LeMone and Burke_s Medical-Surgical Nursing Clinical Reasoning in Patient Care, 7th Edition Gerene B

Instructor’s Resource Manual for LeMone & Burke’s MedicalSurgical Nursing: Clinical Reasoning in Patient Care

LeMone & Burke’s Medical-Surgical Nursing: Clinical Reasoning in Patient Care Seventh Edition

Gerene Bauldoff Paula Gubrud Margaret-Ann Carno

Chapter 1 Medical-Surgical Nursing in the 21st Century Learning Outcomes 1. Describe the core competencies for healthcare professionals: Patient-centered care, interprofessional teams, evidence-based practice, quality improvement, safety, and health information technology.

2. Apply the attitudes, mental habits, and skills necessary for clinical reasoning when using the nursing process in patient care.

3. Explain the importance of nursing and interprofessional codes of ethics, standards of practice, and legal and ethical issues as guidelines for clinical nursing practice.

4. Explain the activities and characteristics of the nurse as caregiver, educator, advocate, leader and manager, and researcher.

Introduction A. Patient Protection and Affordable Care Act (ACA) 1. Healthcare access for more Americans B.

Medical-surgical nursing: Health promotion, healthcare, and illness care of adults

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Requirements of nurse: Knowledge of body systems and disorders Good communication skills Coordination of care and delegation of tasks Application of evidence-based practice, clinical reasoning skills, nursing care standards Awareness of patients’ family and community situations Ability to prioritize activities and care needs

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I. Core Competencies for Safe and Effective Healthcare A. Healthcare system challenges 1. Aging population 2. More chronic illness 3. Changing consumer desires and expectations 4. Rapidly expanding information and technologies 5. Focus on improving quality and safety of care B. IHI Critical objectives 1. Improve the patient care experience (including quality and satisfaction).

2. Improve the health of populations.

3. Reduce the per capita costs of healthcare. .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

C. Quality and Safety Education for Nurses (QSEN) initiative, core competencies for nurses 1. Patient-centered care 2. Teamwork and collaboration 3. Evidence-based practice (EPB) 4. Quality improvement 5. Safety 6. Use informatics II. Clinical Reasoning in the Nursing Process A. Clinical reasoning and judgment 1. Clinical reasoning: Cognition, metacognition, discipline-specific knowledge to gather and analyze information 2. Clinical judgment a) Outcome of clinical reasoning process b) Conclusion about a patient’s needs, concerns, problems c) Decision on whether to take action or not 3. Thinking strategies a) Heuristics: Informal thinking strategies or cognitive shortcuts b) Reflecting-on-action: Analysis in retrospect 4. Clinical Reasoning: a) Knowledge gained through classroom studies, textbooks, and current resources and by interacting with experienced nurses. b) Experience gained by working with patients experiencing similar problems or disorders. c) Understanding the patient as an individual, who presents with both current and previous illness experiences. d) Personal values and beliefs, including recognition of prejudices that may influence thinking. e) An ability to identify other possible options, evaluate the alternatives, and reach a conclusion.

B. The Nursing Process 1. Phases used cyclically 2. Assessment a) Data are collected, validated, organized, clustered into patterns, communicated (1) Objective and subjective data b) Initial (baseline) and ongoing assessments performed c) Focused assessment of identified or potential problem (1) Identify response to disease or treatment d) Wide variety of knowledge and skill needed e) Attitude of inquiry when gathering data 3. Diagnosis .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) Describe actual or potential health problems that can be legally diagnosed by a nurse, for which nurse can prescribe primary interventions b) Conclusion from analysis of data organized within frameworks (1) Basic human needs, body systems, human response patterns, functional health problems (a) Functional health problems: Include physical and psychological c) Diagnostic reasoning (1) Level I: Recognize significant cue (2) Level II: Cluster cues and identify data gaps (3) Level III: Draw conclusions about the present health status (4) Level IV: Determine etiologies and categorize problems d) Categories of nursing diagnoses (1) Nursing problem/actual nursing diagnoses (2) Potential (or risk) nursing problem/diagnoses (3) Collaborative problems: Involve medical interventions as well as nursing interventions e) NANDA system (1) Official system of nursing diagnosis, list of nursing diagnoses 4. Planning a) Identification of desired outcomes, nursing interventions to achieve outcomes (1) Established by patient and nurse b) Documentation of the plan of care c) Outcomes: (1) Patient-centered, time specific, measurable (2) Classifications: Cognitive, affective, psychomotor d) Interventions: Specific and individualized (1) Evidence-based practice guidelines used to evaluate appropriateness e) Moving evidence into action (1) Impact of Integrated Electronic Health Records on Quality of Nursing Care and EBP f) Care bundles (1) 3–5 interventions with strong clinician agreements (2) Each bundle is relatively independent (3) Used with defined patient population in one location (4) Developed by multidisciplinary team 5. Implementation a) Nurse carries out planned interventions or assigns and supervises assistive personnel b) Ongoing assessment essential c) Changes in plan if appropriate d) Principles of implementation (1) Set daily priorities .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(2) Be aware of interrelated nature of interventions (3) Determine the most appropriate interventions for each patient (4) Use resources wisely e) Documentation essential 6. Evaluation a) Determine if plan is effective b) Decide to continue, revise, or terminate plan c) Outcome criteria established in planning step are basis III. Guidelines for Nursing Practice A. Codes for nurses 1. Codes of ethics: Principles of conduct a) ICN Code (2012) b) ANA Code (2001) B. Standards of nursing practice 1. ANA Standards of Practice (2016) 2. Standards of Professional Performance 3. Health information privacy rules a) Ethical code and federal rules b) Health Insurance Portability and Accountability Act and the Standards for Privacy of Individually Identifiable Health Information (HIPAA) (1) Protect health information (2) Allowing for information sharing as needed for care, even without patient’s explicit consent c) Some laws override patient’s right to privacy.

(1) For example, must report evidence of abuse 4. Professional boundaries a) Must maintain appropriate level of involvement C. Legal and Ethical Issues in Nursing 1) Issues involved in dilemmas a) Confidentiality (1) Patient’s right to confidentiality may interfere with nurse’s right to personal safety b) Patient rights (1) Right to refuse treatment may interfere with ethical principle of beneficence c) Issues of dying and death (1) Conflicts regarding quality of life and death with dignity versus technologic methods of preserving life IV. Roles of the Nurse in Medical-Surgical Nursing Practice .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

A. The nurse as caregiver 1. 1900–1960s: Nurse primarily gave personal care and carried out physicians’ orders.

2. Caregiver role today: Independent and collaborative 3. Holistic approach: Understands physical, psychosocial, economic, and developmental differences among adults a) Culturally sensitive nursing care considers beliefs, practices, habits, likes, dislikes, customs, rituals (1) Cultural background component of ethnic identity (2) Healthcare system itself is a culture (3) Ethnocentrism: Belief that one’s own cultural group is superior (4) Nurses must: (a) Develop sensitivity to and accept a range of beliefs about health and illness (b) Be respectful of and interested in other cultures B. The nurse as educator 1. Increasingly important: a) Growing emphasis on health promotion and illness prevention b) Shorter hospital stays—home caregivers perform complex tasks c) Increased numbers of chronically ill 2. Health literacy: Degree in which individuals understand health information and services a) Nurses assess patients’ health literacy to educate 3. Teaching–learning process a) Nurse evaluates effectiveness of teaching 4. Discharge planning: Preparing patient and family for exit from healthcare setting C. The nurse as advocate 1. Assess need for advocacy 2. Communicate with healthcare team members 3. Provide patient and family teaching 4. Assist and support patient decision making 5. Serve as a change agent in the healthcare system 6. Participate in health policy formulation D. The nurse as leader and manager 1. Manage time, people, resources, and the environment 2. Delegate, supervise, and coordinate activities 3. Models of care delivery a) Primary nursing: Nurse provides individualized care to small number of patients during entire stay b) Team nursing: Teams of variously educated healthcare providers, with RN as team leader .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

c) Care coordination: Management of group of patients and the members of the healthcare team who care for them (1) IHI Triple Aim: Improve patient experience, maximize positive outcomes, contain costs (2) Group of patients with similar healthcare needs (3) Emphasis on continuity of care in transitions between healthcare settings (4) Accountable Care Organization (ACA): Healthcare provider leads development of plan; care coordinator (often RN) leads implementation and monitors plans 4. Delegation a) Consider training, experience, competence of members of team b) Determine level required for task c) Consider patients condition, potential harm from performing task d) Know legal practice limitations of team members e) Delegate only tasks that are within the scope of practice f) Assign the right job to the right person. g) Know when to retain direct responsibility for care activities h) Give clear and complete directions i) Give authority and accountability to team members for their tasks j) Monitor care, provide constructive evaluation 5. Quality and safety a) Encourages use of standardized practices, checklists, and technology b) When error occurs, nurse reports incident to promote analysis c) Quality improvement process (1) Health information technology (HIT): Collect data, share information, provide analytic tools, compile comprehensive health history (2) Compare actual care with established set of standards of care E. The nurse as researcher 1. Identifies problems in patient care 2. Develops profession 3. Creates clinical questions based upon the PICOT format 4. Nursing research as external evidence a) Ranking of evidence: (1) Level I: Systematic reviews or meta-analyses of randomized controlled trials (2) Level II: Randomized controlled trials (3) Level III: Controlled trials without randomization (4) Level IV: Case control and cohort studies (5) Level V: Systematic reviews of descriptive and qualitative studies (6) Level VI: Single descriptive or qualitative studies (7) Level VII: Opinion of authorities and/or reports of expert committees. .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

5. Evidence analyzed for: a) Appraisal b) Validity c) Reliability d) Applicability 6. Relationship between research process and nursing process a) Comparing the nursing process with the research process 7. Clinical research: Published findings become evidence-based patient care for all nurses

Chapter Highlights A. The Patient Protection and Affordable Care Act will create new models of care and new roles for nurses that emphasize clinical reasoning, interprofessional teams, and knowledge-based technology.

B. Recommended core competencies for all healthcare professionals include providing patient-centered care, working in interprofessional teams, using evidence-based practice, applying quality improvement, promoting safe healthcare systems, and using informatics.

C. The nursing process is the cyclical series of activities grounded in clinical reasoning and is used by nurses to provide patient care to promote wellness, maintain health, restore health, or facilitate coping with disability or death. The five interrelated phases of the nursing process are assessment, diagnosis, planning, implementation, and evaluation.

D. The clinical practice of nursing is guided by codes for nurses and standards of practice.

E. The human responses that nurses must consider when planning and implementing care result from changes in the structure and/or function of all body systems, as well as the effects of those changes on the psychosocial, cultural, spiritual, economic, and personal life of the patient.

F. Nurses function as caregivers, educators, advocates, leaders and managers, and researchers to promote and maintain health, prevent illness, improve healthcare delivery and systems, and facilitate coping with disability or death for the adult patient.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME ONE Provide the students with the QSEN competencies and have them discuss how each category definition is supported by the knowledge, skills, and attitudes actions.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME ONE Have the students observe nursing staff in the clinical area who are demonstrating the core competencies.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME TWO Provide the students with patient care situations and discuss the skills, attitudes, and mental habits needed to address the patient care need.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME TWO Assign different clinical scenarios for the students to exercise critical thinking skills.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME THREE Discuss the legal and ethical implications of nursing.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME FOUR Provide the students with different scenarios that highlight the unique role of the nurse.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME FOUR Assign the students to shadow different nurse professionals (manager, educator, advance practice nurse, infection control practitioner, nursing informatics nurse) to observe their interaction with patients/other staff. Have the students discuss the major activities within each role during postclinical conference.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter 2 Health and Illness Care of Adults Learning Outcomes 1. Define health and the health–illness continuum, and discuss factors affecting the health of individuals, families, communities, and special populations.

2. Compare and contrast health risks, assessment, and health promotion for the young adult, middle adult, and older adult.

3. Differentiate between disease, illness, and injury, and describe illness behaviors and needs of the patient with acute, critical, and chronic illness.

4. Describe essential elements and goals of coordinated primary care models; the services, settings, and essential components of community-based care and home healthcare; and nursing interventions to deliver safe, effective, and competent care to patients in their homes.

Key Concepts I. Health and Wellness A. Health: 1. WHO definition: a) A state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity. b) Health is not just a state of being, but the resources used by each person in dealing with the challenges of living.

2. Health–illness continuum: a) High-level wellness at one extreme of the continuum and death at the opposite extreme B. Factors affecting health 1. Social determinants of health a) Conditions in which people are born, grow, work, live, and age.

2. Holistic healthcare: a) All aspects of an individual—physical, psychosocial, cultural, spiritual, and intellectual—as essential components of individualized care 3. Genetic makeup a) Affects personality, temperament, body structure, intellectual potential, and susceptibility to alterations in health 4. Cognitive abilities and education a) May affect health practices b) Educational level affects ability to follow guidelines. .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

5. Ethnicity and culture a) Different groups have higher rates in certain diseases b) Ethnic/cultural background may influence health values and behaviors, lifestyles, and illness behaviors c) Different treatment practices 6. Lifestyle and environment a) Patterns of eating, chemical substances, exercise and rest patterns, and coping methods b) Occupational exposure to toxic substances, air, water, and food pollution c) Environmental temperature variations 7. Socioeconomic background a) Both lifestyle and environmental influences impacted by income. b) Poverty and homelessness negatively influence health status.

8. Geographic area a) Influences health status, health risks, and access to healthcare 9. Family a) Social unit of two or more emotionally involved people dependent on one another b) Responsibilities: (1) Developing self-care and dependent-care competencies (2) Fostering resilience of family members (3) Providing social and physical resources (4) Promoting healthy individuals 10. Age, gender, and development a) Some diseases occur in only one gender or the other (prostate and cervical cancer) b) Age increases risk of some diseases (cardiovascular disorders, chronic illnesses) c) Three stages of adult years: Young adult (18–40), middle adult (40–65), and older adult (over 65) 11. The young adult a) Injuries (1) Unintentional injuries: Leading cause of death ages 15–44 b) Sexually transmitted infections (1) Genital herpes, chlamydia, gonorrhea, syphilis, and HIV/AIDS c) Substance abuse (1) Binge drinking more common among young adults (2) Other substances: Nicotine, marijuana, stimulants (amphetamine, methamphetamine, and cocaine), opioid pain relievers d) Physical and psychosocial stressors (1) Malignancies: Top five leading causes of death in young adults .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(2) Behavioral patterns may lead to problems later (3) Work-related risks, exposure to sun, high-risk activities, ingestion of chemical substances, pregnancy 12. The middle adult a) Obesity (1) Increases risk of: Atherosclerosis, hypertension, elevated cholesterol and triglyceride levels, diabetes, cancer, osteoarthritis, fatty liver disease, and gallbladder disease b) Cardiovascular disease (CVD) (1) Second leading cause of death in middle-age adults (2) Risk factors: Diabetes, hypertension, obesity, prevalent chronic diseases, male gender, family history, physical inactivity, cigarette smoking, and elevated blood cholesterol levels (3) Potential consequences: Stroke, kidney disease, hypertension, and peripheral vascular disease c) Cancer (1) Leading cause of death in adults between ages 45–64 in the U.S. (2) Risk factors: Environmental carcinogens, alcohol, nicotine d) Substance abuse (1) Most common substances: Alcohol, nicotine, and prescription drugs e) Physical and psychosocial stressors (1) Changes in appearance, kids, aging parents, career changes, and divorce 13. The older adult a) Most frequent conditions: Arthritis, heart disease, cancer, diabetes, and hypertension b) Injuries (1) Risk increases due to: Normal physiologic changes from aging, pathophysiologic alterations, environmental hazards, and lack of support systems (2) Major causes: Fire, falls, and motor vehicle crashes c) Pharmacologic effects (1) Risk factors (a) Age-related changes alter absorption of medications; poor nutrition and liver function alter drug metabolism; kidney may not excrete drugs at normal rate (b) Self-administration of drugs impacted by aging mind (c) Adverse drug reactions due to multiple medications needed (d) Unable to afford both medications and food .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

d) Physical and psychosocial stressors (1) Accumulation of exposure, living conditions, economic constraints, and elder abuse (2) Psychosocial stressors: Illness/death of spouse, limited income, retirement, isolation, relocation, role loss/reversal, and depression 14. Considerations for special populations a) Military service members and veterans (1) Demographics (a) 1.4 million persons in active-duty military positions in the United States (2) Military Culture (a) Covert displays of service-related values, customs, traditions, philosophical principles, and/or behavioral standards (b) Common attributes: Self-discipline, teamwork, loyalty, selfless duty to one’s country, order, and procedure, rank and obedience to authority (3) Service-related healthcare issues (a) World War II Veterans (b) Korean Conflict Veterans (c) Vietnam Veterans (d) Recent Veterans (4) Nursing implications: (a) Complete a military-specific, service-related health history (b) Assess for historical hazardous exposures b) Gender and sexual minorities (1) Individuals who are LGBTQI continue to experience health disparities due to historical and ongoing stigmatization (2) Nursing implications: (a) Build trust (b) Avoid making assumptions (c) Conduct a critical self-assessment of their personal knowledge, attitudes, assumptions, and unconscious biases 15. Adults with sequelae from congenital/childhood conditions a) Adults surviving childhood cancers: (1) Assess for late effects of treatment b) Adults with congenital heart defects: (1) CHF requires life-long cardiac care (2) Monitor for arrhythmias and pulmonary hypertension c) Nursing implications: .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Facilitate access to routine and comprehensive health screening (2) Identify worsening comorbid chronic conditions or new complications II. Health Promotion and Maintenance A. Activities that maintain wellness: 1. Screening 2. Immunization 3. Health teaching B. Overarching goals 1. Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death.

2. Achieve health equity, eliminate disparities, and improve health.

3. Create social, physical environments that promote good health.

4. Promote quality of life, healthy development, and healthy behaviors.

C. Health indicators 1. Access to health services 2. Clinical preventative services 3. Environmental quality 4. Injury and violence 5. Maternal, infant, and child health 6. Mental health 7. Nutrition, physical activity, and obesity 8. Oral health 9. Reproductive and sexual health 10. Social determinants 11. Substance abuse 12. Tobacco use D. Healthy behaviors to promote health and wellness: 1. Balanced diet to maintain a healthy weight with nutrient-dense foods 2. Exercise moderately and regularly 3. Sleep 7 to 8 hours each day 4. Eliminate smoking and all tobacco products 5. Limit sun exposure and use sunscreen 6. Practice safe sex 7. Regular dental exams and cleanings 8. Maintain recommended immunizations 9. Follow guidelines for recommended health screenings .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

III. Disease, Illness, and Injury A. Disease: Alteration in a body system or organ structure or function 1. Congenital, present at birth, or acquired 2. Causes of disease a) Genetic variations b) Environmental factors c) Infectious agents d) Tissue injury due to lack of oxygen, temperature extremes, radiation, or toxins e) Poor nutrition (obesity, malnutrition) f) Inadequate or disordered immune responses g) Neoplasia 3. Classifications of disease: Acute or chronic, communicable, congenital, degenerative, functional, malignant, idiopathic, or iatrogenic 4. Manifestations: Signs or symptoms of disease B. Illness: Response a person has to a disease 1. Acute illness: Occurs rapidly, lasts short amount of time, and is self-limiting. a) Critical illness: Requires life-saving interventions b) Sequence of illness behaviors (1) Experiencing symptoms (2) Assuming the sick role (3) Seeking medical care (4) Assuming a dependent role (5) Achieving recovery and rehabilitation 2. Chronic illness: Long-term pathologic and psychologic alterations in health a) Behavioral risk factors: Lack of physical activity, poor nutrition, tobacco use, and excessive alcohol consumption b) Link between adverse childhood experience (ACE) and chronic illness c) Remission: No symptoms although disease is present d) Exacerbation: Symptoms reappear e) Common challenges (1) Recognizing and appropriately responding to symptoms.

(2) Using medications effectively (3) Learning to manage an ongoing treatment plan (4) Modifying lifestyle to adapt to and minimize impact of disease (5) Developing effective strategies for coping with the psychosocial effects (6) Maintaining a feeling of being in control (7) Interacting effectively with the healthcare system on an ongoing basis .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

C. Illness prevention 1. Primary prevention: Prevent disease by eliminating risk factors a) Eating nutritious foods, balancing calorie intake with energy expenditure b) Reducing exposure to industrial hazards c) Practicing safer sex d) Obtaining immunizations e) Eliminating the use of alcohol and cigarettes f) Avoiding cell phone use and texting while driving 2. Secondary prevention: Emphasizes early diagnosis and treatment a) Screening for common diseases b) Obtaining regular physical examinations c) Performing self-examination for breast and/or testicular cancer d) Obtaining specific treatment for illness 3. Tertiary prevention: Preventing further health decline and reducing complications a) Rehabilitation programs for cardiovascular problems, head injuries, and strokes b) Work training programs following illness or injury c) Educating the public to employ rehabilitated people to the fullest possible extent D. Injury and violence 1. In the first half of life, more Americans die from violence and injury than any other cause 2. Has a significant economic impact on individuals, families, communities, and country 3. CDC focus: a) Motor vehicle crashes b) Opioid overdoses c) Fall injuries d) Victims of intimate partner violence e) Rape 4. Nurses and other healthcare professionals are at increased risk for occupational injury and workplace violence.

5. OSHA identified settings to implement workplace violence protocols: a) Residential treatment settings such as nursing homes b) Nonresidential treatment/service settings c) Community care settings d) Fieldwork settings E. Injury prevention .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

1. Patient teaching regarding safe practices in many areas a) Motor vehicle safety b) Use of safety gear c) Actions to prevent on-the-job injuries d) Safe medication handling e) Safe handling of sharps f) Safe handling of patients IV. Types of Nursing Care A. Roles of Nursing Care: 1. Health promotion/disease prevention 2. Acute care 3. Chronic care 4. End-of-life care B. Primary care 1. Patient-centered medical home (PCMH) a) Focuses on all levels of illness prevention b) Includes: Primary care provider, care coordinators or case managers, social workers, rehabilitation therapists c) Functions (1) Ongoing patient–primary care provider relationship (2) Responsibility for total patient care (3) Improving access to care and reducing health disparities (4) Increasing preventive services (5) Improving chronic disease management C. Care and disease management 1. Nurses’ role a) Assess problems b) Communicate with healthcare providers c) Navigate healthcare system d) Provide education and instruction about disease D. Transitional care 1. Focused on interventions for transitions between healthcare settings or to home 2. Interventions: Development of an evidence-based plan of care, ongoing support, emphasis on early identification of, and response to, risks and symptoms 3. Goals: Improve care and outcomes of chronically ill patients by a) Streamlining plans of care b) Improving ability of patients and caregivers to manage care needs .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

c) Interrupting patterns of frequent acute health crises E. Community-based care 1. Nurses’ role a) Leading support groups in a hospital b) Managing freestanding clinic to provide care in patient’s home c) Other settings: Medical centers, disease management groups, county health departments, long-term care, parish nursing, homeless shelters, mental health centers, ambulatory surgery centers, alcohol/drug rehabilitation, industry, jails, and prisons F. Skilled Care and Extended care 1. Helps with transition from acute care to home 2. Nurses role a) Assess residents b) Train caregivers to recognize and respond to changes c) Treat residents within the extended care setting d) Communicate with families G. Rehabilitation 1. Primarily focuses on patients with chronic illnesses or impairments 2. Settings: Home, skilled care facilities, specialty programs within medical centers or community 3. Assessment includes: Functional health level and self-care abilities, educational needs, psychosocial needs, and the home environment H. Home healthcare 1. Services include: Skilled nursing, physical and occupational therapy, pharmacy services, and durable medical equipment 2. Medicare reimbursement criteria a) Physician decides patient needs care at home, makes plan for home care. b) Patient needs at least one of the following: (1) Intermittent skilled nursing care (2) Physical therapy (3) Speech language pathology services (4) Occupational therapy c) Patient is homebound. d) Home care agency is Medicare approved. e) Skilled provider performs at least one of the following tasks: (1) Teaching about a new or acute situation (2) Assessing an acute process or a change in patient’s condition .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(3) Performing skilled procedure or hands-on service requiring professional skill of a licensed nurse 3. Patients benefiting from home care a) Cannot live independently from home b) Chronic debilitating illnesses c) Terminally ill and want to die at home d) Do not need in-patient hospital or nursing home care e) Need short-term help at home for postoperative care 4. Safety a) Promoting safety in home care b) Be alert to: 1) How patients ambulate and handle stairs 2) How patients manage care when alone 3) A supply of expired medications 4) Inappropriate clothing or shoes 5) Cooking habits that may precipitate a fire 6) Inadequate food supply 7) Poorly functioning utilities 8) Signs of abusive behavior 9) Disposal of toxic medications and sharp objects 10) Personal safety and survival for nurse 5. Infection control a) Health teaching is most important nursing intervention 1) Effective hand hygiene 2) Use of gloves 3) Disposal of wastes and soiled dressings 4) Handling of linens 5) Practice of standard precautions I. Palliative and Hospice Care 1. Palliative care: a) Focuses on symptom management with intent of improving quality of life for patients with chronic illness 2. Hospice care: a) Model of care delivered in many settings b) Designed to provide medical, nursing, social, psychologic, and spiritual care for terminally ill patients and their families c) Allows the patient to die with dignity 3. Respite care: a) Short-term or intermittent home care, often using volunteers b) Give the family member or primary caregiver some time away from care .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter Highlights A. Health is a dynamic state influenced by multiple internal, external, physical, social, and mental factors.

B. The health–illness continuum represents health as a dynamic process, with high-level wellness at one extreme of the continuum and death at the opposite extreme.

C. The adult years are commonly divided into three stages: The young adult (age 18 to 40), the middle adult (age 40 to 65), and the older adult (over age 65).

D. Young adults are at risk for alterations in health from injuries, sexually transmitted infections, substance abuse, and physical and psychologic stressors. Cancers are a leading cause of death, and behaviors established in young adulthood affect risk for developing common chronic diseases in the future.

E. Middle adults are at risk for alterations in health from obesity, cardiovascular disease, cancer, substance abuse, and the stresses of change and transition.

F. Older adults are at risk for alterations in health from chronic illnesses, injuries, drug toxicities, and changes in income and marital status.

G. Community factors known as social determinants of health include social support systems, access to healthcare services, the environment, and economic resources.

H. Populations that may require extra care include veterans, members of the LGBTQI community, and adult survivors of congenital/childhood conditions.

I. Healthy People 2020 provides a foundation for disease prevention and wellness activities across public and private sectors, as well as a model for measuring achievement of identified goals and objectives.

J. Nurses play a major role in promoting the health of individuals, families, and communities.

Health promotion focuses screening, immunizations, and health teaching.

K. Disease, defined as any alteration in a body system or organ structure or function, are characterized by identifiable signs and symptoms and by specific recognized pathophysiologic processes and etiologies.

L. Illness is the response an individual has to a disease; this response is highly individualized because the individual responds not only to his or her own perceptions of the disease but also to the perceptions of others. Illnesses can be acute or chronic.

M. Injury and violence affect everyone and the medical-surgical nurse will provide care for patients and families experiencing health-related problems created by these unexpected and unintended events.

N. The primary health risks for the individual and family vary, depending on age and developmental stage, among other factors. Behaviors to promote individual health, however, remain very consistent throughout the lifespan.

O. Most health and illness care occurs outside the acute hospital environment, in communitybased and primary care settings. Home healthcare is increasingly important as hospital stays become shorter or are avoided altogether.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

P. Primary care is comprehensive first-contact health and illness care across the lifespan.

Preventive care services as well as care for acute and chronic diseases are encompassed within the primary care model.

Q. Transitional care focuses on interventions to facilitate transitions from one healthcare setting to another or to home. The steps of transitional care include health promotion, acute care, chronic care, and end-of-life care.

R. Community-based care focuses on individual and family healthcare delivered in the local community.

S. Skilled care, which is reimbursed by Medicare, is typically provided in extended care or longterm care facilities such as nursing homes. Rehabilitation nursing is based on a philosophy that each person has a unique set of strengths and abilities that can enable that person to live with dignity, self-worth, and independence.

T. Ensuring safety and patient and family education are major responsibilities of the home healthcare nurse. In this setting, the patient and family are primary members of the team and are instrumental in establishing priorities of care.

SUGGESTION FOR CLASSROOM ACTIVITY- LEARNING OUTCOME ONE Discuss wellness opportunities for yourself and your family. What facilities are available?

SUGGESTION FOR CLASSROOM ACTIVITY- LEARNING OUTCOME TWO Develop an educational poster or brochure that promotes wellness for children

SUGGESTIONS FOR CLASSROOM ACTIVITY- LEARNING OUTCOME THREE Discuss the reactions of clients to disease. How does the patient’s culture and socioeconomic status affect this reaction?

Discuss the differences in caring for acute patients versus long-term care patients.

SUGGESTION FOR CLASSROOM ACTIVITY- LEARNING OUTCOME FOUR Prepare to make a home visit to a patient with a chronic illness. Discuss in class the areas to assess, the areas to focus when teaching, and any tools that should be taken during the visit to provide care.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTION FOR CLINICAL ACTIVITY- LEARNING OUTCOME FOUR Assign the students to different care sites to observe the processes and actions taken to provide care. Have the students discuss their observations during post clinical conference.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter 3 Nursing Care of the Patient with Alterations of Sleep Learning Outcomes 1. Describe the physiology of sleep, normal sleep patterns, and factors affecting sleep.

2. Summarize topics that nurses teach to promote healthy sleep across the lifespan.

3. Outline the components of the assessment of sleep including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.

4. Differentiate considerations for assessing the sleep of older adults, veterans, and individuals in the LGBTQI population.

5. Describe the pathophysiology and manifestations of sleep deprivation, and outline the interprofessional care and nursing care of patients with this disorder.

6. Describe the pathophysiology and manifestations of insomnia, and outline the interprofessional care and nursing care of patients with this disorder.

7. Describe the pathophysiology and manifestations of sleep-disordered breathing, and outline the interprofessional care and nursing care of patients with this disorder.

8. Describe the pathophysiology and manifestations of restless legs syndrome, and outline the interprofessional care and nursing care of patients with this disorder.

Key Concepts I. Overview of Rest and Sleep A. Purpose and use of rest 1. Rest is the process of allowing the body time to recover and conserve energy.

2. During sleep hormones are released and short-term memories/learning are moved to long-term memories/learning.

3. In rest, there is a conservation of energy and a relaxation of the brain where glucose is not being used as much as in strenuous thinking.

B. Physiology of sleep 1. During sleep, the parasympathetic nervous system is more active for the repair and maintenance of the human body.

2. Changes in sleep patterns decrease the quality and quantity of sleep affect many physiologic functions, including: a) Satiety, with overeating leading to obesity and cell insensitivity to insulin b) Mood, including irritability and depression c) Immune system function, including a decreased ability to fight off infection .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

d) Cognitive functioning, such as decreased retention of new material 3. Changes in sleep patterns can be caused by disease processes and medications that cross the blood–brain barrier, including those that are not usually thought to affect sleep.

4. Models for the reasons why humans sleep a) Two-process model: (1) An interaction between a homeostatic process and the circadian process of the body’s natural cycle b) Relationship between sleep and the immune system (1) Both interleukin 1 (IL-1) and tumor necrosis factor (TNF) are involved with the regulation of sleep and the immune response.

C. Normal sleep patterns 1. Light is the most important regulator of sleep and circadian rhythms.

2. Melatonin is a hormone connected to sleep.

3. Light can affect the secretion of melatonin.

4. Normal amount of sleep is about 8 hours of consolidated sleep per 24-hour day during the night time.

5. Sleep is easiest as the body temperature is decreasing.

6. Types of sleep: a) Nonrapid eye movement: (1) N1: Light sleep (2) N2: Slightly deeper sleep (3) N3: Deep or slow-wave sleep (a) Connected with growth hormone secretion b) Rapid eye movement (REM) (1) Memory consolidation occurs (2) Dreaming (3) Muscle atonia occurs 7. Patients with disrupted sleep may experience parasomnias, which are partial arousals from sleep where the person’s brain is partially asleep and partially awake and include: a) Sleep walking, sleep talking, and night terrors D. Factors affecting sleep 1. Intrinsic factors: a) Patient’s baseline emotional state 2. Extrinsic factors: a) Noise, light, hunger, room temperature, nursing actions 3. Disease processes: a) Congestive heart failure affects breathing b) Anxiety causing rumination and delay falling asleep .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

c) Medications E. Bidirectional Nature of Sleep and Physiological Processes 1. Cardiovascular disorders and sleep a) Inadequate sleep is correlated with hypertension, coronary artery disease, subclinical atherosclerotic disease, and cerebrovascular disease. b) Inadequate sleep causes disruption in the autonomic nervous system with a lack of parasympathetic relaxation and a continued high level of sympathetic activity c) There can be changes in cytokine production and other proinflammatory changes. d) Sleep deficits adversely affect glucose homeostasis and insulin sensitivity, leading to increased weight gain, obesity and type 2 diabetes. e) There can be metabolic changes within the sleep–wake system, such as changes in catecholamine levels. f) Sleep deprivation can occur with cardiovascular diseases due to pain or difficulty breathing. g) Untreated or poorly treated obstructive sleep apnea can lead to strokes, which can lead to issues with sleeping along with inducing OSA, depending on where the stroke occurred in the brain.

2. Neurologic disorders, pain, and sleep a) REM behavior disorder has been linked with the development of Parkinson disease or related disorders b) Sleep can also be affected by seizure disorders, and nighttime seizures can induce sleep deprivation. c) Any medication that crosses the blood–brain barrier can affect sleep.

(1) Some SSRIs will decrease the amount of REM sleep while others will increase the amount.

(2) Medications can also induce insomnia and exacerbate the underlying medical issue d) Pain at nighttime affects sleep quantity and quality.

(1) Common opioid analgesics used for pain control can have deleterious effects on sleep.

3. Respiratory disorders and sleep a) Any respiratory disorder has the potential to affect sleep. b) Chronic coughing or wheezing during the night will either awaken the patient fully or cause an arousal or sleep stage change. c) Medications given to prevent wheezing or coughing at nighttime can also disrupt sleep.

(1) Bronchodilators delay sleep onset. .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

II. Health Promotion A. The importance of rest 1. Rest can be promoted by understanding disease processes and how the body recovers.

B. Sleep hygiene 1. Series of practices and habits that help an individual achieve quality sleep.

2. Includes: a) Going to bed at the same time b) Awakening at the same time c) Exercising daily d) Being exposed to bright light in the morning e) Having proper nutrition f) Not eating immediately before bedtime g) Avoiding alcohol before bedtime h) Avoiding caffeine after mid-afternoon i) Avoiding use of electronic devices 1–2 hours before bedtime j) Using the bedroom only for sleeping and other personal activities 3. Avoid watching TV in bed or using cell phones and other electronic devices while in bed.

4. Napping during the day should not occur.

5. The body needs to be trained for good sleep and starts at the time of awakening.

C. Sleeping in the hospital 1. For the hospitalized patient, sleep disturbances may be related to the hospital environment 2. Schedule procedures, medications, meals, and other activities around the patient’s normal sleep schedule.

3. Identify the patient’s normal sleep pattern.

4. Request a sedative/hypnotic for sleep if sleep hygiene does not produce a restful night of sleep.

III. Assessing the Patient with Altered Sleep A. Health assessment interview 1. Any major body system can have an impact on sleep 2. Specific questions concerning sleep/wake habits and patterns include: a) What time do you go to bed? b) What do you do the 2 hours before bedtime? c) What time do you wake up? d) Do you wake up to an alarm clock or spontaneously? .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

e) Do your habits vary on weekdays versus weekends? f) Do you smoke, drink alcohol, or use substances before going to bed or at other times during the day? g) Do you take any prescription or over-the-counter (OTC) medications in general or specifically for sleep? h) Do you snore? Sleep walk? Sleep talk? i) How do you feel when you wake up? j) Do you ever fall asleep during the day? While driving?

3. Have the patient keep a sleep diary for a couple of days for additional information.

B. Physical examination 1. Assess the oropharynx for “crowding” 2. Assess neck size 3. Measure weight and BMI 4. Prepare for diagnostic tests C. Measurement of sleep 1. Sleep diary 2. Questionnaires: a) Epworth Sleepiness Scale b) STOP-BANG questionnaire of obstructive sleep apnea in adults 3. Actigraphy 4. Overnight polysomnography IV. Assessment of Selected Populations A. Older adults 1. Aging can lead to earlier bedtimes and earlier arise times.

2. Lack of activity during the daytime due to illness or disability may not have the buildup of pressure to sleep.

3. Comorbid conditions: a) Pain syndromes b) Respiratory issues c) Benign prostatic hyperplasia d) Menopause 4. Can cause: a) Social isolation b) Increased risk of falls c) Delirium B. Veterans 1. Depends on any injury or disease caused by being in service .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

2. Posttraumatic stress disorder can cause: a) Nightmares b) Insomnia C. LGBTQI community 1. More likely to suffer from stress, depression, and bullying 2. Increases the risk for poor sleep and insomnia V. Sleep Deprivation A. The patient with a sleep deficit 1. Pathophysiology and manifestations a) Physical impact of sleep deficit: (1) Increased heart rate (2) Decreased concentration (3) Slower reflexes (4) Irritability (5) Altered cytokine levels: (a) Increases the risk for infection (6) Changes in leptin/ghrelin: (a) Leads to overeating (b) Obesity (7) Increases insulin resistance: (a) Increases A1C levels (b) Impairs fasting glucose levels 2. Interprofessional and nursing care a) Interprofessional care may involve psychotherapists, respiratory therapists, physicians, sleep technologists, and nurses. b) Adherence to treatment is a major concern for almost all of the sleep disorders.

VI. Insomnia - The inability to fall asleep, stay asleep, or feel rested upon awakening.

- The patient with insomnia will feel tired or fatigued; have difficulties learning, paying attention, or concentrating; and may be irritable and prone to accidents.

A. The patient with insomnia a) Factors that perpetuate insomnia: (1) Poor sleep habits (2) Intrinsic arousals (3) Changes in cognition b) Daytime consequences of insomnia: .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Fatigue (2) Mood changes (3) Performance issues at work c) Bidirectional relationship with emotional, cognitive, and physiologic arousals d) Bidirectional relationship with worry about sleep, rumination about not being able to sleep, and the consequences of not sleeping. e) Can become a perpetuating cycle that is difficult to break. f) Risk factor for: (1) Depression (2) Anxiety (3) Headaches (4) Fibromyalgia (5) Rheumatoid arthritis (6) Osteoporosis (7) Asthma (8) Increased mortality risk 1. Pathophysiology and manifestations a) Models to describe the pathophysiology of insomnia (1) One model states that all individuals have predisposing factors for insomnia (2) Once the insomnia starts, it can become self-reinforcing, which will keep the insomnia going.

2. Interprofessional care a) Diagnosis (1) Diagnosis based on patient report (2) No bloodwork or imaging tests for insomnia b) Medications (1) Once the medication is stopped, the insomnia will still be present.

(2) Medication should be used only short term.

(3) Other proven therapies, such as cognitive-behavioral therapy, are used help resolve the underlying issues of insomnia.

4) Number of medications has significant side effects.

5) Both prescribed and OTC agents for sleep can cause psychologic and physiologic dependency.

6) Fear of not using medication causes self-perpetuating insomnia.

7) Melatonin used by many to induce sleep a) Take < 5mg, 30 minutes before bedtime 8) Valerian also used although efficacy not substantiated .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

c) Nursing care (1) Assess why a patient is on a medication and also ask about any over-the-counter medications being used.

(2) Be alert to dependency on medications for sleeping.

(3) Teach good sleep hygiene.

VII. Sleep-Disordered Breathing A. The patient with obstructed sleep apnea 1. Pathophysiology a) Disorder of breathing during the night b) Caused by the airway either partially or completely collapsing during the nighttime c) Airflow is blocked. d) Signals the brain to arouse but not necessarily wakeup e) Causes snoring, snorting, or gasping f) Sympathetic nervous stimulation, including desaturations and changes in heart rate (first decrease then increase) and blood pressure (increase) due to the changes in the balance between the parasympathetic and sympathetic nervous systems g) Can cause dysrhythmias, up to and including asystole 2. Risk factors a) Obesity b) Large neck size c) Male gender (until menopause for women, then incidence and risk factors are the same) d) Small oropharynx e) Small midface f) Micrognathia 3. Manifestations and complications a) Nighttime symptoms: (1) Snoring (2) Snorting (3) Gasping b) Daytime symptoms: (1) Headache upon arising (2) Daytime sleepiness (3) Irritability (4) Inability to concentrate c) Complications of untreated or poorly treated OSA: .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Poor daytime function (2) Hypertension (3) Cardiovascular disease (4) Stroke 4. Interprofessional care a) Diagnosis (1) Based on: a) Overnight polysomnography b) Limited home sleep study (2) Specific criteria for scoring and interpreting the studies, which leads to the diagnosis of OSA b) Nutrition (1) If the patient is overweight, the best treatment is weight loss. c) Treatment for OSA (1) Weight loss (2) Positional devices (3) Oral devices (4) Positive airway pressure (5) Surgery (6) Neurostimulator 5. Nursing care a) Assessment (1) Asking about adherence to the treatment regimen (2) Troubleshooting issues (3) Support the patient who is using positive airway pressure and educate them on the importance of continued treatment to avoid the consequences of untreated OSA. b) Priorities of care (1) Support the patient with adherence to treatment.

B. The patient with central sleep apnea 1. Pathophysiology a) Is a consolidation of a couple of different types of apnea, including: (1) Central sleep apnea with Cheyne-Stokes breathing (2) Central apnea due to a medical disorder without CheyneStokes breathing (3) Central sleep apnea due to a medication or substance abuse 2. Risk factors a) Medications .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

b) Neurological diseases c) Heart failure d) Obesity 3. Manifestations and complications a) Manifestations depend on the underlying cause. b) Common manifestations: (1) Tiredness and sleepiness during the day (2) Pauses in breathing without any effort or waxing/waning respirations c) Complications of all types of CSA: (1) Hypoxemia (2) Hypercapnea (3) Worsening of underlying disease processes 4. Interprofessional care a) Diagnosis (1) An overnight polysomnography is needed to diagnosis CSA. b) Treatment (1) Different types of positive airway pressure at night (2) Supplemental oxygen (3) Noninvasive ventilation in extreme cases (4) No medications to treat CSA (5) Weaning from medications if found to be the cause of CSA VIII. Restless Legs Syndrome A. The patient with restless legs syndrome 1. Pathophysiology a) A common sleep disorder affecting 5 to 10% of adults b) Pathophysiology relates to dopamine levels in the brain. c) Dopamine is needed for effective neuromuscular action and response. d) In the brain, one of the limiting factors for producing dopamine is iron. e) Patients with low iron stores are more likely to have RLS than those who do not.

2. Risk factors a) Family history of RLS b) Neuromuscular disease, including Parkinson disease c) Any disease process or health state that decreases iron stores: (1) Chronic anemia (2) Pregnancy .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(3) Renal failure (4) Dialysis 3. Manifestations and complications a) “Creepy-crawly” or a “pins-and-needles” feeling in the legs, in the evening, which is relieved by movement b) Prevent the person from falling asleep as moving the legs done to relieve the symptoms c) Main complication: (1) Sleep deprivation 4. Interprofessional care a) Diagnosis (1) Based on patient report (2) Diagnosis of exclusion (3) Symptoms must be in the evening, relieved by movement, and not due to another disease process. b) Medications (1) Stepwise approach: (a) Gabapentin or like medications (b) Dopamine agonists (c) Dopamine precursors (d) Occasional use of benzodiazepines or opiates (e) Final step, iron supplements (2) Monitor the patient for augmentation c) Nutrition (1) Increasing the iron content in the diet (2) Take iron supplements with orange juice d) Integrative therapies (1) Little data that supports integrative therapies (2) Suggestions: (a) Healthy diet (b) Daily exercise (c) Decreasing stress (d) Good sleep hygiene

Chapter Highlights A. Describe the physiology of sleep, normal sleep patterns, and factors affecting sleep.

1. Sleep is a reversible disengagement from the environment that has some common characteristics: Most humans sleep with their eyes closed, in a recumbent position, with regular breathing.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

2. One of the known purposes of sleep is to restore homeostasis along with mental and physical rejuvenation.

3. Rest is a period of diminished activity, without disengagement from the environment, for mental and physical rejuvenation but does not necessarily restore homeostasis.

4. The physiology of sleep is complex, involving multiple body systems, including the immune, metabolic, and sympathetic and parasympathetic nervous systems.

5. Most humans sleep when it is dark and are awake when it is light. Light is the most important regulator of sleep and circadian rhythms.

6. The normal amount of sleep is about 8 hours of consolidated sleep per 24-hour day during the nighttime. This can vary based on the person.

7. Sleep is divided into two main types, nonrapid eye movement (NREM) and rapid eye movement (REM).

8. NREM sleep is divided into three stages: N1, light sleep; N2, slightly deeper sleep; N3, deep or slow-wave sleep.

9. Sleep has a bidirectional relationship with psychologic and physiologic processes in the body.

10. Sleep disturbances can be a harbinger of degenerative neurologic disorders.

B. Summarize topics that nurses teach to promote healthy sleep across the lifespan.

1. Sleep is one of the fundamental processes of the human body. Promoting quality and appropriate quantity of sleep is an important role for nurses.

2. Sleep hygiene is a series of practices and habits that help an individual achieve quality sleep. Good sleep hygiene includes going to bed at the same time, awakening at the same time, exercising daily, being exposed to bright light in the morning, having proper nutrition, not eating immediately before bedtime, avoiding alcohol before bedtime, avoiding caffeine after midafternoon, avoiding use of electronic devices 1 to 2 hours before bedtime, and using the bedroom only for sleeping and other personal activities.

3. For the hospitalized patient, sleep disturbances may be related to the hospital environment rather than physical or emotional discomfort.

C. Outline the components of the assessment of sleep including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.

1. The interview for the patient with altered sleep needs to be comprehensive, as any major body system can have an impact on sleep.

2. The majority of information for sleep disorders is found during the interview phase of an assessment as opposed to the physical examination.

3. Sleep is measured in a number of ways, and some are more accurate and objective than others. Questionnaires, sleep diaries, and polysomnography are all used to measure sleep.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

D. Differentiate considerations for assessing the sleep of older adults, veterans, and individuals in the LGBTQI population.

1. As humans age, there is a tendency for earlier bedtimes and then resultant earlier arise times, though the underlying physiological reasons for this are still to be elucidated.

Lack of activity during the daytime due to illness or disability may not have the buildup of pressure to sleep.

2. Veterans who suffer from PTSD may have nightmares or insomnia. Veterans that suffered an injury may have chronic pain that prevents quality sleep.

3. Patients in the LGBTQI community are more likely to suffer stress, depression, and bullying, putting them at risk for poor sleep (quality and quantity) along with insomnia.

E. Describe the pathophysiology and manifestations of sleep deprivation, and outline the interprofessional care and nursing care of patients with this disorder.

1. Sleep deficit can have a profound effect on physiologic, emotional, and cognitive functioning. There is an increase in heart rate, decrease in concentration, slowing of reflexes, and irritability.

