the affected extremity. Compare with those in
contralateral extremity.
■ Assess any sites of arterial puncture (e.g., arteriogram puncture site or
A-line insertion site) for swelling or hematoma.
■ Assess mobility of affected extremity; compare with that of contralateral
extremity.
■ Assess VS.
■ Notify physician or NP.
■ Document patient’s status, phone call to physician or NP, and physician
or NP response.
FOCUSED ASSESSMENT
■ Assess for pallor, pain, paresthesias, paralysis, and pulselessness (5 Ps)
by assessing circulation (skin color, capillary refill, pulses), movement
(flexion, extension, rotation), and sensation (response to pinprick or light
touch; pain level) of affected extremity.
■ Assess pulses with Doppler amplification.
■ Assess bandages or cast proximal to diminished pulses.
STABILIZING AND MONITORING
■ Continue to monitor condition of extremity.
■ Keep extremity at heart level to promote arterial flow without diminishing
venous return.
■ Remove or do not use ice on the extremity.
■ Control and manage pain.
BE PREPARED TO
■ Remove any external fixtures (casts) on the extremity, or assist the
physician or NP with fasciotomy for immediate relief of pressure.
■ Prepare the patient for surgery.
■ Initiate large-bore IV access.
POSSIBLE ETIOLOGIES
■ Compartment syndrome, major vascular injury, thrombus, ruptured aortic
aneurysm, local or regional block anesthesia, cord injury, lymphedema,
fracture, hypotension, hypothermia, dehydration, shock.
CARDIAC
CARDIAC
Copyright © 2008 by F. A. Davis.
Bradycardia
CLINICAL PICTURE
The patient may have:
■ HR ⬍60 bpm.
■ Nausea and vomiting, dizziness or lightheadedness.
■ Signs of unstable bradycardia:
■ Altered LOC.
■ Chest pain, shortness of breath (SOB).
■ Hypotension, pulmonary congestion, and/or cyanosis.
IMMEDIATE INTERVENTIONS
■
■
■
■
■
■
■
Have patient sit or lie down in bed.
Administer supplemental O2.
Assess BP.
Notify physician or NP.
Obtain a 12-lead ECG.
Check for patent IV access.
Document patient’s status, phone call to physician or NP, and physician
or NP response.
FOCUSED ASSESSMENT
■
■
■
■
Assess LOC and orientation.
Assess BP and HR.
Assess respirations for rate and effort; assess SaO2 if readily available.
Assess skin for color, moistness, and temperature. Assess for associated
symptoms (chest pain, SOB, hypotension).
■ If patient on telemetry or cardiac monitor, assess ECG.
STABILIZING AND MONITORING
■
■
■
■
Monitor VS.
Set up cardiac monitoring, and monitor rate and rhythm.
Assess recent laboratory results.
Chart patient status, and convey to physician or NP.
BE PREPARED TO
■
■
■
■
■
■
Administer oral or IV medications as ordered.
Obtain or order laboratory tests.
Titrate O2 to SaO2 ⬎90%.
Obtain IV access if none available.
Assist with external pacing.
Transfer patient to ICU or telemetry unit.
20
Copyright © 2008 by F. A. Davis.
21
POSSIBLE ETIOLOGIES
■ Medication toxicity, vasovagal response, hyperkalemia, hypothermia,
hypothyroidism, sepsis, severe infection, hypoglycemia, hypothermia,
excellent physical condition (athletes), myocardial infarction, shock.
Chest Pain
CLINICAL PICTURE
The patient may have (see table below on Possible Causes of Chest Pain):
■ Substernal or epigastric sensations of fullness, pressure, or tightness; pain
may radiate to left neck, jaw, back, and/or arm.
■ Cool, pale, and/or diaphoretic skin.
■ Nausea, vomiting.
■ SOB, tachypnea.
■ Dizziness, fatigue, fainting.
■ Marked anxiety, expression of “impending doom.”
IMMEDIATE INTERVENTIONS
■ Elevate head of bed (HOB) to facilitate breathing.
■ Administer high-flow O2 by nonrebreather mask (10–15 L/min) or by nasal
cannula (4–6 L/min).
■ Assess VS, character and quality of pain (PQRST), skin color.
■ Check for standing orders of nitrogylcerine (NTG) sublingual 0.4 mg q
5 min ⫻ 3 doses maximum (hold for BP ⬍90 mm Hg) and one 325 mg
nonenteric-coated aspirin. Administer STAT.
■ Check for IV access. Prepare to initiate saline lock IV access.
■ Notify physician or NP.
■ Document patient’s status, phone call to physician or NP, and physician
or NP response.
FOCUSED ASSESSMENT
■
■
■
■
■
Assess HR, rhythm, BP, respiratory rate (RR), and effort.
Inspect skin for color, temperature, and moistness.
Assess SaO2 with pulse oximetry.
Assess rhythm strip.
Auscultate lung fields.
STABILIZING AND MONITORING
■ Administer medications STAT for cardiac symptoms, if ordered: NTG 0.4
mg SL (hold for BP ⬍90 mm Hg); morphine (MS) 2 mg IV (hold for RR ⬍8,
BP ⬍90 mm Hg); aspirin (ASA) 162–325 mg PO.
CARDIAC
CARDIAC
■
■
■
■
Copyright © 2008 by F. A. Davis.
Assess response to medications.
Identify underlying rhythm.
Obtain cardiac enzymes/troponin levels.
Chart patient status, and convey to physician or NP.
BE PREPARED TO
■
■
■
■
■
■
■
■
Assess need and eligibility for thrombolytic therapy.
Set up cardiac monitoring.
Set up or change the O2 delivery system.
Administer oral or IV medications.
Call for a STAT 12-lead ECG.
Obtain laboratory tests (electrolytes, PT, PTT, cardiac markers).
Transfer patient to ICU.
Call a code; perform CPR.
POSSIBLE ETIOLOGIES
■ Angina, anxiety, MI, pulmonary embolism, pulmonary edema, chest
trauma, endocarditis, pericarditis, indigestion, gastroesophageal reflux
disorder, pleurisy, bronchitis.
22
Copyright © 2008 by F. A. Davis.
Possible Causes of Chest Pain
Provocation
and Onset
Quality
and Relief
Location and
Radiation
Severity and
Time (Duration)
No provocation;
large, heavy meal;
extreme exertion,
stress, or fright.
Sudden onset.
Pressure,
squeezing.
No relief.
Substernal
anterior chest or
epigastrium, →
to left neck, jaw,
arm, back
Severe, lasting
longer than
20 min.
Angina
Provoked by exertion.
Sudden onset.
Pressure,
tightness.
Rest or sl NTG
provides relief
Same as MI
Mild to moderate,
lasting ⬍2 min.
Pneumonia
No provocation or
coughing.
Gradual or sudden
onset.
Ache with sharp,
stabbing pain.
No relief.
Anterior chest,
shoulder, neck.
Moderate, lasting
hours.
PE
No provocation.
Sudden.
Dull, aching but
may also have
sharp pain.
No relief.
Variable.
None, mild, or
moderate of
variable
duration.
23
MI
(Continued on the following page)
CARDIAC
Etiology
Etiology
Provocation
and Onset
Quality
and Relief
Location and
Radiation
Severity and
Time (Duration)
Pericarditis
No provocation;
deep breathing,
coughing.
Gradual or sudden
onset.
Sharp.
Substernal
anterior chest.
Moderate to
severe, endures
for hours to
days.
Epigastric
disorders
Gradual or sudden.
Sharp, burning
when patient
in upright
position,
antacids
provide relief.
Chest, throat,
RUQ, LUQ, back.
Moderate, lasting minutes or
hours.
Musculoskeletal
disorders
Gradual or sudden.
Dull ache;
possible sharp
pain.
Rest and mild
analgesics or
NSAIDs
provide relief.
Arm, shoulder,
neck, back,
sternum, ribs,
abdomen.
Mild to moderate,
lasting minutes
to hours.
24
Copyright © 2008 by F. A. Davis.
CARDIAC
Possible Causes of Chest Pain (continued)
Copyright © 2008 by F. A. Davis.
25
Heart Failure
CLINICAL PICTURE
The patient may have:
■ Fatigue, weakness, anxiety.
■ SOB, orthopnea, dyspnea, adventitious breath sounds (rales or crackles),
cyanosis.
■ Change in mental status anxiety, restlessness, confusion.
■ Edema, jugular vein distention, increased CVP, positive fluid balance.
IMMEDIATE INTERVENTIONS
■
■
■
■
■
■
Assess VS; note if hypotensive.
Elevate HOB, and lower legs if possible.
Administer supplemental O2 (100% nonrebreather mask).
Restrict fluids.
Assess for patent IV.
Notify physician or NP.
FOCUSED ASSESSMENT
■
■
■
■
■
Assess airway, RR and effort, BP, and HR.
Auscultate lung fields for pulmonary congestion (crackles, wheezes).
Assess SaO2 via pulse oximetry.
Assess LOC and orientation.
Assess cardiac rhythm.
STABILIZING AND MONITORING
■ Restrict fluids, and administer diuretics as ordered.
■ Closely monitor I&O.
■ Assess for improvement of LOC and oxygenation status.
BE PREPARED TO
■
■
■
■
Titrate O2 to keep SaO2 ⬎90%.
Obtain IV access.
Set up cardiac monitoring.
Administer oral or IV diuretics, NTG, morphine, and electrolytes as
ordered.
■ Order a chest x-ray and ECG.
■ Order or obtain laboratory tests (BUN, creatinine, CBC, electrolytes).
■ Transfer patient to ICU or telemetry unit.
POSSIBLE ETIOLOGIES
■ Atrial fibrillation, marked bradycardia, systemic infection, septic shock,
pulmonary embolism; physical, environmental, and emotional excesses;
CARDIAC
CARDIAC
Copyright © 2008 by F. A. Davis.
stress; cardiac infection and inflammation; excessive intake of water
and/or sodium administration of cardiac depressants or drugs cause
salt retention; cardiomyopathy, hypertension, severe aortic stenosis,
ischemic myocardial disease, coronary artery disease, acute mitral
or aortic regurgitation, infective endocarditis with acute valve incompetence, MI, anemia, hyperthyroidism, pregnancy, glomerulonephritis,
cor pulmonale, polycythemia vera, carcinoid syndrome, obesity.
Hemorrhage/Wound Hemorrhage
CLINICAL PICTURE
The patient may have:
■ Saturated postoperative dressings.
■ Excessive amounts of blood in wound drainage system.
■ Peri-incisional swelling and hematoma.
■ Subtle changes in LOC, anxiety, irritability, restlessness, decreased
alertness (early CNS signs of blood loss).
■ Confusion, combativeness, lethargy, coma (later CNS signs).
■ Increased HR to severe tachycardia.
■ Delayed capillary refill (⬎3 sec), diminished peripheral pulses (⬍⫹l2),
cool extremities and pale, mottled, or cyanotic skin.
■ Slightly elevated RR to severe tachypnea.
■ Hypotension.
■ Narrowing of pulse pressure.
■ Thirst.
■ Bruising around umbilicus or retroperitoneally in flank areas (internal
bleeding).
IMMEDIATE INTERVENTIONS
■
■
■
■
■
■
■
■
■
Get help, and notify surgeon.
Discontinue thrombolytics or anticoagulants.
Control external bleeding with direct pressure.
Do not remove saturated dressings, as this may also remove any clot
formation.
Instead, reinforce with additional dressing and pressure.
Administer supplemental O2; maintain patent airway.
If IV not in place, obtain large gauge (#18) IV access, and have IVF ready
to hang.
Monitor VS frequently.
Document patient’s status, phone call to physician or NP, and physician
or NP response.
26
Copyright © 2008 by F. A. Davis.
27
FOCUSED ASSESSMENT
■ Assess LOC, orientation, and VS (HR, RR, BP).
■ Assess for orthostatic hypotension if possible.
■ Assess SaO2 via pulse oximetry if available (Note: may be unreliable due
to decreased peripheral perfusion).
■ Assess skin for color, temperature, moistness, turgor, capillary refill.
STABILIZING AND MONITORING
■ Monitor VS and oxygenation status.
■ If patient previously typed and cross-matched, call blood bank to see if
any blood available.
■ Monitor output from Hemovac, JP drains, NGT, and urinary catheter.
■ Check laboratory values.
■ Provide emotional support to patient/family.
■ Chart patient status, and convey to physician or NP.
BE PREPARED TO
■ Assist with insertion of a central line.
■ Obtain laboratory tests STAT (Hgb/Hct, ABGs, electrolytes, blood type and
crossmatch).
■ Prepare the patient for surgery.
■ Administer colloidal infusions.
■ Insert Foley catheter.
■ Administer blood.
■ Mechanically ventilate.
POSSIBLE ETIOLOGIES
■ External bleeding: wounds (postsurgical and traumatic); internal bleeding:
blunt trauma, cancer, ruptured aneurysm, postsurgical, GI perforation,
thrombolytic therapy.
Hypertensive Urgency/Emergency
Hypertensive urgency: systolic BP ⬎200 mm Hg or a diastolic BP ⬎120 mm
Hg. Hypertensive emergency: diastolic BP ⬎140 mm Hg with evidence of
acute end-organ damage.
CLINICAL PICTURE
The patient may have:
■ Fatigue, headache, restlessness, confusion, visual disturbances, seizure.
■ Dyspnea, tachycardia, bradycardia, pedal edema, chest pain.
■ Lightheadedness, dizziness.
■ Nausea, vomiting.
CARDIAC
CARDIAC
Copyright © 2008 by F. A. Davis.
IMMEDIATE INTERVENTIONS
■
■
■
■
■
Assess BP in both arms.
Elevate HOB to 30⬚–45⬚.
Administer supplemental O2.
Notify physician or NP.
Document patient’s status, phone call to physician or NP, and physician
or NP response.
FOCUSED ASSESSMENT
■
■
■
■
■
■
Assess LOC and orientation.
Assess respiratory status.
Assess for neurological deficits (hemiparesis, slurred speech).
Assess baseline VS (temperature, HR, RR, BP).
Assess SaO2 via pulse oximetry, if available.
Assess for associated symptoms: visual disturbances, chest pain,
peripheral edema, hematuria.
STABILIZING AND MONITORING
■
■
■
■
Maintain continuous monitoring of BP and HR.
Assess for changes in cardiac rhythm if patient is on a monitor.
Monitor I&O.
Chart patient status, and convey to physician or NP.
BE PREPARED TO
■
■
■
■
■
■
Titrate O2 to SaO2 ⬎90%.
Obtain a saline lock IV access.
Administer ordered antihypertensive medications (oral or IV).
Obtain or order laboratory tests (BUN, creatinine, electrolytes, UA).
Assist with arterial line placement.
Transfer patient to ICU.
POSSIBLE ETIOLOGIES
■ Atherosclerosis, primary hypertension, stress, anxiety, anger, medication,
stroke, toxemia of pregnancy, diabetes, cardiac or renal disease, drugs
(amphetamine, cocaine, corticosteroids, oral contraceptives).
Hypotension
CLINICAL PICTURE
The patient may have:
■ A systolic BP of ⬍90 mm Hg or systolic BP 40 mm Hg less than baseline.
■ Altered LOC or orientation.
■ Cool, pale, ashen, cyanotic, diaphoretic skin.
28
Copyright © 2008 by F. A. Davis.
29
■
■
■
■
SOB, dyspnea.
Nausea and vomiting.
Tachycardia or bradycardia.
Decreased urine output (⬍30 mL/hr).
IMMEDIATE INTERVENTIONS
■ Place patient in a supine position with legs elevated above heart level to
increase circulation to vital organs. Note: This position is contraindicated
if the airway is compromised; to maintain airway patency, place patient
in supine or low Fowler’s position (HOB slightly elevated).
■ If respiratory effort inadequate (RR ⬍8, cyanosis, SaO2 ⬍90%), administer
high-flow O2 via mask (10–15 L/min), or manually assist ventilations with
an Ambu bag (mask-valve device).
■ Control bleeding, if any, with direct pressure.
■ Check for patent IV access. Note: IVF is not routinely administered until
reason for hypotension is determined. Hypotension could be due to
cardiac compromise, in which case fluids might be contraindicated.
■ Notify physician or NP.
■ Document patient’s status, phone call to physician or NP, and physician or
NP response.
FOCUSED ASSESSMENT
■ Assess LOC, orientation, baseline VS (temperature, HR, RR, BP), and pulse
quality and rhythm.
■ Assess respiratory effort and airway patency.
■ Assess skin for color, temperature, moistness, turgor, and capillary refill.
■ Assess for associated symptoms (chest pain, dyspnea, nausea).
■ Assess I&O; ask patient about recent history of vomiting, diarrhea, or
urinary symptoms (burning, frequency, flank pain, hematuria).
■ Assess MAR for medications that can affect blood pressure.
STABILIZING AND MONITORING
■
■
■
■
■
■
Assess for cause.
Continue to monitor VS.
Review laboratory data (Hgb/Hct; BUN; urine specific gravity, electrolytes).
Evaluate previous 24-hr I&O.
Check MAR for possible medication-induced hypotension.
Chart patient status, and convey to physician or NP.
BE PREPARED TO
■
■
■
■
■
Titrate O2 to SaO2 of 90%.
Obtain IV access, and administer ordered IVF.
Administer ordered vasoactive medications.
Order specific laboratory tests to be drawn STAT.
Transfer patient to a critical care unit.
CARDIAC
CARDIAC
Copyright © 2008 by F. A. Davis.
POSSIBLE ETIOLOGIES
■ Medication; dehydration; hemorrhage; vasovagal response to anxiety;
sepsis; shock; GI bleed or other internal bleeding; aneurysm; congestive
heart failure; cardiac dyrsrhythmias; myxedema; adrenal crisis;
hypoglycemia; completed stroke.
Palpitations
CLINICAL PICTURE
The patient may have or be:
■ Sensation of fluttering in chest, heart racing, or dizziness.
■ Tachycardia, bradycardia, irregular rate.
■ Cold and clammy skin, hypotensive (drop in BP ⱖ20 mm Hg from
baseline).
■ SOB, dyspnea, nausea.
IMMEDIATE INTERVENTIONS
■ Place patient supine in bed. Apply O2 if available at bedside.
■ Stay with patient, and provide reassurance.
■ Take BP, and assess apical HR and rhythm. Compare apical rate to radial
rate as one measure of perfusion.
■ Check for patent IV access.
■ Quickly assess perfusion by assessing mental status, peripheral pulses.
■ Observe cardiac monitor if patient is being monitored. Obtain rhythm strip
to document event.
■ Notify physician or NP.
■ Document patient’s status, phone call to physician or NP, and physician
or NP response.
FOCUSED ASSESSMENT
■
■
■
■
■
■
Assess LOC, VS, and pulse quality and rhythm.
Assess precipitating event, pain level, anxiety, hyperventilation.
Assess breath sounds, O2 saturation
Assess peripheral pulses, skin temperature and color, edema.
Assess trends in pertinent laboratory data, e.g., Hg, Hct, electrolytes.
Obtain and assess laboratory data such as ABG, cardiac enzymes,
if appropriate.
■ Document assessment thoroughly.
STABILIZING AND MONITORING
■ Continue to monitor rhythm; obtain and analyze rhythm strip every
4 hours and when rate or rhythm changes.
■ Continue to monitor VS and O2 saturation.
30
Copyright © 2008 by F. A. Davis.
31
■ Keep IV line patent, and infuse IVF.
■ Review laboratory data such as Hgb/Hct; BUN and creatinine; electrolytes,
other chemistries, blood glucose, liver and cardiac enzymes.
■ Check MAR for possible drug side effect or interactions.
■ Chart patient status, and convey to physician or NP.
BE PREPARED TO
■ Obtain a 12- or 15-lead ECG
■ Administer antiarrhythmic medication (e.g.: procainamide, quinidine,
amiodarone).
■ Obtain IV access, administer ordered IVF and medications.
■ Transfer patient to a unit with cardiac monitoring.
■ Assist with placement of temporary transvenous or external pacemaker
or cardioversion.
POSSIBLE ETIOLOGIES
■ Premature atrial or ventricular contractions (PACs or PVCs) or other
cardiac dyrsrhythmia, mitral valve prolapse; stress, anxiety; medications;
hyperthyroidism; dehydration; hemorrhage; heart failure; adrenal crisis;
hypoglycemia.
Possible Causes of Palpitations
Source
Conditions
Cardiac
Sinus tachycardia or bradycardia.
PAC, PVC, PJC, SVT, VT.
Bradycardia/tachycardia syndrome (sick sinus syndrome).
Atrial fibrillation or flutter.
Wolff-Parkinson-White syndrome.
Heart failure, cardiomyopathy, pericarditis.
Congenital heart disease.
Pacemaker malfunction.
Drugs
Theophylline, digoxin, phenothiazine.
Vasodilators, antiarrhythmics.
Beta2 agonists (e.g., albuterol, terbutaline, salmeterol).
Cocaine, alcohol, tobacco, caffeine.
Vascular
Vasovagal or postural hypotension.
Transient ischemic attack, stroke.
Other
Hyperventilation, hypoxia, fever, hypoglycemia, thyrotoxicosis,
anemia.
CARDIAC
CARDIAC
Copyright © 2008 by F. A. Davis.
Syncope
CLINICAL PICTURE
The patient may have or be:
■ Lightheadedness, feeling faint.
■ Palpitations.
■ Tachypnea, hyperventilation.
■ Nausea, vomiting.
■ Cool, pale, diaphoretic skin.
IMMEDIATE INTERVENTIONS
■
■
■
■
■
■
Assist patient to chair or bed, or floor (if necessary).
Administer supplemental O2 via nasal cannula.
Assess rate, ease of breathing.
Assess BP.
Assess HR, rhythm, and quality.
If patient is hypotensive, keep supine, and elevate lower legs above heart
level, using pillows.
■ Notify physician or NP.
■ Document patient’s status, phone call to physician or NP, and physician
or NP response.
FOCUSED ASSESSMENT
■ Assess patency of airway and patient’s breathing.
■ Assess LOC and mental status; determine if patient had a sensation
of spinning or movement.
■ Assess for associated neurological signs (slurred speech, numbness,
weakness).
■ Assess skin for color, temperature, turgor, and moistness.
■ Ask if patient feels nauseated or is experiencing chest pain.
■ Check recent chemistry and hematology laboratory results.
■ Check if new medications have been administered.
■ Review I&O records from preceding days.
STABILIZING AND MONITORING
■ Assess orthostatic VS: take HR and BP in supine, sitting, and standing
positions, each 2 min apart. Note if pulse increases by 20 or more bpm
and the systolic BP drops by 20 mm Hg or more, which suggests
hypovolemia or dehydration.
■ Assess mucous membranes and skin turgor for signs of dehydration.
■ Continue to assess VS as frequently as indicated.
■ Review history and all current medications.
32
Copyright © 2008 by F. A. Davis.
33
■ Test stool for occult blood.
■ Chart patient status and convey to physician or NP.
BE PREPARED TO
■
■
■
■
■
Obtain IV access.
Administer IVF or a fluid challenge.
Obtain a chemstick blood sugar level.
Administer 50% dextrose IV.
Order specific laboratory tests to be drawn STAT.
POSSIBLE ETIOLOGIES
■ Dysrhythmias, cardiac insufficiency, anemia, hypoxia, orthostatic/postural
hypotension, hypovolemia/dehydration, hypertension, medication reaction,
electrolyte imbalance, hypoglycemia, hyperglycemia, concussion,
vasovagal response, stress/anxiety/fear.
Possible Causes of Syncope
Source
Conditions
Cardiac
Bradycardia (HR ⬍60 bpm).
Tachycardia (HR ⬎100 bpm).
Decreased cardiac output, hemorrhage.
Aortic or pulmonic stenosis.
Pulmonary hypertension.
Neurological
Seizure, head trauma.
Vascular
Vasovagal or postural hypotension.
Transient ischemic attack, stroke.
Other
Hyperventilation, hypoxia.
Tachycardia
CLINICAL PICTURE
The patient may have:
■ HR 100–150 bpm (sinus tachycardia—may be asymptomatic);
HR ⬎150 bpm (supraventricular tachycardia).
■ Palpitations, dizziness or lightheadedness.
■ Chest discomfort, SOB.
■ Anxiety, restlessness.
CARDIAC
CARDIAC
Copyright © 2008 by F. A. Davis.
■ Signs of unstable tachycardia:
■ Altered LOC.
■ Chest pain.
■ Hypotension.
■ Pulmonary congestion and/or cyanosis.
IMMEDIATE INTERVENTIONS
■
■
■
■
■
■
Have patient sit or lie in bed.
Assess blood pressure and respirations.
Administer supplemental O2.
Reduce or eliminate environmental stressors.
Notify physician or NP.
Document patient’s status, phone call to physician or NP, and
physician or NP response.
FOCUSED ASSESSMENT
■
■
■
■
■
Assess LOC, orientation, and VS (temperature, HR, RR, BP).
Assess SaO2 via pulse oximetry, if available.
Assess heart rhythm.
Assess skin for color, turgor, moistness, and temperature.
Assess for associated symptoms (body pain, chest pain, SOB,
hypotension, fever, dehydration).
■ If patient on telemetry or cardiac monitor, assess rhythm strip.
STABILIZING AND MONITORING
■ Assess HR, BP, and SaO2.
■ Assess 12-lead ECG (see ECG in Tools tab).
■ Assess recent history of emotional upset, medication use, infectious
disease, diarrhea, vomiting, blood loss from menses, GI pain or nausea,
melanotic stool.
■ Assess MAR for medications with potential to cause tachycardia.
■ Assess blood glucose level.
■ Assess recent I&O.
■ Chart patient status, and convey to physician or NP.
BE PREPARED TO
■ Set up cardiac monitoring; order 12-lead ECG.
■ Titrate O2 to keep SaO2 ⬎90%.
■ Obtain IV access.
34
Copyright © 2008 by F. A. Davis.
35
■
■
■
■
Administer oral or IV medications as ordered.
Order laboratory tests to be drawn STAT.
Assist with cardioversion.
Transfer patient to the cardiac care or telemetry unit.
POSSIBLE ETIOLOGIES
■ Hypoxia, exercise, caffeine, fever, medications, pain, anxiety, stress, atrial
fibrillation, infection, hypoglycemia, hemorrhage, hypovolemia,
dehydration, electrolyte imbalance.
A & P Snapshot
Brachiocephalic artery
Left common carotid artery
Left subclavian artery
Superior vena cava
Aortic arch
Left pulmonary
artery
Right pulmonary
artery
Left atrium
Left pulmonary
veins
Mitral valve
Right pulmonary
veins
Pulmonary
semilunar valve
Left ventricle
Aortic
semilunar
valve
Right atrium
Tricuspid
valve
Interventricular
septum
Inferior vena
cava
Chordae
tendinea
Apex
Right
ventricle
Papillary
muscles
Cardiac structure and blood flow.
CARDIAC
Copyright © 2008 by F. A. Davis.
CARDIAC
Maxillary
Facial
External carotid
Common carotid
Subclavian
Axillary
Pulmonary
Occipital
Internal carotid
Vertebral
Brachiocephalic
Aortic arch
Intercostal
Brachial
Renal
Gonadal
Inferior
mesenteric
Radial
Ulnar
Celiac
Left gastric
Hepatic
Splenic
Superior
mesenteric
Abdominal aorta
Right
common iliac
Internal iliac
Deep
palmar
arch
External iliac
Deep femoral
Superficial
palmar arch
Femoral
Popliteal
Anterior tibial
Posterior tibial
Arterial circulation.
36
Copyright © 2008 by F. A. Davis.
37
Focused Respiratory System Assessment
■ A focused assessment of respiratory status includes:
■ Ease of breathing and respiratory rate
■ Lung sounds
■ Use of O2 and oxygenation
■ ABGs
■ Ventilator assessment, if applicable
■ Mental status level of alertness, restlessness, confusion, irritability,
or stupor
■ Ease of breathing and respiratory rate:
■ Ask the patient how his breathing is; use his subjective terminology
when documenting. Ask if SOB is triggered by activity and if rest
relieves the feeling. Ask about energy levels and if the patient can eat
and talk comfortably.
■ Assess rate—normal rate is 12–20; however, most adults have a
respiratory rate in the lower end of the range. Rates ⬎20
respirations/min should be investigated. A rate ⬎26 is cause for alarm,
unless it’s the patient’s baseline.
■ Assess use of accessory muscles or nasal flaring, both of which indicate
respiratory distress.
■ Lung sounds:
■ Listen to lung sounds in all fields. Ask the patient to breathe deeply with
his mouth open.
■ Note adventitious sounds, areas where air movement is not heard,
or areas where breath sounds are diminished.
■ Use of O2 and oxygenation:
■ Note the amount of O2 ordered and the method of delivery (e.g., 3
L/min via nasal cannula).
■ Note if the patient is wearing the O2 all the time and if the device is
correctly applied.
■ Check pulse oximetry to assess percentage of oxygen saturation (SaO2):
97% to 99% is normal, although 93% to 97% may be normal for some
patients. Always look at the whole picture, not just a single reading.
Also, pulse oximetry can be inaccurate in the presence of peripheral
vascular disease. Reading of 90% or less indicates possible need for
ventilation support. Compare trends in O2 saturation to determine if
oxygen therapy is effective.
■ Analyze ABG results:
■ ABG allows for assessment of acid-base balance, ventilation, and
oxygenation. It also tells how well the lungs and kidneys are
compensating or responding to treatments.
RESP
RESP
Copyright © 2008 by F. A. Davis.
■ pH, PaCO2, and HCO3 tell about acid-base balance.
■ PaO2 and SaO2 indicate oxygenation status.
■ Normal values (memorize):
pH: 7.35–7.45
PaO2: 80–100 mm Hg
PaCO2: 35–45 mm Hg
O2 saturation: 95%–100%
HCO3: 21–28 mEq/L
Base excess: ⫺2 to ⫹2 mEq/L
See detailed explanation of how to interpret ABGs on page 51 in
this tab.
Aspiration
CLINICAL PICTURE
The patient may have:
■ Sudden onset of coughing and shortness of breath (SOB) associated with
eating, drinking, or regurgitation.
■ Tachypnea, dyspnea, cyanosis, decreased breath sounds.
■ Tachycardia, bradycardia.
■ Crackles and rhonchi (usually on the right, but may be on the left or
bilaterally).
■ Altered mental status.
■ Fever.
■ Chest pain (pleuritic).
IMMEDIATE INTERVENTIONS
■
■
■
■
■
Elevate head of bed (HOB) to upright position; help patient to expectorate.
Provide supplemental oxygen.
Suction oropharynx.
Encourage coughing.
If there is evidence of foreign body obstruction see Choking in the
Emergency tab.
■ Notify physician or NP.
■ Document patient status, phone call to physician or NP, and physician
or NP response.
FOCUSED ASSESSMENT
■ Assess patient’s ability to clear airway and effort to breathe.
■ Assess airway for secretions or foreign objects.
38
Copyright © 2008 by F. A. Davis.
39
■ Assess effectiveness of measures taken to clear airway.
■ Assess oxygenation status: level of consciousness (LOC), SaO2, presence
of circumoral and nailbed cyanosis.
■ Assess HR, BP, respirations (rate, rhythm, and effort), and work of
breathing.
■ Auscultate lung fields.
STABILIZING AND MONITORING
■ Continue to monitor airway and respiratory function.
■ Consider a speech pathology consultation to assess patient’s level of
airway control and/or gag reflexes.
■ Monitor patient during oral intake, and assess patient for evidence of
dysphagia.
BE PREPARED TO
■ Set up and assist with intubation, cricothyrotomy, tracheotomy, or
bronchoscopy, if indicated.
■ Call a code.
POSSIBLE ETIOLOGIES
■ Emesis; disorders that affect normal swallowing and gag reflex (depression of the laryngeal reflexes, stroke); disorders of the esophagus
(esophageal stricture, gastroesophageal reflux); use of sedative drugs;
anesthesia; coma; excessive alcohol consumption; tracheitis; epiglottitis;
foreign body aspiration.
Chest Tube Dislodgement
CLINICAL PICTURE
The patient may have:
■ Signs of respiratory distress: rapid, shallow, or increased work of
breathing; cyanosis; decreased LOC; and SaO2, restlessness, or anxiety.
■ Partially or completely dislodged chest tube.
■ Visible chest tube drain pores.
■ Whistling sound as air enters or exits wound site or chest tube.
IMMEDIATE INTERVENTIONS
■ Immediately cover chest tube insertion site with sterile petroleum gauze
(occlusive dressing) covered with several 4 ⫻ 4 pads.
■ Maintain constant pressure, but do not tape dressing in order to allow air
to escape from chest cavity.
RESP
Copyright © 2008 by F. A. Davis.
RESP
■ Administer supplemental O2.
■ Notify physician or NP and respiratory therapist STAT.
■ Document patient status, phone call to physician or NP, and physician or
NP response.
FOCUSED ASSESSMENT
■ Assess respirations and quality of oxygenation including LOC, SaO2, skin
color, and work of breathing.
■ Auscultate lung fields, and compare ventilation left to right.
■ Assess vital signs (VS) and pain level.
STABILIZING AND MONITORING
■ Assure chest x-ray (CXR) is obtained after reinsertion.
■ Continue to evaluate lung sounds and quality of oxygenation.
■ Make sure all chest tube connections are secure and that tubing is not
tangled or encumbered.
■ Maintain drainage system in upright position below heart.
■ Place emergency equipment in patient’s room (sterile NS, 4 ⫻ 4 pads,
petroleum gauze, tape and nontoothed padded clamps).
■ Assess drainage system for proper functioning.
■ Assure that extra drainage collection system is readily available on the
unit.
■ Assist patient with movement and repositioning.
BE PREPARED TO
■ Set up and assist with reinsertion of chest tube.
■ Order portable CXR.
■ Administer supplemental O2.
POSSIBLE ETIOLOGIES
■ Excessive torque or tension on chest tube due to multiple possible causes
(chest tubes not hanging freely during movement, improper transfer
technique, patient confused).
Dyspnea/SOB
CLINICAL PICTURE
The patient may have or be:
■ Mild sensation of discomfort to feeling of suffocation.
■ Difficulty breathing; inability to take a deep breath.
■ Cyanotic, ashen or pale, and diaphoretic.
40
Copyright © 2008 by F. A. Davis.
41
■ Tachypneic, wheezing, poor air movement, use of accessory muscles.
■ Restless, confused, anxious, fearful, agitated.
■ Maintaining an upright position to facilitate breathing.
IMMEDIATE INTERVENTIONS
■
■
■
■
■
■
■
■
■
Place patient in a position that facilitates breathing.
Administer supplemental O2 if no history of COPD.
Assess VS.
Auscultate lung fields for adventitious sounds and quality of air
movement.
Place on pulse oximetry and cardiac monitor if readily available; assess
O2 saturation and cardiac rhythm.
If patient is hyperventilating, encourage slower, deeper breathing or, if
indicated, have the patient perform pursed-lipped breathing.
Notify physician or NP and respiratory therapy.
Stay with patient; maintain calm, reassuring demeanor.
Document patient’s status, phone call to physician or NP, and physician or
NP response.
FOCUSED ASSESSMENT
■ Assess VS and respiratory status.
■ Assess for chest pain, nausea, leg vein tenderness, other cardiovascular
symptoms.
■ Assess for underlying respiratory conditions.
■ Assess oxygenation status by evaluating for changes in mental status,
noting evidence of chest pain or tightness, measuring SaO2, and
evaluating cardiac rhythm.
■ Ask patient about previous episodes of SOB, what provoked it, if onset
was sudden or gradual, if SOB is made worse by lying flat. Assess cough.
■ Assess work of breathing as evidenced by flared nostrils, retraction of
subclavicular and intercostal spaces, use of accessory muscles, and
orthopnea.
■ Note tracheal alignment, symmetry of chest expansion, bulging
interspaces, and presence of JVD.
■ Assess skin for color, circumoral and nailbed cyanosis, and moistness.
■ Auscultate lung fields, noting diminished breath sounds, crackles,
wheezing, friction rubs or stridor.
■ Assess medication administration record for possible
medication/anaphylactic reactions.
STABILIZING AND MONITORING
■ Continue to monitor respiratory status as detailed in Assessment, and
support effort to breathe.
RESP
RESP
Copyright © 2008 by F. A. Davis.
■ Continue to assess patient for contributing factors and underlying cause.
■ Administer medications as ordered.
■ Chart patient status, and convey to physician or NP.
BE PREPARED TO
■
■
■
■
■
■
■
■
■
Obtain IV access.
Change or set up an O2 delivery system.
Assist with diagnostic testing.
Obtain ABGs.
Place a nasal or oral airway.
Suction the oropharynx/trachea.
Administer medication.
Assist with intubation or chest tube placement.
Transfer to ICU.
POSSIBLE ETIOLOGIES
■ Allergic reaction, airway obstruction, anxiety/panic attack, aspiration,
asthma, cardiac dysrhythmias or tamponade, emphysema, heart failure,
cardiac ischemia, pleural effusion/pleuritis, pneumonia, pneumothorax,
pulmonary edema, pulmonary embolism.
Possible Causes of Shortness of Breath
Source
Potential Causes
Cardiac
Coronary artery disease, angina, MI, heart failure,
cardiomyopathy, valve disease, left ventricular
hypertrophy, pericarditis, dysrhythmias
Pulmonary
COPD, asthma, pneumothorax, pulmonary embolus
(PE), pulmonary edema
Combined
cardiopulmonary
COPD with comorbid cardiac disorder, deconditioning,
chronic pulmonary emboli, trauma
Other
Metabolic acidosis, pain, neuromuscular disorders,
upper airway disorders, anxiety, panic,
hyperventilation
42
Copyright © 2008 by F. A. Davis.
43
Hypoventilation/Ineffective Breathing Pattern
CLINICAL PICTURE
The patient may have or be:
■ Dyspnea at rest or on exertion.
■ Hypoxic and appear cyanotic, ashen, or pale.
■ Lethargic, stuporous, obtunded, or unconscious.
■ Rapid and shallow breathing pattern, periods of apnea as in CheyneStokes (neurological), or notably slow (narcotic) breathing.
■ Signs of right-sided heart failure (JVD, peripheral edema, and
hepatomegaly).
IMMEDIATE INTERVENTIONS
■
■
■
■
■
Attempt to arouse patient with physical stimulation to enhance breathing.
Assess airway for obstruction.
Perform orotracheal suctioning to clear secretions.
Administer supplemental O2.
Manually ventilate patient with a BVM device if RR ⬍8 or O2 saturation
⬍90%.
■ Get help, notify RT, and call physician or NP.
■ Document patient status, phone call to physician or NP, and physician
or NP response.
FOCUSED ASSESSMENT
■
■
■
■
Assess LOC and orientation.
Assess VS, noting RR, depth, and quality.
Assess skin color and moistness.
Auscultate lung fields for adventitious sounds and equality of breath
sounds.
STABILIZING AND MONITORING
■
■
■
■
■
■
Insert oral or nasal airway, if necessary.
Administer bronchodilators.
For narcotic/opioid OD, administer Narcan 0.4 mg IV.
For IM benzodiazepine OD, administer Romazicon 0.2 mg IV.
Continue to monitor breathing and oxygenation closely.
Chart patient status, and convey to physician or NP.
BE PREPARED TO
■ Assist with setup and application of various O2 delivery systems (mask,
CPAP, BiPAP, intubation/ventilator).
■ Obtain IV access.
■ Obtain CXR, ABGs, other laboratory tests.
■ Administer medication as ordered.
■ Transfer to ICU.
RESP
RESP
Copyright © 2008 by F. A. Davis.
POSSIBLE ETIOLOGIES
■ COPD, emphysema, chronic bronchitis, neuromuscular disorders,
amyotrophic lateral sclerosis, muscular dystrophy, diaphragm paralysis,
Guillain-Barré syndrome, myasthenia gravis, chest wall deformities,
kyphoscoliosis, fibrothorax, thoracoplasty, central respiratory drive
depression, drugs: narcotics, benzodiazepines, barbiturates; neurological
disorders: encephalitis, brainstem disease, trauma; primary alveolar
hypoventilation, obesity hypoventilation syndrome.
Pulmonary Embolism
CLINICAL PICTURE
The patient may have or be:
■ Dyspnea, pleuritic chest pain, tachycardia.
■ Anxiety, diaphoresis.
■ Syncope, hypotension.
■ Wheezing.
■ Lower extremity edema.
■ Signs and symptoms of thrombophlebitis.
IMMEDIATE INTERVENTIONS
■
■
■
■
■
■
Administer supplemental O2.
Assess VS.
Assess respiratory rate and work of breathing.
Notify physician or NP.
Place on pulse oximetry and cardiac monitor, if available.
Document patient’s status, phone call to physician or NP, and physician
or NP response.
FOCUSED ASSESSMENT
■ Auscultate lung fields for adventitious sounds and quality of air
movement.
■ Assess O2 saturation, cardiac rhythm, VS.
■ Assess for chest pain, leg vein tenderness.
■ Assess for history of recent surgery, immobilization, recent DVT,
malignancy.
STABILIZING AND MONITORING
■ Continue to assess VS, LOC, respiratory status.
■ Initiate anticoagulant therapy (heparin) as ordered. Have second
practitioner independently calculate dilutions and infusion pump
programming.
■ Chart patient status, and convey to physician or NP.
44
Copyright © 2008 by F. A. Davis.
45
BE PREPARED TO
■
■
■
■
Obtain IV access.
Change or set up an O2 delivery system.
Administer medications or fluids to maintain blood pressure.
Assist with obtaining diagnostic studies (CXR, V/Q scan, spiral CT scan,
pulmonary angiogram).
■ Obtain ABGs.
■ Obtain serial PTTs, and titrate heparin infusion.
■ Transfer to ICU for high acuity care or thrombolytic therapy.
POSSIBLE ETIOLOGIES
■ Embolization of thrombi from deep veins of the femur, pelvis, and lower
extremities from multiple causes including venous stasis, hypercoagulable
states, surgery and trauma, oral contraceptive and estrogen replacement
therapy, pregnancy, malignancy.
Respiratory Distress/Failure
CLINICAL PICTURE
The patient may have:
■ Dyspnea, excessive work of breathing.
■ Cyanosis of skin and mucous membranes.
■ Anxiety, confusion, restlessness, or somnolence.
■ Tachycardia and dysrhythmias (due to hypoxemia and acidosis).
■ Decreased O2 saturation (SaO2 ⬍90% is considered abnormal, and
levels below this can represent unstable respiratory status that requires immediate intervention; however, evaluate in context of patient
baseline—some patients with COPD may never have SaO2 greater than
88% but are stable.
■ Abnormal ABG results: Hypoxemic respiratory failure, characterized by
a PaO2 ⬍60 mm Hg and a normal or low PaCO2, is most common and
is caused by any acute disease of the lung (pulmonary edema, pneumonia). Hypercapnic respiratory failure, characterized by a PaCO2 ⬎50 mm Hg,
is associated with drug overdose, neuromuscular disease, chest wall
abnormalities, and severe airway disorders such as asthma or
emphysema.
■ Seizures (may occur with severe hypoxemia).
IMMEDIATE INTERVENTIONS
■ Notify physician or NP and respiratory therapist of decline in respiratory
function.
■ Elevate HOB; position patient to facilitate breathing.
RESP
RESP
Copyright © 2008 by F. A. Davis.
■ Assess if the airway is patent and if patient is alert enough to manage
secretions and to protect airway.
■ Insert nasal or oral airway, and suction if patient unable to clear
secretions.
■ Apply supplemental oxygen via nasal prongs or face mask to correct
hypoxemia and keep oxygen saturation above 90%. (Use O2 cautiously
in patients with severe COPD and chronic CO2 retention.)