2. Interprofessional care for all patients with sleep difficulties may involve psychotherapists, respiratory therapists, physicians, sleep technologists, and nurses.

F. Describe the pathophysiology and manifestations of insomnia, and outline the interprofessional care and nursing care of patients with this disorder.

1. Insomnia is the inability to fall asleep, stay asleep, or feel rested upon awakening.

During the day, the patient with insomnia will feel tired or fatigued; have difficulties learning, paying attention, or concentrating; and may be irritable and prone to accidents.

2. Insomnia has been shown to be a risk factor for the development of depression, anxiety, and headaches. Insomnia has also been shown to be associated with the development of fibromyalgia, rheumatoid arthritis, osteoporosis, and asthma.

3. There are numerous medications for insomnia, both prescribed and over the counter.

The key issue with medication use in insomnia is once the medication is stopped the insomnia will still be present.

G. Describe the pathophysiology and manifestations of sleep-disordered breathing, and outline the interprofessional care and nursing care of patients with this disorder.

1. Obstructive sleep apnea (OSA) is a disorder of breathing during the night. OSA is caused by the airway either partially or completely collapsing during the nighttime. Respiratory effort continues but airflow is blocked. Complications of untreated or poorly treated OSA are numerous, ranging from poor daytime function to hypertension, cardiovascular disease, and stroke.

2. Central sleep apnea (CSA) is a consolidation of a few types of apnea. The manifestations of CSA depend on the underlying cause.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

3. Treatment of sleep-disordered breathing involves different types of positive airway pressure at night, sometimes supplemental oxygen, and in extreme cases noninvasive ventilation.

H. Describe the pathophysiology and manifestations of restless legs syndrome, and outline the interprofessional care and nursing care of patients with this disorder.

1. Restless leg syndrome (RLS) is a common sleep disorder effecting 5 to 10% of adults. The pathophysiology of RLS relates to dopamine levels in the brain.

2. The manifestations of RLS are primarily a “creepy-crawly” or a “pins-and-needles” feeling in the legs, in the evening, which is relieved by movement.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME ONE Have the students analyze their individual sleep patterns, focusing on how the pattern has changed since being in school.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME TWO Have the students identify/list their personal sleep hygiene practices. Which practice needs to be improved/changed?

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME THREE Have the students create a tool to complete a health history for sleep.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME THREE Have the students complete a sleep history and assessment with a patient during clinical.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME FOUR Have the students identify ways to enhance sleep hygiene for the older patient.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME FOUR Assign the students to care for an older patient to further assess sleep patterns.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME FIVE Have the students participate in an interprofessional group to identify strategies to improve sleep in the hospitalized patient.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME FIVE Have the students share the outcome of the interprofessional group during the classroom activity with the nursing staff.

SUGGESTIONS FOR CLASSROOM ACTIVITY—LEARNING OUTCOME SIX Have the students identify personal feelings when sleep deprived.

Have the students prepare a teaching tool on medications used to treat insomnia.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME SEVEN Invite Respiratory Therapist to the classroom to explain the different appliances used for OSA.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME SEVEN Assign the students to observe a patient having a sleep study.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME EIGHT Have the students create a teaching tool that identifies actions to help reduce the effects of RLS.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME EIGHT Have the students share the teaching tool that identified actions to help reduce the effects of RLS with the nursing staff.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter 4 Nursing Care of Patients Having Surgery Learning Outcomes 1. Compare various methods of and settings for surgical procedures, types of anesthesia, and perioperative patient safety.

2. Differentiate patient risks that can be mitigated in the preoperative stage.

3. Describe the preanesthesia phase, preadmission testing, and procedures for the day of surgery.

4. Outline aseptic practices, safety, and patient care during surgery.

5. Describe postoperative nursing care including postanesthesia care, extended care, and transfers.

6. Summarize postsurgical risks to patients including wound healing, cardiac events, respiratory events, and elimination issues.

7. Differentiate considerations for perioperative care of older adults and transgender adults.

Key Concepts I. Overview of Surgery A. Surgical methods and classifications 1. Purpose, risk, technique, and urgency 2. Minimally invasive or open procedure B. Anesthesia for surgery 1. General anesthesia a) Produces central nervous system depression b) State of unconsciousness, muscle relaxation, analgesia, and amnesia c) Most commonly administered by a combination of intravenous drugs and inhalation agents d) Phases: (1) Induction (2) Maintenance (3) Emergence 2. Regional anesthesia a) Causes analgesia, reflex loss, and muscle relaxation in an area of the body but patients do not lose consciousness b) Classified as: (1) Local nerve infiltration: (a) Lidocaine, bupivacaine, or tetracaine is injected around a local nerve .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(b) Used to suppress sensation over a limited area of the body (c) Used for a skin or muscle biopsy or suturing a wound (2) Nerve block: (a) An anesthetic is injected along a nerve track (b) Reduces sensation over a large area or extremity (3) Epidural block: (a) Local anesthetic agents injected into the epidural space, outside the dura mater of the spinal cord (b) Provides pain relief with less risk of adverse effects than general anesthesia. (c) Used for surgeries of the arms and shoulders, thorax, abdomen, pelvis, and lower extremities (d) Epidural catheter often left in place for pain relief in the postoperative period (e) May be used for chronic pain management (4) Spinal anesthesia: (a) Administered similar to epidural except the anesthetic medication is infused in a single injection (b) Effective for approximately 90 minutes (c) Used for surgeries of the lower abdomen, perineum, and lower extremities (d) Adverse effect: Headache (i) Caused by leakage of cerebrospinal fluid (CSF) into the epidural space (ii) Treatment: Hydration, caffeine, analgesics, or an epidural blood patch. (iii) Hypotension is common with epidural and spinal anesthesia (iv) Blood pressure should be monitored (v) Intravenous fluids and vasoactive medications may be needed 3. Conscious/Moderate sedation a) Provides analgesia, amnesia, and moderate sedation b) Causes an altered level of consciousness. However, the patient is still able to maintain a patent airway and respond to verbal and environmental stimuli 4. Monitored anesthesia care a) Allows for the safe administration of a maximal depth of sedation in excess of that provided during conscious/moderate sedation b) Provides the ability to adjust the sedation level from full consciousness to general anesthesia during the course of a procedure based upon patient needs C. Settings for surgery 1. Inpatients or outpatients a) Complexity of surgery b) Recovery c) Expected needed level of postop care .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

2. Outpatient advantages a) Decreased cost b) Reduced risk of hospital-acquired infection c) Less interruption in patient’s and family’s routine d) Possible reduction in time lost e) Less physiologic stress 3. Criteria for outpatient discharge a) Patient tolerates fluids or food without nausea/vomiting b) Vital signs stable c) Patient can stand and begin to walk without dizziness/nausea d) Pain is controlled or alleviated with oral medication e) Patient can urinate f) Patient is oriented g) Patient and/or significant other understands postoperative instructions D. Perioperative patient safety 1. The Joint Commission: a) Established National Patient Safety Goals b) Universal protocol 2. Safety in the perioperative environment: a) Responsibility of all personnel involved in the patient’s care.

3. Surgical Risk Factors: a) Advanced age b) Malnutrition c) Obesity d) Low socioeconomic status e) Chronic health conditions: (1) Alcoholism/substance use (2) Arthritis (3) Cardiovascular disorders (4) Diabetes mellitus (5) Immune suppression (6) Nicotine use (7) Renal and liver disorders (8) Respiratory disorders f) Medical therapies (1) Medications (a) Anticoagulants/platelet inhibitors (b) Antidepressants (c) Antihypertensives .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(d) Antibiotics (e) Diuretics (f) Herbal supplements (g) Immunosuppressants (2) Treatments (a) Radiation g) In the operating room: (1) Fluid/electrolyte imbalance (2) Hypothermia/hyperthermia (3) Surgical site infections (4) Venous stasis II. Patient Risks: Preoperative Considerations A. Medication interactions 1. Any prescribed, over-the-counter, or herbal preparation can affect anesthesia and the surgical experience 2. Anticoagulant medications, including aspirin and nonsteroidal anti-inflammatory drugs (NSAIDS), should be discontinued prior to surgery to prevent excessive blood loss during surgery B. Transfer of care 1. Hand-off (handover): Transfer of responsibility of care a) Provide: Patient information, opportunity to ask and respond to questions, communication strategies (SBAR), history and assessment to identify risk factors C. Thromboembolism 1. Balance risk of bleeding against risk of postoperative deep venous thrombosis (DVT), thromboembolism a) Prophylactic anticoagulation with low-dose unfractionated heparin, low-molecularweight heparin, factor Xa, or warfarin, intermittent sequential compression devices (ISCDs), and graduated compression stockings D. Hypothermia 1. Methods to minimize risk: Warm blankets, limit skin exposure, warm intravenous fluids, monitor temperature E. Surgical site infections (SSIs) 1. Strategies to decrease instance of SSIs: Prophylactic antibiotics in select procedures, appropriate hair removal, glucose control (in major cardiac surgery), normothermia (in colon surgery)

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

F. Positioning injury/pressure injuries 1. All patients at risk for potential injury and/or the development of pressure injuries 2. Common predictors of perioperative pressure injuries include: a) Advanced age b) Diagnosis of diabetes or vascular disease c) Having a vascular procedure 3. Prevention: a) Anticipate positioning equipment b) Operative procedure c) Postoperative course d) Use of body mechanics and ergonomics e) Ongoing assessment throughout the perioperative period f) Coordination with the entire perioperative team G. Adverse cardiac events 1. Myocardial infarction, cardiac ischemia III. Perianesthesia: Preoperative Nursing Care A. Preanesthesia phase 1. Preadmission testing a) Complete a health history, physical examination, and psychosocial assessment b) Facilitate diagnostic testing and/or review results: (1) Common laboratory tests: (a) Hemoglobin and hematocrit (b) Glucose and hemoglobin A1c (c) White blood cell count (d) Platelet count (e) Carbon dioxide (f) Prothrombin time (g) Urinalysis (h) Serum creatinine (i) Blood urea nitrogen (j) Electrolytes: Potassium, sodium, and chloride c) Identify patient preferences d) Assess the discharge plan e) Patient ability to perform self-care after surgery f) Preoperative teaching: (1) Diagnostic tests—reasons and preparations (2) Arrival time if surgery is scheduled the day of admission (3) Preparations for surgery

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(4) Instructions regarding current medications and any preoperative medications to be taken before admission (5) Informed consent (6) Timetable for surgery and the recovery room (7) Location of the surgical waiting area (8) Anticipated postoperative routine and devices/equipment (9) Postoperative pain control (10) Clothing to wear upon discharge (11) Exercises: (a) Breathing and coughing (b) Leg, ankle, and foot (c) Turning in bed 2. Day of surgery/procedure a) Patient and procedure identification b) Informed consent: (1) Need for the procedure in relation to the diagnoses (2) Description, purpose, and intended outcome of the proposed procedure (3) Possible benefits and potential risks (4) Likelihood of a successful outcome (5) Alternative treatments or procedures available (6) Anticipated risks should the procedure not be performed (7) Physician’s advice as to what is needed (8) Right to refuse treatment or withdraw consent c) Medication administration: (1) Functions: induce sedation, reduce anxiety, induce amnesia, increase comfort, reduce gastric acidity and volume, promote gastric emptying, decrease nausea and vomiting and reduce risk of aspiration (2) Preoperative antibiotic prophylaxis: Prevents postoperative complications (SSIs) d) Complementary care interventions (1) Used to decrease patient anxiety and/or promote comfort (2) Include: Music, massage therapy, acupuncture or acupressure, aromatherapy, hypnosis therapy, Reiki therapy, guided imagery, relaxation audios, and/or essential oils IV. Surgery: Intraoperative Nursing Care A. Members of the intraoperative team 1. Surgeon, surgical assistant(s), anesthesiologist or CRNA, circulating registered nurse (RN), and a scrub nurse, certified surgical technologist (CST), surgical technologist, or operating room technician (ORT) .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

B. Aseptic practices 1. Attire in the surgical environment a) Based upon zones: (1) Restricted: Actual OR (2) Semi-restricted: Hallways, work areas, and sterile processing and storage rooms (3) Unrestricted 2. Hand Hygiene: a) Standardized hand hygiene protocol: (1) before and after patient contact (2) before carrying out a clean or sterile task (3) after risk for blood or body fluid exposure (4) after contact with patient’s surroundings (5) when hands are visibly soiled (6) before and after eating (7) after using the restroom 3. Surgical scrub: a) Prepare hands and arms as clean as possible in preparation for a procedure b) Performed with a sponge or brush and an antimicrobial agent or FDA-approved alcohol-based antiseptic surgical hand rub c) Skin considered “surgically clean” following the scrub d) Purpose of the surgical scrub: (1) Remove dirt, skin oils, and transient microorganisms from nails, hands, and forearms.

(2) Increase patient safety by reducing the number of resident microorganisms on surgical personnel (3) Leave an antimicrobial residue on the skin to inhibit growth of microbes for several hours 4. Surgical technique: a) Prepare a sterile field b) Never leave unattended 5. Sterilization and disinfection a) Be familiar with: (1) Device category/classifications (e.g., critical, semicritical, and noncritical types) (2) Level of disinfection required for each type

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(3) Chemicals, processes, and conditions most effective for achieving disinfection and/or sterilization C. Patient and worker safety in the operating room 1. Implement interventions that promote: a) Safe lifting and moving b) Use of medical devices and personal protective equipment (PPE) c) Identification and response to clinical and alert alarms d) Use of blanket and solution-warming cabinets e) Fire prevention, suppression, and risk assessment f) Use of anesthetic gases g) Handling and storage of hazardous chemicals h) Identification, precautions, and responses to latex-related reactions i) Disposal of hazardous and medical waste 2. Areas of potential risk of injury for patients and intraoperative team members: a) Medication administration b) Radiation exposure c) Counting of surgical items d) Handling sharps e) Managing specimens f) Surgical smoke plume g) Transmissible infections D. Patient care 1. All patients who enter the operating suite are at risk for unintended injury 2. Routine intraoperative care: a) Identify the patient b) Assist with transferring from a stretcher to the OR table c) Provide warm blankets or device to promote normothermia d) Ensure patient comfort and secure to the bed with a safety belt e) Assist with application of patient monitors f) Apply ISCDs to lower extremities to reduce the risk of DVT 3. Circulating nurse: a) Positions the patient b) Removes hair with clippers or depilatory product c) Provides antimicrobial skin preparation d) Applies a dispersive pad if electrosurgery is planed e) Inserts a urinary catheter if required 4. Scrub person: Gowns and gloves the surgeon and assistants using sterile technique 5. Circulating nurse assists the team as needed in this process .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

6. Surgical pause (or time-out) is conducted preincision a) All members of the patient’s intraoperative team participate in this activity 7. Surgeon makes the incision 8. During the procedure the circulating nurse assists other members of the intraoperative team as needed throughout the case 9. At the end of the surgical procedure, the circulating nurse and scrub person concurrently ensures, that all counts are correct a) If counts are incorrect, corrective actions are taken at this time 10. After the wound is closed and dressed, the circulating nurse assists with extubation processes 11. After extubation, circulation nurse prepares the patient for transfer to an inpatient bed or stretcher for admission to the PACU, ICU, or other recovery unit 12. Circulating nurse provides report to the accepting unit 13. Scrub person deconstructs the sterile field, appropriately disposes of sharps and other items that cannot be decontaminated and reprocessed, and transports all dirty instrumentation to the decontamination area within the perioperative setting 14. Positioning: a) Common positions: (1) Supine (2) Semi-Fowler (3) Prone and jackknife (4) Lateral (5) Trendelenburg or reverse Trendelenburg (6) Lithotomy 15. Surgical counts a) Actions to prevent retention of foreign objects: (1) Use a consistent multidisciplinary approach to prevent retaining objects which is enforced during all surgical and invasive procedures (2) Radiopaque surgical soft goods (e.g., sponges, towels, textiles), sharps, and instruments should be counted for all procedures (3) Follow standardized measures for investigation and reconciliation count discrepancies during the closing count and before the end of surgery (a) When a discrepancy in the count(s) is identified, the surgical team should carry out steps to locate the missing item (4) Perioperative staff members may consider the use of adjunct technologies to supplement manual count procedures and to ensure no unintended item remains (5) Measures taken for the prevention of retained objects should be documented in the patient’s medical record

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(6) Policies and procedures for the prevention of retained objects, including device fragments, should be developed, reviewed periodically, revised as necessary, and readily available in the practice setting V. Perianesthesia: Postoperative Nursing Care A. Postanesthesia phase 1 1. Assessment completed upon admission to the postanesthesia care unit (PACU): a) Airway and breathing b) Vital signs c) Surgical site d) Mental status and level of consciousness e) Intake and output f) Pain level 2. Other assessments: a) Integration of data received at transfer of care from the operating suite b) Vital signs c) Comfort level d) Neurological function including level of consciousness and pupillary response e) Sensory and motor function f) Position of patient g) Skin integrity h) Patient safety needs i) Neurovascular (e.g., peripheral pulses, sensation in extremities) j) Condition of dressings and visible incisions k) Type, patency, and securement of drainage tubes, catheters, and receptacles l) Intravenous assessment 3. Postsurgical pain management a) At the end of a surgical procedure or immediately postoperatively, Ketorolac tromethamine (Toradol) is most commonly administered to assist with pain management (1) Used with caution in patients over 65 years of age, those under 50 kg (110 lb), and those with reduced or potentially reduced renal function (2) Usual adult dose is 30 mg given intravenously every 6 hours for 24 to 48 hours (3) Given in conjunction with an opioid analgesic as well.

Contraindications b) NSAIDs allow lower doses of opioid analgesics .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

c) Opioid analgesics are considered the foundation for managing moderate to severe postoperative pain (1) Dosage requirements vary d) Patient-controlled epidural anesthesia (PCEA) may be more effective for older adult patients and is associated with earlier improved mental status and bowel activity B. Postanesthesia phase II 1. Discharge criteria for outpatient surgery: a) Able tolerate fluids or food without nausea and vomiting b) Vital signs stable or within 10% of preoperative status c) Able to stand and walk without dizziness or nausea d) Pain controlled or alleviated with oral medication e) Able to urinate f) Oriented or at preoperative mental status g) Understanding and demonstrates postoperative instructions 2. Teaching needs: a) Wound care b) Signs and symptoms of a wound infection c) How and when to measure temperature d) Limitations or restrictions e) Control of pain 3. Extended care: a) Focuses on nourishment, elimination patterns, and coordination of further care (if needed) and/or safe transport from the institution b) Pain medication provided according to the WHO Pain Ladder c) Nutrition and fluid management: (1) Intravenous fluids used until the patient is fully awake and bowel sounds are present (2) Because surgery causes a hypermetabolic state, patients are at risk for protein-calorie malnutrition (PCM) (3) Reestablishing food intake early postoperatively supports wound healing and gastrointestinal function (4) If oral intake is not reestablished, parenteral nutrition may be required 4. Transfer and Continued Care of Stable Postoperative Patients a) PACU staff provides report to the nurse on the receiving care area b) Assessment to be completed by the receiving nurse includes: (1) General appearance .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(2) Vital signs (3) Level of consciousness (4) Emotional status (5) Respiratory rate (6) Skin color and temperature (7) Discomfort/pain (8) Nausea/vomiting (9) Type of intravenous fluids and flow rate (10) Dressing site (11) Drainage on the dressing/bed linen (12) Urinary output (catheter or ability to urinate) (13) Ability to move all extremities c) All physician orders must be renewed upon admission to the receiving care area VI. Patient Risks: Postsurgical Considerations A. Wound healing 1. Primary intention (cell regeneration): Wound is uncomplicated and clean 2. Secondary intention: Wound is large, gaping, and irregular 3. Phases of wound healing a) Inflammatory phase: Begins with surgical incision (1) Wound drainage: Serous, sanguineous, purulent b) Proliferative phase: Begins within 2–3 days after surgery c) Remodeling phase: Begins 3 weeks after surgery 4. Nursing care of surgical wounds a) Maintain medical asepsis b) Observe aseptic technique during dressing changes and handling of tubes and drains c) Assess vital signs, especially temperature d) Evaluate characteristics of wound discharge e) Assess condition of incision f) Clean, irrigate, and pack wound in the prescribed manner g) Maintain patient’s hydration and nutritional status h) Culture wound prior to beginning antibiotic therapy i) Administer antibiotics and antipyretics as prescribed j) Provide supportive measures to patient and family 5. Dehiscence: Separation in layers of incisional wound 6. Evisceration: Protrusion of body organs from wound dehiscence B. Cardiac events 1. Hemorrhage

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) Concealed hemorrhage: Occurs internally from blood vessel that is no longer sutured or cauterized or from a drainage tube eroding a blood vessel b) Obvious hemorrhage: Occurs externally from dislodged or ill-formed clot at wound c) Assessment findings: Amount and rate of blood loss d) Signs: Tachycardia, cool, pale skin, and decreased urine output 2. Shock a) Causes: Insufficient blood flow to vital organs, inability to use oxygen and nutrients, and inability to rid tissues of waste material b) Common type: Hypovolemic shock 3. Deep venous thrombosis (DVT) a) Most often occurs in lower extremities b) Causes: Vessel trauma during surgery, sluggish blood flow after surgery c) Risk factors (1) Orthopedic surgery to lower extremities, urologic, gynecologic, or obstetric surgeries, or neurosurgery (2) Age over 40 years (3) Pregnancy, varicose veins, hormone replacement therapy, or use of birth control pills (4) History of previous DVT or pulmonary emboli (5) Prolonged immobility (6) Cigarette smoking (7) Infection or sepsis (8) Malignancy d) Prevention: Early ambulation, anticoagulant medications e) Common assessment findings (1) Pain or cramping in calf or thigh, redness and edema of extremity with elevated temperature, positive Homans’ sign f) Nursing care (1) Assess affected extremity, administer and monitor effects of prescribed anticoagulants, maintain activity restrictions, teach and support patient and family 4. Pulmonary embolism a) Common assessment findings (1) Mild to moderate or severe dyspnea, chest pain, diaphoresis, anxiety, restlessness, rapid respirations and pulse, dysrhythmias, cough, cyanosis b) Nursing care (1) Notification of physician, frequent assessment of cardiac, respiratory, neurologic status, oxygen saturation, administration of supplemental oxygen, maintain intravenous access, prescribe anticoagulants and analgesics, support patient and family .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

C. Respiratory events 1. Pneumonia a) Causes: Microbial infection or foreign substance in lung b) Common assessment findings (1) Chills and fever, tachycardia, tachypnea, cough, dyspnea, chest pain, crackles and wheezes c) Nursing care (1) Treat pulmonary infection, support respiratory efforts, promote lung expansion, and prevent organisms’ spread 2. Atelectasis a) Common assessment findings (1) Dyspnea, diminished breath sounds over the affected area, anxiety, restlessness, crackles, cyanosis b) Nursing care (1) Promote lung expansion and systemic oxygenation of tissues D. Elimination issues 1. Urinary retention a) Assess for bladder distention if patient has not voided 7–8 hours after surgery b) Use portable ultrasound scanner c) Promote fluid intake 2. Altered bowel elimination a) Ask patient about flatus, auscultate bowel sounds every 4 hours, assess abdomen for distention, monitor for defecation b) Encourage ambulation, promote fluid intake, provide privacy, administer stool softener or mild laxative, suppository or enema after 3–4 days VII. Surgical Considerations for Special Populations A. Older adults 1. Certain physiologic, cognitive, and psychosocial changes associated with the aging process place older adults at increased risk for surgical complications 2. More prone to: Hypotension, hypothermia, and hypoxia 3. Positioning may cause complications including decubitus ulcer formation 4. Increased risk for surgical infections because of declining immune function 5. Vision and hearing impairments contribute to disorientation B. Transgender adults 1. May have surgical interventions to alter sexual anatomy and physiology 2. May have a medical diagnosis of gender dysphoria 3. Hormone therapy is common but has risks: a) Testosterone can damage the liver .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

b) Estrogen can increase blood pressure, blood glucose, and blood clotting c) Antiandrogens, such as spironolactone, can lower blood pressure, disturb electrolytes, and dehydrate the body

Chapter Highlights A. Surgery is a major physiologic and psychologic stressor that carries significant risks. Nurses have a critical role in advocating for the patient, and for protecting the safety, maintaining the physiologic and psychologic integrity, and promoting the recovery of the patient undergoing surgery.

B. Surgeries take place in inpatient and outpatient settings, often with the use of minimally invasive procedures that expedite discharge, facilitate healing, and increase patient satisfaction.

C. Surgery is an invasive procedure requiring that legal guidelines be followed to protect the patient and healthcare providers. The intraoperative team includes surgeons, anesthetists, nurses, and technicians; all are responsible for the safety of the patient and the progression of the surgery.

D. Systematic, structured, and effective communication among all members of the interprofessional team is essential for safe and effective perioperative care. Care transitions (preadmission to day of surgery care; day of surgery preoperative care to intraoperative care; intraoperative care to postanesthesia Phase I recovery; postanesthesia Phase I recovery to postoperative Phase II recovery; and postoperative Phase II recovery to home or extended care) present significant opportunities for errors, emphasizing the importance of effective communication.

E. The focus on safety during surgery continues to increase, with attention directed to preventing wrong site and wrong patient surgeries (using the Universal Protocol), surgical site infections, DVT and PE, and adverse cardiac events. A team approach to safety works best; each member of the team must feel accountable for the results of the surgery and entitled and safe in sharing observations and concerns as the procedure progresses.

F. Patient teaching prior to and following surgery empowers patients to achieve successful recovery, discharge, and rehabilitation. Most of the care patients receive as they heal from surgery is either provided by self or a caregiver outside the healthcare environment.

Patients and their families need to know how to appropriately assess healing progress and access help if needed and when to report suspected complications.

G. Assessing, coordinating, and implementing preoperative preparation, evaluating and ensuring the patient’s readiness for surgery, and teaching are key preoperative nursing roles.

H. Operating room and perianesthesia care nursing are professional specialties that require unique orientation and education. These professionals make careful assessments of the risks each patient faces and make plans to ensure safe, successful surgical outcomes.

I. Special attention is focused on early recognition of potential patient risks related to surgical experience and implementing nursing interventions to minimize risk and promote safety. .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

J. During the intraoperative phase, the nurse’s focus is on identifying patient risks, taking into account each individual’s health status and history, and implementing a nursing care plan intended to promote and maintain patient safety.

K. Patient advocacy is a critical nursing role during this phase as well. When the patient is under anesthesia and/or unable to speak, it is up to the intraoperative nurse and team members to ensure the patient’s needs and/or surgical expectations are met.

L. During the postoperative phase, nurses are instrumental in promoting the patient’s comfort and initial recovery, identifying and preventing potential complications, and teaching the patient and family or caregivers about continuing care needs.

M. Pain management is offered prior to, during, and after surgery, with methods designed to stimulate best therapeutic response. Although acute pain may be associated with surgery, many patients also experience chronic pain that affects their response to pain management therapies.

N. Wound healing occurs in three stages: Inflammatory, proliferative, and remodeling.

O. Common postoperative cardiovascular complications include hemorrhage, shock, DVT, and PE. P. Hemorrhage, an excessive loss of blood, can be internal or obvious.

Q. Shock, which is a life-threatening postoperative complication, results from an insufficient blood flow to vital organs, an inability to use oxygen and nutrients, or the inability to rid tissues of waste material.

R. Deep venous thrombosis (DVT) is the formation of a thrombus (blood clot) in association with inflammation in deep veins.

S. A pulmonary embolism (PE) is a dislodged blood clot or other substance that lodges in a pulmonary artery.

T. Unique characteristics of older adult patients increase the need for individualized care.

Assessment of physical, emotional, and spiritual status can be more difficult when patients have hearing or visual impairments or when individuals speak and understand a foreign language. Surgery can be frightening to patients and their families and they need reassurance and interventions to relieve anxiety, decrease pain, and promote healing.

U. Some transgender individuals undergo medical and/ or surgical interventions to alter their sexual anatomy and physiology, while others do not request these interventions. Hormone therapy has risk factors that impact surgery.

SUGGESTION FOR CLASSROOM ACTIVITY- LEARNING OUTCOME ONE Ask the class to research a cost comparison between outpatient and inpatient surgeries.

SUGGESTION FOR CLINICAL ACTIVITY- LEARNING OUTCOME ONE Have the student(s) spend some time observing outpatient and inpatient surgeries. .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTIONS FOR CLASSROOM ACTIVITY- LEARNING OUTCOME TWO Review the normal laboratory values for common preoperative tests. Ask students what abnormal values would indicate, and what their impact on the nursing process would be.

Bring normal and abnormal chest x-rays to the classroom. Explain the differences between the two films.

Discuss pulmonary function tests and their impact on anesthesia.

SUGGESTION FOR CLINICAL ACTIVITY- LEARNING OUTCOME TWO Have students observe a pulmonary function test. Ask a pulmonologist to discuss the findings.

SUGGESTION FOR CLINICAL ACTIVITY- LEARNING OUTCOME THREE Assign the students to observe/participate in the outpatient setting by assisting with preadmission testing, preoperative teaching, and preparing the patient for the surgical procedure.

SUGGESTION FOR CLASSROOM ACTIVITY- LEARNING OUTCOME FOUR Ask a perioperative nurse to visit the classroom to discuss the role of the registered nurse in the operating room.

SUGGESTION FOR CLINICAL ACTIVITY- LEARNING OUTCOME FOUR Assign the students to observe the activities of the circulating and scrub nurses.

SUGGESTION FOR CLINICAL ACTIVITY- LEARNING OUTCOME FIVE Assign the students to work with a PACU nurse to provide care to a postoperative patient. Have the student stay with the patient until discharge from the PACU until admission to the receiving care area.

SUGGESTION FOR CLASSROOM ACTIVITY- LEARNING OUTCOME SIX Have the students prepare a teaching tool that integrates preoperative exercises and teaching as prevention of postoperative complications.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTION FOR CLINICAL ACTIVITY- LEARNING OUTCOME SEVEN Assign the students to complete a preoperative assessment of an older patient. Identify the areas in which the patient may be at risk for postoperative complications and list actions to prevent potential postoperative issues.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter 5 Palliative and End-of-Life Care

Learning Outcomes 1. Differentiate theories of loss and grief and outline factors affecting responses to loss.

2. Explain the concept of palliative care and the nurse’s role in care of the patient and family.

3. Outline the legal, ethical, and physiologic issues encountered when caring for the dying patient.

Key Concepts Introduction 1. Loss results in change and stress 2. Grief: Emotional response to loss 3. Grieving: Internal process the individual uses to work through the response to loss 4. Mourning: Actions or expressions of the bereaved 5. Death: Irreversible cessation of circulatory and respiratory functions or irreversible cessation of all functions of the entire brain, including the brainstem I. Loss and Grief A. Theories of Loss, Grief, and Dying 1. Freud: Psychoanalytic theory a) Inability to grieve results in depression 2. Bowlby: Attachment theory a) Successful grieving process ends with emancipation from loss b) Phases: Protest, despair, and detachment c) Basis for “continuing bonds” theory 3. Engel: Acute grief, restitution, and long-term grief a) Related grief to coping of other stress b) Individual perceives, evaluates, adapts 4. Lindemann: Categories of symptoms a) Differentiates normal grief, anticipatory grieving, and morbid grief reaction 5. Caplan: Stress and loss a) Factors that influence coping with loss (1) Psychic pain (2) Loss of assets and guidance (3) Reduced cognitive effectiveness from distress 6. Kübler-Ross: Stages of coping with loss a) Not all people go through all stages .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

b) Stages may be experienced in different sequence c) Stages: Denial, anger, bargaining, depression, and acceptance B. Factors Affecting Responses to Loss 1. Age a) Concept of death changes from age 3 throughout lifespan 2. Social support a) Factors that can interfere (1) Perceived inability to share loss (2) Lack of social recognition of loss (3) Ambivalent relationships (4) Traumatic circumstances b) Important not to place value on loss that may not seem significant c) Withdrawal from social support may occur 3. Families a)Well-functioning family rallies together, adjusts (1) Family included in end-of-life care (2) Family members’ reactions to loss may harm patient’s process 4. Cultural and spiritual practices a) Ethnocultural and religious differences regarding death b) Buddhism, Catholicism, Hinduism, Islam, Judaism, and Protestantism have different ways of dealing with near-death and just after death 5. Spiritual beliefs a) Loss calls into question: Principles, values, personal philosophy, and meaning of life b) May lead to spiritual distress c) Questions to assess regard: Faith, influence, community, and what needs to be addressed d) FICA Assessment: Faith, Influence, Community, and Address 6. Rituals of mourning a) Culture dictates rituals of mourning b) Some cultures prefer to die at home; perform cleaning and burial in different ways 7. Nurses’ response to patients’ loss a) Nurses must analyze own feelings and values about loss and grief b) Many internet resources available for care of dying patients II. Palliative Care Defined as an approach to patient care that improves the quality of life of patients and their families who are facing problems associated with life-threatening illness.

A. The Patient in Palliative Care: 1. Provided in a variety of settings: Hospital, skilled nursing center, home .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

2. Interprofessional care: a) Based on communication and cooperation among the various disciplines on a healthcare team.

3. Nursing care: a) Follows the steps of the nursing process: Assessment, priorities of care, diagnoses, outcomes, and interventions 4. Transitions of care: a) Patients face complex medical decisions b) Need to decide when to transition from palliative care to hospice or end-of-life care B. End-of-Life Care 1. American Association of Colleges of Nursing (AACN) list of competencies Hospice: a) Philosophy of care rather than a program of care. b) Based on a philosophy of death with comfort and dignity, encompassing biomedical, psychosocial, and spiritual aspects of the dying experience c) Services are reimbursed by Medicare for an initial 90-day period, followed by a subsequent 90-day period, and an unlimited number of 60-day periods as long as the patient continues to meet eligibility requirements d) Services usually begin when the patient has 6 months or less to live and ends with the family 1 year after the death of the patient (1) Continuation of care for the family is called bereavement care e) Eligibility requirements: (1) The patient must have a serious, progressive illness with a limited life expectancy (2) A family (or other) caregiver must be continuously in the home with the patient (3) The patient must have Medicare, waive traditional Medicare benefits for the terminal illness (4) Have physician certification of a terminal illness with a life expectancy of 6 months or less (5) Care must be provided by a Medicare-certified hospice agency or program III. Legal and Ethical Issues A. Advance directives: Legal document, plan for health care and financial affairs in event of incapacity 1. Living wills: Directs for life-prolonging procedures 2. Healthcare surrogates: Individual selected to make medical decisions for incapacitated patient

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

3. Durable power of attorney: Individual selected to make medical, financial, legal decisions for incapacitated patient 4. Physician orders for life-sustaining treatment (POLST): Medical plan for those with chronic progressive illnesses 5. Medicare- and Medicaid-funded facilities provide all patients with information about advance directives B. Do-not-resuscitate (DNR) orders: No cardiopulmonary resuscitation in event of respiratory or cardiac arrest 1. Goal of care: Comfortable, dignified death C. Euthanasia, assisted suicide, and aid in dying 1. Euthanasia: The practice of intentionally ending a life to relieve pain and suffering 2. ANA position: Opposes nurse participation 3. State laws vary 4. Assisted suicide: Someone makes means of death accessible, does not act as direct agent 5. Aid in dying: Prescription from physician for mentally competent, terminally ill patients to administer to end life D. Physiologic changes in the dying patient 1. Include: a) Difficulty talking or swallowing b) Nausea, flatus, abdominal distention c) Urinary and/or bowel incontinence, constipation d) Decreased sensation, taste, and smell e) Weak, slow, and/or irregular pulse f) Decreasing blood pressure g) Decreased, irregular, or Cheyne-Stokes respirations h) Changes in level of consciousness i) Restlessness, agitation j) Coolness, mottling, and cyanosis of the extremities 2. Pain a) Undertreated at end-of-life for fear of addiction and respiratory depression (1) Dose increased to whatever is necessary to relieve pain b) Important to keep patient comfortable c) Medications for pain, neuropathic pain, seizures, anxiety 3. Dyspnea: Feeling of suffocation, shortness of breath, tightness in chest a) Lack of oxygen to brain is final cause of death in 50% of deaths b) Morphine is drug of choice

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

c) Crackle sounds in lungs from fluid accumulation, not painful, can be treated with medication or oxygen to relieve anxiety d) Keep head of bed elevated, keep room cool 4. Anorexia, nausea, dehydration a) Parenteral or enteral feedings do not prolong life, may cause discomfort b) Nausea treated with antiemetics c) Dehydration treated with small sips of water, more can cause overhydration 5. Altered levels of consciousness a) Caused by cerebral perfusion, hypoxemia, metabolic acidosis, sepsis, accumulation of toxins from liver and renal failure, effects of medications, disease-related factors b) Normal at end of life, distressing for family c) Delirium (1) May be misinterpreted as pain (2) Many assessment tools for cause (3) Treated with medications d) Hearing often last sense dying patient loses 6. Hypotension a) Cardiac output and intravascular blood volume decrease b) Symptoms visible and palpable in extremities, skin, nails, lips E. Psychosocial support 1. Provide opportunity for patient to express preferences about post-death actions 2. Gives patient sense of control a) Provide opportunity to say goodbye b) Acknowledge termination is painful F. Death 1. Manifestations of death include: a) Absence of respirations, pulse, and heartbeat b) Fixed and dilated pupils; eyes may stay open c) Release of stool and urine d) Waxen color (pallor) as blood settles to dependent areas e) Body temperature drops f) Lack of reflexes g) Flat encephalogram 2. Nurse’s fear of death interferes with ability to provide support 3. After death, family encouraged to acknowledge pain of loss a) Acceptance is first step b) Nurse maintains open, honest dialogue, allows family to interact with by providing the family with the opportunity to view, touch, hold, and kiss the patient’s body and is there with family to provide comfort and support .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

4. Postmortem care a) Nurse documents time of death, notifies physician, and assists family b) In some states, nurse can pronounce death; in others, physician must c) Body left in place until family gives permission to move it d) Body left undisturbed in case of transportation to autopsy 5. Self-care for the nurse a) Nurse must grieve after death of patient to prevent blunting b) Consciously practice coping strategies c) Crying with families not considered unprofessional G. The Patient Experiencing Grief 1. Interprofessional care a) Interventions planned and performed by any member of healthcare team b) Referrals to mental health professionals when needed c) Collaborative care early helps avoid crisis state 2. Nursing care a) Health promotion (1) Consider individual responses (2) Those who delay grieving process are prone to long-term health problems 3. Assessment a) Physical assessment (1) GI manifestations occur frequently (a) Indigestion, nausea or vomitting, anorexia, weight gain or loss, constipation or diarrhea (2) Acute symptoms: Shortness of breath, choking sensation, hyperventilation, or weakness (3) Sleep and energy changes common (4) Crying and sadness normal (5) Patterns of increased illness after loss may indicate dysfunctional grieving (a) Especially when associated with change in body image (6) Address concerns about pain b) Spiritual assessment (1) Inner resources help with grief process (2) Many turn to religion in times of loss (3) Assessment with questions about philosophy of life, alignment of beliefs with family members, spiritual resources, and rituals that are important to patient (4) Assess level of guilt, feelings of responsibility c) Psychosocial assessment (1) Fear, anxiety may threaten patient’s well-being .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(2) Be open to conversation about death, do not avoid it (3) Ask patients to expand on feelings (4) Do not provide false reassurance (5) Acute symptoms of altered sensorium may occur from shock, disbelief d) Priorities of care (1) Optimum level of comfort (2) Managing dyspnea (3) Manage restlessness and delirium (4) Provide time for patient and family to be together (5) Provide emotional and spiritual support 4. Diagnoses, outcomes, and interventions a) Manage pain and other symptoms (1) Pain: Most common symptom, aggressive management and monitoring (2) Symptoms minimized according to verbal and nonverbal signs (3) Interventions to maximize comfort for patient and family (a) Physical and psychologic (b) Involve medications, oxygen, avoiding unnecessary procedures (c) Systematic assessment guide interventions b) Support the grieving patient and family (1) Assess for factors of grief (2) Use open-ended questions (3) Promoting trusting relationship (4) Ask about coping with past losses (5) Teach stages of grief (6) Provide time for decision making and information about resources c) Relieve death anxiety (1) Explore patient’s awareness of condition (2) Determine coping ability (3) Ask patient to identify needed help (4) Encourage independence, life review, relaxing activities, spiritual practices, keeping a journal (5) Explain advance directives d) Provide patient education (1) Encourage both children and adults to discuss expected or impending loss and to express feelings.

(2) Teach problem-solving skills.

(3) Teach individuals and families how to support a person who is dealing with an impending loss.

(4) Explain what to expect with a loss: Sadness, fear, rejection, anger, guilt, and loneliness. .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(5) Teach signs of grief resolution.

Chapter Highlights A. Caring for patients and families experiencing loss, grief, and death emphasizes integration of holistic nursing interventions focused on providing individualized patient-centered care.

B. Providing direct patient care and coordinating, leading, and participating as a member of the interprofessional team is an essential role for the registered nurse when caring for this population.

C. Grief is the emotional response to a loss, experienced by an individual as grieving.

Bereavement, a form of depression accompanied by anxiety, is a common response to loss of a loved one by death. Death, although inevitable, is an immensely difficult loss.

D. There are many different theories of how people respond to loss, grief, and death. These theories are useful when providing nursing care to patients and families.

E. An individual’s response to loss is influenced by age, social support, family members, cultural and spiritual beliefs, and rituals of mourning. Nurses need to assess the way in which they respond to loss to better care for patients.

F. Palliative care is an area of care that has evolved out of the hospice experience, but exists outside of hospice programs, is not restricted to the end of life, and is used earlier in the disease experience.

G. Palliative care usually involves the combined efforts of an interprofessional team, including physicians, nurses, social workers, chaplains, home health aides, and volunteers.

H. The expected outcomes of palliative care are directed by interventions to manage current manifestations of the illness and to prevent new manifestations from occurring.

I. Legal and ethical issues involved in end-of-life care include advance directives (living wills, healthcare surrogates, durable powers of attorney, physician orders for life-sustaining treatment), do-not-resuscitate orders, euthanasia, assisted suicide, and aid in dying.

J. Hospice is a philosophy of care rather than a program of care. It is comprehensive and coordinated care for patients with limited life expectancy that reaffirms the right of every patient and family to fully participate in the final stages of life.

K. To provide knowledgeable and compassionate care at the end of life, nurses must recognize physiologic changes as the patient nears death, support the patient and family, provide postmortem care, and resolve their own grief.

L. Nursing care of patients experiencing an actual or potential loss includes accurate physical, spiritual, and psychosocial assessment. It also includes provision of interventions to alleviate pain and symptoms associated with the end of life and interventions for the human responses of grieving, chronic sorrow, and death anxiety.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTIONS FOR CLASSROOM ACTIVITY- LEARNING OUTCOME ONE Have the students compare and contrast the different theories of loss and grief.

Ask the students to recall the death of a family member, friend, or pet. Have the students discuss the feelings experienced immediately after the loss and the events that transpired afterwards to help resolve feelings of grief.

SUGGESTION FOR CLASSROOM ACTIVITY- LEARNING OUTCOME TWO Invite palliative care and hospice care professionals to the class to discuss their roles and the care provided to the patients receiving these services.

SUGGESTION FOR CLINICAL ACTIVITY- LEARNING OUTCOME TWO If a local hospice organization permits students, assign students to provide care with the hospice nurse in the location of the patient.

SUGGESTIONS FOR CLASSROOM ACTIVITY- LEARNING OUTCOME THREE Provide examples of the different types of advance directives for the students to review. Discuss which type of advance directive they would choose to use.

Discuss the physiologic changes that occur when death approaches and when death occurs. Ask the students to discuss their personal feelings about caring for a patient who has died. Encourage the students to share their thoughts and actions they would take if a patient dies during a clinical experience.

Ask the students to debate the practice of euthanasia.

Invite a senior care attorney to the classroom to discuss the issues and challenges when creating advance directives.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter 6 Nursing Care of Patients with Problems of Substance Abuse Learning Outcomes 1. Outline the pathophysiology, manifestations, and complications of substance abuse; the risk factors for substance abuse; and characteristics of individuals who abuse substances including nurses.

2. Differentiate the effects of selected addictive substances on physiologic, cognitive, psychologic, and social well-being.

3. Describe the interprofessional care, nursing care, and transitions of care for patients who abuse substances.

Key Concepts I. Overview of Substance Abuse Problems A. Substance abuse: Use of chemical inconsistent with medical or culturally defined social norms despite adverse effects B. Substance dependence: Use of chemical is no longer under individual’s control for at least 3 months C. Tolerance: A cumulative state in which a particular dose of the chemical elicits a smaller response than before D.

Physical symptoms of withdrawal can appear within hours 1.

Withdrawal a) Symptoms: Tremors, diaphoresis, anxiety, high blood pressure, tachycardia, possibly convulsions

E. Substance use disorder: The term that encompasses abuse of addictive drugs and alcohol F.

Pathophysiology, Manifestations, and Complications 1.

Dopamine: Identified as the primary neurotransmitter responsible for sustaining the addictive quality of drugs and for increasing drug-seeking behavior 2.

Co-occurring disorders: Refers to the coexistence of substance abuse or dependence and a psychiatric disorder in one individual. a) Most common: Alcohol abuse/dependence with depression or psychoses

G.

Risk Factors

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

1.

Genetic factors a) Hereditary factor, especially with alcohol use b) Family risk factors for alcoholism (a) Children of alcoholics (COAs) 4x more likely to develop alcohol problems (b) Alcoholic parent is depressed or other psychologic problems (c) Both parents abuse alcohol and other drugs (d) Parents’ alcohol abuse is severe (e) Conflicts lead to aggression and violence in family 2.

Biological factors a) Low levels of dopamine and serotonin linked to development of alcohol dependence b) Abused substances mimic or block brain’s most important neurotransmitters at receptor sites 3.

Psychologic factors a) Theories linking psychologic factors to substance abuse (a) Psychoanalytic theory (b) Behavioral theory (c) Family system theory b) May be environmentally influenced, inability to stop after one drink, passivedependent personality c) Childhood sexual or physical abuse d) Psychiatric disorders (depression, anxiety, antisocial, and dependent personalities) 4.

Sociocultural factors a) Ethnic differences in metabolizing alcohol b) Asian Americans report the lowest prevalence of family history of alcoholism because of insufficient ALDH2 c) Caucasians, Hispanics, and African Americans have sufficient ALDH2 for metabolizing alcohol and report higher alcoholism rates H.

Characteristics of Abusers 1.

No addictive personality type exists 2.

Characteristics of addictive behavior a) Compulsive preoccupation with obtaining substance b) Loss of control over consumption c) Development of tolerance and dependence d) Impaired social and occupational functioning 3.

Characteristics of abusers: Impulsive, risk-taking, low tolerance for frustration and pain, rebellious, anxious, angry, and low self-esteem

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

I.

Impaired Nurses 1. At-risk situations a) Easy access to prescription drugs b) Role strain c) Depression d) Signs of alcohol or drug use e) Signs of withdrawal 2. Warning signs a) Inaccurate narcotic counts, frequent missing drugs, patients deny receiving meds, excessive “wasting” of drugs, frequent bathroom trips b) Frequent tardiness, haphazard charting, patient care judgment errors, unorganized c) Irritability, mood swings, isolating, apathetic, depressed, unexplained absences from assigned unit d) Smell of alcohol; excessive use of perfumes, mouthwash, mints; slurred speech; long sleeves in hot weather e) Tremors, restlessness, sweating, watery eyes, runny nose, stomachaches

II. Addictive Substances and Their Effects A. Caffeine 1.

Stimulant and diuretic 2.

Negative effects: Cardiac-related risks, higher total cholesterol levels, insomnia 3.

Withdrawal symptoms: Headaches, irritability B.

Alcohol 1.

Most commonly used and abused legal substance in U.S. 2.

Acts on neurotransmitters such as gamma-aminobutyric acid (GABA), creates additive effect 3.

Alcohol is absorbed in mouth, stomach, digestive tract, 95% metabolized by liver 4.

Positive physiologic effects (in moderation): Increases level of good cholesterol (HDL), lowers levels of bad cholesterol (LDL), decreases platelet aggregation 5.

Chronic use effects: Severe neurologic and psychiatric disorders, severe damage to liver, fatal cirrhosis, myocardial disease, erosive gastritis, acute and chronic pancreatitis, sexual dysfunction, increased risk of breast cancer, malnutrition 6.

Wernicke–Korsakoff syndrome a) Wernicke encephalopathy: Acute stage of illness b) Korsakoff psychosis: Chronic stage 7.

Effects on sleep: Alters sleep cycle, decreases quality, obstructive sleep apnea, reduces sleep time 8.

Blood alcohol levels (BALs) and CNS effects

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) 0.05%: Euphoria, reduced inhibitions, impaired judgment, increased confidence b) 0.08%: Legal level of intoxication c) Excess of 0.5%: Can cause coma, respiratory depression, peripheral collapse, and death 9.

Withdrawal symptoms: Hyperexcitability (anxiety, tachycardia, hypertension, diaphoresis, nausea, vomiting, tremors, sleeplessness, irritability), seizures, convulsions, and delirium tremens (DT) C.

Nicotine 1.

Tobacco entering system through lungs or oral mucous membranes 2.

Stimulates nicotinic receptors in brain to release norepinephrine and epinephrine, causing vasoconstriction 3.

Increases respiration, mental alertness, cognitive ability, but eventually depresses these responses 4.

Withdrawal symptoms: Craving, nervousness, restlessness, irritability, impatience, increased hostility, insomnia, impaired concentration, increased appetite, and weight gain 5.

Chronic health problems: Cancer, heart disease, emphysema, hypertension, and death 6.

Smoking: Number one cause of preventable death and disease among women 7.

Risks of smoking during pregnancy: Low birth weight, stillbirth, preterm delivery, perinatal mortality, and sudden infant death syndrome (USDHHS) 8. eCig/eCigarette: Device that simulates smoking a) Vaping: Administers nicotine through a vapor b) Biologic effects on humans is inconclusive

D.

Cannabis 1.

Most commonly used illicit drug 2.

Psychoactive component: Delta-9-tetrahydrocannabinol (THC) a) Causes release of endogenous opioids and dopamine 3.

Physiologic effects (short term): Increased heart rate, bronchodilation 4.

Physiologic effects (long term): Airway constriction, bronchitis, sinusitis, asthma, increased risk of respiratory cancer, decreased spermatogenesis and testosterone levels in males, suppressed follicle stimulation, luteinizing, and prolactin hormones in females 5.

Risks of smoking while pregnant: Risk of abnormalities in the fetus such as CNS disturbances, low birth weight, decreased length, smaller head circumference, and fetal death 6.

Subjective effects: Euphoria, sedation, and hallucinations

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

7.

Chronic use effects: Amotivational behaviors, high doses lead to tolerance and physical dependence E.

CNS depressants 1.

Barbiturates, benzodiazepines, paraldehyde, meprobamate, chloral hydrate 2.

Effects: Mild sedation to sleep to coma to death 3.

CNS depressants taken together can result in death

F.

Psychostimulants 1.

Cocaine a) Cocaine base (crack): Cooked in baking soda and smoked (freebasing) b) Cocaine hydrochloride (HCl): Snorted or injected c) Skin popping: Subcutaneous injection of cocaine d) Mild overdose: Agitation, dizziness, tremor, and blurred vision e) Severe overdose: Anxiety, hyperpyrexia, convulsions, ventricular dysrhythmias, severe hypertension, hemorrhagic stroke with possible angina or myocardial infarction (MI) f) Risks during pregnancy: Spontaneous abortion, premature delivery, retardation of intrauterine growth, congenital abnormalities, fetal addiction g) Chronic use effects: Atrophy of nasal mucosa, necrosis and perforation of nasal septum, lung damage 2.

G.

Amphetamine a) Methamphetamine: Most widespread amphetamine, inhaled, injected, ingested, or smoked (1) Referred to as speed, crystal, crank, go, and ice b) Linked with HIV infection and high rates of STIs c) Users report severe to moderate depressive symptoms d) Effects: Arousal and mood elevation, sense of increased strength, mental capacity, self-confidence, decreased need for food and sleep e) Physical symptoms: Weight loss, tachycardia, tachypnea, hyperthermia, insomnia, and muscular tremors f) Behavioral and psychiatric symptoms: Violent behavior, repetitive activity, memory loss, paranoia, delusions of reference, auditory hallucinations, and confusion or fright g) Withdrawal symptoms: Dysphoria and craving with fatigue, prolonged sleep, excessive eating, and depression

Opiates 1. Narcotic analgesics: Morphine, codeine, hydrocodone, and oxycodone 2. Pain relievers derived from natural or synthetic opiates

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

3. Majority of abusers: Urban poor 4. Increase in use due to: Changes in medication prescribing practices, changes in drug formulations, easy access via internet or family and friends 5. Withdrawal symptoms a) First phase (lasts 10 days): Drug craving, lacrimation, rhinorrhea, yawning, and diaphoresis b) Second phase (lasts for months): Insomnia, irritability, fatigue, potential GI hyperactivity and premature ejaculation 6. Methadone: Synthetic opiate to treat chronic pain and addiction to other opiates H.

Hallucinogens (psychedelics) 1. Phencyclidine (PCP), 3,4-methylenediosy-methamphetamine (MDMA), d-lysergic acid diethylamide (LSD), mescaline, dimethyltryptamine (DMT), psilocin 2. Bring on thoughts, perceptions, feelings of dreams 3. Physical dependence does not occur, no withdrawal symptoms

I.

Inhalants 1. Anesthetics, volatile nitrites, organic solvents 2. Risks: Brain damage or sudden death 3. Organic solvents ingested by bagging, huffing, or sniffing a) Common organic solvents: Toluene, gasoline, lighter fluid, paint thinner, nail polish remover, benzene, acetone, chloroform, model airplane glue b) Effects produce a high

III. Care of Patients with Substance Abuse Problems A. Interprofessional care 1. Therapies: Detoxification, aversion therapy to maintain abstinence, group and/or individual psychotherapy, psychotropic medications, medication-assisted treatment (MAT), cognitive-behavioral strategies, family counseling, self-help groups B.

Emergency care 1. Mechanical ventilation in the case of respiratory depression 2. Keep patient awake 3. Seizures may occur 4. Monitor for signs of suicidal ideation

C.

Diagnostic tests: 1. Breathalyzer: Detects blood alcohol levels (BAL) 2. Urine drug screening: Noninvasive, preferred method for detecting substances

D.

Treatment of withdrawal

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

1. Symptoms of severe withdrawal: Disorientation, paranoid delusions, visual hallucinations, marked withdrawal symptoms, seizures 2. Treatment: Mostly symptomatic through acetaminophen, vitamins, and medications 3. Alcohol withdrawal: Minimize adverse outcomes and adverse effects of medications E.

Medications used to treat alcoholism 1. Benzodiazepines 2. Vitamins 3. Anticonvulsants 4. Abstinence medications 5. Antidepressants 6. Antihypertensives 7. Nicotine replacement and adjunct therapy

F. Nursing care 1. Assessment a) Use open-ended questions b) Assess substance use history (1) How many substances used simultaneously in the past?

(2) How often, how much, and when did patient first use the substance(s)?

(3) History of blackouts, delirium, or seizures?

(4) History of withdrawal syndrome, overdoses, and complications from previous substance use?

(5) Has patient ever been treated in an alcohol or drug abuse clinic?

(6) Has patient ever been arrested for DUI or charged with any criminal offense while using drugs or alcohol?

(7) Family history of drug or alcohol use?

(8) Substance abuse in the older adult (a) Increased risk of falls, injuries, hypertension, cardiac dysrhythmias, cancers, gastrointestinal problems, cognitive deficits, bone loss, emotional challenges (b) More likely to use prescription or OTC medications; can be harmful when mixed with alcohol and/or drugs (c) Makes medical problems harder to diagnose c) Assess medical and psychiatric history (1) Include concomitant physical or mental condition (2) Prescribed and OTC medications as well as allergies, sensitivity to drugs (3) Overview of mental status .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(a) History of abuse or family violence (b) Ever tried to commit suicide (c) Currently having suicidal or homicidal ideation d) Assess psychosocial issues (1) Has substance use affected his or her ability to hold a job?

(2) Has substance use affected relationships with spouse, family, friends, or coworkers?

(3) How does the patient cope with stress?

(4) Support system in times of need?

(5) How is leisure time spent? e) Screening tools (1) Michigan Alcohol Screening Test (MAST) Brief Version (2) CAGE questionnaire (3) Brief Drug Abuse Screening Test (B-DAST) f) Withdrawal assessment tools (1) Clinical Institute Withdrawal Assessment of Alcohol-Revised (CIWAAr) (2) Clinical Opiate Withdrawal Scale (COWS) G. Diagnoses, outcomes, and interventions 1. Reduce risk for injury a) Expected outcome: Patient is free of injury as evidenced by steady gait, absence of subsequent falls b) Assess patient’s level of disorientation to determine specific risks to safety c) Obtain drug history, as well as urine and blood samples for laboratory analysis of substance content d) Place patient in quiet, private room to decrease excessive stimuli, but do not leave patient alone if excessive hyperactivity or suicidal ideation is present e) Frequently orient patient to reality and environment, ensuring potentially harmful objects stored outside patient’s access f) Monitor vital signs every 15 minutes until stable and assess for signs of intoxication or withdrawal 2. Promote coping strategies a) Expected Outcome; Patient will express true feelings associated with using substances and identify healthy adaptive methods of coping with stressful situations (1) Establish trusting relationship.

(2) Encourage patient participation in therapeutic group activities (3) Set limits on manipulative behavior and maintain consistency in responses. .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(4) Encourage patient to verbalize feelings, fears, or anxieties (5) Encourage the patient to focus on strengths and accomplishments rather than weaknesses and failures 3. Promote adequate nutrition a) Expected outcome: Patient will gain 0.45 kg (1 lb) per week without evidence of increased fluid retention.

(1) Administer vitamins and dietary supplements as ordered by physician.

(2) Monitor labwork and report significant changes to physician (3) Collaborate with the dietitian to determine number of calories needed to provide adequate nutrition and realistic weight gain (4) Teach the importance of adequate nutrition 4. Provide patient education a) Expected outcome: Patient will verbalize the negative effects of substance abuse and agree to seek professional help to quit abusing substances (1) Assess the patient’s level of knowledge and readiness to learn the effects of drugs and alcohol on the body (2) Develop a teaching plan that includes measurable objectives (3) Begin with simple concepts and progress to more complex issues.

Use interactive teaching strategies and written materials appropriate to the patient’s educational level (4) Teach assertiveness techniques and effective communication techniques 5. Promote orientation to reality a) Expected outcome: Patient will be alert and oriented to time, place, and person and free of hallucinations or delusions (1) Observe for withdrawal symptoms, monitor vital signs, provide adequate nutrition and hydration, and place on seizure precautions (2) Assess level of orientation frequently; orient and reassure the patient of safety in presence of hallucinations, delusions, or illusions.

(3) Explain all interventions before approaching the patient, avoid loud noises and talk softly to the patient, decrease external stimuli by dimming lights.

(4) Administer prn medications according to detoxification schedule (5) Use simple, step-by-step instructions and face-to-face interaction when communicating with the patient (6) Express reasonable doubt if the patient relays suspicious or paranoid beliefs .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(7) Convey acceptance that the patient believes a situation (hallucination) to be true, but that the nurse does not see or hear what is not there (8) Talk to the patient about real events and real people H. Delegating nursing care activities 1.

May be delegated: Monitoring vital signs, assessing for symptoms of withdrawal, obtaining daily weights, assisting with ADLs, providing for distraction and socialization I. Transitions of care 1. Locations for medical detoxification: Hospitals, psychiatric units, special substance abuse units, methadone clinics, outpatient settings, residential rehabilitation programs, halfway houses, partial hospitalization programs 2. Vocational counseling, self-help groups (AA, NA) 3. Drug and health education for patient and family a) Negative effects of substance abuse (physical and psychologic complications) b) Signs of relapse and importance of after care programs and self-help groups c) Information about medications that help to reduce craving for alcohol and maintain abstinence, including side effects, possible drug interactions, and any precautions to be taken d) Ways to manage stress (progressive muscle relaxation, abdominal breathing techniques, imagery, meditation, effective coping skills) e) Suggest following resources: (1) Alcoholics Anonymous, Narcotics Anonymous, other self-help groups (2) Employee assistance programs (3) Individual, group, and/or family counseling (4) Community rehabilitation programs (5) National Alliance for the Mentally Ill 4. Medications used for treatment: a) Alcoholism: (1) Disulfiram (Antabuse) (a) Naltrexone (ReVia, Depade) (b) Acamprosate (Campral) (2) Opioid dependence: (a) Buprenorphine (Buprenex, Subutex) (b) Methadone (used in MAT programs) (c) Naloxone (Narcan) 5. Help patients recognize relapse with HALT (hungry, angry, lonely, tired)

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

J. Care of Special Populations 1. Older adults a) Rapidly growing health problem b) Contributing factors: (1) Financial stress (2) Mobility problems (3) Social isolation (4) Caregiver role strain 2. Military service members and veterans a) High rate of PTSD b) High rate of: (1) Nonmedical use of prescriptions, opioid misuse and abuse, and heroin addiction 3. Gender and sexual minorities a) At greater risk for substance abuse than their heterosexual peers b) Issues with social stigma and discrimination due to homophobic practices by healthcare professionals

Chapter Highlights A. Substance abuse is the unsanctioned use of any chemical despite adverse effects on the individual’s physical, psychological, interpersonal, or social health.

B. Substance dependence occurs when control over the chemical substance is lost and the individual must use increasing amounts to produce the desired effect (tolerance) and must use the substance to avoid or relieve uncomfortable symptoms (withdrawal).

C. Combinations of genetic, biologic, psychological, and sociocultural factors contribute to substance abuse or dependence. Addictive behavior has been linked to biochemical changes in dopamine and serotonin brain levels as well as heredity, ethnic differences, and peer pressure.

D. Adolescents are particularly influenced by society and peers to use substances, predominantly tobacco, alcohol, and illicit drugs. A positive cultural identity and family environment act as protective deterrents for substance use.

E. People with substance abuse problems have common characteristics, including risk-taking behavior, low tolerance for frustration or pain, compulsive preoccupation with the substance, anxiety, anger, and low self-esteem. Stress management, anger control, social support, and counseling are helpful strategies to avoid substance abuse and dependence.

F. Alcohol is the most commonly used and abused legal substance in America; however, polysubstance abuse is frequent in many individuals. Marijuana is the most commonly used illicit drug. Both alcohol and marijuana are considered gateway drugs to harder substance abuse. Substances such as cocaine and methamphetamines are often used in conjunction with alcohol. Abuse of prescription antianxiety agents and narcotic analgesics such as opioids is a significant problem. .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

G. Although not an illicit substance, caffeine is a stimulant that increases the heart rate and acts as a diuretic. Some 85% of the U.S. population consumes at least one caffeinated beverage per day, with caffeine intake highest among adults aged 50 to 64 years.

H. Alcohol is the most commonly used and abused legal substance in the United States. There were 136.7 million current alcohol drinkers in 2016, including 65.3 million who were binge alcohol users and 16.3 million who were heavy alcohol users.

I. Binge drinking for males is defined as drinking five or more drinks on the same occasion on at least 1 day in the past 30 days, while binge alcohol use for females has been defined as drinking four or more drinks on the same occasion on at least 1 day in the past 30 days.

J. Overuse of alcohol causes damaging effects to the liver and many other systems; its potential effects include myocardial disease, erosive gastritis, acute and chronic pancreatitis, sexual dysfunction, and an increased risk of breast cancer.

K. Nicotine acts on the central nervous system (CNS) as a stimulant, binding to acetylcholine receptors in the brain and causing the release of dopamine and norepinephrine. Chronic health problems from smoking include cancer, heart disease, emphysema, hypertension, and death.

L. Nicotine replacement therapy (NRT) and related medication may help users quit using tobacco.

M. Marijuana is the most commonly used drug, with an estimated 24.0 million Americans aged 12 or older in 2016 currently using marijuana. The psychoactive component of marijuana is a chemical known as delta-9-tetrahydrocannabinol (THC), which activates specific cannabinoid receptors in the brain.

N. Central nervous system depressants, including barbiturates, benzodiazepines, paraldehyde, meprobamate, and chloral hydrate, are also subject to abuse. Cross-dependence exists among all CNS depressants and cross-tolerance can develop to alcohol and general anesthetics.

O. Depressant effects related to barbiturates are dose dependent and range from mild sedation to sleep to coma to death.

P. Psychostimulants such as cocaine and amphetamines have a high potential for abuse.

Euphoria is the main subjective effect associated with cocaine and amphetamines, leading to addiction. Cocaine overdose produces anxiety, hyperpyrexia, convulsions, ventricular dysrhythmias, severe hypertension, and possible hemorrhagic stroke, angina, or myocardial infarction.

Q. Methamphetamine is often taken in combination with other drugs such as cocaine and marijuana and, like heroin and cocaine, can be inhaled, injected, ingested, or smoked.

Methamphetamine users experience numerous physical symptoms including weight loss, tachycardia, tachypnea, hyperthermia, insomnia, and muscular tremors.

R. Opiates such as morphine, meperidine, codeine, hydrocodone, and oxycodone are narcotic analgesics. Some individuals used opiates for prescription pain management; however, many others use opiates under social or illicit circumstances. In 2016, there were 11.8

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

million past-year opioid misusers aged 12 or older in the United States, the vast majority of whom misused prescription pain relievers.

S. Hallucinogens are also called psychedelics and include a number of substances such as LSD, PCP, peyote, mescaline, psilocybin mushrooms, “Ecstasy,” ketamine, and salvia. When under the influence of either type of drug, people often report rapid, intense emotional swings and seeing images, hearing sounds, and feeling sensations that seem real but are not.

T. Inhalants are categorized into three types: Anesthetics; volatile nitrites; and organic solvents, solvents, aerosols, gases, or nitrites. Long-term effects of inhalant use may include liver and kidney damage, hearing loss, bone marrow damage, loss of coordination and limb spasms from nerve damage, delayed behavioral development, and brain damage from restricted oxygen flow to the brain.

U. Effective treatment of substance abuse and dependence results from the efforts of an interprofessional team specializing in the treatment of psychiatric and substance abuse disorders. Substance dependency treatment occurs in two major phases: Acute and rehabilitation.

V. The interprofessional team often includes the nurse, physicians such as psychiatrists and addictionologists, psychologists, case managers, social workers, recreational therapists, and dietitians, among others.

W. Nurses will interact with patients experiencing substance abuse or substance dependence in a variety of settings in the hospital including emergency departments, medical/surgical units, and intensive care units.

X. Urgent and ambulatory care centers and pain clinics are other settings in which patients with substance abuse disorders will frequently appear for other health problems.

Y. Nursing care of patients experiencing substance abuse problems includes health promotion efforts to prevent substance abuse; comprehensive physical, spiritual, and psychosocial assessment; and interventions for the human responses of ineffective coping and denial, imbalanced nutrition, readiness for enhanced knowledge, acute confusion, and risk for injury or violence.

Z. Severe alcohol withdrawal or delirium tremens is a medical emergency that usually occurs 2 to 5 days following cessation of alcohol consumption. A symptom-triggered approach to the administration of benzodiazepines during alcohol withdrawal results in less total medication use and requires a shorter duration of treatment than other treatments.

AA. Nurses and other healthcare professionals are susceptible to substance abuse due to pressures in the workplace and easy access to drugs. Nurses need to assess their response to stress and seek early treatment for depressive symptoms to avoid practicing while impaired.

BB. Substance abuse among older adults is a growing health problem that can be confused with comorbidities and co-occurring conditions. There is a high prevalence of substance abuse among service members and veterans. LGBTQ patients may have experienced social stigma and discrimination within the healthcare systems. Nurses should approach all patients in a .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

caring and nonjudgmental manner, use therapeutic communication to conduct a holistic assessment, communicate findings of concern to the healthcare team, and facilitate referrals for treatment.

SUGGESTIONS FOR CLASSROOM ACTIVITY- LEARNING OUTCOME ONE Research the internet for research and theories about substance abuse.

Ask a substance abuse counselor to speak to the class about substance abuse.

Discuss the legal implications of substance abuse in healthcare workers.

Ask students to research the provisions and guidelines written by your state board of nursing for impaired nurses.

SUGGESTION FOR CLASSROOM ACTIVITY- LEARNING OUTCOME TWO Lead a discussion about the effects of substance abuse on the family and community.

SUGGESTION FOR CLINICAL ACTIVITY- LEARNING OUTCOME TWO Assign students to the chemical dependency unit to care for patients with addictive problems.

SUGGESTION FOR CLASSROOM ACTIVITY- LEARNING OUTCOME THREE Research the internet for new data and theories about factors that contribute to substance abuse.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter 7 Nursing Care of Patients Experiencing Disasters

Learning Outcomes 1. Explain the difference between an emergency and a disaster.

2. Outline the five phases of the disaster continuum and discuss the nurse’s role in each.

3. Describe the types of injuries and manifestations associated with biologic, chemical, or radiologic terrorism.

4. Differentiate the common injuries associated with various types of disasters.

5. Describe the interprofessional care and nursing care of patients in a disaster.

Key Concepts I. Disasters and Emergencies A. Disaster: Disrupts normal functioning 1. Natural disasters: Caused by nature or emerging disease 2. Human-generated disasters (accidental or intentional) a) Complex emergencies b) Technologic disasters c) Disasters that are not caused by natural hazards but occur in human settlements 3. Complex emergencies that overwhelm general emergency systems (seldom involve single victim) 4. Mass casualty events (MCEs): Label for disasters B. Emergency: Encompasses unforeseen combination of circumstances calling for immediate action for a range of victims from one to many 1. Can be handled by usual emergency management systems already in place II. The Disaster Continuum A. Three major phases in the cycle of activity related to disaster 1. Preimpact (before) 2. Impact (during) 3. Postimpact (after) a) Do not necessarily happen in sequence. Phases may overlap or occur simultaneously.

B. Five phases of disaster management 1. Preparedness

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) Comprehensive disaster plan that coordinates many people, agencies, and levels of government b) Nurses are largest group of healthcare professionals and have key role in disaster relief. c) U.S. National Response Framework (NRF): Integrates resources of the local, state, and federal governments and includes voluntary relief agencies, private sector companies, and international resources for assistance in disasters (1) Coordinated by the Department of Homeland Security (DHS) and Federal Emergency Management Association (FEMA) d) National Incident Management System (NIMS) works with NRF to facilitate nation’s incident management capacity. e) Nurses participate in disaster planning by having a nurse representative on the planning committee at least at the agency level. f) Surge capacity: Healthcare system’s ability to rapidly expand beyond normal services 2. Mitigation a) Measures to reduce the harmful effects of a disaster when there is knowledge of an impending disaster (1) Activities include warning, preimpact, mobilization, evacuation 3. Response a) Happens after disaster occurs b) Local disaster response organizations: Fire departments, police departments, public health departments, public works, emergency services, and the local branch of American Red Cross c) Nurses should follow the disaster plan of their agencies, communities, and the local emergency management agency. This includes having a disaster plan for the nurse’s immediate family. d) Nurses should determine boundaries of their practices when mass treatment needed without on-site physician.

4. Recovery a) Restoration and reconstitution take place 5. Evaluation a) Determining what worked and what did not work, and what anticipated and unanticipated challenges b) Future-oriented activities: Increased security, surveillance measures, suggestions for efficiency in treating victims

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

c) Nurses may suggest ideas for responding the other victims of disasters more effectively and efficiently.

III. Terrorism A. Terrorism: “Unlawful use of violence or the threat of violence, often motivated by religious, political, or other ideological beliefs, to instill fear and coerce governments or societies in pursuits of goals that are usually political.”

1. Conventional weapons: Bombs and guns 2. Nonconventional weapons: Chemical, biologic, radiologic, and nuclear terrorism B. Bioterrorism 1. Use of etiological agents to cause harm or kill a population, food, and/or livestock 2. Healthcare facilities should have disaster preparedness plan in response to attack.

3. Infection control nurse and public health department is alerted with subtle changes or trends in symptoms among patients are seen.

C. Nuclear/radiologic terrorism 1. Radiologic dispersion bomb (dirty bomb): Most accessible nuclear device 2. Centers for Disease Control and Prevention (CDC) has created detailed planning and response toolkits about radiological terrorism.

IV. Types of Disasters and Associated Common Injuries A. Hurricanes and tornados 1. Most common health effects: Asphyxia due to drowning, wounds, bone, joint, muscle injuries, aggravation of chronic illnesses, stress-related symptoms, upper respiratory infections, gastrointestinal illnesses, clean-up injuries, animal, snake, insect bites, skin irritations and infections, obstetric complications, waterborne and insect-borne diseases B. Thunderstorms 1. Risks: Lightning strike 2. Bodily conductors (due to high electrolyte and water content): Nerves, muscle, blood vessels 3. High resistors: Bone, tendon, fat C. Earthquakes and tsunamis 1. Most common health effects: Stress-related symptoms, wounds, bone, joint, and muscle injuries, burns from explosions, cleanup injuries, gastrointestinal and respiratory problems, aggravation of chronic illnesses, obstetrical complications, and death 2. Tsunamis: Injuries similar to hurricanes D. Snowstorms .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

1. Most common health effects: Overexertion and exhaustion from shoveling E. Hazardous materials 1. Hazards exist at any stage of use from production and storage to transport, use, and disposal.

2. Symptoms will vary depending on the type of hazardous material patients are exposed to.

F. Explosives 1. Most common health effects: Abdominal and lung injuries, penetrating wounds, traumatic amputations, burns, high risk of hemorrhage 2. Radiologic dispersion bomb blast (dirty bomb) a) TNT packed with radioactive waste by-products b) Radiation sickness: Symptoms resulting from ion’s electrical charge breaking DNA bonds (cell mutations possibly turning cancerous) c) Effects of radiation may not be immediate, but could kill people years later 3. Nuclear detonations a) Injury and death most commonly caused by thermal burns b) Injuries from radiation exposure: Cellular damage in DNA in bone marrow, blood, bowel, skin, nervous and cardiovascular systems c) Immune system suppressed from radiation d) Major activities performed: Triage, evacuation or sheltering, search and rescue, radioactive monitoring, decontamination, direct patient care e) Manifestations of serious radiation exposure may take several hours to appear.

V. Care of Patients in a Disaster A. The Emergency Medical Services System 1. Emergency medical services (EMS) system: Uses common triage tag state or region wide 2. Includes emergency medical responders (EMRs), Emergency medical technicians (EMTs), Advanced emergency medical technicians (AEMTs), and Paramedics B. Personal protective equipment and Isolation 1. Gloves, gowns, masks, protective eyewear, and respirators should be worn by all healthcare providers as needed in disaster situations.

C. Triage 1. In ER: Expedite discharge or transfer of lowest-acuity patients to free up resources 2. Assess need at emergency site: Simple Triage and Rapid Transport (START) System a) Red: Needing most support b) Yellow: Less critical, but need of transport to emergency centers c) Green: Minor injuries, no need of transport d) Black: Least likely to survive or already deceased .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

D. Reverse triage: In case of mass casualty event (greater than 100 victims) 1. Principle of greatest good for greatest number E. Hot, warm, and cold zones 1. Hot zone: Contaminated site of disaster 2. Warm zone: Adjacent to hot zone (control zone) where decontamination of victims or triage take place 3. Cold zone: Safe zone adjacent to warm zone, area where in-depth triage of victims occurs F. Crowd control 1. Responsibility of security, local police to control crowds 2. Nurses and healthcare personnel should not enter unsecured area.

G. Psychosocial needs 1. Mental health experts can assess individual needs, offer advice, and refer for follow-up care 2. Common aftereffects of disaster: Depression, difficulty concentrating, and trouble sleeping 3. Reactions influenced by: Developmental level and maturity, prior experiences, and cultural background H. Nursing care 1. The role of the nurse in disaster relief a) Identify the event b) Function as a first responder c) Work with rapid needs assessment team to identify needed resources d) Provide direct care to disaster victims in hospital e) Federal medical stations (FMS) f) Public health department or field medical team g) Manage communications, work with media h) Assume leadership roles in coordination of multiple disaster response activities i) Prepare selves, families, friends, and communities for disasters j) Educate self on disasters and appropriate responses k) National Disaster Medical System (NDMS): Multiagency program that supplements an integrated national medical response to assist states and local authorities 2. Roles of nurses working with victims of disasters a) Begins with triaging and assessing victims for the best care and best use of resources b) Variety of roles based on expertise and needs of victim c) Local authorities will guide nurse in securing area and determining safe zone.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

3. Considerations for patients with special needs a) Older adults (1) Determine appropriateness of sheltering (2) Plan for extended period of evacuation if unable to care for themselves (3) Consideration of time of year and need for heating and cooling during extended power outages (4) Current list of medications, doses, times of administration in easily accessible place (5) Names and phone numbers of emergency contacts in accessible place (6) Review essential materials in case of evacuation to shelter b) Immunocompromised patients (1) At increased risk in the case of a bioterrorist attack (2) Discuss patients’ preparation for disaster events related to infection control (i) Treatment calendars (ii) Backup location for chemotherapy (iii) Knowledge level for avoiding raw seafood or posiblly contaminated water (iv) Bottled water available (v) Avoidance of fresh fruits (for bone marrow and stem cell transplant patients) c) Patients with sensory, speech, or literacy deficits (1) Assessed for the most effective means of communication in case of disaster (2) Learn basic phrases in American Sign Language (ASL) (3) Hearing and visual impairments: Carry a notepad and pencil or directions in large print (4) Nurses: Alert community leaders about special needs of community members d) Patients with mobility deficits (1) Assistive technology devices (ATDs): Accommodate mobility and other impairments (2) Make arrangements in advance to provide enough volunteers or staff to assist relocating this group e) Patients with limited proficiency in English (1) Literacy assessed in own language and English (2) Obtain assistance of interpreter (if possible, don’t use children) (3) Prepare communication aids in advance (practice regularly) (4) Use visual aids f) Spiritual considerations (1) Include religious leaders in community planning for disaster preparedness (2) Rescue personnel informed about specific religious obligations or rights

Chapter Highlights A. Disasters are destructive events that disrupt the normal functioning of a community.

They can be natural or generated by humans.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

B. Emergencies are circumstances that require immediate action for one or more victims. Emergencies can usually be accommodated within the emergency management system.

C. The disaster continuum is a cycle that occurs before, during, and after a disaster.

D. Preparedness, proactive planning and preparation while the threat of a disaster is still in the future, is the first phase of the disaster continuum.

E. The mitigation phase includes measures to reduce the harmful effects of a disaster and occurs when there is knowledge about an impending disaster that has not yet occurred.

F. The response phase happens after the disaster has occurred and includes the immediate response to the effects of the event.

G. In the recovery phase, reconstruction, restoration, and reconstitution take place.

This includes rebuilding, replacing lost or damaged property, returning to school and work, and continuing life without those who were killed in the disaster.

H. Evaluation is the final phase, and it involves determining what worked and what didn’t work.

I. Terrorism is defined as the unlawful use of violence or the threat of violence, often motivated by religious, political, or other ideological beliefs, to instill fear and coerce governments or societies in pursuit of goals that are usually political.

J. Conventional weapons of terror include guns and bombs. Nonconventional weapons of terror include chemical, biologic, and nuclear agents.

K. Bioterrorism involves the use of etiologic agents (disease) with deliberate intent to cause illness or death in a population, food, and/or livestock.

L. The nuclear category of nonconventional terrorist weapons encompasses the use of a nuclear device to cause mass murder and devastation.

M. Hurricanes are natural disasters that cause wind, rain, floods, and tornadoes. Injuries in hurricanes include asphyxia due to drowning; bone, joint, and muscle injuries; aggravation of chronic illnesses; stress-related symptoms; upper respiratory infections; gastrointestinal illnesses; cleanup injuries; animal, snake, and insect bites; skin irritations and infections; obstetric complications; and waterborne and insect-borne diseases.

N. Tornadoes are wind storms that cause many fatalities and injuries primarily due to flying debris.

O. Thunderstorms can generate lightning strikes resulting in surface burns, concussive blunt trauma, internal burns, cardiac or respiratory arrest, vascular spasm, and neurologic damage.

P. Earthquakes are natural disasters that can cause bone, joint, and muscle injuries; burns from explosions; cleanup injuries; gastrointestinal and respiratory problems; aggravation of chronic illnesses; obstetric complications; and death. Tsunamis cause similar injuries.

Q. Hazardous materials pose a potential risk to life, health, or property if they are released because of their chemical, biologic, or physical nature. Symptoms will vary depending on the type of hazardous material patients are exposed to. .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

R. Blast injuries from explosives cause penetrating and blunt injuries. Emergency care focuses on abdominal and lung injuries, penetrating wounds, traumatic amputations, and burns.

S. Radiologic and nuclear blasts cause exposure to radiation, which has long-term consequences.

T. Personal protective equipment, including gloves, gowns, masks, protective eyewear, and respirators, should be worn by all healthcare providers as needed in disaster situations.

U. Triage is used to categorize or label victims needing the most support and emergency care. The principle in reverse disaster triage is to do the greatest good for the greatest number of people.

V. Mental health services for victims, the community, and first responders are critical.

W. Nurses have roles in many facets of disaster management, including identifying the event, functioning as a first responder at the scene, working with a rapid needs assessment team to identify needed resources, and providing direct care to disaster victims in hospitals, federal medical stations, public health departments, or field medical teams.

X. Nurses should take into consideration the special needs of older adults, immunocompromised patients, and patients with communication or mobility issues.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME ONE Research on the internet the effects on healthcare for those clients who lived on the Gulf Coast and were affected by Hurricane Katrina. Discuss findings as a group.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME ONE Visit a local emergency management department. Ask a department representative to speak to the class regarding disaster preparedness.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME TWO Look up the effects of radioactivity on the people of Chernobyl after the nuclear plant disaster.

What effects did this have on children? Were the effects different on adults? What about long-term effects? Discuss findings in class.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME TWO Ask a hospital leader to discuss with students evidence-based standards of nursing practice that the facility implements for patients with injuries suffered as a result of a disaster.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME THREE Evaluate and revise a plan of care for a patient who has sustained injuries due to biologic, chemical, or radiologic terrorism.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME THREE Ask a hospital representative to share the aspects of reverse triage. Encourage students to explore their feelings about treating the most severely injured last.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME FOUR Break students into small groups to compare and contrast common injuries associated with various types of disasters.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME FOUR Have each student review and then discuss the hospital’s disaster policy at their clinical site.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME FIVE Provide students with time in class to create a personal and family disaster plan to allow for their participation in disaster response.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME FIVE Ask students to discuss with nurse preceptors how they maintain personal safety and the safety of others at the scene of a disaster.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter 8 Genetic Implications of Adult Health Nursing Learning Outcomes 1. Outline the basics of genetics including cell division chromosomal alterations and the role of genes.

2. Describe the principles of inheritance.

3. Describe the interprofessional care, nursing care, and transitions of care for patients with genetic disorders.

Key Concepts I.

Genetics Basics A. Cells: Nucleus contains 46 chromosomes, and organelles B. DNA molecules: Long sequences of nucleotides or bases represented by letters A, T, G, and C C. Human genome: Total sum of DNA in a human cell D. Chromosomes 1. Two copies of each chromosome (homologous chromosomes) 2. Numbered according to size (1 is largest) 3. Autosomes: First 22 pairs (same in males and females) 4. Sex chromosomes: 23rd pair, determines gender a) Female: Two copies of the X chromosome (one copy inherited from each parent) b) Male: One X chromosome (inherited from his mother) and one Y chromosome (inherited from his father) E. Cell division 1. Mitosis: Process of making new cells a) Takes place in somatic (tissue) cells b) Heals wounds, replaces cells lost daily, responsible for human development c) Results in two daughter cells that are genetically identical to the original or mother cell, and to each other 2. Meiosis: Cell division a) Occurs in the sex cells of testes and ovaries b) Results in formation of sperm and oocyte (gametes) c) Purposes (1) Produce gametes (2) Reduce number of chromosomes by half

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(3) Make new combinations of genetic material from crossing over and independent assortment processes F. Chromosomal alterations 1. Occur during cell division 2. Alterations in chromosome number a) Can occur during meiosis or mitosis b) Nondisjunction: Paired chromosomes failing to separate during meiosis c) Variations in chromosomal number (1) Monosomy: One member of chromosome pair missing (2) Trisomy: Three chromosomes (3) Aneuploidy: Extra or missing chromosomes exist (4) Euploidy: Presence of normal number of 46 chromosomes (5) Polyploidy: Two or more pairs of all chromosomes present d) Produces conditions such as monosomy of sex chromosomes in a female (Turner syndrome) or trisomy of autosomes (trisomy 21/Down syndrome) 3. Alterations in chromosome structure a) Inversions, deletions, duplications, and translocations b) Unbalanced arrangement: Chromosomal alteration that includes missing (deletion) or additional (duplication) whole chromosome 4. Translocation: Chromosomal reshuffling a) Translocation between chromosomes 9 and 22 is not inheritable. b) 4% of trisomy caused by translocation, inherited from parent G. Genes 1. Small portion of nucleotide (base) sequence of a chromosome DNA molecule 2. Genotype: Specific sequence of nucleotides (genes and variations therein) a) Genetic locus: Specific location of a gene on a specific chromosome 3. Alleles: Pairs of genes 4. Homozygous: Two identical forms of a gene 5. Heterozygous: Two different forms (alleles) of a gene 6. Altered or mutated: When change in gene has occurred 7. Expressed: When gene has an impact on outward appearance of individual and/or functioning of cells.

8. Phenotype: Observable, outward expression of an individual’s entire physical, biochemical, and physiologic makeup as determined by genotype and environment H. Function and distribution of genes 1. Provide directions for how to make proteins a) Transmit messages between cells, fight infection, direct genes to turn “on” or “off,” form structures, sense light, taste, smell I. Mitochondrial genes .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

1. Mitochondria: Energy production and metabolism 2. Mitochondrial DNA (mtDNA): DNA contained within mitochondrion a) Primarily inherited from mother J. Gene alterations and disease 1. Gene alterations responsible for 6000 hereditary diseases K. Gene alterations that decrease risk of disease 1. Gene alterations can decrease risk of disease. a) Gene alteration that causes sickle cell disease also protects against malaria b) APOE gene: Three different versions of gene; one type has higher chance for developing Alzheimer’s but another type is less likely to develop it.

L. Single nucleotide polymorphisms 1. Greater than 99% of human DNA sequences are the same.

2. Polymorphisms: DNA sequences that are natural variations in a gene in which each possible sequence is present in at least 1% of people, but have no adverse effect a) Single nucleotide polymorphisms (SNPs, or snips): Most common type of genetic variation among humans and are one-letter (base pair) variations in the DNA sequence (serve as biological markers) 3. Biological markers: Easily tracked, stable segments of DNA II.

Principles of Inheritance A. Basic principles 1. All genes are paired.

2. Only one gene of each pair is transmitted (passed on) to an offspring.

3. One copy of each gene in offspring comes from mother, other copy comes from father.

B. Mendelian pattern of inheritance 1. Monogenic or single-gene disorders: Conditions caused by mutation or alteration of single gene 2. Inheritance patterns: Autosomal dominant, autosomal recessive, X-linked recessive, Xlinked dominant a) Autosomal dominant (AD): Result of altered gene on any of 22 autosomes or non-sex chromosomes b) Autosomal recessive (AR): Requires two copies of altered genes, result of altered gene on any of the 22 autosomes or non-sex chromosomes c) X-linked recessive: Result of an altered gene on the X chromosome d) X-linked dominant: Very rare condition, often lethal in affected males C. Variability in classic Mendelian patterns of inheritance 1. Penetrance

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) Probability that a gene will be expressed phenotypically, “all or none” concept 2. New mutation a) De novo mutation: Spontaneous new mutation b) Most frequently seen in autosomal dominant conditions, often seen in X-linked recessive disorders, also possible in autosomal recessive diseases 3. Anticipation a) Successive generations of a family exhibit more severe signs and symptoms of certain diseases; disease often has earlier onset. b) “Genetic stutter”: Small section within gene is repeated too many times.

4. Variable expressivity a) Used to describe severity of gene expression of a phenotype b) Variable expression: Term used to describe people with same genetic makeup exhibiting signs and/or symptoms with varying degrees of severity D. Multifactorial (polygenic or complex) disorders 1. Occur as a result of several gene (polygenic) variations, lifestyle, and environmental influences working together 2. Accumulate in families but don’t follow characteristic Mendelian pattern of inheritance III.

Care of Patients with Genetic Disorders A. Goals of interprofessional care our early diagnosis through testing and assessment and development of an effective treatment plan including psychosocial support and referral to a genetic specialist B. Genetic testing 1. Testing involves analysis of DNA, RNA, chromosomes, serum levels of specific enzymes or metabolites-classified as screening or diagnostic (1) Should be voluntary (2) Nurse is responsible to ensure that informed consent is complete prior to testing.

(3) Healthcare providers are legally liable to maintain testing results in confidence (a) Exceptions may be made when genetic test results indicate a significant probability of your reversible harm that can be prevented by knowledge of the threat 2. Genetic tests for diagnosis a) Newborn screening: Identify children with increased risk for genetic diseases b) Carrier testing: For asymptomatic individuals who may be carriers of one copy of a gene alteration that can be transmitted to future children in autosomal recessive or Xlinked pattern of inheritance c) Preimplantation genetic diagnosis (PGD): Detection of disease-causing gene alterations in human embryos after in vitro fertilization and before implantation in uterus

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

d) Predictive genetic testing: For asymptomatic individuals, includes predispositional and presymptomatic testing e) Other uses of genetic testing: Organ transplantation tissue typing, pharmacogenetic testing C. Diagnosing chromosomal alterations 1. Accomplished with blood, skin, or buccal cell sampling 2. Karyotype: Chromosome pairs lined up and positioned on paper, allows for visual chromosomal analysis 3. International System of Human Cytogenetic Nomenclature (ISCN): Establishes guidelines for writing results of karyotyping D. Diagnosing 1. DNA-based tests: Permits examination of the DNA 2. Genotyping: Done to confirm diagnosis and specific type of galactosemia 3. Complete gene sequence: Utilized when only one mutation can be found or when none of the coming mutations are found E. Nursing Care 1. Standards of genetic nursing a) Complete a genetics family history to identify simple risk factors b) Perform an accurate physical assessment c) A apply concepts of health promotion and health maintenance to assist in inform decision-making by the patient d) Provide patient advocacy—provide information about resources and services e) Provide patient education and make referrals when appropriate f) Complete an evaluation of the planet care for the patient g) Apply knowledge of the ethical, legal, cultural, and social implications of genetic information 2. Psychosocial issues a) Carrier status concerns: May impact development of intimacy and interpersonal relationships b) Nonpaternity: May lead to feelings of unworthiness, anger, confusion, depression, self-image disturbance c) Survivor guilt with negative results when siblings test positive d) Gene alteration for late-onset disease: Increased tendency for risky behavior e) Relatives: May be frightened realizing their own future f) Resentment, guilt, for inheriting/passing on gene 3. Economic issues a) Genetic tests can range from hundreds to thousands of dollars. .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

b) Most tests not covered by insurance c) If covered, must weigh cost of insurance company having access to genetic information 4. Health promotion and health maintenance a) U.S. Department of Health and Human Services, Surgeon Generals Family Health History Initiative b) Genetics Home Reference website 5. Assessment a) Increased importance of obtaining a family history with the recent expanded knowledge of the interaction of genes and the environment b) Pedigrees: Pictorial representation or diagram of medical history of a family (1) Can identify other family members who might need genetic consultation (2) Can identify single-gene alteration pattern of inheritance or cluster of multifactorial conditions 6. Nursing diagnosis and interventions a) Nurses must be aware of the limitations of their own knowledge and expertise in regard to genetics b) Patients may experience grieving, anxiety, disturbed body image, ineffective coping, decisional conflict, interrupted family processes, ineffective health maintenance, deficient knowledge, powerlessness, spiritual distress 7. Genetic referrals and counseling a) Nurses are responsible for making referrals for patients with a suspected genetic problem (1) Referrals can be made to: Geneticist, genetic clinical nurse specialist, genetic clinic b) Nurse should provide: (1) Advantages of a referral to genetic specialists (2) Disadvantages in not following through with referral (3) Anticipatory guidance about what to expect c) Discussion about findings of genetic tests will cover: (1) Natural history of the condition (2) Inheritance patterns (3) Current preventive or treatment options (4) Risks to the patient and/or family d) Nondirective counseling: Allow patients to make decisions not influenced by biases or values from nurse, counselor, or geneticist 8. Patient teaching and support a) Assess cultural and religious beliefs and values of patients prior to teaching .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

b) Obtain educational materials in native language c) Identify and deal with barriers to learning (e.g., denial, anxiety, guilt, etc.) d) Encourage open discussions, expression of fears and concerns e) Assess coping mechanisms and available support systems f) Help patients with communicating genetic information to extended family 9. Genetic Information Nondiscrimination Act of 2008 (GINA) 10. Evaluation a) Expected outcomes of delivering genetic-focused nursing care (1) Patient will make informed and voluntary decisions related to genetic health issues (2) Patient will accurately identify the following: (i) Basic genetic concepts and simple inheritance risk probabilities (ii) What to expect from a genetic referral (iii)The influence of genetic factors in health promotion and health maintenance (iv) Differences between medical and genetic tests (v) Social, legal, and ethical issues related to genetic testing 11. Transitions of care a) Patients receiving early intervention and a health promotion focus can live longer with a better quality of life b) Identify and utilize reliable sources of information on health promotion and health maintenance c) Genetic information is constantly evolving—nurses should remain educated in form knowledgeable in ready to discuss current trends in changes with patients in their family.

Chapter Highlights A. When cell division does not occur as expected, chromosomal alterations on the autosomes or sex chromosomes can result. Chromosomal alterations can be seen in a human karyotype.

B. A gene is a small portion (segment) of the nucleotide (base) sequence of a chromosome that provides specific directions for a particular function or characteristic.