■ Document patient’s status, phone call to physician or NP, and physician
or NP response.
FOCUSED ASSESSMENT
■ Assess oxygenation, lung sounds, respiratory rate, and work of breathing;
assess for circumoral or nailbed cyanosis.
■ Assess VS, LOC, orientation.
■ Assess for underlying cause of respiratory distress.
STABILIZING AND MONITORING
■
■
■
■
Assess cardiac monitor, BP, pulse oximetry, and ABG results.
Continue to assess temperature, LOC, orientation.
Administer medications to treat underlying cause.
If hypoxemia is severe, intubation and mechanical ventilation to increase
PaO2, lower PaCO2, and rest respiratory muscles may be required.
■ Assist with diagnostic and laboratory studies (portable CXR, ABGs, ECG,
other diagnostic tests, sputum culture, bronchoscopy).
■ Insert IV access.
BE PREPARED TO
■ Call a code.
■ Assist with intubation.
■ Transfer to ICU.
POSSIBLE ETIOLOGIES
■ Hypoxemic respiratory failure: chronic bronchitis and emphysema (COPD),
pneumonia, pulmonary edema, pulmonary fibrosis, asthma, pneumothorax, pulmonary embolism, pulmonary arterial hypertension, pneumoconiosis, granulomatous lung diseases, bronchiectasis, adult respiratory
distress syndrome, fat embolism syndrome.
■ Hypercapnic respiratory failure: COPD, severe asthma, drug overdose,
poisonings, myasthenia gravis, polyneuropathy, poliomyelitis, primary
muscle disorders, head and cervical cord injury, primary alveolar
hypoventilation, obesity hypoventilation syndrome, pulmonary edema,
adult respiratory distress syndrome, myxedema.
46
Copyright © 2008 by F. A. Davis.
47
Ventilators/Mechanical Ventilation
Indications
■ Airway obstruction.
■ Inadequate oxygenation—O2 saturation (90% on hi-flow oxygen via
nonrebreather mask).
■ Inadequate ventilation—hypoventilation (high pCO2, pH acidosis).
■ Increased work of breathing, ineffective breathing pattern.
■ Airway protection.
Common Settings
■ AC (assist control)—patient triggers ventilator to deliver a breath. If apnea
occurs, a minimum rate and volume will be delivered to the patient.
■ CPAP (continuous positive airway pressure)—continuous, nonstop
positive pressure is applied throughout entire respiratory cycle.
■ BiPAP (bilevel positive airway pressure)—same as CPAP but with two
preset pressure settings: one for inspiration and one for expiration.
■ CMV (continuous mandatory ventilation)—ventilator delivers a set tidal
volume at a set rate regardless of patient’s own attempts to breathe.
Expect patient to require sedation.
■ IMV (intermittent mandatory ventilation)—ventilator delivers a set tidal
volume at a set rate, yet also allows the patient to initiate breaths.
■ PSV (pressure support ventilation)—for patients with spontaneous
breathing. Ventilator delivers a preset positive pressure for the duration
of inspiration when the patient initiates a breath.
■ SIMV (synchronized intermittent mandatory ventilation)—ventilator
is triggered only by a patient-activated demand valve and, therefore,
synchronizes with the patient’s own respiratory efforts.
■ PEEP (positive end-expiratory pressure)—maintains a preset positive
airway pressure at the end of each expiration. PEEP is used to treat a
PaO2 of 60 mm Hg on FiO2 of 50%.
Troubleshooting Ventilator Problems
Patient in sudden, severe repiratory distress
■ Unhook the ventilator from the endotracheal (ET) tube, and manually
ventilate patient with 100% oxygen using an Ambu bag. Get help after
unhooking patient from ventilator.
■ If patient is easy to ventilate manually and is no longer in distress,
the ventilator is the probable source of the problem. Notify respiratory
therapy (RT). While you manually ventilate the patient, the respiratory
therapist should assess the ventilator per manufacturer’s guidelines. The
ventilator may need to be changed if the problem cannot be found.
RESP
RESP
Copyright © 2008 by F. A. Davis.
■ If patient is difficult to ventilate manually: suction the ET tube
to clear secretions. Notify RT. If unable to clear obstruction or pass
suction catheter, extubate and manually ventilate with 100% oxygen
using an Ambu bag and face mask. Suction the oropharynx to clear
secretions. Notify RT/physician STAT, and assist with reintubation.
■ Assess for air leak. Listen for air around the cuff, and check cuff pressure
with a manometer, if available. Notify RT for possible reintubation if air
leak cannot be fixed.
■ Assess for dislodgement. If tube is dislodged, remove and manually
ventilate patient with 100% oxygen using Ambu bag and face mask.
Suction oropharynx to clear secretions. Notify RT/physician STAT, and
assist with reintubation.
■ Assist with reintubation if needed or replacement of ventilator or
ventilator components.
■ If ineffective ventilation continues, inspect and auscultate the patient’s
chest for equal and adequate air entry. If there is unequal chest wall
movement and/or decreased air entry on one side, it may be related to
a malpositioned tube, atelectasis, or a tension pneumothorax. Notify
physician and RT.
■ If ineffective ventilation continues and no physical or mechanical cause
can be found, consider sedating the patient.
Ventilator Alarms: Implications and Interventions
When the ventilator alarms, check the patient first. If patient is in no apparent
distress, check vent to determine source of problem. If patient is showing
signs of distress (“fighting the vent”), try to calm the patient. If unsuccessful, immediately disconnect patient from vent, and manually ventilate
with 100% oxygen using an Ambu bag and call for help.
Alarm
Low-Pressure
Alarm
Usually caused by
system disconnections or leaks.
Interventions
■ Reconnect patient to ventilator.
■ Evaluate cuff, and reinflate if needed (if
ruptured, ET tube will need to be
replaced).
■ Evaluate connections, and tighten or
replace as needed.
■ Check ET tube placement (auscultate lung
fields, and assess for equal, bilateral
breath sounds).
48
Copyright © 2008 by F. A. Davis.
49
Alarm
Interventions
High-Pressure
Alarm
Usually caused by
resistance within
the system. Can
be kink or water
in ET tubing,
patient biting the
tube, copious
secretions, or
plugged tube.
■ Suction patient if secretions are suspected.
■ Insert bite block to prevent patient from
biting ET tube.
■ Reposition patient’s head and neck, or
reposition tube.
■ Sedation may be required to prevent a
patient from fighting the vent, but only
after careful assessment excludes a
physical or mechanical cause.
High Respiratory
Rate
Can be caused by
anxiety or pain,
secretions in ET
tube/airway,
hypoxia
■ Suction patient.
■ Look for source of anxiety (e.g., pain).
■ Evaluate oxygenation.
Low Exhaled
Volume
Usually caused
by ET tubing
disconnection,
inadequate seal
■ Evaluate/reinflate cuff; if ruptured, ET tube
must be replaced.
■ Evaluate connections; tighten or replace as
needed; check ET tube placement;
reconnect
to ventilator.
Tracheostomy Dislodgement
CLINICAL PICTURE
The patient:
■ Coughs out tracheostomy tube.
■ If on a ventilator, low pressure alarms may sound.
IMMEDIATE INTERVENTIONS
■ If the tracheostomy is less than 4 days old, STAT intervention is required
as the tract can collapse suddenly. Page respiratory therapist and
physician or NP STAT. Only trained personnel should replace a new
tracheostomy tube.
RESP
RESP
Copyright © 2008 by F. A. Davis.
■ Open the tracheostomy with a sterile hemostat, suction catheter, or
sterile gloved finger to maintain airway patency, and prevent the edges
of the tracheostomy from collapsing.
■ If patient cannot breathe, ventilate with bag-valve mask.
■ If you cannot be sure that someone clinically prepared to reinsert the tracheostomy tube will arrive within 1 minute, call a code.
■ If the tracheostomy is older than 4 days, the tract will be well formed and
will not close quickly.
■ Notify physician or NP and respiratory therapist that tube needs to be
replaced.
■ Obtain replacement tube, if not already at the bedside.
■ Stay with patient, and prepare for insertion of new tube.
■ Document patient’s status, phone call to physician or NP, and physician or
NP response.
FOCUSED ASSESSMENT
■ Assess patient’s ability to breathe through stoma. Look, listen, and feel for
signs of air movement through stoma.
■ Assess tracheostomy site for secretions (blood, mucus, etc.), swelling, or
trauma.
■ Auscultate lungs, and assess patient’s ability to cough effectively and clear
airway.
STABILIZING AND MONITORING
■ After tube is reinserted and tracheostomy dressing is in place, check that
ties are secure but not excessively tight. You should be able to easily
insert 1 finger under the ties.
■ Administer humidified supplemental O2.
■ Assess oxygenation status by monitoring LOC and SaO2.
■ For future tracheostomy care, have another nurse hold tube in place while
ties are changed.
■ Obtain sterile hemostat, sterile obturator, and replacement tracheostomy
tube to be kept at bedside.
■ Chart patient status, and report to physician or NP.
BE PREPARED TO
■ Call a code.
■ Assist with the insertion of a new tracheostomy tube.
■ Perform tracheostomy care.
50
Copyright © 2008 by F. A. Davis.
51
POSSIBLE ETIOLOGIES
■ Coughing, patient movement, poorly secured tracheostomy tube,
accidental self-extubation, excessive torque or tension on a tracheostomy
tube attached to a ventilator or other O2 administration device, deflated
tracheostomy cuff.
Basic ABG Interpretation
Commonly Used Terms
■ SaO2 is the oxygen saturation, frequently called O-2-”sats”
■ PaO2 is the partial pressure of oxygen in the blood and is referred to
as P-O-2
■ PaCO2 is the partial pressure of carbon dioxide. It can be called carbon
dioxide or carbonic acid, but people generally call it C-O-2
■ HCO3 is bicarbonate, usually called “bicarb”
Step-by-Step Interpretation
Determine the acid base balance: is it acidic, alkaline, or normal?
■ Evaluate pH. The range of 7.35–7.45 is very precise.
■ If the pH is between 7.35 and 7.40 it is considered normal, trending to
acidic; a pH between 7.41 and 7.45 is considered normal, trending to
alkalotic.
1. Determine the source of the imbalance. Is the problem primarily
respiratory or metabolic?
■ Evaluate Paco2. This is the respiratory component. Carbon dioxide is
an acid; therefore, an elevated CO2 ⫽ respiratory acidosis. A decreased
CO2 ⫽ respiratory alkalosis.
■ Evaluate HCO3. This is the metabolic component. Bicarbonate is a base;
therefore, if it is too low, it means metabolic acidosis. High bicarbonate
⫽ metabolic alkalosis.
■ Putting it together: to determine if the imbalance is primarily respir
tory or metabolic, compare the pH with both the respiratory and the
metabolic components. Whichever of the two is consistent with the
pH result (acidosis or alkalosis) is the system that is dominating. For
example: if the ABG results are pH ⫽ 7.50, PaCO2 ⫽ 28, and HCO3 ⫽ 23,
the pH level is high: alkalosis. PaCO2, which is a respiratory acid, is low.
Low acidity is another way of saying alkalosis, so they are consistent.
HCO3, a metabolic buffer, is normal, neither acidosis or alkalosis. This
means the respiratory system is causing the alkalosis, which is called
respiratory alkalosis.
RESP
RESP
Copyright © 2008 by F. A. Davis.
2. Determine the body’s response. Is it compensated or not?
■ The kidneys attempt to compensate for respiratory abnormalities,
whereas the lungs try to correct metabolic disturbances. The extent
of correction is referred to as compensation.
■ Compensated: Look at the pH. If it is normal, but the carbon dioxide
or bicarbonate level is off, then the body has fully compensated.
■ If pH is not normal, determine if problem is partially compensated or
uncompensated.
■ Partially compensated: Abnormal pH with either the PaCO2 or the
HCO3 abnormal indicates partial compensation.
■ Abnormal pH with both the PaCO2 and the HCO3 abnormal indicates
no compensation.
3. Determine how well the lungs are oygenating.
■ The two basic measures of oxygen in the blood are SaO2 and PaO2,
although there may be others (hemoglobin and O2CT).
■ PaO2 is a measure of the amount of oxygen dissolved in the blood. It
reflects how well the lungs are getting oxygen into the bloodstream
from the atmosphere. Normal PaO2 ⫽ ⬎80 mm Hg.
■ PaO2 60–80 mm Hg ⫽ mild hypoxemia
■ PaO2 40–60 mm Hg ⫽ moderate hypoxemia
■ PaO2 ⬍40 mm Hg ⫽ severe hypoxemia
■ Decreased PaO2 levels are associated with
■ anemia
■ hypoventilation
■ heart failure
■ COPD and other restrictive pulmonary diseases.
■ SaO2 reflects to what degree oxygen is carried by hemoglobin. Hemoglobin has four oxygen-carrying sites. When all four sites have a
molecule of oxygen attached, the hemoglobin is “saturated.” Normal
SaO2 is 95%–100%. Some patients may have lower levels and not be
in distress; the nurse must look at the whole picture and not just an
isolated number. SaO2 less than 90% requires rapid intervention, unless
it is within the patient’s baseline range.
■ You will sometimes see a PaO2 and a PaO2. These are different
measures. PaO2 is the partial pressure of oxygen in the arteries. PaO2 is
the partial pressure of oxygen in the alveoli. Both are used to calculate
the A-a gradient, which indicates how well the lungs are getting oxygen
from the air into the pulmonary circulation. If the A-a gradient is
elevated, it means the lungs are not performing well.
52
Copyright © 2008 by F. A. Davis.
53
Oxygen Delivery Systems
Cannula (nasal prongs)
■ Indicated when low-flow, smallpercentage oxygen therapy is desired.
■ Flow rate of 1–6 L/min delivers
24%–44% oxygen.
■ Allows patient to eat, drink, and talk.
■ Extended use can dry the nose and
nasopharynx; use with humidifier.
Cannula (nasal prongs).
Simple Mask
■ Indicated when desired FiO2 to be
delivered is 40%–60%.
■ Flow rate of 6–10 L/min delivers
35%–60% oxygen.
■ Lateral perforations permit exhalation
of CO2.
■ Permits humidification.
Exhalation
ports
Elastic
strap
To oxygen
source
Simple mask.
Bag-Mask (nonrebreather)
■ Indicated when high concentrations of O2
are desired.
■ Flow rate of up to 15 L/min delivers up to
100% oxygen.
■ One-way flaps open and close with respiration, resulting in a high concentration of
delivered oxygen and minimal to no CO2
rebreathed by the patient.
(one-way valves)
Exhalation
port
Inhalation
port
Bag-mask (nonrebreather).
RESP
RESP
Copyright © 2008 by F. A. Davis.
Venturi Mask (Ventimask)
■ Indicated for precision titration of oxygen.
■ Accurate delivery of O2 is accomplished with
a graduated dial that is set to the desired
percentage of oxygen to be delivered.
■ Flow rate of 4–8 L/min delivers 24%–40%
oxygen.
Venturi mask (Ventimask).
Ambu Bag, Bag-Valve-Mask
■ Indicated for resuscitation or to
manually ventilate a patient
during transport or ventilator
failure or interruption.
■ Can deliver up to 100% oxygen.
■ Appropriate size and fit are essential, both to create a good seal
and to prevent injury.
■ To create seal, hold mask with
thumb and pointer finger (thumb
toward nose), and grasp underneath the ridge of the jaw with
remaining three fingers
(see picture).
One-way
valve
Reservoir
Mask
Bag
O2 supply
Ambu bag, bag-valve-mask.
Humidified Systems
■ Indicated for patients requiring longterm oxygen therapy to prevent
drying of mucous membranes.
■ Setup may vary among brands.
Fill canister with sterile water to
recommended level, attach to
oxygen source, and attach mask
or cannula to humidifier.
■ Adjust flow rate.
To oxygen
source
To patient
Maximum
fill line
Sterile water
in reservoir
Humidified systems.
54
Minimum
water level
line
Copyright © 2008 by F. A. Davis.
55
Transtracheal Oxygenation
■ Indicated for patients with a
tracheostomy who require longterm oxygen therapy and/or
intermittent, transtracheal
aerosol treatment.
■ Ensure proper placement (over
stoma, tracheal tube).
■ Assess for and clear secretions
as needed.
■ Assess skin for signs of irritation.
Chain necklace
Tract
Transtracheal catheter
(connect to oxygen)
Trachea
Transtracheal oxygenation.
Artificial Airways
Oropharyngeal Airway
■ Indicated for unconscious
patients who do not have a
gag reflex.
■ Measure either from the corner of the mouth to the earlobe
or from the center of the mouth
to the angle of the jaw.
■ Rotate airway 180⬚ while inserting into oropharynx.
OROPHARYNGEAL AIRWAY
TRACHEA
TONGUE
ESOPHAGUS
OROPHARYNGEAL
AIRWAY
PHARYNX
Oropharyngeal airway.
Nasopharyngeal Airway
■ Indicated for patients with a gag
reflex, comatose with spontaneous
respirations, lockjaw.
■ Measure from the tip of the
patient’s nose to the earlobe.
■ The diameter should match that
of the patient’s pinkie.
■ NEVER insert in the presence
of facial trauma.
PHARYNX
NASOPHARYNGEAL
AIRWAY
TRACHEA
ESOPHAGUS
Nasopharyngeal airway.
RESP
RESP
Copyright © 2008 by F. A. Davis.
Endotracheal Tube
■ Indicated for apnea, airway obstruction, respiratory failure, risk of
aspiration, combative patient (protect from further injury), or when goal of
therapy is hyperventilation.
■ Can be inserted through the mouth or nose.
■ Inflated cuff protects patient from aspiration.
Endotracheal tube.
56
Copyright © 2008 by F. A. Davis.
57
A & P Snapshot
Arteriole Pulmonary
capillaries
Alveolar
duct
Frontal sinuses
Sphenoidal
sinuses
Nasal cavity
Nasopharynx
Soft palate
Epiglottis
Larynx and
vocal folds
Trachea
Alveolus
B
Superior lobe
Right lung
Venule
Left lung
Left
primary
bronchus
Superior
lobe
Right
primary
bronchus
Middle
lobe
Bronchioles
Inferior lobe
Inferior
lobe
Mediastinum
Cardiac notch
Diaphragm
A
Respiratory system.
RESP
Pleural
membranes
Pleural space
Copyright © 2008 by F. A. Davis.
RESP
sp
ac
e
Pulmonary
capillary
e
Alv
ir
ra
ola
O2
pickup
O2
Hb
Hb O2
O2
O2
Systemic
capillary
O2
delivery
Plasma
Hb O2
Red blood
cells
Hb
O2
s
O2
e
in su
lls tis
Ce ral
e
iph
per
A
Oxygen pickup and delivery.
58
O2
Copyright © 2008 by F. A. Davis.
59
sp
ac
e
Pulmonary
capillary
e
Alv
ir
ra
ola
CO2
delivery
CO2
CO2
H2CO3
H 2O
CO2
Systemic
capillary
Hb
Hb CO2
Hb
CO 2
H2CO3
H 2O
s
Hb
e
in su
lls tis
Ce ral
CO2
iph
per
e
CO2
B
CO2 delivery and pickup.
RESP
CO2
pickup
NEURO
Copyright © 2008 by F. A. Davis.
Neurological Assessment
Mental Status
■ See Mini Mental Status Examination.
■ Assess affect, mood, appearance, grooming.
■ Assess speech for clarity and coherence.
■ Assess LOC—alert, lethargic, stuporous, obtunded.
■ Assess orientation—person, place, time.
Cranial Nerves
■ See Cranial Nerve Assessment in this tab.
Balance and Coordination
■ Gait/balance
■ Observe gait patterns while instructing patient to walk away from you
and then back again.
■ Have patient hop in place on each foot.
■ Have patient stand from a sitting position.
■ Coordination
■ Instruct patient to tap the tip of the thumb with the tip of the index
finger as fast as possible.
■ Instruct patient to touch nose and your index finger alternately several
times. Continually change the position of your finger during the test.
Sensation, Strength, Motion, Reflexes
■ Ask about altered sensations such as numbness and tingling.
■ Using your finger and a toothpick, instruct patient to distinguish between
sharp and dull sensations. Compare left side of body with right, with
patient’s eyes closed.
■ Assess motor strength of all four extremities.
Muscle Strength Grading Scale
0
No muscle movement
1
Visible muscle movement, but no movement at the joint
2
Movement at the joint, but not against gravity
3
Movement against gravity, but not against added resistance
4
Movement against resistance, but less than normal
5
Normal strength
■ Assess reflexes using a reflex hammer
Tendon Reflex Grading Scale
0
Absent
1⫹
Hypoactive
2⫹
Normal
3⫹
Hyperactive without clonus
4⫹
Hyperactive with clonus
60
Copyright © 2008 by F. A. Davis.
61
■ Assess plantar (Babinski’s) reflex by stroking the lateral aspect of the
sole of each foot with the reflex hammer. Normal response is flexion
(withdrawal) of the toes.
Glasgow Coma Scale (GCS)
The GCS is an LOC assessment tool.
Best Eye Response (E)
Spontaneously
4
On command
3
To pain
2
No response
1
Score:_______
Best Verbal Response (V)
Alert and oriented
Confused
Inappropriate
Incomprehensible
No response
Score:_________
5
4
3
2
1
Best Motor Response (M)
Follows direction
Localizes pain
Withdraws from pain
Abnormal flexion
Abnormal extension
No response
Score:________
6
5
4
3
2
1
Score may range from 3 (lowest neurological function) to 15 (highest
function). However, a number of combinations of eye opening, verbal
response, and motor response will give the same score. To provide a clearer
picture of the patient’s neurological functioning, record the score in the
following manner:
GCS ⫽ 9/15 (E ⫽ 2, V ⫽ 3, M ⫽ 4)
This is read as “Glasgow Coma Score ⫽ 9 out of a possible 15, eye opening
score 2, verbal response score 3, motor response score 4.”
NEURO
Copyright © 2008 by F. A. Davis.
NEURO
Cranial Nerve Assessment
Nerve
Name
Function
Test
I
Olfactory
Smell
Identify familiar odors (e.g., coffee,
peppermint).
II
Optic
Visual acuity
Assess visual acuity using eye chart.
Visual field
Assess peripheral vision.
III
Oculomotor
Pupillary
reaction
Assess pupils for equality and
reactivity to light.
IV
Trochlear
Eye
movement
Patient follows finger without
moving head.
V
Trigeminal
Facial
sensation
Touch face, and assess for sharp
and dull sensation.
Motor
function
Have patient hold mouth open.
VI
Abducens
Motor
function
Patient follows finger without
moving head.
VII
Facial
Motor
function
Have patient smile, wrinkle face,
puff cheeks.
Sensory
Patient differentiates between sweet
and salty taste.
Hearing
Snap fingers close to patient’s ears.
Balance
Feet together, arms at side, eyes
closed for 5 sec.
VIII
Acoustic
IX
Glossopharyngeal
Swallowing
and voice
Have patient swallow and then say
“Ah.”
X
Vagus
Gag reflex
Use tongue depressor or swab to
elicit gag reflex.
XI
Spinal
accessory
Neck motion
Patient shrugs or turns head against
resistance.
XII
Hypoglossal
Tongue
movement
Patient sticks out tongue and moves
it from side to side.
62
Copyright © 2008 by F. A. Davis.
63
Mini Mental Status Examination
Task
Instructions
Scoring
Date orientation
“Tell me the date.”
Ask for omitted
items.
1 point each for
year, season,
date, day of
week, and month.
Place
orientation
“Where are you?”
Ask for omitted
items.
1 point each for
state, county,
town, building,
and floor or
room.
Register
three objects
Name three
objects slowly
and clearly. Ask
patient to repeat
them.
1 point for each
item repeated
correctly.
Serial 7s
Ask patient to
count backward
from 100 by 7.
Stop after five
answers (or ask
patient to spell
“world”
backwards).
1 point for each
correct answer
(or letter).
Recall three
objects
Ask patient to
recall the objects
mentioned
above.
1 point for each
item remembered
correctly.
Naming
Point to your watch
and ask patient
“What is this?”
Repeat with a
pencil.
1 point for each
correct answer.
Repeating
a phrase
Ask patient to say
“No ifs, ands, or
buts.”
1 point if successful
on first try.
Score
(Continued on the following page)
NEURO
Copyright © 2008 by F. A. Davis.
NEURO
Mini Mental Status Examination (continued)
Task
Instructions
Scoring
Verbal commands
Give patient a plain
1 point for each
piece of paper and
correct action.
say “Take this
paper in your right
hand, fold it in
half, and put it on
the floor.”
Written commands
Show patient a piece 1 point if patient
of paper with
closes eyes.
“Close your eyes”
printed on it.
Writing
Ask patient to write
a sentence.
Drawing
Ask patient to copy a 1 point if the
pair of intersecting
figure has
pentagons onto a
10 corners and
piece of paper.
2 intersecting
lines.
Score
1 point if
sentence has
a subject and
a verb and
makes sense.
Scoring
Total possible score: 30. Score of 24 or above is considered normal.
Altered Level of Consciousness
CLINICAL PICTURE
The patient may have or be:
■ Change in usual state of full consciousness.
■ Difficulty or inability to respond to verbal stimuli.
■ Inability to speak, obey commands, or open eyes in response to verbal
or painful stimuli.
■ Confused, lethargic, obtunded, stuporous, or comatose (see following
table for definitions).
64
Copyright © 2008 by F. A. Davis.
65
IMMEDIATE INTERVENTIONS
■ Assess and protect airway.
■ Administer supplemental O2, or ventilate if patient is not breathing
adequately (RR ⬍8 and/or cyanosis).
■ Suction the oropharynx, and clear secretions as needed.
■ Assess VS, O2 saturation, and pupillary reaction.
■ Notify physician or NP.
■ Document patient’s status, phone call to physician or NP, and physician
or NP response.
FOCUSED ASSESSMENT
■
■
■
■
Assess airway for patency and secretions/obstructions.
Assess breathing and oxygenation.
Assess HR for rate and regularity.
Assess LOC (see GCS in this tab), pupil reactivity and size, best motor
response, and orientation.
■ Assess responsiveness to verbal or painful stimuli. Note: Does patient
respond to verbal stimuli? If not, does patient respond to gentle stimuli
(shaking the arm) or only to painful stimuli (e.g., grasping the pectoralis
muscle)? Is the motor response to stimuli purposeful (removing or
withdrawing from stimuli or posturing)?
■ Assess for associated neurological deficits such as weakness or numbness
on one side of the body.
■ Assess medication administration record (MAR) for drugs capable of
causing altered LOC.
STABILIZING AND MONITORING
■ Collaborate with health-care team to treat underlying causes (such as
drug overdose), if applicable.
■ Continue to monitor VS, breathing, and oxygenation closely.
■ Continue to monitor neurological status.
BE PREPARED TO
■
■
■
■
■
Assist with airway management or intubation if needed.
Start an IV.
Give medications.
Order laboratory tests.
Transfer patient to ICU.
NEURO
Copyright © 2008 by F. A. Davis.
NEURO
POSSIBLE ETIOLOGIES
■ Brain lesions/interruptions in blood flow, metabolic disorders (hypoglycemia, hypoxia), psychiatric disorder, toxic medication levels/drug
overdose, increasing intracranial pressure (ICP), dysrhythmia.
Levels of Consciousness
LOC
Characteristics
Full consciousness
Awake, alert, and oriented. Understands written
and spoken language, and responds reliably.
Confusion
Disoriented first to time, then place, then person.
Memory deficits, difficulty following commands,
restless, agitated.
Lethargy
Oriented to time, person, and place, but
demonstrates slow mental processes, sluggish
speech. Sleeps frequently, but wakens to spoken
word or gentle shake. Maintains wakefulness
with sufficient stimulation.
Obtundation
Extreme drowsiness, responds with one or two
words, follows very simple commands, requires
more vigorous stimulation to waken, and stays
awake for only a few minutes at a time.
Stupor
Minimal movement, responds unintelligibly, and
wakens briefly only to repeated vigorous
stimulation.
Coma
Does not respond to verbal stimuli, does not speak.
May have appropriate motor response (e.g.,
withdraws from noxious stimuli), nonpurposeful
response, or no response.
66
Copyright © 2008 by F. A. Davis.
67
Change in Mental Status/Delirium
CLINICAL PICTURE
The patient may have or be:
■ Confused, restless, agitated, disoriented to time and place.
■ Easily distracted, delusional, hallucinating.
■ Disturbed general appearance, motor activity, dress, and facial expression.
■ Agitated or obtunded with fluctuating LOC.
■ Rambling, disorganized speech.
■ Impaired cognitive function.
■ Reversal of sleep-wake cycle.
IMMEDIATE INTERVENTIONS
■
■
■
■
■
■
Assist patient to safe area or back to bed.
If LOC is diminished, position to maintain patent airway.
Provide supplemental O2 if saturation in room air is 93%.
Check MAR for recently given medications.
Stay with patient, and notify physician or NP.
Document patient status, phone call to physician or NP, and physician or
NP response.
FOCUSED ASSESSMENT
■ Assess VS, oxygenation, and neurological status.
■ Assess mental status with Mini Mental Status Examination (see table in
this tab).
■ Assess for associated neurological deficits, such as weakness or
numbness on one side of the body or changes in consciousness.
■ Assess for history of alcohol abuse, medication use, psychiatric illness.
■ Assess for possible source of infection.
STABILIZING AND MONITORING
■
■
■
■
■
■
■
■
■
■
Assess neurological status, motor function, and respiratory function.
Auscultate lungs for adventitious sounds.
Reorient as needed. Place calendar, clock, and family photos in room.
Provide stable, quiet, and well-lighted environment.
Keep staff consistent, if possible.
Explain procedures before beginning care.
Have patient wear eyeglasses and hearing aids, if applicable.
Enhance safety of environment.
Stay with patient, and offer support and reassurance.
Avoid use of restraints.
NEURO
Copyright © 2008 by F. A. Davis.
■
■
■
■
■
■
NEURO
Assess nutritional status and ability to take foods and fluids.
Monitor I&O/fluid status.
Monitor laboratory results.
Provide support.
Collaborate with health-care team to treat identified cause(s).
Document patient status, and communicate to physician.
BE PREPARED TO
■
■
■
■
■
Start a peripheral IV.
Obtain laboratory work; prepare patient for diagnostic studies.
Obtain blood, sputum, and urine cultures.
Administer appropriate medications as ordered.
Arrange for one-on-one care.
POSSIBLE ETIOLOGIES
■ Hypoglycemia, hypoxia, low blood pressure, compromise of cerebral
blood supply (stroke), elevated ammonia levels (end-stage liver failure),
toxic medication levels, drug-induced psychosis, urosepsis (especially in
the elderly), structural lesions, metabolic disorders, psychiatric disorders,
renal disease, compromise of cerebral blood flow.
Dizziness
CLINICAL PICTURE
The patient may have or be:
■ Sensation of spinning (vertigo), disequilibrium, or faintness.
■ Weakness, nausea.
■ Chest pain, tightness, squeezing, or pressure.
■ Shortness of breath, palpitations.
■ Tingling, pins-and-needles, weakness of extremities.
IMMEDIATE INTERVENTIONS
■
■
■
■
■
■
Assist patient to safe place to sit or lie down.
Administer supplemental O2.
Assess VS.
Encourage slow deep breaths.
Stay with patient, and provide reassurance.
Document patient’s status, phone call to physician or NP, and physician
or NP response.
68
Copyright © 2008 by F. A. Davis.
69
FOCUSED ASSESSMENT
■ Assess VS and respiratory status.
■ Assess cardiac rhythm and rate; assess for orthostasis (take blood
pressure supine, sitting, and standing; note changes in systolic BP
and HR).
■ Assess for circumoral cyanosis, skin temperature, and moistness.
■ Assess MAR for recently taken medications that can cause dizziness.
■ Assess history of similar episodes.
■ Assess for history of inner ear disease or migraine.
■ Assess recent laboratory values for electrolyte abnormality.
■ If patient is diabetic, obtain blood glucose level by fingerstick.
STABILIZING AND MONITORING
■
■
■
■
■
Administer medications for dizziness as ordered.
Assess VS and subjective feeling of dizziness.
Help patient with ambulation and self-care until dizziness resolves.
Monitor I&O.
Monitor laboratory values.
BE PREPARED TO
■ Start an IV.
■ Assist with diagnostic testing.
POSSIBLE ETIOLOGIES
■ Hypertension, hypotension, stroke, hypoglycemia, cardiac dysrhythmias,
myocardial infarction, neuropathy, deconditioning, dehydration,
arteriosclerosis, Ménière’s disease, medications, migraine,
hyperventilation.
Head Trauma
CLINICAL PICTURE
The patient may have:
■ Scalp lacerations, hematoma, bilateral orbital ecchymosis.
■ Battle’s sign (bruising behind the ear at the mastoid process).
■ Altered mental status of LOC: agitated, semiconscious, consciousness
or unconscious; may have seizures.
■ CSF leakage from ear or nose.
■ Signs of ICP:
■ Decreasing LOC, deterioration in GCS.
■ Cushing’s response (bradycardia, hypertension, bradypnea).
NEURO
Copyright © 2008 by F. A. Davis.
NEURO
IMMEDIATE INTERVENTIONS
■ Assess airway, breathing, circulation; assess VS.
■ Call for assistance, and notify physician or NP.
■ If patient conscious, open airway, and inspect. Clear blood, vomitus, or
secretions.
■ Immobilize cervical spine with collar or by holding head and neck in
neutral alignment with body.
■ With proper assistance and C-spine aligned or in collar, transfer patient to
bed or stretcher.
■ Treat bleeding lacerations.
■ Document patient status, phone call to physician or NP, and physician or
NP response.
FOCUSED ASSESSMENT
■
■
■
■
■
■
■
■
Examine for lacerations, depressions, swelling, Battle’s sign.
Inspect mouth for blood, foreign bodies, and vomitus.
Inspect pupils for equality and reactivity.
Inspect ears and nose for leakage of clear fluid (CSF) suggestive of skull
fracture.
Assess for distal deficits such as numbness or paralysis in the arms or
legs.
Assess cause and underlying conditions.
Assess for history of seizures.
Assess recent laboratory values, if available.
STABILIZING AND MONITORING
■ Continue to assess for impaired consciousness, deterioration in LOC,
unequal pupils/decrease in reactivity, severe tachycardia or bradycardia—
report changes in condition immediately.
■ Assess for severe and persistent headache, nausea and vomiting,
irritability or altered behavior.
■ Assist with diagnostic procedures (x-ray or CT scan).
BE PREPARED TO
■
■
■
■
■
■
■
■
Set up and assist with intubation.
Administer O2, and monitor oxygen saturation.
Monitor cardiac rhythm and VS.
Assist with diagnostic testing.
Insert an indwelling urinary catheter.
Start an IV; administer IVF and medications as ordered.
Assist with immobilization of neck and back.
Insert a nasogastric tube once skull fracture has been ruled out.
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Copyright © 2008 by F. A. Davis.
71
POSSIBLE ETIOLOGIES
■ Patient fall, trauma.
Increasing Intracranial Pressure (ICP)
CLINICAL PICTURE
The patient may have or be:
■ Subtle to dramatic changes in LOC; restlessness, confusion, drowsiness,
stupor, coma.
■ Double or blurred vision, headache, nausea and vomiting, sensitivity to
light.
■ Decreased motor function.
■ Late findings: changes in VS (widening pulse pressure, bradycardia, and
increased respiratory rate).
IMMEDIATE INTERVENTIONS
■
■
■
■
■
■
■
■
■
Assess airway patency and breathing.
Assess VS.
Notify physician or NP of findings.
Elevate head of bed to 15⬚–30⬚.
Provide high-flow O2 with a non-rebreather mask.
Keep head in neutral alignment.
Avoid flexion of the neck or hips.
Minimize environmental stimuli.
Document patient’s status, phone call to physician or NP, and physician or
NP response.
FOCUSED ASSESSMENT
■ Assess neurological status (see Neurological Assessment in this tab and
GCS in this tab).
■ Assess cranial nerves as condition allows (see Cranial Nerve Assessment
in this tab).
■ Asses oxygen saturation, cardiac rhythm.
■ Assess for signs of decreased oxygenation (LOC, desaturation, cyanosis,
increase in respiratory rate).
STABILIZING AND MONITORING
■ Monitor neurological status and VS.
■ Keep systolic blood pressure between 100 and 160 mm Hg (check with
physician for parameters).
NEURO
Copyright © 2008 by F. A. Davis.
NEURO
■ Limit suctioning (increases ICP); suction for fewer than 10 seconds in
duration, and administer 100% O2 beforehand; limit to two passes.
■ Maintain SaO2 at 100%.
■ Maintain and assess I&O.
■ Monitor ABGs, electrolytes.
■ If necessary, insert an oral or nasal airway.
■ Maintain quiet environment; protect patient from injury.
■ Provide education/reassurance/comfort measures.
■ Document all findings, and communicate to physician or NP.
■ Obtain or perform chest physiotherapy as needed. Perform skin
assessment. Assess nutritional status; obtain consult if needed.
BE PREPARED TO
■ Assist with intubation if needed.
■ Establish IV access, and give medications (sedatives, osmotic diuretics,
corticosteroids, anticonvulsants).
■ Insert nasogastric tube or urinary catheter.
■ Transfer to ICU.
POSSIBLE ETIOLOGIES
■ Tumor, cranial abcess, intracranial bleed, cerebral hypoxia, hypertension,
hydrocephalus, head trauma.
Seizure
CLINICAL PICTURE
The patient may have:
■ Repetitive, jerking movements of the upper and lower extremities.
■ Extreme muscle rigidity.
■ LOC or disorientation.
■ Tongue or eye deviation.
■ Cyanosis or apnea.
■ Urinary or fecal incontinence.
■ Blinking or repetitive behaviors (e.g., playing with buttons).
■ Difficulty in arousing from stuporous state (postictal).
■ Aura (warning or recognition that seizure may occur).
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Copyright © 2008 by F. A. Davis.
73
IMMEDIATE INTERVENTIONS
■ Ascertain that airway is not compromised by secretions or emesis.
Suction if necessary. Turn head/body to side, if able.
■ Protect patient from injury—clear immediate area of potentially harmful
objects; e.g., overbed table or glasses.
■ Raise siderails; if patient is OOB, guide to floor.
■ Stay with patient, and call for help.
■ Do not insert objects into patient’s mouth.
FOCUSED ASSESSMENT
■ Assess VS, airway patency, and respiratory status.
■ Note length, onset, duration, progression, and location (i.e., body parts
involved) of seizure activity.
■ Note tongue/eye deviation.
■ Note LOC, orientation, and responsiveness during seizure.
■ Assess pupil size, shape, and reactivity to light.
■ Assess for incontinence.
STABILIZING AND MONITORING
■ Suction the oropharynx, and clear secretions as needed.
■ Remove dentures.
■ Once seizure subsides (postictal phase), complete assessment, and
document findings. Include seizure description: aura; onset; duration;
body part in which seizure started; and progression of seizure activity;
LOC before, during, and after seizure; pupils; respiratory status; and any
precipitating factors.
■ Reorient patient if necessary.
■ Allow patient to sleep.
■ Provide reassurance and education.
BE PREPARED TO
■ Start an IV, and administer antiseizure medications. Check blood levels
of antiseizure medications.
■ Prepare patient with new onset seizures for extensive evaluation,
including CT scan, EEG, lumbar puncture, glucose level, Mg level, Ca
level, CBC, electrolytes, BUN, and creatinine levels.
POSSIBLE ETIOLOGIES
■ Inadequate blood levels of a prescribed anticonvulsant, arteriovenous
malformation, stroke, infection, trauma, tumor, metabolic disorders
(severe electrolyte disorders, low blood glucose level, renal failure,
hypoxia), drug or alcohol withdrawal.
NEURO
Copyright © 2008 by F. A. Davis.
NEURO
Spinal Cord Trauma/Syndrome
CLINICAL PICTURE
The patient may have:
■ History of recent back trauma with varying amounts of weakness and
sensory loss at and below the injury; pattern depends on whether cord
injury is complete or partial (incomplete).
■ Arm and/or leg weakness, paralysis.
■ Breathing difficulties.
■ Spasticity (increased muscle tone).
■ Altered sensation, numbness, pain.
■ Loss of bowel and bladder control.
■ Constipation, incontinence, bladder spasms.
■ Rapid blood pressure fluctuations; abnormal sweating and
thermoregulation (injuries to cervical or high thoracic cord).
■ Loss of sensation, reflexes, and mobility below level of injury.
■ Nausea and vomiting.
IMMEDIATE INTERVENTIONS
■ Immobilize cervical-spine (with light traction, hold head and neck in
neutral alignment with body).
■ If immobilizing entire body on a backboard, legs and torso must be
secured prior to securing head to board.
■ Assess airway, breathing, circulatory status.
■ Assess LOC, mental status.
■ Assess VS.
FOCUSED ASSESSMENT
■ Examine spine for lacerations, swelling, hematoma, deformity.
■ Assess mobility by asking patient to open and close fist, squeeze your
hand, and move toes and turn feet (see Neurological Assessment in this
tab).
■ Assess sensation by asking patient about numbness and altered sensation
and by touching patient lightly, beginning at shoulder and working down
arms and legs of both sides.
STABILIZING AND MONITORING
■ Frequently assess motor or sensory function—call physician or NP
immediately if condition changes.
■ Assess VS, O2 saturation, temperature.
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Copyright © 2008 by F. A. Davis.
75
■ Assess for potential complications: neurogenic shock (hypothermia
and hypotension without tachycardia), spinal shock (urinary and bowel
retention leading to abdominal distention, ileus, and delayed gastric
emptying), autonomic hyperreflexia, respiratory compromise, nutritional
decline, skin breakdown, urinary retention, constipation.
■ Maintain spinal stabilization and immobilization. Move the patient
very carefully using logroll technique. Use a spine board with
restraints or other items, such as head blocks and pillows, to
maintain position.
■ Document findings, and communicate with physician or NP.
■ Assist with diagnostic studies (spine x-rays, CT, MRI).
BE PREPARED TO
■
■
■
■
■
■
■
■
■
■
Administer O2, and monitor O2 saturation.
Set up and assist with intubation.
Assist with placing patient in spinal traction.
Monitor cardiac rhythm and VS.
Assist with diagnostic testing.
Insert an indwelling urinary catheter.
Start an IV.
Administer IVF and medications (e.g., methylprednisone).
Assist with immobilization of neck and back.
Insert a nasogastric tube.
POSSIBLE ETIOLOGIES
■ Blunt or penetrating trauma, auto versus pedestrian, motor vehicle
accident, spinal lesion or abcess.
Sudden Neurological Deficit (Stroke/
Transient Ischemic Attack)
CLINICAL PICTURE
The patient may have:
■ Weakness or numbness of one side of the face or body.
■ Slurred speech, aphasia, difficulty finding words.
■ Difficulty swallowing.
■ Ataxia, clumsiness.
■ Double vision, severe headache.
■ Problems with respiratory function/gag reflex.
■ Tachycardia/bradycardia/hypertension.
NEURO
Copyright © 2008 by F. A. Davis.
■
■
■
■
NEURO
Changes in affect/memory/judgment.
Altered LOC, confusion, agitation.
Seizures.
Nausea/vomiting.
IMMEDIATE INTERVENTIONS
■ Maintain patent airway.
■ If in bed, elevate head of bed 30⬚, and position head to one side to prevent
aspiration of secretions (if no signs of shock present).
■ Administer supplemental O2.
■ Assess VS.
■ Do not give anything by mouth.
■ Call physician or NP.
■ Stay with patient.
■ Document patient status, phone call to physician or NP, and physician or
NP response.
FOCUSED ASSESSMENT
■ Assess airway, ability to clear secretions, breathing pattern, heart rate and
rhythm, oxygenation status, and blood pressure.