Gene alterations are responsible for approximately 6000 hereditary diseases.

C. An individual may be identified as heterozygous or homozygous for a single gene.

Some gene alterations cause disease and some are protective from disease. Multifactorial inheritance does not follow Mendelian inheritance patterns.

D. Exceptions or variations to the traditional Mendelian patterns of inheritance include penetrance, new mutation, anticipation, and variable expressivity.

E. Many types of genetic tests are available. All genetic tests have social, financial, ethical, and legal implications. Genetic healthcare providers are obligated to present the individual and his or her family with information to promote informed decisions.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

F. Nurses are responsible for basic genetic knowledge and for delivering the expected standard of genetic nursing care. Nurses must beware of the social, ethical, cultural, and spiritual issues related to the delivery and genetic nursing care.

G. Basic genetic nursing care involves assessing family risk through a detailed family history, integrating genetic concepts into a physical assessment, and initiating a referral to a genetic specialist.

H. Genetic concepts can be applied to health promotion and health maintenance with the nurse taking into consideration cultural and spiritual influences on health decisions.

Knowledge of the principles of inheritance allows the nurse to not only offer and reinforce genetic information to patients and their families but also to assist them in managing their care and in making reproductive decisions.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME ONE Ask students to look up hereditary disease and gene alteration as well as the National Coalition for Health Professional Education in Genetics on the internet. Engage students in an open discussion on what they learned.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME ONE Ask students to provide patient teaching on the basics of genetics including cell division chromosomal alterations and the role of genes.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME TWO Ask students to do create a fictitious genetic family history and include three generations of pedigree. Discuss how students might proceed if genetic testing were an option?

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME TWO Obtain genetic family history, including three generations of pedigree, from a patient.

SUGGESTIONS FOR CLASSROOM ACTIVITY—LEARNING OUTCOME THREE Discuss where genetic nurses are employed as well as professional organizations for registered nurses who are genetic specialists.

Role-play a scenario for a couple who are asking about genetic counseling. In this role-playing scenario, there is no family history of genetic disease.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME THREE Shadow a genetic nurse.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter 9 Nursing Care of Patients in Pain

Learning Outcomes 1. Define pain, why it is called the fifth vital sign, the adverse effects of it, and myths and misconceptions about it.

2. Describe the theories about, physiology of, pathways of, and modulation of pain.

3. Differentiate definitions and characteristics of acute, chronic, breakthrough, nociceptive, and neuropathic pain.

4. Outline factors affecting responses to pain.

5. Describe interprofessional care, nursing care, and transitions of care for patients in pain.

Key Concepts Pain A. Pain-subjective response to both physical and psychologic stressors B. Most common types of chronic pain: Low back pain, migraine, severe headache, and joint pain I. The Concept of Pain A. Fifth vital sign—experienced as uncomfortable and unwelcome but serves a protective role warning of potential health-threatening conditions 1. Relief of pain is a patient right a) a) 2018 Joint Commission updated standards require healthcare facilities to (1) Establish a clinical leadership team for the treatment of pain (2) Actively engage the interprofessional team in improving pain assessment and management, including strategies to decrease opioid use and minimize risks associated with opioid use (3) Offer at least one complementary pain treatment modality (4) Facilitate access to prescription drug monitoring programs (5) Improve pain assessment by concentrating more on how pain is affecting patients physical function (6) Engage patients in treatment decisions about their pain management (7) Educate patients on the topic of storage and disposal of opioids (8) Provide referral of patients addicted to opioids to treatment programs 2. Unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage 3. Only the person affected can experience pain; that is, pain has a personal meaning 4. If the patient says he or she has pain, the patient is in pain. All pain is real 5. Pain has physical, emotional, cognitive, sociocultural, and spiritual dimensions .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

6. Pain affects the whole body, usually negatively 7. Pain may serve as both a response to and a warning of actual or potential trauma B. Adverse effects of pain 1. Purpose of acute pain is to warn of injury to body tissues 2. Chronic pain serves no useful purpose and instead becomes part of the problem of a chronic illness 3. Physiological response to pain can have adverse effects on the patient’s health a) Interferes with sleep quantity and quality b) Increases metabolism and myocardial oxygen demand c) Increases catabolism or break down of the body tissue d) Impairs healing e) Suppresses immune function f) Linked to depression C. Myths and misconceptions about pain 1. Pain is a result, not a cause 2. Chronic pain is really a masked form of depression 3. Narcotic medication is too risky to be used in chronic pain 4. It is best to wait until a patient has pain before giving medication 5. Many patients lie about the existence or severity of their pain 6. Pain relief interferes with diagnosis II.

Neurophysiology of Pain A. Neurons of the peripheral nervous system: Sensory and motor 1. Pain is transmitted through sensory neurons, responded to through motor neurons 2. Pain is perceived within the CNS 3. Connections or synapses occur within the spinal cord and within the brain 4. Interpretation of the stimulus occurs in the brain, which leads to a response B. Pain theories 1. Specificity and pattern theories 2. Melzack and Wall’s gate-control theory 3. Neuromatrix theory a) Brain contains a body–self neuromatrix 4. Theory about effect of sensitizing the central and peripheral nervous system to painful stimuli C. Physiology of pain 1. Nociceptors: Nerve receptors for pain 2. Types of noxious stimuli: Mechanical, chemical, or thermal 3. Biochemicals are released from tissue trauma, inflammation, and ischemia

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

4. Silent nociceptors: Sensory receptors in the gut that don’t respond to mechanical or thermal stimuli D. Pain pathways 1. A-delta (Aδ) and C nerve fibers transmit action potential from nociceptors to spinal cord a) Fast pain: Produced by Aδ fibers b) Slow-wave pain: Produced by C fibers 2. Sensory neuron enters spinal cord via dorsal root and terminates in dorsal horn of spinal cord; pain signal transmitted to brain 3. Impulses ascend the spinothalamic tracts and pass through the medulla and midbrain to the thalamus 4. Pain signal is distributed via third-order neurons to several areas of the cerebral cortex 5. Noxious impulse becomes pain when sensation reaches conscious levels and is perceived and evaluated by the person E. Modulation of pain 1. Endogenous opioids—Naturally occurring morphine-like neuropeptides a) Enkephalins, endorphins, dynorphins, endomorphins 2. Locally, inflammatory mediators lower the threshold for pain perception and augment pain 3. ATP, substance P, and other peptides: Promote the local spread of pain and contribute to vasodilation, vascular permeability, and increasing discomfort 4. Serotonin, norepinephrine: Inhibit pain impulse transmission in the spinal cord and brain III.

Types and Characteristics of Pain A. Acute pain: Sudden onset, self-limited, localized 1. Types of acute pain a) Cutaneous and deep somatic pain b) Visceral pain c) Referred pain 2. Initiates the fight-or-flight autonomic stress response 3. Physical responses include a) Tachycardia b) Rapid and shallow respirations c) Iincrease blood pressure d) Dilated pupils e) Sweating f) Pallor 4. Physiologic response of anxiety and fear may further increase physical response to acute pain B. Chronic pain: Prolonged pain that persists after the condition causing it has resolved

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

1.

2.

3.

4.

Does not always have an identifiable cause May be from an imbalance of pain modulation mechanisms Clear association between chronic pain and depression Categories of chronic pain a) Recurrent acute pain b) Chronic malignant pain c) Chronic nonmalignant pain 5. Common chronic pain conditions a) Lower back pain: Most common chronic pain condition b) Myofascial pain syndromes: Injury or disease of muscle and fascia; leads to guarding and limited motion c) Cancer: Due to tumor growth pressing on nerves or other structures, stretching of viscera, obstruction of ducts, metastasis to bones, treatments such as chemotherapy and radiation therapy d) Chronic postoperative pain: Uncommon, follows incisions in the chest wall, radical mastectomy, radial neck dissection, and surgical amputation C. Breakthrough pain: Exceeds baseline chronic or persistent pain 1. Temporary and can be debilitating 2. Incident (episodic) pain: Predictable, precipitated by an event or activity D. Nociceptive pain: Caused by stimulation of peripheral or visceral pain receptors 1. Acute or chronic, resulting from disease processes, tissue trauma, or medical treatment E. Neuropathic pain: Arises from consequence of lesion or disease affecting the somatosensory system 1. Usually chronic, associated with conditions such as diabetic neuropathy or postherpetic neuralgia 2. Central pain: Caused by lesion or damage in the brain or spinal cord 3. Complex regional pain syndromes (CRPS): Pain receptors in the affected part of the body become sensitized to catecholamines, neurotransmitters associated with sympathetic nervous system activity 4. Phantom limb pain a) Treatment (1) Medications including opioids, calcitonin/N-methyl-D-aspartate receptor antagonists, and ketamine, gabapentin, pregabalin, tricyclic antidepressants, and muscle relaxants (2) Have patient to move the effected extremity (3) Ongoing pain assessment

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

IV.

Factors Affecting Responses to Pain A. Pain threshold: Point at which a stimulus elicits response B. Pain tolerance: Amount (duration, intensity) of pain an individual can endure before outwardly responding to it 1. Decreased by repeated episodes of pain, fatigue, anger, anxiety, and sleep deprivation 2. Medications, alcohol, hypnosis, warmth, distraction, and spiritual practices may increase pain tolerance C. Age 1. No evidence that nociception is altered by age 2. Older adults a) Pain stimulus transmission, central processing is slower b) Referred pain is less typical c) Visceral pain may present as less severe d) May experience acute and chronic pain related to arthritis, peripheral neuropathy e) Pain tolerance decreases D. Gender 1. Women have a lower pain threshold, experience higher intensity of pain than men a) Due to fluctuating estrogen levels associated with menstrual cycle 2. Women and men may respond differently to opioid analgesics E. Sociocultural influences 1. Cultural standards teach how much pain to tolerate, what types of pain to report, to whom to report pain, and what kind of treatment to seek 2. Nurse’s role: Approach each patient as an individual, observe them carefully, ask questions, and avoid assumptions F. Psychologic influences 1. Intense concentration may block sensation of pain 2. Anxiety, fear may increase sensation of pain 3. Placebo effect: Positive patient response to an inactive substance 4. Pain’s impact on ability to sleep induces fatigue which can lower pain tolerance 5. Depression linked to pain 6. Meaning associated with the pain influences the experience of pain

V.

Care of the Patient in Pain A. Interprofessional care 1. Effective pain relief results from collaboration among the patient and all members of the healthcare team

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

B. Acute pain management 1. Straightforward, short-term analgesia and management of the underlying problem C. Chronic pain management 1. Multidisciplinary approach D. Pain clinics 1. Centers that use traditional pharmacologic agents, complementary therapies, nutritional counseling, psychotherapy, biofeedback, hypnosis, acupuncture, massage E. Medications 1. Most common approach to pain management 2. Nurse’s role: Administer prescribed medications, select appropriate dosage and timing, assess side effects, evaluate effectiveness, provide patient teaching 3. Analgesic (pain-relieving) drugs a) Aspirin, acetaminophen, NSAIDS (1) Produce analgesia and reduce fever (2) Used for mild to moderate pain (3) Hepatotoxicity: Can result from use of acetaminophen; risk for malnourished or immunosuppressed patients or those with history of alcohol abuse (4) Multimodal approach to analgesic therapy: Combination of opioid and adjunctive pain relief measures (5) Associated with gastric irritation (6) Aspirin: Interferes with platelets and blood clotting (7) NSAIDS: Increase blood pressure in many patients, may be toxic to kidneys over long-term use b) Opioid analgesics (1) Treatment of choice for acute moderate-to-severe pain (2) Morphine, codeine, fentanyl (3) Opioid agonists: Stimulate receptor they bind with (morphine) (4) Agonist–antagonist effect: Block activity of some receptors (mu receptors), while activating others (kappa receptors) (5) Produce sedation, drowsiness, and dizziness (6) Side effects: Nausea, vomiting, constipation, can cause physical and psychological dependence (7) Little risk for addiction when medications are used as recommended c) Nursing responsibilities (1) Record the date, time, patient name, type, and amount of drug used, and sign the entry in a narcotic inventory sheet (2) Keep an opioid antagonist available to treat respiratory depression (3) Assess allergies or adverse effects from opioids (4) Assess for respiratory disorders .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(5) Assess the characteristics of the pain and the effectiveness of drugs used in treatment (6) Take and record baseline vital signs before administering the drug (7) Administer drugs following established guidelines (8) Monitor vital signs and respiratory status, level of consciousness, papillary response, nausea, bowel function, urinary function, and effectiveness of pain management (9) Provide for patient safety (10) Report adverse effects (11) Employ protocols or prn orders as needed (12) Monitor if any patient is receiving more than one dose of meperidine (13) Teach noninvasive methods of pain management d) Health education for the patient and family (1) Use of opioid analgesics to treat severe pain is unlikely to cause addiction (2) Do not drink alcohol while taking drugs (3) Do not take OTC medications (4) Increase intake of fluids and fiber (5) Drugs often cause dizziness, drowsiness, and impaired thinking (6) Report adverse effects or decreasing effectiveness 4. Antidepressants a) Inhibits pain sensation by acting on production and retention of serotonin in the CNS b) May be used to manage severe persistent or malignant pain; treating neuropathic pain c) Promote normal sleeping patterns d) Adverse effects: Orthostatic hypotension, drowsiness, urinary retention, constipation, and impaired memory 5. Anticonvulsants a) Useful with neuropathic pain, migraine headaches, diabetic neuropathy b) Frequently used with opioids in multimodal postoperative pain control 6. Local anesthetics a) Block the initiation and transmission of nerve impulses in a local area F. Analgesic administration 1. Benefits to preventative approach to pain a) Patient may spend less time in pain b) Inadequate relief of pain may contribute to chronic pain c) Frequent analgesic administration may allow for smaller doses and less analgesic administration d) Smaller doses mean fewer side effects e) Patient’s fear and anxiety about the return of pain decreases f) Pain relief allows the patient to be more physically active; avoid complications of immobility 2. Administration: Around-the-clock (ATC) or as necessary (PRN) .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

G. Routes of administration 1. Oral (PO) a) Simplest route b) Some must be given with food, some irritate gastrointestinal system, some patients have trouble swallowing pills 2. Rectal a) For patients unable to swallow or experiencing nausea and vomiting b) Must be placed above rectal sphincter 3. Transdermal (patch) a) Simple, painless, and delivers continuous level of medication b) Ease to store and apply c) Titrate: Increase or decrease a dose in small increments d) Effective for 72 hours, new patches applied on different site 4. Parenteral (IM) a) Disadvantages: Uneven absorption from the muscle, discomfort on administration, and time consumed for preparing and administering medication 5. Intravenous (IV) a) Provides most rapid onset of effect (1–15 minutes) b) Given by drip, bolus, patient-controlled analgesia (PCA) c) PCA advantages: Dose precision, timeliness, and convenience d) PCA disadvantages: Nursing care needed for intravenous line, potential for infection, cost of disposable supplies, risk for a serious medication error e) Risk factors for respiratory depression: Basal infusion, age greater than 70, obesity, sleep apnea, concurrent use of central nervous system depressants, upper abdominal or thoracic surgery, renal hepatic, pulmonary or cardiac impairment, PCA bolus of more than 1 mg of morphine without a basal rate 6. Intraspinal (intrathecal or epidural) a) Invasive, requires more extensive nursing care b) Used to manage chronic intractable malignant pain and postoperative pain c) Provides better analgesia and postoperative recovery than intravenous delivery d) Lower risk for respiratory depression and failure e) Complications: Hypotension, development of an epidural hematoma or abscess, and neurologic damage 7. Nerve blocks: Local anesthetic is injected into or near a nerve a) May be performed to determine the precise location of the source of the pain b) Allows patient to develop more hopeful attitude that pain relief is possible, allow local procedures to be performed without causing discomfort, or exercise and move affected part c) Neurolytic blocks: Long-term pain relief used for terminally ill patients H. Surgery 1. Reserved for nerve pain .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

2. Surgical approaches to pain relief: a) Cordotomy—Incision to the anterolateral tracks of the spinal cord to interrupt the transmission of pain b) Neurectomy—Removal or destruction of a nerve (1) Methods for destroying nerve: Injection of glycerol into the nerve, use of radiofrequency-generated heat, compression of the nerve using a balloon (2) Peripheral neurectomy—Severing of a nerve at any point distal to the spinal cord c) Sympathectomy—Destruction by injection or incision of the ganglia of sympathetic nerves, usually in the lumbar region or the cervicodorsal region at the base of the neck d) Rhizotomy—Surgical severing of the dorsal spinal routes I. Transcutaneous Electrical Nerve Stimulation (TENS): Application of electrical current through skin to control acute or chronic pain 1. Controls pain by: a) Activates opioid receptors in the spinal cord and medulla b) Affects release of excitatory and inhibitory neurotransmitters c) Stimulates large-diameter A-beta touch fibers to close gate controlling pain transmission within the spinal cord d) Stimulates serotonin release, activates serotonin receptors, and prompts endorphin release 2. Commonly used to relieve chronic benign pain, neuropathic pain, and acute postoperative pain 3. Advantages: Avoidance of drug side effects, patient control, and good interaction with other therapies 4. Disadvantages: Cost, need for expert training for initiation, doesn’t work for all patients J. Integrative therapies 1. Acupuncture 2. Biofeedback 3. Chiropractic 4. Distraction 5. Hypnotherapy and guided imagery a) Hypnotherapy trance levels: superficial trance, alpha trance, somnambulism 6. Massage 7. Natural products: Herbals, natural oils, and other natural substances 8. Relaxation a) Diaphragmatic breathing b) Progressive muscle relaxation c) Meditation d) Music therapy

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

K. Nursing Care 1. Assessment a) Patient perceptions (1) Memory cue: PQRST mnemonic (a) P = precipitating cause of the pain, what relieved it, what is the pattern of the pain (constant, episodic)? (b) Q = qualities of the pain? (c) R = region (location) of the pain? (d) S = severity or intensity of the pain? (e) T = timing of the pain?

(2) McGill Pain Questionnaire (3) Pain rating scales: Numeric rating, verbal descriptor, faces rating scales, Iowa Pain Thermometer b) Physiologic responses (1) Muscle tension; tachycardia; rapid, shallow respirations; increased blood pressure; dilated pupils; sweating; pallor c) Behavioral responses (1) Pain behaviors: Facial grimacing, bracing or guarding the painful part, taking medication, crying, moaning, withdrawing from activity and socialization, becoming immobile, talking about pain, holding the painful area, breathing with increased effort, exhibiting a sad facial expression, being restless (2) Reasons for denial of pain: Fear of injections, fear of addiction, misinterpretation of terms, misconception that healthcare providers know when patients experience pain, denial that there is something wrong (3) May use pain as a mechanism for attention, may think “as needed” medications only given if pain rating is high (4) Patients with advanced dementia (a) Pain Assessment in Advanced Dementia (PAINAD) scale (i) Breathing, vocalization, facial expression, body language, consolability d) Self-management of pain (1) Information is individualized and patient specific (2) Get descriptions of actions, when and how measures were applied, how well they worked 2. Diagnoses, outcomes and interventions a) Diagnoses—Acute pain and chronic pain (1) Relieve acute pain (a) Assessed by having patient point out location, assess intensity by using evidence-based pain scale (b) Describe quality of pain (c) Described pattern of pain (d) Describe precipitating or relieving factors .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(e) Identify and use appropriate pain scale (i) Don’t assume older or cognitively impaired patient is not having pain or unable to identify it (f) Monitor manifestations of pain (g) Consider pain the fifth vital sign and assess for pain every time temperature, respirations, blood pressure are checked (h) Communicate belief in patient’s pain (i) Administer prescribed analgesics (2) Manage chronic pain (a) Ask patient to describe pain and its meaning (b) Assess for depression using accepted depression screening tool (c) If underlying cause has not been identified, advocate for consultations, diagnostic testing, or other means of diagnosis (d) Administer prescribed NSAIDS, opioid and nonopioid analgesics, and other medications around the clock as ordered (e) Do not crush or break or allow patients to chew controlled-release oral preparations (f) Teach the patient, family, caregivers how to manage side and adverse effects (g) Encourage and advocate for a multimodal approach to pain management (i) Recognize that many older adults may experience both acute and chronic pain simultaneously (3) Transitions of care (a) Specific drugs to be taken (b) How to take or administer the drugs (c) Importance of taking pain medications before the pain becomes severe (d) Explanation that the risk of addiction is small when used for pain management (e) Discussion about physical tolerance and the importance of contacting prescriber if medications become less effective (f) Importance of scheduling periods of rest and sleep (g) Use of CAM therapies (h) Suggest the following resources: Pain clinics, community support groups, American Cancer Society, and American Pain Society

Chapter Highlights A. Pain is a subjective response to both physical and psychologic stressors and all people experience pain at some point during their lives.

B. Although pain is usually experienced as uncomfortable and unwelcome, it also serves a protective role, warning of potentially health-threatening conditions.

C. Pain is a distinctive personal experience influenced by genetic, physiologic, psychologic, cognitive, sociocultural, cultural, and spiritual factors.

D. Acute pain has a defined purpose: To warn of injury to body tissues. .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

E. Pain is transmitted by the peripheral and central nervous systems and perceived in the CNS. Opioids and other analgesics block the perception of pain; NSAIDs and most nonpharmacological interventions block or decrease the transmission of pain from the periphery to the CNS. F. Pain occurs when the tissue containing nociceptors is subjected to a noxious insult: The intensity and duration of the stimulator determine the sensation.

G. The pain pathway goes from transduction to transmission to modulation to perception.

H. Acute pain, which may be cutaneous or deep somatic, visceral, or referred, usually decreases the healing progresses.

I. Breakthrough pain is that which exceeds the baseline or persistent level of pain.

J. Nociceptive pain is caused by stimulation of peripheral or visceral pain receptors. It is generally localized and responsive to treatment; and maybe acute or chronic.

K. Neuropathic pain arises as a consequence of a lesion or disease affecting this somatosensory system; it may be acute but is usually chronic. Examples include central pain, complex regional pain syndrome, and phantom limb pain.

L. Age, gender, and culture impact pain perception and behavior.

M. A patient’s emotional state, past experiences with pain, and the underlying causes and meaning of the painful experience also affect responses to pain.

N. Pain tolerance is the amount (duration, intensity) of pain an individual can endure before outwardly responding to it.

O. The intensity of perceived pain has been shown to be affected by psychologic variables such as attention, expectation, and suggestion.

P. Nurses play a pivotal role in managing pain for patients in all healthcare settings.

Q. Completion of a comprehensive assessment and development of an individualized and patient-centered plan lead to effective pain management.

R. Pain management involves pharmacologic and nonpharmacologic interventions.

S. Behavioral assessment of pain intensity is less accurate than a patient’s report of pain intensity, particularly when pain is chronic. Behavioral responses may be used to assess pain in patients who are significantly cognitively impaired, however. Older adults perceive pain as intensely as younger adults, but may hesitate to report pain for fear of losing independence or being considered a bother. Physical tolerance develops with long-term opioid use, necessitating dose increases to achieve the same effect. Although patients who are addicted to opioids need greater doses of opioid analgesics to control pain because of tolerance, treating physicians and nurses providing care often withhold or use lower doses of opioid analgesics, leading to inadequate pain relief.

T. Pain management includes assessment, intervention, and evaluation. It is important to verify that interventions have been effective. If not, interventions must be identified that bring pain down to a level of intensity with which the patient feels satisfied.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME ONE Break students into small groups to discuss how they perceive pain as well as myths and misconceptions of pain. Discuss small group findings with the entire class.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME ONE Ask a pain-management physician or nurse to speak to the students during a clinical rotation.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME TWO Ask students to role-play a situation where a care provider would be explaining pain pathways to a patient.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME TWO Ask students to review a patient’s chart and share with the clinical group information found regarding pain theories, physiology, and modulation.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME THREE Have students work together to develop a care plan for patients with acute pain and patients with chronic pain.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME THREE Assign students to patients experiencing pain. Have students identify whether the patient’s pain is acute, chronic, breakthrough, nociceptive, or neuropathic.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME FOUR Ask students to discuss the various factors that affect clients’ responses to pain.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME FOUR Ask students to assess patients for factors that relieve or worsen their pain using the PQRST mnemonic.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME FIVE Ask students to search the Internet for local pain resources such as pain clinics, community support groups, American Cancer Society, American Pain Society, etc.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME FIVE Visit a pain-management clinic. Note which pain methods are used and which type of patient utilizes the clinic.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter 10 Nursing Care of Patients with Altered Fluid, Electrolyte, and Acid–Base Balance

Learning Outcomes 1. Describe the functions and regulatory mechanisms that maintain water and electrolyte balance in the body.

2. Describe the pathophysiology and manifestations of fluid volume deficit and fluid volume excess, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.

3. Describe the pathophysiology and manifestations of hyponatremia and hypernatremia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.

4. Describe the pathophysiology and manifestations of hypokalemia and hyperkalemia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.

5. Described the pathophysiology and manifestations of hypocalcemia and hypercalcemia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.

6. Described the pathophysiology and manifestations of hypomagnecemia and hypermagnecemia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.

7. Describe the pathophysiology and manifestations of hypophosphatemia and hyperphosphatemia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.

8. Describe the functions and regulatory mechanisms that maintain acid–base balance in the body.

9. Described the pathophysiology and manifestations of metabolic acidosis, metabolic alkalosis, respiratory acidosis, and respiratory alkalosis, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.

Key Concepts A. Introduction B. A. Homeostasis: Internal equilibrium 1. Disruption from illness, trauma can disrupt functional health patterns a) Goal of care is to reestablish and maintain homeostasis b) Nursing care (1) Identifying and assessing patients who are likely to develop imbalances (2) Monitoring patients for early manifestations .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(3) Implementing interventions to prevent or correct imbalances I. Overview of Fluid and Electrolyte Balance A. Body fluid composition: Water and various dissolved substances are solutes 1. Water a) Medium for transport of nutrients and other substances b) Medium for metabolic reactions within cells c) Assists in regulating body temperature d) Intake and output equal during fluid balance (1) Intake from foods, fluids, and metabolic processes (2) Output from urine, excretion, and perspiration 2. Electrolytes a) Chemicals that form ions in solution (1) Cations are positively charged (2) Anions are negatively charged b) Functions (1) Assist with water balance regulation (2) Regulate acid–base balance (3) Contribute to enzyme reactions (4) Essential for neuromuscular activity C. Body fluid distribution 1. Intracellular fluid (ICF) located within cells 2. Extracellular fluid (ECF) located outside of cells a) Interstitial fluid: Located in spaces between cells b) Intravascular fluid/plasma: In blood vessels c) Transcellular fluid: Urine, digestive secretions, perspiration, cerebrospinal, pleural, synovial, intraocular, gonadal, and pericardial fluids 3. Solutes a) ICF: High in potassium (K+), magnesium (Mg2+), phosphate (PO42–), glucose, and oxygen b) ECF: High in sodium (Na+), chloride (Cl–), and bicarbonate (HCO3–) 4. Compartments separated by membranes a) Cell membranes (1) Permeable to water, oxygen, carbon dioxide, and small molecules (2) Impermeable to proteins and intracellular colloids b) Capillary membranes separate plasma and interstitial fluid (1) Permeable to dissolved gases, water, and solute molecules c) Epithelial membranes separate transcellular fluid from interstitial fluid and plasma D. Body fluid movement 1. Osmosis: Water movement across a permeable membrane from an area of low solute to an area of high solute concentration .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) Osmolality: Number of solutes per kilogram of water (1) ECF osmolality reflective of sodium concentration b) Osmotic pressure: Power to draw water across a membrane (1) Colloid osmotic pressure/oncotic pressure: Pressure in intravascular compartment c) Tonicity: Effect of osmotic pressure on water movement within that solution (1) Isotonic: Same concentration of solutes as plasma (2) Hypertonic: Greater concentration of solutes than plasma (3) Hypotonic: Lower concentration of solutes than plasma 2. Diffusion: Solute movement from an area of high concentration to an area of low concentration to become evenly distributed a) Simple diffusion: Passive movement of smaller molecules b) Facilitated diffusion/carrier-mediated diffusion: Proteins in cell membranes assist passage of large water-soluble molecules 3. Filtration: Water and dissolved substances move from high hydrostatic pressure to low hydrostatic pressure a) Hydrostatic pressure: From heart pumping and gravity on capillary wall 4. Active transport: Molecules movement across membranes against concentration gradient, requires energy and carrier mechanism E. Body fluid regulation 1. Thirst: Primary regulator of water intake a) The thirst center, located in the hypothalamus, stimulated when blood volume drops or when serum osmolality increases b) Effective regulation of sodium level in ECF c) Declines with aging 2. Kidneys: Regulate fluid volume and electrolyte balance in the body a) Control excretion of water and electrolytes 3. Renin–angiotensin–aldosterone system: Helps to maintain intravascular fluid balance and blood pressure a) Kidneys produce renin which converts angiotensin in the blood into angiotensin I. This travels through the bloodstream to the lungs where it is converted to angiotensin II by angiotensin-converting enzyme (ACE). b) Angiotensin II: Vasoconstrictor, raises blood pressure, stimulates thirst, causes kidneys to retain water and sodium, and stimulates release of aldosterone c) Aldosterone causes sodium and water retention in kidney 4. Antidiuretic hormone (ADH)/vasopressin: Regulates water excretion from the kidneys a) Released by posterior pituitary in response to decreased blood volume, increased serum osmolality, and stress b) Increases water reabsorption in kidneys

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

5. Atrial natriuretic peptide: Hormone released by atrial muscle cells in response to distention from fluid overload a) Promotes sodium and urine output II.

Fluid and Electrolyte Imbalances A. The patient with fluid volume deficit 1. Pathophysiology a) Most common: Loss from vomiting, diarrhea, GI suctioning, intestinal fistulas, and intestinal drainage b) Other causes: Diuretics, renal disorders, endocrine disorders, excessive exercise, hot environment, hemorrhage, chronic abuse of laxatives and/or enemas, and lack of intake c) Hypovolemia: Decreased circulating blood volume (1) Isotonic fluid volume deficit when water and electrolytes are lost (2) Shock and cardiovascular collapse is possible 2. Second and third spacing a) Second spacing: Fluid present in interstitial space b) Third spacing: Fluid is in a transcellular space (1) Shift of fluid out of vascular space into unusable space (2) Triggered by stress hormones from trauma or sepsis, hypoproteinemia contributes (3) Shock, multiorgan system failure may occur 3. Manifestations a) Rapid weight loss, decreased skin turgor, postural or orthostatic hypotension, and decreased venous pressure b) Compensatory mechanisms: Tachycardia, vasoconstriction, decreased urine output, and increased urine specific gravity B. Interprofessional care 1. Goal of care: Prevent deficits in patients at risk and correct deficits and their underlying causes 2. Diagnosis a) Serum electrolytes, serum osmolality, hemoglobin, hematocrit, and hemodynamic pressures b) Urine specific gravity and osmolality 3. Fluid management a) Oral rehydration: Safest, most effective in alert patients (1) Carbohydrate/electrolyte solution when electrolytes have been lost, too b) IV therapy: For severe cases or when patient cannot orally intake

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Isotonic electrolyte solutions for hypotensive patients, expand plasma volume (2) Normal saline or balanced electrolyte solutions to increase blood volume C. Nursing care 1. Assessment a) Health history b) Physical assessment (1) Weight, vital signs, skin conditions, peripheral pulses, jugular neck vein distention, and level of consciousness 2. Priorities of care a) Restore fluid volume to support tissue perfusion and organ function b) Prevent injury associated with fluid volume deficit 3. Diagnoses, outcomes, and interventions a) Promote adequate fluid volume (1) Access intake and output and monitor fluid balance (2) Assess vital signs, CVP, and peripheral pulse volume at least every 4 hours (3) Weigh daily understanding conditions (4) Administer and monitor intake of oral fluids (5) Administer IV fluids using infusion pump (6) Monitor laboratory values b) Promote effective tissue perfusion (1) Monitor for change in level of consciousness and mental status (2) Monitor serum creatinine, BUN, and cardiac enzymes (3) Turn the patients at least every 2 hours; Monitor for evidence of skin or tissue breakdown c) Reduce risk for injury (1) Institute safety precautions (2) Teach methods to reduce orthostatic hypotension d) Delegating nursing care activities 4. Transitions of care a) Teach manifestations, importance of adequate fluid intake, how to replace fluids D. The patient with a fluid volume excess 1. Retention of water and sodium by the body 2. Causes a) Fluid overload b) Impairment of mechanisms that maintain homeostasis 3. Hypervolemia: Excess intravascular fluid .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

4. Edema: Excess interstitial fluid 5. Pathophysiology a) Conditions that cause water and sodium retention, excessive sodium intake, and medication side effects (1) Heart failure, cirrhosis of the liver, renal failure, adrenal gland disorders, corticosteroid administration, and stress conditions 6. Manifestations and complications a) Extracellular: Hypovolemia, circulatory overload b) Interstitial: Peripheral or generalized edema c) Congestive heart failure and pulmonary edema 7. Interprofessional care a) Diagnosis (1) Serum electrolytes, serum osmolality: Normal (2) Serum hematocrit, hemoglobin: Deceased (3) Renal and liver function tests to determine cause b) Medications: Diuretics (1) Types of diuretics and part of kidney they affect (a) Loop: Affect ascending loop of Henle (b) Thiazide-type: Affect distal convoluted tubule (c) Potassium-sparing: Affect distal nephron c) Treatments (1) Fluid intake restriction (2) Dietary management: Sodium-restricted diet (a) Discuss relationship between sodium and fluid retention (b) Provide guidelines for low-sodium diet 8. Nursing care a) Assessment (1) Health history (2) Physical assessment (a) Weight, vital signs, circulatory signs, lung sounds, dyspnea, cough, urine output, and mental status b) Priorities of care (1) Support cardiovascular and respiratory function c) Diagnoses, Outcomes, and interventions (1) Manage fluid volume excess (a) Monitor: Vital signs, heart sounds, and peripheral pulse amplitude (b) Assess for the presence and extent to edema .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(c) Assess urine output hourly (d) Obtain daily weights at the same time of day using the same equipment (e) Administer oral and parent general fluids cautiously, adhering to prescribed fluid restrictions (f) Provide oral hygiene at least every 2 hours (g) Teach about sodium restricted diet (h) Administer prescribed diuretics as ordered; Monitor the patients’ response to therapy (i) Promptly report significant changes in serum electrolytes or osmolality or abnormal results of tests related to fluid volume excess (2) Reduce risk for skin breakdown (a) Assess skin, reposition patient frequently, provide devices to reduce pressure on tissues (b) Monitor gas exchange: Auscultate lungs and heart for sounds (c) Monitor oxygen saturation levels and arterial blood gases (ABGs) (d) Place in Fowler’s position if dyspnea or orthopnea is present (3) Delegating nursing care activities 9. Transitions of care a) Educate patient and family (1) Manifestations, medications, and sodium intake III.

Sodium Imbalances A. Sodium 1. Normal levels: 135–145 mEq/L 2. Affects distribution of fluids 3. Average daily dietary intake is above recommended intake B. Kidney: Primary regulator 1. Fall in blood volume a) Renin–angiotensin–aldosterone system triggered b) Antidiuretic hormone (ADH) released 2. Rise in blood volume a) Increased glomerular filtration rate b) Atrial natriuretic peptide (ANP) released C. The patient with hyponatremia: Serum sodium level less than 135 mEq/L 1. Pathophysiology a) Excessive loss through kidneys, GI tract, skin, cerebral wasting, and third spacing b) Water gains from systemic diseases c) Causes decrease in serum osmolality

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

2. Manifestations a) Early signs: Muscle weakness, cramps; GI system discomfort, nausea and vomiting b) Cerebral edema: Headache, dulled senses, mood and personality changes, and tremors c) Severe case: Coma 3. Interprofessional care a) Diagnosis (1) Serum sodium, osmolality: Decreased (2) 24-hour urine specimen to evaluate excretion b) Medications (1) Sodium-containing fluids: For low-sodium and low-fluid volume (2) Loop diuretics: For hyponatremia but not low-fluid volume c) Fluid and dietary management (1) Increased sodium intake and restricted fluids 4. Nursing care a) Assessment (1) Health history (2) Physical assessment (a) Vital signs, presence of edema, and mental status b) Priorities of care (1) Restoring sodium and water balance (2) Preventing complications of cerebral edema c) Diagnoses, outcomes, and interventions (1) Reduce risk for imbalanced fluid volume (a) Monitor intake and output, daily weights; calculate 24-hour fluid balance (b) Using infusion pump to administer hypertonic saline and monitor for hypervolemia (c) Educate patient on fluid restriction (2) Reduce risk for ineffective cerebral tissue perfusion (a) Monitor serum electrolytes and osmolality (b) Assess neurologic changes, muscle strength d) Delegating nursing care activities 5. Transitions of care a) Educate on underlying cause, prevention, and manifestations D. The patient with hypernatremia: Serum sodium level greater than 145 mEq/L 1. Pathophysiology a) Excessive water loss or excessive sodium intake .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

b) Causes hyperosmolality of ECF and cellular dehydration 2. Manifestations a) Thirst, altered neurologic function b) Severe cases: Seizures, coma, and death 3. Interprofessional care a) Diagnosis (1) Serum sodium levels and serum osmolality: High b) Medications (1) Oral, enteral, or IV fluid replacement 4. Nursing care a) Health promotion: Education about fluid intake b) Assessment (1) Health history (2) Physical assessment (a) Mental status (b) Manifestations of fluid volume excess or fluid volume deficit c) Priorities of care (1) Reduce risk of injury d) Diagnoses, outcomes, and interventions (1) Reduce risk for injury (a) Monitor: Fluid replacement, serum sodium and osmolality, and neurologic function (b) Institute safety precautions and orient patient e) Delegating nursing care activities f) Transitions of care (1) Educate on fluid intake, low-sodium diet, and monitoring of serum electrolyte levels IV.

Potassium Imbalances A. Normal serum level: 3.5–5.0 mEq/L 1. ICF level: 140–150 mEq/L 2. Transmission of nerve impulses 3. Maintenance of cardiac rhythms 4. Muscle contraction B. Regulation 1. Sodium–potassium pump, aldosterone, and kidneys

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

C. The patient with hypokalemia 1. Pathophysiology a) Inadequate intake, excessive intestinal losses b) Redistribution between ICF and ECF from metabolic acidosis or insulin c) Excessive renal losses from medications, hyperaldosteronism, stress, trauma, metabolic acidosis, and magnesium deficit 2. Manifestations a) Muscle weakness and cramps, GI discomfort and vomiting b) Decreased cardiac output, polyuria 3. Interprofessional care a) Diagnosis (1) Serum potassium (2) Serum electrolytes: Other imbalances concurrently (3) Arterial blood gases: Often increased (4) Renal function studies: To determine cause (5) ECF readings: To determine cardiac effects b) Medications (1) Administer diluted, with food (2) Assess for GI bleeding, abdominal pain; manifestations of hyperkalemia c) Dietary management (1) High-potassium diet 4. Nursing care a) Assessment (1) Health history (2) Physical assessment (a) Mental status, GI status, and muscle strength b) Priorities of care c) Diagnoses, outcomes, and interventions (1) Monitor cardiac output (a) Monitor: Potassium levels in those at risk (b) Monitor vital signs (c) Monitor for toxicity and response to medications (d) Administer diluted IV potassium (2) Promote activity tolerance (a) Monitor: Muscle strength and tone (b) Monitor respiratory status (c) Assist with self-care activities (3) Reduce risk for imbalanced fluid volume (a) Maintain accurate intake and output records .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(b) Monitor bowel sounds and abdominal distention d) Delegating nursing care activities e) Transitions of care (1) Educate on recommended diet, medications, manifestations, and prevention for at-risk patients D. The patient with hyperkalemia 1. Pathophysiology a) Inadequate excretion from impaired renal function b) Rapid IV administration c) Acidosis, tissue trauma, chemotherapy, and starvation 2. Manifestations a) Neuromuscular: Muscle weakness and tremors b) Gastrointestinal discomfort c) Cardiac: ECG changes, dysrhythmias, and cardiac arrest 3. Interprofessional care a) Diagnosis (1) Serum electrolytes: Low calcium and sodium increase effects (2) ABGs: For acidosis (3) ECG: To monitor cardiac effects b) Medications (1) Calcium gluconate, calcium chloride: Counter cardiac effects (2) Insulin and glucose, hypertonic dextrose, and sodium bicarbonate: Increase uptake by cells (a) Monitor for sodium overload (3) Sodium polystyrene sulfonate: Increases excretion (a) Monitor for water retention, sodium overload c) Dialysis: For severe renal dysfunction 4. Nursing care a) Identify patients at risk b) Prevent hyperkalemia c) Manage systemic effects of hyperkalemia 5. Assessment (1) Health history (2) Physical assessment (a) Apical and peripheral pulses, bowel sounds, muscle strength, and ECG pattern .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

b) Priorities of care c) Diagnoses, outcomes, and interventions (1) Reduce risk for decreased cardiac output (a) Monitor response to medications (2) Promote activity tolerance (a) Monitor muscle strength, respiratory status (b) Assist with self-care activities d) Delegating nursing care activities e) Transitions of care (1) Educate on diet restrictions, manifestations, and OTC medications to avoid V.

Calcium Imbalances A. Normal serum level: 9–11 mg/dL B. 99% bound to phosphorous in bones C. 1% in ECF; half is ionized D. Functions (of ionized calcium in ECF) 1. Stabilizing cell membranes 2. Regulating muscle contraction and relaxation 3. Maintaining cardiac function and blood clotting E. Regulation 1. Parathyroid hormone (PTH): Mobilizes skeletal calcium stores, increases calcium absorption in intestines, and promotes calcium reabsorption by kidneys 2. Calcitriol: Stimulates effects of PTH 3. Calcitonin: Inhibits movement of calcium out of bone, reduces intestinal absorption of calcium, and promotes calcium excretion by kidneys 4. Acid–base balance 5. Plasma protein levels F. The patient with hypocalcemia 1. Risk factors a) Parathyroidectomy b) Older adults, especially women c) Lactose intolerance, alcoholism 2. Pathophysiology a) Pancreatitis or hypoparathyroidism from surgery, other electrolyte imbalances, alkalosis, malabsorption disorders, and inadequate vitamin D b) Administration of banked blood, loop diuretics, anticonvulsants, and phosphates 3. Manifestations and complications a) Neuromuscular: Tetany

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

b) Cardiovascular: Hypotension, bradycardia, and ventricular dysrhythmias c) Respiratory: Airway obstruction and possible respiratory arrest 4. Interprofessional care a) Diagnosis (1) Total serum calcium/ionized calcium, serum albumin, serum magnesium, and serum phosphate (2) Parathyroid hormone: To identify possible cause (3) ECG: To monitor cardiac effects b) Medications (1) Oral supplements for chronic, asymptomatic cases, sometimes with vitamin D (a) Patient education: Do not take with food, milk, or other medications (2) IV supplements for severe cases (a) Do not administer with bicarbonate or phosphate (b) Monitor ECF and serum levels c) Dietary management (1) Diet high in calcium 5. Nursing care a) Assessment (1) Health history (2) Physical assessment: (a) Muscle spasms, deep tendon reflexes, Chvostek’s sign, Trousseau’s sign, and convulsions b) Priorities of care c) Diagnoses, outcomes, and interventions (1) Reduce risk for injury (a) Monitor airway and respiratory status, cardiovascular status, ECG (b) For tetany: Provide quiet environment, institute seizure precautions d) Transitions of care (1) Educate on risk factors, medications, dietary recommendations, and manifestations G. The patient with hypercalcemia 1. Pathophysiology a) Hyperparathyroidism: Excess PTH produced b) Malignancies: Bone destruction or hormone-like substances from tumor c) Prolonged immobility, excessive intake of calcium or vitamin D 2. Manifestations and complications a) Neuromuscular: Muscle weakness and fatigue .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

b) GI: Discomfort, nausea, vomiting, and constipation c) CNS: Confusion, lethargy, behavior or personality changes, and coma d) Cardiovascular: Dysrhythmias, ECG changes, and hypertension e) Can lead to: Peptic ulcer disease, pancreatitis, kidney stones, and hypercalcemic crisis 3. Interprofessional care a) Diagnosis (1) Serum PTH levels, ECG test, and bone density scans b) Medications (1) Loop diuretics: For acute cases (2) Bisphosphonates: For cases from malignancies (3) Sodium phosphate, potassium phosphate: For emergency situations (4) Glucocorticoids with a low-calcium diet c) Fluid management (1) Isotonic saline 4. Nursing care a) Assessment (1) Health history (2) Physical assessment (a) Mental status, bowel sounds, muscle strength, and deep tendon reflexes b) Priorities of care c) Diagnoses, outcomes, and interventions (1) Reduce risk for injury (a) Institute safety precautions (b) Observe for dioxin toxicity (if administered) (c) Promote fluid intake (d) In case of excess bone reabsorption, use cause when ambulating (2) Monitor fluid volume (a) Monitor intake and output, vital signs, respiratory status, and heart sounds (b) Place in semi-Fowler’s to Fowler’s position d) Delegating nursing care activities e) Transitions of care (1) Educate on limiting intake, using prescribed medications, increasing fluid intake, and weight-bearing exercise VI.

Magnesium Imbalances A. Majority in cells and bones, 1% in ECF B. Normal serum concentration: 1.8–3.0 mg/dL C. Functions: 1. Intracellular process: Enzyme reactions, synthesis of proteins, and nucleic acids

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

2. Neuromuscular transmission, cardiovascular function D. The patient with hypomagnesemia 1. Risk factors a) Excessive GI loss, alcoholism, protein-calorie malnutrition, diabetic ketoacidosis, kidney disease, and certain medications 2. Pathophysiology a) Occurs with low serum potassium and calcium levels 3. Manifestations and complications a) Neuromuscular: Tremors, hyperreactive reflexes, tetany, and seizures b) CNS effects: Confusion, mood changes, hallucinations, and psychoses c) Cardiac: Increased heart rate, ventricular dysrhythmias, and cardiac arrest 4. Interprofessional care a) Diagnosis (1) Serum electrolyte levels, ECG changes b) Treatment (1) Oral intake of foods or supplements (2) Parenteral magnesium sulfate (IV or IM) (a) Assess renal function and deep tendon reflexes before administering 5. Nursing care a) Assessment (1) Health history (a) Risk factors for hypomagnesemia (2) Physical assessment (a) Observe diagnostic tests and for manifestations, monitor GI function b) Diagnoses, outcomes, and interventions (1) Monitor serum magnesium, potassium, calcium; cardiac status; dioxin toxicity; and deep tendon reflexes c) Transitions of care (1) Educate on magnesium sources (2) For alcohol abuse, discuss treatment options E. The Patient with Hypermagnesemia 1. Pathophysiology and manifestations a) Renal failure: Common cause b) Other causes: Nausea and vomiting; interfered neuromuscular transmission; depressed CNS; hypotension, flushing sweating, bradydysrhythmias, and respiratory depression

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

2. Interprofessional care a) Hemodialysis or peritoneal dialysis for renal failure b) Calcium gluconate to treat neuromuscular and cardiac effects c) Mechanical ventilation, pacemakers to support respiratory function 3. Nursing care a) Identification and prevention for patients at risk b) Monitoring for critical effects c) Reduce risk for injury 4. Transitions of care VII.