■ Assess LOC (see GCS in this tab).
■ If patient is conscious, assess level of orientation.
■ Assess pupillary response, vision, and facial symmetry.
■ Assess speech.
■ Assess motor strength and control (see Neurological Examination in
Tools tab).
STABILIZING AND MONITORING
■ Continue to maintain patent airway.
■ Reassess airway, ability to clear secretions, breathing pattern, heart rate
and rhythm, oxygenation status, and blood pressure every 15 minutes.
■ Initiate seizure precautions.
■ Suction the oropharynx as needed to clear secretions.
■ Assist with diagnostic testing (CT scan, MRI, ECG).
■ Monitor laboratory values, I&O.
■ Administer medications as ordered.
■ Stay with patient for continued monitoring and support.
■ Obtain nutrition assessment.
■ Perform skin assessment; initiate pressure ulcer prevention strategies.
■ Support patient, and provide safe environment.
■ Begin discharge/rehabilitation planning if stroke is confirmed.
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Copyright © 2008 by F. A. Davis.
77
BE PREPARED TO
■
■
■
■
■
■
■
■
Aggressively manage airway.
Start an IV.
Administer O2.
Draw laboratory tests.
Accompany the patient to CT scan.
Assess if patient meets thrombolytic criteria.
Prepare patient for thrombolytic or anticoagulant therapy.
Transfer patient to a higher level of care.
POSSIBLE ETIOLOGIES
■ Embolic, thrombotic, or hemorrhagic stroke, TIA.
A & P Snapshot
Premotor area
Motor area
Frontal lobe
General sensory area
Sensory
association area
Parietal
lobe
Occipital
lobe
Visual
association
area
Visual area
Motor speech
area
Auditory
association
area
Auditory area
Temporal lobe
Functional areas of the brain.
NEURO
Copyright © 2008 by F. A. Davis.
NEURO
OLFACTORY 1
OCULOMOTOR 3
TROCHLEAR 4
ABDUCENS 6
OPTIC 2
TRIGEMINAL 5
FACIAL 7
GLOSSOPHARYNGEAL 9
VESTIBULOCOCHLEAR 8
HYPOGLOSSAL 12
VAGUS 10
ACCESSORY 11
Cranial nerves.
78
Copyright © 2008 by F. A. Davis.
79
Central
canal
Interneuron
Synapse
Dorsal root
Dorsal
column
Corticospinal tract
Rubrospinal
tract
Dorsal root
ganglion
Cell body
of sensor
neuron
Dendrite
of sensory
neuron
Ventral root
Receptor
Axon of motor neuron
Synaptic knobs
Spinothalamic
tract
White matter
Gray matter
Effector muscle
Cell body of
motor neuron
Cross section of the spinal cord.
NEURO
Copyright © 2008 by F. A. Davis.
RENAL/F&E
Focused Renal/GU Systems Assessment
■ A focused nursing assessment of renal function includes:
■ Assessing blood work: blood urea nitrogen (BUN) and creatinine
values including BUN to creatinine ratio, electrolytes, other chemistries,
hemoglobin, hematocrit level, ABGs.
■ Assessing urine laboratory tests: specific gravity, urine osmolality,
creatinine clearance for renal function; urinalysis to screen for urinary
system dysfunction; urine C&S to assess for infection. (Many more
urine tests are available and are used to assess for diseases of systemic
or other body systems diseases. This tab cites only the urine tests used
specifically to assess the urinary system.)
■ Physical examination: vital signs; palpate for flank and CVA
(costovertebral angle) tenderness; assess hydration status.
■ Blood work:
■ BUN is a by-product of protein metabolism and is excreted by the
kidneys. A rise in BUN reflects a decrease in kidney function (kidneys
are less able to filter and excrete the urea). BUN is affected by other
variables (e.g., dehydration, upper GI bleed) and can remain within
normal range even when kidney function is markedly impaired.
Therefore, creatinine is a better measure of renal function, and
creatinine clearance is preferred among the three blood tests. A rise in
BUN without a rise in creatinine is most likely not related to a decline
in renal functioning.
■ Normal value: Adults: 5–20 mg/dL
■ Critical Level: ⬎40 mg/dL (not dehydrated/no history of renal disease)
■ Critical Level: ⬎100 mg/dL (patient with history of renal disease)
■ Critical Level: ⬎20 mg/dL increase in 24 hr (indicates acute renal
failure)
Call physician or NP immediately with critical results.
■ Creatinine is a breakdown product of creatine phosphate in muscle.
It is generally produced at a constant rate by the body and then is
excreted by the kidney. It is used to estimate glomerular filtration rate.
A rise in serum creatinine reflects a decrease in glomerular filtration rate
(kidneys are less able to filter and excrete the creatinine, therefore, blood
levels rise).
■ Normal values: Adult: Male: 0.6–1.2 mg/dL; Female: 0.5–1.1 mg/dL
■ Critical level: ⬎4 mg/dL
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Copyright © 2008 by F. A. Davis.
81
Call physician or NP immediately with critical results.
■ Creatinine clearance (CrCl) compares the level of creatinine in urine
with the serum creatinine level. CrCl is used to determine safe dosing
of nephrotoxic drugs. Urine creatinine is based on a 24-hour urine
collection; blood for serum creatinine is collected at the end of the
24-hour period. However, CrCl is usually estimated by using a formula
based on age, mass, and serum creatinine. Normal values: Male:
107–139 mL/min; Female: 85–105 mL/min. CrCl of 10–20 mL/min is
indicative of renal failure and the need for dialysis.
■ Other urine tests include urinalysis for screening, urine osmolality and
specific gravity for assessing renal concentrating ability, and urine culture
and sensitivity for assessing urinary tract infection (UTI).
■ Assess urine for cloudiness, color, and volume.
■ Vital signs and ABGs: In coordination with other organs (lungs, adrenal glands, hypothalamus, endocrine system), the kidneys regulate
acid-base balance, electrolyte concentrations, blood volume, and BP.
The kidneys maintain BP through the renin-angiotensin system (RAS)
and regulate hydration status by retaining sodium in response to
aldosterone secretion. Therefore, kidney disorders may be reflected
in changes in BP, fluids and electrolytes, and acid-base balance. When
assessing BP, calculate the pulse pressure, which is the difference between
the systolic and diastolic pressures. High pulse pressure (⬎40 mm Hg) is
a risk factor for cardiac events. See Tab 3 for ABG interpretation. Briefly,
the sodium bicarbonate value represents the metabolic componet of the
ABG and is controlled by the kidneys.
■ Hydration status: Assess I&O, daily weights, mucous membranes,
sodium levels, BUN to creatinine ratio, urine osmolality, specific
gravity.
■ CVA tenderness: The angle created where the lowest ribs connect
with the vertebral column. CVA pain and tenderness with other UTI
symptoms suggests a kidney infection.
■ Focused assessment of the lower urinary tract includes:
■ Voiding patterns, including stress, urge, or overflow incontinence
and difficulties initiating stream.
■ Residual urine volume (amount of urine left in the bladder after
voiding).
■ Prostate examination in males.
RENAL/F&E
Copyright © 2008 by F. A. Davis.
RENAL/F&E
Electrolyte Imbalances
Electrolyte imbalances are encountered frequently in patients with all types
of conditions.
See p. 86 for hyperkalemia, p. 88 for hypokalemia, p. 87 for hypernatremia,
and p. 89 for hyponatremia
Hypocalcemia: Ca ⬍8.4 mg/dL
S&S
Treatment
Abdominal and
muscle cramps,
lethargy, ↑ BP,
tetany, seizure,
ECG changes.
Calcium gluconate
10%*: 1 g in 50–100
mL of D5W over 1 hr,
then infusion of 1–2
mg/kg/hr.
Nursing
Given by physician or NP on
general care units and by
RNs in ICU. Do not infuse
too rapidly—is cardiotoxic
and can cause ↓ BP.
Never given IM or
subcutaneously—causes
severe sloughing of tissue.
Check calcium and magnesium levels.
Antidote: IV magnesium
sulfate.
*Do not confuse with calcium chloride.
Hypercalcemia: Ca ⬎10.2 mg/dL
S&S
Treatment
Nursing
Dehydration, renal
stones, confusion,
severe thirst, constipation, polyuria,
shortening of QT
interval ↑ BP.
D5NS at 250–500
mL/hr; furosemide
20–80 mg IV over 2
min to bring Ca
down with
diuresis.
Monitor electrolyte levels.
Encourage fluid intake,
provide ↑ fiber diet and
stool softeners.
Potentiate digoxin toxicity;
assess as indicated.
Monitor ECG, if available,
or assess pulse for
irregular beats.
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Copyright © 2008 by F. A. Davis.
83
Hypomagnesemia Mg ⬍1.5 mEq/L
S&S
Treatment
Nursing
Weakness, vertigo,
muscle twitching,
tachycardia,
seizures, tetany,
PVCs.
2 g magnesium
sulfate in D5W over
10–20 min, then 1
g/hr for 3–4 hr.
Check other electrolyte
levels; can have ↓
potassium, ↓ phosphate,
↓ calcium.
Assess reflexes and monitor
Mg levels.
Hypermagnesemia Mg ⬎2.1 mEq/L
S&S
Treatment
Nursing
Nausea, vomiting,
↓ BP, weakness,
drowsiness, hyperreflexia, ↓ HR,
coma, respiratory
failure.
Calcium gluconate
10%*: 1–10 mL in
50–100 mL of D5W
over 10–20
minutes.
Assess for changes in LOC.
Assess reflexes.
Hold medications containing magnesium, especially in patients with renal
failure.
*Do not confuse with calcium chloride.
Hypophosphatemia PO4 ⬍2.5 mg/dL
S&S
Treatment
Nursing
Anorexia, weakness,
muscle pain, confusion, rhabdomyolysis, hemolysis,
cardiac and respiratory failure.
Potassium or sodium
phosphate 2 mg/kg IV
over 6 hr if PO4 level is
⬍1–5 mg/dL. Oral
replacement with KPhos or Neutra-Phos if
depletion is less severe.
Too rapid IV
administration can
cause severe
hypocalcemia;
assess for tetany.
RENAL/F&E
Copyright © 2008 by F. A. Davis.
RENAL/F&E
Hyperphosphatemia PO4 ⬎4.5 mg/dL
S&S
Limited symptoms;
possible tetany if
calcium is low,
which is a result
of hyperphosphatemia.
Treatment
Nursing
Phosphate binders,
possibly acetazolamide,
low-phosphate diet
Teach patient about
avoiding foods and
OTC medications
high in phosphorus
Dehydration
CLINICAL PICTURE
The patient may have:
■ Increased thirst, dry mouth, and swollen tongue (see table below of Signs
and Symptoms of Progressive Dehydration).
■ Weakness, dizziness, palpitations.
■ Tachycardia, hypotension.
■ Confusion, sluggishness, fainting, seizure.
■ Decreased urine output.
IMMEDIATE INTERVENTIONS
■
■
■
■
■
Assess VS; check BP lying, sitting, and standing; note changes.
Assess current urine output and recent intake and output (I&O).
Make sure patient is comfortable and safe.
Notify physician.
Document patient’s status, phone call to physician or NP, and physician
or NP response.
FOCUSED ASSESSMENT
■
■
■
■
■
Assess VS including temperature.
Assess skin for color, moistness, temperature, integrity.
Assess mucous membranes.
Assess LOC and orientation.
Assess for patent IV access.
STABILIZING AND MONITORING
■
■
■
■
Administer oral or IVF.
Closely monitor I&O.
Monitor urine output for adequate hourly rate.
Assess electrolytes, BUN, creatinine.
84
Copyright © 2008 by F. A. Davis.
85
■ Maintain safe environment.
■ Provide oral care.
■ Chart patient status and convey to physician or NP.
BE PREPARED TO
■ Obtain IV access.
■ Obtain a nutritional/dietary assessment.
■ Insert urinary catheter with a urometer to monitor hourly output.
Signs and Symptoms of Progressive Dehydration
Symptom/
Sign
Mild
Dehydration
Moderate
Dehydration
Severe
Dehydration
LOC
Alert
Lethargic
Obtunded
Capillary refill
2 sec
2–4 sec
Greater than 4
sec, cool limbs
Mucous membranes
Normal
Dry
Parched, cracked
HR
Slight increase
Increased
Very increased
RR
Normal
Increased
Increased and
hyperpnea
BP
Normal
Normal, but
orthostasis
Decreased
Pulse
Normal
Thready
Faint or
impalpable
Skin turgor
Normal
Slow
Tenting
Urine output
Decreased
Oliguria
Oliguria/anuria
POSSIBLE ETIOLOGIES
■ Gastroenteritis, stomatitis, diabetic ketoacidosis, febrile illness,
pharyngitis, burns, GI obstruction, heat stroke, diabetes insipidus,
thyrotoxicosis.
RENAL/F&E
Copyright © 2008 by F. A. Davis.
RENAL/F&E
Hyperkalemia
CLINICAL PICTURE
The patient may have:
■ Muscular weakness.
■ Cardiac dysrhythmias.
■ ECG abnormalities (tall, peaked T waves).
■ Nausea.
IMMEDIATE INTERVENTIONS
■
■
■
■
■
■
Assess VS; note cardiac rate and rhythm.
Administer oxygen.
Assess for patent IV access.
Assess recent laboratory results (BUN, creatinine, electrolytes).
Notify physician or NP.
Document patient’s status, phone call to physician or NP, and physician
or NP response.
FOCUSED ASSESSMENT
■
■
■
■
Monitor VS, and assess cardiac rhythm if available.
Assess LOC and orientation.
Assess musculoskeletal function.
Assess previous 2 days’ I&O.
STABILIZING AND MONITORING
■ Obtain IV access.
■ Administer potassium-binding resins (Kay-exalate) orally or rectally.
■ Monitor cardiac rhythm, I&O, serial potassium levels, and other laboratory
tests.
■ Chart patient status and convey to physician or NP.
BE PREPARED TO
■ Set up cardiac monitoring.
■ Administer IV calcium, sodium bicarbonate, insulin and glucose, or
furosemide per order.
■ Order or obtain laboratory tests.
■ Order a 12-lead ECG.
■ Transfer to telemetry unit.
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Copyright © 2008 by F. A. Davis.
87
POSSIBLE ETIOLOGIES
■ Medication, chemotherapy, acute or chronic renal failure,
hypoaldosteronism trauma, hemolysis, digitalis poisoning, acidosis,
burns, insulin deficiency, uncontrolled hyperglycemia, excessive use of
salt substitutes, metabolic acidosis.
Hypernatremia
CLINICAL PICTURE
The patient may have:
■ Sodium level ⬎ 144 mEq/L
■ Confusion, lethargy, seizures, coma (if imbalance is severe)
■ Restlessness, irritability, disorientation, hallucinations
■ Thirst (many older adults have an impaired sense of thirst and may not
express thirst) of flushed skin, peripheral edema
■ Postural hypotension, tachycardia
IMMEDIATE INTERVENTIONS
■ Assess recent lab values.
■ Assess vital signs; obtain orthostatic BP if possible.
■ Notify physician or NP, and document findings and discussion with
physician or NP in the chart.
FOCUSED ASSESSMENT
■ Assess total intake and output over previous several days.
■ Assess skin and mucous membranes; note dry cracked skin, sticky oral
membranes.
■ Assess mental status (see Mini Mental Status Examination in Tab 4)
■ Assess for intact IV site.
STABILIZING AND MONITORING
■ Insert IV, if necessary.
■ Administer parenteral fluids as ordered using a volume control infusion
device; make sure fluids do not infuse too quickly; doing so in the
presence of elevated sodium levels causes fluid shifts that can result in
cerebral edema and brain damage.
■ If patient is disoriented, move patient to a room near the nurse’s station
or ask if a family member can stay with the patient.
■ Continue assessment outlined above as treatment progresses.
■ Provide mouth care and measures to protect skin integrity.
RENAL/F&E
Copyright © 2008 by F. A. Davis.
RENAL/F&E
BE PREPARED TO
■ Change IVF as soon as a different concentration is ordered, depending
on changes in patient’s status
■ Monitor changes in mental status, laboratory values, VS
POSSIBLE ETIOLOGIES
■ Poor water intake due to inability to express thirst or insensible water
loss; diabetes insipidus, excess salt intake, near-drowning in salt water.
Hypokalemia
CLINICAL PICTURE
The patient may have:
■ Serum potassium ⬍3.5 mEq/L.
■ Palpitations, ventricular dysrhythmias, bradycardia or tachycardia,
hypotension.
■ Malaise, fatigue, weakness, muscle cramps.
■ Nausea, vomiting, ileus, constipation.
■ Hypoventilation, respiratory distress.
IMMEDIATE INTERVENTIONS
■
■
■
■
■
Assess BP sitting and standing; note orthostasis.
Assess HR; note rhythm.
Assess LOC and muscle strength.
Notify physician or NP.
Document patient’s status, phone call to physician or NP, and physician
or NP response.
FOCUSED ASSESSMENT
■
■
■
■
Assess recent I&O.
Assess cardiac rhythm if patient on telemetry.
Assess for digitalis toxicity, if indicated.
Assess recent laboratory results (BUN, creatinine, electrolytes,
magnesium level).
■ Assess medication history, use of diuretics or laxatives.
■ Assess for patent IV access.
STABILIZING AND MONITORING
■ Obtain IV access.
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Copyright © 2008 by F. A. Davis.
89
■ Administer oral and/or IV potassium supplement. Oral supplementation
is much safer; IV rate should not exceed 200–400 mEq/24 hr (based on
serum potassium level of 2.0–2.5 mEq/L); never give as a bolus: may
precipitate cardiac arrest. Patient should be on telemetry if receiving
treatment level amounts of potassium.
■ Monitor potassium and other electrolyte levels.
■ Monitor HR and rhythm.
■ Maintain safety precautions due to muscle weakness.
■ Nutrition/dietary education, especially if taking diuretics.
■ Chart patient status, and convey to physician or NP.
BE PREPARED TO
■ Place patient on telemetry.
■ Order or obtain laboratory tests, urine sample for potassium, ECG.
POSSIBLE ETIOLOGIES
■ Deficient potassium intake, vomiting, diarrhea, fistulas, laxative abuse,
metabolic alkalosis, diuretic therapy, aldosteronism, excess adrenocortical
secretion, renal tubule disease, chronic respiratory acidosis.
Hyponatremia
CLINICAL PICTURE
The patient may have:
■ Mild: Na⫹ ⬎120 mEq/L: headache, nausea, vomiting, weakness, muscle
cramps.
■ Moderate: Na⫹ 110–120 mEq/L: hallucinations, bizarre behavior,
hyperventilation, gait disturbance.
■ Severe: Na⫹ ⬍110 mEq/L: coma, respiratory arrest, hypertension, dilated
pupils, seizures.
■ Neurological symptoms usually reflect severe, sudden drop in serum
sodium level, which causes intracerebral osmotic fluid shifts and cerebral
edema. A gradual drop in serum sodium may be tolerated because of
neuronal adaptation.
IMMEDIATE INTERVENTIONS
■
■
■
■
■
Assess VS, LOC, feelings of weakness.
Make sure patient is comfortable and safe.
Check if blood for laboratory was drawn above a running IV site.
Notify physician or NP.
Document patient’s status, phone call to physician or NP, and physician
or NP response.
RENAL/F&E
Copyright © 2008 by F. A. Davis.
RENAL/F&E
FOCUSED ASSESSMENT
■ Assess HR and BP lying, sitting, and standing (if possible); note changes
in BP and HR.
■ Assess fluid status: examine mucous membranes and skin turgor, assess
lung sounds, check for peripheral edema.
■ Assess recent I&O.
■ Assess for recent infusion of hypotonic IVF (common cause of ↓ Na⫹
in hospitalized patients) or use of continuous bladder irrigation (CBI).
■ Review medication and dietary history (salt and water intake).
STABILIZING AND MONITORING
■ Treament depends on patient’s volume status, duration and magnitude
of hyponatremia, and severity of symptoms (see Table on p. 91, Treatment
for Mild or Moderate Hyponatremia).
■ Monitor neurological status, laboratory values, I&O, VS.
■ Restrict fluids, and administer diuretics or IVF as ordered.
■ Chart patient status and convey to physician or NP.
BE PREPARED TO
■ Order or obtain laboratory tests (electrolyes, BUN, creatinine, urine
and serum osmolality, urine sodium concentration).
■ Obtain IV access.
■ Administer oral or IV diuretics.
■ Administer hypertonic saline solution IV if CNS symptoms present.
Caution: Must be administered slowly via an infusion pump. Too
rapid correction can cause permanent neurological impairment.
POSSIBLE ETIOLOGIES
■ Vomiting, diarrhea, excessive sweating, GI fistulas or drainage tubes,
pancreatitis, burns, acute or chronic renal insufficiency, medications
(thiazide diuretics, chlorpropamide, cyclophosphamide, clofibrate,
carbamazepine, oxcarbazepine, opiates, oxytocin, desmopressin,
vincristine, selective serotonin reuptake inhibitors, trazodone, or
tolbutamide), administration of hypotonic IV or irrigation fluids in the
immediate postoperative period, prolonged exercise in a hot environment, hepatic cirrhosis, congestive heart failure, nephrotic syndrome,
uncorrected hypothyroidism, cortisol deficiency, SIADH, use of the
recreational drug MDMA (ecstasy).
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Copyright © 2008 by F. A. Davis.
91
Hypotonic Hyponatremia
Inability of the kidneys to excrete free water adequately. Categorized
according to the associated intravascular volume: hypovolemic,
hypervolemic, and euvolemic. Most common cause of hyponatremia in
surgical patients is infusion of hypotonic fluids.
Treatment for Mild or Moderate Hyponatremia
Cause
Intervention
Hypovolemic
hyponatremia
Type
↑ sympathetic tone, ↓ renal
perfusion due to intravascular
volume depletion leading to ↑
renin and angiotensin excretion, ↑ sodium absorption
and resultant impairment of
renal free water excretion.
Increase in serum ADH
further impairs free water
excretion.
Infuse 0.9% NS IV.
Euvolemic
hyponatremia
Associated with SIADH arising
from many clinical conditions
including CNS disturbances,
major surgery, trauma,
pulmonary tumors, infection,
stress, and certain medications (e.g., chlorpropamide,
carbamazepine, cyclophosphamide, vincristine,
vinblastine, amitriptyline,
haloperidol, SSRI, and MAOI).
Treat underlying
cause.
Restrict free
water.
Hypervolemic
hyponatremia
↑ in total body water and
sodium with paradoxical ↓ in
circulating volume. Stimulates the same pathophysiological mechanism of
impaired water excretion as
is found in hypovolemic
hypotonic hyponatremia.
Also called dilutional
hyponatremia.
Restrict free
water.
Possible diuretics.
RENAL/F&E
Copyright © 2008 by F. A. Davis.
RENAL/F&E
Oliguria (Low Urine Output/Acute Renal Failure)
CLINICAL PICTURE
The patient may have:
■ Urine output ⬎500 mL in 24 hr.
■ Peripheral edema, neck vein distention, pulmonary crackles.
■ Orthostatic hypotension (if volume depleted), dry mucous membranes,
hypotension.
■ Electrolyte imbalance.
■ Fatigue, nausea, vomiting, abdominal pain.
IMMEDIATE INTERVENTIONS
■
■
■
■
■
Assess vital signs, recent I&O, LOC.
Assess for bladder distention.
Assess for patent IV access.
Notify physician or NP of low urine output.
Document patient status, phone call to physician or NP, and physician or
NP response.
FOCUSED ASSESSMENT
■ Assess recent laboratory chemistry tests, especially BUN/creatinine.
■ Assess for orthostatic hypotension, mucosal membrane moisture, and
tissue turgor.
STABILIZING AND MONITORING
■
■
■
■
■
Insert IV access, and hang fluids to reverse hypovolemia.
Monitor I&O; assess for fluid overload.
Insert urinary catheter, and monitor urine output hourly.
Monitor BP, HR, capillary refill time, mental status.
Chart patient status, and convey to physician or NP.
BE PREPARED TO
■
■
■
■
■
■
Administer IVF challenge.
Obtain urine samples for analysis, culture, other studies.
Obtain or order laboratory tests including BUN/creatinine, chemistries, CBC.
Administer diuretics.
Transfer patient to ICU if invasive monitoring is required.
Educate patient and family about dialysis.
POSSIBLE ETIOLOGIES
■ Renal hypoperfusion (hypovolemia, CHF, sepsis, blood loss); renal arterial
disease; acute glomerulonephritis; acute tubular necrosis; tubular, ureteral,
or urethral obstruction; drugs (aminoglycosides, radiocontrast medium).
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Copyright © 2008 by F. A. Davis.
93
Urinary Retention
CLINICAL PICTURE
The patient may have:
■ Difficulty initiating stream, feeling of not emptying bladder.
■ Inability to void.
■ Lower abdominal pain, bladder distention and spasm.
■ Voiding in frequent small amounts.
IMMEDIATE INTERVENTIONS
■ Palpate bladder to assess distention and tenderness.
■ Assist patient to assume natural voiding position if possible (stand male
patients, assist females to commode or raise HOB when using bedpan).
■ Implement triggers to help initiate stream (Credé’s maneuver, running
water, pouring warm water over perineum).
■ If patient still unable to empty bladder, check for PRN order to catheterize
patient.
■ If ordered, catheterize patient; note amount and characteristics of urine.
Remove catheter. Note: Do not catheterize patient if suspected pelvic
trauma or blood at meatus.
■ If patient does not have a straight catheter order or if residual volume is
excessive (⬍500 mL), call physician or NP, and relate findings.
■ Document patient status, phone call to physician or NP, and physician or
NP response.
FOCUSED ASSESSMENT
■
■
■
■
Assess urine volume with a bladder scanner, if available.
Inspect and palpate for distention or tenderness of the lower abdomen.
Assess temperature; recent WBC count, if available.
Assess voiding patterns, recent urological procedure or procedure
requiring anesthesia, medications, history of BPH, urethral stricture,
history of incontinence.
STABILIZING AND MONITORING
■ Monitor I&O.
■ Evaluate subsequent attempts to void and PVR.
■ Chart patient status, and convey to physician or NP.
BE PREPARED TO
■
■
■
■
■
Collect sterile urine sample.
Initiate timed voiding and obtain postvoid residual (PVR) until PVR ⬎100 mL.
Place indwelling urinary catheter.
Teach self-intermittent catheterization.
Instruct patient about urodynamic testing.
RENAL/F&E
Copyright © 2008 by F. A. Davis.
RENAL/F&E
POSSIBLE ETIOLOGIES
■ Obstruction in the bladder or urethra, neurogenic bladder (secondary
to CVA, spinal trauma/tumor, MS, neuropathy), long period of inactivity or bedrest, surgery, low fluid intake, benign prostatic hyperplasia
(BPH), kidney stones, urinary tract infection (UTI), medications—
antihypertensives, antihistamines (can be over-the-counter),
anticholinergics, sedatives, spinal anesthesia.
Urinary Catheterization
Straight Catheter
Also called red rubber catheter or “straight cath.” Straight catheters have
only a single lumen and do not have a balloon near the tip. Straight
catheters are inserted for only as much time as required to drain the bladder
or obtain a urine specimen.
Indwelling Catheter
Also called Foley or retention catheter. Indwelling catheters have two
lumens, one for urine drainage and one for inflation of the balloon near the
tip. Three-way Foley catheters are used for continuous or intermittent
bladder irrigation. They have a third lumen for irrigation.
Procedure
1. Prepare patient: explain procedure, and provide privacy.
2. Collect appropriate equipment.
3. Place patient in supine position (female: knees up, legs apart; male:
legs flat, slightly apart).
4. Open and set up catheter kit using sterile technique.
5. Don sterile gloves, and set up sterile field.
6. If placing indwelling catheter, test patency of balloon by filling
balloon with 5 mL sterile water. Check for leaks and proper inflation.
Remove water.
7. Lubricate end of catheter; saturate cotton balls with cleansing solution.
8. With nondominant hand and using forceps to hold cotton balls: female—
hold labia apart; swab from front to back, starting with the outer labia
and working inward toward the meatus. Use one swab per swipe (total of
five); male—retract foreskin; swab in a circular motion from the meatus
outward. Repeat at least three times, using a different swab each time.
9. Gently insert catheter (about 2–3 inches for females and 6–9 inches for
males) until return of urine is noted. Straight: collect specimen or drain
bladder, and remove catheter. Indwelling: insert an additional inch, and
inflate balloon.
10. Attach catheter to drainage bag, using sterile technique.
11. Secure catheter to patient’s leg according to hospital policy.
12. Hang drainage bag on bed frame below level of bladder.
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Copyright © 2008 by F. A. Davis.
95
Patient Care
■ Wash hands with soap and water before and after handling catheter,
tube, or bag.
■ Keep bag below level of patient’s bladder at all times.
■ Check frequently to be sure there are no kinks or loops in tubing and that
patient is not lying on tubing.
■ Do not pull or tug on catheter.
■ Wash around catheter entry site with soap and water twice each day and
after each bowel movement.
■ Do not use powder around catheter entry site.
■ Periodically check skin around catheter entry site for signs of irritation,
redness, tenderness, swelling, or drainage.
■ Offer fluids frequently (if not contraindicated by health status), especially
water or cranberry juice.
■ Record urine output according to physician orders.
■ Empty collection bag each shift; note color, clarity, and odor.
■ Notify physician for any of the following:
■ Blood, cloudiness, or foul odor.
■ Decreased urine output (⬍30 mL/hr).
■ Irritation or leaking around catheter entry site.
■ Fever, abdominal or flank pain.
Removal
■ Don gloves.
■ Use a 10-mL syringe to withdraw all water from balloon.
■ Hold a clean 4 ⫻ 4 pad at meatus in the nondominant hand. With
dominant hand, gently pull catheter. If you meet resistance, stop and
reassess if balloon is completely deflated. If balloon appears to be
deflated and catheter cannot be removed gently, notify physician or
nursing supervisor for assistance.
■ Catheter should withdraw easily. Wrap tip in clean 4 ⫻ 4 pad as it is
withdrawn to prevent leakage of urine.
■ Provide bedpan, urinal, or assist patient to toilet. Measure spontaneous
void amount. Palpate bladder to ascertain it is empty.
■ Note time catheter discontinued.
Urinary Tract Infection (UTI)
CLINICAL PICTURE
The patient may have:
■ Lower UTI S&S (cystitis):
■ Dysuria, frequency, urgency, hesitancy.
■ Cloudy, foul-smelling, or bloody urine.
RENAL/F&E
Copyright © 2008 by F. A. Davis.
RENAL/F&E
■ Suprapubic pain.
■ Fever ⬍101⬚F, chills, and malaise.
■ Upper UTI S&S (pyelonephritis):
■ Fever ⬍101⬚F, shaking chills.
■ Nausea, vomiting, flank pain.
■ Elderly: altered mental status, delerium, anorexia, abdominal pain,
incontinence, or asymptomatic.
IMMEDIATE INTERVENTIONS
■
■
■
■
Assess VS.
Notify physician or NP of symptoms.
Obtain clean catheter urine specimen.
Offer acetaminophen (if ordered) and heating pad or hot water bottle
to relieve suprapubic pain.
■ Encourage patient to drink fluids to flush urinary system.
■ Document patient status, phone call to physician or NP, and physician
or NP response.
FOCUSED ASSESSMENT
■ Assess history of UTI and usual voiding patterns.
■ Assess urine characteristics (odor, volume, color, cloudiness).
■ Assess for flank pain.
STABILIZING AND MONITORING
■
■
■
■
Administer antibiotics promptly and on schedule.
Administer phenazopyridine PRN for dysuria.
Monitor temperature. Encourage fluids.
Monitor for relief of symptoms or complications (urosepsis, onset of
upper UTI symptoms).
BE PREPARED TO
■
■
■
■
Insert saline lock for IV antibiotics for upper UTI.
Administer IVF.
Obtain catheterized urine sample.
Change or discontinue indwelling urinary catheter.
POSSIBLE ETIOLOGIES
■ Bacterial invasion of urinary tract (usually E. coli), factors that increase
risk: incomplete emptying of bladder secondary to benign prostatic hyperplasia, prostatitis, and urethral strictures, neurogenic bladder; lack of
adequate fluids, bowel incontinence, immobility or decreased mobility,
indwelling urinary catheters.
96
Copyright © 2008 by F. A. Davis.
97
A & P Snapshot
Ribs
Aorta
Inferior vena
cava
Left adrenal
gland
Superior
mesenteric
artery
Left renal
artery and
vein
Diaphragm
Left kidney
Left ureter
Right
kidney
Left common
iliac artery
and vein
Lumbar
vertebra
Pelvis
Psoas
major
muscle
lliacus
muscle
Sacrum
Right
ureter
Urinary bladder
Urethra
Opening of ureter
Trigone of bladder
Symphysis pubis
Urinary system.
RENAL/F&E
Copyright © 2008 by F. A. Davis.
RENAL/F&E
Parietal peritoneum
Ureter
Detrusor muscle
Openings of
ureters
Rugae
Ureter
B
Trigone
Prostate
gland
Prostatic
urethra
Trigone
A
Internal
urethral sphincter
External
urethral sphincter
Urethra
Membranous
urethra
Cavernous
(spongy)
urethra
Cavernous
(erectile)
tissue of
penis
Urethral orifice
Bladder and urethra. (A) Female. (B) Male.
98
Copyright © 2008 by F. A. Davis.
99
Focused GI Assessment
■ A focused nursing assessment of the GI system includes:
■ Investigation of abdominal pain, nausea, and vomiting.
■ Frequency and character of bowel sounds.
■ Amount of abdominal distention
■ Frequency and character of bowel movements (constipation or
diarrhea).
■ Appetite, intake, swallowing, and tolerance of foods and fluids.
■ Abdominal pain, nausea, and vomiting:
■ Ask the patient about the nature of the abdominal pain. Use the PQRST
guideline in the Basics tab.
■ Ask about nausea, and consider any recent procedures or new
medication.
■ If the patient has vomited, assess quantity and characteristics of
emesis.
■ Use a hemeoccult slide to test for blood in the emesis.
■ Fecal material in the emesis is rare but is an emergency if found.
■ Assess bowel sounds:
■ Assess bowel sounds before palpating the abdomen. Listen in all four
quadrants; however, most clinicians think that it is difficult to pinpoint
the origin of bowel sounds because they can be heard even when
ausculatating the lungs.
■ Bowel sounds provide supporting information to the clinical picture for
the patient with an evolving GI problem.
■ Normal bowel sounds are small gurgles heard every few seconds,
although there is considerable variability that is still considered normal.
■ Absence of bowel sounds can indicate an inflammatory process such
as peritonitis or a bowel obstruction.
■ High-pitched, frequent, tinkling bowel sounds can be heard in the initial
stages of a bowel obstruction.
■ Bowel sounds are absent after abdominal surgery and may take a few
days to return. Patients are not fed when bowel sounds are absent.
■ When bowel sounds return, which is usually accompanied with passing
flatus, it indicates that the intestinal tract is beginning to function again.
■ Assess abdominal distention:
■ The abdomen can be distended in many bowel problems; such distention is frequently associated with abnormal or absent bowel sounds.
The abdomen can be distended from constipation, excessive
abdominal gas, severe bowel dysfunction, obstruction, or infection.
■ Ascites, the abnormal accumulation of fluid in the peritoneal cavity, can
cause massive distention. For patients with ascites, mark the abdomen,
and measure girth at the same level each day to assess if ascites is
decreasing or increasing.
GI
Copyright © 2008 by F. A. Davis.
GI
■ Bowel distention is usually observed; measurement as described above
is not done routinely, especially when the distention is of acute onset
as in a postoperative complication. Measurements only become
meaningful once a baseline is established.
■ Palpate or precuss the abdomen after listening to bowel sounds. Both
skills take practice to be helpful in an assessment. Refer to an
assessment textbook for more information.
■ Frequency and character of bowel movements (constipation
or diarrhea):
■ Monitor bowel movements, and ask the patient if he or she feels
constipated. Ask about normal bowel habits.
■ If the patient has diarrhea, ascertain the frequency and amount of stool.
Diarrhea, especially when accompanied by vomiting, can quickly cause
electrolyte imbalances and dehydration.
■ If the patient is constipated, look to the recent history (procedures),
medications that affect peristalsis (narcotics and many others), NPO
status, or other possible causes. If constipation is chronic, discuss
eating habits.
■ Assess for black, tarry stools (melena). Test the stool for blood when
GI bleeding is suspected.
■ Appetite, intake, swallowing, and tolerance of foods and fluids:
■ Any impairment in swallowing is serious and should be evaluated by a
speech pathologist. Suggest a consultation to the physician or NP.
■ If the patient complains of loss of appetite, find out more about the
problem. How long has it been; is there early satiety (feeling full after
eating small quantities); is there nausea, vomiting or weight loss?
■ If general food intake is low, especially in older adults, assess
dentition, and ascertain if foods have lost their taste to the patient.
■ Does the patient tolerate the foods and fluids offered? If not, why not?
Ask about allergies.
■ Decreased appetite is a symptom of many conditions, such as cancer,
COPD, esophageal problems, decline in acuity of taste buds, and others
and promptly needs to be evaluated.
Abdominal Pain and/or Distention
CLINICAL PICTURE
The patient may have:
■ Abdominal pain, tenderness, flank pain.
■ Nausea/vomiting/diarrhea.
■ Abdominal distention or rigidity.
■ High-pitched, hyperactive, hypoactive, or absent bowel sounds.
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101
IMMEDIATE INTERVENTIONS
■ Place patient in position of comfort.
■ If patient has a nasogastric tube (NGT) but is unattached to suction,
reconnect NGT to suction—note amount of immediate NGT drainage.
■ Assess vital signs (VS), including temperature.
FOCUSED ASSESSMENT
■
■
■
■
■
■
■
■
Ask patient to describe pain; use the PQRST guidelines in the Basics tab.
Assess recent bowel habits, recent laxative or enema use.
Inspect abdomen; auscultate bowel sounds.
Palpate abdomen for pulsations, tenderness, and rigidity. Assess from
area of least tenderness to area of most tenderness.
Assess hydration status and urine output (UO) by reviewing I&O record
for previous 2 days.
Check all recent laboratory values including WBC count.
Test emesis for occult blood.
Notify physician or NP of assessment findings. Document findings and
phone call.
STABILIZING AND MONITORING
■
■
■
■
■
Administer antiemetic and pain medication, if ordered.
Monitor VS as frequently as indicated.
Assess output from NGT (if placed).
Insert an IV and hang 0.9% NS (with order).
Clarify with physician or NP on alternative route for administration of
PO medications.
■ Obtain stool/emesis sample, and test for occult blood.
■ Monitor nutritional status.
BE PREPARED TO
■
■
■
■
■
■
Hang IVF.
Administer pain medication, antiemetics, antibiotics.
Insert an NGT, or set up suction.
Insert indwelling urinary catheter.
Order or obtain laboratory tests.
Facilitate diagnostic tests such as abdominal x-ray, CT, endoscopy,
ultrasound, and diagnostic imaging.
POSSIBLE ETIOLOGIES
■ Bowel obstruction, ileus, peritonitis, irritable bowel syndrome (IBS),
ascites, gastroenteritis, malignancy, liver disease, ulcers, appendicitis,
cholecystitis, pancreatitis.
GI
Copyright © 2008 by F. A. Davis.
GI
NGT Insertion
Indications
■ Aspirate blood or fluids and gas from stomach.
■ Control nausea and vomiting.
Procedure
1. Explain procedure to the patient.
2. Position patient upright in high Fowler’s position. Instruct patient to keep
chin-to-chest posture during insertion. This helps to prevent accidental
insertion into the trachea.
3. Measure tube from tip of the nose to the ear lobe, then down to xyphoid.
Mark this point on the tube with a piece of tape.
4. Lubricate tube by applying water-soluble lubricant to tube. Never use
petroleum-based jelly.
5. Insert tube through nostril until the previously marked point on the tube
is reached. Instruct patient to take small sips of water during insertion to
help facilitate passing of the tube. Withdraw tube immediately if patient
becomes cyanotic or develops breathing problems.
6. Secure tube to patient’s nose using tape. Be careful not to block the
nostril. Tape tube 12–18 inches below insertion line. Then pin tape to
patient’s gown, allowing slack for movement.
7. Confirm proper location of tube.
■ Checking the pH of aspirate is the preferred method for
checking placement.
■ Pull back on plunger of a 20-mL syringe to aspirate stomach contents.
Typically, gastric aspirates are cloudy and green, or tan, off-white,
bloody, or brown in some cases. Gastric aspirate can look like
respiratory secretions.
■ Dip litmus paper into gastric aspirate. A reading of 1–3 suggests
placement in the stomach.
■ An alternate, but less reliable, method, is to inject 20 mL of air into tube
while auscultating the abdomen. Hearing a loud gurgle of air suggest
placement in the stomach. If no bubbling is heard, remove tube, and
reattempt. Withdraw tube immediately if patient becomes cyanotic or
develops breathing problems.
■ An inability to speak also suggests intubation of trachea instead of
stomach.
8. Assemble suction canister, liner, and attachment for wall suction. If using
portable suction, have ready at bedside.
■ Attach a connector to the end of tube.
■ Attach the extension tubing that comes with the suction canister to the
connector.
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Copyright © 2008 by F. A. Davis.
103
■ Connect the other end of the tubing to suction canister where indicated.
■ Set suction as ordered.
Patient Care
■ Reassess placement of tube.
■ Assess amount and character of drainage.
■ Replace collection liner before it is full (full or nearly full liner prevents
thorough suction of GI material).
■ Flush tube with water after each feeding and after each medication.
■ Assess skin around nose for irritation and breakdown, and replace tape
as needed. Change at least every other day.
■ Gently wash around the nose with soap and water, and dry before
replacing tape.
■ Provide mouth care every 2 hours and PRN.
■ Mouthwash, water, toothettes: clean tongue, teeth, gums, cheeks, and
mucous membranes.
■ If patient is performing oral hygiene, remind him or her not to swallow
any water.
Removal
1. Explain procedure to patient. Don gloves.
2. Remove tape from nose and face. Offer patient some tissues as he or she
may gag slightly as the tube is withdrawn.
3. Clamp or plug tube (prevents fluid from entering lungs), and remove tube
in one gentle, swift motion.
4. Assess for signs of aspiration.
Constipation
CLINICAL PICTURE
The patient may have:
■ Complaints of constipation.
■ Infrequent stools accompanied by discomfort, bloating, flatulence.
IMMEDIATE INTERVENTIONS/FOCUSED ASSESSMENT
■ Assess abdomen for bowel sounds. Bowel sounds may be infrequent;
listen for a full minute before concluding that bowel sounds are absent.
If no bowel sounds are heard, do not administer laxatives or PRN
enemas; notify physician or nurse practitioner with findings.
■ Assess for abdominal distention and pain.
■ Ask about last bowel movement and recent dietary intake.
■ Check MAR for medications that can cause constipation; check MAR for
PRN orders for laxatives and daily stool softener order.
GI
Copyright © 2008 by F. A. Davis.
GI
■ If the patient has bowel sounds, is on a solid diet, and has a PRN order
for a laxative, check how soon the laxative is designed to work, and
administer it at the appropriate time (e.g., some magnesium-containing
laxatives work very quickly; some are designed to work over 8 hrs).
■ If there is an order for a small-volume enema that can be selfadministered or an oral laxative, ask the patient which he or she would
prefer. Explain how to use the enema if the patient chooses that option.
STABILIZING AND MONITORING
■ Assess effectiveness of laxative and return of usual bowel function.
■ Review diet and medications for possible changes that can prevent or
treat constipation.
■ Assess need for daily stool softener or bulk-forming laxative. Stimulant
laxatives should be used infrequently.