Phosphate Imbalances A. Most in bones, 14% in ICF, 1% in ECF B. Normal serum level: 2.5–4.5 mg/dL C. Functions: 1. Production of ATP: Supports muscle contraction, nerve cell transmission, and electrolyte transport 2. Red blood cell, nervous system, and muscle function; metabolism and acid–base balance D. Regulated by parathyroid hormone, calcitonin, and vitamin D E. The patient with hypophosphatemia 1. Pathophysiology a) Decreased GI absorption; increased renal excretion b) Iatrogenic causes: Refeeding syndrome, medications c) Alcoholism, hyperventilation, respiratory alkalosis, and diabetic ketoacidosis 2. Pathophysiology and manifestations a) CNS: Irritability, apprehension, lack of coordination, seizures, and coma b) Hematologic: Decreased oxygen to cells, hemolytic anemia c) Musculoskeletal: Muscle weakness, rhabdomyolysis d) Cardiovascular: Chest pain and dysrhythmias e) GI: Anorexia, dysphagia, nausea, vomiting, and ileus 3. Interprofessional care a) Oral intake of food or supplement b) IV phosphate for severe cases 4. Nursing care a) Identify at-risk patients b) Teach about causes and manifestations, stress well-balanced diet F. The patient with hyperphosphatemia

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

1. Pathophysiology and manifestations a) Renal failure b) Rapid administration of phosphate-containing solutions c) Phosphate shift to ECF from: Chemotherapy, sepsis, hypothermia, and trauma d) Imbalanced serum calcium 2. Interprofessional care a) Treatment of underlying disorder b) Phosphate-rich foods; phosphate-containing drugs; and agents that bind with phosphate in GI tract 3. Nursing care a) Discuss risk, manifestations, and phosphate-binding preparations VIII. Regulation of Acid–Base Balance A. Acids release hydrogen ions in solution B. Bases/alkalis accept hydrogen ions in solution C. pH of 7 is neutral D. Normal body fluid pH: 7.35–7.45 E. Regulation of acid–base balance 1. Metabolic processes produce acids a) Volatile acids: Eliminated as gas (1) Carbonic acid (H2CO3) splits: Carbon dioxide (CO2) and water (H2O) b) Nonvolatile acids: Eliminated as fluid (1) For example, lactic acid, hydrochloric acid, phosphoric acid, and sulfuric acid 2. Buffer systems a) Bicarbonate–carbonic acid buffer system: CO2 + H2O ↔ H2CO3 ↔ H+ + HCO3¯ (1) Bicarbonate: Weak base; Carbonic acid: Weak acid (2) Ratio of bicarbonate to carbonic acid is 20:1 b) Phosphate buffer system (1) More important as intracellular than extracellular buffer c) Protein buffers (1) Plasma proteins buffers in ECF (2) Hemoglobin buffers in red blood cells (ICF) 3. Respiratory system a) Eliminates or retains carbon dioxide 4. Renal system a) Eliminate excess nonvolatile acids b) Reabsorb and regenerate bicarbonate ions c) Selectively excrete or retain hydrogen ions and bicarbonate ions F. Assessing acid–base balance 1. Arterial blood gases measured: pH, PaCO2, PaO2, and bicarbonate levels .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) PaCO2: Pressure exerted by dissolved carbon dioxide in blood (1) Measures respiratory regulation; normal value 35–45 mmHg (2) Hypocapnia and hypercapnia: Low and high measurements b) PaO2: Pressure exerted by dissolved oxygen in blood (1) Hypoxemia: Under 80 mmHg (2) Evaluates respiratory function; not primary measurement for acid–base status c) Serum bicarbonate (1) Measures renal regulation/metabolic component d) Base excess (BE): Buffer base capacity (1) Represents amount of acid or base needed to achieve serum pH of 7.4 (2) Normal: –3.0 – +3.0 IX.

Acid–Base Imbalances A. Acidosis: Hydrogen ion increases above normal (pH below 7.35) B. Alkalosis: Hydrogen ion falls below normal (pH above 7.45) C. Metabolic: Change in concentration of bicarbonate D. Respiratory: Change in concentration of carbonic acid E. Primary (simple): Due to one cause F. Mixed: Combinations of respiratory and metabolic disturbances G. Compensation 1. Rate and depth of respirations for metabolic disorders 2. Hydrogen ion and bicarbonate conservation and elimination by kidneys for respiratory disorders H. The patient with metabolic acidosis 1. pH < 7.35 and bicarbonate < 22 mEq/L 2. Risk factors a) Tissue hypoxia b) Type I diabetes mellitus c) Acute or chronic renal failure d) Diarrhea, intestinal suctioning, abdominal fistulous 3. Pathophysiology a) Accumulation of metabolic acids (1) Lactic acidosis: Tissue hypoxia leads to lactate and hydrogen ion production (2) Ketoacidosis: Inadequate cellular glucose leads to release of fatty acids which become ketones (3) Ingested substances can cause toxic increase in body acids (4) Renal failure impairs excretion b) Excess loss of bicarbonate (1) Intestinal suction, severe diarrhea, ileostomy drainage, and fistulas

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

c) Increase in chloride levels (1) Hyperchloremic acidosis: From infusion of excess chloride solutions, renal disease, and administration of carbonic anhydrate inhibitor diuretics d) Anion gap: Subtracted sum of chloride and bicarbonate (anions) from sodium (cation) (1) Normal (8–12 mEq/L) when caused by loss of bicarbonate or increase in chloride 4. Manifestations a) Anorexia, nausea, and vomiting b) Abdominal pain c) Weakness and fatigue d) General malaise e) Decreasing levels of consciousness f) Dysrhythmias, bradycardia g) Warm, flushed skin h) hyperventilation (Kussmaul respirations) 5. Interprofessional care a) Diagnosis (1) ABGs: pH under 7.35, bicarbonate level under 22 mEq/L (2) Serum electrolytes: Elevated potassium, sometimes low magnesium; calculate anion gap (3) ECG: Reflect severe acidosis and hyperkalemia (4) Blood glucose, renal function: To determine cause b) Medications (1) Alkalinizing solution to reduce cardiac effects (a) Sodium bicarbonate, lactate, citrate, and acetate (b) IV for acute; oral for chronic (c) Carefully monitor: Rapid correction can lead to metabolic alkalosis and hypokalemia (2) IV insulin and fluid for diabetic ketoacidosis (3) Saline solutions and glucose for alcoholic ketoacidosis 6. Nursing care a) Assessment (1) Health history: Risk factors (2) Physical assessment: Mental status, apical and peripheral pulses, skin status, abdominal status, and urine output b) Priorities of care c) Diagnoses, outcomes, and interventions (1) Monitor cardiac output

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(a) Monitor vital signs, peripheral pulses, capillary refill, ECG pattern, and laboratory diagnostic tests (2) Monitor fluid volume (a) Administer fluid replacement, monitor serum sodium, and osmolality (b) Assess respiratory status, heart sounds, edema, urine output, and daily weights (c) Administer prescribed diuretics, monitor response (3) Reduce risk for injury (a) Monitor neurologic function (b) Institute safety precautions (c) keep clocks and familiar objects at bedside (4) Delegating nursing care activities (5) Transitions of care (a) Continuity of care: Focus on underlying cause I. The patient with metabolic alkalosis 1. pH > 7.45 and bicarbonate > 26 mEq/L 2. Risk factors a) Hospitalization, hypokalemia, treatment with alkalizing solutions 3. Pathophysiology a) Hydrogen lost via gastric secretions or through kidneys (may be prompted by hypokalemia) b) Hydrogen shifts into cells c) Excess bicarbonate from ingesting antacids 4. Manifestations and complications a) CNS: Confusion, decreased level of consciousness, hyperreflexia, tetany, and seizures b) Cardiovascular: Dysrhythmias, hypotension, and respiratory failure 5. Interprofessional care a) Diagnosis (1) ABGs: pH > 7.45 and bicarbonate >26 mEq/L (2) Serum electrolytes: Hypokalemia, decreased chloride, high bicarbonate, low ionized calcium (3) Urine pH low; ECG changes similar to hypokalemia b) Medications (1) Potassium chloride and sodium chloride (2) Acidifying solution for severe cases 6. Nursing care a) Assessment .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Health history (2) Physical assessment (a) Apical pulse and respiration quality, muscle strength, and deep tendon reflexes b) Priorities of care c) Diagnoses, outcomes, and interventions (1) Monitoring gas exchange (a) Monitor: Respiratory quality, oxygen saturation, skin color, and mental status (b) Administer oxygen as needed (c) Place in semi-Fowler’s position and allow rest periods (2) Monitor fluid volume (a) Monitor serum electrolytes, osmolality, ABG values, weight, and vital signs (b) Administer IV fluids d) Delegating to nursing care activities e) Transitions of care (1) Discuss appropriate antacids, potassium supplements, and manifestations J. The patient with respiratory acidosis 1. pH < 7.35 and PaCO2 > 45 mmHg 2. Risk factors: Conditions that depress ventilation 3. Pathophysiology a) Acute: Chest trauma, aspiration of a foreign body, acute pneumonia, overdoses over narcotic or sedative, cardiac arrest b) Chronic: COPD, asthma, cystic fibrosis, and multiple sclerosis 4. Manifestations a) Acute: Cerebral vasodilation, headache, blurred vision, mental cloudiness, can progress to unconsciousness, ventricular fibrillation, dysrhythmias, and cardiac arrest b) Chronic: Weakness, dull headache, sleep disturbances, impaired memory, and personality changes 5. Interprofessional care a) Diagnosis (1) ABGs: pH is low and PaCO2 is high (2) Serum electrolytes: Hypochloremia in chronic cases (3) Chest X-ray and sputum studies to identify underlying cause b) Medications (1) Bronchodilators to open airways; antibiotics to treat infections c) Respiratory support (1) Pulmonary hygiene measures may be instituted .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(2) Caution to avoid carbon dioxide narcosis d) High-acuity care (1) Intubation and mechanical ventilation for severe cases with hypoxemia 6. Nursing care a) Assessment (1) Health history (2) Physical assessment (a) Mental status, skin color, respiration quality, and examination of optic fundus b) Priorities of care c) Diagnoses, outcomes, and interventions (1) Monitor gas exchange (a) Frequently assess respiratory status, oxygen levels, level of consciousness, and ABG results (b) Place in Fowler’s position (c) Administer oxygen as needed (2) Maintain effective airway clearance (a) Auscultate breath sounds (b) Encourage ambulation, fluid intake, and pursed-lip breathing (c) Provide percussion, postural drainage, and medications d) Deleting nursing care activities e) Transitions of care K. The patient with respiratory alkalosis 1. pH > 7.45 and PaCO2 < 35 mmHg 2. Risk factors a) Anxiety b) Mechanical ventilation 3. Pathophysiology a) Anxiety, high fever, hypoxia, gram-negative bacteremia, thyrotoxicosis, aspirin overdose, encephalitis, high progesterone levels, and mechanical ventilation 4. Manifestations a) Light-headedness, dizziness, numbness and tingling, and difficulty concentrating b) Cardiovascular: Palpitations, chest tightness c) Seizures and loss of consciousness possible 5. Interprofessional care a) Diagnosis .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) ABGs: High pH and low PaCO2 (2) Chronic cases: Serum bicarbonate decrease and near normal pH b) Medications (1) Sedative or antianxiety agent and drugs for underlying conditions c) Respiratory therapy (1) Instruct patient to breathe slowly into paper bag or rebreather mask (2) Ventilator settings adjusted (3) Oxygen administered for hypoxia 6. Nursing care a) Diagnoses, outcomes, and interventions (1) Maintain effective breathing pattern (a) Assess respiratory quality (b) Reassure patient that they are not having a heart attack (c) Instruct patient to breathe into bag, maintain eye contact (d) Protect patient from injury (2) Transitions of care—Focus on controlling underlying cause (3) Refer anxiety cases to counselor (4) Teach how to identify hyperventilation

Chapter Highlights A. The volume and composition of body fluid is normally maintained by a balance of fluid and electrolyte intake; elimination of water, electrolytes, and acids by the kidneys; and hormonal influences.

B. Change in any of these factors can lead to a fluid, electrolyte, or acid–base imbalance that adversely affects health.

C. Fluid, electrolyte, and acid–base imbalances can affect all body systems, especially the cardiovascular system, the central nervous system, and the transmission of nerve impulses.

D. Conversely, primary disorders of the respiratory, renal, cardiovascular, endocrine, or other body systems can lead to an imbalance of fluids, electrolytes, or acid–base status.

E. Fluid and sodium imbalances are related; both affect serum osmolality.

F. Because of the effect of serum osmolality, correction of sodium level should be done slowly.

This is to prevent rapid fluid shifts in the brain. Careful monitoring of levels of consciousness is required when treating hypo- or hypernatremia.

G. Potassium imbalances are commonly seen in patients with acute or chronic illnesses. Both hypokalemia and hyperkalemia affect cardiac conduction and function. Carefully monitor the cardiac rhythm and status in patients with very low or very high potassium levels.

H. Replacement of potassium requires careful monitoring. Reduction in high levels of potassium can be a medical emergency.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

I. Calcium imbalances primarily affect neuromuscular transmission: Hypocalcemia increases neuromuscular irritability; hypercalcemia depresses neuromuscular transmission.

Magnesium imbalances have a similar effect.

J. Hypocalcemia should always be suspected with surgery near or on the thyroid gland.

K. With both hypo- and hypercalcemia, the nurse should monitor for dysrhythmias.

L. High levels of magnesium are usually seen in patients with renal failure, and adrenal insufficiency.

M. Low levels of magnesium are usually seen in patients with pancreatitis and excessive loss from the gastrointestinal system.

N. Careful monitoring is needed when replacing magnesium via intravenous route.

O. Phosphate imbalances are usually iatrogenic in nature.

P. When monitoring replacement of another electrolyte, phosphate should also be monitored.

Q. Buffers, lungs, and kidneys work together to maintain acid–base balance in the body.

R. Buffers respond to changes almost immediately; the lungs respond within minutes; the kidneys require hours to days to restore normal acid–base balance.

S. By assessing bloodwork including arterial blood gases, the nurse can determine the acid– base balance and compensatory mechanisms of the patient under treatment.

T. The lungs compensate for metabolic acid–base imbalances by excreting or retaining carbon dioxide. This is accomplished by increasing or decreasing the rate and depth of respirations.

U. The kidneys compensate for respiratory acid–base imbalances by producing and retaining or excreting bicarbonate, and by retaining or excreting hydrogen ions.

V. Acid–base imbalances may be caused by either metabolic or respiratory health problems.

W. Simple acid–base imbalances (respiratory or metabolic acidosis or alkalosis) are more commonly seen than mixed imbalances.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME ONE Have a guest speaker speak to students about the functions and regulatory mechanisms used by the body to maintain fluid and electrolyte balance.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME ONE Assign students to care for patients with fluid deficits, including preoperative patients, postoperative patients, and patients with nausea and vomiting.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME TWO Discuss methods to encourage a patient with a fluid deficit to increase fluid intake

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME TWO Ask students to develop an individualized care plan with patient-centered strategies to reduce risk of fluid, electrolyte, or acid imbalances for patients assigned to them in the clinical setting.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME THREE Discuss different laboratory values for sodium imbalances. What symptoms might the patient display?

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME THREE Assign students to care for a patient with a sodium imbalance.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME FOUR Discuss different laboratory values for potassium imbalances. What symptoms might the patient display?

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME FOUR Assign students to care for a patient with a potassium imbalance.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME FIVE Discuss different laboratory values for calcium imbalances. What symptoms might the patient display?

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME FIVE Assign students to care for a patient with a calcium imbalance.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME SIX Discuss different laboratory values for magnesium imbalances. What symptoms might the patient display?

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME SIX Assign students to care for a patient with a magnesium imbalance. .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME SEVEN Discuss different laboratory values for phosphate imbalances. What symptoms might the patient display?

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME SEVEN Assign students to care for a patient with a phosphate imbalance.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME EIGHT Have a respiratory therapist to speak to the class on how to interpret arterial blood gas results.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME EIGHT Assign students to care for patients requiring arterial blood gas sampling and result interpretation.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME NINE Provide a case study highlighting lung or kidney compensation of an acid base imbalance.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME NINE Ask students to shadows the multidisciplinary team as they complete rounds on the unit. Ask students to identify patients diagnosed during rounds that are at risk for acid–base imbalances.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter 11 Nursing Care of Patients Experiencing Trauma and Shock Learning Outcomes 1. Outline the components and types of trauma and the effects of traumatic injury on the body.

2. Describe the pathophysiology and manifestations of traumatic injury, and outline the interprofessional care, nursing care, and transitions of care for patients experiencing trauma.

3. Outline the pathophysiology of the different types of shock and the effects of shock on body systems.

4. Describe the pathophysiology and manifestations of shock, and outline the interprofessional care, nursing care, and transitions of care for patients with shock.

Key Concepts I.

Traumatic injury A. Trauma: Injury to human tissues and organs resulting from the transfer of energy from the environment B. Components of trauma 1. Factors influencing person’s potential for injury: Age, sex, race, economic status, preexisting illnesses, and use of substances such as street drugs and alcohol a) Host: Person or group at risk of injury b) Mechanism: Source of the energy transmitted to host c) Energy: Mechanical, gravitational, thermal, electrical, physical, or chemical 2. Intention 3. Environment: Weather, occupation, and social environment 4. Assessing intimate partner violence (IPV) 5. Violence directed at the elderly a) Elder abuse: Anything that endangers the life of an elderly person C. Types of trauma 1. Minor trauma: Injury to a single part or system of the body 2. Major or multiple trauma: Serious single-system injury or multiple-system injuries 3. Blunt trauma: No communication between damaged tissues and outside environment 4. Penetrating trauma: Foreign object enters the body, causing damage to body structures 5. Inhalation injuries: From gases, smoke, or steam 6. Burn or freezing injuries 7. Blast injuries (from explosions)

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

8. Classification of trauma patients based on mechanism of injury, vehicle speed, height of falls, location of penetrating injuries a) Class 3: Least severe b) Class 2: c) Class 1: Life-threatening injuries likely to require medical specialists or immediate surgical intervention D. Effects of traumatic injury 1. Categories of death from time span between injury and death: Immediate, early, and late 2. Head and neck effects—airway obstruction a) Determine airway patency b) Identify any potential obstruction from tongue, loose teeth, foreign bodies, bleeding, secretions, vomitus or edema c) Assessment of breathing effectiveness d) Closed head injury (1) Maintain adequate cerebral perfusion pressure by minimizing changes in hemodynamics, oxygenation, and ventilation (2) Maintain PaCO2 of 30–35 mmHg e) Maxillofacial trauma (1) Method: Surgical airway may be only alternative f) Direct airway trauma (1) Airway involvement: Dyspnea, cyanosis, subcutaneous emphysema, hoarseness, or air bubbling from the wound (2) Method: Orotracheal intubation with rapid sequence intubation g) Cervical spine injury (1) Method: Oral intubation with manual in-line axial head and neck stabilization (MILS) (2) Criteria for decreased probability of C-spine injury (a) Absence of midline cervical spine tenderness (b) Normal alertness (c) Absence of intoxication (d) Absence of a painful distracting injury (e) No focal neurologic defects h) Burns (1) Secure airway sooner than later 3. Thoracic effects a) Tension pneumothorax: Results when air enters potential space between parietal and visceral pleura (1) Life threatening, requires immediate intervention (2) Signs and symptoms (a) Severe respiratory distress .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

4.

5.

6.

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(b) Hypotension (c) Jugular vein distension (d) Tracheal deviation toward uninjured side (e) Cyanosis (3) Intervention: Needle thoracostomy b) Flail chest: Fracture of two or more ribs in two or more separate locations (1) Impacted area must be supported to reestablish thoracic bellows effect c) Thoracic contusion and rupture: Bruising of thoracic tissue (1) Diaphragmatic rupture: Rare traumatic injury (2) Myocardial contusion: Result of extravasation of red blood cells into myocardial fibers (3) Cardiac tamponade: Blood or fluid collects in pericardial sac (4) Aortic rupture (transection): Can result in acceleration–deceleration injury or blunt chest trauma Hemorrhage a) External hemorrhage: Control bleeding by applying direct pressure over wound and arterial pressure points b) Internal hemorrhage: Results from blunt or penetrating traumatic injury (1) Third spacing: Potential spaces in body that can accommodate large amounts of blood to accumulate (2) Interventions: Operative control of bleeding and continual assessment of patient Integumentary effects a) Specific injuries to integument (1) Contusions: Superficial tissue injuries resulting from blunt trauma (2) Abrasions: Denudations of an area of integument from falls or scrapes (3) Puncture wounds: From sharp or blunt object penetrating integument (4) Lacerations: Open wounds resulting from sharp cutting or tearing (5) Full thickness avulsion injuries: Loss of all layers of skin, fat and muscle exposed b) Treatment: Allow new skin to grow from edges, stitch wound together, reattach avulsed skin, skin grafting Abdominal effects a) Effects of direct trauma to abdomen (1) Lacerate and compress solid organs, causing burst injuries to hollow organs (2) Blood vessels torn and organs displaced from blood supply, causing hemorrhage (3) Damage to mesenteric vessels can result in bowel ischemia and infarction b) Effects of injury to stomach, pancreas, and small bowel (1) Digestive enzymes may leak into abdominal cavity c) Effects of injury to large bowel (1) Escape of feces, causing peritonitis Musculoskeletal effects a) Usually not high priority unless life- or limb-threatening

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

b) May provide clues to presence of other serious injuries 8. Neurologic effects a) Head injuries are the most common type of injuries sustained as the result of trauma b) Sources of head and spinal cord injuries: Car crashes, falls, sports injuries, and assault 9. Multiple organ dysfunction syndromes (MODS) a) Progressive impairment of two or more organ systems b) Patients at risk are those with disturbance in homeostasis resulting from following: (1) Infection, injury, inflammation, ischemia, immune response, intoxication of substances, iatrogenic factors c) Primary organ systems involved in MODS: Respiratory, renal, hepatic, hematologic, cardiovascular, gastrointestinal, and neurologic d) Therapies: Surgical intervention, antibiotic administration, corticosteroid administration, or correction coagulopathies 10. Effects on the family a) Suddenness and seriousness of the event may lead to psychologic crisis b) Some ERs allow families to be present during resuscitation II.

The Patient Experiencing Trauma A. Interprofessional care 1. Team approach with prompt delegation of tasks and responsibilities improves chances for survival B. Prehospital care 1. Injury identification a) Injuries in need for trauma center care: Penetrating injuries to abdomen, pelvis, chest, neck, or head; spinal cord injuries with deficit; crushing injuries to the abdomen, chest, or head, major burns, injuries leading to airway compromise or obstruction b) Scoring systems: Trauma and Injury Severity Score (TRISS), Glasgow Coma Scale c) Primary trauma assessment (1) A: Airway assessment (2) B: Breathing evaluation for spontaneous respirations or ventilatory impedance (3) C: Circulatory assessment to palpate peripheral and central pulses; assess capillary refill, skin color, temperature; identify external sources of bleeding (4) D: Disability and refers to neurovascular status (5) E: Expose/environment d) Secondary assessment - “SAMPLE” mnemonic (1) S: Signs/symptoms (2) A: Allergies (3) M: Medications (4) P: Pertinent past medical history (5) L: Last oral intake (last menstrual period for women of childbearing age)

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(6) E: Events leading up to the injury 2. Critical interventions a) On-the-scene interventions: Life support, immobilize cervical spine, manage airway, and treat hemorrhage and shock 3. Rapid transport a) Ground ambulance or air ambulance (specially staffed and equipped helicopters) C. Emergency department care 1. Diagnosis—tests ordered depend on type of injury a) Blood type and crossmatch b) Complete blood count c) Arterial blood gas d) Blood alcohol levels e) Urine drug screen f) Pregnancy test g) Focused assessment by sonography in trauma (FAST) h) Computerized tomography (CT) i) Magnetic resonance imaging (MRI) 2. Medications a) Blood components and crystalloids: Treat traumatic shock b) Inotropic drugs: Increase cardiac output and improve tissue perfusion c) Vasopressors: Treat neurogenic, septic, and anaphylactic shock d) Opioids: Treat pain e) Immunization: In the case of penetrating and open wounds (tetanus immunization status must be determined) 3. Blood transfusions a) May be whole blood, packed red blood cells (RBCs), platelets, plasma, albumin, clotting factors, prothrombin, or cryoprecipitate b) Four blood types: A, B, AB (universal recipient), and O (universal donor) c) A type and crossmatch: Determine donor and recipient ABO types and Rh groups d) Reactions to transfusions (1) Febrile reaction: Antibodies within the patient receiving blood are directed against the donor’s white blood cells, causing fever and chills (2) Hypersensitivity: Antibodies in blood react against proteins in donor blood (3) Hemolytic reaction: Results from an ABO incompatibility e) Other risks: Circulatory overload, electrolyte imbalances, and infectious diseases f) Autotransfusion: A method of blood administration in which special equipment collects and returns the patient’s own blood 4. Emergency surgery a) Needed when patient remains in shock despite resuscitation and no obvious external sign of blood loss .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

b) Methods to identify source of blood loss: Abdominal and chest x-rays, ultrasound studies, diagnostic peritoneal lavage, or CT scan 5. Forensic considerations a) Identify, store, and properly transfer potential evidence for medical–legal investigations b) Clothing removed and placed in breathable container c) Bullets or knives labeled and given to proper authorities d) Holes in clothing should not be disturbed e) In case of death, paper bags placed over hands if presence of evidence suspected f) Evidence collected by nail clippings g) Identify all wounds and document h) Chain of custody maintained D. Nursing care 1. Assessment a) Priorities of care (1) Ensure adequate treatment of underlying injury while providing oxygenation and perfusion (2) Teach patient/caregivers strategies to prevent injuries and optimize home and work environments (3) Focus on promoting comfort and maintaining asepsis for all interruptions of integument 2. Diagnoses, outcomes, and interventions a) Manage airway clearance (1) Assess if airway is patent, maintainable, or unable to be maintained (2) Assess for manifestations of airway obstruction (3) Monitor oxygen saturation by applying pulse oximeter (4) Monitor level of consciousness b) Reduce risk for infection (1) Use careful hand hygiene practices (2) Use strict standard precautions and aseptic techniques when caring for wounds (a) Monitor wounds for odor, redness, heat, swelling, and copious or purulent drainage (b) Monitor hidden wounds, observe for increased drainage and heat (c) Ensure cross-contamination between wounds does not occur; collect drainage in ostomy bags if copious (3) Take and record vital signs, including temperature, every 2–4 hours (4) Provide adequate fluids and nutrition (5) Assess for manifestations of gas gangrene (6) Assess for development of life-threatening conditions (necrotizing fasciitis)

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(7) Assess status of tetanus immunization and administer tetanus toxoid or human toxin–antitoxin (TAT) as prescribed (8) Use strict aseptic technique when inserting catheters, suctioning, administering parenteral medications, or other invasive procedures c) Promote physical mobility (1) High-risk patients: Multiple injuries, spinal cord injuries, peripheral nerve injuries, and traumatic amputations (2) If active bleeding or edema is not present, provide active or passive exercises to extremities once every 8 hours (3) Help patient turn, cough, deep breathe; use incentive spirometer at least every 2 hours (4) If the patient is unable to be moved, consider specialty bed (5) Monitor lower extremities for manifestations of deep vein thrombosis d) Measure and record circumference of thigh and calf each day (1) Antiemboli stockings or intermittent compression stockings: Remove for 1 hour during each shift and assess skin e) Help manage feelings of grief and loss (1) Offer referral to spiritual advisor if needed (2) Give family information about option to donate organs (3) Encourage family to ask questions and express feelings (4) Refer family for follow-up care f) Teach coping strategies (1) Assess emotional responses while providing physical care (2) Be available if patient wishes to talk about trauma, and encourage expression of feelings (3) Teach relaxation techniques (4) Refer patient and family members for counseling, psychotherapy, or support groups g) Delegating nursing care activities E. Transitions of care 1. Educate on health promotion and trauma prevention a) Motor vehicle safety b) Home safety c) Farm safety d) Work safety e) Relationships f) Communities 2. Prepare patient and family for home care a) Type of home environment, including changes required to let patient function b) Medications, dressings, wound care, equipment, and supplies .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

c) Special diet, if needed d) Rehabilitation plan and effect on patient’s family e) Follow-up appointments with physician or at trauma clinic f) Emotional changes that the patient may undergo as a result of trauma g) Helpful resources: Home health care, community support groups, National Institute of Neurological Disorders and Stroke 3. Organ donation a) Uniform Anatomical Gift Act: Requires that people are informed about options for organ donation b) Exceptions for potential organ donors (1) Currently abuse intravenous drugs (2) Have preexisting untreated infections, such as septicemia (3) Have any malignancy other than a primary brain tumor (4) Have active tuberculosis III.

Shock A. Overview of cellular homeostasis and hemodynamics 1. Physiologic components of homeostatic regulation a) Cardiac output sufficient to meet bodily requirements b) Uncompromised vascular system c) Volume of blood sufficient to fill circulatory system and blood pressure adequate to maintain blood flow d) Tissues that are able to extract and use oxygen delivered through capillaries 2. Basic hemodynamics a) Stroke volume (SV) b) Cardiac output (CO): CO = SV × HR (heart rate) c) Systemic vascular resistance (SVR) d) Mean arterial pressure (MAP): MAP = [(2x diastolic BP) + systolic BP] / 3 e) Sympathetic tone: Partial contraction maintained by nervous system around smooth muscle surrounding arteries and arterioles B. Pathophysiology 1. Shock: Triggered by sustained drop in mean arterial pressure 2. Stage I: Early, reversible, and compensatory shock a) Compensatory shock: Begins after MAP falls 10–15 mmHg below normal b) Compensatory mechanisms to maintain MAP for short period (1) Stimulation of sympathetic nervous system results in release of epinephrine and norepinephrine (2) Rennin–angiotensin response (3) Hypothalamus releases adrenocorticotropic hormone (ACTH) (4) Posterior pituitary gland releases antidiuretic hormone (ADH)

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(5) Decreased capillary hydrostatic pressure causes fluid shift from interstitial space into the capillaries 3. Stage II: Intermediate or progressive shock a) Progressive stage occurs after sustained decrease in MAP of 20 mmHg or more below normal and a fluid loss of 35–50% b) Cells switch from aerobic to anaerobic metabolism c) ATP produced inefficiently, causing sodium–potassium pump to fail d) Acid byproducts of anaerobic metabolism dilate precapillary arterioles, constrict postcapillary venules e) Heart rate and vasoconstriction increase f) Perfusion of skin, muscles, kidneys, and gastrointestinal organs diminishes g) Generalized state of acidosis and hyperkalemia ensues 4. Stage III: Refractory or irreversible shock a) Tissue anoxia, cellular death so widespread that treatment cannot reverse process b) Results in death C. Effects of shock on body systems 1. Cardiovascular system a) Myocardial cells become hypoxic and myocardial muscle function diminishes b) Sympathetic stimulation increases heart rate c) Palpated pulse is rapid, weak, and thready d) Tachycardia reduces time available for left ventricular filling and coronary artery perfusion; cardiac output reduced e) Progressive shock: Damage to heart’s electrical systems and contractility f) Decreased blood volume with decreased venous return causes decreased cardiac output, fall in blood pressure g) Progressive decrease in systolic and diastolic pressures, narrowing pulse pressure 2. Respiratory system a) Impaired oxygen delivery to cells b) Respiratory rate increases, number of alveoli that are perfused decreases, and gas exchange impaired c) Oxygen levels in blood decrease and carbon dioxide levels increase; respiratory acidosis occurs d) Acute respiratory distress syndrome (ARDS) 3. Gastrointestinal and hepatic systems a) Splanchnic arterioles constrict, arterial blood flow redirected to heart and brain b) Gastrointestinal organs become ischemic c) Lesions of gastric and duodenal mucosa develop d) Permeability of damaged mucosa increases, may result in sepsis e) Gastric and intestinal motility impaired and may result in paralytic ileus f) Necrosis of the bowel .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

g) Initial increase in gluconeogenesis and glycogenolysis h) Liver functions impaired as shock progresses; hypoglycemia develops i) Metabolic acidosis develops j) Liver’s reticuloendothelial Kupffer cells destroyed 4. Neurologic system a) Changes in mental status and orientation b) Cerebral hypoxia c) Continued ischemia of brain cells causes swelling, cerebral edema, neurotransmitter failure, and irreversible brain cell damage d) Loss of sympathetic tone from worsening of cerebral ischemia 5. Renal system a) Blood shunted to heart and brain, resulting in renal hypoperfusion b) Drop in renal perfusion and decrease in glomerular filtration rate c) Urine output is reduced and highly concentrated d) Acute tubular necrosis develops e) Renal failure, metabolic waste products retained in plasma 6. Effects on skin, temperature, and thirst a) Blood vessels supplying skin are vasoconstricted and the sweat glands are activated b) Skin color, lips, oral mucous membranes, nail beds, and conjunctiva become pale c) Skin is usually cool and moist d) Body temperature decreases e) People become thirsty due to decreased blood volume and increased serum osmolality D. Types of shock 1. Hypovolemic shock: Decrease in intravascular volume of 15% or more a) Most common type of shock b) Hypovolemic triggered from the following: (1) Loss of blood volume from hemorrhage (2) Loss of intravascular fluid from the skin due to injuries such as burns (3) Loss of intravascular volume from severe dehydration (4) Loss of body fluid from gastrointestinal system due to persistent and severe vomiting or diarrhea, or continuous nasogastric suctioning (5) Renal losses of fluid due to use of diuretics or to endocrine disorders (6) Conditions causing fluid shifts from the intravascular compartment to the interstitial space (7) Third spacing due to disorders such as liver diseases with ascites, pleural effusion, or intestinal obstruction c) Manifestations of an initial stage (1) Blood pressure: Normal to slightly decreased (2) Pulse: Slightly increased from baseline (3) Respirations: Normal or at baseline .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(4) Skin: cool, pale in periphery, and moist (5) Mental status: Alert and oriented (6) Urine output: Slight decrease (7) Other: Thirst, decreased capillary refill time d) Compensatory and progressive stage (1) Blood pressure: Hypotension (2) Pulse: Rapid, thread (3) Respirations: Increased (4) Skin: cool, pale; poor turgor with fluid loss, edematous with fluid shift (5) Mental status: Restless, anxious, confused, and agitated (6) Urine output: Oliguria (less than 30 mL/h) (7) Other: Marked thirst, acidosis, hyperkalemia, decreased capillary refill time, and decreased or absent peripheral pulses e) Irreversible stage (1) Blood pressure: severe hypotension (2) Pulse: Very rapid and weak (3) Respirations: Rapid, shallow; crackles and wheezes (4) Skin: Cool, pale, and mottled with cyanosis (5) Mental status: Disoriented, lethargic, or comatose (6) Urine output: Anuria (7) Other: Loss of reflexes and decreased or absent peripheral pulses f) Older adults experiencing hypovolemia (1) Cardiac compliance decreases with age (2) Secondary volume depletion due to chronic diuretic use or malnutrition (3) Patients prescribed with beta blockers may not present with tachycardia 2. Cardiogenic shock: Heart’s pumping ability compromised to the point that it cannot maintain cardiac output and adequate tissue perfusion a) Loss of pumping action may be caused by: (1) Myocardial infarction (most common cause) (2) Cardiac tamponade (3) Restrictive pericarditis (4) Cardiac arrest (5) Dysrhythmias (fibrillation or ventricular tachycardia) (6) Pathologic changes in valves (7) Cardiomyopathies from hypertension, alcohol, bacterial or viral infections, or ischemia (8) Complications of cardiac surgery (9) Electrolyte imbalances (10) Drugs affecting cardiac muscle contractility (11) Head injuries causing damage to the cardioregulatory center

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

3.

4.

5.

6.

b) Cyanosis due to stagnating blood increasing extraction of oxygen from hemoglobin at capillary beds c) Manifestations (1) Blood pressure: Hypotension, possible narrowing pulse pressures (2) Pulse: Rapid, thready; distention of veins of hands and neck (3) Respirations: Increased, labored; crackles and wheezes; pulmonary edema (4) Mental status: Restless, anxious, and lethargic progressing to comatose (5) Other: Dependent edema, elevated CVP; elevated pulmonary capillary wedge pressure; and arrhythmias Obstructive shock: Obstruction in heart or great vessels that either impedes venous return or prevents effective cardiac pumping action a) Causes: Impaired diastolic filling, increased right ventricular afterload, and increased left ventricular afterload Distributive shock (vasogenic shock): Results from widespread vasodilatation and decreased peripheral resistance Septic shock a) Result of gram-negative or gram-positive bacterial infections b) At-risk patients: Hospitalized people, those with debilitating chronic illnesses, those with poor nutritional status, older adults, and immunocompromised c) Ports of entry: Urinary system, respiratory system, gastrointestinal system, integumentary system, and female reproductive system d) Begins with septicemia: Cardiac output is high, systemic vascular resistance is low e) Monitor for condition changes (1) Changes in respiratory function needing increase in FiO2 requirements (2) Decrease in blood pressure (3) Decrease in urine output (4) Changes in coagulation (5) Changes in mentation (6) Potential changes in liver function (7) Potential changes in G.I. function f) Disseminated intravascular coagulation (DIC) (1) Simultaneous bleeding and clotting throughout the vasculature Neurogenic shock: Result of an imbalance between parasympathetic and sympathetic stimulation of vascular smooth muscle (1) Causes dramatic reduction in systemic vascular resistance as the size of vascular compartment increases (2) Conditions that can cause neurogenic shock (a) Head injury (b) Trauma to spinal cord (c) Insulin reactions (d) Central nervous system depressant drugs

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(e) Anesthesia (f) Severe pain (g) Prolonged exposure to heat (3) Early stages: Extremities warm and pink (4) Late stages: Skin pale in cool (5) Manifestations: (a) Blood pressure: Hypotension (b) Pulse: Slow and bounding (c) Respirations: Vary (d) Skin: Warm, dry (e) Mental status: Anxious, restless, lethargic progressing to comatose (f) Urine output: Oliguria to anuria (g) Other: Lower body temperature 7. Anaphylactic shock: Result of widespread humorally mediated hypersensitivity reaction (anaphylaxis) a) Pathophysiology: Vasodilatation, pooling of blood in periphery, hypovolemia with altered cellular metabolism b) Causes: Allergens, medications, blood administration, latex, foods, snake venom, and insect stings c) Manifestations: (1) Blood pressure: hypotension (2) Pulse: Increased, dysrhythmias (3) Respirations: Dyspnea, stridor, wheezes, laryngospasm, bronchospasm, and pulmonary edema (4) Skin: Warm and edematous (5) Mental status: Restless, anxious, and lethargic to comatose (6) Urine output: Oliguria to anuria (7) Other: Parethesias; urticarial; pruritus; abdominal cramps, vomiting, and diarrhea IV.

The Patient Experiencing Shock 1. Interprofessional care 2. Diagnosis a) Blood hemoglobin and hematocrit: Detect concentration that occurs in hypovolemic shock b) Arterial blood gases (ABGs): Determines oxygen and carbon dioxide levels and pH c) Serum electrolytes: Monitor severity and progression of shock d) Blood urea nitrogen (BUN), serum creatinine levels, urine specific gravity, and osmolality: Check renal function e) Blood cultures: Identify causative organism in septic shock

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

f) White blood cell count and differential: In patient with septic or anaphylactic shock g) Serum cardiac enzymes: Elevated in cardiogenic shock h) X-ray studies, computerized tomography (CT) scans, magnetic resonance imaging (MRI), endoscopic examinations, and echocardiograms i) Newer diagnostic methods for hypoperfusion (1) Gastric tonometry and sublingual PCO2 3. Medications a) Vasoactive and inotropic drugs used when fluid replacement is not enough b) Drugs used to treat shock (1) Diuretics to increase urine output (2) Sodium bicarbonate to treat acidosis (3) Calcium to replace calcium lost as a result of blood transfusions (4) Antiarrhythmic agents to stabilize heart rhythm (5) Broad-spectrum antibiotics to suppress organisms responsible for septic shock (6) Epinephrine, antihistamines, and inhaled beta-2 agonists to treat anaphylactic shock 4. Oxygen therapy a) All patients in shock should receive oxygen therapy to maintain PaO2 at greater than 80 mmHg during first 4 to 6 hours 5. Fluid resuscitation a) Most effective treatment for patients in hypovolemic shock b) Also can treat septic and neurogenic shock c) Cardiac shock may require fluid replacement or restriction d) Crystalloid solutions (1) Contain dextrose or electrolytes dissolved in water (a) Hypertonic, isotonic, and hypotonic (b) Ringer’s lactate: Electrolyte solution e) Colloid solutions (1) Contain substances (colloids) that should not diffuse through capillary walls (a) 5% albumin, 25% albumin, hetastarch, plasma protein fraction, and dextran f) Blood and blood products (1) Fresh whole blood, stored whole blood, packed red blood cells, platelet concentrate, fresh-frozen plasma, and cryoprecipitate (2) Used if hypovolemic shock is due to hemorrhage 6. Nursing care a) Assessment (1) Older adults considered high-risk population .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(2) Hypovolemic shock (a) Most at risk: Patients who have undergone surgery, have sustained multiple traumatic injuries, or have been seriously burned (b) Preventive nursing care: Monitor fluid status (c) Assessments for critically ill: Fluid balance, hemodynamic values, and vital signs (3) Cardiogenic shock (a) Most at risk: Patients with left anterior wall myocardial infarctions (b) Preventive nursing care: Maintain or improve myocardial oxygen supply (4) Neurogenic shock (a) Most at risk: Patients who have spinal cord injuries and those who have received spinal anesthesia (b) Preventive nursing care: Maintain immobility of patients with spinal cord trauma, elevate bed 15–20 degrees (5) Anaphylactic shock (a) Preventive nursing care: Collect information about allergies and drug reactions during health history; careful assessments during blood administration (6) Septic shock (a) Most at risk: Patients who are hospitalized, debilitated, or chronically ill, and those who have undergone invasive procedures or tube insertions (b) Preventive nursing care: Careful hand hygiene, use of aseptic techniques for procedures, and monitoring for local and systemic manifestations of infection b) Priorities of care c) Diagnoses, outcomes, and interventions (1) Maintain cardiac output (a) Assess and monitor blood pressure, heart rate and rhythm, pulse oximetry, peripheral pulses (b) Hemodynamic monitoring of arterial pressures, pulmonary artery pressures, and central venous pressures (CVPs) (c) Measure and record intake and output hourly (d) Monitor bowel sounds, abdominal distention, and abdominal pain (e) Monitor for sudden, sharp chest pain, dyspnea, cyanosis, anxiety, and restlessness (f) Maintain bed rest and provide a calm, quiet environment (2) Promote adequate tissue perfusion (a) Monitor skin color, temperature, turgor, and moisture

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(b) Monitor cardiac function: Blood pressure, rate and depth of respirations, lung sounds, pulse oximetry and arterial blood gases, peripheral pulses, jugular vein distention, and CVP measurements (c) Monitor body temperature (d) Monitor urinary output (e) Assess mental status and level of consciousness (3) Manage anxiety (a) Assess cause(s) of anxiety and manipulate the environment to provide periods of rest (b) Administer prescribed pain medications on regular basis and implement any applicable nonpharmacologic comfort measures (c) Provide interventions to increase comfort and reduce restlessness (d) Provide support for patient and family (e) Provide information about the current setting to both the patient and family; give the family information about available resources d) Transitions of care (1) Assessment findings for shock vary in older adults (a) Decreased stroke volume and cardiac output (b) Decreased arterial wall elasticity and vasomotor tone (c) Decreased elasticity and turgor of the skin (d) Previous medication and blood administration increased risk of anaphylactic shock (e) Decreased immune response

Chapter Highlights A. Trauma is defined as injury to human tissues and organs resulting from the transfer of energy from the environment. Energy sources can be mechanical, gravitational, thermal, electrical, physical, or chemical.

B. Trauma types include minor trauma, which causes minimal damage to underlying tissues, or major/multiple trauma, which involves at minimum a serious single-system injury or multiple trauma. Trauma can also be categorized as blunt and penetrating trauma. Blunt trauma is caused by forces like deceleration, acceleration, shearing, compression, or crushing. Penetrating trauma is the entrance of a foreign object into the body.

C. Maintenance of the airway and cervical spine is the highest priority in the trauma patient, with airway assessment superseding all other interventions.

D. The primary assessment conducted by the nurse identifies all life-threatening injuries and the performance of appropriate interventions. The secondary assessment is when the nurse identifies all injuries in order to prioritize care.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

E. Shock is a clinical syndrome characterized by a systemic imbalance between oxygen supply and demand. This imbalance results in a state of inadequate blood flow to body organs and tissues, causing life-threatening cellular dysfunction.

F. The symptoms of shock arise from the body’s attempts to maintain vital organs (heart and brain) and to preserve life following a drop in oxygen delivery to the cells.

G. An important early sign of shock is a change in the level of consciousness, with restlessness a common symptom of cerebral hypoxia.

H. Shock is defined in three stages: Compensatory (stage 1), an early and reversible stage; progressive (stage 2), where the affected cells switch from aerobic to anaerobic metabolism in order to stay alive; and the final stage, refractory/irreversible (stage 3), where tissue anoxia and death becomes widespread.

I. Hypovolemic shock is the most common type of shock and is caused by a decrease in circulating blood volume by 15% or greater.

J. Cardiogenic shock is caused when the pumping ability of the heart is compromised to the point where adequate cardiac output cannot be maintained.

K. Obstructive shock is caused by an obstruction in the heart or great vessels that either impedes venous return or prevents effective cardiac pumping action. Causes can include cardiac tamponade, pneumothorax, pulmonary embolism, and aortic stenosis.

L. Distributive shock includes several types of shock that result from widespread vasodilatation and decreased peripheral resistance. As the blood volume does not change, relative hypovolemia results, leading to altered cellular metabolism. Examples of distributive shock include septic, neurogenic, and anaphylactic shock.

M. Septic shock is part of a progressive syndrome called systemic inflammatory response syndrome (SIRS), a condition most commonly caused by gram-negative infections.

N. Anaphylactic shock is caused by a fulminating hypersensitivity reaction to a foreign substance.

O. Maintaining adequate intravascular volume is the most important aspect in the care of a patient whose experiencing shock.

P. Supplemental oxygen is required.

Q. Monitoring of vital signs and patient condition for subtle changes is important.

SUGGESTIONS FOR CLASSROOM ACTIVITY—LEARNING OUTCOME ONE Using the internet, research the types of trauma that cause deaths in the different age groups.

Discuss findings in class.

Separate students into small groups. Ask the students to either list the types of penetrating trauma and instruments that are used in penetrating trauma or list objects that are used in blunt trauma.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME ONE Assign students to care for patients with fluid deficits, including preoperative patients, postoperative patients, and patients with nausea and vomiting.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME TWO Discuss methods to encourage a patient with a fluid deficit to increase fluid intake.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME TWO Assign students to care for a patient experiencing trauma in the Intensive Care Unit.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME THREE Break students into small groups. Have each group write a short synopsis of each type of shock.