BE PREPARED TO
Check for impaction; administer saline enemas.
POSSIBLE ETIOLOGIES
Medications such as diuretics, loperamide, opioids, antidepressants, and
medications containing iron, calcium, or aluminum; insufficient intake of
dietary fiber; dehydration; hypothyroidism; hypokalemia; injury to the anal
sphincter; diminished or absent peristalsis related to surgery, cancer,
diverticula, irritable bowel syndrome, functional incapacity.
Diarrhea
CLINICAL PICTURE
The patient may have:
■ Frequent loose, watery, bowel movements.
■ Loose stools containing blood, pus, or mucus.
■ Abdominal pain, cramps, flatulence.
■ Nausea, vomiting, dehydration.
■ Fatigue, temperature elevation.
IMMEDIATE INTERVENTIONS
■
■
■
■
Assess VS and mental status.
Provide comfort measures and perineal care.
Obtain stool samples.
Assess for patent IV access.
104
Copyright © 2008 by F. A. Davis.
105
■ Notify physician or NP of symptoms.
■ Document patient status, phone call to physician or NP, and physician or
NP response.
FOCUSED ASSESSMENT
■ Assess hydration status (orthostasis, hypotension, and tachycardia; tissue
turgor, mucous membrane moisture, mentation, UO).
■ Assess recent GI history (onset, frequency and nature of stools, presence
or absence of blood and mucus, vomiting, cramps, and fever).
■ Assess recent antibiotic use, use of stool softeners and opiates (all
associated with increased risk of psuedomembranous colitis [PMC]
caused by Clostridium difficile).
■ Ask about recently eaten meals (raw eggs, contaminated food, raw
seafood) and travel history.
■ Assess recent blood chemistries (electrolyte levels).
STABILIZING AND MONITORING
■ Insert IV, and administer IVF (D5 1/2 NS with KCl) if dehydrated or unable
to tolerate oral fluids (with order).
■ Encourage fluids if able to tolerate.
■ Monitor I&O.
■ Administer appropriate antibiotic/anti-infective agent promptly and on
schedule.
■ Avoid use of antimotility drugs (diphenoxalate, loperamide) or opiates if
infectious diarrhea suspected.
■ Monitor for relief of symptoms or complications (toxic megacolon if PMC,
dehydration, electrolyte imbalance, skin breakdown).
■ Document patient’s status in medical record, and communicate to
physician or NP.
BE PREPARED TO
■ Insert IV access and administer IVF.
■ Obtain specimens.
■ Implement enteric precautions.
POSSIBLE ETIOLOGIES
■ Viral, bacterial, or parasitic gastroenteritis; food-borne diarrhea; ulcerative
colitis; Crohn’s disease; AIDS; pseudomembranous colitis; drug side effect;
inflammatory bowel disease.
GI
Copyright © 2008 by F. A. Davis.
GI
Feeding Tube Complications
CLINICAL PICTURE
The patient may have:
■ Occluded tube.
■ Tube displacement.
■ Extubation.
■ Stomal infection.
■ Stomal leak.
IMMEDIATE INTERVENTIONS
■ Assess site for leak.
■ Assess for signs and symptoms of infection (elevated temperature, pain,
redness, warmth, purulent discharge).
■ Assess for proper placement (is tube too far in tract, too far out, or
completely out?).
■ If tube is occluded, attempt to dislodge using method described in table
below.
■ Elevate HOB to minimize risk of aspiration.
■ For other complications or if attempt to dislodge tube is ineffective, notify
physician or NP.
■ Document patient status, phone call to physician or NP, and physician or
NP response.
FOCUSED ASSESSMENT
■ Assess for signs and symptoms of aspiration (temperature, RR, lung
sounds).
■ Assess LOC/mental status.
■ Assess hydration status.
STABILIZING AND MONITORING
■
■
■
■
■
See table below for guide to ongoing interventions.
Monitor nutritional status.
Provide stomal care.
Obtain nutrition consult if indicated.
Chart patient status, and convey to physician or NP.
BE PREPARED TO
■ Obtain replacement tube, and assist with bedside reinsertion.
■ Obtain portable chest x-ray for placement if nasoenteric tube is inserted.
■ Resume tube feedings.
POSSIBLE ETIOLOGIES
■ Varies according to complication; see following table.
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Feeding Tubes: Preventing and Managing Complications
Complication/Cause
Interventions
Leakage of gastric secretions:
Improper positioning of patient.
Tube migration.
Stomal erosion or widening.
■ Position patient upright for feeding.
■ Stabilize tube with gauze pads; adjust
crosspiece.
■ Keep skin around stoma clean and
dry; use protective ointments and
gauze.
Tube migration:
Internal balloon deflates
or external tube suture,
bumper, or disc falls out.
■ Reposition tube.
Extubation:
Internal balloon deflates or suture,
bumper, or disc falls out.
Stomal infection:
Leakage around tube.
Inadequate stomal care.
Allergic reaction to soap.
■ Tract can close within a few
hours. Feeding tubes must be
replaced within a few hours.
Gastroesophageal reflux/
large residuals:
Delayed gastric emptying.
■ Elevate patient’s head 30⬚–45⬚ during
feeding and for 1 hr after meal.
■ Check residuals before feeding. Hold
feeding if greater than 100 mL, and
call physician or NP.
■ Use gastric stimulant, if ordered, to
promote gastric emptying.
■ Consider continuous feeds or smaller,
more frequent boluses
■ Note length of tube outside of body,
using either the external marks on
the tube or a tape measure.
■ Document length in nursing record,
and measure each shift.
■ Check that disc, suture, or attachment
device is secure.
■ Correct cause of leakage.
■ Carefully clean and protect stoma per
facility protocol.
■ If stoma site is irritated, use plain
water or change type of soap used.
(Continued on the following page)
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Copyright © 2008 by F. A. Davis.
GI
Feeding Tubes: Preventing and Managing Complications (continued)
Complication/Cause
Interventions
Nausea, vomiting, cramps,
bloating:
Too rapid administration
of feeding, lactose intolerance,
fat malabsorption, contamination of food or feeding bag.
■ Change to a low-fat formula.
■ Administer feeding at room
temperature.
■ Reduce rate of administration.
■ Check residuals before bolus feeding
or every 4 hr for continuous feeding.
Hold feeding if greater than 125 mL;
call physician or NP.
■ Refrigerate open cans of formula, and
keep only as long as manufacturer
suggests.
■ Clean tops of formula cans before
opening.
■ Hang only 4-hr amount of formula at a
time.
■ Clean feeding sets well, and replace
per facility policy.
Diarrhea:
Too rapid increase in amount of
feeding, too rapid administration, feeding too cold,
lactose intolerance, tube
migration from stomach
to small intestine
■ Add fiber, or use a formula with fiber.
■ Reduce rate of administration.
■ Administer feeding at room
temperature.
■ Do not add medication to formula.
■ Retract tube to reposition against
stomach wall.
Feeding Tubes: Preventing and Managing Occlusions
Prevention
■ Flush with 30 mL of water every 4–6 hr and before and after
administering tube feedings, checking for residuals and administering
medications.
■ Use a feeding pump with an automatic water flush feature.
■ Dilute liquid medications with 20–30 mL of water.
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109
■ Obtain all medications in liquid form. If liquid form is not available, check
with pharmacist to see if medication can be crushed.
■ Administer each medication separately, and flush with 5–10 mL of water
between each medication.
■ Do not mix medications with feeding formula.
Management
■ Check the feeding tube for kinks.
■ Inject a small amount of air into tube.
■ Change patient’s position.
■ If no obvious kink is found, place flushing syringe (30 mL) into the tube
end, and gently pull back on the plunger to dislodge the occluding plug.
■ If tube still blocked, instill warm water into the tube. Gently depress, and
withdraw syringe plunger to remove obstruction. If unsuccessful, leave
instilled warm water in tube, clamp tube for 10–15 min, and try again.
■ Milk the tube with fingers from the insertion site out.
■ Do not instill meat tenderizer—can cause metabolic complications and
allergic reactions.
■ Commercial products that use thin plastic devices for clearing feeding
tubes or products that use a catheter and chemical declogging powder are
available; however, a physician or NP usually must perform the
procedure.
■ To prevent tube damage, do not use force to unclog, or use a syringe
smaller than 30 mL.
Hematemesis/Upper GI Bleed
CLINICAL PICTURE
The patient may have:
■ Bright red or dark coffee ground–appearing emesis.
■ Distended, rigid, and/or tender abdomen.
■ Nausea, black stools.
■ Tachycardia, hypotension.
■ Dizziness, weakness, SOB.
■ Anxiety.
IMMEDIATE INTERVENTIONS
■ To prevent aspiration of blood and subsequent respiratory compromise,
position patient to facilitate an open airway (upright or turned to one
side), particularly in patients who have inadequate gag reflexes or altered
LOC.
■ Provide emesis basin.
■ Assess BP, HR, RR, temperature.
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Copyright © 2008 by F. A. Davis.
GI
■ Differentiate that patient has vomited, not expectorated, blood.
■ Suction oropharynx if patient vomiting copious amounts of blood and
cannot clear vomitus/secretions.
■ Assess for patent IV.
■ Call physician or NP.
■ Document patient status, phone call to physician or NP, and physician
or NP response.
FOCUSED ASSESSMENT
■ Assess BP, HR, and RR. Check blood pressure supine and standing (if
feasible), and document difference.
■ Check oxygen saturation via pulse oximetry. Assess LOC.
■ Assess skin color and temperature, capillary refill.
■ Assess respiratory status and lung sounds.
■ Assess abdomen for distention, tenderness, guarding, peristalsis, and
rigidity.
■ Hematest emesis; assess amount and characteristics.
■ Assess for use of anticoagulants, NSAIDs, or steroids.
■ Check if patient has been previously typed and cross-matched and if any
blood products are available in the blood bank.
STABILIZING AND MONITORING
■ Insert a large-bore IV, and administer IVF per order.
■ Monitor VS frequently (every 5 min if unstable).
■ Place an NG tube (per level of practice and physician’s order). Connect
to low intermittent suction.
■ Monitor laboratory studies (CBC, electrolytes, BUN, PT/PTT/INR, ABGs;
type and cross-match).
■ Insert a urinary catheter, and monitor I&O.
■ Monitor serial Hgb/Hct.
■ Provide oral hygiene and other comfort measures after episodes of
vomiting.
■ Chart patient status, and convey to physician or NP.
BE PREPARED TO
■
■
■
■
■
■
■
Start an IV (two large-bore IVs if vomiting copious amounts of blood).
Assist with central line placement.
Give IVF or blood products.
Administer H2 blockers.
Set up gastric suction, and perform room temperature saline lavage.
Obtain ECG, laboratory and diagnositic studies (x-ray, endoscopy).
Prepare for ICU transfer if hemodynamically unstable.
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111
POSSIBLE ETIOLOGIES
■ Gastric ulcer, duodenal ulcer, gastric erosions, esophagitis, esophageal
varices, Mallory-Weiss syndrome, carcinoma, peptic ulcer, polyps,
salicylates, NSAIDs, corticosteroids, leukemia, uremia, blood dyscrasias,
hemorrhagic gastritis.
Lower GI Bleed/Melena
CLINICAL PICTURE
The patient may have:
■ Frankly bloody or melanotic stool or stool tests positive for occult blood.
■ Abdominal cramping.
■ Signs and symptoms of hypovolemic shock (acute bleed): hr ⬍110
beats/min, SBP ⬎100 mm Hg, orthostatic drop in systolic BP of ⬍16 mm,
oliguria, cold clammy extremities, mental status changes.
■ Anemia, fatigue, pallor, dizziness, chest pain (chronic bleed).
IMMEDIATE INTERVENTIONS
■
■
■
■
■
Assist patient to bed.
Administer supplemental oxygen.
Assess VS; check for orthostasis.
Notify physician or NP.
Document patient status, phone call to physician or NP, and physician
or NP response.
FOCUSED ASSESSMENT
■
■
■
■
■
Assess VS (HR, BP, RR, and temperature).
Assess LOC and orientation; assess oxygen saturation.
Assess skin color, moistness, and temperature; assess capillary refill.
Assess abdomen (distention, tenderness, pain, bowel sounds).
Obtain detailed GI history (history of tarry stools, use of NSAIDs,
associated symptoms).
■ Check recent CBC.
■ Check if patient has been previously typed and cross-matched and if any
blood products are available in blood bank.
■ Assess for patent IV access.
STABILIZING AND MONITORING
■
■
■
■
Monitor VS, hemodynamic status, and UO.
Insert large-bore IV access.
Record frequency and character of stools.
Chart patient status, and convey to physician or NP.
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Copyright © 2008 by F. A. Davis.
GI
BE PREPARED TO
■ Obtain or order laboratory tests including coagulation studies (platelet
count, PT, PTT, INR), electrolytes, BUN, creatinine, serial Hb and Hct; type
and cross-match.
■ Start an IV, and administer IVF or blood products.
■ Insert NGT, and check aspirate for blood; remove if negative.
■ Prepare patient for or assist with anoscopy or colonoscopy.
■ Insert a urinary catheter, and monitor UO.
POSSIBLE ETIOLOGIES
■ Diverticulitis, GI polyps, anal fissures, hemorrhoids, ulcerative colitis,
Crohn’s disease, ischemic colitis, upper GI bleed.
Nausea
CLINICAL PICTURE
The patient may have:
■ Sensation/urge to vomit.
■ Tachycardia, bradycardia.
■ Diaphoresis, skin pallor.
■ Decreased or high-pitched bowel sounds.
■ Abdominal pain.
IMMEDIATE INTERVENTIONS
■ Elevate HOB to high Fowler’s position; provide emesis basin.
■ Place weak, confused, or debilitated patient in a side-lying position to
reduce risk of aspiration.
■ Offer a cool compress to the forehead or nape of neck.
■ Keep NPO.
FOCUSED ASSESSMENT
■
■
■
■
Assess patient’s ability to protect airway.
Assess VS.
Assess for chest pain, SOB, headache, visual disturbances.
Assess onset of symptoms and associated events (e.g., eating,
medication, activity).
■ Assess hydration status (orthostatic hypotension, skin turgor, mucous
membranes, recent I&O).
■ Assess for patent IV access.
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113
STABILIZING AND MONITORING
■ Determine if nausea is an anticipated side effect of treatment (anesthesia,
chemotherapy).
■ Check MAR for as-needed antiemetic; administer if clinically indicated.
■ If nausea is not expected given the patient’s clinical problem, notify
physician or NP.
■ Clarify with physician or NP whether to withhold PO medication or give
by alternate route.
■ Monitor and record I&O.
■ Document patient status, phone call to physician or NP, and physician
or NP response.
BE PREPARED TO
■
■
■
■
■
■
Administer antinausea medication as ordered.
Start an IV, and give IVF for hydration.
Monitor serial electrolytes, nutritional status, and UO.
Facilitate diagnostic studies.
Insert NGT if bowel obstruction is present.
Call for an ECG if associated with chest pain; SOB; slow, fast, or
irregular HR.
POSSIBLE ETIOLOGIES
■ Gastroenteritis, appendicitis, bowel obstruction, other GI disorder,
vascular headache, head injury, meningitis, other neurological cause,
pregnancy, drug side effect, infection, pain, motion sickness, stress,
chemotherapy.
Vomiting
CLINICAL PICTURE
The patient may have:
■ Small or large amounts of emesis.
■ Tachycardia, bradycardia, diaphoresis, skin pallor.
■ Abdominal pain, decreased or high-pitched bowel sounds.
IMMEDIATE INTERVENTIONS
■ Elevate HOB to high Fowler’s position; provide emesis basin.
■ Place weak, confused, or debilitated patient in a side-lying position to
reduce risk of aspiration.
■ Offer a cool compress to the forehead or nape of neck.
■ Keep NPO.
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Copyright © 2008 by F. A. Davis.
GI
FOCUSED ASSESSMENT
■ Assess patient’s ability to protect airway.
■ Assess VS.
■ Assess for chest pain, SOB or other symptoms (headache, dizziness,
abdominal pain, diarrhea).
■ Assess onset of symptoms and associated events (e.g., eating,
medication, activity).
■ Inspect emesis for color, odor, amount, and contents.
■ Assess abdomen for distention and tenderness.
■ Note if vomiting is projectile.
■ Assess hydration status (orthostatic hypotension, tissue turgor, mucous
membranes, recent I&O).
■ Assess for patent IV access.
STABILIZING AND MONITORING
■ Determine if vomiting is an anticipated side effect of treatment
(anesthesia, chemotherapy).
■ Check MAR for as-needed antiemetic; administer if clinically indicated.
■ If vomiting is not expected given the patient’s clinical problem, notify
physician or NP.
■ Clarify with physician or NP whether to withhold PO medication or give
by alternate route.
■ Monitor and record I&O.
■ Administer IVF if ordered.
■ Monitor laboratory tests for electrolyte imbalances (from loss of fluid) or
metabolic alkalosis (from loss of gastric acid).
■ Document patient status, response to treatment, phone call to physician
or NP, and physician or NP response.
BE PREPARED TO
■
■
■
■
■
■
Start an IV, and give IVF for hydration.
Facilitate diagnostic studies.
Insert NGT if bowel obstructed or vomiting continues.
Administer antinausea medication as ordered.
Monitor serial electrolytes, nutritional status, and UO.
Call for an ECG if associated with chest pain; SOB; slow, fast, or irregular
heart rate.
POSSIBLE ETIOLOGIES
■ Gastroenteritis, appendicitis, bowel obstruction, other GI disorders,
vascular headache, head injury, meningitis, other neurological cause,
pregnancy, drug side effect, infection, pain, motion sickness, stress,
chemotherapy.
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115
A & P Snapshot
Tongue
Teeth
Parotid gland
Pharynx
Sublingual
gland
Esophagus
Submandibular
gland
Liver
Left lobe
Stomach (cut)
Spleen
Right lobe
Gall bladder
Bile duct
Duodenum
Pancreas
Transverse
colon (cut)
Descending
colon
Small intestine
Ascending
colon
Cecum
Rectum
Anal canal
Vermiform
appendix
Digestive system.
GI
Copyright © 2008 by F. A. Davis.
ENDO
Focused Endocrine Assessment
The endocrine system comprises hormone-secreting glands. These
hormones are instrumental in all aspects of homeostasis. The glands and
the hormones they secrete include:
■ Hypothalamus and pituitary: antidiuretic hormone (ADH), oxytocin,
growth hormone (GH), thyroid-stimulating hormone (TSH), adrenocorticotropic hormone (ACTH), follicle-stimulating hormone (FSH), luteinizing
hormone (LH), and prolactin (PRL)
■ Thyroid: thyroxine (T4), triiodothyronine (T3), and calcitonin
■ Parathyroids: parathyroid hormone (PH)
■ Adrenals: medulla: epinephrine and norepinephrine; cortex: glucocorticoids (cortisol), mineralocorticoids (aldosterone), and adrenal androgens
■ Endocrine pancreas: insulin; glucagon, somatostatin
■ Ovaries or testes: sex hormones
Physical assessment of the endocrine system is difficult in that the thyroid
gland is the only palpable gland, and signs and symptoms can be vague or
attributable to other causes. Diagnostic testing is the cornerstone of
endocrine assessment.
Some physical signs and symptoms that may be the result of endocrine
malfunction include:
■ Change in appearance of hair, nails, and skin
■ Increased or decreased energy, insomnia, fatigue
■ Heat or cold intolerance, hypothermia or fever
■ Tremors, tetany, muscle aches
■ Tachycardia, hypertension or hypotension
■ Kidney stones, pathological fractures, muscle weakness, memory loss
■ Polyuria, polydipsia, polyphagia (excessive eating and drinking, excessive
urination)
■ Anorexia, weight gain or loss, constipation, dehydration
■ Change in thought processes, agitation, confusion
Laboratory and diagnostic tests consist of radioimmunoassay of hormone
levels, blood glucose levels, and other tests, 24-hour urine studies, and
radiological scans.
Diabetic Ketoacidosis (DKA)
CLINICAL PICTURE
The patient may have:
■ Rapid onset excessive thirst, nearly constant urination.
■ Abdominal pain, N&V
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Copyright © 2008 by F. A. Davis.
117
■
■
■
■
Lethargy progressing to coma (in later stages).
Dehydration leading to hypotension and shock.
Blood glucose level of 250–800 mg/dL.
Abnormal ABGs indicating metabolic acidosis (pH ⬍7.3, bicarbonate
⬍15 mEq/L).
■ Multiple electrolyte abnormalities, including high potassium levels.
■ Hyperventilation (Kussmaul’s respirations), and fruity-smelling breath
(somewhat like nail polish remover).
IMMEDIATE INTERVENTIONS
■ Assess VS, LOC, and ability to protect airway.
■ Assess for patent IV access.
■ Notify physician or NP of elevated glucose; decreased LOC, if present;
and other findings.
■ Document findings, phone call to physician or NP, and the response.
■ Insert IV and hang IVF (NS, with order); administer medications (regular
insulin) as ordered.
■ Stay with patient.
FOCUSED ASSESSMENT
■
■
■
■
Assess electrolyte values, ketones, and osmolality.
Continue to assess LOC and VS—hypotension can be severe.
Assess ABG results.
Assess for other complications of diabetes (e.g., skin infections, peripheral
neuropathy, poor circulation to feet and toes).
STABILIZING AND MONITORING
■ Ongoing assessment of VS, LOC, and ability to protect airway.
■ Monitor blood glucose and electrolytes.
■ Monitor I&O.
BE PREPARED TO
■
■
■
■
Obtain blood work.
Hang IVF.
Administer IV insulin.
Transfer patient to ICU.
POSSIBLE ETIOLOGIES
■ An infection in an otherwise well-controlled diabetic patient; too little
insulin or failure to take any insulin; new onset of diabetes; underlying
medical illness.
ENDO
Copyright © 2008 by F. A. Davis.
ENDO
Hyperglycemia*
CLINICAL PICTURE
The patient may have:
■ Blood glucose level 180–300 mg/dL on routine fingerstick.
■ Usually there are few or no symptoms or signs other than blood glucose
level
■ Can have:
■ Flushed, dry skin; poor skin turgor, and dry mucous membranes.
■ Fruity breath odor (like acetone).
■ Blurred vision, generalized weakness, and dizziness.
■ N&V, cramping, increased urination.
IMMEDIATE INTERVENTIONS
■
■
■
■
Obtain a blood glucose level if not already done.
Check MAR for regular insulin sliding scale based on blood glucose level.
Administer appropriate dose of regular insulin, based on sliding scale.
If patient is symptomatic, if MAR does not contain a sliding scale, or if
blood glucose level exceeds parameters of sliding scale, notify physician
or NP.
FOCUSED ASSESSMENT
■ Assess HR, BP, RR; assess LOC if indicated.
■ Assess for signs of dehydration (dry mucous membranes, poor skin
turgor, and dry scaly skin).
■ Ask patient about recent health changes, usual level of glucose control,
and if there has been a recent change in diabetic management.
■ Assess if infusing IVF contains dextrose (if applicable).
STABILIZING AND MONITORING
■
■
■
■
■
Continue to assess LOC and orientation.
Reassess blood glusose level at appropriate intervals.
Discuss diabetic management with health-care team.
Consider nutrition consult.
Assess patient’s understanding of disease process and treatment; educate
as needed.
■ Chart patient status, and convey to physician or NP.
BE PREPARED TO
■ Administer insulin as ordered.
■ Obtain serial blood glucose levels.
■ Dipstick urine for ketones.
*This is a discussion of uncomplicated, moderately elevated blood glucose, not
diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic nonketotic coma (HHNC).
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119
POSSIBLE ETIOLOGIES
■ New-onset DM, infection, illness, stress, trauma, noncompliance with
insulin and diet regimen, certain medications such as cortisone.
Hyperosmolar Hyperglycemic Nonketotic Coma (HHNC)
CLINICAL PICTURE
The patient may have:
■ Hyperglycemia (⬎600 mg/dL)
■ Polyuria, excessive thirst, weight loss.
■ Dehydration—dry mucous membranes, dry skin.
■ Confusion, delirium, lethargy to coma.
■ Visual changes.
■ Hypotension, tachycardia.
IMMEDIATE INTERVENTIONS
■ Call physician or NP as soon as the serum glucose level is known or if the
patient’s LOC has changed. If patient’s LOC is declining from drowsiness to
stupor or coma (which can happen rather quickly), assess ability to protect
airway.
■ Check for a patent IV access; if none, gather needed supplies for IV
insertion. Take NS to keep the vein open (with order) until treatment-level
IV orders are written.
FOCUSED ASSESSMENT
■ Check ABGs as frequently as indicated, possibly every 15 min. Assess LOC
at the same time. Note shallow, rapid respirations.
■ Monitor BP; shock can develop quickly. Assess for orthostasis (drop in
systolic BP ⬎10 mm Hg when position changes from lying to standing
or lying to sitting upright if standing is not possible).
■ Assess HR apically or with ECG monitoring, if available. Note
dysrhythmias, tachycardia.
■ Check electrolytes for hypokalemia, ↑ BUN, ↑ serum osmolality (⬎350
mOsm/L).
■ Assess for focal neurological changes, including aphasia and hemiparesis,
which can resemble signs of stroke.
■ Assess for history of type 2 diabetes (HHNC occurs almost exclusively in
this group).
■ Assess for underlying illness, possibly infection, that triggered HHNC.
STABILIZING AND MONITORING
■ Continue all assessments as outlined above.
■ Hang IVF as ordered.
ENDO
Copyright © 2008 by F. A. Davis.
ENDO
■ Begin insulin drip, and monitor glucose levels.
■ Monitor serum chemistries, and replace electrolytes as ordered.
■ Assess for signs or symptoms of venous thrombosis (due to dehydration,
blood becomes hyperosmolic, meaning the blood is very thick. This
predisposes the patient to thrombosis.).
■ Assess coagulation studies for signs of disseminated intravascular
coagulation (DIC), a complication of HHNC.
■ Assess for other serious complications, such as adult respiratory distress
syndrome (ARDS) and multiorgan dysfunction syndrome (MODS).
BE PREPARED TO
■
■
■
■
■
■
■
Obtain ABGs.
Facilitate blood tests and other diagnostic tests.
Assist with intubation.
Assist with insertion of a central venous catheter.
Insert a nasogastric tube.
Transfer to ICU.
Teach patient about process of HHNC to avoid recurrence.
POSSIBLE ETIOLOGIES
■ Preceding or concomitant illness that triggers dehydration (pneumonia
and urinary tract infection are common triggers); stress response to
illness that raises glucose levels; drugs that raise glucose levels, inhibit
insulin, or cause dehydration.
Hypoglycemia
CLINICAL PICTURE
The patient may have:
■ Cool, pale, and diaphoretic skin.
■ Agitation, disorientation, slurred speech, blank stare.
■ Headache, palpitations/tachycardia, trembling, hunger.
■ ↓ LOC progressing to coma and/or seizures if not treated.
IMMEDIATE INTERVENTIONS
■ Obtain a blood glucose level by fingerstick.
■ Assess VS and LOC.
■ Give oral, rapidly absorbed carbohydrates (orange juice) if alert and no
risk of aspiration.
■ Notify physician or NP.
■ If patient has ↓ LOC, position patient to protect airway.
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Copyright © 2008 by F. A. Davis.
121
■ If patient has ↓ LOC, give 1 amp (25 g in 50 mL) of 50% dextrose IV push
(with order).
■ Document patient status, phone call to physician or NP, and physician or
NP response.
FOCUSED ASSESSMENT
■
■
■
■
■
Assess time the insulin or oral hypoglycemic agent was taken and amount.
Ascertain that dose/type of insulin/oral hypoglycemic given was accurate.
Assess if patient has eaten.
Assess other medications for potential to affect glucose control.
Assess response to oral or IV administration of glucose.
STABILIZING AND MONITORING
■ Repeat serum glucose test, and reevaluate patient as needed.
■ Once symptoms improve, provide more slowly absorbed carbohydrates
(e.g., milk, crackers).
■ Consult dietitian/nutrition support.
■ Monitor for hypokalemia.
■ Reassess insulin dosages with team.
■ Chart patient status, and convey to physician or NP.
BE PREPARED TO
■
■
■
■
■
Start a peripheral IV.
Administer glucagon or other medications if necessary.
Obtain serial blood glucose levels.
Assist with airway management and intubation if needed.
Manage seizure activity if needed.
POSSIBLE ETIOLOGIES
■ Diabetic patients: overdose of insulin or oral hypoglycemic agent,
increased activity, too little food intake, alcohol, drugs, emotional stress,
infections; nondiabetic patients: liver disease, excessive alcohol
consumption, drug reaction (beta-adrenergic blockers and sulfonylureas
are most common).
Myxedema Coma
CLINICAL PICTURE
The patient may have:
■ Low body temperature, cold intolerance.
■ Confusion, depression.
■ Hypoventilation.
■ Weakness.
■ Edema.
ENDO
Copyright © 2008 by F. A. Davis.
ENDO
IMMEDIATE INTERVENTIONS
■ Assess LOC, VS, and ability to protect airway.
■ Assess patent IV access.
■ Provide blankets (not a warming blanket—can cause vasodilation and
lower BP even further).
■ Call physician or NP; document phone call and response.
FOCUSED ASSESSMENT
■ Assess laboratory values—may have low sodium, low glucose, low
calcium, high CPK and high creatinine. Will have high T4 and low TSH.
■ Assess respiratory pattern and ABGs; may have ↓ pH, ↓ oxygen
saturation, with ↑ carbon dioxide (respiratory acidosis).
■ Assess for other signs and symptoms of hypothyroidism:
■ Altered mentation, such as apathy, confusion, psychosis, or coma.
■ Alopecia; coarse, sparse hair.
■ Dry, cool, skin.
■ Elevated diastolic BP in early stages; hypotension later.
■ Bradycardia.
■ Decreased GI motility, abdominal distention, myxedema megacolon
(late).
■ Low temperature.
■ Generalized facial swelling, ptosis, periorbital edema.
STABILIZING AND MONITORING
■ Continued assessment of cardiac and respiratory status.
■ Administer IV thyroid hormone replacement, cortisol, or electrolytes
as ordered.
■ Provide blankets.
BE PREPARED TO
■ Assist with obtaining laboratory studies, inserting and hanging IVF,
administering medications as appropriate to the unit.
■ Transfer patient to ICU.
POSSIBLE ETIOLOGIES
■ New infection in an otherwise well-controlled hypothyroid patient; medications such as diuretics, opioids, beta blockers, tranquilizers, and others
in a hypothyroid patient; GI bleed; stroke; surgery; trauma.
Thyroid Storm
CLINICAL PICTURE
The patient may have:
■ Tachycardia, palpitations, widened pulse pressure, atrial fibrillation.
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123
■
■
■
■
Anxiety, irritability, restlessness to unresponsiveness.
Elevated free thyroxin level (T4), low TSH.
SOB, chest pain.
Warm, flushed skin, high fever (105⬚–106⬚F).
IMMEDIATE INTERVENTIONS
■
■
■
■
Assess VS, cardiac rhythm, LOC, and ability to protect airway.
Check oxygen saturation by pulse oximetry.
Assess patent IV access.
Call physician or NP with findings. Document phone call and response.
FOCUSED ASSESSMENT
■
■
■
■
Continued assessment of cardiac, respiratory, and neurological status.
Assess for signs and symptoms of heart failure.
Assess electrolyte levels, if recent ones are available.
Assess for signs and symptoms consistent with hyperthyroidism:
■ Edematous legs and feet.
■ Intolerance to heat; increased sweating.
■ Labile mood, possible psychosis.
◆ Exophthalmia (bulging eyeballs).
◆ Weakness.
◆ Pretibial myxedema—itchy lesions on the legs and feet (not to
be confused with myxedema as seen in hypothyroidism).
STABILIZING AND MONITORING
■
■
■
■
Continue frequent assessments.
Insert IV if no access; hang IVF.
Administer electrolytes as ordered.
Administer medications as ordered, propylthiouracil (PTU) or methimazole
(MMI) to control T4 production, hydrocortisone, and propranolol to control
signs and symptoms.
■ Reduce fever with acetaminophen, cooling blanket, and/or tepid baths
if needed.
BE PREPARED TO
■ Assess glucose level; obtain other laboratory values.
■ Transfer patient to ICU.
POSSIBLE ETIOLOGIES
■ Lung infections, discontinuing hyperthyroid medications, excessive dose
of thyroid replacement medications, thyroid surgery in patients with
overactive thyroid gland.
ENDO
Copyright © 2008 by F. A. Davis.
ENDO
A & P Snapshot
PITUITARY (HYPOPHYSIS) GLAND
Anterior: GH, TSH, ACTH
FSH, LH, Prolactin
Posterior: ADH, Oxytocin
HYPOTHALAMUS
Releasing hormones
for anterior pituitary
PINEAL GLAND
Melatonin
THYROID GLAND
Thyroxine and T3
Calcitonin
PARATHYROID GLANDS
PTH
THYMUS GLAND
Immune hormones
ADRENAL (SUPRARENAL)
GLANDS
Cortex: Aldosterone
Cortisol
Sex hormones
Medulla: Epinephrine
Norepinephrine
PANCREAS
Insulin
Glucagon
OVARIES
Estrogen
Progesterone
Inhibin
TESTES
Testosterone
Inhibin
The endocrine system.
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125
Focused Assessment of Musculoskeletal System
■ Assess the musculoskeletal system on all patients with an orthopedic
problem or recent trauma, patients with arthritis or who have been on
bedrest, and patients with neurological (e.g., stroke) or neuromuscular
disease.
■ Clinicians usually assess the peripheral nervous system simultaneously.
Assessment includes evaluation of dressings and wound drainage
systems.
■ Assessment of musculoskeletal status includes:
■ Gait.
■ Joint mobility.
■ Neurovascular status (CMS: circulation, motion, sensation); an
assessment of circulatory compromise and/or nerve damage.
■ Pain.
■ Fall risk.
■ Gait
■ Assess patient’s ability to ambulate independently.
■ Assess need for assistive devices. If the patient uses an assistive
device, asses if he or she is using it safely.
■ Joint range of motion (ROM)
■ Ask patient to put shoulders, elbows, wrists and fingers, hips, knees,
and ankles through full range of joint motion as indicated. Neck and
back can be included if appropriate.
■ As a nursing assessment, joint ROM evaluation may be necessary only
with initial assessment. If the patient is receiving physical therapy to
increase that joint’s ROM, then the physical therapist will assess the
extent to which the joint can move.
■ If the patient is not able to move or participate, passively move the
joints to assess ROM.
■ Do not push a joint past its range, even if limited.
■ Do not push the joint if the patient has pain.
■ Neurovascular status (CMS: Circulation, Motion, Sensation)
■ Palpate peripheral pulse and check capillary refill.
■ Note skin color of extremity; compare with that of opposite extremity.
■ Have patient move hands and fingers, flex and extend feet. Focus on
the extremity of interest, but initially compare with the contralateral
arm, hand, leg, or foot.
■ Assess strength by having patient push or pull against resistance.
■ Ask about paresthesias (numbness and tingling, odd sensations);
lightly trace your finger over different surfaces of the at-risk area
MSKEL/
INTEG
Copyright © 2008 by F. A. Davis.
MSKEL/
INTEG
to assess sensation. Have the patient close his or her eyes while
you do this.
■ Ask about pain. (See Pain Assessment in Basics tab.)
Focused Assessment of Skin Integrity
■ Assess skin integrity each shift for patients at risk for skin breakdown and
patients with incisions, pressure ulcers, or wounds.
■ Assessment of skin integrity includes:
■ Skin condition.
■ Surgical or traumatic wounds.
■ Bandages, casts, wound dressings, and drainage systems.
■ Pressure points.
■ Pressure ulcers.
■ Skin condition
■ Note if skin is dry, moist, abraded, or fragile.
■ Assess for skin tears, which are common in older patients, and other
disruptions in skin integrity such as surgical incisions.
■ Surgical or traumatic wounds
■ If dressings are not to be removed, assess for bleeding or drainage on
dressings, intactness of dressings, and any tubes or drains exiting from
the periwound area.
■ When changing the dressing, assess for intactness of sutures or
staples, drainage, swelling, or signs of infection.
■ Assess for skin problems related to bandaging. For example,
tape covering a postoperative dressing can cause skin maceration and blistering. The tape is secured to the surface of the skin,
but as the skin stretches with swelling, the tape causes a shear
injury by pulling the skin. This sometimes occurs in the total hip
replacement dressing, especially in the older person who has
fragile skin.
■ Bandages, casts, wound dressings, and drainage systems
■ Assess for signs of skin breakdown or pressure points from casts.
Be extra vigilant if the patient is diabetic, as circulation to lower
extremities is decreased.
■ Casts and circular dressings can abrade skin and impair circulation.
Assess the tightness of these dressings, which can become irritating
and quite injurious.
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127
■ Pressure points
■ Assess pressure points; do not massage reddened areas.
■ Use position changes, pillows, and preventive mattresses to alleviate
pressure.
■ Pressure ulcers
■ Perform and document a thorough wound assessment and staging (see
pressure ulcer later in this tab).
■ Assess healing. Note that ulcers may progress to a later stage but do
not “regress” as they heal. The correct term, for example, is “healing
stage 3 ulcer,” with a description of signs of healing (granulation tissue,
decreased circumference).
Compartment Syndrome
■ Muscle groups are contained within a tough, inelastic tissue called fascia.
This envelope of tissue creates a compartment that contains muscles,
nerves, veins, and arteries.
■ After injury or surgery, swelling of the muscles in the fascial compartment
causes increased pressure because the fascia cannot expand with the
swelling. The increased pressure closes off capillaries, arterioles and,
eventually, arteries, causing ischemia that will progress to necrosis if not
treated.
■ Compartment syndrome is more common in the extremities, particularly
the anterior or posterior compartments of the lower leg, but is possible at
other sites of injury such as the abdomen. This discussion is focused on
the arm or leg.
CLINICAL PICTURE
■ The patient may have or complain of the “5 Ps.”
■ Severe Pain not relieved by opioid analgesics and unusual for the
injury. The pain worsens with stretching of the involved muscles. This
pain is the first symptom to appear. Once the other Ps are evident, the
process is well established, and tissue damage is probable.
■ Pallor—paleness of the involved extremity.
■ Pulselessness—loss of pulses or markedly diminished pulses of the
affected extremity.
■ Paresthesia—numbness and tingling.
■ Paralysis—loss of ability to move the extremity.
■ Diminished capillary refill time (⬎3 seconds).
MSKEL/
INTEG
Copyright © 2008 by F. A. Davis.
MSKEL/
INTEG
IMMEDIATE INTERVENTIONS
■ The extreme pain is the first warning sign. When pain is more severe than
expected, immediately consider compartment syndrome, and notify
physician or NP.
■ Although pain medication should not be delayed or withheld, do not
simply medicate and return later to see if the medication is working.
■ Stay with the patient, and perform a focused assessment.
■ Elevate the extremity to the level of the heart to prevent further swelling
and increase venous return.
■ Do not put ice bags on the extremity.
■ Document phone call to physician or NP and physician or NP response.
FOCUSED ASSESSMENT
■
■
■
■
Palpate pulses. Use a Doppler if not palpable.
Note skin color and if pallor is present.
Blanch the skin, and check capillary refill time.
Assess nerves in the affected extremity. Is there altered sensation or
impaired mobility?
STABILIZING AND MONITORING
■ Continue to monitor vascular status. Pain indicates ischemia, but if pallor
or pulselessness develops, tissue necrosis and permanent damage will
occur.
■ Remain with patient until the physician or NP arrives. Loss of pulses
and/or the extreme pain that accompanies compartment syndrome
constitutes a surgical emergency. The physician or NP must rapidly
determine the treatment plan and if immediate surgery is necessary.
BE PREPARED TO
■ Assist with pressure measurements of the affected compartment.
■ Get the patient ready for an emergency fasciotomy in the OR: draw blood,
start an IV, etc. Make sure the time of the patient’s last meal or fluids is
documented and easy to find.
POSSIBLE ETIOLOGIES
■ Severe muscle injury, burns, fractures.
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Copyright © 2008 by F. A. Davis.
129
Hip Fracture
CLINICAL PICTURE
The patient may have:
■ Groin, knee, or hip pain.
■ Inability to bear weight on affected extremity.
■ Shortened and externally rotated leg.
■ Inability to move affected leg.
IMMEDIATE INTERVENTIONS
■ Do not move leg; allow patient to maintain position of comfort.
■ Inspect and palpate for deformity, hematoma, laceration, and asymmetry.
■ Call 4–6 staff members to help transfer patient from stretcher to bed
or, if patient has fallen, to lift patient into bed.
■ Assess vital signs (VS); assess for patent IV access.
■ Call physician or NP.
FOCUSED ASSESSMENT
■ If patient has experienced trauma, perform a primary survey and
stabilize ABCs. Then perform a secondary survey to detect associated
injuries.
■ Assess VS, and observe for signs and symptoms of shock such as cool,
clammy skin; mental status changes; and decreased urine output (blood
loss from hip fracture can be as much as 1500 mL).
■ Assess VS, level of consciousness (LOC), and orientation.
■ Inspect affected leg for shortening and rotation as compared with the
opposite leg.
■ Do not assess ROM unless x-ray is negative.
■ Assess distal circulation, sensation, and ability to move toes.
ONGOING CARE AND ASSESSMENT
■ Administer pain medication (determine that there is no associated head
injury first).
■ Avoid PO medications because patient may need surgery.
■ Monitor patient’s response to pain management.
■ Insert a urinary catheter, and monitor urinary output.
MSKEL/
INTEG
Copyright © 2008 by F. A. Davis.
MSKEL/
INTEG
BE PREPARED TO
■ Start an IV.
■ Obtain laboratory work, x-rays, possible CT or MRI.
■ Assist with set-up and application of traction.
POSSIBLE ETIOLOGIES
■ Osteoporosis, trauma.
Necrotizing Fasciitis (NF)
A very rapidly progressing infection by Streptococcus pyogenes of the
deeper layers of skin and tissue, requiring immediate intervention. Very high
mortality rate.
CLINICAL PICTURE
The patient may have or be:
■ Minor skin disruption, no disruption at all, or major disruption (e.g.,
surgical incision).
■ Severe or worse than expected pain at site, which gets progressively
worse.
■ Cellulitis-like appearance of affected area, which is hot and painful to the
touch.
■ Swollen, purplish, blistered tissue with foul-smelling, watery discharge.
■ High fever with flu-like symptoms.
■ Dehydrated and hypotensive.
IMMEDIATE INTERVENTIONS
■ Take the patient’s vital signs.
■ Circle the affected area on the dressing, if present, or apply a dressing,
and circle the area so that rapid spreading can be ascertained.
■ Call physician or NP, describe the affected area and patient’s condition.
■ Document your findings, phone call to physician or NP, and physician or
NP response.
FOCUSED ASSESSMENT
■ Assess and document VS frequently, at least every half hour.
■ Assess area for rapid progression of swelling and erythema and
crepitance.
■ Assess for changes in skin such as a grayish color beneath the skin,
blackened areas (necrotic tissue), purple blisters, foul drainage.
■ Assess laboratory values; ↑ BUN and hematocrit level, and ↓ hemoglobin
are characteristic of dehydration; ↓ sodium, ↓ albumin, ↑ WBCs, and ↑
bilirubin level are common with NF.
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131
STABILIZING AND MONITORING
■ Obtain wound cultures immediately so that antibiotics (penicillin and
clindamycin) can be given.
■ Insert an IV, and hang ordered IV fluids.
■ Administer antibiotics immediately; delay in administration of the correct
antibiotics is associated with a higher mortality rate.
■ Facilitate assessment of laboratory values.
■ Administer pain medication.