Share synopsis with class.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME THREE Assign students to care for a patient with a sodium imbalance.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME FOUR Work with students to develop a care plan for a patient in shock. Repeat this activity for all individual types of shock.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME FOUR Assign students to work in the Emergency Department caring for patients experiencing shock.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter 12 Nursing Care of Patients with Infections and Inflammation Learning Outcomes 1. Explain the components and functions of the immune system and the immune response.

2. Outline the process of acquired immunity and the importance of immunizations and isolation precautions in preventing disease.

3. Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions.

Key Concepts I. Overview of the Immune System and Inflammation A. Innate immunity: Natural barriers of the body to infection and injury; nonspecific, generic response to harmful events B. Adaptive immune response: Develops over a person’s lifetime; more specific response activated when inflammatory process is unable to destroy invading organisms or toxins C. Immune system components 1. Leukocytes: White blood cells (WBCs); primary cells involved in both innate and adaptive immune system responses Margination: Adhesion of leukocytes to vascular epithelial cells along the vessel walls, in other tissue spaces, or in the lymph system Leukocytosis: WBC count of greater than 10,000/mm3 Leukopenia: Occurs when bone marrow activity is suppressed or when leukocyte destruction increases 3 major groups of leukocytes (1) Granulocytes: Derive from myeloid stem cells of bone marrow; instrumental in inflammatory response (a) Neutrophils (polymorphonuclear leukocytes, PMNs or polys): Phagocytic cells produced in bone marrow; responsible for destroying foreign agents (i) Segmented neutrophils (segs): Mature forms (ii) Bands: Immature neutrophils (b) Eosinophils: Phagocytic cells found in respiratory and gastrointestinal tracts (c) Basophils: Contain proteins and chemicals; released into bloodstream during acute hypersensitivity reaction or stress response (2) Monocytes, macrophages, and dendritic cells .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(a) Recognize foreign matter and initiate an immune response (b) Monocytes: Derive from myeloid stem cells of bone marrow; instrumental in inflammatory response; mature into monocytes (i) Types: Histiocytes, Kupfer cells, alveolar macrophages, microglia (ii) Dendritic cells: Intermediaries between innate and adaptive immune (c) Monocytes, macrophages, dendritic cells: Mediators of immunity; antigen-presenting cells (APCs) which activate immune responses in B, T lymphocytes (3) Lymphocytes (a) Principal effector and regulator cells of specific immune responses (b) Derive from lymphoid stem cells of bone marrow; primary cells involved in specific immune response (c) Types: T lymphocytes (T cells), B lymphocytes (B cells), natural killer cells (NK cells) 2. Antigens: Substances the immune system recognizes as foreign or “nonself” Immunogens: Complete antigens (1) Immunogenicity: Ability to stimulate specific immune response (2) Specific reactivity: Stimulation of specific immune system components Antibodies: Molecules that bind with antigen and inactivate it (1) Two separate but overlapping immune responses (a) Antibody-mediated (humoral) immune response (i) 5 Classes of antibodies make up this response: IgG, IgA, IgM, IgD, IgE (b) Cell-mediated (cellular) immune response (i) Intracellular pathogens are primary agents of this response in which lymphocytes inactivate antigen directly or indirectly 3. Lymphoid system Lymph nodes (1) Occur in groups at junction of lymphatic vessels (2) Filter foreign products or antigens from lymph and then house and support proliferation of lymphocytes and macrophages (3) Lymph: Clear, protein-containing fluid transported within lymph vessels Spleen (1) Largest lymphoid organ, only one that can filter blood (2) Types of tissue: White pulp, red pulp (3) Stores blood and the breakdown products of RBCs for future use Thymus gland (1) Fetal life—childhood: Serves as site for maturation and differentiation of thymic lymphoid cells (T cells) (2) Thymosin stimulates lymphopoiesis Bone marrow .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Soft organic tissue found in hollow cavity of long bones (2) Produces and stores hematopoietic stem cells Tonsils and adenoids (1) Protect from inhaled or ingested foreign pathogens Lymphoid tissue in connective tissues and mucosa (1) Located in submucosa of genitourinary, respiratory, gastrointestinal tracts and the skin (2) Mucosa-associated lymphoid tissue (MALT): Defends body against bacterial invasion at areas exposed to external environment (3) Gut-associated lymphoid tissue (GALT or Peyer’s patches): Processes common intestinal antigens without producing acute inflammatory responses D. Innate immune response and information 1. First line of defense against infection 2. Nonspecific, includes skin and mucosal barriers, vascular and cellular responses, phagocytosis 3. Inflammation: Response to injury that brings fluid, dissolved substances, and blood cells to interstitial tissues where invasion or damage has occurred Two stages: Vascular response and cellular response Vascular response (1) Vasodilation of capillary arterioles and venules (2) Inflammatory mediators released (i) Vasoactive substances, chemotactic factors, plasma enzymes, miscellaneous cell products (3) Vasocongestion at injury site (4) Fluid exudate escapes from capillaries into interstitial spaces of tissue (5) Fibrinous exudate forms meshwork of fibrinogen (6) Histamine: Causes vasodilation and vascular permeability in affected area (7) Prostaglandins: Chemotactic substances that draw leukocytes to inflamed tissue (8) Plasma proteases: Activate clotting cascade, kinin system, complement system Cellular response (1) Marked by changes in lining of blood vessels and movement of phagocytic blood cells into damaged tissue (2) Margination occurs (3) Leukocytes emigrate into area of inflammation; drawn to damaged or inflamed tissues by chemotactic signals (4) Neutrophils increase around site (5) Monocytes become transient macrophages 4. Phagocytosis: Process by which foreign agent or target cell is recognized, engulfed, and destroyed

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Factors that help phagocytes differentiate foreign tissue from normal cells: Smooth surface, surface charge, opsonization Phagosome: Chamber containing the antigen, which is ingested into cytoplasm Lysomes fuse with phagosome, release antibacterial molecules (defensins) and digestive enzymes to destroy antigen Neutrophils are destroyed and ingested by macrophages once they have ingested toxic substances to capacity 5. Healing Debridement: Process that prepares wound for healing Reconstruction: Second phase of healing process Resolution: Restoration of original structure and function of damaged tissue Regeneration (1) Labile cells: Continue to regenerate throughout life (2) Stable cells: Stop replicating when growth ceases; capable of regeneration when stimulated by injury (3) Permanent or fixed cells: Unable to regenerate Repair: Regeneration and complete resolution not possible; destroyed tissue replaced with collagen scar tissue E. Adaptive immune response: More specific reaction to introduction of antigens 1. Distinctive properties of immune response Self-recognition—Directed against materials recognized as foreign Systemic—Not restricted to initial site of infection or entry foreign tissue Memory—More rapid response to repeat exposures to an antigen 2. Immunocompetent: Patient whose immune system is able to identify antigens and effectively destroy them 3. Antibody-mediated immune response Produced by B lymphocytes (B cells) Immunoglobulin (Ig) molecule: Antibody with the ability to bind and inactivate a specific antigen Antibodies: Y-shaped molecules with two light and two heavy polypeptide chains (1) Fab or antigen-binding fragment: Top portion of Y (2) Fc or crystallized fragment: Lower portion of Y Antibodies produced by B cells inactivate antigen through the following processes: (1) Cover antigen with antibodies to attract phagocytes (2) Precipitation (3) Neutralization (4) Complement activation and fixation to antigenic cell surface leading to cell lysis (5) Agglutination (clumping) of insoluble antigens to form large complex (6) Opsonization

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Secondary response: Elicited from subsequent exposure to same antigen due to the formation of memory cells during primary response 4. Cell-mediated immune response T-cells— (1) Initiated by T cells (2) Two major populations of T cells: CD4, CD8 cells (3) Antigen-specific clones: Formed from dividing T cells (a) Cytotoxic T cell (Tc cell): Seeks out and destroys abnormal cells and cells harboring anything foreign (b) Helper T cells (Th cells): Coordinate immune responses to antigen (c) Suppressor T cells (Ts cells): Regulators of immune response Cytokines: Soluble protein important in amplifying innate immunity and specific immune responses (1) Stimulate (a) B cells to become plasma cells and to produce antibodies (b) attraction and activation of macrophages to become aggressive phagocytes (c) Proliferation of cytotoxic T cells and memory helper T cells (d) Stimulation of cytotoxic T cells to destroy abnormal T cells and pathogens II. Acquired Immunity, Immunizations, and Precautions A. Immunity 1. Protection of the body from disease 2. Natural or acquired and active or passive B. Active immunity 1. Memory cells provide long-term immunity 2. Immunization or vaccination: Provide artificially acquired active immunity C. Passive immunity 1. Provides temporary protection against disease-producing antigens 2. Source: Antigens produced by other people or animals D. Diagnostic tests can assess patient’s immune status 1. Serum protein: Measures total protein in blood, including albumin and globulins 2. Protein electrophoresis: Analyzes protein content; used to assess immune function 3. Antibody testing: Determines if patient has developed antibodies in response to infection or immunization 4. Skin testing: Assesses cell-mediated immunity Anergy: No reaction to common antigens; indicates depressed cell-mediated immunity .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

E. Immunizations 1. Vaccines: Suspensions of whole or fractionated bacteria or viruses treated to make them nonpathogenic 2. Routine immunizations: MMR vaccine, varicella (chickenpox), zoster, tetanus and diphtheria (Td) toxoids, hepatitis B (HB), influenza, pneumococcal, HPV, hepatitis A, meningococcal Sensitivity test: Performed prior to administration Common reactions: Redness, swelling, tenderness, muscle ache F. Nursing care 1. Review immunization needs and illness risks for entire communities 2. Public education through presentations to groups, articles in newspapers, advertising, radio presentations, PSAs, one-to-one discussions, teaching G. Assessment Health history: Age, medication use and blood transfusion, nutrition, known allergies, pregnancy status, infection, immunizations, autoimmune disorders, chronic diseases, smoking history Physical assessment: Skin lesions or rashes, breath sounds, respiratory rate H. Priorities of care Promoting immunity while preventing injury from immunization and educating the patient I. Diagnoses, outcomes, and interventions Provide education regarding vaccinations (1) Determine knowledge level, understanding, attitudes, religious beliefs about immunization (2) Discuss values and reasons for recommended immunizations (3) Reinforce positive health-seeking behaviors (4) Using recommended immunization schedules, develop plan to attain optimal immunization status (5) Do not administer influenza vaccine if patient is allergic to eggs, or tetanus antitoxin if sensitive to horse serum (6) Withhold administration of active immunologic products in the presence of upper respiratory infection or other infection (7) Do not administer oral polio vaccine, MMR, or any live virus vaccine to immunosuppressed patients or those in close contact with immunosuppressed patients (8) Do not administer vaccines such as MMR, pneumococcal, or varicella to pregnant women .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(9) Do not administer live attenuated virus vaccines and passive immunizations such as gamma globulin simultaneously (10) Prior to administering prescribed vaccine, check expiration date and manufacturer’s instructions.

(11) Keep epinephrine 1:1000 readily available for subcutaneous injection when administering immunizations Vaccine Adverse Event Reporting System (VAERS): Report any clinically important medical events that occur after vaccination Helpful resources: State and county health departments, the CDC, the National Institute of Allergy and Infectious Diseases J. Isolation precautions Standard precautions apply to: Blood; body fluids, secretions, excretions; nonintact skin, mucous membranes (1) Barrier protection: Gloves, gowns, masks, goggles (2) Aseptic technique: Sterile single-use disposable needles and syringes, single use vials for preparing and administering parenteral medications (3) Respiratory hygiene/cough etiquette Transmission-based precautions Types of precautions: Airborne, droplet, contact precaution III. Patients with Inflammation and Infection A. Inflammation 1. Nonspecific response to injury that serves to destroy, dilute, or contain the injurious agent for damaged tissue 2. Acute inflammation: Follows sequences of vascular response, cellular and phagocytic response, and healing Primary manifestations: Erythema, local heat (hyperemia), swelling, pain, loss of function from swelling and pain Pus: Accumulation of dead neutrophils, necrotic tissue, digested bacteria as a result of inflammation and phagocytosis Abscess: Localized collection of pus that necessitates incision and drainage (I&D) Lymphadenopathy: Lymph node swelling 3. Chronic inflammation Self-perpetuating, lasting weeks to months or years Occurs when acute inflammatory process is ineffective in removing offending agent Granulomatous inflammation: Dense infiltration of site by lymphocytes and macrophages (1) Granuloma: Lesion that isolates offending agent from rest of body, but may not destroy infectious agent which can survive within for long periods of time

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Nonspecific chronic inflammation: Diffuse accumulation of macrophages and proliferation of fibroblasts in response to ongoing chemotaxis B. Complications 1. Factors that affect inflammation and wound healing: Lack of adequate nutrition, blood supply, oxygenation, impaired inflammatory and immune processes, infection, chronic diseases (diabetes, arterial and venous disorders), drug therapy 2. External factors: Exposure to ionizing radiation and wound cleaning agents C. Interprofessional care 1. Promotion of healing with care being supportive and allowing the patient’s own physiologic process to remove foreign matter and damage cells 2. Diagnostic tests to identify the source and extent of inflammation WBC with differential Erythrocyte sedimentation rate (ESR) C-reactive protein (CRP) test Blood and other bodily fluids may be cultured 3. Medications Anti-inflammatory medications (1) Salicylates: Aspirin (antipyretic, analgesic, antiplatelet effects) (2) NSAIDS: Inhibit COX and prostaglandin synthesis, reducing pain and inflammatory response (3) Corticosteroids: For acute hypersensitivity reactions of inflammation that cannot be managed by NSAIDs Other medications: Acetaminophen (reduce fever and pain), antibiotics (prevent or treat infection) 4. Nutrition Inflammation produces catabolism (body tissues broken down) Healing is a process of anabolism (building up) (1) Well-balanced diet of sufficient kilocalories needed to meet metabolic needs of body or catabolism might predominate, impairing healing (2) Protein (complete protein sources preferred): Tissue healing, production of antibodies and WBCs (3) Carbohydrates: Needed to meet energy demands, support leukocyte function (4) Dietary fats: Synthesis of cell membranes (5) Vitamins A: Capillary formation and epithelialization (6) B-complex: Promotes wound healing (7) Vitamin C: Collagen synthesis (8) Vitamin K: Synthesis of clotting factors in liver (9) Minerals: Maintain normal cell function and cofactors in enzyme reactions for cell proliferation .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(10) Oxygen: Necessary for collagen synthesis D. Nursing care 1. Assessment Health history: Risk factors, nutrition, medication use, location, duration, and type (redness, heat, pain, swelling, and impaired function) of manifestations Physical assessment: Movement of injured area, pain, circulation, wounds, lymph nodes 2. Priorities of care Relieving pain due to the inflammatory response Supporting tissue healing Preventing infection 3. Diagnoses, outcomes, and interventions Manage Pain (1) Assess pain on scale of 0–10; note character, location, duration of pain (2) Use physical nonverbal cues to further assess pain (3) Administer anti-inflammatory medications as prescribed (4) Administer analgesic medications as prescribed (5) Provide comfort measures (6) Encourage activities such as reading, watching TV, socializing (7) Encourage rest (8) Provide cold or heat as pain-relief measures, as ordered (9) Elevate inflamed area if possible (10) Teach about appropriate use and expected effects of anti-inflammatory medications Promote good tissue integrity (1) Assess general health and nutritional status (2) Assess circulation to affected area (3) Monitor skin and surrounding tissue for increased manifestations of inflammation (4) Provide protection and support for inflamed tissue (5) Clean inflamed tissue gently (6) Keep inflamed area dry, expose to air as much as possible (7) Balance rest with activity (8) Provide supplemental oxygen as ordered (9) Provide well-balanced diet to meet body’s metabolic healing needs Reduce risk for infection (1) Assess wound for specific manifestations of infection (2) Evaluate complete blood counts for adequate WBC response (3) Monitor viral signs at least every 4 hours

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(4) Apply dry or moist heat to affected area for no longer than 20 minutes several times a day; monitor temperature closely (5) Provide and encourage fluid intake of 2500 mL/day as allowed (6) Ensure adequate nutrition (7) Use good hand hygiene techniques (8) Use aseptic technique when providing wound care 4. Delegating nursing care activities E. Transitions of care 1. Reducing the risk for accident exposure to harmful agents that can result in injury 2. Acute injury Increase fluid intake to 2500 mL per day Well-balanced diet high in vitamins, minerals; adequate protein, and kilocalories Use good hand hygiene Elevate inflamed area to reduce swelling and pain Apply heat or cold for no longer than 20 minutes at a time Take medications as prescribed; notify physician if adverse effects or hypersensitivity responses are noted Rest acutely inflamed tissue; do not engage in strenuous activity until the inflammation has subsided 3. Chronic inflammation Can result from chronic injury such as infection or auto-immune conditions Autoimmune disease cause damage to joint, blood vessels, and the GI system Treatment varies based on the underlying condition and may include immunosuppressant therapy Nonpharmacological treatments (heat, cold, complementary therapies) Cancer cells increase immune response as do chemotherapeutic agents Increases in inflammatory markers are seen at the end stages of life in patients with cancer Loss of muscle mass in patients with cancer increases inflammation and causes further inflammation within the body, contributing to further decline in conditions Inflammation is a factor leading to arthrosclerosis and arterial wall thickening Chronic obstructive pulmonary disease is characterized by persistent airway limitation caused from damage and inflammation of pulmonary structures Care of patients at the end of life include antianxiety agents that decrease oxygen demands and may include steroid therapy to diminish further inflammatory processes F. The Patient with an Infection 1. Pathogens: Virulent organisms rarely found in the absence of disease 2. Pathophysiology Infection: Occurs when organism is able to colonize and multiply within host .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

3.

4.

5.

6.

7.

8.

(1) Chain of infection: Microorganism has disease-causing potential, is transmitted from its reservoir, gains entry into susceptible host Pathogens: Bacteria, viruses, mycoplasma, rickettsia, chlamydia, fungi, parasites, and prions Exotoxins: Soluble proteins secreted into the surrounding tissue by microorganism Endotoxins: Found in the cell wall of gram-negative bacteria, released only when cell is disrupted Reservoir and transmission Reservoir (source): May be endogenous or exogenous Transmission: Direct or indirect contact, droplet or airborne transmission, or a vector Host: Factors that enable host to resist infection Physical barriers Hostile environment created by acid stomach secretions, urine, and vaginal secretions Antimicrobial factors in saliva, tears, prostatic fluid Respiratory defenses Innate and adaptive immune responses to pathogenic invasion Stages of the infectious process Incubation period: Initial stage (1) Pathogen begins active replication but does not yet cause manifestations Prodromal stage (1) Manifestations first appear, often nonspecific, and include general malaise, fever, myalgias, headache, and fatigue Acute stage (1) Maximal impact of infectious process (2) Pathogen proliferates and disseminates rapidly (3) Tissue damage and inflammation due to toxic by-products of microorganism metabolism and cell lysis, along with immune response Convalescent stage (1) Infection contained and pathogen eliminated; affected tissues repaired and manifestations resolved (2) Chronic disease or organism driven to protected site (abscess) if balance between organism and host factors exists with neither predominating Complications Septicemia and septic shock Bacteremia: Bacteria in the blood Healthcare-associated infections (HAIs): Acquired in healthcare setting Occur in 1 out of every 25 patients hospitalized in the United States.

Many result from use of invasive devices Hand hygiene: Single most important measure in infection control Antibiotic-resistant microorganisms: Result of prolonged or inappropriate antibiotic therapy

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Standard precautions: Hand hygiene, use of carefully selected antibiotics, restrict equipment use (stethoscopes, blood pressure cuffs, thermometers) by each patient identified with one of these diseases, use of personal protective gear and appropriate disposal G. Interprofessional care 1. Goals: Identify organ system affected by infection, identify causative agent, achieve a cure by least toxic, least expensive, and most effective means 2. Older adults are at greater risk of acquiring an infection than younger people Cardiovascular changes Respiratory system changes Genitourinary changes Gastrointestinal system changes Skin and subcutaneous tissue changes Immune changes Lower activity level, poor nutrition, increased risk for dehydration, higher prevalence of chronic disease, use of multiple medications, altered mentation 3. Healthcare-associated infections are more common in older adults Reduce risk (1) Avoid prolonged bed rest (2) Encourage deep breathing (3) Provide adequate fluids (4) Provide regular toileting (5) Avoid use of invasive devices 4. Diagnosis WBC count, WBC differential Procalcitonin (CTpr) and C-reactive protein (CRP) Cultures of the wound, blood, or other infected body fluids Serologic testing Direct antigen detection methods Antibiotic peak and trough levels Radiologic examination of the chest, abdomen, or urinary system Lumbar puncture Ultrasonic examination 5. Medications Antimicrobial preparations classified as: Bacteriostatic or bactericidal Mechanisms for activity of antimicrobial agents on bacteria, fungi, and viruses (1) Impair cell wall synthesis, leading to lysis and cell destruction (2) Inhibit protein synthesis, causing impaired microbial function (3) Alter cell membrane permeability, causing intracellular contents to leak (4) Inhibit the synthesis of nucleic acids .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(5) Inhibit cell metabolism and growth Antibiotics: Used to treat bacterial infections Antivirals: Used on viruses since antibiotics have little effect Antifungals: Interfere with cytoplasmic membrane of fungus Antiparasitics: Varied as organisms that cause them, generally expensive, toxic 6. Nursing care Assessment Health history: Current manifestations, age, medication use, nutrition, exposure to infectious persons, immunizations, invasive procedures and therapies, and chronic diseases Physical assessment: Vital signs, body system(s) where infection is suspected, lymph node enlargement, and tenderness 7. Priorities of care 8. Diagnoses, outcomes, and interventions Reduce risk for infection (1) Admit patients with known or suspected infections to private room (2) Perform hand hygiene (hand sanitizer) upon entering and leaving patient’s room (3) Use standard precautions and personal protective devices (4) Explain reasons for, and importance of, isolation procedures (5) Place mask on patient and/or cover all infectious lesions or wounds when transporting patient (6) Collect a culture and sensitivity (C&S) specimen as ordered or indicated by manifestations of infection (7) Administer prescribed anti-infective agents (8) Inform all personnel having contact with patient of diagnosis (9) Ensure visitors don appropriate protective wear (10) Use appropriate measures for disposing of contaminated materials (11) Teach importance of complying with prescribed treatment for course of regimen Reduce Anxiety (1) Asses level of anxiety (2) Discuss infection, treatments, prognosis, and expected outcomes (3) Support and enhance patient’s coping strategies (4) Include significant others in plan of care (5) Explain isolation procedures, answer concerns (6) Provide referrals as needed Manage Hyperthermia (1) Monitor temperature, note heart rate and rhythm (2) Administer prescribed antipyretic as indicated for elevated temperature (3) Promote body cooling through lowering room temperature .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(4) Monitor fluid loss (5) Bathe and provide dry clothing and bedding if diaphoretic (6) Promote bedrest Delegating nursing care activities H. Transitions of care 1. Guidelines to prevent the spread of infection should include: Avoid crowds and contact with the susceptible individuals Use disposable tissues to contain respiratory secretions Use appropriate food-handling precautions for diseases spread via the fecal oral route Avoid contact with her sharing body fluids 2. Prevent spread of acute infections Use good hand hygiene Take all prescribed antibiotics as ordered Do not share prescription or save medication in anticipation of future infection Notify healthcare provider if: Symptoms do not improve in 24–48 hours, manifestations of antibiotic allergy arise, adverse responses occur, manifestations of infection recur after completing prescribed antibiotic Report redness, swelling, or drainage around wounds or persistent high fever Increase fluid intake to at least 2500 mL per day Report manifestations of opportunistic infections Suggest resources: County or public health department, Centers for Disease Control and Prevention 3. Chronic infection Can require ongoing care (Hepatitis B and C, HIV infections, osteomyelitis) Chronic respiratory infections common in COPD (1) Council on smoking cessation (2) Pulmonary rehabilitation (3) Instructional proper use of inhaled medication (4) Teaching on hand hygiene and prevention of infection (5) Ensuring the patient receives influenza and pneumonia vaccine Chronic lower extremity wound infections cannot occur in patients with diabetes (1) Provide teaching that emphasizes the need to inspect feet often and wear protective footwear (2) And minister wound care including debridement of necrotic tissue, and antibiotic therapy, and collagen-based dressings Septicemia-infection of the blood (1) Immunocompromised individuals, older adults, and infants at greatest risk

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter Highlights A. Innate immunity, a nonspecific response to tissue injury, and the adaptive immune response that directly targets invading microorganisms and abnormal cells, are critical components of the body’s defenses. Supporting these defenses is a key nursing responsibility in promoting patient health.

B. Both natural barriers and the immune system prevent the invasion and replication of pathogens.

C. The adaptability and specificity of immune responses is possible because immune cells are genetically encoded to capture pathogens, move them to lymph nodes, and develop specific immune responses to destroy them.

D. The inflammatory response serves to isolate invading antigens. When it occurs in response to acute injury, inflammation produces discomfort but serves a protective role. In contrast, chronic inflammation can damage affected tissue and may serve no protective function.

E. Inflammation is a protective mechanism designed to prevent pathogens from entering the bloodstream and populating functional tissues such as heart, liver, and kidney. Pain acts as a signal that tissue has been damaged and stimulates protective responses such as limiting function while healing progresses. Healing occurs as the inflammatory process isolates the injury and repairs damaged tissue.

F. A fully immunized population is an important infection-control strategy and a major factor in maintaining the health of individuals and the population as a whole.

G. Nurses are instrumental in protecting vulnerable patients from infection, identifying early manifestations of infection, participating with the interdisciplinary team in treating infection, and educating patients and their families about the effective treatment of infection.

H. Localized infections may damage tissue and create pain, but systemic infections can be lifethreatening. Unfortunately, hospitals are hazardous environments populated with collections of pathogens. Healthcare-associated infections are often introduced into the body by medical procedures.

I. Hygiene, protection from harm, and nutrition support the immune defenses. Antimicrobial medications limit the spread of pathogens, but can lose their effectiveness when microbes mutate and develop resistance.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME ONE Review and discuss the roles of killer T cells and suppressor T cells.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME ONE Ask students to devise an educational handout that explains the immune response. Ask students to use this as a visual during patient teaching.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTIONS FOR CLASSROOM ACTIVITY—LEARNING OUTCOME TWO Discuss the importance of hand hygiene to prevent hospital acquired infections. Have students wash hands with a special soap that clings to bacterial and glows under a black light to reinforce the importance of hand washing using proper technique.

Research the Internet for data about HAIs. Identify and discuss the most commonly occurring infections.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME TWO Ask the infection-control nurse to speak to the class about the role of the infection-control nurse.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME THREE Discuss the chain of infection, and how the chain could be disrupted.

SUGGESTIONS FOR CLINICAL ACTIVITY—LEARNING OUTCOME THREE Assign the students to care for clients with active infections. Have the students discuss at post conference the interventions that were performed to help prevent and monitor infections.

Ask students to devise an educational poster for preschool children that teaches methods of preventing the spread of pathogens.

Develop a nursing care plan that includes education for the family of a diabetic patient with a foot ulcer.

While caring for a patient with a chronic wound, develop a teaching plan for the family.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter 13 Nursing Care of Patients with Altered Immunity

Learning Outcomes 1. Review the normal immune system function, including self-recognition.

2. Compare and contrast the four types of hypersensitivity reactions.

3. Describe the pathophysiology and manifestations of autoimmune disorders and tissue transplant rejection, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.

4. Describe the pathophysiology and manifestations of disorders of impaired immune response, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.

Key Concepts I.

Overview of the Altered Immune System A. Antigenic substances: Stimulate an immune system response B. Human leukocyte antigens (HLAs): Markers, or cell surface characteristics unique to each individual’s body cells 1. Major histocompatibility complex (MHC): Large cluster of genes where HLA characteristics are coded C. Hypersensitivity disorders: Caused by overreaction of the immune system (allergies) D. Autoimmune disorders: Occur when immune system loses ability to recognize self E. Antibody-mediated immune response 1. B lymphocytes (B cells) further divided into memory or plasma cells 2. B cells are activated by contact with an antigen and by T cells 3. B cells begin producing antibodies (immunoglobulins) 4. Immunoglobulin M (IgM) forms; most prevalent immunoglobulin is IgG F. Immunosenescence—immune function decline with age 1. Responsiveness, strength, and duration of immune responses decrease G. Assessing the Altered Immune System Response 1. Health history a) Review biographic data (age, gender, race, and ethnic background) and family history

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

b) Provide privacy prior to the interview; start with least sensitive questions before asking about drug use or sexual activity 2. Physical assessment a) Assess the general appearance b) Inspect the mucous membranes of the nose and mouth for color and condition c) Assess skin color, temperature, and moisture d) Inspect and palpate the cervical, axilla, and groin lymph nodes for evidence of lymphadenopathy or tenderness e) Inspect and palpate the joints for redness, swelling, tenderness, or deformity II.

Hypersensitivity Reactions A. Hypersensitivity: Altered immune response to an antigen that results in harm to the patient 1. Allergy: Antigen is environmental or exogenous 2. Reactions: From runny nose or itchy eyes to blood cell hemolysis or laryngospasm 3. Classifications of hypersensitivity responses: Immediate or delayed B. Type I: Immediate or IgE-mediated hypersensitivity: Triggered when an allergen interacts with IgE bound to mast cells and basophils a) Prompts release of histamine and other chemical mediators b) Examples: Allergic asthma, allergic rhinitis, allergic conjunctivitis, hives, anaphylactic shock c) Anaphylaxis: An acute systemic type I response that occurs in highly sensitive individuals following injection of a specific antigen (1) Potential triggers (a) Hormones: Insulin, vasopressin, parathormone (b) Enzymes: Trypsin, chymotrypsin, penicillinase (c) Pollens: Ragweed, grass, trees (d) Foods: Eggs, seafood, peanuts, tree nuts, greens, beans, cottonseed oil, chocolate (e) Vitamins: Thiamine, folic acid (f) Insect venom: Yellow jacket, hornet, paper wasp, honey bee (g) Occupational agents: Rubber, latex, industrial chemicals (h) Antibiotics: Penicillins, cephalosporins, amphotericin B, nitrofurantoin (i) Local anesthetics: Procaine, lidocaine (2) Reaction begins within minutes and maybe almost instantaneous (3) Manifestations: Sense of foreboding or uneasiness, lightheadedness, itching palms and scalp, Hives, angioedema of eyelids, lips, tongue, hands, feet, and genitals, swelling of uvula and larynx, impaired breathing, bronchial constriction, air hunger, stridor, wheezing, and barking cough

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(a) Anaphylactic shock—impaired tissue perfusion and hypotension due to vasodilatation and fluid loss from the vascular system d) Atopic responses: Genetic predisposition, localized (1) Potential triggers (a) Pollens, fungal spores, house dust mites, animal dander, and feathers (b) Hives: Most common systemic response to food allergies C. Type II cytotoxic hypersensitivity: Formation of IgG or IgM antibodies against normal or foreign cells or tissues (hemolytic transfusion reaction to blood of an incompatible type) a) Endogenous antigens can also stimulate a type II reaction D. Type III immune complex–mediated hypersensitivity: Results from formation of IgG or IgM antibody–antigen immune complexes in the circulation 1. Systemic or local responses E. Type IV delayed hypersensitivity: Reactions are cell-mediated, involving T cells of immune system and delayed (24–48 hours after exposure to the antigen) 1. Contact dermatitis—redness, itching, blister formation and thickening affect the skin in the area exposed to the antigen (poison ivy, positive tuberculin test) F. Latex allergy: Can present as a simple irritant dermatitis or contact dermatitis (type I systemic allergic reactions or type IV hypersensitivity) G. The Patient with a Hypersensitivity Reaction 1. Minimize exposure to the allergen 2. Prevent the hypersensitivity response 3. Provide prompt, effective interventions for allergic responses 4. Interprofessional care a) Provide supportive care to relieve discomfort (antihistamine, anti-inflammatory medications, plasmapheresis) 5. Diagnosis: Diagnostic tests a) White blood cell (WBC) count with differential: Detects high levels of circulating eosinophils b) Radioallergosorbent test (RAST): Measures the amount of IgE directed toward specific antigens c) Blood type and crossmatch: Ordered prior to anticipated transfusions d) Immune complex assays: Detect the presence of circulating immune complexes in suspected type III hypersensitivity responses e) Complement assay: Detects immune complex disorders 6. Skin tests for allergies: Used to identify specific allergens to which an individual may be sensitive .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) Types of tests: Prick (epicutaneous or puncture), intradermal, patch 7. Food allergy testing a) Patient keeps diary of foods consumed and allergic responses for a week b) Elimination diet is then prescribed c) If symptoms are relieved, foods are reintroduced until symptoms recur 8. Medications a) Immunotherapy (hyposensitization): Inject an extract of an allergen in gradually increasing doses b) Antihistamines: Major class of drug used in treating hypersensitivity responses c) Glucocorticoids (corticosteroid therapy): Used for severe asthma, allergic contact dermatitis, some immune complex disorders 9. Treatments a) Airway management: Insertion of an endotracheal tube or emergency tracheostomy b) Fluid resuscitation with an isotonic solution through intravenous line in case of anaphylaxis c) Plasmapheresis: Removal of harmful components in the plasma to treat complex responses 10. Anaphylaxis a) Parenteral epinephrine: Adrenergic agonist drug with vasoconstricting and bronchodilating effects H. Nursing care 1. Prevention, early identification, and providing prompt, effective treatment 2. Assessment a) Health history: Risk factors, hypersensitivities, reaction, type of treatment for hypersensitivity reactions; allergy skin testing; asthma, hay fever, or dermatitis b) Physical assessment: Mucous membranes of nose and mouth, skin for lesions or rashes, eyes, respiratory rate, adventitious breath sounds 3. Priorities of care a) Airway, breathing, and circulation 4. Diagnoses, outcomes, and interventions a) Promote effective airway clearance (1) Initiate oxygen per nasal cannula at a rate of 2 to 4 L/min (2) Assess respiratory rate and pattern, level of consciousness and anxiety, nasal flaring, use of accessory muscles of respiration, chest wall movement, audible stridor; oxygen saturation; auscultate lung sounds (3) Position in Fowler to high Fowler to promote optimal lung expansion and ease of breathing (4) Insert a nasopharyngeal or oropharyngeal airway, arrange for immediate intubation (5) Administer intramuscular or subcutaneous epinephrine 1:1000, 0.3–0.5 mL .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(6) Administer parenteral diphenhydramine (7) Provide calm reassurance b) Monitor cardiac output (1) Monitor vital signs (2) Assess skin color, temperature, capillary refill, edema, and other indicators of peripheral perfusion (3) Monitor level of consciousness (4) Insert one or more large-bore intravenous catheters as prescribed (5) Administer warmed intravenous solutions of lactated Ringer or normal saline (6) Insert an indwelling catheter, monitor urinary output frequently 5. Delegating nursing care activities 6. Transitions of care: Help patients identify possible allergens that prompt a hypersensitivity response and discuss strategies to avoid allergens a) When and how to use an anaphylaxis kit b) When to seek medical attention c) Use and adverse reactions of antihistamines and decongestants d) Advantages of autologous blood transfusion if future surgery is scheduled e) Skin care to prevent and care for contact dermatitis f) Helpful resources: ALERT, Inc; Food Allergy and Anaphylaxis Network III.

Autoimmune Disorders A. Autoimmune disorder: Self-recognition (self-tolerance) is impaired and immune defenses are directed against normal host tissue B. The patient with an autoimmune disorder 1. Can affect any tissue in the body 2. May be tissue or organ specific 3. Pathophysiology and manifestations a) Possible factors that contribute to autoimmune disorders (1) Release of previously “hidden” antigens into circulation (2) Chemical, physical, or biologic changes in host tissue cause self-antigens to stimulate production of autoantibodies (3) Introduction of an antigen, such as bacteria or virus, whose antigenic properties closely resemble those of host tissue, resulting in the production of antibodies that target not only the foreign antigen but also normal tissue (molecular mimicry) (4) Defect in normal cellular immune function that allows B cells to produce autoantibodies unchecked b) Other factors: Genetics, age, gender, environmental factors

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

4. Interprofessional care a) Diagnosis (1) Serologic assays (a) Antinuclear antibody (ANA): Detects antibodies produced to DNA and other nuclear material (b) Lupus erythematosus (LE) cell test: Detects SLE and monitors its treatment (c) Rheumatoid factor (RF): An immunoglobulin present in the serum of 80% of patients with rheumatoid arthritis (d) Complement assay: Useful in identifying autoimmune disorders (e) Anti-CCP antibody test: Blood test for RA b) Medications: Focus on suppressing autoimmune responses and restoring normal regulatory mechanisms to prevent target organ damage (1) Immunosuppressive drugs: Inhibit immune responses in autoimmune disorders (2) Corticosteroids: Suppress immune responses and have potent anti-inflammatory effects (3) Biologicals: Laboratory-produced antibodies that bind tumor necrosis factor alpha (TNF- ) and interleukin-1 5. Nursing care a) Consider following nursing diagnoses in planning care (1) Promote activity tolerance related to fatigue caused by inflammatory effects of autoimmune disorder (2) Teach effective coping strategies to help manage living with a chronic disease (3) Educate family about autoimmune disorders and their effects (4) Reduce risk of infection related to disordered immune function b) Transitions of care (1) Teach patient and family about disorder and management (a) Drugs with multiple side effects or long-term effects (b) May not appear to be ill, difficult for family and friends to understand care needs (c) Patient is at high risk for unproven remedies and quackery (d) Provide psychological support, listening, teaching (e) Resources (local support groups, American Autoimmune Related Diseases Association) C. The Patient with a Tissue Transplant 1. Pathophysiology and manifestations a) Autograft: Transplant of the patient’s own tissue b) Allograft: Grafts between members of the same species that have different genotypes and HLA c) Xenograft: Transplant from an animal species to a human .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

d) Histocompatibility: Ability of cells and tissues to survive transplantation without immunologic interference by recipient; determined by tissue typing e) Rejection episodes: Typically begins after first 24 hours of transplant (1) Hyperacute tissue rejection: Due to preformed antibodies and sensitized T cells to antigens in the donor organ (2) Acute tissue rejection: Mediated by cellular immune response (3) Chronic tissue rejection: Result of antibody-mediated immune response (4) Graft-versus-host disease (GVHD): Complication of stem cell transplantation to immunocompromised patients (a) Strategies for preventing or decreasing the severity of GVHD (i) Deleting donor T cells in the tissue or organ prior to infusion into the patient (ii) Using umbilical cord stem cells in adult patients (iii) Closer HLA matching between donor and recipient 2. Interprofessional care a) Care is directed toward reducing the risk that transplanted tissue will be rejected or result in GVHD b) Diagnosis: Diagnostic tests (1) Blood type of donor and recipient (2) Crossmatching: Identify any preformed antibodies against antigens on donor tissues (3) HLA testing of donor and recipient (4) Mixed lymphocyte culture (MLC) assay tests: Determine histocompatibility between the donor and the recipient (5) Panel reactive antibodies: Determine the patient’s level of sensitization to donor antigens (6) Ultrasonography or magnetic resonance imaging (MRI): Evaluate size, perfusion, and function of the transplanted organ (7) Tissue biopsies of the transplanted organ: Assess for evidence of tissue rejection c) Medications (1) Maintenance therapy: Combination of corticosteroids and cyclosporine or tacrolimus (2) Antilymphocyte therapy and the use of monoclonal antibodies: Used for immediate post-transplant period and for steroid-resistant rejection episodes (3) Immunosuppressive agents: Calcineurin inhibitors, cytotoxic agents, monoclonal antibodies, calcineurin inhibitors, cytotoxic agents, monoclonal antibodies, antilymphocyte globulin, corticosteroids (4) Azathioprine (Imuran): Inhibits DNA synthesis and proliferation of T and B cells, suppresses cell-mediated and antibody-mediated immunity

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(5) Muromonab-CD3 (OKT3): Monoclonal antibody produced for therapeutic use in humans (6) Polyclonal antilymphocyte antibodies: Used as adjunctive immunosuppressant therapy 3. Nursing care a) Assessment (1) Identify potential rejection episodes b) Priorities of care (1) Reducing risk of infection (2) Reducing the risk of graft failure c) Diagnoses, outcomes, and interventions (1) Reduce the risk of infection (a) Expected outcome: Will remain free of infection (i) Wash hands and use hand sanitizer before providing direct care (ii) Assess frequently for manifestations of infection; monitor vital signs (iii) Monitor laboratory values, including CBC and tests of organ function; report changes to physician (iv) Initiate reverse or protective isolation procedures as indicated by patient’s immune status (v) Instruct ill family members and visitors to avoid contact with the patient (vi) Help ensure adequate nutrient intake (vii) Change intravenous bags and tubing at least every 24 hours, change peripheral intravenous sites every 72–96 hours (viii) Emphasize the importance of hand hygiene (ix) Provide good mouth care (x) Monitor for potential adverse effects of medications (2) Reduce risk for graft failure (a) Expected outcome: Episodes of rejection will be detected early and effectively managed to preserve integrity of the transplant (i) Administer immunosuppressive therapy as prescribed (ii) Assess for evidence of graft rejection (iii) Monitor results of laboratory studies for function of transplanted organ (iv) Assess for and report signs of GVHD immediately (v) Stress the importance of maintaining immunosuppressive therapy and reporting signs of graft rejection promptly to physician (3) Reduce anxiety (a) Expected outcome: Will appropriately communicate needs, fears, and concerns (i) Assess level of anxiety (ii) Provide opportunities to express feelings, listen attentively (iii) Arrange tasks to allow as much time with the patient as possible .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(iv) Provide clear, concise directions (v) Encourage involvement in care but do not request unnecessary decisions (vi) Encourage family members to remain with the patient as much as possible (vii) Encourage the use of coping behaviors (viii) Reduce or eliminate environmental stressors to the extent possible (ix) Refer to a counselor, mental health specialist, or spiritual advisor (4) Delegating nursing care activities: Nurse may delegate measuring intake and output, obtaining daily weights, assisting with ADLs 4. Transitions of care a) Initial teaching: Options, risks, potential benefits of the transplant b) Following the transplant, provide instructions (1) Manifestations of transplant rejection and the importance of notifying physician (2) Immunosuppressive drug regimen and side effects (3) Wound care (4) Avoiding exposure to infectious diseases, wearing a mask when going outside (5) Meticulous personal hygiene, hand hygiene technique, and frequent mouth care (6) Wearing medical alert bracelet or tag (7) Follow-up visits to the physician or clinic (8) Helpful resources: American Council on Transplantation, local and state support groups related to specific organ transplant IV.