■ Insitute contact isolation or precautions.
■ Change dressings as ordered.
BE PREPARED TO
■
■
■
■
Assist with bedside débridement, or get the patient ready for the OR.
Obtain x-rays or CT.
Start a heparin drip (to decrease risk of vasculitis and thrombosis).
Transfer the patient to ICU.
POSSIBLE ETIOLOGIES
■ Infection with Group A beta-hemolytic streptococcus alone or in combination with S aureus; infection with Clostridium, Peptococcus, E. coli,
Pseudomonas, S. pyogrenes, S. aureus, or S. marcescens.
Pathological Fracture
CLINICAL PICTURE
The patient may have:
■ Sudden pain in leg/hip/back/shoulder/arm while moving in bed,
transferring to wheelchair or stretcher, or ambulating. Audible crack may
be heard.
■ Abnormal or limited motion of extremity.
■ Back pain (with spinal compression fracture).
■ Unexplained ecchymosis, edema over bone or joint.
■ Obvious deformity of extremity.
IMMEDIATE INTERVENTIONS
■ Immobilize extremity in its position. Do not attempt to realign bone.
■ Notify physician or NP.
■ Document patient’s status, phone call to physician or NP, and physician or
NP response.
MSKEL/
INTEG
Copyright © 2008 by F. A. Davis.
MSKEL/
INTEG
FOCUSED ASSESSMENT
■ Assess VS.
■ Assess extremity for swelling or hematoma.
■ Assess sensation and mobility of fingers or toes distal to injury if
extremity fracture is suspected.
■ Assess mobility and sensation of arms and legs if spinal fracture
suspected.
■ Assess history of falls or fractures.
STABILIZING AND MONITORING
■ Medicate for pain as indicated. Monitor for signs of respiratory depression
or excessive sedation.
■ Assist with diagnostic procedures (x-ray or bone scan).
■ Prepare patient for surgery, if applicable.
■ Assist with casting or immobilization with splint or traction.
■ Monitor foot or hand of affected extremity for peripheral neurovascular
dysfunction.
■ Initiate rehabilitation consultation.
■ Initiate care to prevent complications of restricted mobility, such as foot
and ankle exercises to decrease risk of deep venous thrombosis, early
mobilization, and cough and deep-breathing exercises.
BE PREPARED TO
■
■
■
■
■
Initiate pressure ulcer prevention strategies.
Manage pain so that patient is comfortable but not sedated.
Protect patient from additional injury.
Obtain assistive devices for ambulation or self-care activities.
Initiate discharge planning and collaborate with home care nurse for
follow-up care and prevention.
POSSIBLE ETIOLOGIES
■ Osteoporosis, osteomalacia, primary bone tumors, metastatic bone
lesions, Paget’s disease.
Patient Fall
CLINICAL PICTURE
The patient may have or be:
■ Found on floor, unexplained abrasions, or reported falling.
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Copyright © 2008 by F. A. Davis.
133
IMMEDIATE INTERVENTIONS
■ Do not move patient if he or she is unconscious, complains of severe
pain, or has a deformity of an extremity (obvious fracture, internal
rotation of hip or knee).
■ If unconscious, get help, assess ABCs, immobilize cervical spine (with
light traction, hold head and neck in neutral alignment with body).
■ If conscious, have patient lie still while you call for help.
■ If the patient is alert with no obvious injuries, assist to bed or chair with
help from another staff member.
■ Notify physician or NP.
■ Document patient’s status, phone call to physician or NP, and physician or
NP response.
FOCUSED ASSESSMENT
■
■
■
■
■
■
■
■
■
■
■
Assess LOC and orientation.
Assess VS and pain level.
Assess ability to move all extremities.
Assess alignment and symmetry of extremities.
Assess soft tissue and skin for abrasions, swelling, deformity.
Assess for acute underlying condition, such as infection, transient
ischemic attack, urinary tract infection, hypotension, or cardiac
dysrhythmia.
Assess for orthostasis, problems with gait, changes in mental status, and
recent changes in functional status.
Review records for preexisting conditions, medication use, and previous
falls.
Assess medication administration record for polypharmacy or medication
that may have contributed to fall.
Ask if patient felt dizzy or lightheaded before falling.
Assess environment for potential cause of fall and safety hazards.
STABILIZING AND MONITORING
■ Treat minor injuries—clean and dress abrasions; apply ice to contusions
or areas of swelling.
■ Assess for injuries.
■ Monitor patient closely for changes in condition, especially changes in
mental status, which can suggest brain injury.
■ Assess distal circulation, sensory, and motor function of injured
extremities.
■ Assess history of falls.
MSKEL/
INTEG
Copyright © 2008 by F. A. Davis.
MSKEL/
INTEG
BE PREPARED TO
■
■
■
■
■
■
Assist with x-rays or other diagnostic test.
Modify environment to eliminate hazards.
Arrange for one-on-one care if patient is confused.
Administer oxygen.
Order laboratory tests.
Complete an incident report.
POSSIBLE ETIOLOGIES
■ Sedation, debilitation, unfamiliar surroundings, side rails left down, callbell malfunction or not left within easy reach, drug reaction, improper use
of restraints, dysrhythmias, altered LOC, altered proprioception, spill on
the floor.
Fall Risk Factor and Nursing Interventions
Risk Factor
Nursing Intervention
Polypharmacy
Review medications with physician or NP.
Eliminate medications if possible; reduce
dosages if possible. Limit number of PRN
medications. Assess drug interactions for
additive CNS effects
Specific medications: benzodiazepines, antipsychotics,
hypnotics, sedatives, antidepressants
Avoid medications known to cause adverse
events in older patients.
Deconditioning
Start physical therapy for strengthening
exercises, balance training.
Postural hypotension;
change in proprioception
Tell patient to get out of bed or up from a
chair slowly; avoid turning on heels quickly.
Uneven surfaces, poor
lighting
Tell patient to consciously look around and
evaluate the walking surface. Make sure to
be aware of where one surface changes to
another and the potential for thresholds in
doorways. Make sure path from bed to
bathroom is well lit and that objects the
patient can use for support (cane, walker)
are within reach
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Copyright © 2008 by F. A. Davis.
135
Pressure Ulcer
CLINICAL PICTURE
The patient may have:
■ Reddened, blistered, open skin over pressure point such as sacrum, coccyx,
scapula, trochanter, or heel.
■ History of immobility, decreased sensorium, incontinence.
IMMEDIATE INTERVENTIONS
■ Relieve the pressure by turning patient or supporting extremity with pillows.
■ Do NOT massage the area; massage can cause tissue damage under the skin.
■ Do NOT use doughnut-shaped or ring-shaped cushions or sock-like heel
booties; these items impede circulation.
■ Assess wound using Wound Assessment Guidelines and/or Pressure Ulcer
Stage chart in this tab.
■ Assess patient for other areas of pressure and skin breakdown.
■ Notify physician or NP.
■ Document patient status, characteristics of wound, phone call to physician or
NP, and physician or NP response.
FOCUSED ASSESSMENT
■ Assess temperature, VS.
■ Assess wound (size, depth, edges, undermining, type and amount of necrotic
tissue [color, consistency adherence, and amount], exudate type and amount,
color of skin surrounding wound, peripheral tissue edema, induration,
granulation tissue, infection). See Wound Assessment Guide in this tab.
■ Assess patient’s pain level.
■ Assess for pressure ulcer risk.
STABILIZING AND MONITORING
■ Perform dressing changes as ordered. (See Wound Care Products for Pressure
Ulcers in this tab.)
■ Turn and reposition patient at least every 2 hours.
■ Keep wound free of contamination from urine and stool.
■ Assess nutritional status; consult dietitian.
BE PREPARED TO
■ Clean, dress, pack the wound.
■ Obtain special wound care products.
■ Obtain specialized support surface for bed or wheelchair.
POSSIBLE ETIOLOGIES
■ Pressure or shearing forces, immobility.
MSKEL/
INTEG
Copyright © 2008 by F. A. Davis.
MSKEL/
INTEG
Pressure Ulcer Assessment and Intervention Guides
Braden Scale Risk Assessment
The Braden Scale assesses six domains or risk factors:
■ Activity—Amount of physical activity.
■ Nutrition—Usual food intake pattern.
■ Friction and Shear—Extent to which skin is subject to friction and shear
forces.
■ Mobility—Ability to change or control body position.
■ Sensory perception—Ability to respond meaningfully to pressure-related
discomfort.
■ Moisture—Extent to which skin is exposed to moisture.
The patient is assigned a score of 1–4 (1–3 for Friction and Shear), depending
on amount of impairment. The total possible score is 23. The lower the score,
the greater the risk.
There are other scales as well; find out which pressure risk assessment tool
is used in your facility.
Pressure Ulcer Prevention Strategies
■ Inspect skin daily, document findings.
■ Effectively manage urinary and fecal incontinence. Clean skin
promptly, using a mild, nonirritating, nondrying cleansing
solution. Avoid friction during cleansing.
■ Use topical moisture barriers and moisture absorbing pad for incontinent
patients.
■ Position patient to alleviate pressure and shearing forces.
■ Reposition patient every 2 hours when in bed and every hour when in
a chair.
■ Teach the patient to shift his or her weight every 15 minutes while in
a chair.
■ Use positioning devices and foam padding. Do not use doughnut-shaped
devices.
■ Avoid placing the patient on his or her trochanters or directly on a wound.
■ Maintain the lowest head elevation possible to prevent sacral pressure.
■ Use lifting devices such as draw sheets or a trapeze.
■ Prevent contractures.
■ Provide adequate nutrition and hydration.
■ Do not massage reddened areas over bony prominences.
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Copyright © 2008 by F. A. Davis.
137
Wound Assessment and Documentation Guide
■ Measure length, width, and depth using a centimeter ruler.
■ Assess characteristics of wound edges (i.e., attached, not attached,
fibrotic).
■ Assess for undermining: Insert a cotton-tipped applicator under the
wound edge; gently advance it until resistence is met. Using a felt-tipped
pen, mark the skin where applicator is felt. Continue around the wound.
■ Describe necrotic tissue type:
■ White/gray.
■ Nonadherent yellow slough.
■ Loosely adherent yellow slough.
■ Adherent, soft black eschar.
■ Firmly adherent, hard black.
■ Describe exudate type:
■ Bloody.
■ Serosanguineous.
■ Serous.
■ Purulent.
■ Foul purulent.
■ Describe exudate amount:
■ None—wound tissues dry.
■ Scant—wound tissues moist; no measurable exudates.
■ Small—wound tissues wet; drainage involved 25% of dressing.
■ Moderate—wound tissues saturated; drainage involved 25%–75% of
dressing.
■ Large—wound tissues bathed in fluid; drainage involves ⬎75% of
dressing.
■ Assess and describe skin color surrounding wound: Assess tissues
within 4 cm of wound edge. For light-skinned persons, note if skin is
reddened. For dark-skinned persons, note if skin is reddened or darker or
purplish around wound edges.
■ Assess wound edge for tissue edema: Note if edema is pitting or
nonpitting and if wound is crepitant (crackly noises when tissue is palpated).
Notify physician immediately if wound is crepitant: may indicate gas
gangrene.
■ Assess amount of induration: Induration is abnormal firmness of tissues
with margins. Assess by gently pinching the tissue distal to wound edge; if
indurated, you will be unable to pinch a fold of skin.
■ Assess for granulation tissue: Granulation tissue is present in the
healing wound. It is the regrowth of small blood vessels and connective
tissue. Healthy granulation tissue is bright, beefy red, shiny, and granular.
Poorly vascularized tissue supply appears pale pink, dull, or dusky red.
■ Stage the pressure ulcer: (see the following table).
MSKEL/
INTEG
Stage
Ulcer Characteristics
Interventions
I
Intact skin. Nonblanchable erythema of
intact skin. For patients with darker
skin: discoloration, edema, redness,
and warmth over a bony prominence.
No dressing. Prevent continued injury from
pressure or shearing forces. Monitor frequently.
II
Clean wound base. Partial-thickness
skin loss involving epidermis, dermis,
or both. Ulcer is superficial and looks
like an abrasion, blister, or shallow
crater.
Use a dressing that will keep ulcer bed
continuously moist. Keep surrounding intact
skin dry. Fill wound dead space with loosely
packed dressing material to absorb excess
drainage and maintain a moist environment.
III
Eschar and necrosis. Full-thickness skin
loss involving damage or necrosis of
subcutaneous tissue. May extend down
to fascia. The ulcer looks like a deep
crater with or without undermining of
adjacent tissue.
Same as stage II treatment plus débride eschar
and necrotic tissue. (Heel ulcers with dry eschar
and no edema, erythema, or drainage may not
need to be débrided.) Débridement may be
done surgically with enzymatic agents or
mechanically with wet-to-dry dressings, water
jets, or whirlpool. Do not use topical
antiseptics.
IV
Extensive tissue damage. Fullthickness skin loss. Extensive
destruction and necrosis or damage to
muscle, bone, or supporting structures.
Undermining and sinus tracts present.
Same as stages II and III plus remove all dead
tissue, explore undermined areas, and remove
the skin “roof.” Use clean, dry dressings for
8–24 hours after sharp débridement to control
bleeding, then resume moist dressings.
138
MSKEL/
INTEG
Copyright © 2008 by F. A. Davis.
Pressure Ulcer Stages and Treatment
Copyright © 2008 by F. A. Davis.
139
Product
Characteristics
Transparent
Films
■ Tegaderm
■ CarraFilm
■ OpSite
■ BIOCLUSIVE
■ Semipermeable
membrane.
■ Waterproof.
■ Permeable to oxygen and
water vapor.
■ Provide moist healing
environment and prevent
bacterial contamination.
Hydrogels
■ Hypergel
■ CarraSorb
■ Nu-gel
■ Curafil
■ Water- or glycerin-based
gels, impregnated gauzes,
or sheet dressings.
■ Provides moist wound
environment. Helps clean
and débride by supplying
liquid to dry, sloughy
wounds.
■ Occlusive and adhesive
wafer dressings, or
hydrocolloid powders and
pastes.
■ Facilitate rehydration and
autolytic débridement of
dry, sloughy, or necrotic
wounds.
Hydrocolloid
dressings
■ Tegasorb
■ Comfeel
■ DuoDERM
■ Restore
Indications
Nursing Considerations
■ Stage I and II wounds. ■ Transparency allows visual
inspection of wound.
■ Work best on
■ Can be a secondary dressuperficial wounds,
sing over alginates or gels.
blisters, and skin tears.
■ Dressing change up to three
times per week. Do not
absorb exudates; change
when fluid collects
underneath.
■ Reduce pain and promote
■ Stage II, III, and IV
soothing effect. Easy to
wounds.
apply and remove.
■ Require secondary dressing.
■ Do not absorb large
amounts of exudate due to
large water content.
■ Change once daily.
■ Stage II and III wounds. ■ Conformable for easy
application; help reduce
■ Granulating and
pain at wound site.
epithelizing wounds
■ Breakdown of product may
with low to moderate
produce residue and foul
amounts of exudate.
odor; do not confuse with
infectious process.
■ Changed up to three times/
week.
(Continued on the following page)
MSKEL/
INTEG
Wound Care Products for Pressure Ulcers
Product
Alginates
■ CURASORB
■ AlgiDERM
■ Sorbsan
■ Algosteril
Copyright © 2008 by F. A. Davis.
Foam dressings
■ Flexzan
■ CURAFOAM
■ Mepilex
Enzymatic
débriding
agents
■ Panafil
■ Santyl
■ Accuzyme
Characteristics
Indications
■ Soft nonwoven fibers
■ Stage III and IV
derived from seaweed.
wounds with
■ Available in pads, ropes,
moderate to heavy
or ribbons.
exudate, but not
■ Can absorb up to 20
wounds with eschar
times their weight.
or dry wound beds.
■ Highly absorbent
■ Stage III and IV
dressings made from
wounds.
hydrophilic
■ Heavily exudating
polyurethane foam.
wounds, especially
■ Some have adhesive
during inflammatory
borders.
phase following
débridement and
desloughing.
■ Deep cavity wounds
and weeping ulcers
such as venous stasis
ulcers.
■ Agents selective in
■ Stage III and IV
removing necrotic
wounds.
tissues from wound
■ Tunneling wounds
bed.
(may remove debris
in areas that cannot
be visualized).
Nursing Considerations
■ Highly absorbent, therefore
good for packing exudating
wounds.
■ Require secondary dressing.
■ Usually changed once daily.
■ Highly absorbent foam may
allow less frequent dressing
changes.
■ Can be left undisturbed for
3–4 days.
■ Decrease maceration of
surrounding tissue.
Comfortable and
conformable.
■ Usually changed up to three
times/week.
■ Surgical débridement may
be avoided in some cases
with use of enzymatic
débriding agents.
■ Require prescription.
140
MSKEL/
INTEG
Wound Care Products for Pressure Ulcers (continued)
Copyright © 2008 by F. A. Davis.
141
Surgical Site Infection/Complication
CLINICAL PICTURE
The patient may have:
■ Warm, reddened, tender, swollen, painful wound.
■ Low-grade fever.
■ Separation of wound edges with serous-sanguineous or purulent drainage
from wound.
■ Purulent discharge from wound drain.
■ Feeling of wound tearing or opening.
■ Exposure or protrusion of abdominal contents through open wound.
IMMEDIATE INTERVENTIONS
■ Examine wound for evisceration—total separation of deep wound layers
(fascia and muscle) with protrusion of internal organs and viscera;
dehiscence—partial or complete separation of deep wound layers; or
superficial wound separation—separation of skin and subcutaneous
tissue.
■ Abdominal wound: If there is evidence of dehiscence or evisceration, place
the patient in semi-Fowler’s position, with knees bent to decrease tension on
abdominal wall. Saturate a sterile dressing with normal saline, and cover the
open wound. Place a large sterile dressing over top. Do not manipulate
viscera or attempt to replace. Keep patient NPO and NOTIFY PHYSICIAN OR
NP STAT. Stay with patient and offer support and reassurance.
■ For dehiscence of wounds elsewhere on the body, position patient to
alleviate tension on suture line, then saturate a sterile dressing with normal
saline, and cover the open wound. Place a large sterile dressing over top.
Notify physician or NP immediately.
■ For superficial wound separation, cover wound with a sterile normal saline
wet-to-dry dressing. Notify physician or NP.
■ If evidence of infection, obtain wound culture.
■ Assess for patent IV access.
■ Assess pain level, and medicate per order.
■ Document patient’s status, phone call to physician or NP, and physician or NP
response.
FOCUSED ASSESSMENT
■ Assess temperature, VS.
■ Assess wound: determine or describe size, depth, edges, undermining, type
and amount of necrotic tissue (color, consistency adherence, and amount),
exudate type and amount, color of skin surrounding wound, peripheral tissue
edema, induration, granulation tissue, infection. (See Wound Assessment
Guide in this tab).
■ Assess patient’s pain level.
MSKEL/
INTEG
Copyright © 2008 by F. A. Davis.
MSKEL/
INTEG
STABILIZING AND MONITORING
■
■
■
■
Perform dressing changes as ordered.
Administer antibiotics.
Assess nutritional status; consult dietitian.
Document assessment findings.
BE PREPARED TO
■ Prepare the patient for surgery.
■ Clean, dress, pack the wound.
■ Start an IV.
POSSIBLE ETIOLOGIES
■ Infection, excessive tension on suture line (vomiting or coughing),
dehydration, long surgery time, hematoma, abdominal distention, obesity,
poor nutritional status, diabetes, insufficient suturing, stretching or pulling
at suture site (trauma), higher risk in geriatric patients.
Wound Vacuums
Vacuum-assisted closure (VAC) units are negative pressure devices that help
promote wound healing by removing exudate and other fluids with
continuous and/or intermittent subatmospheric pressure; in other words, by
suction. The suction, in conjunction with the system, also helps pull the
wound edges together, stimulates granulation tissue, and improves blood
flow to the wound bed.
Setting up the wound VAC:
■ Wash your hands, don gloves, and clean the wound using aseptic
technique.
■ Apply skin preparation to peri-wound area to help secure the dressing.
■ Cut foam to fit wound, and place in the wound; do not push it in, just
place it on the wound.
■ Apply Tegaderm-like plastic sheet over foam and onto healthy skin; put it
on in patches, if necessary.
■ Cut a small hole in the plastic sheet over the foam. This is essential for
suction to reach wound bed.
■ Apply suction disc over the hole in the plastic dressing.
■ Connect suction tubing, remove kinks, and set suction as ordered.
■ Remove gloves, discard old dressing properly, wash hands.
142
Copyright © 2008 by F. A. Davis.
143
Dressing before suction is turned on.
Dressing appearance after suction is applied.
MSKEL/
INTEG
Copyright © 2008 by F. A. Davis.
MSKEL/
INTEG
A & P Snapshot
Skull (cranium)
Zygomatic arch
Cervical vertebrae
Maxilla
Thoracic vertebrae
Mandible
Clavicle
Scapula
Sternum
Humerus
Ribs
Lumbar
vertebrae
Radius
Ulna
Ilium
Sacrum
Carpals
Metacarpals
Coccyx
Phalanges
Pubis
Ischium
Femur
Patella
Tibia
Fibula
Tarsals
Metatarsals
Phalanges
Skeletal system.
144
Copyright © 2008 by F. A. Davis.
145
Receptor
for touch
(encapsulated)
Pore
Epidermis
Papillary
layer with
capillaries
Dermis
Pilomotor
muscle
Sebaceous
gland
Hair
follicle
Receptor
for pressure
(encapsulated)
Nerve
Arteriole
Venule
Stratum
germinativum
Stratum
corneum
Fascia of
muscle
Adipose
tissue Subcutaneous
Eccrine
tissue
sweat gland
Free nerve ending
Skin structure.
MSKEL/
INTEG
Copyright © 2008 by F. A. Davis.
INFECT
Standard Precautions
Use standard precautions for the care of all patients. Add contact, droplet,
or airborne precautions, depending on the mode of transmission.
Handwashing:
■ Wash hands.
■ After touching blood, body fluids, secretions, excretions, and
contaminated items.
■ Immediately after gloves are removed.
■ Between patient contacts.
■ To avoid transfer of microorganisms to other patients or environments.
■ Between tasks and procedures on the same patient to prevent cross
contamination of different body sites.
Gloves:
■ Wear clean, nonsterile gloves:
■ When touching blood, body fluids, secretions, excretions, and
contaminated items.
■ Before touching mucous membranes and nonintact skin.
■ Change gloves between procedures on the same patient after contact
with contaminated material.
■ Remove gloves promptly after use and before touching noncontaminated
items and environmental surfaces. Wash hands immediately.
Mask, Eye Protection, Face Shield:
■ Wear mask and eye protection or face shield when patient-care activities
are likely to generate splashes or sprays of blood, body fluids, secretions,
or excretions.
Gown:
■ Wear a clean, nonsterile gown when patient-care activities are likely
to generate splashes or sprays of blood, body fluids, secretions, or
excretions.
Patient-Care Equipment:
■ Prevent skin, mucous membrane, and clothing exposure to contaminated
equipment.
■ Do not use reusable equipment for another patient until cleaned
appropriately.
■ Discard single-use items properly.
Linen:
■ Prevent skin, mucous membrane, and clothing exposure to contaminated
linen.
146
Copyright © 2008 by F. A. Davis.
147
Preventing Needle and Sharps Injuries
Never recap used needles or manipulate them using both hands.
■ Do not direct needle point toward self.
■ Use one-handed “scoop” technique.
■ Do not remove used needles from disposable syringes by hand; do not
bend, break, or manipulate used needles by hand.
■ Place used disposable syringes and needles, scalpel blades, and other
sharp items in appropriate puncture-resistant containers.
Airborne Precautions
For patients who are or may be infected with microorganisms transmitted
by airborne droplet nuclei.
■ Private room with:
■ Monitored negative air pressure in relation to the surrounding
area.
■ 6 to 12 air changes per hour.
■ Monitored high-efficiency filtration of room air.
■ Door closed.
■ Keep patient in room.
Droplet Precautions
For patients who are or may be infected with microorganisms transmitted
by large-particle droplets that occur with coughing, sneezing, talking.
■ Private room or in room with patient who has active infection with same
microorganism but no other infection.
■ If private room not possible, maintain at least 3 ft of space between
infected patient and other patients and visitors.
■ Door may be open.
■ Wear a mask when working within 3 ft of patient.
■ Place mask on patient when leaving the room, if possible.
INFECT
Copyright © 2008 by F. A. Davis.
INFECT
Contact Precautions
For patients who are or may be infected or colonized with microorganisms
transmitted by direct contact with the patient or indirect contact with
environmental surfaces or patient-care items.
■ Private room or in room with patient who has active infection with same
microorganism but with no other infection.
■ Wear clean, nonsterile gloves when entering the room.
■ Remove gloves before leaving patient room, and immediately wash hands
with antimicrobial or waterless antiseptic agent.
■ Do not touch potentially contaminated surfaces once gloves are removed
and hands washed.
■ Wear clean, nonsterile gown when entering room if clothing will have
contact with patient, surfaces, or items in the room or if patient is
incontinent, has diarrhea, an ileostomy, a colostomy, or wound drainage
not contained by a dressing.
■ Remove the gown before leaving room.
Clostridium-Associated Diarrhea
(CDAD, Psuedomembranous Colitis)
CLINICAL PICTURE
The patient may have:
■ Frequent, watery diarrhea, possibly with blood.
■ Fever.
■ Loss of appetite, nausea.
■ Abdominal cramping, pain, and tenderness.
IMMEDIATE INTERVENTIONS
■ Assess hydration status, electrolyte balance, and recent I&O records
(to assess hydration).
■ Note trends in recent VS assessment; reassess as needed.
■ Assess for recent antibiotic use; if patient is still on antibiotics, withhold until you speak with the physician or NP. Clostridium difficile
infection is usually caused by antibiotic-induced derangement of
normal intestinal flora, and discontinuation of the antibiotic is part
of the treatment.
■ Call physician or NP about the character and frequency of the stool.
■ Document findings, phone call, and physician or NP response.
■ Move patient to a private room, and initiate contact precautions.
■ Obtain stool sample for laboratory testing.
148
Copyright © 2008 by F. A. Davis.
149
FOCUSED ASSESSMENT
■ Assess for IV access as rehydration may be necessary.
■ Assess stool for blood or pus, which can occur with severe infection.
■ Auscultate bowel sounds, and palpate abdomen for tenderness.
STABILIZING AND MONITORING
■ Make sure all visitors wear gloves when touching the patient, and
wash their hands with soap and water each time before they leave
the room.
■ Administer oral metronidazole or Vancomycin as ordered.
■ Collect stools for testing as ordered—usually three stools from three
separate bowel movements on consecutive days.
■ Provide incontinence care, if needed, and monitor perianal skin for
breakdown.
■ Monitor hydration status and food intake
■ Monitor electrolytes, albumin, WBC count.
■ Assess for complications of severe infection including anasarca,
dehydration, toxic megacolon, and colonic perforation.
BE PREPARED TO
■ Transfer patient to high-acuity unit if infection is severe with
complications.
■ Insert an IV, and hang IV fluids.
POSSIBLE ETIOLOGIES
■ C. difficile, which produces two toxins that cause tissue damage;
inflammation of colonic tissues.
Fever
CLINICAL PICTURE
The patient may have:
■ Temperature elevation (low-grade fever: T ⬍101⬚F; high-grade ⬎101⬚F).
■ Fatigue, weakness.
■ Flushed, dry skin.
IMMEDIATE INTERVENTIONS
■ Assess VS.
■ Offer cool compress for forehead.
INFECT
Copyright © 2008 by F. A. Davis.
INFECT
FOCUSED ASSESSMENT
■ Auscultate lungs for diminshed breath sounds, crackles, rhonchi.
■ Assess for stiff neck, headache, photophobia, irritability, confusion.
■ Assess IV sites, surgical incisions for redness, warmth, tenderness,
swelling.
■ Assess legs for swelling, warmth, pain (do not massage calves).
■ Assess for urinary symptoms.
■ Assess for GI symptoms.
■ Evaluate medications for possible drug fever; note any rashes.
■ Assess mucous membranes, I&O.
■ Ask about prosthetic implants (heart valve, artificial joint).
■ Check recent laboratory test for ↑WBC count.
■ Notify physician or NP.
■ Document patient’s status, phone call to physician or NP, and physician or
NP response.
STABILIZING AND MONITORING
■ Encourage patient to cough, breathe deeply, and use incentive spirometer.
■ Encourage fluids (unless contraindicated by renal or cardiac disease).
■ Check medication administration record for order for PRN antipyretic.
Administer if patient feels uncomfortable.
■ Obtain cooling blanket, or give tepid bath, if ordered.
BE PREPARED TO
■ Obtain sputum, blood, or urine sample for Gram stain, culture, and
sensitivity.
■ Obtain or change IV access.
■ Order a chest x-ray.
■ Order or obtain laboratory tests.
POSSIBLE ETIOLOGIES
■ Numerous potential causes include bacterial, viral, or fungal infection;
deep venous thrombosis; medications; tumor; neutropenia.
Fever With SIRS/Sepsis
Terms:
■ Infection: Inflammatory response to microorganisms, or the invasion
of normally sterile host tissue by those organisms.
150
Copyright © 2008 by F. A. Davis.
151
■ Systemic Inflammatory Response Syndrome (SIRS): Systemic
inflammatory response to severe clinical insults, including infection,
pancreatitis, trauma, and burns. This response is manifested by two
or more of the following conditions:
■ Core temperature ⬎38⬚C (100.4⬚F) or ⬍36⬚C (96.8⬚F).
■ HR ⬎90 beats/min.
■ RR ⬎20 breaths/min or PaCO2 ⬍32 mm Hg.
■ WBC count ⬎12,000/mm3, ⬍4000/mm3, or the presence of ⬎10%
immature neutrophils.
■ Sepsis: A systemic inflammatory response to infection that initiates a
cascade of biochemical events resulting in hypotension, coagulopathy,
suppression of fibrinolysis, and multisystem organ dysfunction. Sepsis is
diagnosed when there is a documented infection with at least two of the
four systemic inflammatory response criteria.
■ Severe sepsis: Sepsis with dysfunction of one or more organ systems,
hypoperfusion, or hypotension.
■ Septic shock: Sepsis with hypotension (systolic BP ⬍90 mm Hg or a
reduction of 40 mm Hg from baseline) despite adequate fluid resuscitation
and with perfusion abnormalities that include lactic acidosis, oliguria, or
change in mental status.
■ Multiple organ dysfunction syndrome: Altered organ function in an
acutely ill patient such that homeostasis cannot be maintained without
intervention.
CLINICAL PICTURE
The patient may have:
■ Temperature ⬎38⬚C (100.4⬚F) or ⬍36⬚C (96.8⬚F).
■ Chills, sweating.
■ Tachypnea, respiratory alkalosis.
■ Tachycardia.
■ Elevated or depressed WBC count.
■ Change in mental status.
■ Abdominal or flank pain.
■ Rash; warm, dry, flushed skin.
Progressive Indications:
■ Restlessness, confusion, altered LOC.
■ Hypotension, widening pulse pressure.
■ Oliguria.
■ Rapid thready pulse, delayed capillary refill.
■ Decreased urinary output.
INFECT
Copyright © 2008 by F. A. Davis.
INFECT
■ Hypoactive bowel sounds.
■ Rapid shallow breathing.
■ Cold, clammy, mottled skin.
IMMEDIATE INTERVENTIONS
■
■
■
■
■
■
■
■
■
Assess HR, BP, RR, and temperature (rectally).
Administer supplemental oxygen.
Assess for patent IV access.
Obtain SaO2 via pulse oximetry.
Review recent WBC count if available.
Notify physician or NP.
Obtain large-bore IV access if needed.
Obtain IV fluids (NS) for administration.
Document patient’s status, phone call to physician or NP, and physician
or NP response.
FOCUSED ASSESSMENT
■
■
■
■
■
Assess airway status, LOC, and VS (HR, RR, BP) frequently.
Assess SaO2 via pulse oximetry.
Assess VS and capillary refill.
Assess onset, recent history of fever.
Assess for possible source of infection.
STABILIZING AND MONITORING
■ Obtain and administer prescribed antibiotic STAT.
■ Administer isotonic IV fluids to correct hypovolemia (due to vasodilation
and capillary leak) and restore blood pressure and tissue perfusion.
■ Monitor for signs of volume overload: dyspnea, pulmonary crackles,
jugular vein distention.
■ Monitor mental status, HR, BP, capillary refill, and urinary output.
■ Monitor coagulation studies, BUN, and creatinine.
BE PREPARED TO
■
■
■
■
■
■
■
Obtain urine, blood, wound, and sputum samples for culture.
Assist with line placement.
Assist with central line placement.
Order or obtain laboratory tests.
Facilitate diagnostic testing such as x-rays or CT scan.
Insert indwelling urinary catheter.
Administer vasoactive drugs to treat hypotension.
152
Copyright © 2008 by F. A. Davis.
153
■ Assist with intubation and airway management.
■ Call a code.
■ Transfer patient to ICU or monitored unit.
POSSIBLE ETIOLOGIES
■ Head and neck infections; chest and pulmonary infections; GI infections;
pelvic/genitourinary infections; bone, soft-tissue, and skin infections.
Hepatitis
Inflammation of liver cells that results in necrosis and obstruction of bile.
There are many forms of hepatitis, including viral, bacterial, alcoholic, and
drug-induced hepatitis.
The various forms of viral hepatitis are named with a letter of the alphabet,
using A through G.
CLINICAL PICTURE
The patient may have:
■ Fever, loss of appetite, nausea, and vomiting
■ Fatigue, headache.
■ Tea-colored urine, clay-colored stools, jaundice.
■ Right upper quadrant abdominal pain.
IMMEDIATE INTERVENTIONS/FOCUSED ASSESSMENT
■
■
■
■
■
Assess laboratory values for positive hepatitis test.
Institute contact precautions if needed (see following table).
Assess pain, activity tolerance, appetite.
Assess for jaundice.
Observe urine for characteristic tea color and stools for the absence
of bile, which renders them clay-colored.
■ Document findings.
STABILIZING AND MONITORING
■ Continue ongoing assessment.
■ Implement energy-conserving routines for self-care.
■ Teach patient about self-care during recovery and how to prevent transmission to others.
POSSIBLE ETIOLOGIES
■ Viral infection.
INFECT
Copyright © 2008 by F. A. Davis.
INFECT
Precautions for Major Types of Viral Hepatitis
Type
Route of
Transmission
HAV
Fecal-oral route;
exposure to
contaminated
food or water
HBV
Parenteral: bloodto-blood contact
HCV
Parenteral:
blood-to-blood
contact
HDV
Parenteral: bloodto-blood contact
Fecal-oral: possible person-toperson contact
HEV
Precautions
Standard precautions plus contact precautions.
Found in feces; spread under poor sanitary
conditions and poor personal hygiene. Can
also be transmitted through oral and anal
sexual activity, drinking contaminated water,
eating raw shellfish taken from contaminated water, or eating fruits and vegetables
contaminated during handling.
Standard precautions.
Spread by blood-to blood contact via
punctures of the skin with bloodcontaminated needles or scalpels, blood
splashes to open skin or mucous
membranes, or indirectly when dried blood
on a surface or instrument gets transferred
to open skin or mucous membranes.
Saliva can contain very low concentrations of
hepatitis B virus, thus disease can be spread
by a bite. Spread by sharing needles and
through unprotected sexual contact.
Feces, nasal secretions, sputum, sweat, tears,
urine, and emesis do not spread hepatitis B
unless visibly contaminated with blood.
Not transmitted by casual contact.
Standard precautions.
Spread by blood-to-blood contact or exposure
of contaminated blood to open skin or
mucous membranes.
People may get hepatitis C by sharing needles
to inject drugs or through exposure to blood
in the workplace. Can be sexually transmitted. Not spread by casual contact or
through food or water.
Standard precautions.
See Hepatitis B.
Standard precautions plus contact precautions.
See Hepatitis A.
154
Copyright © 2008 by F. A. Davis.
155
Meningitis
Inflammation of the meninges, which cover the brain and spinal cord. May
be septic meningitis, which is caused by bacteria, or aseptic, which is viral or
secondary to a lymphoma, leukemia, or a brain abscess. Bacterial meningitis
is much more severe than viral meningitis and will be fatal if not treated
promptly.
CLINICAL PICTURE
The patient may have:
■ Fever, headache, nausea and vomiting.
■ Confusion, delirium, seizure.
■ Neck stiffness, lethargy, rash.
■ Photophobia, sore throat, weakness.
IMMEDIATE INTERVENTIONS
■ Assess VS, LOC, SaO2.
■ Start antibiotics immediately.
■ Institute droplet precautions for meningococcal meningitis; maintain until
48 hours after antibiotics are started.
■ Discuss diagnosis with physician or NP for information about causative
organism.
■ Document findings.
FOCUSED ASSESSMENT
■ Assess cranial nerves for possible complication (hearing loss, visual impairment, nerve palsy). See cranial nerve assessment in Neurological tab.
■ Assess for Brudzinski’s sign (hip and knee flexion in response to forced
flexion of the neck).
■ Assess for Kernig’s sign (inability to completely extend the legs).
■ Initiate seizure precautions.
STABILIZING AND MONITORING
■ Record I&O, and observe patient for signs of dehydration.
■ Administer IV fluids and medications, as ordered by the physician.
■ Monitor patient’s vital signs and neurological status and record. Use
Glasgow Coma Scale in this tab for accuracy and consistency.
BE PREPARED TO
■ Assist with lumbar puncture.
■ Obtain blood for CBC, blood cultures, protein.
■ Send patient for CT scan or MRI.
POSSIBLE ETIOLOGIES
■ Bacterial, viral, fungal, amoebic, neonatal, or TB infection.
INFECT
Copyright © 2008 by F. A. Davis.
INFECT
Pneumonia
Acute infection of the lungs. Alveoli become inflamed and fluid-filled.
The patient may have:
■ Cough, chest pain, fever, tachycardia.
■ Shortness of breath, cyanosis, tachypnea, hemoptysis.
■ Joint pain, muscle aches.
■ Loss of appetite, fatigue.
IMMEDIATE INTERVENTIONS
■ Assess VS, and determine if patient has SOB.
■ Apply O2 if already ordered.
■ Assess HR and RR; note if patient is short of breath or struggling
to breathe.
■ Listen to lung sounds, assess use of accessory muscles.
■ Notify physician or NP of assessment findings.
■ Document phone call and physician or NP response.
FOCUSED ASSESSMENT
■
■
■
■
■
■
■
Assess
Assess
Assess
Assess
Assess
Assess
Assess
sputum quantity and character.
oxygen saturation by pulse oximetry.
LOC and orientation.
for pleuritic chest pain, chills.
for cyanosis.
appetite.
for patent IV line.
STABILIZING AND MONITORING
■
■
■
■
■
Administer antibiotics as soon as they are available.
Maintain O2, and check oxygen saturation frequently.
Keep patient well hydrated.
Provide diet high in protein.
Assess for complications such as empyema, respiratory distress, or
superinfection (worsening signs and symptoms despite treatment).
BE PREPARED TO
■ Obtain sputum culture and sensitivity, blood cultures, ABGs, or other
laboratory work.
■ Assist with thoracentesis, and monitor for complications (pneumothorax).
■ Obtain chest x-ray STAT.
■ Suction the patient; assist with bronchoscopy.
156
Copyright © 2008 by F. A. Davis.
157
POSSIBLE ETIOLOGIES
■ Viral, fungal, bacterial infection; prolonged bedrest; mechanical
ventilation; TB; aspiration; smoking; malnutrition; upper respiratory
tract disorder.
MRSA and Vancomycin-Resistant Staph Infection
Methicillin-resistant Staphylococcus aureus (MRSA) infection is caused by
S. aureus bacteria, which are often found in hospitals. S. aureus is resistant
to the broad-spectrum antibiotics commonly used to treat it. A patient or
health-care worker can be colonized with MRSA, which means the bacterium
lives on the skin and nares but does not cause infection. The danger with
colonization is that the patient or health-care worker can transmit the
bacteria to others, who may develop the hard-to-treat infection. CA-MRSA
is community-acquired MRSA. MRSA can be fatal. Vancomycin is one of the
few antibiotics that effectively treat MRSA; however, vancomycin-resistant
staph has begun to emerge.
CLINICAL PICTURE
The patient may have:
■ Small red pimple-like bumps that may look like boils or spider bites.
■ Erythema, swelling, and warmth around bumps; purulent drainage.
■ Fever, SOB, chest pain, muscle aches.
■ Painful skin abscesses.
■ Infection of bone, joints, incisions, blood, cardiac valves, lungs.
IMMEDIATE INTERVENTIONS
■ Using gloves, cover the wound(s), abscesses, or bumps with a clean,
dry, dressing; wash hands thoroughly.
■ Assess VS.
■ Notify physician or NP of possible staph infection.
■ Document phone call and physician or NP response.
FOCUSED ASSESSMENT
■ Assess for signs and symptoms of internal infection: auscultate lungs
for adventitious sounds; take apical pulse, and listen for murmurs;
assess urine for cloudiness; check BUN and creatinine for signs of
renal impairment.
■ Ask patient about general aches and pains, chills, headache, feeling
unwell (malaise).
INFECT
Copyright © 2008 by F. A. Davis.
INFECT
■
■
■
■
Obtain culture of wound and drainage.
Obtain blood cultures.
If pneumonia is suspected, obtain sputum culture.
If urinary tract infection is suspected, obtain urine culture.
STABILIZING AND MONITORING
■
■
■
■
■
Initiate contact precautions (See Contact Precautions in this tab).
Move patient to private room.
Wear a mask if patient has a productive cough.
Start antibiotics promptly.
Do not discontinue contact precautions until two sets of cultures, taken
24 hours apart and 48 hours after all antibiotics are discontinued, are
negative for MRSA.
BE PREPARED TO
■ Transfer patient to ICU if septic.
■ Teach family about preventing spread of MRSA.
■ Assist with incision and drainage of skin abscesses.
POSSIBLE ETIOLOGIES
■ S. aureus colonization or infection.
Tuberculosis
CLINICAL PICTURE
The patient may have:
■ Productive cough, worse in the morning.
■ Hemoptysis.
■ Chest pain, SOB.
■ Fever, night sweats.
■ Extreme weight loss if disease is advanced.
IMMEDIATE INTERVENTIONS/FOCUSED ASSESSMENT
■ Institute airborne precautions (see Airborne Precautions in this tab).
■ Auscultate lungs for possible diminished breath sounds, bronchial
breathing, coarse crackles.
■ Assess findings of chest x-ray: cavitation, calcification (indicates healed
disease), and nodes in the upper lobes suggest pulmonary TB.
■ Assess sputum production and patient’s ability to clear airway.
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159
STABILIZING AND MONITORING
■ Obtain early morning sputum specimens for 3 consecutive days for
culture and acid-fast bacilli (AFB). Obtain proper medium for AFB
specimen.
■ Administer standard therapy, and teach patient that it is critical that he
or she take medications as prescribed for the duration of therapy (6 to
18 months). A combination of the following drugs is standard treatment:
■ Isoniazid (INH).
■ Rifampin (RM).
■ Pyrazinamide (PZA).
■ Ethambutol (EMB).
■ Vitamin B6 for neuropathy of hands/feet.
■ Assess for signs and symptoms of tuberculosis outside the lungs
(meningitis, peritonitis, renal or bone involvement, pericarditis).
BE PREPARED TO
■ Assist with bronchoscopy.
■ Assist with chest tube placement (ruptured TB granuloma, empyema).
POSSIBLE ETIOLOGIES
■ Mycobacterium tuberculosis.
INFECT
Copyright © 2008 by F. A. Davis.
EMERG
Assessment in an Emergency
This assessment guideline was developed for the multiple trauma patient
brought into the emergency department (ED). However, the basic primary
survey—the ABCs (airway, breathing, circulation)—take precedent in
any emergency situation, whether in the ED, ICU, or general care floor. The
primary survey should be accomplished within the first few minutes.
■ Put on gloves and face mask with visor.
■ Check that needed equipment is readily available.
■ Ensure that needed staff is available.
Primary Survey: Airway, Breathing, Circulation
The primary survey is a crucial, rapid (less than 5 minutes) assessment. The
highest priorities are to establish an airway, supplement breathing or provide
ventilation, and support circulation. These are the ABCs and must always be
addressed first in any situation in which a patient’s status is deteriorating. The
order of assessment is critical (a blunt clinical saying: “If you do not have A
and B, you can forget about C.”). If the team encounters a problem with the
ABCs, an intervention to correct or improve the problem is initiated immediately, and its efficacy is assessed before proceeding. Once ABC is established,
proceed to D (disability) and E (expose) and then to the seconday survey.
Throughout, the team ALWAYS reassesses ABCs—if problems arise in ABCs,
all attention is directed to the problem.
■ During the primary survey all patients are
■ Given high-flow O2.
■ Assessed multiple times by cardiac monitoring, pulse oximetry, and
BP measurement
■ Penetrating objects are NOT removed. This should be done only in the
OR. Otherwise, catastrophic bleeding or additional injury can occur.
A: Airway
Assessment (with cervical spine immobilized):
■ Ask “are you all right?” Can the patient speak? If so, ABC is functional to
some extent. If there is no answer, rapidly begin more in-depth airway
and breathing assessment.
■ Look in the oropharynx for foreign objects, blood, teeth, vomitus, etc.
You may hear abnormal sounds such as wheezing or stridor.
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Interventions:
■ Immobilize cervical spine.
■ Establish patent airway with:
■ Jaw thrust/chin lift maneuver.
■ Consider a nasal airway. Do not use an oral airway in a conscious
patient as it may induce vomiting and aspiration.
■ Suction fluid from oropharynx.
■ If patient is not breathing or the airway cannot be cleared, endotracheal
intubation will be attempted. This will help:
■ Protect airway and ensure patency.
■ Correct hypoxemia.
■ Provide access for some medications.
■ If the patient cannot be intubated, a tracheotomy will be performed.
B: Breathing
Assessment:
■ Some patients are not breathing in an emergency (see CPR Quick
Reference in this tab). In a hospital, the code team will take over, and an
anesthesiologist, respiratory therapist, or other highly skilled individual
will assess the airway.
■ If the patient is breathing and you hear any noises with breathing, open
the mouth, and inspect the airway. Remove any obstructing material by
sweeping with a gloved finger.
■ Assess rate and ease of breathing. Check nailbed and circumoral area
for cyanosis.
■ Is the patient restless, thrashing about, extremely anxious? You will see
this in an emergency unless the patient has had a head injury and is
unconscious.
■ Feel trachea, examine the chest, and auscultate lungs.
■ Evaluate ABG results.
Interventions:
■ Provide high-flow supplemental O2; manually ventilate if necessary.
■ Identify and treat major thoracic injuries:
■ Pneumothorax (simple, open, or tension).
■ Hemo-pneumothorax.
■ Rib fractures.
■ Flail chest.
EMERG
Copyright © 2008 by F. A. Davis.
EMERG
C: Circulation
Assessment:
■ Check cardiac rate and rhythm and BP. Recheck every few minutes.
■ Check peripheral perfusion.
Interventions:
■ Control external bleeding.
■ Insert two large-bore IV accesses.
■ Send blood for laboratory tests, and type and crossmatch.
■ Infuse a warmed crystalloid.
D: Disability
Assessment:
■ Initial neurological assessment is limited to checking pupils and assessing
LOC (responsiveness) using the AVPU scale:
■ A ⫽ Alert
■ V ⫽ responds to Voice
■ P ⫽ responds to Pain
■ U ⫽ Unresponsive
■ Any change in AVPU requires reassessment of ABC.
E: Exposure
■ Remove clothing (expose), and inspect for obvious injuries.
■ Cover patient to reduce heat loss.
Secondary Survey
■ Follows primary survey and resuscitation.
■ Involves head-to-toe systematic assessment to detect injuries.
■ Includes AMPLE history (allergies, medications, past medical history, last
meal eaten, events prior).
■ Includes continuous reassessment of primary survey.
■ Provides for assessment of each body area for signs of deformity,
contusion, abrasion, hemorrhage, penetrating injury, altered perfusion,
and altered function.
Head and Face
■ Inspect and palpate head and face for lacerations, contusions, fractures, or
other injury.
■ Eyes (injury, hemorrhage, contact lens, dislocation of lens).
■ Ears and nose for CSF.
■ Mouth.
■ Cranial nerves.
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163
Cervical Spine and Neck
■ Inspect for signs of injury, tracheal deviation.
■ Palpate for tenderness, deformity, swelling, subcutaneous emphysema.
■ Auscultate for carotid bruits.
Chest
■
■
■
■
Inspect for injury, use of accessory muscles.
Auscultate lungs, and compare left with right.
Palpate entire chest for tenderness, crepitation, and injury.
Percuss.
Abdomen
■
■
■
■
Inspect for distention, skin condition.
Auscultate for bowel sounds.
Percuss.
Palpate; soft or rigid, tender or nontender?
Extremities
■ Inspect for signs of injury or deformity.
■ Palpate for sensation, tenderness, crepitation, abnormal movement.
■ Check all pulses.
Perineum
■ Inspect for rectal blood, sphincter tone.
■ Assess for bleeding or other injury to genitalia.
Back
■ Inspect for injuries, swelling.
■ Assess for flank pain, hematoma.
Fractures
■ Assess for bone/joint deformity.
■ Assess for loss of function.
Neurological
■ Reevaluate pupils and LOC.
■ Determine GCS.
■ Evaluate for paralysis, paresis, motor and sensory responses of
extremities.
EMERG
Copyright © 2008 by F. A. Davis.
EMERG
Diagnostic Studies
■
■
■
■
■
■
■
■
■
■
■
■
Type and crossmatch for blood.
Hemoglobin and hematocrit levels.
WBC count.
Glucose.
Urinalysis.
Amylase.
Cardiac and liver enzymes.
Arterial blood gas.
Cervical-spine radiographic series.
Chest x-ray.
Head CT.
Abdominal CT.
Advance Directives and Do Not Resuscitate Orders
First, make sure you know the patient’s wishes (or family’s, if the patient is
unable to make decisions) regarding “heroic measures.” Ideally, all patients
should have advance directives in the medical record indicating whether
they wish to be resuscitated and to what extent resuscitative efforts should
be carried out. Admission personnel often ask this of the patient when he or
she is admitted. However, sometimes this is not possible, and if there is any
doubt as to the interpretation or whereabouts of a patient’s advance directives a code must be called and resuscitative efforts initiated. Therefore,
make sure this document is always available in the record.
■ Help patients and families address end-of-life care issues.
■ Suggest discussing with a religious leader of their faith.
■ Keep in mind the role of culture, ethnicity, and religion in end-of-life
questions.
■ Always treat the patient as an individual.
■ Tell patients that they will not be abandoned or given substandard care
if they or their advance directive limit medical interventions.
Rapid Response Teams
Patients typically go through several hours of subtle changes in condition
before a respiratory or cardiac arrest. HR and BP changes, changes in
mentation, breathing difficulties, and other signs precede a full-blown code.
Intervening earlier in the downward spiral of events vastly increases the
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165
patient’s chance of survival. The nurse’s role is critical in getting the right
help for the patient. Many hospitals have rapid response teams that can
be and should be called when the patient’s condition changes, even if you
cannot say for sure what it is (“something’s different/wrong”). The rapid
response team may consist of:
■ Resident, NP, or physician’s assistant.
■ ICU nurse.
■ Nurse anesthetist or respiratory therapist.
The staff nurse is usually responsible for:
■ Calling the rapid response team.
■ Calling the attending physician.
■ Providing the recent history and background information.
■ Continuing to assess the patient.
■ Obtaining and administering medications.
■ Providing other noncritical care.
If your facility does not have a rapid response team, notify the nurse
manager or nursing supervisor, who can help you get the resources
needed.
What to Do If Your Patient Codes
If you are by yourself:
■ Establish unresponsiveness, call for help, and check ABC; clear airway
by sweeping your fingers in the patient’s mouth or by suctioning.
■ If you have no help, call the code before proceeding. As you do this,
pull the call bell out so that the light flashes continually, ask any visitors
to wait outside the room, and pull the curtain if another patient is
present.
■ Note if the patient has a running IV or an IV access device.
■ Place the patient in a supine position in bed, if possible.
■ Place the arrest board under the patient’s back, if you have help. If not,
proceed until a second person arrives.
■ Next, assess breathing for 5 seconds, using the head-tilt/chin-lift maneuver
(see first figure below). If the patient is not breathing, initiate ventilations,
preferably with a bag-valve-mask device. If one is not available, quickly
apply a barrier, and give two breaths of 11/2–2 seconds each.
EMERG
Copyright © 2008 by F. A. Davis.
EMERG
■ Check for a pulse. If the patient has no pulse, begin one-person CPR until
another person or the code team arrives (see CPR Quick Reference in this
tab).
When another nurse arrives to help:
■ Bring the crash cart into the room.
■ Get an IV of NS running.
■ Switch to bag-valve-mask ventilations by:
■ Inserting an oral airway.
■ Connecting the bag-valve-mask to oxygen tubing.
■ Setting up the flowmeter.
■ Turning on the oxygen to 12–15 L/min.
■ Make sure the seal around the patient’s airway is tight, and resume CPR.
■ Once the code team arrives, someone will relieve you and begin other
resuscitative interventions.
■ Once you are relieved:
■ Make sure one nurse is documenting and another nurse is retrieving
medications and supplies as needed from the code cart.
■ Stay in the room to be available to the team.
■ Many other tasks may be required of you in a code situation, including
obtaining laboratory tests and transporting them to the laboratory,
inserting an IV or Foley catheter, suctioning the airway, administering
medications, calling the attending physician, arranging for a bed in the
ICU, etc. Do not practice beyond your level of expertise.
■ Offer support to any visitors who are present.
■ Document all events up to and including time code was called. Document
after time the code ended. Check that the code record is complete and on
the chart.
■ If the patient survives, write a transfer note, and give report to
receiving unit. If you work in an ICU and the patient is not being moved,
detail the events in your end-of-shift report, and document on the ICU
flowsheet.
■ If the patient does not survive, leave all tubes in place, and check with
your supervisor to determine what can be removed. If an autopsy will be
performed, you will not remove anything.
■ Clean and cover the patient, and straighten the room before the family
views the body. If family members were present at the time the patient
coded, sensitively ask them if they would like you to do this first. It may
be unbearable for them to wait. ALWAYS consider the family’s needs first.
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167
Adult/Child CPR, Hemlich, and Recovery Positions
Head—tilt, chin—lift.
Jaw thrust maneuver.
Hand placement.
Heimlich maneuver.
Heimlich maneuver:
abdominal thrusts if
unresponsive.
EMERG
Recovery position.
Copyright © 2008 by F. A. Davis.
EMERG
Infant CPR and Heimlich Positions
Head—tilt, chin—lift.
Heimlich maneuver: back blows;
support head.
CPR hand placement.
Heimlich maneuver: chest thrusts;
support head.
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Copyright © 2008 by F. A. Davis.
169
CPR Quick Reference
Determine unresponsiveness
■ Adult: Call 911: get help—obtain AED if available.
■ Child or infant: Call 911 after 2 min (5 cycles) of CPR.
Open airway
■ All ages: head—tilt, chin—lift
■ If trauma suspected, use jaw-thrust method.
Assess for breathing
■ If not breathing, give two slow breaths at 1 sec/breath.
■ If unsuccessful, reposition airway, and reattempt to ventilate. If still
unsuccessful, refer to Choking Quick Reference below.
Check for a pulse for 10 seconds
■ If pulse is present but patient is not breathing, begin rescue breathing (see
table below).
■ If no pulse after 10 seconds, start chest compressions.
CPR Parameters for Adults, Children, Infants, and Neonates
Adult
Child and Infant
Newborn
Ventilations
10–12/min
12–20/min
40–60/min
Pulse check
location
Carotid
Child: Carotid
Infant: Brachial
Brachial
Umbilicus
Compression
rate
100/min
100/min
120/min
Ratio of compressions
to breaths
30:2 (1 or
2 rescuers)
30:2 (15:2 if
2 rescuers)
3:1 (1 or
2 rescuers)
Compression
depth
11/2–2 inches
1/2–1/3
1/3
the depth
of the chest
the depth
of the chest
If a defibrillator is available
Power on, and follow voice prompts (AED)
■ Perform 2 minutes of CPR between each shock.
■ Adults: Do not use pediatric pads.
■ Child: Use after 2 min (5 cycles) of CPR (may use adult pads if pediatric pads
are unavailable).
Note: Recheck pulse every 2 minutes and after each shock. Check without
interrupting chest compressions.
EMERG
Copyright © 2008 by F. A. Davis.
EMERG
Choking Quick Reference
Conscious Patient
1. Assess for airway obstruction
■ Adult or child: Ask victim if he/she is choking; can he/she speak or make
any sounds?
■ Infant: Cannot cry or ineffective cough.
2. Attempt to relieve obstruction
■ Adult or child: Abdominal thrusts until the obstruction is relieved or
victim becomes unresponsive (see step 3 below).
■ Pregnant or obese patients: Chest thrusts until the obstruction is
relieved or the patient becomes unresponsive (see step 3 below).
■ Infant: 5 back blows and 5 chest thrusts until the obstruction is relieved
or victim becomes unresponsive (see step 3 below).
Unresponsive Patient
3. Determine unresponsiveness
■ Adult: Get help or call 911 prior to any intervention.
■ Child or infant: Get help or call 911 after 1 min.
4. Open airway
■ Head—tilt, chin—lift.
■ If trauma suspected, use the jaw-thrust method.
5. Assess breathing and attempt to ventilate
■ If unsuccessful, reposition airway, and reattempt ventilation.
■ If still unsuccessful, begin CPR (for all ages).
6. Inspect mouth and remove obstruction
■ Adult, child, and infant: Use a tongue-jaw lift while opening the airway
during CPR.
■ Perform a finger sweep only to remove a visible foreign body.
7. Repeat manuevers
■ Inspect, sweep, ventilate.
■ Perform CPR until obstruction relieved.
Note: If patient resumes breathing, place into recovery position, and
reassess ABCs every minute.
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171
Automatic External Defibrillators (AEDs)
■ Assessment: Determine unresponsiveness and assess ABCs.
■ Children 1–8 years: get help/AED after 2 min of CPR.
■ Adults ≥8 years: get help/AED immediately.
■ Perform CPR until AED arrives.
■ Power: Turn on the AED, and follow voice prompts.
■ Attach pads: Stop CPR, attach appropriate-size pads to patient, and plug
pad cable into the AED unit if needed.
■ Upper right sternal border and cardiac apex.
■ Analyze: Press the “Analyze” button, and wait for instructions (do not
make contact with patient while AED is analyzing rhythm).
■ Shock: Announce “Shock indicated, stand clear,” and assure that no one
is in contact with the patient.
■ Fully automatic units analyze rhythm and shock if indicated.
■ Semiautomatic units analyze rhythm, and then instruct the operator to
press the “shock” button if indicated.
Transcutaneous Pacing (TCP)
INDICATIONS
■
■
■
■
Symptomatic 2nd-degree AV block type II or 3rd-degree AV block.
Symptomatic bradycardia unresponsive to atropine.
Bradycardia with ventricular escape rhythms.
Overdrive pacing of tachycardia refractory to drug therapy or electrical
cardioversion (to be performed by physician only).
PACING MODES
■ Demand (synchronous) mode senses the patient’s heart rate and paces
only when the HR falls below the clinician-set rate.
■ Fixed (asynchronous) mode does not sense the HR, but rather paces at the
rate set by the clinician.
PROCEDURE
■
■
■
■
Pads: Apply pacing electrodes to patient per package instructions.
Power: Turn on pacemaker, and assure all cables are connected.
Rate: Set demand rate to approximately 80 bpm.
Current: Output ranges 0–200 mA
■ Bradycardia: Increase mA from minimum setting until a consistent
capture is achieved, then increase by 2 mA.
■ Asystole: Begin at full output. If capture occurs, slowly decrease until
capture is lost, then increase by 2 mA.
EMERG
Copyright © 2008 by F. A. Davis.
EMERG
Emergency Conditions
INJURY AND ILLNESS
■ Appendicitis (leading to peritonitis)
■ Chest pain or sudden severe
abdominal pain
■ Cholecystitis
■ Compound fracture
■ Drug overdose or withdrawal
■ Gangrene
■ Head trauma
■ Hypothermia or hyperthermia
■ Intestinal obstruction
■ Malignant hyperthermia
■ Necrotizing faciitis
■ Pancreatitis
■ Peritonitis
■ Septicemia blood infection
■ Severe burn
■ Spreading wound infection
■ Spinal injury
CARDIAC AND CIRCULATORY
■
■
■
■
■
■
■
■
■
■
■
■
Air embolism
Aortic aneurysm (ruptured)
Aortic dissection
Cardiac arrest
Cardiac arrhythmia
Cardiac tamponade
Hemorrhage
Hypertensive emergency
Myocardial infarction
Subarachnoid hemorrhage
Subdural hematoma, acute
Ventricular fibrillation
METABOLIC
■
■
■
■
■
■
■
Acute renal failure
Addisonian crisis
Dehydration, advanced
Diabetic ketoacidosis
Electrolyte disturbance, severe
Hepatic encephalopathy
Hypoglycemic coma
■ Lactic acidosis
■ Thyroid storm
NEUROLOGICAL
■
■
■
■
Cerebrovascular accident (stroke)
Meningitis
Seizure
Syncope (fainting)
OPHTHALMOLOGICAL
■ Acute angle–closure glaucoma
■ Orbital perforation/penetration
■ Retinal detachment
RESPIRATORY
■ Acute asthma
■ Agonal breathing
■ Asphyxia secondary to
angioedema, choking. drowning,
smoke inhalation
■ Epiglottitis or severe croup
■ Pneumothorax
■ Pulmonary embolism
■ Respiratory failure
SHOCK
■
■
■
■
■
Anaphylaxis
Cardiogenic shock
Hypovolemic or hemorrhagic shock
Neurogenic shock
Septic shock
UROLOGICAL, GYNECOLOGICAL,
AND OBSTETRIC
■
■
■
■
■
■
■
■
Eclampsia
Ectopic pregnancy
Gynecological hemorrhage
Obstetrical hemorrhage
Paraphimosis
Priapism
Testicular torsion
Urinary retention
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173
Anaphylaxis
CLINICAL PICTURE
The patient may have:
■ Angioedema, hives, itching.
■ Feelings of impending doom, anxiety, restlessness.
■ Bronchospasm, laryngeal edema, respiratory distress.
■ Hypotension, dysrhythmia.
■ Nausea, vomiting, diarrhea.
IMMEDIATE INTERVENTIONS
■ Call physician and respiratory therapist or anesthesiologist STAT. Get help.
Have someone bring code cart or emergency medications box to room.
■ Establish patent airway. Administer high concentrations of supplemental
O2, or manually assist ventilations with an Ambu-bag.
■ Initiate continuous cardiac and VS monitoring.
■ Obtain IV access.
■ Anticipate need for mechanical ventilation.
■ Assess recent exposure to allergen (food, insect sting, medication, blood
product, contrast medium, latex).
■ Document patient’s status, phone call to physician, and physician response.
FOCUSED ASSESSMENT
■ Assess airway status, LOC, and VS (HR, RR, BP) on a continuous basis.
■ Assess SaO2 via pulse oximetry.
■ Assess skin for color, temperature, turgor, moistness, and capillary refill.
STABILIZING AND MONITORING
■
■
■
■
Monitor VS every 5 min. or more frequently.
Administer medications, IV fluids as ordered.
Provide emotional support to family/patient.
Record patient’s status in chart, and communicate to physician.
BE PREPARED TO
■
■
■
■
■
Administer epinephrine subcutaneously.
Call a code.
Assist with intubation and airway management.
Assist with obtaining central venous access.
Administer IV fluids and medications (vasopressors, diphenhydramine,
steroids, volume expanders).
■ Transfer patient to ICU.
POSSIBLE ETIOLOGIES
■ Exposure to antigen.
EMERG
Copyright © 2008 by F. A. Davis.
EMERG
Transfusion Reaction
CLINICAL PICTURE
The patient may have:
■ Fever, chills, tachycardia, hypotension.
■ Chest pain, SOB.
■ Apprehension, restlessness.
■ Burning at infusion site.
■ Nausea, vomiting, diarrhea.
■ Urticaria, pruritus, skin erythema.
■ Flank, back, or joint pain.
■ Hematuria.
IMMEDIATE INTERVENTIONS
■ Stop the transfusion. Run normal saline through the IV to maintain
IV access.
■ Assess airway, breathing, and circulation. Get help.
■ Check VS.
■ Administer supplemental O2.
■ Notify physician or NP.
■ Recheck patient ID and blood labels for error. Notify blood bank of
reaction.
■ Document patient’s status, phone call to physician or NP, and physician
or NP response.
FOCUSED ASSESSMENT
■
■
■
■
Assess LOC, orientation, and VS (temperature, HR, RR, BP).
Assess SaO2 via pulse oximetry if available.
If patient on telemetry or cardiac monitor, assess rhythm strip.
Assess skin for color, turgor, moistness, and temperature.
STABILIZING AND MONITORING
■
■
■
■
Return unused portion of blood product to blood bank for analysis.
Administer prescribed medications and O2.
Document specific reaction.
Continue to monitor VS, temperature, respiratory status, LOC, and
urine output.
■ Chart patient status, and convey to physician or NP.
BE PREPARED TO
■ Administer epinephrine, treat shock, initiate CPR if necessary.
■ Administer IV fluids.
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175
■ Insert indwelling catheter to monitor hourly urine output.
■ Administer medications such as:
■ Antihistamine, antipyretic, steroids, and furosemide (Lasix) IV.
■ Acute hemolytic reaction: IV normal saline with diuretics to maintain
urine output of 100 mL/hr.
■ Allergic response: corticosteroids such as Solu-Medrol.
■ Urticaria: diphenhydramine 25–50 mg IV, deep IM.
■ Fever: acetaminophen.
■ Septicemia: antibiotics, IV fluids, vasopressors.
■ Kidney failure and shock: IV fluids and vasopressors.
■ Obtain or order STAT laboratory tests.
■ Titrate O2 to keep SaO2 ⬎90%.
■ Obtain two large-bore IV accessories.
POSSIBLE ETIOLOGIES
■ ABO incompatibility, blood contamination, allergic response.
Types of Reactions
Type
Cause
Signs and Symptoms
Acute hemolytic
ABO incompatibility
reaction to RBC
antigens.
Fever, chills, low back pain,
flushing, tachycardia,
hypotension, vascular
collapse, cardiac arrest.
Febrile
nonhemolytic
Sensitization to donor
WBCs, platelets, or
plasma proteins.
Fever, chills, headache,
flushing, muscle aches,
respiratory distress,
cardiac dysrhythmias.
Anaphylactic
Administration of
donor’s IgA proteins to recipient with
anti-IgA antibodies.
Restlessness, urticaria,
wheezing, shock, cardiac
arrest.
Allergic
Sensitivity to foreign
proteins.
Hives, urticaria, fever,
flushing, itching.
Bacteremia
Infusion of bacteriacontaminated blood.
Chills, fever, hypotension,
vomiting, diarrhea,
septic shock.
EMERG
Copyright © 2008 by F. A. Davis.
EMERG
Shock
CLINICAL PICTURE
The patient may have:
■ Anxiety (early), lethargy and coma (later).
■ Hypotension.
■ Decreased urine ouput.
■ Tachycardia (bradycardia in neurogenic shock).
■ Delayed capillary refill (⬎3 sec), diminished peripheral pulses (⬍⫹2).
■ Cool, pale, mottled, or cyanotic skin (hypovolemic shock).
■ Tachypnea.
■ Diaphoresis.
■ Throat tightness, stridor, flushing, urticaria (anaphylactic shock).
IMMEDIATE INTERVENTIONS
■
■
■
■
■
■
■
■
■
■
Call physician or NP STAT. Get help from other staff.
Establish patent airway.
Insert nasal or oral airway, and suction oropharynx if needed.
Administer high-flow O2 via nonrebreather mask (10–15 L/min), or
manually assist ventilations with an Ambu-bag (mask-valve device).
Anticipate need for mechanical ventilation.
Obtain IV access.
Set up cardiac monitoring.
Place patient in a supine position with legs elevated above heart level to
increase circulation to vital organs. Note: This position is contraindicated
if the airway is compromised; to maintain airway patency, place patient
in supine or low Fowler’s position (HOB slightly elevated).
Control bleeding with direct pressure if patient hemorrhaging.
Document patient’s status, phone call to physician or NP, and physician
or NP response.
FOCUSED ASSESSMENT
■ Assess LOC, orientation, and VS (HR, RR, BP).
■ Assess SaO2 via pulse oximetry if available (may be unreliable due to
decreased peripheral perfusion).
■ Assess skin for color, temperature, turgor, moistness, and capillary refill.
■ Evaluate previous 2-hour I&O.
STABILIZING AND MONITORING
■ Monitor VS every 5 minutes or more frequently.
■ Manage various types of shock accordingly:
■ Hypovolemic: O2; IVF; volume replacement with crystalloids, colloids,
plasma volume expanders, and/or blood; elevate lower limbs (if not
contraindicated); control bleeding; arterial line placement.
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Copyright © 2008 by F. A. Davis.
177
■ Cardiogenic: O2; IVF; vasopressors, cardiotonics, antidysrhythmics (i.e.,
dopamine, dobutamine, lidocaine); correct dysrhythmias; arterial line
placement and hemodynamic monitoring.
■ Septic: O2; IVF; volume replacement; antibiotics, vasopressors,
antipyretics; arterial line placement.
■ Anaphylactic: O2; IVF; epinephrine, antihistamines (Benadryl/Atarax),
steroids; intubation and airway management; arterial line placement.
■ Neurogenic: O2; IVF; spinal stabilization; vasopressors; intubation and
airway management; arterial line placement; insert Foley’s catheter.
■ Provide emotional support to family/patient.
■ Record patient’s status in chart, and communicate to physician or NP.
BE PREPARED TO
■
■
■
■
■
Call a code.
Assist with intubation and airway management.
Assist with obtaining central venous access.
Administer fluids, blood products, and medications as ordered.
Order or obtain specific laboratory tests to be drawn STAT (Hgb, Hct,
WBC, cardiac markers, electrolytes, ABG, UA).
■ Transfer to ICU.
POSSIBLE ETIOLOGIES
■ Blood loss, vomiting, dehydration (hypovolemic shock), MI, profound
brady/tachycardia, pump failure (cardiogenic shock), infection, endo/
exotoxin release (septic shock), exposure to antigen (anaphylactic), spinal
cord injury, anesthesia (neurogenic shock), pharmacological overdose.
Comparison of Different Types of Shock States
Type
Pathophysiology
Anaphylactic:
Acute, lifethreatening
allergic reaction
to a specific
antigen.
Massive vasodilation; fluid
shifts out of
intravascular
space; ↓ tissue
perfusion;
peripheral and
laryngeal
edema;
bronchospasm.
Signs and
Symptoms
Respiratory distress (stridor);
↓ BP; edema;
rash, hives;
cool, pale skin;
possible
seizure activity,
tight chest.
Interventions
O2, airway
management,
epinephrine,
antihistamines,
steroids, IV
fliuds.
(Continued on the following page)
EMERG
Copyright © 2008 by F. A. Davis.
EMERG
Comparison of Different Types of Shock States (continued)
Type
Signs and
Symptoms
Pathophysiology
Cardiogenic:
Pump failure
due to MI, PE,
cardiac tamponade, heart failure,
aneurysm.
Inadequate cardiac output
due to lack of
contractile
force to create
BP; decreased
tissue
perfusion.
Hypovolemic: ↓
Decrease in intracirculating volume
vascular
due to hemorvolume with
rhage, burns,
which to create
dehydration,
a BP;
third spacing
decreased
of fluids.
tissue
perfusion.
Neurogenic:
Profound vasodiSpinal shock
lation that
secondary to
results in lack
spinal cord injury,
of peripheral
anesthesia.
vascular resistance sufficient
to sustain BP;
decreased
tissue
perfusion.
Septic: Septicemia Circulatory
secondary to
failure due to
endo/exotoxin
systemic
release, most
inflammatory
commonly Gramresponse;
negative bacteria.
capillary leak
syndrome;
decreased
tissue
perfusion.
Interventions
Hypotension,
weak pulse,
tachycardia,
clammy skin,
altered LOC;
dysrhythmias.
O2, IV fliuds,
vasopressors,
cardiotonics,
antidysrhythmics.
Hypotension;
tachycardia;
weak pulse; ↓
capillary refill;
cyanosis;
dysrhythmias;
altered LOC;
cool, clammy,
pale skin.
Hypotension,
bradycardia,
or tachycardia;
tachypnea;
possible
flaccid
paralysis and
absent
reflexes.
O2, control
bleeding,
fluid replacement with
crystalloids,
colloids,
volume
expanders,
blood.
O2, IV fluids,
airway
management,
spinal
stabilization,
possible
vasopressors.
Fever or low
temperature;
bounding
pulse; ↓ urine
output;
flushed, warm,
moist to
diaphoretic
skin; increased
HR/RR.
O2, IV fluids,
blood
cultures, UA,
sputum C&S
antibiotics,
vasopressors.
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Copyright © 2008 by F. A. Davis.
179
Cardiogenic Shock
Ineffective Pump
Ventricular Emptying
Stroke Volume
End-diastolic Volume
Cardiac Output
Filling Pressures
Tissue Perfusion
Cardiogenic shock.
Hypovolemic Shock
Volume
Venous Return
Filling Pressures
Stroke Volume
Cardiac Output
Tissue Perfusion
Hypovolemic shock.
EMERG
Copyright © 2008 by F. A. Davis.
EMERG
Neurogenic Shock
Massive Vasodilation
Venodilation
Arteriolar Dilation
Venous Return
Peripheral Resistance
Filling Pressures
Stroke Volume
Cardiac Output
Blood Pressure
Tissue Perfusion
Neurogenic shock.
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Copyright © 2008 by F. A. Davis.
181
High-Alert Medications
High-alert medications are those medications that have a high risk of causing
injury or death when improperly handled or administered. Many of these
drugs are used commonly in the general population or are used frequently
in urgent clinical situations. The Joint Commission monitors the five most
often prescribed high-alert medications: insulin, opiates and narcotics,
injectable potassium chloride (or phosphate) concentrate, IV anticoagulants
(heparin); and sodium chloride solutions above 0.9%. Exercise extreme
caution when administering these medications:
■ Adrenergic agonists (e.g., epinephrine, isoproterenol, norepinephrine).
■ Cardioplegic solutions.
■ Chemotherapeutic agents.
■ Chloral hydrate (in pediatric patients).
■ Colchicine injection.
■ High-concentration dextrose (greater than 10% dextrose).
■ Hypoglycemic agents (oral).
■ Hypertonic sodium chloride injection (⬎0. 9% concentration).
■ Insulin.
■ IV adrenergic antagonists (propranolol, esmolol, metoprolol).
■ IV calcium.
■ IV digoxin.
■ IV magnesium sulfate.
■ IV potassium (phosphate and chloride).
■ Lidocaine/benzocaine; other topical anesthetics.
■ Midazolam.
■ Neuromuscular blocking agents.
■ Opiates (opioids).
■ Thrombolytics, heparin, warfarin.
Safe Medication Administration
■ Carefully read product packaging to note strength of solution, dosage,
and/or route of administration.
■ Double-check with a pharmacist about dose range.
■ Have a colleague double-check dosage calculations and infusion pump
programming.
■ Use the Five Rights (right drug, right dose, right patient, right route, right
time) as a guide.
MEDS/LABS
Copyright © 2008 by F. A. Davis.
MEDS/LABS
■ Clarify any order that is incomplete, contains abbreviations, is confusing
or hard to read, or raises a question.
■ Suspect a missed decimal point, and clarify any order if the dose requires
more than 3 dosing units.
■ If taking a verbal order, ask prescriber to spell out the drug name and
dosage to avoid sound-alike confusion (e.g., hearing Cerebyx for
Celebrex, or fifty for fifteen).
■ Read back the order to the prescriber after you have written it in the chart.
■ Do not borrow medications from other patients or begin new medications
before the order has been received in the pharmacy; to do so circumvents
the built-in checks that can detect a prescribing error.
■ Review each patient’s medications for:
■ Medication use without an indication.
■ Contraindications.
■ Improper drug selection.
■ Overdose/subtherapeutic dose (consider age, renal/hepatic impairment).
■ Medication duplication.
■ Efficacy.
■ Adverse drug reactions/toxicity.
■ Potential drug or food interactions.
■ Weight changes requiring dosage adjustments.
■ Appropriate duration of therapy.
■ Adherence with prescribed medication therapy.
Patient Education and Medication Use
Educating patients about their medications is a critical nursing function
that promotes proper medication use and improved outcomes. It also can
prevent adverse drug reactions or early or improper discontinuation of a
medication. Many issues related to medication errors, such as ambiguous
directions, unfamiliarity with a drug, and confusing packaging, affect the
patient as well as the health-care providers, thereby emphasizing the need
for careful education. Patient education also enhances compliance, which
is a factor in proper medication use.
■ All patients need clear written and verbal instruction for all medications.
■ Present information in a format the patient can understand.
■ Use an interpreter if provider and patient speak different languages.
■ Do not rush.
■ Include family members.
■ Have the patient repeat the information you provide.
182
Copyright © 2008 by F. A. Davis.
183
■ Make sure to tell the patient:
■ The brand and generic names of the medication.
■ The purpose of the medication.
■ The strength and dose and when to take the medication.
■ Possible side effects and what to do if they occur.
■ How long to take the medication.
■ What medications or foods to avoid and why they should be avoided.
■ How to store the medication.
■ What to do if a dose is missed.
■ What activities, if any, should be avoided while on the medication.
■ Signs and symptoms of adverse drug reactions.
Error-Prone Abbreviations and Symbols
Abbreviations
■ ␮g
■ AD, AS, AU
■ OD, OS, OU
■ BT
■ cc
■ D/C
■ IJ
■ IN
■ HS, hs
■ IU
■ o.d., OD
■ OJ
■ per os
■ q.d., QD
■ q1d
■ q6PM, etc.
■ SC, SQ, sub q
■ ss
■ SSRI, SSI
■ 1/d
■ TIW, tiw
■ U, u
Symbols
■
(dram)
■
(minim)
■ @ (at)
■ & (and)
■ ⬚ (hour)
■ / (slash)
■ ⫹ (plus)
■ ⫺ (minus)
■ ⬎ (greater than)
■ ⬍ (less than)
■ Apothecary symbols
Drug Names
■ ARA A
■ AZT
■ CPZ
■ DPT
■ DTO
■ HCl
■ HCT
■ HCTZ
■ IV Vanc
■ MgSO4
MEDS/LABS
■ MTX
■ Nitro drip
■ Norflox
■ PCA
■ PTU
■ T3
■ TAC
■ TNK
■ ZnSO4
General Tips
■ Avoid using a zero
after a decimal point.
■ Use a zero before a
decimal point.
■ Use commas for
dosing units at or
above 1,000.
■ Place adequate
space between a
drug name, dose,
and the unit of
measure.
Copyright © 2008 by F. A. Davis.
MEDS/LABS
IV Fluid Drip Rate Table (drops/min)
Rate: mL/
hr →
TKO
50
75
100
125
200
250
10 gtt/
mL set
5
8
13
17
21
150 175
25
29
33
42
12 gtt/
mL set
6
10
15
20
25
30
35
40
50
15 gtt/
mL set
8
13
19
25
31
37
44
50
62
20 gtt/
mL set
10
17
25
33
42
50
58
67
83
60 gtt/
mL set
30
50
75
100
125
150
175
200
250
Note: TKO is 30 mL/hr.
Emergency Medications (62 Medications)
Note: This list is a reference only. It is not meant to be exhaustive. Always
consult an authoritative, current reference about dose, dilution, interactions,
and route and rate of administration before administering medications,
especially IV medications. Have a second licensed person independently
check dose calculations, preparation, original orders, and infusion pump
programming for high-alert medications.
ACE Inhibitors (Antihypertensive)
Common Agents: Captopril, Enalapril, Lisinopril.
Indications: MI, heart failure without hypotension, ST elevation.
Dose: See individual order and drug for route and dosage.
Contraindications: Hypotension, pregnancy, angioedema.
Side Effects: Dizziness, HA, fatigue, hypotension, altered LOC.
Precautions: Lower doses in renal failure.
Activated Charcoal (Absorbent)
Indications: Overdose and poisoning.
Dose: 25–100 g PO, NG tube.
Contraindications: Concurrent use with syrup of ipecac.
Side Effects: Constipation, N&V, diarrhea.
Precautions: Ineffective in iron (heavy metals) OD.
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Copyright © 2008 by F. A. Davis.
185
Adenosine (Adenocard®) (Antidysrhythmic)
Indications: Narrow complex PSVT.
Dose: 6 mg IV. Repeat with 12 mg IV in1–2 min if needed. A third dose
of 12 mg may be given in 1–2 min. Max: 30 mg.
Contraindications: Drug- or poison-induced tachycardia.
Side Effects: Flushing, chest pain, tightness, bradycardia, heart block,
asystole, ventricular ectopy, VF.
Precautions: Ineffective in treating atrial fibrillation, atrial flutter, or VT.
Avoid in patients on dipyridamole or with a history of MI or cerebral
hemorrhage.
Albuterol (Ventolin®) (Bronchodilator)
Indications: Reversible airway restriction due to acute bronchospasm,
asthma, or COPD.
Dose: 1.25–5 mg nebulized in 3-mL saline.
Contraindications: Hypersensitivity to adrenergic amines.
Side Effects: Nervousness, restlessness, tremor, tachycardia, anxiety, N&V,
diarrhea, HA, HTN, hyperglycemia.
Precautions: Tachydysrhythmias, cardiac disease, elderly, hypersensitivity.
Alteplase (Activase®, t-PA) (Thrombolytic, Fibrinolytic)
Indications: Within 4–6 hr of acute MI and 3 hr from onset of symptoms
in acute ischemic stroke, pulmonary embolus.
Dose: Per order.
Contraindications: Active internal bleeding within 10 days (except
menses), history of neurovascular event within 2 months, major surgery
or trauma within 2 weeks, aortic dissection, severe (uncontrolled) HTN,
bleeding disorder, prolonged CPR, lumbar puncture within 1 week.
Side Effects: Hypotension, reperfusion dysrhythmias, heart failure, HA,
increased bleeding time, deep or superficial hemorrhage, flushing, urticaria,
anaphylaxis.
Precautions: Patients with severe renal or hepatic disease.
Alupent (Metaproterenol®) (Adrenergic Agonist [Bronchodilator])
Indications: Reversible airway restriction due to asthma or COPD.
Dose: 10–15 mg nebulized in 3-mL saline.
Contraindications: Hypersensitivity to adrenergic amines.
Side Effects: Nervousness, restlessness, tremor, tachycardia, anxiety, N&V,
diarrhea, HA, HTN, hyperglycemia.
Precautions: Tachydysrhythmias, cardiac disease, elderly, hypersensitivity.
Aminophylline (Truphylline®) (Bronchodilator)
Indications: Long-term control of reversible airway obstruction due to
asthma or COPD.
Dose: Per order.
MEDS/LABS
Copyright © 2008 by F. A. Davis.
MEDS/LABS
Contraindications: Uncontrolled dysrhythmias, hyperthyroidism.
Side Effects: Seizures, dysrhythmias, anxiety, N&V, tremors.
Precautions: Geriatric patients, patients with CHF or liver failure, obesity;
multiple drug interactions.
Amiodarone (Cordarone®) (Antidysrhythmic)
Indications: Wide- and narrow-complex tachycardia, VF, and pulseless VT.
Dose: 150 mg over first 10 min (15 mg/min), 360 mg over next 6 hr (1 mg/
min), 540 mg over next 18 hr (0.5 mg/min).
Contraindications: Sinus bradycardia, cardiogenic shock, 2nd- or 3rddegree heart block.
Side Effects: Hypotension, prolonged QT interval, ARDS, CHF, PSVT.
Precautions: Avoid concurrent use with procainamide.
Amyl Nitrate (Antidote to Cyanide Poisoning)
Indications: Cyanide poisoning.
Dose: Inhale vapors from crushed ampules for 30 sec of every min
continuously.
Contraindications: Cerebral hemorrhage, head trauma, hypotension,
glaucoma, recent MI, hypersensitivity to nitrates or nitrites.
Side Effects: HA, hypotension, tachycardia, N&V.
Precautions: Increased hypotension with alcohol consumption.
Aspirin (Acetylsalicylic Acid) (Antiplatelet, Analgesic)
Indications: Analgesic, acute coronary syndrome.
Dose: 160–325 mg PO nonenteric-coated for antiplatelet effect.
Contraindications: Known allergy to aspirin, pregnancy.
Side Effects: Anorexia, nausea, epigastric pain, anaphylaxis.
Precautions: Active ulcers and asthma, blood dyscrasias.
Ativan® (Lorazepam) (Anticonvulsant,
Anxiolytic, Sedative, Hypnotic)
Indications: Status epilepticus, acute ETOH withdrawal.
Dose: 50 ␮g (0.05 mg)/kg, maximum 4 mg each dose; may be repeated after
10–15 min, not to exceed 8 mg/12 hr or 2 mg/min IV infusion.
Contraindications: Allergy to benzodiazepines, narrow-angle glaucoma.
Side Effects: Dizziness, drowsiness, lethargy, apnea, cardiac arrest,
paradoxical excitation, N&V, diarrhea.
Precautions: Severe hepatic, renal, pulmonary impairment.
Atracurium (Tracrium®) (Neuromuscular
Blocking Agent [Nondepolarizing])
Indications: Paralysis to facilitate endotracheal intubation.
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Copyright © 2008 by F. A. Davis.
187
Dose: 0.4–0.5 mg/kg IV bolus, may repeat subsequent boluses of 0.1 ␮g/kg
q 15–20 min or an infusion of 5–9 ␮g/kg/min.
Contraindications: Myasthenia gravis, asthma, Eaton-Lambert syndrome,
severe electrolyte imbalances.
Side Effects: Bronchospasm, flushed skin, hypotension, tachycardia,
urticaria, hypersensitivity.
Precautions: Ensure intubation and suction equipment available, set up,
and in working order; multiple drug interactions.
Time Action Profile: Onset 2–2.5 min; peak 1–2 min; duration 30–40 min.
Atropine (Anticholinergic)
Indications: Sinus bradycardia, asystole, PEA with rate ⬍60, organophosphate and neurotoxin (nerve gas) exposure, antidote to cholinergic drug
toxicity and mushroom poisoning.
Dose: Bradycardia: 0.5–1 mg IV (may give via ET tube at double the dose)
q 3–5 min, maximum 0.04 mg/kg; cardiac arrest: 1 mg q 3–5 min, maximum
0.04 mg/kg; nerve gas and organophosphate exposure: 2–6 mg IV or IM
depending on severity of symptoms, may repeat in 2-mg increments q 3 min
titrated to relief of symptoms.
Contraindications: Atrial fibrillation, atrial flutter, glaucoma.
Side Effects: Tachycardia, HA, dry mouth, dilated pupils, VF/VT.