Impaired Immune Responses A. Congenital or Acquired B. Antibody-mediated response is primarily affected: Risk for severe, chronic bacterial infections C. Defect of cell-mediated immunity: Risk for disseminated viral, fungal infections D. Combined immunodeficiency: Risk for all varieties of infectious organisms E. Genetically determined and rare, affecting children more than adults F. The Patient with HIV Infection 1. Acquired immunodeficiency syndrome (AIDS): Immune system deficits associated with opportunistic disorders 2. Human immunodeficiency virus (HIV): Retrovirus transmitted by direct contact with infected blood and body fluids 3. Antiretroviral therapy (ART) 4. Incidence and prevalence a) Risk factors: Behavioral (unprotected sex, drug use)

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

b) African Americans, men who have sex with men (MSM), people who engage in high-risk heterosexual behavior (sex with individuals known to be infected with HIV), and injection drug users disproportionately affected by HIV c) Adults over 50 account for 45% of individuals living with AIDS in the United States 5. Pathophysiology a) Retrovirus: Carries genetic information in RNA b) Seroconversion: Antibodies produced to virus’ proteins 6. Manifestations: Range from no symptoms to severe immunodeficiency with multiple opportunistic infections and cancers a) Pathologic changes in CNS b) Initial manifestations similar to common viral illness (1) Development of acute mononucleosis-type illness in days to weeks after contracting the virus (2) Typical manifestations: Fever, sore throat, and headache; arthralgias and myalgias; rash and lymphadenopathy; nausea, vomiting, and abdominal cramping c) Patients enter prolonged asymptomatic period after initial acute illness (1) Following acute illness, treated patients enter an asymptomatic period (mean is 8–10 years) d) Some patients develop persistent generalized lymphadenopathy e) AIDS: CD4 T-cell count of less than 200/mcL f) The move from asymptomatic or persistent lymphadenopathy to AIDS is often not clearly defined g) Patient complaints: General malaise and fatigue, fever, night sweats, involuntary weight loss h) Manifestations: Persistent skin dryness and rash, diarrhea, hairy leukoplakia and candidiasis, gingival inflammation and ulceration 7. Neurologic effects a) Inflammatory, demyelinating, and degenerative changes b) HIV-associated neurocognitive disorders (HAND): Complex of neurologic manifestations of the HIV infection (1) Disruption of motor function, cognitive, behavioral, psychosocial symptoms (2) HIV-associated dementia (3) Infections and lesions may affect CNS (4) Cryptococcal meningitis and CMV infection common 8. Opportunistic infections a) Risk of opportunistic infection is predictable by the CD4 T-cell count .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

b) Pneumocystis pneumonia (PcP): Most common pneumonia affecting AIDS patients (1) Manifestations are nonspecific, may progress insidiously c) Tuberculosis (TB): Worldwide leading cause of death among HIV infected d) Other infections: Herpes virus infections, CMV, disseminated herpes simplex, herpes zoster, sinusitis, parasitic infections (Toxoplasma gondii and Cryptococcus neoformans), Candida albicans infection, pelvic inflammatory disease (PID) e) Secondary cancers (1) Kaposi sarcoma (KS): Caused by herpes virus transmitted through sexual contact (2) Lymphomas: Malignancies of the lymphoid tissue, including lymphocytes, lymph nodes, and lymphoid organs (3) Cervical cancer: Develops frequently in women with HIV infection f) Other HIV/AIDS-associated diseases (1) Cardiovascular complications: Coronary heart disease (CHD) (a) Risk factors: Dyslipidemia, smoking, CD4 counts lower than 500/mcL (2) Hepatic complications: Liver disease, hepatitis B virus, infection with HCV and other hepatitis viruses, negative effects on the liver due to antiretroviral therapy (3) HIV-associated nephropathy (HIVAN): Leading cause of ESRD in patients with HIV infection 9. Interprofessional care a) Goals (1) Early identification of the infection and determination of appropriate treatment (2) Promoting health-maintenance activities to prolong the asymptomatic period as long as possible (3) Preventing opportunistic infections (4) Treating disease complications, such as cancers (5) Providing emotional and psychosocial support b) Panel on Antiretroviral Guidelines for Adults and Adolescents (2017) guidelines for ART in older patients who have an HIV infection (1) Use ART for patients over 50 regardless of CD4 cell count (2) Closely monitor bones, kidney, metabolic, cardiovascular, and liver function in older adults on ART (3) Collaborate with HIV specialist and primary care providers to optimize care (4) Provide counseling to prevent secondary transmission of HIV c) Diagnosis: Diagnostic tests (1) HIV rapid antibody test: Test strips with embedded HIV antigen (2) Enzyme-linked immunosorbent assay (ELISA): Tests for HIV antibodies, does not detect the virus

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(3) Western blot antibody testing: Patient’s serum mixed with HIV proteins to detect reaction (4) HIV viral load tests: Measure amount of actively replicating HIV (5) CBC: Detects anemia, leucopenia, and thrombocytopenia (6) Absolute CD4 lymphocyte count: Monitors the progress of the disease and guide therapy (7) HIV drug-resistance testing: Helps guide ART (8) Other diagnostic tests: Used to detect secondary cancers and opportunistic infections (a) Tuberculin skin testing (b) MRI of the brain to identify lymphomas (c) Specific cultures and serology examinations for opportunistic infections (d) Pap smears d) Medications (1) Goals: Suppress the infection; provide prophylaxis of opportunistic infections; reduce HIV morbidity (2) Panel on Antiretroviral Guidelines for Adults and Adolescents (2017) recommends initiation of treatment when CD4 helpful to 500/mm3 or lower (3) Initiate treatment in symptomatic patients, those co-infected with hepatitis B, those with HIV-associated neuropathy, and women who are pregnant (4) Effectiveness monitored by viral load in CD4 cell counts (5) Classifications of action of antiretroviral drugs (a) Agents that inhibit replication of the virus (b) Agents that block entry of the virus into cells (6) ART treatment regimen (a) $1931–$3057 per month (b) Significant adverse reactions (c) Discontinuation or interruption of ART dangerous (d) Provider–patient relationships have significant influence on adherence behavior (7) Nucleoside reverse transcriptase inhibitors (NRTIs): Inhibit action of viral reverse transcriptase (a) Necessary for viral integration into cellular DNA and replication (8) Protease inhibitors: Bond chemically with protease to block the function of the enzyme and result in production of immature, noninfectious viral particles (a) Side effects: Elevated cholesterol and triglycerides, insulin resistance and diabetes mellitus, lipodystrophy (9) Nonnucleoside reverse transcriptase inhibitors: Etravirine, delavirdine, efavirenz, nevirapine (a) Side effects: Liver toxicity, severe rash .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(10) Entry inhibitors: Bind to the virus or host cells and prevent viral entry into host cells (a) Side effects: Injection site pain, itching, hardening of tissue, allergic reactions, peripheral neuropathy, insomnia, depression, dyspnea, anorexia, and arthralgia (11) HIV integrase strand transfer inhibitor: Raltegravir targets integrase, HIV enzyme that integrates the viral genetic material into human DNA (a) Side effects: Nausea, diarrhea, headache (12) Other drugs (a) Currently under investigation: Interferon-α, active immunotherapy with inactivated HIV, bone marrow transplant, transfer of genetically modified lymphocytes (b) Peginterferon-α or adefovir: For patients coinfected with hepatitis B or C (c) Recommended vaccines: Pneumococcal, influenza, hepatitis A, hepatitis B, Haemophilus influenzae b e) Nursing care (1) Promote knowledge and understanding, self-care, comfort, and quality of life (2) Assessment (a) Health history: Risk factors, infections, medications, recreational drug use (b) Physical assessment: Height, weight, nutrition, skin and mucous membranes, vision, lymph nodes, breath sounds, abdominal tenderness, motor strength, coordination, cranial nerves, gait, deep tendon reflexes, genitourinary examination, and mental status (3) Priorities of care (a) Early stages: Health maintenance activities, education, and support of coping mechanisms (b) Disease progression: Direct care for symptoms and continued psychosocial support (4) Diagnoses, outcomes, and interventions (a) Nursing roles: Teaching and counseling for health maintenance, preventing spread of HIV (b) Teach coping strategies (i) Assess social support network and usual methods of coping (ii) Support the patient’s social network (iii) Communicate with the focus on respect and concern (iv) Use short-term counseling to help the patient cope with the crisis (v) Promote interaction between the patient, significant others, and family (vi) Provide information, support, guidance for the patient in making decisions regarding care and treatment

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(vii) Provide reassurance, acceptance, and encouragement during crisis episodes (viii) Assist to accept responsibility for actions without blaming others (ix) Support positive coping behaviors, decisions, actions, and achievements (c) Reduce risk-prone health behavior (i) Assist to accept responsibility for actions without blaming others (ii) Provide positive reinforcement of self-directed lifestyle and behavior changes initiated by the patient (iii) Assist the patient to clarify his/her own values and beliefs (iv) Reinforce personal strengths that are identified (v) Assist in setting realistic goals (vi) Refer to clergy, social worker, clinical specialist, and/or counselor as appropriate (d) Promote good skin integrity (i) Assess skin frequently for lesions and areas of breakdown (ii) Monitor lesions for signs of infection or impaired healing (iii) Turn at least every 2 hours if unable to turn self, more frequently if necessary (iv) Keep skin clean and dry using mild, nondrying soaps or oils for cleansing (v) If blisters are noted, leave intact, and dress with hydrocolloid dressing (vi) Caution against scratching (vii) Encourage ambulation, if possible (viii) Monitor nutritional intake and albumin levels (e) Promote adequate weight and nutrition (i) Manifestations of the disease: Nausea, anorexia, chronic diarrhea, wasting syndrome, pain in eating due to oral and esophageal candidiasis and KS of gastrointestinal tract (ii) Assess nutritional status (iii) Identify possible causes of altered nutrition (iv) Administer prescribed medications for candidiasis and other manifestations as prescribed (v) Administer antidiarrheal medications after stools and antiemetics prior to meals; provide antipyretics as needed to control fever (vi) Provide a diet high in protein and kilocalories (vii) Offer soft foods and serve small portions (viii) Involve in meal planning and encourage significant others to bring favorite foods from home (ix) Assist with eating as needed (x) Provide supplementary vitamins and enteral feedings, such as Ensure (xi) Provide or assist with frequent oral hygiene (xii) Administer appetite stimulants as ordered .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(f) Promote sexual function (i) Examine own feelings about sexuality, role in dealing with a patient’s sexuality, the patient’s lifestyle, and sexual preferences (ii) Establish a trusting, therapeutic relationship (iii) Provide factual information about HIV infection and its effects (iv) Discuss safer sex practices (v) Encourage discussion of fears and concerns with significant other (vi) Meet people and develop social relationships while practicing safer sex (vii) Refer the patient and significant other to local support groups (g) Delegating nursing care activities 10. Transitions of care a) Topics to discuss with the patient and family to prepare for home care (1) Importance of identifying those who are infected but not diagnosed with HIV (2) Totally safe sex practices (a) No sex (b) Long-term mutually monogamous sexual relations between two uninfected people (c) Mutual masturbation without direct contact (3) Risk reduction (a) Guidelines for safer sex practices (b) Nutrition, rest, exercise, stress reduction, lifestyle changes, and maintaining positive outlook (c) Infection prevention and transmission (d) Importance of regular medical follow-up and monitoring of immune status (e) Signs and symptoms of opportunistic infections and malignancies, other symptoms that should be reported (f) Medications and adverse effects; the importance of adherence to ART once initiated (g) Cessation of smoking, alcohol, recreational or illicit drug use (h) Home health, hospice, and respite care services as appropriate (i) Community resources (j) Helpful resources: CDC National AIDS Hotline, Gay Men’s Health Crisis Network, National Association of People with AIDS, National Organization on HIV over Fifty (k) Healthcare workers: Inform medical personnel providing direct care about diagnosis; use standard precautions (4) HIV is now considered a chronic disease (a) Monitor adherence to treatment plan and discuss emotional and psychosocial concerns with patient and significant others

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(b) Monitor CD4 response as drug resistance may develop, which required evaluation of drug therapy (c) Explain that due to metabolic changes fat redistribution may occur (d) Inform patients of symptoms of potential drug therapy side effects and complications and the importance to contact the medical provider without delay (e) Reinforced the diligence is required by the patient to avoid opportunistic infections (f) Instruct on the potential symptoms for early treatment of cancers common in HIV patients (g) Continually assess psychosocial needs and for indications of isolation and depression (5) End-of-life care (a) Ensure patient wishes are outlined in advanced directives (b) Encourage enrollment in palliative and hospice care (c) Ensure comfort by monitoring pain, anxiety, and depression levels and medicate as ordered (d) Promote skin integrity to avoid further problems and discomfort (e) Monitor albumin levels for indicators of a poor prognosis (f) Perform nursing measures to improve respiratory status and administer pain medications (g) Provide emotional support to patient and significant others

Chapter Highlights A. Normal immune functioning is essential in protecting the body from internal and external threats. A hyperresponsive immune system, however, which overreacts to antigens or fails to distinguish self proteins from abnormal or nonself proteins, can threaten health and well-being.

B. The immune system is a complex combination of cellular and humoral components that protect against disease. Immunity develops when the body recognizes foreign proteins as “nonself” and develops nonspecific inflammatory responses and specific cellular responses to each foreign antigen.

C. With aging, there is a general decline in the sensitivity and regulation of the immune system, which may result in autoimmune disease.

D. A type I IgE-mediated response is a rapidly occurring response to an antigen source where the antigen and mass cells bind with IGE cells. Mast cells contain histamine and are commonly found in the respiratory system. The response contributes to vasodilatation, skin rash, nasal discharge, and bronchial constriction. Common sources are animal dander, pollen, dust, peanuts, shellfish, chocolate, and penicillin. Type I responses are the most common hypersensitivity reaction.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

E. In type II hypsersensitivity response, Ig cell response to antigens originates on cell surfaces. The immune system targets these antigens and either destroys them by phagocytosis or through the complement system that actually attacks the cell membrane, causing lysis of the cell itself. The lysis causes further immune response. The most noted type II hypersensitivity reaction is a transfusion reaction where donor blood cells are incompatible with the recipient. Transfusion reactions can cause serious complications and require immediate attention.

F. In type III immune complex-mediated reactions, this response is caused by antibody reactions to circulating antigens, which are then deposited within tissues such as joints and organs. The resulting deposits cause alterations in the structures. This reaction is common in rheumatoid arthritis and Raynaud disease. In Raynaud disease the immune response affects capillary circulation in the hands, feet, and nose, limiting blood flow and resulting in cyanosis of the affected area.

G. Type IV delayed hypersensitivity reactions are caused by T lymphocytes rather than antibody–antigen reactions. Lymphocytes do not respond as quickly as antibodies to antigens; thus, a delay is seen in symptoms of the reaction. The body may take several days to respond to an antigen. A common example of this type of reaction is poison ivy where a person may have contact with the plant and not develop itching and rash until days later.

Type IV reactions can also be seen in organ transplant patients.

H. Immune function that targets normal cells and tissues (autoimmunity) or that leads to destruction of transplanted tissue or organs (transplant rejection) and threatens the wellbeing of affected patients. Immunosuppressant therapy is used to prevent tissue and organ damage and maintain the function of transplanted tissue.

I. Autoimmune disorders are diverse, ranging from damage limited to specific cells within an individual organ to systemic disorders with widespread effects, and characterized by an abnormal immune response to normal cells and tissues.

J. Intentional immunosuppression is necessary to prevent initial rejection of a transplanted organ or tissue, to maintain the transplant, and to halt any rejection process that may develop. Most immunosuppressing drugs are nephrotoxic; immunosuppression places patients at greater risk for infection and cancers.

K. Impaired immune function, whether congenital or acquired, threatens health and physiologic integrity because the patient cannot effectively respond to threats such as infection. Nurses play a major role in teaching behaviors to prevent HIV infection, the leading cause of acquired immunodeficiency, and in teaching health and disease management strategies to those affected.

L. HIV infection continues to spread and many patients are unaware they have the virus. AIDS, the end-stage of HIV infection, is profound immunosuppression that results from viral destruction of cellular components of host immunity.

M. Although HIV infection cannot be cured, it can be treated with antiretroviral therapy (ART), a combination of drugs that limits viral replication and host susceptibility to opportunistic infections and cancer. Consistent adherence to the treatment regimen is .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

critical to inhibiting viral replication. ART is, however, expensive and associated with significant adverse effects.

N. Education, counseling, and psychosocial support are key components of care for the person with HIV infection and his or her significant others.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME ONE Develop a nursing care plan for a patient who has altered immunity.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME ONE Assign students to care for a patient who has altered immunity.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME TWO Discuss the reaction chain due to a type II cytotoxic hypersensitivity.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME TWO Ask an allergy specialist or an allergy nurse to speak to the clinical group.

Demonstrate the technique for administering intradermal injections.

SUGGESTIONS FOR CLASSROOM ACTIVITY—LEARNING OUTCOME THREE Research autoimmune diseases that are listed in the text, and create a nursing care plan for one of the diseases.

Discuss the history of transplants, and how transplants have evolved to the current rates of successful transplantation.

Discuss blood products do not require type and crossmatch and explain why.

Invite an organ recipient to speak to the class.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME THREE Assign students to patients with immunosuppression.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME FOUR Discuss common disease processes that are classified as immunosuppressive. Which are acquired, and which are genetic?

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME FOUR Develop a nursing care plan for teaching a patient and his family about HIV.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter 14 Nursing Care of Patients with Cancer

Learning Outcomes 1. Differentiate the nonmodifiable and modifiable risk factors for cancer.

2. Outline the process and theories of carcinogenesis, and list the known carcinogens.

3. Describe the types and characteristics of neoplasms and the process of tumor invasion and metastasis.

4. Outline the physiologic and psychologic effects of cancer.

5. Describe the interprofessional care, nursing care, and transitions of care for patients with cancer.

Key Concepts Cancer A. Cancer: Group of complex diseases characterized by uncontrolled growth and spread of abnormal cells 1. Affects people of any age, gender, ethnicity, or geographic region.

2. Chronic disease with acute episodes 3. Nursing care: Patient education, delivery of accurate health information, symptom assessment and treatment, patient advocacy, and psychological support throughout the cancer continuum, including end-of-life care.

B. Oncology: Study of cancer 1. Oncologists: Medical doctors, surgeons, radiologists, immunologists, or researchers that specialize in caring for patients with cancer 2. Oncology nurse: Specialized training in cancer care and treatment I. Incidence and Mortality A. Second most common cause of death in United States B. Lung cancer is the leading cause of death in both males and females C. Socioeconomic status 1. Lower socioeconomic status increases risk of being diagnosed and dying of cancer D. Nonmodifiable risk factors 1. Genetic and heredity a) Genetics: Study of genes b) Human genome: Totality of human genes c) Genomics: Study of all the genes in the human genome together, including the genes’ interactions with each other, the environment, in and the influence of other psychosocial and cultural factors .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

d) Heredity: How genes are passed from generation to generation e) 5–10% of cancers have hereditary component f) Cancer gene testing: Breast Cancer Gene 1 and 2 (BRCA-1 and BRCA-2) g) Hereditary cancer: Usually occurs at younger age 2. Age a) Cancer is associated with aging (>87% occur over age 50) b) Factors associated with increased risk in older adults (1) Inflammation (2) Immunosenescence (3) Long-term exposure to high doses of promotional agents (4) Hormonal changes associated with aging (5) Stress from severe and/or cumulative losses 3. Gender a) Women: Breast cancer, thyroid cancer more common b) Men: Prostate cancer more common, bladder cancer four times higher E. Modifiable risk factors 1. Stress a) Systemic fatigue and impaired immunologic surveillance can result from continuous unmanaged stress 2. Diet a) High risk: High in red meat and saturated fat, excessively fried or broiled fish and meat, repeated use of fat to fry foods at high temperatures, sodium saccharin, red food dyes, regular and decaffeinated coffee b) Protective: Vegetables, fruits, fiber c) Genotoxic: Nitrosamines and nitrous indoles 3. Occupation a) Risks considered to be modifiable and nonmodifiable b) Risks vary according to occupation 4. Infection a) Viruses: Hepatitis B and hepatitis C for liver and pancreatic cancer, HPV for cervical and anal cancers 5. Tobacco use a) Smoking-related diseases are world’s most preventable cause of death b) Increased risks for smokers: Lung, oropharyngeal, esophageal, laryngeal, gastric, pancreatic, and bladder cancers c) Increased risks for pipe and cigar smokers: Oropharyngeal and laryngeal cancers d) Increased risks for chewing tobacco, snuff: Oral and esophageal cancers e) Secondhand smoke (SHS) or environmental tobacco smoke increases risk 6. Alcohol use a) Risk for breast cancer in females .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

b) Risk for oral, pharyngeal, laryngeal, esophageal, liver, and colorectal cancer in both genders c) Increased risk of cancer of the oral cavity, larynx, esophagus with a considerable amount of daily alcohol consumption 7. Recreational drug use a) Promotes unhealthy lifestyle that increases general cancer risk b) Marijuana causes chromosomal damage 8. Obesity a) Increased risk of developing: Cancers of breast, bowel, ovary, colon, pancreas, endometrium, prostate, liver, stomach, kidney, brain, thyroid, ovary, gallbladder, esophagus, and multiple myeloma b) Physical activity may decrease the risk of cancers associated with obesity.

9. Sun exposure a) Skin cancer rates increasing due to thinning ozone layer b) Most at risk: People of northern European descent with fair hair; elderly people with decreased pigment II.

Pathophysiology A. Normal cell growth 1. Genetic code in DNA of every gene is translated into protein structures that determine type, maturity, function of a cell 2. Change or disruptions in genes can result in producing aberrant cells (may become cancerous) 3. Functions of DNA a) Determines protein production b) Instructs cells to produce specific chemicals c) Instructs self to develop specific structures d) Determines individual traits and characteristics e) Controls other DNA by telling a cell to “switch on” B. The cell cycle 1. Reproduction: Result of replication of cellular DNA and mitosis 2. Four phases of cell cycle a) Gap 1 or G1 phase: Cell enlarges and synthesizes proteins to prepare for DNA replication. b) Synthesis (S) phase: DNA replicated and chromosomes in cell are duplicated. c) Gap 2 or G2 phase: Cell prepares itself for mitosis. d) M phase: Cell begins mitosis.

3. Cyclins: Control cell cycle 4. Malfunctions of the regulators of cell growth and division can result in rapid proliferation of immature cells (can sometimes be considered cancerous)

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

C. Differentiation: Allows cells to specialize in certain tasks 1. Hyperplasia: Increase in number or density of normal cells 2. Metaplasia: Change in normal pattern of differentiation (dividing cells differentiate into cell types not normally found in that location in body) 3. Dysplasia: Loss of DNA control over differentiation occurring in response to adverse conditions 4. Anaplasia: Regression of a cell to an immature or undifferentiated cell type D. Theories of carcinogenesis 1. Carcinogenesis: Process by which normal cells are transformed into cancer cells.

2. Cellular mutation a) Theory of cellular mutation: Certain agents (carcinogens) cause mutations in cellular DNA, transforming cells into cancer cells b) Stages of carcinogenic process: Initiation, promotion, and progression 3. Oncogenes a) Proto-oncogenes: Normal genes that promote cell growth and repair b) Oncogenes: Abnormal genes that promote cell proliferation and are capable of triggering cancerous characteristics 4. Tumor suppressor genes: Block cell growth by suppressing oncogenes 5. Known carcinogens a) Genotoxic: Directly alter DNA and cause mutations b) Promoter substances: Do not cause cancer in absence of previous cell damage 6. Viruses a) Damage cells and induce hyperplastic cell growth b) Viral infection may lead to cell mutation that progresses to malignant cells c) Weaken immunologic defenses against neoplasms 7. Drugs and hormones a) Drugs and hormones: Can be genotoxic or promotional 8. Chemical agents a) Many chemicals are genotoxic and promotional b) Natural substances in the body may be carcinogenic or promotional c) Foods: May contain carcinogens added during preparation or preservation 9. Physical agents a) Excessive exposure to radiation (solar and ionizing) III.

Characteristics and Behavior of Neoplasms A. Types of neoplasms 1. Neoplasm: Mass of new tissue that grows independently of its surrounding structures (no physiologic purpose) a) Require a blood supply with nutrients and oxygen to sustain growth

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

2. Benign neoplasms a) Localized growths, respond to body’s homeostatic controls b) Can be destructive if they crowd surrounding tissue and obstruct function of organs 3. Malignant neoplasms a) Grow aggressively and do not respond to body’s homeostatic controls b) Cause bleeding, inflammation, necrosis as they grow c) Metastasis: Secondary tumor B. Characteristics of malignant cells 1. Loss of regulation of the rate of mitosis 2. Loss of specialization and differentiation 3. Loss of contact inhibition 4. Progressive acquisition of a cancerous phenotype 5. Irreversibility 6. Altered cell structure 7. Simplified metabolic activities 8. Transplantability 9. Ability to promote their own survival C. Tumor invasion and metastasis 1. Invasion a) Qualities of aggressive tumors to facilitate invasion (1) Ability to cause pressure atrophy (2) Ability to disrupt the basement membrane of normal cells (3) Motility (4) Response to chemical signals from adjacent tissues (a) Autocrine motility factor: Calls other malignant cells to normal tissue 2. Metastasis a) Blood- or lymph-borne metastasis requires: (1) Intravasation of malignant cells through blood or lymphatic vessel walls and into circulation (2) Survival of malignant cells in the blood (3) Extravasation from circulation and implantation in a new tissue b) Metastatic lesions (1) Differentiated from primary by cell morphology (2) Common sites: Lymph nodes, liver, lungs, bones, brain c) Ways cells escape detection by immune system: (1) Cancer cells compile a large mass so rapidly that the immune system is unable to overcome the tumor before it takes hold.

(2) Tumor cells must display on their surface tumor-associated antigen (TAA) to be recognized as foreign by the immune system; some oncogenic viruses depress .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

the expression of TAA on infected cells; tumors in advanced stages of growth no longer display TAA. (3) If individual’s immune response is weakened or altered, then a metastatic tumor may take hold with little opposition.

IV.

Physiologic and Psychologic Effects of Cancer A. Disruption of function 1. Obstruction or pressure: Can upset physiologic functioning; cause anoxia, necrosis of surrounding tissues, causing loss of function of involved organ or tissue 2. Results of functional impairments of liver: Severe nutritional, hormonal, hematologic, and immunologic problems, portal hypertension, ascites, varices B. Hematologic alterations 1. Can impair the normal function of blood cells C. Infection 1. Becomes a serious problem when tumor invades and connects two incompatible organs 2. Center of tumor can be infected when tumor is less efficient in creating capillaries.

3. Malignant involvement of organs or tissues of immunity can impair immune response.

D. Hemorrhage 1. Caused from tumor erosion through blood vessels E. Anorexia-cachexia syndrome 1. Cachexia: Wasted appearance of victims due to pain, infection, depression, or side effects of chemotherapy and radiation 2. Cancer cells support growth through catabolism of body’s tissue and muscle proteins.

3. Metabolic rate increases in starvation state of people with cancer F. Paraneoplastic syndromes 1. Endocrine and neurologic are most common.

2. Hematologic abnormalities 3. Nephrotic syndrome 4. Cutaneous syndromes 5. Neurologic syndromes G. Pain 1. Barriers to pain management: Communication and knowledge deficit 2. Types of cancer pain a) Acute: Well-defined pattern of onset, exhibits common signs and symptoms, often identified with hyperactivity of autonomic system

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Often reported as primary symptoms that led to diagnosis b) Chronic: Lasts more than 6 months, lacks objective manifestations of acute pain, results in personality changes, alterations in functional abilities, lifestyle disruptions (1) May be related to treatment or indicate progression of disease c) Patients with preexisting pain d) Patients with a history of drug abuse e) Dying patients with cancer-related pain 3. Causes of cancer pain a) Direct tumor involvement: Metastatic bone disease, nerve compression, involvement of visceral organs b) Side effects or toxic effects of cancer therapies H. Physical stress 1. Massive effort requiring tremendous energy required by immune system to destroy a newly discovered neoplasm I. Psychologic stress 1. Some patients see it as a death sentence, resulting in grief, guilt, anger, feelings of powerlessness, fear, isolation 2. Body image concerns, sexual dysfunction V.

Care of the Patient with Cancer A. Interprofessional Care 1. Specialized laboratory and diagnostic tests B. Diagnosis 1. Diagnostic tests a) X-ray imaging, computed tomography, ultrasonography, magnetic resonance imaging b) Tissue samples through biopsy, collections of secretions c) Simple screening procedures (prostatic-specific antigen (PSA) blood test, increases in enzymes or hormones) d) Tumor markers 2. Classification: Naming the tumor, describing its aggressiveness and spread within or beyond the tissue of origin 3. Grading and staging a) Grading: Evaluates the amount of differentiation of cell and estimates the rate of growth b) Staging: TNM classification system (1) T: Relative tumor size, depth of invasion, surface spread (2) N: Presence and extent of lymph node involvement (3) M: Denotes presence or absence of distant metastases 4. Cytologic examination

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) Specimens collected by these methods: (1) Exfoliation from an epithelial surface (2) Aspiration of fluid from body cavities or blood (3) Needle aspiration of solid tumors 5. Tumor markers a) Protein molecule detectable in serum or other body fluids, used as biochemical indicator of presence of a malignancy b) Categories: Those derived from tumor itself and those associated with host (immune) response to tumor c) Examples: Antigens, hormones, proteins, enzymes 6. Oncologic imaging a) Routine x-ray imaging (usually for screening only), CT, MRI, ultrasonography, nuclear imaging, angiography, positron-emission tomography 7. X-ray imaging a) Method of choice for breast (mammography), lung, bone 8. Computed tomography (CT) a) Visualization of cross sections of anatomy, reveals subtle differences in tissue densities 9. Magnetic resonance imaging (MRI) a) Diagnostic tool of choice for screening and follow-up of cranial and head and neck tumors b) Related diagnostic imaging procedures: Positron-emission tomography (PET), singlephoton-emission computed tomography (SPECT) 10. Ultrasonography a) Measures sound waves as they bounce off body structures, revealing abnormalities (indicating tumors) 11. Nuclear imaging a) Use of special scanner in conjunction with the ingestion or injection of specific radioactive isotopes; used for possible bone or organ metastasis 12. Angiography a) Used when the precise location of tumor cannot be identified or there is a need to visualize tumor’s extent prior to surgery 13. Direct visualization a) Sigmoidoscopy, cystoscopy, endoscopy, bronchoscopy b) Allows the visual identification of the organs within the limits of the scope and usually permits biopsy of suspicious lesions or masses 14. Laboratory tests a) Used to rule out nutritional disorders and other noncancerous conditions that may be causing patient’s symptoms 15. Psychologic support during diagnosis a) Coping mechanisms: Denial or intellectualization b) Nurse’s role .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Provide support by helping patients become actively involved (2) Actively listen and be supportive, but avoid giving advice and false reassurance (3) Provide appropriate information (4) Support and communicate with significant other C. Cancer treatment 1. Goals: Achieving remission, control, palliation of symptoms a) Treatment goals (1) Eliminating the tumor or malignant cells (2) Preventing metastasis (3) Reducing cellular growth and the tumor burden (4) Promoting functional abilities and providing pain relief 2. Surgery a) Prophylactic surgery: Aims to remove tissues or organs likely to develop cancer b) Diagnostic surgery: Aims to ensure histologic diagnosis and staging of cancer through biopsy, endoscopy, laparoscopy, open surgical exploration c) Tumor removal: Primary treatment; goal is to remove entire tumor and involved surrounding tissue and lymph nodes d) Surgeries that eliminate cancer without radical body changes: (1) Removing a nonessential portion of the organ or tissue containing the tumor (2) Removing an organ whose function can be replaced chemically (3) Resecting one of a pair of organs when the unaffected organ can take over the function of the missing one e) Other functions of surgery (1) Achieve palliation to allow organs to function as long as possible, relieve pain, provide comfort, or bypass an obstruction (2) Reduce tumor size (3) Reconstruction and rehabilitation after curative or radical surgery f) Nursing responsibilities: Prepare patient physically and psychologically, teach routine postoperative care 3. Chemotherapy: Cytotoxic medications to cure liquid and solid cancers, decrease tumor size, adjunctive to surgery or radiation therapy, prevent or treat metastases, in conjunction with biotherapy a) Protocols often involve a combination of drugs administered over varying periods of time b) Classes of chemotherapy drugs (cell cycle–specific and cell cycle–nonspecific agents) (1) Alkylating agents: Not phase-specific (a) Act on preformed nucleic acids by creating defects in tumor DNA

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(b) Subclasses: Nitrogen mustard, nitrosoureas, alkyl sulfonates, triazines, ethyleneamines, cisplatin (2) Antimetabolites: Phase specific (a) Interfere with nucleic acid synthesis (b) Types: Folic acid analogues, pyrimidine analogues, cytosine arabinoside, purine analogues (3) Antitumor antibiotics: Not phase-specific (a) Disrupt DNA replication and RNA transcription, create free radicals, interfere with DNA repair, bind to cells and kill them (4) Mitotic inhibitors (a) Prevent cell division during the M phase (b) Include plant alkaloids and taxoids c) Effects of chemotherapeutic drugs (1) Toxic effects vary with type of drug and length of treatment (2) Tissues affected by cytotoxic drugs: (a) Mucous membranes of mouth, tongue, esophagus, stomach, intestine, and rectum (b) Hair cells (c) Bone marrow depression affecting most blood cells (d) Organs, such as heart, lungs, bladder, kidneys (e) Reproductive organs d) Chemotherapy preparation and administration (1) Take care when handling excretory products of patients undergoing chemotherapy (2) Teach patients to dispose of body fluids safely (3) Administration: Orally, intramuscularly, intravenous infusion or direct injection into intraperitoneal or intrapleural body cavities (4) Vascular access devices (VADs) (a) Peripherally inserted central catheters (PICCs) (b) Catheters tunneled under the skin on chest into a major vein (c) Surgically implanted ports placed under skin with a connected catheter inserted into a major vein (i) Risk of infection, catheter obstruction, and extravasation e) Management of patients receiving chemotherapy (1) Assessment and monitoring of patient’s manifestations of toxic effects or side effects of drugs (2) Organ toxicities reported immediately to physician (3) Teach patient how to care for access sites; dispose of used equipment and excretions (4) Teach patient to increase fluid intake, get rest, identify major complications, know when to call for physician, limit exposure to other people .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(5) Psychologic issues: Need to plan activities around chemotherapy; weight loss, alopecia, may cause feelings of powerlessness and depression f) Hormonal therapy (1) Corticosteroids, hormone antagonists (2) Side effects are similar to the action of the hormone used or suppression of the normal hormonal. g) Biotherapy (1) Natural substances from organisms or laboratory-made versions of these substances (2) Precision medicine; requires analysis of the genetic changes of a tumor that allow it to grow and spread (3) Side effects are related to the stimulation of the immune system (4) Life-threatening hypersensitivity reactions may occur h) Monoclonal antibodies (1) Targeted therapy produced in the laboratory (2) Side effects include reversible cardiac toxicity and drug resistance i) Chimeric antigen receptor T-cell therapy (1) Uses a synthetic protein that directs the patient’s own T cells to target cancerous cells j) Immune checkpoint inhibitors (1) Promotes detection of cancer cells to enhance immune function against cancer k) Immune modulating agents (1) Enhance the body’s immune system response 4. Radiation therapy: Kill tumor, reduce size, decrease pain, or relieve obstruction a) Forms of radiation therapy (1) External radiation (teletherapy): Delivery of radiation from a source at some distance from patient (2) Internal radiation (brachytherapy): Radiation given inside the body (a) Can be dangerous for those around patient (3) Intraoperative radiation therapy: Larger dose of penetrating radiation directed to the tumor bed with less trauma to vulnerable tissues or organs (4) Intensity-modulated radiation therapy: Delivers a precise radiation dose to the tumor while sparing normal surrounding tissue (5) Proton therapy: Emerging therapy used in pediatric and young adults; uses protons to deliver energy protecting vulnerable organs in close proximity to the tumor b) Planning for radiation therapy: Assess disease site, tumor size, histologic findings c) Biotherapies and biochemotherapies have serious side effects and toxicities

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

5. Bone marrow transplantation (BMT) and peripheral blood stem cell transplantations (PBSCT) a) BMT: Treatment to stimulate a nonfunctioning marrow or to replace marrow b) PBSCT: Process of removing circulating stem cells from peripheral blood through apheresis and returning these cells to patient after chemotherapy 6. Integrative therapies: Therapies patients choose as complement to medical treatment a) Categories: Botanical agents, nutritional supplements, dietary regimens, mind–body modalities, energy healing, spiritual approaches, and miscellaneous therapies.

D. Pain management 1. Categories of pain syndromes in patients with cancer a) Pain associated with direct tumor involvement b) Pain associated with treatment c) Pain from a cause not related to either the cancer or therapy 2. Goals of pain management a) Provide/optimize analgesia b) Optimize activities of daily living c) Minimize adverse effects d) Avoid aberrant drug use e) Optimize patient affect 3. Multidisciplinary team that incorporates psychosocial support is needed to provide adequate pain management.

4. Steps of pharmacologic pain management a) Conduct careful initial and ongoing assessment of the pain b) Evaluate the patient’s functional goals c) Establish a plan with combinations of nonnarcotic drugs with adjuvants d) Evaluate the degree of pain relief e) Progress to stronger drugs as needed, from mild to strong narcotics and monitor side effects f) Continue to try combinations and escalate dosages until maximal pain relief balanced with patient’s need to function is achieved 5. Medications a) Usually administered orally on a regular time schedule b) Primary narcotic administered intramuscularly, subcutaneously, or rectally on intermittent schedule c) Other therapies: Injection of anesthetic drugs into spinal cord or nerve plexuses, surgical severing of nerves, radiation to reduce tumor size and pressure, behavioral approaches VI.

Nursing Care

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

A. Assessment 1. Health history a) What brought you to see the doctor? b) Are any other medical conditions or problems troubling you at this time? c) Describe the kind of physical problems are you having? Pain? Nauseated? Lost a great deal of weight? Are you so tired you have difficulty carrying on your daily activities? Are you feeling blue or discouraged because of your illness? d) What options has your physician suggested for treating your cancer? e) What do you expect to happen as a result of this treatment? f) What effects are the disease and/or treatment having on your ability to carry on with your usual daily activities? g) Who is available to help you at home and run errands? Who can provide transportation for you? Who can you rely on to be a good listener? Is there someone you would like to make healthcare decisions if there is a time when you are unable to make them for yourself? h) How do you manage your stress or your feelings of discomfort? What helps you feel better? Do you think these measures work well for you?

2. Physical assessment a) Conduct physical assessment to establish baseline (1) Include nutritional status using anthropomorphic measurements (2) Evaluate laboratory results and note specific signs and symptoms (3) Assess patient’s hydration status B. Nursing diagnoses and interventions 1. Nursing care includes everyone involved with the patients from the time of diagnosis through the entire disease and treatment process 2. Relieve anxiety a) Expected outcome: Patient will be free of or decrease level of anxiety related to cancer diagnosis and treatment (1) Assess patient’s level of anxiety being mindful of patients with a lack of social support, advanced disease, functional limitations, or history of trauma or anxiety disorders (2) Ask about sleep habits and functional limitations (3) Assess level of anxiety with validated and approved tools (4) Work with the patient to determine the appropriate interventions to manage anxiety (yoga, art therapy, music therapy, massage, mindfulness-based stress reduction) (5) Establish therapeutic relationship by conveying warmth and empathy and listening in nonjudgmental manner (6) Review the coping strategies the patient has used in the past and build on past successful behaviors, introducing new strategies as appropriate .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(7) Identify resources in the community to help manage anxiety-producing situations (8) Provide specific information for patient about the disease, treatment, what may be expected (9) Use crisis intervention theory to promote growth in patient and significant others 3. Promote acceptance of changes to the body a) Expected outcome: Patient will accept after-cancer treatment body image (1) Discuss the meaning of the loss or change with patient (2) Observe and evaluate interaction with significant others (3) Allow denial, but do not participate in it (4) Assist the patient and significant others to cope with changes in appearance (a) Provide a supportive environment (b) Encourage patient and significant others to express feelings (c) Give matter-of-fact responses to questions and concerns (d) Identify new coping strategies to resolve feelings (e) Enlist family and friends in reaffirming the patient’s worth (5) Teach patient or significant others to participate in care of the afflicted body area (6) Teach strategies for minimizing physical changes (7) Provide anticipatory guidance regarding alopecia from chemotherapy (a) Discuss the pattern and timing of hair loss (b) Refer patient to a wig shop before hair loss is expected (c) Referred to support programs (d) Reassure the patient that hair will go back after chemotherapy is discontinued, but also inform that the color and texture of new hair may be different 4. Promote healthy grieving a) Expected outcome: Patient will use effective and healthy responses to actual, anticipated, or perceived cancer-related losses (1) Use therapeutic communication skills to provide open environment for patient and significant others to discuss their feelings (2) Answer questions about illness and prognosis honestly, but encourage hope (3) Encourage the dying patient to make funeral and burial plans and to be sure will is in order; make sure the necessary phone numbers can be easily located (4) Encourage the patient to continue taking part in activities he or she enjoys, including maintaining employment as long as possible 5. Reduce risk for infection a) Expected outcome: Patient will be free of infections related to cancer or treatment (1) Monitor vital signs (2) Maintained good hand hygiene .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(3) Monitor WBC counts frequently, especially if chemotherapy is known to cause bone marrow suppression (4) Teach the patient to avoid crowds, small children, and people with infections when WBC count is at nadir and to practice scrupulous personal hygiene (5) Protect skin and mucous membranes from injury (6) Encourage the patient to consume diet high in protein, minerals, and vitamins 6. Reduce risk for injury a) Expected outcome: Patient will be free of injuries related to cancer or treatment (1) Assess frequently for signs and symptoms indicating problems with organ obstruction (2) Teach to differentiate minor problems from serious ones (3) Monitor laboratory values that may indicate presence of ectopic functioning and report abnormal findings to physicians immediately 7. Restore and promote adequate nutrition a) Expected outcome: Patient will restore and maintain balanced nutrition (1) Assess current eating patterns; identify factors that impair food intake (2) Evaluate degree of malnutrition (a) Check laboratory values for total serum protein, serum albumin and globins, total lymphocyte count, serum transferrin, hemoglobin, and hematocrit (b) Calculate nitrogen balance and creatinine-height index. Calculate skeletal muscle mass, and compare findings to normal ranges (c) Take anthropometric measurements and compare them to standards (3) Teach principles of maintaining good nutrition and adapting the diet to medical restrictions and current preferences (4) Manage problems that interfere with eating (5) Teach to supplement meals with nutritional supplements and to take multivitamin and mineral tablets with meals (a) Encourage eating whenever it is appealing and consider adding nutritional supplements (b) Eat small, frequent meals (c) Encourage to try icy foods or those that are more highly seasoned if food has no taste (d) Encourage cold and bland semisoft or liquid foods with painful oropharyngeal ulcers (e) Manage nausea and vomiting by administering antiemetic drugs (6) Teach to supplement meals with nutritional supplements and suggest increasing calories by adding ice cream or frozen yogurt to the liquid supplement or commercial protein carbohydrate powders to milk or fruit juice (7) Teach to keep a food diary to document daily intake

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(8) Teach to administer parenteral nutrition via a central line or other VAD; teach safety measures and care of the VAD; provide emergency phone number for help with administration problems 8. Promote integrity of gastrointestinal tissues a) Manifestations of this problem (1) Small ulcers on the tongue and mucous membranes in the mouth and throat (2) Herpes simplex type 1 lesions or vesicles evolve into ulcerations (3) Fungal infections (4) Red, swollen, friable gums bleed with minimal or no trauma (5) Xerostomia b) Expected outcome: Patient will restore and maintain tissue integrity c) Interventions to manage these problems (1) Assess and evaluate type of tissue impairment present; identify possible sources (2) Implement and teach measures for preventing oropharyngeal infection (3) Implement and teach measures for reducing trauma to delicate tissues (4) Administer specific medications as ordered to control infection and/or pain C. Nursing interventions for oncologic emergencies 1. Cancer prevention strategies: Smoking cessation, maintaining healthy weight, preventing infections 2. Most important factors influencing prognosis: Early detection and treatment a) Screening procedures: Mammograms, PSA, occult blood stool tests, colonoscopies 3. Routine cancer checkup: Counseling to improve health behaviors, physical examination with related tests of breast, colon, rectum, cervix, and lungs D. Oncologic emergencies 1. Pericardial effusions and neoplastic cardiac tamponade a) Signs: Caused by compression of the heart b) Interventions (1) Start oxygen and alert respiratory therapy for other respiratory support as needed (2) Insert an intravenous catheter if one is not already in place (3) Monitor vital signs and initiate hemodynamic monitoring (4) Prepare vasopressor drugs (5) Bring emergency cart to bedside (6) Set up for and assist the physician with a pericardial tap (pericardiocentesis) (7) Reassure the patient 2. Superior vena cava syndrome a) Signs: Facial, periorbital, arm edema; respiratory distress, dyspnea, cyanosis, tachypnea, altered consciousness b) Emergency measures: .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

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(1) Provide respiratory support with oxygen, and prepare for tracheostomy (2) Monitor vital signs (3) Administer corticosteroids (e.g., dexamethasone) to reduce edema (4) If the disorder is due to a clot, administer antifibrinolytic or anticoagulant drugs (5) Provide a safe environment, including seizure precautions Sepsis and septic shock a) Phases of Gram-negative sepsis (1) First phase: Vasodilation with vascular dehydration, high fever, peripheral edema, hypotension, tachycardia, tachypnea, hot flushed skin with creeping mottling beginning in the lower extremities, and anxiety or restlessness (2) Second phase: Hypotension, rapid thready pulse, respiratory distress, cyanosis, subnormal temperature, cold clammy skin, decreased urinary output, and altered mentation Spinal cord compression a) Occurs from pressure from expanding tumors of the breast, lung, or prostate; lymphoma; or metastatic disease b) Symptoms: Back pain, leg pain, numbness, paresthesias, coldness, bowel and bladder dysfunction, and neurologic dysfunction c) Treatment: Radiation or surgical decompression Obstructive uropathy a) Manifestations of bladder neck obstruction: Urinary retention, flank pain, hematuria, or persistent urinary tract infections Hypercalcemia a) Associated with cancers of breast, lung, esophagus, thyroid, head, and neck with multiple myeloma b) Symptoms: Fatigue, anorexia, nausea, polyuria, constipation, muscle weakness, lethargy, apathy, and diminished reflexes Hyperuricemia a) Complication of rapid necrosis of tumor cells after chemotherapy for lymphomas and leukemias b) Manifestations: Nausea, vomiting, lethargy, and oliguria Tumor lysis syndrome (TLS): Two or more metabolic abnormalities a) Major cause: Chemotherapy to tumors with high proliferative rate, relatively large tumor burden, high sensitivity cytotoxic agents, leading to massive and rapid cell death b) Manifestations: Nausea, vomiting, lethargy, edema, fluid overload, congestive heart failure, sudden death

E. Health education for the patient 1. Prevention a) Report to public health department known leaking of chemicals or radioactive materials in water or air; noted increase in incidence of cancer in community .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

2. Rehabilitation and survival a) Rehabilitation centers, in-home support, certified home health aide, physical and occupational therapists F. Continuity of care 1. Teach patient and significant others or caregivers to manage the patient at home a) Teach wound care to the patient with open wound or draining lesion, and provide a referral to a home health nurse to monitor progress b) Explain special diets clearly, or refer patient to a dietitian before discharge c) Review physician’s instructions; medications, any other treatments, when to see the doctor for follow-up care d) Provide or order equipment and supplies needed for home care e) For patient who will need complex care, provide referral to a home health nurse 2. Hospice care: For patient that elects to die at home

Chapter Highlights A. Cancer is a life-threatening and complicated disease characterized by uncontrolled growth and spread of abnormal cells. Cancer can affect people of any age, gender, ethnicity, or geographic region.

B. Cancer is the second leading cause of death in the United States. The incidence of cancer increases with advancing age. The most commonly seen cancers in women are breast, lung, colorectal, uterine, and thyroid. In men, prostate, lung, colorectal, bladder, and skin melanoma cancers occur most frequently.

C. An estimated 5 to 10% of cancers have a hereditary component; therefore it is important to determine patient who have a genetic predisposition. Recurring patterns of cancer within a family may indicate a genetic component, as well as shared environmental exposures, lifestyle, and other nongenetic risk factors.

D. A neoplasm or tumor is a mass of new tissue that grows independently of its surrounding structures and has no physiologic purpose. Neoplasms are typically classified as benign or malignant on the basis of their potential to damage the body and on their growth characteristics.

E. Malignant neoplasms (i.e., cancer) grow aggressively and do not respond to the body’s homeostatic controls. Malignant cells from the primary tumor may travel through the blood or lymph to invade other tissues and organs of the body and form a secondary tumor called a metastasis.

F. Metastasis, the ability of cancer cells to invade adjacent tissues and travel to distant organs, is considered cancer cells’ most ominous characteristic. This quality makes treatment a considerable challenge.

G. The diagnosis and treatment of cancer is a pivotal, life-changing event that requires immediate and ongoing adjustment to this life-threatening illness. Effective physical and

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

psychosocial adjustment to cancer diagnosis and treatment enhances patients’ ability to cope and improves survival and quality of life.

H. The goals of cancer treatment are aimed at cure and control of cancer as well as management of cancer-related and treatment-related symptoms.

I. Cancer may be treated through surgery, chemotherapy, radiation therapy, biotherapy, photodynamic therapy, bone marrow and stem cell transplants, hormonal therapy, and complementary therapies. Chemotherapy uses cytotoxic medications to cure or control cancer by interrupting cell metabolism and replication and by interfering with the ability of the malignant cell to synthesize vital enzymes and chemicals.

J. Common complementary therapies for cancer include botanical agents, nutritional supplements, dietary regiments, mind–body modalities, spiritual approaches, and miscellaneous therapies.

K. Nurses play a pivotal role in cancer prevention, providing quality patient-centered individualized care for patients with cancer.

L. Managing cancer-related for treatment-related symptoms, such as pain, nausea and vomiting, mucositis, or fatigue, is a major nursing responsibility.

M. Managing oncologic emergencies is an important nursing responsibility. Tumor lysis syndrome (TLS) is a life-threatening oncologic emergency for patients with cancer.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME ONE Explain known carcinogens, carcinogenesis, and identify risk factors for cancer.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME ONE Ask students to identify risk factors in their patient’s environment such as pollution and secondhand smoke. Identify the risk factors that can be changed and those that cannot be changed.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME TWO Ask students to brainstorm factors that can cause cancer. Classify factors as external or internal.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME TWO Assign students to screen patients during a health history for exposure to potential factors that can cause cancer. Encourage students to provided patient teaching on interventions to limit exposure.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME THREE Discuss the characteristics of a malignant melanoma.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME THREE Have students screen patients for and name nonmalignant growths that are identified on the skin.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME FOUR Assign different forms of cancer to each student. Ask the student to research the symptoms, pathology, and course of the disease. Discuss findings in class.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME FOUR Ask an oncology nurse to speak to the class regarding psychological support of the client and family with cancer.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME FIVE Create a plan of care for a patient who has been diagnosed with cancer and is in the early stages, and then modify the plan for the end stage.

SUGGESTIONS FOR CLINICAL ACTIVITY—LEARNING OUTCOME FIVE Assign students to care for a patient that is in the early stages of cancer.