Precautions: Use caution in hypoxia. Avoid in hypothermic bradycardia and
2nd-degree (Mobitz) type-II HB.
Beta Blockers (Antihypertensive)
Common Agents: Atenolol, Labetalol, Metoprolol, Propranolol.
Indications: MI, unstable angina, PSVT, atrial fibrillation, atrial flutter, HTN.
Dose: See individual order and drug for route and dosage.
Contraindications: HR ⬍50, SBP ⬍100, 2nd- or 3rd-degree HB, left
ventricular failure.
Side Effects: Hypotension, dizziness, bradycardia, HA, N&V.
Precautions: Concurrent use with calcium channel blockers can cause
hypotension; use caution in patients with a history of bronchospasm;
multiple drug interactions.
Benadryl® (Diphenhydramine) (Antihistamine)
Indications: Anaphylactic reaction, extrapyramidal symptoms.
Dose: 10–50 mg IV or deep IM up to 100 mg; not to exceed 400 mg/24 hr.
Contraindications: Asthma, pregnant, lactating.
Side Effects: Dry mouth, drowsiness, hypotension.
Precautions: Elderly, severe liver disease, narrow angle glaucoma,
pregnancy.
MEDS/LABS
Copyright © 2008 by F. A. Davis.
MEDS/LABS
Bretylium (Bretylol®) (Antidysrhythmic)
Indications: Ventricular dysrhythmias.
Dose: VF, pulseless VT 5 mg/kg IVP, repeat 10 mg/kg q 15 min, maximum
30 mg/kg in 24 hr; VT w/pulse 5–10 mg/kg in 50–100 mL over 10 min;
maintenance drip 1–2 mg/min.
Contraindications: Severe aortic stenosis, severe pulmonary hypertension.
Side Effects: Hypotension, N&V, CP, bradycardia.
Precautions: Digoxin toxicity, renal failure.
Calcium Chloride (Minerals/Electrolytes/Calcium Salt)
Indications: Hyperkalemia, hypocalcemia, hypermagnesemia, antidote
to calcium channel blockers and beta blockers, given prophylactically with
calcium channel blockers to prevent hypotension.
Dose: Antidote to calcium channel blocker: 2–4 mg/kg IV, may be repeated
as needed; given prophylactically prior to IV calcium channel blockers 8–16
mg/kg IV; hyperkalemia: 2.25–14 mEq; may repeat in 1–2 min; give amount
sufficient to return ECG to normal; hypocalcemia: 2.3–9.3 mEq as needed
or 7–14 mEq if emergent need elevates Ca⫹⫹; hypermagnesemia: 2–7 mEq
slows IVP, may be repeated in 10 min, then observe for response before any
additional dose administered.
Contraindications: Hypercalcemia, VF, digoxin toxicity.
Side Effects: Bradycardia, asystole, hypotension, VF, N&V.
Precautions: Incompatible with sodium bicarbonate; administered
undiluted IVP.
Calcium Gluconate (Minerals/Electrolytes/Calcium Salt)
Indications: Hypocalcemia, hypocalcemic tetany, hyperkalemia with cardiac
toxicity, hypermagnesemia.
Dose: Hypocalcemia: 7–14 mEq IV; hypocalcemic tetany: 4.5–16 mEq IV,
repeat until symptoms are controlled; hyperkalemia with cardiac toxicity:
2.25–14 mEq IV, may repeat in 1–2 min; hypermagnesemia: 4.5–9 mEq IV.
Contraindications: Hypercalcemia, renal calculi, VF.
Side Effects: Cardiac arrest, dysrhythmias, phlebitis, N&V, bradycardia,
tingling, syncope.
Precautions: Monitor blood pressure, pulse, and ECG; do not administer
IM due to potential for tissue necrosis.
Cardizem® (Diltiazem) (Calcium Channel Blocker)
Indications: Atrial fibrillation, atrial flutter, PSVT refractory to adenosine.
Dose: 15–20 mg IVP over 2 min (0.25 mg/kg). May repeat in 15 min at 20–25
mg IVP over 2 min (0.35 mg/kg); maintenance drip: start at 5–15 mg/hr, and
titrate to HR.
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Copyright © 2008 by F. A. Davis.
189
Contraindications: Drug or poison induced tachycardia, wide-complex
tachycardia of uncertain type, WPW syndrome, cardiogenic shock, pulmonary
edema.
Side Effects: Hypotension, BBB, ventricular extrasystoles.
Precautions: Severe hypotension in patients on beta blockers; do not
withdraw abruptly.
Dantrolene (Dantrium®) (Skeletal Muscle Relaxant)
Indications: Emergency treatment of malignant hyperthermia.
Dose: 1–3 mg/kg IVP, may repeat as needed, maximum 10 mg/kg.
Contraindications: Pregnancy.
Side Effects: Drowsiness, muscle weakness, confusion, HA.
Precautions: Cardiac, pulmonary, or liver disease.
Decadron® (Dexamethasone) (Glucocorticoid, Anti-inflammatory)
Indications: Anaphylaxis, cerebral edema, spinal trauma, shock.
Dose: 10 mg IVP.
Contraindications: Ulcer, infection, alcohol intolerance.
Side Effects: Peptic ulceration, HTN, N&V.
Precautions: Tissue necrosis with infiltration.
Demerol® (Meperidine) (Opioid-Narcotic Analgesic [Agonist])
Indications: Moderate to severe pain.
Dose: 25–100 mg IM or 15 to 35 mg/hr continuous IV infusion.
Contraindications: Concurrent or recent use of MAO inhibitors, pregnancy,
respiratory depression, epilepsy or convulsive states, increased ICP, asthma.
Side Effects: Respiratory depression, confusion, sedation, seizure, CNS
toxicity, hypotension, N&V.
Precautions: Head trauma, elderly.
Dextrose 50% (Caloric Agent)
Indications: Hypoglycemic coma/altered LOC.
Dose: 25 g slow IVP.
Contraindications: CNS bleed, allergy to corn, hyperglycemia.
Side Effects: Hyperglycemia, fluid overload.
Precautions: Tissue necrosis with infiltration.
Digibind® (Digoxin Immune fab) (Antidote to Digoxin, Digitoxin)
Indications: Symptomatic digoxin toxicity or acute ingestion of unknown
amount of digoxin.
Dose: Dependent on serum digoxin levels. One 40 mg vial binds to
approximately 0.6 mg of digoxin.
Contraindications: Allergy only, otherwise, none known.
MEDS/LABS
Copyright © 2008 by F. A. Davis.
MEDS/LABS
Side Effects: Worsening of CHF, atrial fibrillation, hypokalemia, increased
serum digoxin levels.
Precautions: Patients with allergies to sheep proteins.
Digoxin (Lanoxin®) (Inotropic, Antidysrhythmic)
Indications: Atrial fibrillation and atrial flutter, CHF, pulmonary edema.
May be used as an alternative treatment for PSVT.
Dose: Loading dose of 10–15 ␮g/kg.
Contraindications: Uncontrolled atrial dysrhythmias, AV block, idiopathic
hypertrophic subaortic stenosis (IHSS), constrictive pericarditis.
Side Effects: Dysrhythmias, particularly VF, AV block, atrial fibrillation,
fatigue, bradycardia, N&V, blurred or yellow vision, HA, hypersensitivity,
hypokalemia.
Precautions: Avoid electrical cardioversion of stable patients. If unstable,
use lower current settings such as 10–20 joules; elderly; pregnancy.
Dobutamine (Dobutrex®) (Inotropic)
Indications: Short-term treatment of cardiac decompensation in organic
heart disease or cardiac surgical procedures.
Dose: Per order.
Contraindications: Idiopathic hypertrophic subaortic stenosis.
Side Effects: Ventricular ectopy, chest pain, hypersensitivity,
bronchospasm.
Precautions: Safe use in acute MI not established. Ensure adequate
hydration prior to infusion.
Dopamine (Intropin®) (Vasopressor, Inotropic)
Indications: Cardiogenic shock d/t MI, trauma, endotoxic septicemia, open
heart surgery, renal failure, and chronic cardiac decompensation.
Dose: Per order.
Contraindications: Pheochromocytoma, uncorrected tachycardia, VF, and
pediatric clients.
Side Effects: Tachycardia, angina, hypo- and hypertension, palpitations,
vasoconstriction, dyspnea, N&V.
Precautions: Adjust dosage in elderly patients and in those with occlusive
vascular disease. Extravasation may result in sloughing of tissue. Ensure
adequate hydration prior to infusion.
Epinephrine (Adrenalin®) (Adrenergic Agonist)
Indications: All cardiac arrest, anaphylaxis. Also used for symptomatic
bradycardia refractory to atropine, dopamine, and TCP; severe hypotension,
acute asthma attack, and vasopressor shock.
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Copyright © 2008 by F. A. Davis.
191
Dose: Cardiac arrest: 1 mg IV of 1:10,000 solution q 3–5 min; double the
dose if administering via ET tube; anaphylaxis: 0.1–1 mg SQ or IM of 1:1000
solution; asthma: 0.1–0.3 mg SQ or IM of 1:10,000 solution; refractory
bradycardia and hypotension: 2–10 ␮g/min (1 mg of 1:1,000 solution in 500
mL of saline and start at 1–5 mL/min).
Contraindications: Hypersensitivity to adrenergic amines, narrow-angle
glaucoma.
Side Effects: Angina, HTN, tachycardia, VT, VF, nervousness, restlessness,
tremors, pallor, cerebral or subarachnoid hemorrhage and aortic rupture,
suicidal/homicidal tendencies.
Precautions: Use caution in HTN, tachydysrhythmias, cardiac disease,
hyperthyroidism, glaucoma, DM, elderly, pregnancy, multiple drug
interactions.
Esmolol (Brevibloc) (Selective Beta Blocker, Antidysrhythmic)
Indications: SVT in those with atrial fibrillation or atrial flutter,
noncompensatory ST, tachycardia and HTN during induction or emergence
from anesthesia.
Dose: 80 mg over 30 sec followed by 150 ␮g/kg/min. May repeat dose.
Contraindications: Dosage has not been established in children.
Side Effects: Flushing, pallor, induration, burning and/or edema at site of
infusion, urinary retention, midscapular pain, asthenia.
Precautions: Avoid use in children.
Glucagon (Hormone)
Indications: Antidote to beta-blocker and calcium channel blocker overdose;
hypoglycemia when IV access unavailable and patient cannot protect airway
(cannot take oral glucose); used to decrease GI motility during GI
procedures.
Dose: Antidote to calcium channel blocker: 2 mg IV; antidote to beta
blocker: 50–150 ␮g/kg IVP followed by a 1–5 mg/hr infusion; hypoglycemia:
0.5–1 mg IV, IM, SC; to decrease GI motility: 0.25–1 mg slow IVP or up to
2 mg IM.
Contraindications: Known allergy to beef or pork protein.
Side Effects: N&V.
Precautions: Use caution in patients with insulinoma or
pheochromocytoma.
Glycoprotein IIb and IIIa Inhibitors (Platelet Aggregation Inhibitor)
Common Agents: Abciximab (ReoPro®), Eptifibatide (Integrilin®), Tirofiban
HCl (Aggrastat®).
Indications: Acute coronary syndrome without ST-segment elevation,
adjunct to percutaneous coronary intervention in patients with high risk of
abrupt closure of treated coronary vessel.
MEDS/LABS
Copyright © 2008 by F. A. Davis.
MEDS/LABS
Dose: See individual order and drug for route and dosages.
Contraindications: Active internal bleeding within 30 days, history of
neurovascular event within 1 month (within 2 years of surgery or trauma
within 1 month) aortic dissection, severe (uncontrolled) HTN, within 6 weeks
of a known GI or GU bleed, known bleeding disorder.
Side Effects: Increased bleeding and bruising, GI irritation.
Precautions: Increased chance of bleeding; use with caution in elderly, in
patients with history of GI disease, or those receiving thrombolytics; multiple
herb interactions.
Heparin (Anticoagulant)
Indications: Acute pulmonary/peripheral embolism, atrial fibrillation with
emoblization, treatment of DIC.
Dose: Per order.
Contraindications: Active bleeding, blood dyscrasias, thrombocytopenia,
liver disease, suspected intracranial hemorrhage, ulceration of the GI tract,
subendocarditis, shock, threatened abortion, severe HTN, hypersensitivity.
Side Effects: Minor to major hemorrhage, thrombocytopenia, anaphylaxis.
Precautions: Use with caution in menstruating women, post-partally,
following CVA, and in the elderly; multiple herb interactions.
Histamine Blockers (H2-Receptor Antagonists)
Common Agents: Cimetidine (Tagament®), famotidine (Pepcid®), nizatidine
(Axid®), ranitidine (Zantac®).
Indications: Duodenal and gastric ulcers; management of gastroesophageal
reflux disease (GERD); upper GI bleed.
Dose: See individual order and drug for route and dosages.
Contraindications: Hypersensitivity, impaired renal or hepatic function.
Side Effects: Confusion, dizziness, agitation, drowsiness, HA, site pain,
N&V, constipation, bradycardia, tachycardia, PVCs, cardiac arrest,
bronchospasm, anaphylaxis.
Precautions: Assess elderly and severely ill patients for confusion routinely.
Ibutilide Fumarate (Corvert®) (Antidysrhythmic)
Indications: SVT, including atrial fibrillation and atrial flutter.
Dose: Patients ⴝ 60 kg: 1 mg slow IVP over 10 min, may repeat same
dose in 10 min; Patients ⬍60 kg: 0.01 mg/kg slow IVP over 10 min, may
repeat in 10 min.
Contraindications: Known allergy, concomitantly with other antidysrhythmics such as quinidine, procainamide, amiodarone.
Side Effects: Severe ventricular dysrhythmias such as torsades de pointes,
HA, N&V, hypotension, bundle branch block, HTN, nodal dysrhythmias.
Precautions: CHF, LV dysfunction, pregnancy, multiple drug interactions.
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193
Inamrinone (Inocor®) (Inotropic)
Indications: Short-term treatment of CHF unresponsive to traditional
therapies.
Dose: Per order.
Contraindications: Hypersensitivity to bisulfates, IHSS.
Side Effects: Dyspnea, dysrhythmias, hypotension, N&V, diarrhea,
hepatotoxicity, hypersensitivity, tachyphylaxis.
Precautions: Use cautiously in atrial fibrillation or atrial flutter, electrolyte
imbalances, renal impairment, and geriatric patients.
Ipecac Syrup (Emetic)
Indications: OD/poisoning of noncaustic substance.
Dose: 15–30 mL PO followed by 240 mL of water, may repeat 15 mL in 30
min if ineffective.
Contraindications: Altered LOC, ingestion of caustic substance, severe
inebriation, shock, TCA OD, seizures.
Side Effects: Diarrhea, dysrhythmias, atrial fibrillation, sedation, coughing
or choking with emesis.
Precautions: Pregnancy, abuse in bulemic or anorexic patients.
Isuprel® (Isoproterenol) (Inotropic)
Indications: Symptomatic bradycardia, torsades de pointes refractory to
magnesium, bradycardia in heart transplant patients, beta-blocker OD,
bronchospasm.
Dose: 2–10 ␮g/min titrated to desired heart rate.
Contraindications: Cardiac arrest, concurrent use with epinephrine, high
dosages (except in beta-blocker OD), heart block caused by digitalis
intoxication, angina, tachydysrhythmias.
Side Effects: Hypotension, HA, VT, VF, tachycardia, pulmonary edema,
cardiac arrest.
Precautions: Increase cardiac ischemia, consider Isuprel last, cautious use
in persons with tuberculosis.
Kayexalate® (Sodium Polystyrene Sulfonate)
(Cation Exchange Resin)
Indications: Mild to moderate hyperkalemia.
Dose: 15 g PO or 25–100 g rectally as a retention enema 1–4 times daily in
water or sorbitol (if severe, more immediate measures such as sodium
bicarbonate IV, calcium, or glucose/insulin infusion should be instituted).
Contraindications: Life-threatening hyperkalemia, ileus, known alcohol
intolerance, hypersensitivity to saccharin or parabens.
Side Effects: Constipation, N&V, fecal impaction, gastric irritation,
hypocalcemia, hypokalemia, sodium retention.
Precautions: Monitor ECG and electrolytes during therapy, use cautiously
in the elderly, CHF, hypertension, constipation.
MEDS/LABS
Copyright © 2008 by F. A. Davis.
MEDS/LABS
Lasix® (Furosemide) (Diuretic, Distal Loop)
Indications: CHF with acute pulmonary edema, hypertensive crisis,
increased ICP, nephrotic syndrome, hepatic cirrhosis.
Dose: 0.5–1 mg/kg slow IVP over 1–2 min, may repeat once at 2 mg/kg
slow IVP over 1–2 min.
Contraindications: Never use with ethacrinic acid, anuria, hypotension,
hepatic coma, dehydration, hypokalemia, hypersensitivity to sulfonamides.
Side Effects: Severe dehydration/hypovolemia, hypotension, hypokalemia,
hyponatremia, hypochloremia, azotemia, vertigo, dizziness.
Precautions: Monitor urine output and electrolytes during therapy and
injection site for thrombophlebitis, cardiac arrest following IV administration.
Lidocaine (Xylocaine®) (Antidysrhythmic, Anesthetic)
Indications: Pulseless VF/VT, wide-complex tachycardia of uncertain type.
Dose: 1–1.5 mg/kg IVP or ET tube (double dose if giving via ET tube), may
repeat q 5–10 min, maximum 3 mg/kg. If conversion successful, start an
infusion of 2–4 mg/min.
Contraindications: 2nd- or 3rd-degree HB, Stokes-Adams and WPW
syndromes, hypotension, hypersensitivity to amide-type local anesthetics.
Side Effects: Altered LOC, seizure, slurred speech, malignant hyperthermia,
hypotension, bradycardia, cardiovascular collapse, respiratory arrest.
Precautions: Reduce infusion dose by 50% if ⬎70 yr, CHF, shock, liver
disease, marked hypoxia, digitalis toxicity, severe respiratory depression.
Magnesium Sulfate (Electrolyte, Anticonvulsant)
Indications: Seizures associated with toxemia of pregnancy, hypomagnesemia or hypothyroidism, torsades de pointes, severe asthma, VF refractory
to lidocaine, digoxin-induced VT/VF.
Dose: Hypomagnesemia: 0.5–1 g/hr IV; cardiac arrest 1–2 g IVP; torsades de
pointes (noncardiac arrest): load with 1–2 g infused over 5–60 min, then
infuse 0.5–1 g /hr; digoxin-induced VT/VF: 1–2 g IVP; toxemia of pregnancy:
1–4 g slow IVP (4–5 g IV followed by an infusion of 1–2 g/hr) continuous
infusion not to exceed 40 g/24 hr.
Contraindications: Hypermagnesemia, hypocalcemia, renal disease, heart
block, toxemia of pregnancy 2 hr prior to delivery.
Side Effects: Hypotension, cardiac arrest, respiratory depression, altered
LOC, flushed skin, diaphoresis, hypocalcemia.
Precautions: Renal insufficiency.
Mannitol (Osmitrol®) (Diuretic [Osmotic])
Indications: Increased ICP, the oliguric phase of acute renal failure, severe
intraocular pressure, diuresis of toxic substances.
Dose: 1.5–2 g/kg IV over 30–60 min.
Contraindications: Intracranial bleeding, pulmonary edema, anuria,
dehydration.
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195
Side Effects: Altered LOC, HA, blurred vision, N&V, tachycardia, hypotension or HTN, chest pain, CHF, seizures.
Precautions: Elderly, cardiovascular and renal disease.
Milrinone (Primacor®) (Inotropic)
Indications: Short-term treatment of CHF in patients receiving digoxin and
diuretics.
Dose: Per order.
Contraindications: Obstructive pulmonic or aortic valvular disease,
hypersensitivity.
Side Effects: VT, SVT, hypotension, abnormal digoxin levels, angina, HA,
hypokalemia, tremors.
Precautions: Use cautiously in patients with a history of dysrhythmias,
electrolyte imbalances, renal impairment, pregnancy.
Morphine Sulfate (Opioid-Narcotic Analgesic [Agonist])
Indications: Moderate to severe pain, chest pain unrelieved with NTG,
CHF and dyspnea associated with pulmonary edema.
Dose: 4–15 mg IVP q 3–4 hr or as a loading dose titrated to respiratory
status followed by an infusion of 0.2–1 mg/mL.
Contraindications: Heart failure due to chronic lung disease, respiratory
depression, hypotension, undiagnosed acute abdominal pain, head injury,
altered LOC, acute alcoholism, DTs.
Side Effects: Respiratory depression, hypotension, N&V, bradycardia,
altered LOC, seizures.
Precautions: Reverse with Narcan, multiple drug interactions.
Narcan (Naloxone®) (Opioid-Narcotic Antagonist)
Indications: Narcotic-induced respiratory depression.
Dose: 0.4–2 mg IV, IM, SC, ET (double the dose when administered via ET
tube) q 2–3 min intervals, maximum 10 mg.
Contraindications: Known allergy to Narcan, narcotic addicts.
Side Effects: Acute withdrawal symptoms in addicted patients, VT, VF,
hypotension or hypertension, seizures.
Precautions: Avoid total narcotic reversal in addicted patients, half-life may
not be as long as narcotic half-life. May cause severe HTN in hypertensive
patient during labor.
Nipride® (Nitroprusside, Nitropress®) (Vasodilator)
Indications: Hypertensive crisis, acute CHF.
Dose: Per order.
Contraindications: Aortic coarctation or AV shunting, high output failure in
endotoxic sepsis.
Side Effects: Dizziness, restlessness, nausea, HA, palpitations, bradycardia,
tachycardia, flushing, seizures, increased ICP, thiocyanate toxicity.
MEDS/LABS
Copyright © 2008 by F. A. Davis.
MEDS/LABS
Precautions: Use with caution in hypothyroidism, liver or renal impairment,
increased ICP, and the elderly.
Nitroglycerin (Nitrostat®) (Antianginal, Nitrate)
Indications: Angina, CHF associated with acute MI, cardiac load-reducing
agent, hypertensive crisis.
Dose: 0.3–0.4 mg SL q 5 min, maximum 3 doses.
Contraindications: SBP ⬍90 mm Hg, severe bradycardia, severe
tachycardia, Viagra® within 24 hr, RV infarction.
Side Effects: Hypotension with secondary tachycardia, syncope, HA,
flushed skin.
Precautions: Do not mix with other medications, titrate IV form to maintain
SBP ⬎90 mm Hg.
Pitocin® (Oxytocin) (Hormone)
Indications: Postpartum hemorrhage.
Dose: 10 units IM or 10–40 units in 1000 mL saline, LR, or D5W, and infuse at
0.02–0.1 units/min (titrate to effect).
Contraindications: Known allergy, incomplete delivery.
Side Effects: Anaphylaxis, dysrhythmias, HTN, seizure, coma, hypotension,
postpartum hemorrhage, uterine rupture.
Precautions: Evaluate for multiple births.
Potassium Chloride (Mineral/Electrolyte)
Indications: Hypokalemia.
Dose: Hypokalemia (⬎2.5) up to 200 mEq/day as an infusion (not to exceed
20 mEq/hr or a concentration of 40 mEq/L via peripheral line) (up to 80
mEq/L has been used via central line [unlabeled]). Hypokalemia (⬍2) up to
400 mEq/day as an infusion (rate should generally not exceed 20 mEq/hr).
Contraindications: Hyperkalemia, severe renal impairment, untreated
Addison’s disease, severe tissue trauma.
Side Effects: Dysrhythmias including heart block, abdominal pain, N&V,
diarrhea, confusion, restlessness, weakness, respiratory paralysis, irritation
at IV site.
Precautions: Monitor HR, BP, RR, and ECG throughout infusion. Severe pain
and tissue necrosis with extravasation. Use with caution in the elderly with
cardiac or renal disease.
Procainamide (Pronestyl®) (Antidysrhythmic)
Indications: VT, PSVT refractory to adenosine and vagal stimulation, rapid
atrial fibrillation in WPW, paroxysmal atrial tachycardia, stable wide-complex
tachycardia of uncertain type, maintenance after conversion.
Dose: 20 mg/min, maximum 17 mg/kg; maintenance of 1–4 mg/min.
Contraindications: 2nd- or 3rd-degree HB, torsades de pointes, lupus,
myasthenia gravis, digoxin toxicity, hypersensitivity.
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197
Side Effects: Hypotension, widening QT, asystole, HA, N&V, flushed skin,
seizure, ventricular dysrhythmias, partial or complete HB.
Precautions: Stop administration for hypotension or when QT interval
begins to widen. Use cautiously in patients with CHF, cardiomyopathy, or
acute ischemic heart disease, and in patients with liver or renal disease.
Multiple drug interactions.
Propofol (Diprivan®) (Sedative, Anesthetic)
Indication: Sedation, anesthesia.
Dose: Initial dose 2–2.5 mg/kg; maintenance 100–200 ␮g/kg/min or may be
given in 25–50-mg increments; use half the dose for elderly and debilitated
patients.
Contraindications: Allergy to egg, soy, or glycerol products; labor and
delivery.
Side Effects: Apnea, HTN, bradycardia, dizziness, HA, N&V, flushed skin,
burning at the site.
Precautions: Lipid metabolism disorders, increased ICP, cardiovascular
disease, the elderly.
Proton Pump Inhibitors
Common Agents: Lansoprozole (Prevacid®), omprazole (Prilosec®),
pantroprazole (Protonix®), esomeprazole (Nexium®), rabeprazole (Aciphex®).
Indications: Duodenal and gastric ulcers; management of GERD; upper
GI bleed.
Dose: See individual order and drug for route and dosages.
Contraindications: Hypersensitivity.
Side Effects: Confusion, dizziness, drowsiness, HA, site pain, N&V,
hypotension or HTN, CVA, MI, shock.
Precautions: Assess elderly and severely ill patients for confusion routinely,
reduce dosage in impaired hepatic function.
Romazicon® (Flumazenil) (Antagonist [Benzodiazepines])
Indication: Antidote to benzodiazepines.
Dose: 0.2 mg IVP, may repeat 0.3 mg in 30 sec, followed with 0.5 mg q min,
maximum 3 mg/hr (0.2 mg given over 15 sec, followed by 0.2 mg if no
patient response after 45 sec). May be repeated at 60-sec intervals, up to a
maximum of 1 mg.
Contraindications: TCA OD, known history of seizures, increased ICP,
allergy to benzodiazepine.
Side Effects: Withdrawal symptoms, dizziness, seizures, N&V.
Precautions: Avoid using in multiple drug OD; use associated with high risk
of seizures in certain patients, especially those with head injury or alcoholism.
Sodium Bicarbonate (Alkalizing Agent, Buffer)
Indications: Hyperkalemia, tricyclic antidepressant OD, cocaine or
diphenhydramine or ASA OD, metabolic acidosis, shock associated with
severe diarrhea, dehydration, uncontrolled DM.
MEDS/LABS
Copyright © 2008 by F. A. Davis.
MEDS/LABS
Dose: 1 mEq/kg IVP, may repeat 0.5 mEq/kg q 10 min.
Contraindications: Metabolic or hypochloremic alkalosis, hypocalcemia,
renal failure, as an antidote to ingestion of strong mineral acid, HTN,
convulsions.
Side Effects: Hypokalemia, metabolic alkalosis, seizures, N&V, tetany.
Precautions: CHF, renal disease, concurrent use with glucocorticoids,
multiple drug interactions.
Succinylcholine chloride (Sucostrin®)
(Neuromuscular Blocking Agent [Depolarizing])
Indications: Paralysis to facilitate endotracheal intubation.
Dose: Initial dose: 1–2 mg/kg IVP (0.3–1.1 mg/kg IVP; maintenance: 0.5–10
mg/min continuous infusion).
Contraindications: Cannot use with lactated Ringer’s solution or in
patients with a family history of malignant hyperthermia, myopathies with
elevated CPK, acute narrow-angle glaucoma.
Side Effects: Hypotension, bradycardia, apnea, bronchospasm, hyperkalemia, malignant hyperthermia, severe persistent respiratory depression or apnea, anaphylaxis.
Precautions: Ensure intubation and suction equipment available, set up,
and in working order. Use with caution in clients with CV, pulmonary, or
metabolic disorders. Patients with myasthenia gravis may show resistance.
Time Action Profile: Onset 0.5–1 min; peak 1–2 min; duration 4–10 min.
Thrombolytics
Common Agents: Activase® (Alteplase, recombinant; t-PA); Retavase®
(Reteplase), Streptase® (Streptokinase)
Indication: Acute MI ⬍12 hr from onset of symptoms and acute ischemic
stroke.
Dose: See individual order and drug for route and dosages.
Contraindications: Active internal bleeding within 21 days (except
menses), history of neurovascular event within 3 months, major surgery or
trauma within 2 weeks, aortic dissection, severe (uncontrolled) HTN,
bleeding disorder, prolonged CPR, LP within 1 week.
Side Effects: Hypotension, reperfusion arrhythmias, HA, increased bleeding
time, hemorrhage, flushing, urticaria.
Precautions: Patients with severe renal or hepatic disease.
Toradol® (Ketorolac) (NSAID, Nonopioid Analgesic)
Indication: Short-term management of moderate acute pain.
Dose: 15–30 mg IV or 30–60 mg IM; use half the dose for patients over 65 yr,
⬍50 kg, or have renal impairment.
Contraindications: Allergy, prior to and during surgery, known alcohol
intolerance, active peptic ulcer disease or GI bleeding, renal impairment,
pregnancy, lactation.
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199
Side Effects: Drowsiness, GI bleed or perforation, nausea, HA, increased
bleeding time, anaphylaxis, bronchospasm.
Precautions: GI bleed; renal, hepatic, or CV disease.
Vasopressin (Pitressin®) (Vasopressor, Hormone)
Indication: Cardiac arrest as an alternative to epinephrine, GI hemorrhage,
neurogenic diabetes insipidus.
Dose: Cardiac arrest: 40 units IVP one-time dose; GI hemorrhage: 0.1–0.4
units/min; IV diabetes insipidus: 5–10 units IM/SC.
Contraindications: Pregnancy, epilepsy, heart failure, asthma, CAD,
migraine, allergy to beef or pork protein, renal failure with BUN.
Side Effects: Dizziness, HA, N&V, MI, chest pain, abdominal cramps,
diaphoresis, heartburn, diarrhea, bronchoconstriction, anaphylaxis, coma,
convulsions.
Precautions: Monitor ECG throughout therapy, never give the tannate IV,
multiple drug interactions.
Vecuronium (Norcuron®) (Neuromuscular
Blocking Agent [Nondepolarizing])
Indications: Paralysis to facilitate endotracheal intubation.
Dose: Initial dose: 80–100 ␮g/kg; maintenance 10–15 ␮g/kg 25–40 min after
initial dose, repeat every 12–15 min as needed or as a continuous infusion
at 1 ␮g/kg/min
Contraindications: Cannot use with lactated Ringer’s solution, sensitivity
to bromides.
Side Effects: Hypotension, tachycardia, bradycardia, dyspnea, flushed skin,
urticaria, malignant hyperthermia.
Precautions: Ensure intubation and suction equipment available, set up,
and in working order; avoid use in patients with myasthenia gravis or EatonLambert syndrome.
Time Action Profile: Onset 1 min; peak 3–5 min; duration 15–25 min.
Verapamil (Calan®, Isoptin®) (Calcium Channel Blocker)
Indications: PSVT refractory to adenosine, atrial fibrillation, atrial flutter.
Dose: 2.5–5 mg (5–10 mg slow IVP over 2 min, may repeat 5–10 mg q
10 min, maximum 30 mg/min); may give prophylactic calcium chloride
(8–16 mg/kg IV) to counteract hypotension.
Contraindications: Atrial fibrillation/flutter with WPW, VT, or wide-complex
tachycardia of uncertain type, 2nd or 3rd degree heartburn, hypotension,
severe CHF.
Side Effects: Hypotension, exacerbation of CHF, asystole, bradycardia,
AV heart block, MI, CVA.
Precautions: Patients on oral beta blockers, hypertrophic cardiomyopathy,
impaired hepatic or renal function. Multiple drug interactions.
MEDS/LABS
Copyright © 2008 by F. A. Davis.
MEDS/LABS
Medications Compatible With IV KCl
acyclovir
alatrovafloxacin
aldesleukin
allopurinol
amifostine
aminophylline
amiodarone
ampicillin
amrinone
atropine
aztreonam
betamethasone
calcium gluconate
chlordiazepoxide
chlorpromazine
cimetidine
ciprofloxacin
cisatracurium
cladribine
cyanocobalamin
dexamethasone
digoxin
diltiazem
diphenhydramine
dobutamine
docetaxel
dopamine
doxorubicin liposome
droperidol
droperidol/fentanyl
edrophonium
enalaprilat
epinephrine
esmolol
conjugated
estrogens
ethacrynate sodium
etoposide
famotidine
fentanyl
filgrastim
fludarabine
fluorouracil
furosemide
gatifloxacin
gemcitabine
granisetron
heparin
hydralazine
idarubicin potassium
indomethacin
insulin
isoproterenol
kanamycin
labetalol
lidocaine
linezolid
lorazepam
magnesium sulfate
melphalan
menadiol
meperidine
methoxamine
methylergonovine
midazolam
minocycline
morphine
neostigmine
norepinephrine
ondansetron
oxacillin
oxytocin
paclitaxel
penicillin G potassium
pentazocine
phytonadione
piperacillin/tazobactam
procainamide
prochlorperazine edisylate
propofol
propranolol
pyridostigmine
ranitidine
remifentanil
sargramostim
scopolamine
sodium bicarbonate
succinylcholine
tacrolimus
teniposide
theophylline
thiotepa
tirofiban
trimethaphan
trimethobenzamide
vinorelbine
warfarin
zidovudine
Medications Incompatible With IV KCl
adrenaline HCl
amphotericin B cholesteryl sulfate complex
atropine sulfate
cephalothin sodium
chloramphenicol
sodium succinate
chlorpromazine HCl
diazepam
ergotamine tartrate
methicillin sodium
200
phenytoin
phenytoin sodium
sulphadiazine sodium
suxamethonium chloride
thiopentone sodium
Copyright © 2008 by F. A. Davis.
201
Reference Ranges for Common Laboratory Tests
Arterial Blood Gases (ABGs)
Normal ABG Results (U.S. System of Measurements)
pH
PaO2
PaCO2
7.35–7.45
80–100
35–45
mm Hg
mm Hg
Normal ABG Results (SI Units)
O2 sat
HCO3
Base Excess
95%–100%
21–28
mEq/L
⫺2 to ⫹2 mEq/L
pH
PaO2
PaCO2
O2 sat
HCO3
7.35–7.45
10.6–12.6
kPa
4.66–5.98
kPa
95%–100%
21–28
mmol/L
Base Excess
⫺2 to ⫹2
mmol/L
Critical Levels:
pH: ⬍7.25 or ⬎7.55
PaO2: ⬍45
PaCO2: ⬍20 or ⬎60
HCO3: ⬍15 or ⬎40
Base Excess: ⫾ 3 mEq/L
Chemistries
Test
Conventional
Albumin
Alkaline phosphatase
ALT
AST
BUN
Bilirubin, direct
Bilirubin, total
Calcium
Chloride
Cholesterol, total
CO2
Creatinine
Gamma-GT
Glucose
Lactic acid
3.9–5.0 g/dL
44–147 units/L
6–59 units/L
10–34 units/L
7–20 mg/dL
0.0–0.3 mg/dL
0.2–1.9 mg/dL
8.5–10.9 mg/dL
101–111 mmol/L
100–240 mg/dL
20–29 mEq/L
0.8–1.4 mg/dL
0–51 units/L
64–128 mg/dL
0.5–1.5 mEq/L or
8.1–15.3 mg/dL
SI Units
35–50 g/L
40–120 U/L
20–65 U/L
15–45 U/L
2.9–8.9 mmol/L
0–8 ␮mol/L
0–20 ␮mol/L
2.15–2.5 mmol/L
98–106 mmol/L
2–5.19 mmol/L
20–29 mmol/L
70–120 ␮mol/L
10–58 U/L
3.3–11 mmol/L
SI units: 0.5–1.5 mmol/L
(Continued on the following page)
MEDS/LABS
Copyright © 2008 by F. A. Davis.
MEDS/LABS
Chemistries (continued)
Test
LDH
Magnesium
Phosphorus
Potassium
Protein, total
Sodium
Uric acid, serum
Conventional
105–333 units/L
1.5–2 mEq/L
2.4–4.1 mg/dL
3.5–5 mEq/L
6.3–7.9 g/dL
136–144 mEq/L
Male: 4.0–8.5 mg/dL
Female: 2.8–7.3 mg/dL
SI Units
300–600 mmol/L
0.7–1.05 mmol/L
0.8–1.4 mmol/L
3.5–5 mmol/L
60–80 g/L
136–144 mmol/L
0.24–0.51 mmol/L
0.16–0.43 mmol/L
Coagulation Profile
Test
INR
PT
PTT/aPTT
D-dimer
FDP (fibrin degradation products)
Fibrinogen
Conventional
SI Units
0.9–1.2
10–14 sec
21–37 sec
⬍0.5 ␮g/mL
⬍5 ␮g/mL
0.9–1.2
10–14 sec
21–37 sec
150–400 mg/dL
1.7–4.1 g/L
Cardiac Markers
Test
Conventional
SI Units
Albumin cobalt binding test
⬍85 U/mL
⬍85 U/mL
B-type natriuretic peptide
0–100 pg/mL
Ø–100 ng/L
Creatinine phosphokinase, creatine kinase
Male: 55–170 U/L
Female: 30–135 U/L
Male: 55–170 U/L
Female: 30–135 U/L
CK isoenzymes
CK-MB: 0%–3%
0–0.03
Troponins (TnI, TnT)
Cardiac troponin
T: ⬍0.2 ng/mL
Cardiac troponin
I: ⬍0.03 ng/mL
Cardiac troponin
T: ⬍0.2 ng/mL
Cardiac troponin
I: ⬍0.03 ng/mL
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Copyright © 2008 by F. A. Davis.
203
Cardiac Markers (continued)
Test
Conventional
SI Units
Myoglobin, serum
Lactate dehydrogenase
(LD, LDH), LDH isoenzymes
Aspartate aminotransferase
⬍90 ␮g/L
100–190 U/L
⬍90 ␮g/L
100–190 U/L
0–35 U/L
0-0.58 ␮kat/L
Hematology
Test
Conventional
8.5–9.0% of body weight in kg
Male: 4.6–6.2 million/mm3
Red blood cell (RBC) Female: 4.2–5.9 million/mm3
Male: 13–18 g/100 mL
Female: 12–16 g/100 mL
Hemoglobin (Hgb)
Male: 45%–52%
Hematocrit (Hct)
Female: 37%–48%
4.300–10.800/mm3
Leukocytes (WBC)
0%–5%
■ Bands
0%–1%
■ Basophils
1%–4%
■ Eosinophils
25%–40%
■ Lymphocytes
10%–20%
■ B lymphocytes
60%–80%
■ T lymphocytes
2%–8%
■ Monocytes
54%–75%
■ Neutrophils
150,000–350,000/mm3
Platelets
Male: 1–13 mm/hr
Erythrocyte sediFemale: 1–20 mm/hr
mentation rate
150,000–450,000 mm3
Platelets
Males under 50 yr: ⬍15 mm/hr;
Sedimentation rate
males over 50 yr: ⬍20 mm/hr;
females under 50 yr: ⬍20 mm/
hr; females over 50 yr: ⬍30 mm/
hr (Westergren method)
Blood volume
MEDS/LABS
SI Units
80–85 mL/kg
4.6–6.2 ⫻ 1012/L
4.2–5.9 ⫻ 1012/L
8.1–11.2 mmol/L
7.4–9.9 mmol/L
0.45–0.52
0.37–0.48
4.3–10.8 ⫻ 109/L
0.03–0.08
0–0.01
0.01–0.04
0.25–0.40
0.10–0.20
0.60–0.80
0.02–0.08
0.54–0.75
150–350 ⫻ 109/L
1–13 mm/hr
1–20 mm/hr
150–450 ⫻ 109/L
Copyright © 2008 by F. A. Davis.
MEDS/LABS
A & P Snapshot
IM injection sites.
204
Copyright © 2008 by F. A. Davis.
205
Two inches away
from the umbilicus
SC injection sites, technique, and variations.
MEDS/LABS
Copyright © 2008 by F. A. Davis.
TOOLS/
INDEX
Electrical Conduction of the Heart
SA node
Left bundle
branch
Intra-atrial
pathways
AV Node
Purkinje
fibers
Bundle of His
Right bundle
branch
Electrical conduction of the heart.
Standard Placement: Lead-II & 7-Channel
White's
G
on the right
(negative)
and...
Smoke
(Ground)
Over
Fire
Chest lead
and
Right leg lead
Included for seven
channel monitoring
(positive)
+
Standard placement: Lead II and 7-channel.
Normal Cardiac Rhythm Parameters
NSR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Between 60 and 100 bpm
SB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Fewer than 60 bpm
ST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Over 100 bpm
QRS width . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Between 0.08 and 0.12 sec
P-R interval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Between 0.12 and 0.20 sec
Q-T interval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .0.30–0.40 sec
Atrial rate, inherent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60–100 bpm
Junctional rate, inherent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40–60 bpm
Ventricular rate, inherent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20–40 bpm
206
Copyright © 2008 by F. A. Davis.
207
Lead Placement and Normal Deflection of PQRST Waves
Midclavicular
line
Anterior
axillary line
Midaxillary
line
V6
V5
V 1 V2
V3
V4
Right
lung
Left
lung
V6
V5
V4
V1
V2
V3
Lead placement and normal deflection of PQRST waves.
TOOLS/
INDEX
Copyright © 2008 by F. A. Davis.
TOOLS/
INDEX
ECG Waveform of the Cardiac Cycle
R
P
PR
T
Q
S
Atrial
Ventricular
Ventricular
depolarization depolarization repolarization
ECG waveform of the cardiac cycle.
208
Copyright © 2008 by F. A. Davis.
209
Heart Sounds
QRS
P
QRS
T
S1
P
S2
T
S1
S2
Aortic
valve
Pulmonic
valve
S1
S2
S2
S1
Tricuspid
valve
Heart sounds.
TOOLS/
INDEX
Mitral
valve
Copyright © 2008 by F. A. Davis.
TOOLS/
INDEX
Figuring Rate and Measurement
To figure out rate (regular rhythms only), you can do one
of the following:
Count the number of QRS complexes
(regular rhythms only) in a 6-sec strip
and multiply by 10.
Irregular
rhythms
should be
counted for
an entire
minute.
Divide the number of large boxes
between two R waves into 300.
Remember the number sequence below and find an
R wave that falls on a heavy line. Starting from the
next heavy line, count 300, 150, 100, and so forth,
and whatever line the next R wave falls on is the
heart rate (see below for example).
1st R wave
300 150 100 75
Next R wave here
would be 150 bpm.
60
50
43
Next R wave here
would be 60 bpm.
Inherent rates of different cardiac regions:
SA Node ..................... 60–100 bpm
AV Node ....................... 40–60 bpm
Ventricles..................... 20–40 bpm
One small box
represents
0.04 sec and
is 1 mm2.
One big box represents
0.20 sec and is 5 mm2.
210
Copyright © 2008 by F. A. Davis.
211
Normal Cardiac Cycle and Measurements
P
QRS
P
R
T
Q
S
P-R interval
Normal
Rate bpm
60–100 bpm
Normal Rate
→ 60–100
Normal P-RNormal
→ 0.12–0.20
0.12–0.20 sec
P-R sec
Normal QRS → 0.08–0.12 sec
P wave → atrial depolarization; QRS → ventricular
depolarization; T wave → ventricular repolarization
0.04 sec
0.20 sec
Normal Sinus Rhythms
P waves before every QRS, P-R <0.20
Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Between 60–100
Rhythm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Regular
P waves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Present
P-R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Normal
QRS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Normal (0.08–0.12 sec)
TOOLS/
INDEX
Copyright © 2008 by F. A. Davis.
TOOLS/
INDEX
Analyzing the P-R Interval (PRI)
■ PRI is consistent and between 0.12 and 0.20 sec (3–5 small boxes). This is
considered a normal PRI.
■ PRI is ⬍0.12 sec (3 small boxes): consider junctional rhythm.
■ PRI is longer than 0.20 sec (5 small boxes), it remains consistent in length
from PRI to PRI: consider 1⬚ AV block.
■ PRI undergoes progressive lengthening until a QRS is dropped: consider
2⬚ AV block, type I.
■ PRI is consistent; however, there are additional P waves that do not
precede a QRS complex: consider 2⬚ AV block, type II.
■ PRI is not consistent, nor is there any correlation between the P wave and
the QRS: consider 3⬚ AV block (CHB).
Analyzing the QRS Complex
■ QRS between 0.08 and 0.12 (2–3 small boxes): consider normal.
■ QRS ⬎0.12 sec; “wide and bizarre”: consider ventricular ectopy.
■ QRS ⬎0.12 sec (3 small boxes), with notched or “rabbit ears” appearance:
consider BBB.
■ QRS preceded by 1–2 very narrow “spikes”: think pacemaker.
Basic ECG Assessment
1. Determine ventricular rate.
2. Determine QRS duration and shape.
3. Identify P waves, and determine if a P wave precedes every QRS
complex.
4. If more than 1 P wave precedes a QRS complex, determine ratio of P
waves to QRS complex (ex., 4:1, 3:1, 2:1).
5. Is P wave shape consistent?
6. Determine atrial rate and rhythm.
7. Determine P-R intervals and if they are consistent.
212
Copyright © 2008 by F. A. Davis.
213
Sinus Tachycardia
Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Fast (⬎100 bpm)
Rhythm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Regular
P waves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Present
P-R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Normal
QRS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Narrow (0.08–0.12 sec)
Sinus Bradycardia
Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Slow (⬍60 bpm)
Rhythm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Regular
P waves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Present
P-R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Normal
QRS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Narrow (0.08–0.12 sec)
TOOLS/
INDEX
Copyright © 2008 by F. A. Davis.
TOOLS/
INDEX
Atrial Fibrillation
Rate..............................................................................................................Variable
Rhythm ....................................................................................Irregularly-irregular
P waves ...............................................................................None (nondiscernible)
P-R....................................................................................................Nondiscernible
QRS.....................................................................................Narrow (0.08–0.12 sec)
Atrial Flutter
Flutter
waves
Rate .....................................Atrial → 250–350 bpm; ventricular → 125–175 bpm
Rhythm ...........................................................................................Usually regular
P waves ...........................................................Flutter waves → sawtooth pattern
P-R....................................................................................................Nondiscernible
QRS.....................................................................................Narrow (0.08–0.12 sec)
214
Copyright © 2008 by F. A. Davis.
215
Junctional Rhythm
No P waves
Rate .............................................................Normal junctional rate is 40–60 bpm
Rhythm ........................................................................................................Regular
P waves ................................If present: inverted, retrograde, buried in the QRS
P-R..................................................................................If present, it will be ⬍0.12
QRS...............................................................................................................Narrow
Ventricular Tachycardia (Fast and Wide)
Rate.....................................................................................................100–220 bpm
Rhythm ...........................................................................................Usually regular
P waves.................................................................................................Not present
P-R .........................................................................................................Not present
QRS ..........................................................................Wide and bizarre (⬎0.12 sec)
TOOLS/
INDEX
Copyright © 2008 by F. A. Davis.
TOOLS/
INDEX
Ventricular Fibrillation
Rate ................................................................VF rate is 350–450 (no Ps or QRSs)
Rhythm.......................................................Completely chaotic and disorganized
P waves............................................................................................................None
P-R .......................................................................................................................N/A
QRS ..................................................................................................................None
Asystole
Rate...............................................................................................................No rate
Rhythm ...................................................................................................No rhythm
P waves............................................................................................................None
P-R .........................................................................................................Not present
QRS......................................................................None (occasional agonal beats)
216
Copyright © 2008 by F. A. Davis.
217
1⬚ AV Block
Prolonged
P-R interval
Rate .........................................................................Usually between 60–100 bpm
Rhythm ........................................................................................................Regular
P waves ...................................................................Present, one P for every QRS
P-R .............................................................................................Remains ⬎0.20 sec
QRS.....................................................................................Narrow (0.08–0.12 sec)
2⬚ AV Block (Mobitz I—Wenckebach)
0.16
0.32
0.20
Dropped
QRS
Rate ......................................................................................................Slow (⬍100)
Rhythm ........................................................................................................Regular
P waves ........................................................................................................Present
P-R..........................................Gets progressively longer until a QRS is dropped
QRS.....................................................................................Narrow (0.08–0.12 sec)
TOOLS/
INDEX
Copyright © 2008 by F. A. Davis.
TOOLS/
INDEX
2⬚ AV Block (Mobitz II)
Blocked
P waves
Rate .....................................................................................................Usually slow
Rhythm ........................................................................................................Regular
P waves....................................................................................More Ps than QRSs
P-R.........................................................Unblocked Ps usually have a normal P-R
QRS........................................................................Narrow, but may also be wide
3⬚ AV Block (Complete Heart Block)
No correlation
between atria
and ventricles
P
P
P
P
Rate ..................................................Atrial: 60–100 bpm; ventricular: 20–40 bpm
Rhythm ........................................Both ventricular and atrial are usually regular
P waves..........................................................More Ps than QRSs; no correlation
P-R .........................................................................................................Inconsistent
QRS ............................................................................Usually wider than 0.12 sec
218
Copyright © 2008 by F. A. Davis.
219
PVC (Premature Ventricular Complex)
Compensatory
Pause
Rate .....................................................................................................................N/A
Rhythm..................................Temporary delay caused by compensatory pause
P waves............................................................................................................None
P-R .......................................................................................................................N/A
QRS ..........................................................................Wide and bizarre (⬎0.12 sec)
Premature Atrial and Junctional Complex
P
PAC
No
P
PJC
Rate..........................................................................................................Premature
Rhythm....................................................................................................Premature
P waves ..................................Present in PAC, but may be hidden in the T wave
P-R .......................................................................................Not present in the PJC
QRS ..............................................................................................................Normal
TOOLS/
INDEX
Copyright © 2008 by F. A. Davis.
TOOLS/
INDEX
Starting an IV
Prepare the patient: explain procedure, answer any questions, and give
reassurance.
Gather equipment: IV bag with primed tubing, sharps container, catheter,
tape, dressing, tourniquet, antiseptic swabs, gloves, IV catheter of appropriate size.
Organize supplies: tear tape, hang IV solution with primed tubing close by,
sharps container within easy reach, 2 ⫻ 2 or other dressing open.
Apply tourniquet: proximal to intended insertion site, either mid-forearm
or above the elbow; don gloves.
Locate vein: palpate with finger tips; to further enhance dilation, gently tap,
apply heat/warm soak, have patient make a fist, or dangle arm below heart.
Cleanse site: using moderate friction, cleanse in a circular motion, moving
outward from intended site.
Put on gloves: while waiting for cleansed area to dry, avoid touching site
once it has been prepared.
Apply traction (opposite the direction of the catheter).
Position needle: bevel side up, 15⬚–30⬚ Note: hold the needle with the
thumb and pointer finger in a way that allows for visualization of the flash
chamber.
Insert needle, and observe for “flash back” in flash chamber. Lower catheter
almost parallel to the skin, and insert the needle 1–2 additional mL to ensure
catheter has also entered the vein.
Advance the catheter: thread catheter into vein while maintaining skin
traction and pulling back on needle.
Release the tourniquet, and apply digital pressure just above the end of
the catheter tip while gently stabilizing the hub of the catheter.
Remove needle, and discard into approved sharps container.
Connect IV tubing, open clamp, and observe for free flow of IV fluid.
Secure catheter, and apply sterile dressing per hospital policy/procedure.
Clean up, and document per hospital policy/procedure.
Peripheral and Central Line Care
General Care for All Vascular lines
■ Always use aseptic technique when caring for IV sites.
■ Assess for signs of infection every shift.
■ Remove peripheral line if site appears infected or phlebitic.
■ Call physician if IV access appears infected.
■ Change loose, soiled, or wet dressings immediately.
220
Copyright © 2008 by F. A. Davis.
221
Peripheral Access IV Lines
■ Change site every 72 hours.
■ Assess for signs of infiltration (swelling, tenderness, redness, burning
with infusion, decreased or no infusion rate, blanching of skin, site cool
to touch) or phlebitis (vein feels firm and appears red; warmth, swelling,
and tenderness); discontinue IV, and restart in a new site.
CVC: External Access Port(s) (Groshong)
■ Avoid touching the exit site with fingers.
■ Change the end cap(s) every 7 days or sooner if any blood, cracks, or
leaks are seen.
■ Change the dressing, and clean the exit site every day.
■ If using a transparent film, change and clean the exit site dressing once
a week.
■ Clean with alcohol. Never use iodine!
Tunneled CVC: External Access Ports (Hickman, Broviac, Leonard,
or Ventra Catheters)
■ Keep tubes clamped when not being used.
■ Change the end cap(s) every 7 days or sooner if any blood, cracks, or
leaks are seen.
■ Change the dressing, and clean the exit site every 2 days. If using an opsite, change and clean the exit site dressing once a week.
Implanted Port Catheters: Groshong
■ Wash skin around area of port daily with soap and water. If recently
inserted, provide aseptic incision care until healed.
IV Solutions: Crystalloids and Colloids
IV solutions can be divided into two basic categories: crystalloids and colloids
(volume expanders). Crystalloids contain water, dextrose, and/or electrolytes
and are commonly used to treat different fluid and electrolyte imbalances.
Colloids (also referred to as plasma expanders or volume expanders) have an
increased osmotic pressure in comparison with crystalloids; they remain in
intravascular space longer and are used for volume expansion.
Comparison of Crystalloids
Type of Solution
Saline solutions
NS, 0.9% NaCl, sodium
chloride, saline, 3%
and 5% saline
Components
Na and Cl
Indications
■ Alkalosis
■ Fluid loss
■ Sodium depletion
(Continued on the following page)
TOOLS/
INDEX
Copyright © 2008 by F. A. Davis.
TOOLS/
INDEX
Comparison of Crystalloids (continued)
Type of Solution
Components
Indications
Dextrose solutions
D5W, D10W
Dextrose in
water
■
■
■
■
Replace calories as carbohydrates
Prevent dehydration
Maintain water balance
Promote sodium diuresis
Dextrose and
saline mixtures
D5NS, D51/2NS, D10NS
Dextrose in
saline
■
■
■
■
Promote diuresis
Correct moderate fluid loss
Prevent alkalosis
Provide calories and sodium chloride
Multielectrolyte
solutions
Lactated Ringer’s,
Ringer’s lactate
Combination
of Na, Cl,
K, Ca, and
lactate
■ Replaces fluid lost due to vomiting
or GI suctioning
■ Treats dehydration
■ Restores normal fluid balance
Volume Expanders (Colloids)
Volume expanders include colloids, dextran, and hetastarch. Colloids are protein
solutions such as albumin, plasma, and commercial plasmas (e.g., Plasmanate).
Dextran is a complex, synthetic sugar. Because Dextran is slowly metabolized, it
does not stay in the vascular space as long as a colloid. Hetastarch is a synthetic
colloid that works similarly to Dextran.
Comparison of Volume Expanders (Colloids)
Type of Solution
Albumin
5% and 25%
Components
Human plasma
protein
Plasma plasmanate Contains human
Plasma protein
plasma proteins
fraction
in NS
Indications
5%: Rapid volume expansion
and mobilize interstitial edema
25%: Hypoproteinemia
To increase serum colloid
osmotic pressure
Dextran
40% and 70%
Volume expansion
Synthetic colloid
made of glucose Mobilize interstitial edema
polysaccharides
Hetastarch:
Hespan
Synthetic colloid
made from corn
Volume expansion
Mobilize interstitial edema
Blood products: any of the components found in whole blood.
222
Copyright © 2008 by F. A. Davis.
223
Comparison of Blood Products
Blood Product
Components
Indications
Whole blood
Contains all blood
products.
Rarely used; may be given to
an exsanguinating patient.
Packed red blood
cells (PRBCs)
Platelets
No clotting factors or Acute and chronic anemia;
platelets, 80%
blood loss.
plasma removed.
Low platelet counts; coaguUsually given in
lopathies; 1 unit may increase
pools of 6–10 units.
platelet count by 6000 units.
Fresh frozen
plasma
Plasma and clotting
factors.
To replace clotting factors after
multiple transfusions (⭓6
PRBCs); Coumadin intoxication; replace clotting factors
Cryoprecipitate
Clotting factors
Hemophilia, fibrinogen
deficiency, DIC
Autologous Blood Donation/Transfusion
■ A procedure for collecting and storing a patient’s own blood several
weeks before its anticipated need by the patient.
■ Salvage of blood normally lost during a surgical procedure.
■ Used to prevent transmission of disease from donor blood. It is not
without risk—stored blood may still become contaminated.
TOOLS/
INDEX
Reusable Assessment Flowsheet
Patient
DX/S/P
Time
↓
Vital Signs
BP
HR
RR
Notes
O2 sats
Temp
on
on
Copyright © 2008 by F. A. Davis.
TOOLS/
INDEX
on
on
on
on
on
224
on
Labs/Diagnostics
Time
↓
General Chemistry
Na⫹
Cl⫺
K⫹
Ca⫹
Hct
Hgb RBC WBC
ACT
PT
Mg⫹⫹
Glu
BUN
Platelets
Troponin-I
Troponin-T
Thrombin
time
pH
PO2
Cardiac Enzymes
CPK-MB
SGOT LDH Myoglobin
Copyright © 2008 by F. A. Davis.
TOOLS/
INDEX
225
Hematology
Creat.
Coagulation
INR
PTT
Blood Gases
PCO2
HCO3
BE
CO2 SaO2
Copyright © 2008 by F. A. Davis.
TOOLS/
INDEX
Intake and Output Record
Intake
Amount In
Output
IVF
Urine
IVPB
NG drainage/emesis
Blood/colloid
Oral intake
Liquid stool
Other
Total In
Total Out
226
Amount Out
Copyright © 2008 by F. A. Davis.
227
Selected References
Crimlisk JT, Grande MM. Neurologic assessment skills for the acute medical surgical
nurse. Orthop Nurs 2004 Jan-Feb; 23(1):3–9.
Deglin JH, Vallerand AH: Davis’s Drug Guide for Nurses, ed. 10. FA Davis, Philadelphia,
2006.
Gallimore D. Caring for patients after mechanical ventilation. Part 1: Physical and
psychological effects. Nurs Times 2007 Mar 13–19;103(11):28–29.
Gallimore D. Caring for patients after mechanical ventilation. Part 2: Nursing care to
prevent complications. Nurs Times 2007 Mar 20–26;103(12):28–29.
Garner JS. Hospital infection control practices advisory committee: Guideline for
isolation precautions in hospitals. Am J Infect Control 1996; 24:24–52.
Halvorsan L, et al. Building a rapid response team. Adv Crit Care Nurse 2007 AprJun;18(2):129–40.
Jackson, M. Critical thinking models and their application. In M Jackson, DD
Ignatavicius, B Case (eds.), Conversations in Critical Thinking and Clinical Judgment.
Pohl Publishing, Pensacola, FL, 2004, pp. 49–67.
Jaul E, Singer P, Calderon-Margalit R. Tube feeding in the demented elderly with severe
disabilities. Isr Med Assoc J 2006 Dec;8(12):870–74.
Offner PJ, Heit J, Roberts R. Implementation of a rapid response team decreases
cardiac arrest outside of the intensive care unit. J Trauma 2007 May;62(5):1223–27;
discussion 1227–28.
Sagarin M, McAfee A. Hyperosmolar hyperglycemic, nonketotic coma
http://www.emedicine.com/emerg/topic264.htm. Accessed March 2007.
Scheffer BK, Rubenfeld MG. A consensus statement on critical thinking in nursing.
J Nurs Educ 2000 39(8):352–59.
Sole ML, et al. Introduction to Critical Care Nursing. Elsevier Saunders, Philadelphia,
2005.
Varughese S. Management of acute decompensated heart failure. Crit Care Nurs Q.
2007 Apr-Jun;30(2):94–103. Review.
Venes D, Thomas CL, Taber CW (eds): Taber’s Cyclopedic Medical Dictionary, ed. 19. FA
Davis, Philadelphia, 2001.
Wilkinson JM, Van Leuven K. Fundamentals of Nursing. FA Davis, Philadelphia, 2007.
Illustration Credits
Pages 17, 59, 167–168, 206 from Myers E: RNotes: Nurse’s Clinical Pocket Guide,
FA Davis, Philadelphia, 2003; pages 53, 55 from Williams L and Hopper
P: Understanding Medical Surgical Nursing, ed 2. FA Davis, Philadelphia, 2003;
pages 55–56 from Taber’s Cyclopedic Medical Dictionary, ed 19. FA Davis,
Philadelphia, 2001; pages 35, 36, 57, 77–79, 97–98, 115, 124, 144–145 from Scanlon VC
and Sanders T: Essentials of Anatomy and Physiology, ed 4. FA Davis, Philadelphia,
2003. Page 9 from Hockenberry MJ, Wilson D, Winkelstein ML: Wong’s Essentials of
Pediatric Nursing, ed. 7, St. Louis, 2005, p. 1259. Used with permission. Copyright,
Mosby.
Adapted from Folstein et al, Mini Mental State, J Psych Res 12:196–198 (1975)
*Reference ranges vary according to brand of laboratory assay materials used; check
normal reference ranges from your facility’s laboratory when evaluating results.
TOOLS/
INDEX
Copyright © 2008 by F. A. Davis.
TOOLS/
INDEX
Index
Note: Page numbers followed by f refer to figures (illustrations).
A
Abdomen, assessment of, in emergency, 163
distention of, 100–101
pain in, 100–101
thrusts to, in Heimlich maneuver, 167f
ABG (arterial blood gas) values, 201
assessment of, 37–38, 51–52
AC (assist-control) ventilation, 47
ACE (angiotensin-converting enzyme) inhibitors,
184
Acetylsalicylic acid (aspirin), 186
Acidosis, diabetic, 116–117
Activase (alteplase, t-PA), 185
Activated charcoal, 184
Acute hemolytic reaction, to transfusion, 175
Acute renal failure, 92
Adenosine (Adenocard), 185
Adrenalin (epinephrine), 190–191
Adrenergic agonists, 185, 190
Adult, choking in, 170
CPR in, 167f, 169
Heimlich maneuver in, 167f
Advance directives, 164
AEDs (automated external defibrillators), 169,
171
Airborne precautions, in infection prevention, 147
Airway(s), artificial, 55–56, 55f–56f
assessment of, in emergency, 160
methods of opening, 167f, 168f, 169, 170
Alarms, ventilator, 48–49
Albumin, reference range for, 201
Albumin solution, 222
Albuterol (Ventolin), 185
Alginates, for pressure ulcer, 140
Alkaline phosphatase, reference range for, 201
Allergic reaction, to transfusion, 175
ALT, reference range for, 201
Alteplase (Activase, t-PA), 185
Alupent (metaproterenol), 185
Ambu bag, oxygen delivery via, 54, 54f
Aminophylline (Truphylline), 185–186
Amiodarone (Cordarone), 186
Amyl nitrate, 186
Analgesics, 186, 189, 195, 198
routes for administration of, 11–12
Anaphylaxis, 173, 177
in reaction to transfusion, 175
Angina, 23
Angiotensin-converting enzyme (ACE) inhibitors,
184
Antibiotic-resistant staphylococcal infections,
157–158
Antidysrhythmics, 185, 186, 188, 190, 191, 192, 194,
196
Antihypertensives, 184, 187
Arterial blood gas (ABG) values, 201
assessment of, 37–38, 51–52
Arterial circulation, 36f
Arterial hematoma, 17–18
Arterial occlusion, 18–19
Artificial airways, 55–56, 55f–56f
Aspiration, 38–39
Aspirin (acetylsalicylic acid), 186
Assist-control (AC) ventilation, 47
AST, reference range for, 201
Asystole, 216f
Ativan (lorazepam), 186
Atracurium (Tracrium), 186–187
Atrial fibrillation, 214f
Atrial flutter, 214f
Atrioventricular (AV) block, 217f–218f
Atropine, 187
Autologous blood transfusion, 223
Automated external defibrillators (AEDs), 169,
171
AV (atrioventricular) block, 217f–218f
B
Back, assessment of, in emergency, 163
blows to, in Heimlich maneuver, 168f
Bacteremia, transfusion and, 175
Bag delivery, of oxygen, 53, 53f, 54, 54f
Balance, assessment of, 60
Benadryl (diphenhydramine), 187
Beta blockers, 187, 191
Bilevel positive airway pressure (BiPAP), 47
Bilirubin, reference range for, 201
BiPAP (bilevel positive airway pressure), 47
Bleeding/hemorrhage, 26–27
gastrointestinal, 109–112
wound, 26–27
Bloating, in patient with feeding tube, 108
Blood flow, 35f, 36f
Blood gas values, 201
assessment of, 37–38, 51–52
Blood loss. See Bleeding/hemorrhage.
228
Copyright © 2008 by F. A. Davis.
229
Blood tests, reference ranges for, 203
Blood transfusion, 223
adverse reactions to, 174–175
Blood urea nitrogen (BUN) values, 201
assessment of, 80
Braden scale, for pressure ulcer risk, 136
Bradycardia, 20–21
sinus, 213f
Brain, functional areas of, 77f
vascular lesions of, and sudden neurological
deficit, 75–77
Breathing, assessment of, 37
in emergency, 161, 169, 170
compromised, 16, 40–44, 45–46
rescue, in CPR, 169
Bretylium (Bretylol), 188
Brevibloc (esmolol), 191
Bronchodilators, 185
BUN (blood urea nitrogen) values, 201
assessment of, 80
C
Calan (Isoptin, verapamil), 199
Calcium, reference range for, 201
Calcium channel blockers, 188, 199
Calcium chloride, 188
Calcium gluconate, 188
Calcium imbalance, 82
Cannula delivery, of oxygen, 53, 53f
Capillary refill, normal vs. delayed, 16
Carbon dioxide, delivery and pickup of, 59f
reference range for, 201
Cardiac cycle. See also Heart and Cardioentries.
waveform of, 208f
studies of, 206, 206f–219f, 210, 212
Cardiac markers, 202–203
Cardiogenic shock, 178, 179f
Cardiopulmonary resuscitation (CPR), 167f, 168f,
169
Cardiovascular system, assessment of, 15–16
Cardizem (diltiazem), 188–189
CDAD (Clostridium difficile–associated diarrhea),
148–149
Central lines, care of, 220–221
Cervical spine, assessment of, in emergency, 163
Charcoal, activated, 184
Chemistries, reference ranges for, 201–202
Chest, assessment of, in emergency, 163
compressions of, in CPR, 169
pain in, 21–24
thrusts to, in Heimlich maneuver, 168f
Chest tube, dislodgement of, 39–40
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Child/infant, choking in, 170
CPR in, 167f, 168f, 169
Heimlich maneuver in, 167f, 168f
Chin lift, head tilt and, to open airway, 167f, 168f,
169, 170
Chloride, reference range for, 201
Choking, management of, 170
Cholesterol, reference range for, 201
Circulation, arterial, 36f
assessment of, 16
in emergency, 162, 169
Clostridium difficile–associated diarrhea (CDAD),
148–149
CMV (continuous mandatory ventilation), 47
Coagulation tests, 202
Code responses, 165–166
COLDERRA mnemonic, in pain assessment, 11
Colitis, pseudomembranous, 148–149
Colloids, 222
Coma, 66
assessment scale for, 61
hyperosmolar hyperglycemic nonketotic,
119–120
myxedema, 121–122
Communication, of patient’s status, 1–2
Compartment syndrome, 127–128
Complete heart block, 218f
Compressions (chest compressions), in CPR,
169
Confusion, 66
Consciousness level, altered, 64–66
Consent, informed, 3–4
Constipation, 103–104
Contact precautions, in infection prevention,
148
Continuous mandatory ventilation (CMV), 47
Continuous positive airway pressure (CPAP), 47
Coordination, assessment of, 60
Cordarone (amiodarone), 186
Corvert (ibutilide fumarate), 192
CPAP (continuous positive airway pressure), 47
CPR (cardiopulmonary resuscitation), 167f, 168f,
169
Cramps, in patient with feeding tube, 108
Cranial nerves, 78f
assessment of, 62
Creatinine values, 201
assessment of, 80–81
Critical thinking, in nursing, 6–8
Cryoprecipitate, 223
Crystalloids, 221–222
Cultural sensitivity, in nursing, 12–13
Cyanide poisoning, antidote to, 186
Copyright © 2008 by F. A. Davis.
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D
Dantrolene (Dantrium), 189
Data sheets, 224f–226f
Débriding agents, for pressure ulcer, 140
Decadron (dexamethasone), 189
Defibrillators, automated external, 169, 171
Dehydration, 84–85
Delegation, in nursing, 5–6
Delirium, 67–68
Deltoid site, for IM injection, 204f
Demerol (meperidine), 189
Dexamethasone (Decadron), 189
Dextran solution, 222
Dextrose solutions, 189, 222
Diabetic ketoacidosis (DKA), 116–117
Diagnostic studies, in emergency, 164
Diarrhea, 104–105
Clostridium difficile–associated, 148–149
in patient with feeding tube, 108
Digestive tract, 115f
assessment of, 99–100
bleeding from, 109–112
Digoxin (Lanoxin), 190
Digoxin immune fab (Digibind), 189–190
Diltiazem (Cardizem), 188–189
Diphenhydramine (Benadryl), 187
Diprivan (propofol), 197
Disability, assessment for, 162
Distention, abdominal, 100–101
Diuretics, 194
Dizziness, 68–69
DKA (diabetic ketoacidosis), 116–117
Dobutamine (Dobutrex), 190
Documentation, in emergency situations, 4–5
in management of pressure ulcer, 137
Do Not Resuscitate orders, 164
Dopamine (Intropin), 190
Dorsogluteal site, for IM injection, 204f
Dressings, for pressure ulcers, 139–140
Droplet precautions, in infection prevention,
147
Dyspnea, 16, 40–42
Dysrhythmias, medications for, 185, 186, 188, 190,
191, 192, 194, 196
types of. See specific problems, e.g.,
Tachycardia.
E
ECG (electrocardiography), 206, 206f–219f, 210,
212
Edema, assessment of, 16
Education, of patients, regarding medications,
182–183
Electrocardiography (ECG), 206, 206f–219f, 210,
212
Electrolyte imbalances, 82–91
Electrolyte solutions, 222
Embolism, pulmonary, 44–45
chest pain from, 23
Emergency(ies), 172
assessment in cases of, 160–164
documentation in cases of, 4–5
hypertensive, 27–28
medications used in, 184–199
response to, when patient codes, 165–166
Endocrine system, 124f
assessment of, 116
disorders of, 116–123
Endotracheal tube, 56, 56f
Enzymatic débriding agents, for pressure ulcer,
140
Epigastric disorders, and chest pain, 24
Epinephrine (Adrenalin), 190–191
Esmolol (Brevibloc), 191
Euvolemic hyponatremia, 91
External defibrillators, 169, 171
Extremities, assessment of, 15
in emergency, 163
Eye protection, in infection prevention, 146
F
Face and head assessment, in emergency, 162
Face shield, in infection prevention, 146
Fall(s), 132–134
Fasciitis, necrotizing, 130–131
Feeding tube(s), problems with, 106–109
Fever, 149–152
nonhemolytic transfusion reaction and, 175
sepsis and, 151
SIRS and, 151
Fibrillation, atrial, 214f
ventricular, 216f
Film dressings, for pressure ulcer, 139
First-degree AV block, 217f
′′Five P’s,′′ in compartment syndrome, 127
Flumazenil (Romazicon), 197
Flutter, atrial, 214f
Foam dressings, for pressure ulcer, 140
Fracture(s), assessment for, 163
hip, 129–130
pathological, 131–132
Fresh frozen plasma, 223
Furosemide (Lasix), 194
G
Gait, assessment of, 125
230
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231
Gamma-GT, reference range for, 201
Gastric secretions, leakage of, in patient with
feeding tube, 107
Gastroesophageal reflux, in patient with feeding
tube, 107
Gastrointestinal tract, 115f
assessment of, 99–100
bleeding from, 109–112
Genitourinary system, 97f–98f
assessment of, 80–82
Glasgow coma scale, 61
Gloves, in infection prevention, 146
Glucagon, 191
Glucose, reference range for, 201
Glucose imbalance, 118–121
Glycoprotein IIb/IIIa inhibitors, 191–192
Gowns, in infection prevention, 147
H
Hand placement, in CPR, 167f, 168f
Hand washing, in infection prevention, 146
Head, assessment of, 15
in emergency, 162
support of, in Heimlich maneuver, 168f
tilting of, chin lift and, to open airway, 167f,
168f, 169, 170
trauma to, 69–70
Heart. See also Cardiac and Cardio- entries.
anatomy of, 35f
conditions compromising, and chest pain, 23,
24
electrical conduction in, 206f
studies of, 206, 206f–219f, 210, 212
Heart block, 217f–218f
Heart failure, 25–26
Heart sounds, 209f
sites for assessment of, 17f
Heimlich maneuver, 167f, 168f
Hematemesis, 109–111
Hematological tests, reference ranges for, 203
Hematoma, arterial, 17–18
Hemolytic reaction, to transfusion, 175
Hemorrhage/bleeding, 26–27
gastrointestinal, 109–112
wound, 26–27
Heparin, 192
Hepatitis, 153–154
Hetastarch solution, 222
HHNC (hyperosmolar hyperglycemic nonketotic
coma), 119–120
High-alert medications, 181
High-pressure alarm, 49
High respiratory rate alarm, 49
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Hip, fracture of, 129–130
Histamine blockers, 192
Humidified systems, of oxygen delivery, 54,
54f
Hydrocolloid dressings, for pressure ulcer, 139
Hydrogels, for pressure ulcer, 139
Hypercalcemia, 82
Hyperglycemia, 118
Hyperglycemic nonketotic coma, hyperosmolar,
119–120
Hyperkalemia, 86–87
Hypermagnesemia, 83
Hypernatremia, 87–88
Hyperosmolar hyperglycemic nonketotic coma
(HHNC), 119–120
Hyperphosphatemia, 84
Hypertension, as emergency, 27–28
medications for, 184, 187
Hypervolemic hyponatremia, 91
Hypocalcemia, 82
Hypoglycemia, 120–121
Hypokalemia, 88–89
Hypomagnesemia, 83
Hyponatremia, 89–91
Hypophosphatemia, 83
Hypotension, 28–30
Hypotonic hyponatremia, 91
Hypoventilation, 43–44
Hypovolemic hyponatremia, 91
Hypovolemic shock, 178, 179f
I
Ibutilide fumarate (Corvert), 192
ICP (intracranial pressure), increased,
71–72
IM (intramuscular) injection sites, 204f
IMV (intermittent mandatory ventilation), 47
Inamrinone (Inocor), 193
Ineffective breathing, 43–44
Infant/child, choking in, 170
CPR in, 167f, 168f, 169
Heimlich maneuver in, 167f, 168f
Infarction, myocardial, and chest pain, 23
Infection prevention, 146–148
Inflammatory response syndrome, systemic,
151
Informed consent, 3–4
Injection sites, 204f, 205f
Inocor (inamrinone), 193
Inotropics, 190, 193
Intermittent mandatory ventilation (IMV), 47
Intracranial pressure (ICP), increased, 71–72
Intramuscular (IM) injection sites, 204f
Copyright © 2008 by F. A. Davis.
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Intravenous infusion, 184, 220
blood products used in, 223
adverse reactions to, 174–175
KCl in, medications incompatible with, 200
solutions used in, 221–222
Intropin (dopamine), 190
Ipecac syrup, 193
Ischemic attack, transient, 75–77
Isoproterenol (Isuprel), 193
Isoptin (Calan, verapamil), 199
IV infusion. See Intravenous infusion.
J
Jaw thrust, to open airway, 167f, 169, 170
Junctional rhythm, 215f
K
Kayexalate (sodium polystyrene sulfonate), 193
Ketoacidosis, diabetic, 116–117
Ketorolac (Toradol), 198–199
Kidney(s). See also Urinary tract; Urine.
assessment of, 80–82
failure of, acute, 92
L
Laboratory tests, reference ranges for, 201–203
Lactic acid, reference range for, 201
Lanoxin (digoxin), 190
Lasix (furosemide), 194
LDH, reference range for, 202
Lead placement, in electrocardiography, 206f,
207f
Legal aspects, of nursing, 1–4
Lethargy, 66
Level of consciousness, altered, 64–66
Lidocaine (Xylocaine), 194
Linens, prevention of infection from, 146
Liver, viral infection of, 153
Lorazepam (Ativan), 186
Lower gastrointestinal tract, bleeding from,
111–112
Low exhaled volume alarm, 49
Low-pressure alarm, 48
Lung(s), embolism in, 44–45
chest pain from, 23
infection of, 156, 158
chest pain from, 23
Lung sounds, assessment of, 37
M
Magnesium, reference range for, 202
Magnesium imbalance, 83
Magnesium sulfate, 194
Mannitol (Osmitrol), 194–195
Mask(s), in infection prevention, 146
in oxygen delivery, 53, 53f, 54, 54f
Mechanical ventilation, 47
alarms used with, 48–49
problems with, 47–48
Medical-surgical nursing. See Nursing and see
also Patient(s).
Medications, administration of, 2, 181–182. See
also Intravenous infusion.
(in)compatibility of IV potassium chloride in,
200
sources of error in, 183
educating patients about, 182–183
emergency, 184–199
high-alert, 181
Melena, 111–112
Meningitis, 155
Mental status, assessment of, 15, 60, 63–64
change in, 67–68
Meperidine (Demerol), 189
Metaproterenol (Alupent), 185
Methicillin-resistant Staphylococcus aureus
(MRSA) infection, 157–158
MI (myocardial infarction), chest pain from, 23
Milrinone (Primacor), 195
Mini–Mental Status Examination, 63–64
Mnemonic aids, to pain assessment, 10–11
Mobitz-type AV block(s), 217f–218f
Monitoring, of patient, 1
Morphine sulfate, 195
Motion, assessment of, 60, 125
MRSA (methicillin-resistant Staphylococcus
aureus) infection, 157–158
Multielectrolyte solutions, 222
Multiple organ dysfunction syndrome, 151
Musculoskeletal system, assessment of, 125–126
disorders of, and chest pain, 24
Mycobacterium tuberculosis infection, 158–159
Myocardial infarction (MI), chest pain from, 23
Myxedema coma, 121–122
N
Naloxone (Narcan), 195
Narcan (naloxone), 195
Nasal prongs, oxygen delivery via, 53, 53f
Nasogastric tube (NGT), insertion of, 102–103
Nasopharyngeal airway, 55, 55f
Nausea, 112–113
in patient with feeding tube, 108
Neck, assessment of, 15
in emergency, 163
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Necrotizing fasciitis (NF), 130–131
Needles/sharps, prevention of injury from, 147
Neurogenic shock, 178, 180f
Neurological assessment, 60–61
in emergency, 163
Neurological deficit, sudden, 75–77
Neuromuscular blocking agents, 186, 198
Neurovascular status, assessment of, 125–126
NF (necrotizing fasciitis), 130–131
NGT (nasogastric tube), insertion of, 102–103
Nitroglycerin (Nitrostat), 196
Nitroprusside (Nipride, Nitropress), 195
Nonhemolytic reaction, febrile, transfusion and,
175
Nonketotic coma, hyperosmolar hyperglycemic,
119–120
Nonrebreather delivery, of oxygen, 53, 53f
Norcuron (vecuronium), 199
Numeric rating scale, in pain assessment, 9
Nursing, 1–14. See also Patient(s).
critical thinking in, 6–8
cultural sensitivity in, 12–13
delegation in, 5–6
documentation in, 4–5
legal aspects of, 1–4
pain management in, 8–12. See also Pain.
spiritual care in, 14
O
Obtundation, 66
Oliguria, 92
Organ dysfunction syndrome, multiple, 151
Oropharyngeal airway, 55, 55f
Osmitrol (mannitol), 194–195
Oxygen delivery systems, 53–55, 53f–55f
Oxygen transport, in respiratory system, 58f
Oxytocin (Pitocin), 196
P
Pacing, transcutaneous, 171
Packed red blood cells, 223
Pain, 8–12
abdominal, 100–101
assessment of, 9–11
mnemonics aiding, 10–11
rating scales in, 9–10
chest, 21–24
management of, 8–12
Palpitations, 30–31
Pathological fracture, 131–132
Patient(s). See also Nursing.
code responses for, 165–166
communication of status of, 1–2
education for, regarding medications, 182–183
equipment used in care of, prevention of
infection from, 146
falls by, 132–134
monitoring of, 1
safety of, 2–3
medication administration and, 181–182
PE (pulmonary embolism), 44–45
chest pain from, 23
PEEP (positive end-expiratory pressure), 47
Pericarditis, chest pain from, 24
Perineum, assessment of, in emergency,
163
Peripheral lines, care of, 220–221
Phosphate imbalance, 83–84
Phosphorus, reference range for, 202
Physician orders, 3
Pitocin (oxytocin), 196
Pitressin (vasopressin), 199
Plasma infusions, 222, 223
Platelets, in transfusion, 223
reference range for, 203
Pneumonia, 156
chest pain from, 23
Positive end-expiratory pressure (PEEP), 47
Potassium, reference range for, 202
Potassium chloride solutions, 196
IV, medications incompatible with, 200
Potassium imbalance, 86, 88–89
PQRST mnemonic, in pain assessment, 10
PQRST waves, normal deflection of, 207f
Premature atrial complex, 219f
Premature junctional complex, 219f
Premature ventricular complex, 219f
Pressure support ventilation (PSV), 47
Pressure ulcer, 127, 135–140
Primacor (milrinone), 195
P-R interval, analysis of, 212
Procainamide (Pronestyl), 196–197
Propofol (Diprivan), 197
Protein, reference range for, 202
Proton pump inhibitors, 197
Pseudomembranous colitis, 148–149
PSV (pressure support ventilation), 47
Pulmonary embolism (PE), 44–45
chest pain from, 23
Pulmonary infection(s), 156, 158
chest pain from, 23
Pulse, assessment of, 16
in emergency, 169
Q
QRS complex, analysis of, 212
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R
Rapid response teams, 164–165
Recovery position, 167f
Reference ranges, for laboratory tests, 201–203
Reflexes, assessment of, 60–61
Reflux, in patient with feeding tube, 107
Renal assessment, 80–82
Renal failure, acute, 92
Rescue breathing, in CPR, 169
Respiratory distress/failure, 45–46
Respiratory system, 57f
assessment of, 37–38
oxygen and carbon dioxide transport in,
58f–59f
Responsiveness, assessment of, 65
management of choking victim based on, 170
Resuscitation, cardiopulmonary, 167f, 168f, 169
orders against, 164
Romazicon (flumazenil), 197
S
Safety, of patient, 2–3
medication administration and, 181–182
Saline solutions, 221, 222
SC (subcutaneous) injection sites, 205f
Second-degree AV block, 217f–218f
Seizure(s), 72–73
Self-harm, protection of patient from, 2–3
Sensation, assessment of, 60
Sepsis, 151
Septic shock, 151, 178
Sharps/needles, prevention of injury from, 147
Shock, 176–178, 179f–180f
anaphylactic, 177
cardiogenic, 178, 179f
hypovolemic, 178, 179f
neurogenic, 178, 180f
septic, 151, 178
Shortness of breath (SOB), 16, 40–42
SIMV (synchronized intermittent mandatory
ventilation), 47
Sinus bradycardia, 213f
Sinus rhythm, 211f
Sinus tachycardia, 213f
SIRS (systemic inflammatory response
syndrome), 151
Skeletal system, 144f
Skin, assessment of, 126–127
structures of, 145f
SOB (shortness of breath), 16, 40–42
Sodium, reference range for, 202
Sodium bicarbonate, 197–198
Sodium imbalance, 87, 89–91
Sodium polystyrene sulfonate (Kayexalate),
193
Sore, pressure, 127, 135–140
Spinal cord, 79f
trauma to, 74–75
Spine, assessment of, in emergency, 163
Spiritual care, in nursing, 14
Standard infection-prevention precautions,
146–147
Standard of care, in nursing, 4
Staphylococcal infection, antibiotic-resistant,
157–158
State practice laws, for nurses, 1
Stomal infection, in patient with feeding tube,
107
Strength, assessment of, 60
Stroke, 75–77
Stupor, 66
Subcutaneous (SC) injection sites, 205f
Succinylcholine chloride (Sucostrin), 198
Sudden neurological deficit, 75–77
Surgical site, problems involving, 141–142
Synchronized intermittent mandatory ventilation
(SIMV), 47
Syncope, 32–33
Systemic inflammatory response syndrome
(SIRS), 151
T
Tachycardia, 33–35
sinus, 213f
ventricular, 215f
TCP (transcutaneous pacing), 171
Tendon reflexes, grading of, 60
Third-degree AV block, 218f
Thrombolytics, 185, 198
Thyroid disorders, 121–123
Toradol (ketorolac), 198–199
t-PA (Activase, alteplase), 185
Tracheostomy tube, dislodgement of, 49–51
Tracrium (atracurium), 186–187
Transcutaneous pacing (TCP), 171
Transfusion, 223
adverse reactions to, 174–175
Transient ischemic attack, 75–77
Transparent films, for pressure ulcer, 139
Transtracheal oxygenation, 55, 55f
Trauma, head, 69–70
spinal cord, 74–75
Truphylline (aminophylline), 185–186
Tuberculosis, 158–159
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235
U
Ulcer, pressure, 127, 135–140
Unresponsiveness, assessment for, 169
management of choking in presence of,
170
Upper gastrointestinal tract, bleeding from,
109–111
Urgent situations. See Emergency(ies).
Uric acid, reference range for, 202
Urinary tract, 97f–98f
assessment of, 80–82
catheterization of, 94–95
infection of, 95–96
Urine, low output of, 92
retention of, 93–94
UTI (urinary tract infection), 95–96
V
Vacuum-assisted closure (VAC) units, for
wounds, 142, 143f
Vancomycin-resistant staphylococcal infection,
157–158
Vasopressin (Pitressin), 199
Vastus lateralis site, for IM injection, 204f
Vecuronium (Norcuron), 199
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Ventilation rate, in CPR, 169
Ventilator(s), 47
alarms on, 48–49
problems with, 47–48
Ventolin (albuterol), 185
Ventricular fibrillation, 216f
Ventricular tachycardia, 215f
Ventrogluteal site, for IM injection, 204f
Venturi mask, oxygen delivery via, 54, 54f
Verapamil (Calan, Isoptin), 199
Viral hepatitis, 153–154
Visual analog scale, for rating pain, 9
Volume expanders, 222
Vomiting, 113–114
in patient with feeding tube, 108
W
Wenckebach AV block, 217f
Whole blood, for transfusion, 223
Wound(s), hemorrhage from, 26–27
pressure-ulcer, 127, 135–140
vacuum-assisted closure units for, 142, 143f
X
Xylocaine (lidocaine), 194
Copyright © 2008 by F. A. Davis.
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Notes
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Copyright © 2008 by F. A. Davis.
Notes