Assign students to care for a patient that is in the late stages of cancer.

Ask a hospice nurse to speak to the clinical group about care of the end-stage cancer patient.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter 15 Assessing the Integumentary System

Learning Outcomes 1. Describe the anatomy, physiology, and functions of the skin, hair, and nails, and identify abnormal findings that may indicate impairment of the integumentary system.

2. Outline the components of the assessment of the integumentary system including topics for health assessment interview, techniques for physical assessment, and the diagnostic test used in the assessment.

3. Differentiate considerations for assessing the integumentary system of older adults, veterans, individuals in the LGBTQI population, and adults with sequelae from complex congenital conditions.

4. Summarize topics that nurses teach to promote healthy tissue integrity across the lifespan.

Key Concepts I. Anatomy, Physiology, and Functions of the Integumentary System A. The skin 1. Largest organ of the body that provides an external covering for the body, separating and protecting the bodies organs and tissues from the external environment 2. The epidermis: Surface or outermost part of skin consisting of epithelial cells a) Layers of the epidermis (1) Stratum basale: Deepest layer (a) Melanocytes: Produce melanin (b) Keratinocytes: Produce keratin (2) Stratum spinosum: Contains cells from bone marrow that migrate to epidermis (3) Stratum granulosum: 2–3 cells thick (a) Keratinization begins in this layer (4) Stratum lucidum: Present in areas of thick skin (5) Stratum corneum: Outermost layer 3. The dermis: Second, deeper layer of skin composed of flexible connective tissue a) Papillary layer: Contains capillaries and receptors for pain and touch b) Reticular layer: Contains blood vessels, sweat and sebaceous glands, deep pressure receptors, and dense bundles of collagen fibers 4. Superficial fascia: Layer of subcutaneous tissue under the dermis composed of adipose tissue 5. Glands of the skin a) Sebaceous (oil) glands: Secrete sebum b) Sudoriferous (sweat) glands .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Eccrine: More numerous on forehead, palms, and soles (2) Apocrine glands: Located in axillary, anal, and genital areas c) Ceruminous glands: Modified apocrine sweat glands that secrete waxy cerumen 6. Skin color a) Result of varying levels of pigmentation (1) Melanin: Yellow-to-brown pigment (2) Carotene: Yellow-to-orange pigment b) Erythema: Reddening of the skin from blushing, fever, hypertension, or inflammation c) Cyanosis: Bluish discoloration of skin and mucous membranes resulting from poor oxygenation of hemoglobin d) Pallor: Paleness of skin that may occur with shock, fear, anger, or anemia and hypoxia e) Jaundice: Yellow-to-orange color visible in skin and mucous membranes from hepatic disorder B. The hair 1. Produced by a hair bulb; root is enclosed in a hair follicle 2. Shaft: Exposed part consisting of dead cells 3. Growth influenced by nutrition and hormones C. The nails 1. Modified scale-like epidermal structure consisting of dead cells 2. Lunula: Proximal visible end of nail that has a white crescent 3. Nail folds: Sides of nail overlapped by skin 4. Eponychium (cuticle): Thickened proximal nail fold II. Assessing the Integumentary System A. Health assessment interview 1. Ask about changes in health, rashes, itching, color changes, dryness or oiliness, growth or changes in warts or moles, and presence of lesions 2. Precipitating causes: Medications, use of new soaps, skin care agents, cosmetics, pets, travel, stress, and dietary changes 3. Hair problems: Ask about thinning or baldness, excessive hair loss, change in distribution of hair, use of hair care products, diet, and dieting 4. Nail problems: Ask about nail splitting or breakage, discoloration, infection, diet, exposure to chemicals 5. Medical history: Previous problems, allergies, and lesions 6. Occupational and social history: Ask about travel, exposure to toxic substances at work, use of alcohol, and responses to stress 7. Assess presence of risk factors for skin cancer; include specific questions to identify risk factors for malignant melanoma

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

B. Physical assessment 1. Conducted by inspection and palpation 2. Skin: Assess for odor, color, presence of lesions, alterations, temperature, texture, moisture, turgor, and presence of edema 3. Note characteristics of lesions: Location and distribution, color, pattern, edges, size, elevation, and type of exudates a) Primary skin lesions: Macule, patch; papule, plaque; nodule, tumor; vesicle, bulla, wheal, pustule, and cyst b) Secondary skin lesions: Atrophy, erosion, ulcer, fissure, lichenification, scar, scales, keloid, and crust c) Vascular skin lesions: Spider angioma, venous star, petechiae, purpura, and ecchymosis 4. Hair: Examine color, texture, quality, and scalp lesions 5. Nails: Determine shape, color, contour, and condition C. Diagnosis 1. Purposes of diagnostic tests a) Support diagnosis of specific injury or disease b) Provide information to identify or modify appropriate medication or treatments used to treat disease c) Help interprofessional team monitor patients’ responses to interventions 2. Diagnostic tests: Biopsy, culture, immunofluorescent slides, oil slides, patch test, scratch tests, potassium hydroxide (KOH), Tzanck smear, and Wood’s lamp 3. Nursing responsibilities a) Explain procedure and any special preparation needed b) Assess medication use that may affect outcome of tests c) Support patient during examination as necessary d) Document procedures as appropriate e) Monitor results of tests III. Assessment of Selected Populations A. Age-related skin changes 1. Skin tags: Soft brown or flesh-colored benign papules 2. Keratosis: Horny growth of keratinocytes; may be seborrheic (benign) or actinic (premalignant) 3. Lentigines (liver spots): Brown or black benign macules for the defined border 4. Angiomas (hemangioma): Benign vascular tumors with dilated blood vessels; found in the middle to upper dermis 5. Telangiectases: Single dilated blood vessels, capillaries, or terminal arteries 6. Venous leaks: Small, dark blue, slightly raised benign papules 7. Photoaging: Wrinkling, mottling, pigmented areas, loss elasticity, benign or malignant lesions .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

8. Veterans: May have unusual skin presentations due to length of service, where they were stationed and chemical exposure a) Chloracne (acneform disease): Eruption of nodules, cysts, and blackheads that have been linked to contaminants found in herbicides like Agent Orange b) Porphyria Curtanea Tarda (PCT): Thinning/blistering of skin with sun exposure following hexachlorabenzene exposure in the presence of alcohol overuse. Skin irritation/chemical burns are secondary to industrial solvent exposure IV. Health Promotion A. Use sunscreen 1. Limiting exposure to skin cancer risk factors a) Minimize sun exposure between 10 A.M. and 3 P.M. b) Cover up with a wide brimmed hat, sunglasses, Long sleeve shirt, and long pants made of tightly woven material when the sun c) Apply a water proof or water-resistant sunscreen of SPF 15 or more at least 30 minutes before every exposure to sun. Reapply every hour if swimming or sweating heavily. Apply sunscreen on sunny and cloudy days. d) Apply adequate sunscreen to achieve SPF 15, which requires 2 mg of sunscreen per square centimeter of skin. This is about 2 tablespoons to exposed face and body, or about a nickel-sized amount for the face alone. e) Use sunscreen and protective clothing when you are on or near sand, snow, concrete, or water. f) Avoid tanning booth; ultraviolet rays and knitted by tanning booth damaged the deep skin layers g) Slip! Slop! Slap! Wrap!

(1) Slip on a shirt (2) Slop on 15 SPF or higher sunscreen (3) Slap on a hat (4) Wrap on sunglasses before exposure to the sun B. Skin self-examination 1. Conduct on the same day each month 2. Recruit family members to help with the areas that are hard to examine such as the ears, scalp, and back 3. ABCDE rule a) Asymmetry b) Border c) Color d) Diameter e) Evolving

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

C. Prevention of burns 1. Advocate for patients 2. Develop teaching plans for families and communities to heightened awareness of the problem 3. Investigate conditions leading to burn injury and suggest methods to reduce prevalence

Chapter Highlights A. Intact structure and function of the integumentary system is vital to the protection of the body organs from the external environment.

B. This skin is the body’s largest organ, providing protection of fluid electrolyte balance, temperature regulation, and prevention of infection.

C. The hair serves a protective function over the body, including temperature regulation and capture of foreign particles. Another function is to trap sweat, which contains pheromones, useful in attraction.

D. The nails protect tips of fingers and toes as well as the soft tissue of the distal ends of the digits. The nails also enhance precise movements of the digits.

E. Manifestations of dysfunction, injury, and disorders affecting the integumentary system may be detected during a general health assessment as well as during focused integumentary assessments.

F. The health assessment interview determines the problems with the integumentary system as noted by the client.

G. The physical assessment is conducted by inspection and palpation. Examination provides an objective determination of integumentary issues.

H. Diagnostic test of the integumentary inform and support the diagnosis of specific injury or disease of the integumentary system.

I. Older adult integument commonly reveals expected age-related changes.

J. Integumentary issues of veterans are commonly related to exposure to environmental, chemical, or other substances not experienced by the general population.

K. While LGBTQI experience few primary integumentary conditions, those seen are usually related to other primary disease processes.

L. Adults with a history of complex congenital conditions do not usually have significant integumentary disorders. Any disorders noted to further commonly addressed in infancy or childhood.

M. The use of sunscreen is the most important health promoting action that patients can do to prevent long-term skin damage and reduce the risk of skin cancer.

N. Skin self-examination is an underutilized, but important skill set for patients. Use of monthly self-examination provides early detection of skin changes.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME ONE Separate the class into two groups. Have one group discuss normal integumentary assessment findings and have the other group discuss abnormal integumentary assessment findings. Then, have both groups share the information they discussed.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME ONE Ask students to assess their assigned patients for integumentary assessment findings. Discuss normal and abnormal findings.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME TWO Role-play, examining the skin of a patient with a rash. Ask questions based on the health history format.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME TWO Ask a dermatologist to speak to the clinical group regarding skin assessment on patients.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME THREE Discuss integumentary changes that occur with age.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME THREE Assign students to care for and perform a skin assessment on an older adult or veteran.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME FOUR Ask students to prepare patient education materials on how to prevent skin cancer. Share this with the class.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME FOUR Ask students to provide patient teaching on methods to prevent skin cancer to patients in the clinical setting.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter 16 Nursing Care of Patients with Integumentary Disorders

Learning Outcomes 1. Describe the pathophysiology and manifestations of common skin problems and lesions, and outline the interprofessional care and nursing care of patients with these disorders.

2. Describe the pathophysiology and manifestations of infections and infestations of the skin, and outline the interprofessional care and nursing care of patients with these disorders.

3. Describe the pathophysiology and manifestations inflammatory disorders of the skin, and outline the interprofessional care and nursing care of patients with these disorders.

4. Describe the risk factors for and pathophysiology and manifestations of an acute skin disorders, and outline the interprofessional care and nursing care of patients with these disorders.

5. Describe the risk factors for and pathophysiology and manifestations of malignant skin disorders, and outline the interprofessional care and nursing care of patients with these disorders.

6. Describe the pathophysiology in manifestations of skin trauma, and outline the interprofessional care and nursing care of patients with these disorders.

7. Describe the pathophysiology and manifestations of disorders of the hair and nails, and outline the interprofessional care of patients with these disorders.

Key Concepts I.

Common Skin Problems and Lesions A. The patient with pruritus 1. Pruritus: Subjective itching sensation producing an urge to scratch 2. Common causes: Insects, animals, plants, fabrics, metals, medications, allergies, and emotional distress 3. Pathophysiologic response: Irritating agent stimulates receptors in junction between epidermis and dermis; may also trigger release of chemical mediators; response is to scratch or rub the affected area 4. Itch–scratch–itch cycle 5. Secondary effects: Skin excoriation, erythema, wheals, changes in pigmentation, and infections 6. Management: Identify and eliminate cause, provide medications to relieve the itch B. The patient with dry skin (Xerosis) 1. Causes: Older age, environmental heat and low humidity, sunlight, excessive bathing, and decreased intake of liquids 2. Types of severe dry skin: Xeroderma and ichthyosis

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

3. Manifestations: Pruritus, visible flaking of surface skin and observable pattern of fine lines 4. Teach patient and family how to reduce dry skin and pruritus C. The patient with benign skin lesions 1. Cysts: Benign closed sacs lined with epithelium and contain fluid or semisolid material a) Most common types: Epidermal inclusion, pilar cysts 2. Keloids: Elevated, progressively enlarging scars a) More common in young adults b) Appear within one year of the initial trauma c) Risk factors: (1) African or Asian descent (2) Familial tendency (3) Excessive tension on a wound, poor alignment of skin edges 3. Nevi (moles): Flat or raised macules or papules with round, well-defined borders a) Nevocellular nevi: Tan to deep brown in color, small in size, grow in groups b) Dysplastic nevi: Flat, slightly raised, can appear as lesions with a darker, raised center and irregular border (1) It can transform into malignant lesions 4. Angiomas (hemangiomas): Benign vascular tumors a) Nevus flammeus (port-wine stain): Congenital vascular lesion that involves capillaries b) Cherry angiomas: Small rounded papules most commonly arising in the 40s c) Spider angiomas: Dilated superficial arteries d) Telangiectases: Single dilated capillaries or terminal arteries e) Venous lakes: Small, flat, blue blood vessels 5. Skin tags: Soft papules on a pedicle 6. Keratoses: Skin condition where there’s a benign overgrowth and thickening of the cornified epithelium a) Seborrheic keratosis: Superficial flat, smooth, or warty surfaced growth, 5–20 mm in diameter, on our face and trunk D. The patient with psoriasis 1. Most common type: Plaque psoriasis 2. Occurs most often in Caucasians 3. Precipitating factors: Sunlight, stress, seasonal changes, hormone fluctuations, steroid withdrawal, certain drugs, family history, skin trauma from surgery, sunburn, and excoriation 4. Pathophysiology and manifestations a) Hyperkeratosis (1) Immature cells produce abnormal keratin (2) Increased cell metabolism stimulates increased vascularity 5. Manifestations

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) Characteristic lesions: Well-demarcated regions of erthematous plaques that shed thick, silver-gray flakes b) Nails: Pitting, yellow or brown discoloration; nail may separate from bed, thicken, and crumble c) Psoriatic arthritis 6. Interprofessional care a) Diagnosis (1) Skin biopsy (2) Ultrasound b) Medications (1) Topical medications (2) Photochemotherapy (3) Corticosteroids, tar preparations, anthralin, calcipotriene, a vitamin D derivative, adalimumab, and tazarotene (4) Ustekinumab: Injectable monoclonal antibody (5) Medications that impact inflammatory and immune responses may be indicated c) Treatment (1) Generalized psoriasis (a) Phototherapy: Ultraviolet-B light or narrow band UVB (b) Photochemotherapy: Uses light-activated form of methoxsalen 7. Nursing care a) Assessment b) Priorities of care (1) Ensure adequate treatment of underlying process (2) Support physical and psychological responses; provide emotional support (3) Teach patient and caregivers strategies for self-care c) Diagnosis, outcomes, and interventions (1) Reduce the risk for impaired skin integrity (a) Teach methods to reduce injury to skin when taking therapeutic baths (b) Teach how to apply topical medications (c) Teach manifestations of infection; how to contact healthcare provider (d) Teach manifestations of complications of treatment (2) Address disturbed body image (a) Establish trusting relationship; demonstrate lesions are not contagious (b) Encourage expression of self-perception and asking of questions (c) Promote social interaction through family involvement and support groups d) Delegating nursing care activities e) Transitions of care: (1) The chronic nature of the disease, factors that may precipitate an exacerbation, and methods to reduce stress (2) Interventions for pruritus and dry skin, specific care for psoriasis

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(3) Suggest the National Psoriasis Foundation, the National Institutes of Health, or the American Academy of Dermatology as resources II.

Infections and Infestations of the Skin A. The patient with a bacterial infection of the skin 1. Pyoderma: Infection resulting from a break in the skin allowing invasion by pathogenic bacteria 2. Pathophysiology and manifestations a) Folliculitis: Bacterial infection of hair follicle commonly caused by Staphylococcus aureus b) Furuncles (boils): Infection of hair follicle c) Carbuncles: Group of infected hair follicles d) Cellulites: Localized infection of dermis and subcutaneous tissue e) Methicillin-resistant staphylococcus aureus (MRSA) infection: Caused by S. aureus bacteria (1) Healthcare-associated infections and community-associated infections 3. Interprofessional care a) Diagnosis: Lesion or blood culture b) Medications: Antibiotics specific to organism (taken orally and topically) 4. Assessment 5. Priorities of care a) Priorities of care: Prevent spread of infection, promote comfort, and prevention of infection recurrence 6. Diagnosis, outcomes, and interventions a) Reduce risk for infection (1) Practice good hand washing and teach its importance (2) Assess for and teach how to identify an increase in infection (3) Cover draining lesions with a sterile dressing, and handle soiled dressings or linens according to standard precautions; wear disposable gloves and masks when changing dressings 7. Delegating nursing care activities a) Measuring fluid intake and output, collecting vital signs, encouraging oral or enteral fluid intake, and skin care 8. Transitions of care a) Reduce MRSA with good hand hygiene b) People colonized or infected patients with MRSA on contact precautions c) Provide patient teaching (1) Maintain good nutrition (2) Maintain cleanliness through hand hygiene; proper handling, disposal of dressings (3) Prevent the spread of infection by not sharing linens, towels; washing clothing, linens in hot water

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(4) Do not squeeze or open a pimple or boil (5) Take the full course of prescribed antibiotics B. The patient with a fungal infection 1. Dermatophytes: Fungi that cause superficial skin infections 2. Pathophysiology and manifestations a) Dermatophytoses (tinea): Superficial fungal infections of the skin (1) Risk: Moisture, use of broad-spectrum antibiotics, diabetes mellitus, immunodeficiencies, nutritional deficiencies, pregnancy, increasing age, and iron deficiency (2) Types: Tinea pedis, tinea corporis, and tinea cruris 3. Interprofessional care: Primarily diagnosed in outpatient settings; treated at home a) Diagnosis (1) Cultures (2) Microscopic examination using KOH (3) Examination of skin with ultraviolet light (Wood’s lamp) b) Medications: Topical or systemic antifungal medications 4. Nursing care: a) Teaching topics (1) Do not share linens or personal items (2) Use a clean towel and washcloth each day (3) Carefully dry all skinfolds (4) Wear clean cotton underclothing each day (5) Do not wear same pair of shoes every day, wear socks that permit moisture to wick away from the skin surface, do not wear rubber- or plastic-soled shoes, use talcum powder, or an OTC antifungal powder twice a day C. The patient with a parasitic infestation 1. It can occur in any geographic area of the world, associated with crowded or unsanitary living conditions 2. Pathophysiology in manifestations a) Pediculosis: Lice infestation (1) Common types: Pediculosis corporis and pediculosis pubis b) Scabies: Mite infestation 3. Interprofessional care a) Diagnosis (1) Pediculosis: Examine hair shaft, clothing (2) Scabies: Skin scrapings and microscopic examination for mites or feces 4. Medications a) Lice: Topical medications that contain gamma benzene hexachloride, malathion (Prioderm lotion), or permethrin (NIX); shampoos containing lindane b) Scabies: Single treatment of lindane lotion applied to skin surface for 12 hours .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

5. Nursing care a) Patient teaching: (1) Wash clothing and linens in soap and hot water, or dry clean (2) Ironing the clothes kills any lice eggs (3) All family members and sexual partners must also be treated (4) Lice and mites may infest anyone D. The patient with a viral infection 1. Causes: Birth control, corticosteroids, and antibiotics 2. Pathophysiology a) Warts: Lesions of skin caused by the human papillomavirus (HPV) (1) Common wart (verruca vulgaris) (2) Plantar warts: Occur at pressure points on soles of feet (3) Flat wart (verruca plana): Small, flat lesion on forehead or dorsum of hand (4) May be treated with medications, cryotherapy, electrodesiccation, and curettage (5) Wart removal: Acid therapy, cryosurgery, and electrodesiccation b) Herpes simplex (fever blister, cold sore) (1) Caused by two types of herpesvirus: HSV I and HSV II (2) Transmitted by physical contact, oral sex, or kissing (3) May form in response to sunlight, menstruation, injury, and stress c) Herpes zoster (shingles) (1) Caused by reactivation of varicella zoster (2) Most common in adults over 60, patients with Hodgkin’s disease, certain types of leukemia, lymphomas, and immunocompromised (3) Complications: Postherpetic neuralgia and visual loss 3. Interprofessional care a) Focused on stopping viral replication and treating patient responses b) Diagnosis (1) Manifestations and appearance of lesions (2) Tzanck smear, cultures of fluid from vesicles and antibody tests: Used to differentiate herpes zoster from contact dermatitis and herpes simplex (3) HIV test should be considered for patients under 55 with a history of HIV risk factors c) Medications (1) Herpes zoster: Antiviral drugs (2) Decrease severity of herpes infections: Acyclovir (Zovirax) (3) Pain management: Nerve blocks, narcotic and nonnarcotic analgesics (4) Relief of pruritus: Antihistamines (5) Eye involvement: Topical steroid ophthalmic ointments and mydriatics (6) Zostavax: Vaccine for adults over 60 to prevent herpes zoster 4. Nursing care a) Assessment .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

b) Priorities of care (1) Managing infection, puritis, and pain (2) Teach about preventing the spread of the viruses to others 5. Diagnosis, outcomes, and interventions a) Manage acute pain (1) Monitor the location, duration, and intensity of the pain (2) Explain the rationale for taking prescribed medications on a regular schedule (3) Teach measures to relieve pruritus (4) Encourage the use of distraction (such as music) or a specific relaxation technique b) Reduce risk for infection (1) If hospitalized, monitor white blood cell count and assess for lymph gland enlargement (2) Teach interventions to decrease itch–scratch–itch cycle (3) Institute infection control procedures for hospitalized patients c) Delegating nursing care activities 6. Transitions of care a) A vaccine is available to help prevent herpes zoster b) Self-limiting and heals completely; second occurrences of herpes zoster are rare c) Do not have social contact with children or pregnant women until crusts have formed over the blistered areas with herpes zoster d) Use pain medications regularly e) Follow suggestions to help reduce itching, scratching, and pain f) Report any increase in pain, fever, chills, drainage that smells bad and has pus, or a spread in the blisters to your healthcare provider III.

Inflammatory Disorders of the Skin A. The patient with dermatitis 1. Dermatitis: Inflammation of skin characterized by erythema and pain or pruritus 2. Pathophysiology and manifestations a) Caused by exogenous and endogenous agents b) Skin responses: Erythema, formation of vesicles and scales, pruritus 3. Contact dermatitis (a) Causes: Alkalis, cosmetics, hydrocarbons, fabrics, metal salts, and plants (i) Allergic contact dermatitis: Cell-mediated or delayed hypersensitivity to a wide variety of allergens; first exposure is sensitizing with manifestations experienced on second exposure (ii) Irritant contact dermatitis: Latex dermatitis, inflammation from irritants, and it is not a hypersensitivity response (2) Atopic dermatitis (eczema) (a) Cause unknown, but related factors: Depressed cell-mediated immunity, elevated IgE levels, and increased histamine sensitivity

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(b) Results from a Type-1 hypersensitivity response (3) Seborrheic dermatitis (a) Chronic inflammatory disorder involving scalp, eyebrows, eyelids, ear canals, nasolabial folds, axillae, and trunk (b) Cause unknown (4) Exfoliative dermatitis (a) Inflammatory skin disorder characterized by excessive peeling or shedding of skin (b) Causes: Unknown in half of cases; preexisting skin disorder found in 63% of cases; cancer may also be a cause (c) Systemic and localized manifestations 4. Interprofessional care a) Diagnosis (1) Based on manifestations, history of exposures to irritants, and suspected foods (2) Scratch tests and intradermal tests b) Medications (1) Minor cases: Antipruritic medications (2) Severe cases: Oral antihistamines, oral and/or topical corticosteroids, and wet dressings (3) Topical immunosuppressive modulators: Possible link to skin cancer and lymphoma 5. Nursing care a) Information for self-care at home B. The patient with acne 1. Acne: Disorder of pilosebaceous structure 2. Pathophysiology and manifestations a) Noninflammatory or inflammatory b) Comedones (1) Closed or open c) Inflammatory acne lesions: Comedones, erythematous pustules, and cysts d) Forms of acne (1) Acne vulgaris (2) Acne conglobata (3) Acne rosacea 3. Interprofessional care a) Diagnosis (1) Location and appearance of lesions (2) Culture of drainage performed in case of pustules b) Medications (1) Tailored to individual, based on severity of lesions (2) Comedones: Tretinoin, benzoyl peroxide, and azelaic acid .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(3) Mild papular inflammatory acne: Topical clindamycin (4) Moderate forms of popular inflammatory acne: Oral or topical antibiotics c) Treatments (1) Scars: Dermabrasion and laser treatment 4. Nursing care a) Individualized, conducted through teaching in clinics or healthcare provider offices b) General guidelines for skin care, health, and specific guidelines for care of acne lesions C. The patient with pemphigus vulgaris 1. Chronic disorder of skin and oral mucous membranes characterized by blister formation 2. Causes: Autoantibodies that cause acantholysis D. The patient with lichen planus 1. Inflammatory disorder of the mucous membranes and skin 2. Causes: Unknown cause, associated with exposure to drugs or to film processing chemicals IV.

Acute Skin Disorders A. The patient with Stevens–Johnson syndrome 1. Serious condition of the skinny mucous membranes a) Cause: Unpredictable reaction to medication or an infection b) Can be life-threatening depending on the extent of skin sloth c) Risk factors (1) Immune system abnormalities (2) History of prior Stevens–Johnson syndrome (3) Family history is Stevens–Johnson syndrome d) Initial signs and symptoms: General and integument specific (fever, unexplained skin pain; red-purple spreading rash and blister formation) e) Skin sloughing begins within days of blister formation 2. Interprofessional care a) Hospitalization in an ICU or burn unit b) Stop nonessential medications to limit exposure to potential triggers c) New skin may grow within several days if underlying cause is eliminated; full recovery may take several months 3. Diagnosis a) History and physical examination b) Skin biopsy to confirm diagnosis c) Scaling cultures to confirm or rule out infection d) Calculate SCORTEN scale within 3 days of hospitalization to determine risk of death 4. Medications a) Manage pain b) Topical steroids to reduce inflammation of ice mucous membranes

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

c) Immune response modifiers or immunoglobulin on a case-by-case basis 5. Treatments a) Fluid replacement, nutrition, wound care of cool, wet compress for blisters or burntype dressings where sloughing has occurred; ophthalmology care, if eyes are involved 6. Nursing care a) Skin care, reduction of discomfort, avoidance of fluid and electrolyte loss, and prevention infection, burn care interventions for severe cases 7. Transitions of care a) Recovery can take weeks to months b) Permanently avoid drug and others related to it if caused by a medication c) Recurrence can be more severe and potentially fatal V.

Malignant Skin Disorders A. Malignant skin tumors are the most common of all cancers B. The patient with actinic keratosis 1. Epidermal skin lesion directly related to chronic sun exposure and photodamage 2. Treatment: Cryosurgery, 5-fluorouracil cream C. The patient with nonmelanoma skin cancer 1. Main types: Basal cell cancer and squamous cell cancer 2. Other types (less than 1%): Merkel cell carcinoma, Kaposi sarcoma, lymphomas, sarcomas, and adnexal tumors of skin 3. Incidence and risk factors a) Most common malignant neoplasm in fair-skinned, freckles, blue or green eyes, and blonde or red hair b) Family history of skin cancer c) Unprotected and/or excessive exposure to ultraviolet radiation d) Occupational exposure to coal tar, pitch, creosote, arsenic compounds, or radium e) Severe sunburns as a child 4. Environmental factors a) Ultraviolet radiation (UVR) from the sun (1) Tumor suppressor genes (a) P53: Damaged gene in basal cell cancer (b) “Patched” (PTCH) gene: Damaged gene in squamous cell cancer (2) Geographic, environmental, lifestyle factors affect amount of exposure to sun (3) Chemicals: Polycyclic aromatic hydrocarbons, psoralens (4) Other risk factors: Ionizing radiation, viruses, physical trauma, x-ray therapy for tinea capitis, radium treatment, HPV, damage to skin from burns, and organ transplant recipients undergoing immunosuppression b) Host factors (1) Skin pigmentation

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(2) Change in an existing lesion or presence of a premalignant lesion 5. Pathophysiology and the manifestations a) Basal cell cancer: Epithelial tumor believed to originate from basal layer or from cells in surrounding dermal structures (1) Impaired ability of basal cells to mature into keratinocytes (2) Most common, least aggressive type of skin cancer (3) Reoccurring (4) Nodular basal cell cancer: Most common; appears that face neck and head (5) Superficial basal cell cancer: Second most common; found on trunk and extremities (6) Pigmented basal cell cancer: Less common; found on head and neck and face (7) Morpheaform basal cell cancer: Rarest, develop some head and neck (8) Keratotic basal cell cancer: Tends to recur locally, most likely to metastasize; find on preauricular and postauricular groove b) Squamous cell cancer (1) Malignant tumor of the squamous epithelium of the skin or mucous membranes (2) Aggressive, faster growth rate, greater potential for metastasis if untreated (3) Bowen’s disease or cancer in situ: Early form of squamous cell cancer (4) Invasive squamous cell cancer: Comes from preexisting skin lesions 6. Interprofessional care a) Diagnosis (1) Microscopic examination of tissue biopsied from tumor (2) Types of biopsy: Shave, punch, incisional, and excisional b) Treatments (1) Surgical excision (2) Mohs’ surgery (3) Curettage and electrodesiccation (4) Radiation therapy (5) Other forms of local therapy (a) Cryosurgery (b) Photodynamic therapy (PDT) (c) Topical chemotherapy (d) Immune response modifiers (e) Laser surgery (f) Vismodegib (Erivedge) and sonidegib (Odmzo) 7. Nursing care a) Health promotion (1) Prevention and early detection b) Transition of care (1) Teach patient and family measures for self-care following surgery D. The patient with melanoma .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

1. Melanoma (malignant melanoma): Arises from melanocytes 2. Incidence and risk factors a) 10× more common in fair-skinned people b) Slightly more common in men c) Greatest rate in those over 80 3. Exact cause unknown 4. Risk factors a) High number of moles or large moles b) Fair skin, freckling, blonde hair color, or blue eyes c) Men with gene changes from a family history of breast or ovarian cancer d) Treatment with medications that suppress the immune system e) Over exposure to UV radiation f) Age over 50 g) Xeroderma pigmentosus h) Past history of melanoma 5. Pathophysiology and manifestations a) Melanomas: More than 6 mm diameter, asymmetric, initially develop within the epidermis over long period b) Precursor lesions (premalignant lesion) (1) Congenital nevi: Present at birth (2) Dysplastic nevi (atypical moles): Become dysplastic after puberty (3) Lentigo maligna (Hutchinson’s freckle) c) Classification (1) Superficial spreading melanoma: Most common type (2) Lentigo maligna melanoma: Arises from precursor lesion, lentigo maligna (3) Nodular melanoma (4) Acral lentiginous melanoma (mucocutaneous melanoma) 6. Interprofessional care a) Identification (1) Most often found on trunk of men, lower extremities of women (2) Physical examination and total skin assessment (3) Palpation of regional lymph nodes, liver, and spleen (4) ABCDE rule + the ugly duckling sign b) Diagnosis (1) Test to determine whether tumor has metastasized: Microscopic examination, biopsy, and tests for metastasis c) Microstaging: Assessment of level of invasion of a malignant melanoma and maximum tumor thickness (1) Clark system d) Treatments (1) Surgery: Preferred treatment

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(a) Clinically suspicious lymph node: Excision of primary lesions, surgical dissection (b) Palliative management of isolated metastasis (2) Immunotherapy: Relatively new treatment (3) Radiation therapy: Frequently used for palliation of symptoms (4) Biological therapy: Boosts or restores ability of immune system to fight cancer (a) Agents: Monoclonal antibodies, growth factors, and vaccines (5) New methods of treatment (a) Gene therapy (b) Melanoma DNA research (c) Staging 7. Nursing care a) Assessment (1) Health history and physical assessment b) Priorities of care (1) Teach strategies to prevent infection, optimize comfort, promote safe behaviors, promote comfort, and maintain asepsis for interruptions of integument c) Diagnoses, outcomes, and interventions (1) Promote skin integrity (a) Monitor for manifestations of infection (b) Keep incision line clean and dry by changing dressings as necessary (c) Follow principles of medical and surgical asepsis when caring for incision (d) Encourage and maintain adequate caloric and protein intake in the diet (2) Promote hopefulness (a) Provide environment that encourages patient to identify and express feelings, concerns, and goals (b) Encourage active participation in self-care as well as mutual decision-making and goal setting (c) Encourage a focus not only on the present but also on the future (3) Reduce anxiety (a) Provide reassurance and comfort (b) Decrease sensory stimuli by using short, simple sentences (c) Provide interventions that decrease anxiety levels and increase coping 8. Delegating nursing care activities 9. Transitions of care a) Teach self-care and ongoing self-monitoring; type of care specific to type of treatment VI.

Skin Trauma A. The patient with a pressure injury 1. Pressure ulcers: Ischemic lesions of skin and underlying tissues caused by unrelieved pressure that impairs flow of blood and lymph 2. Incidence and risk factors

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) Prevention and treatment is a public health issue b) Complications: Infection, loss of function, and pain 3. Pathophysiology and manifestations a) Causes (1) External pressure compressing blood vessels (2) Shearing forces: One tissue layer slides over another b) Interprofessional care (1) Prevention c) Diagnosis (1) Diagnostic test to identify secondary infection and differentiate the cause d) Medications (1) Topical and systemic antibiotics, products to promote healing e) Treatment (1) Surgical debridement: In case of deep pressure ulcer, if subcutaneous tissues are involved, if an eschar has formed over the ulcer (2) Skin grafting in case of large wounds 4. Nursing care a) Assessment b) Priorities of care (1) Ensure adequate prevention in high-risk patients (2) Treat pressure ulcer while providing care that promotes healing, infection prevention (3) Teach strategies to prevent development or progression of ulcers (4) Promote comfort and maintain asepsis c) Diagnoses, outcomes, and interventions (1) Reduce risk for impaired skin integrity (a) Identify at-risk individuals (b) Assess bed- and chair-bound patients for additional risk factors (c) Assess patients on admission to acute care and rehabilitation hospitals, nursing homes, home care programs, and healthcare facilities (d) Use systemic risk assessment by using validated risk assessment tool (e) Document all assessments of risk (f) Conduct systemic skin inspection at least once a day (i) Location of any lesion or ulcer (ii) Tunneling (iii) Undermining (iv) Visible necrotic tissue (v) Presence of an exudate (vi) Presence or absence of granulation tissue (g) Clean the skin at time of soiling and at routine intervals (h) Minimize environmental factors leading to skin drying, such as low humidity and exposure to cold .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(i) Avoid massage over bony prominences (j) Minimize skin exposure to moisture (k) Minimize skin injury due to friction and shearing forces (l) Avoid placing patients in sideline position directly on the trochanter (m) Assess factors involved in inadequate dietary intake of protein or kilocalories (n) Maintain patient’s current level of activity, mobility, and range of motion (o) Provide interventions for patient on bed rest, or immobile (p) For totally immobile patients, use devices to relieve pressure on heels (q) Avoid placing patients in the side lying position directly on the trochanter (r) Maintain head of bed at lowest degree of elevation (s) Use assistive devices to move patients in bed who cannot assist during transfers and position changes (t) Place any at-risk patient on a pressure-reducing device (u) For chair-bound patients, use pressure-reducing devices 5. Delegating nursing care activities 6. Transitions of care a) Teach care for pressure ulcer and prevention b) Referrals to home health agency or community health department B. The patient with frostbite 1. Skin freezes at 14°F to 24.8°F 2. Most common on exposed or peripheral areas of body 3. Pathophysiology: Increase in intracellular sodium content, cellular and tissue swelling, infarction, and necrosis of affected tissue 4. Superficial frostbite: Numbness, itching, and prickling 5. Deeper frostbite: Stiffness and paresthesia 6. Guidelines for rewarming areas of frostbite a) Outdoors, superficial frostbite: Apply firm pressure with a warm hand or place frostbitten hands in the axillae b) Feet: Remove wet footwear, dry, put on dry footwear; do not rub with snow c) Hospital: Rapidly rewarm affected areas in circulating warm water, 104°F to 105°F (40°C to 40.5°C) for 20–30 minutes; do not rub or massage the areas 7. Following rewarming: Bed rest, elevated, administer pain medication and antiinflammatory agents, debride blisters, whirlpool therapy, and amputate necrotic tissue C. The patient undergoing cutaneous or plastic surgery 1. Interprofessional care 2. Cutaneous surgery and procedures a) Fusiform excision: Removal of full thickness of epidermis and dermis, usually with thin layer of subcutaneous tissue b) Electrosurgery: Destruction or removal of tissue with high-frequency alternating current .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Procedures: Electrodesiccation, electrocoagulation, and electrosection c) Cryosurgery: Destruction of tissue by cold or freezing with agents such as fluorocarbon sprays, carbon dioxide snow, nitrous oxide, and liquid nitrogen d) Curettage: Removal of benign and malignant superficial epidermal lesions with a curette e) Laser surgery: Treats a variety of skin disorders using lasers to cause coagulation, vaporization, excision, and ablation f) Chemical destruction: Application of a specific chemical to produce destruction of skin lesions (benign and premalignant) g) Sclerotherapy: Removal of benign skin lesions with sclerosing agent that causes inflammation with fibrosis of tissue 3. Plastic surgery a) Skin grafts and flaps: Restore function and maintain acceptable appearance (1) Skin graft: Split thickness or full thickness (2) Skin flap: Carry their own blood supply b) Chemical peeling: Cosmetic surgery to make skin firmer, smoother, and less wrinkled c) Liposuction: Aspirating fat from subcutaneous layer of tissue d) Dermabrasion: Removes facial scars, severe acne, and pigment from unwanted tattoos e) Facial cosmetic surgery (1) Rhinoplasty (2) Blepharoplasty (3) Rhytidectomy 4. Nursing care a) Individualized for the patient and procedure performed b) Assessment c) Priorities of care (1) Ensure adequate treatment of viral skin infection, provide care promoting recovery and comfort, teach patient to prevent infection, optimize comfort, promote safe home and work environments, and maintain asepsis d) Diagnoses, outcomes, and interventions (1) Address impaired skin integrity (a) Monitor incisions and graft, flap donor and recipient sites, manifestations of infection and necrosis (b) Provide care for donor site (c) Encourage a diet high in protein, ascorbic acid, vitamins, and minerals (d) Change dressings as prescribed, or as necessary (2) Manage acute pain (a) Administer pain medications regularly (b) Use alternative pain relief measures (c) Teach noninvasive methods of pain relief (3) Promote a healthy body image (a) Provide preoperative teaching .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(b) Provide time for patient to verbalize feelings and concerns (c) Refer to a consultant who can provide information on use of cosmetics and apparel to enhance personal appearance 5. Delegating nursing care activities 6. Transitions of care a) Provide self-care at home after cutaneous and plastic surgery procedures b) Ask about patient’s expectations and stress final results won’t be seen for months c) Written instructions for wound care, manifestations of infection VII.

Hair and Nail Disorders A. The patient with a disorder of the hair 1. Pathophysiology and manifestations a) Hirsutism (hypertrichosis): Excessive hair in women (1) Manifestations: Male pattern hair growth, acne, menstrual irregularities, defeminization, and virilization b) Alopecia (1) Causes: Scarring, various systemic diseases, genetic predisposition, androgenic causes, and drug induced (2) Types (a) Male pattern baldness (b) Female pattern alopecia (c) Alopecia areata 2. Interprofessional care a) Diagnosis (1) Hirsutism: Serum testosterone levels, adrenal CT scan, pelvic examination, and tests for ovarian function (2) Alopecia: Assess appearance of hair and hair loss, assess for systemic diseases, and use of medications b) Medications (1) Hirsutism: Oral contraceptives, dexamethasone, ketoconazole, and antiandrogenic medications (2) Male pattern baldness: Topical minoxidil, Rogaine Extra Strength c) Surgery (1) Hair transplant techniques, scalp reduction, and flaps 3. Nursing care a) Teach self-care, provide support for long-term care B. The patient with a disorder of the nails 1. Pathophysiology and manifestations a) Onycholysis: Separation of the distal nail plate from the nail bed b) Paronychia: Infection of the cuticle of fingernails or toenails c) Onychomycosis: Fungal or dermatophyte

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

d) Unguis incarnates (Ingrown toenail): Edge of nail plate grows into soft tissue of the toe 2. Interprofessional care a) Treatment: Pharmacologic treatment to surgical removal 3. Nursing care a) Focuses on teaching self-care

Chapter Highlights A. Pruritus (itching) accompanies dry skin (xerosis) and many skin disorders and may result in excoriation and infection as a result of scratching.

B. Cysts, keloids, nevi, angiomas, skin tags, and keratoses are benign skin lesions.

However, nevi should be monitored for changes indicating transformation into a malignant lesion.

C. Psoriasis is a chronic immune skin disorder arising from keratinocytes. A variety of medications and treatments are used, with ultraviolet light therapy being most effective for generalized lesions.

D. Skin disorders may be caused by a variety of bacteria, fungi, parasites, and viruses.

The disorders are treated with organism-specific antibiotics, fungicides, antiviral agents, or agents that kill the parasites.

E. Methicillin-resistant Staphylococcus aureus (MRSA) infection is divided into two types: Healthcare-associated infections (acquired in hospitals and other healthcare settings) and community-associated infections (acquired in the community in otherwise healthy people). MRSA causes significant impacts on care management, resource use, and costs.

F. Herpes zoster, believed to follow a childhood infection with chickenpox, causes acute pain.

G. Inflammatory disorders of the skin range from mild dermatitis to potentially lethal.

H. Acne, a disorder of the hair and sebaceous glands opening to the skin surface, is characterized by comedones, pustules, and cysts.

I. Other inflammatory disorders include pemphigus vulgaris (chronic disorder of the skin and oral mucous membranes characterized by blister formation) and lichen planus (persistent thick, dark red lesions). Care focuses on reducing severity of the illness, symptom management, and prevention of infection.

J. Stevens–Johnson syndrome, a rare and serious condition of the skin and mucus membranes, results as an immune response to medication or infection. The process is characterized by epidermal necrosis with minimal associated inflammation.

K. Care focuses on skin care, reduction of discomfort, avoidance of fluid and electrolyte loss, and prevention of infection. For severe cases, nursing care is similar to care of the burn patient.

L. Malignant skin disorders include actinic keratosis, nonmelanoma skin cancer (basal cell cancer and squamous cell cancer), and malignant melanoma skin cancer. Skin cancer is the most common malignancy found in fair-skinned Americans.

M. Avoiding sunburn, using sunscreen, and maintaining monthly skin self-examination is critical in preventing loss of tissue or metastasis and death. .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

N. Skin trauma may be intentional (as in the case of cutaneous and plastic surgery) or unintentional (as from trauma, frostbite, and pressure injuries).

O. Older adults with limited mobility, as well as patients who are unable to move or who are in critical care units, are at greater risk for pressure injuries. Prevention of pressure injuries is the goal of both interprofessional and nursing care.

P. Disorders of the hair include hirsutism (excess hair in women) and alopecia (loss of hair).

Q. Nails may be discolored, multicolored, malformed, infected, or separated from underlying tissue.

SUGGESTIONS FOR CLASSROOM ACTIVITY—LEARNING OUTCOME ONE Discuss the cause and treatment of dry skin. What nursing interventions should be considered?

Discuss the cardinal signs of a melanoma.

Arrange for the students to practice that application of topical medications in the nursing skills laboratory.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME ONE Discuss the proper method of application of topical medications. Arrange for the students to practice that application of topical medications in the nursing skills laboratory.

SUGGESTIONS FOR CLASSROOM ACTIVITY—LEARNING OUTCOME TWO Develop a teaching plan for patients to prevent the spread of infectious lesions.

Split the class into small groups of 3–4 students. Assign each group an infectious skin disorder.

Have the groups research the pathophysiology and interprofessional and nursing care of the assigned disease and then present the information to the class.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME TWO Assign students to care for a patient with a skin infection.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME THREE Split the class into small groups of 3–4 students. Assign each group an inflammatory skin disorder.

Have the groups research the pathophysiology and interprofessional and nursing care of the assigned disease and then present the information to the class.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME THREE Assign students to care for a patient with an inflammatory skin disorder.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME FOUR Work with students to create a care plan for the patient with Stephens–Johnson syndrome.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME FOUR Arrange for the students to shadow a nurse in a dermatologist’s office. Have them observe various treatments of skin disorders.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME FIVE Split the class into small groups of 3–4 students. Assign each group a malignant skin disorder. Have the groups research the pathophysiology and interprofessional and nursing care of the assigned disease and then present the information to the class.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME FIVE Ask students to screen patients for risk factors for malignant skin disorders.

SUGGESTIONS FOR CLASSROOM ACTIVITY—LEARNING OUTCOME SIX Create a nursing care plan based on an 82-year-old homebound, wheelchair-bound stroke patient.

Create a care plan for a postoperative patient who has had a flap reconstruction.

Discuss the differences between cosmetic and reconstructive procedures.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME SIX Demonstrate proper skin care for the mobility-compromised patient.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME SEVEN Discuss the disease process that is common in patients who use nail salons. How can one prevent contracting an infection in a salon?

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME SEVEN Assign students to care for a patient with a hair or nail disorder.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter 17 Nursing Care of Patients with Burns

Learning Outcomes 1.

2.

3.

4.

Discuss the types and causative agents of burns.

Explain burn classification by depth and extent of injury.

Outline the three stages of burn wound healing.

Describe the pathophysiology and manifestations of minor burns of the skin, and outline the interprofessional care and nursing care of patients with minor burns.

5. Describe the pathophysiology and manifestations of major burns of the skin, and outline the interprofessional care and nursing care of patients with major burns.

Key Concepts Burn: An injury resulting from exposure to heat, chemicals, radiation, or electric current.

A. Infants and older adults at greater risk for death I. Types of Burn Injury A. Thermal burns 1. Result from dry heat (flames) or moist heat (steam, hot liquids) 2. Most common burn injuries B. Chemical burns 1. Caused by direct skin contact with acids, alkaline agents, and organic compounds 2. Chemical destroys tissue protein, leading to necrosis 3. Classification of chemical agents: Oxidizing, corrosive, and protoplasmic poisons C. Electrical burns 1. Severity depends on type and duration of current, amount of voltage 2. Destructive processes are concealed, may persist for weeks after incident 3. Alternating current (AC): Leads to titanic muscle contractions 4. Direct current (DC): High voltage exposure for instantaneous period of time D. Radiation burns 1. Most common: Sunburn or radiation treatment for cancer II.

Factors Affecting Burn Classification A. Depth of burn: Results from temperature of burning agent and length of contact 1. Superficial burns: Involves epidermal layer

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) Examples: Sunburn, UV light, minor flash injury, and mild radiation burn from cancer treatment b) Treatment: Mild analgesics, water-soluble lotions (extensive burns may require intravenous fluid treatment) 2. Partial-thickness burns a) Superficial partial-thickness burn: Epidermis and papillae of the dermis (1) Treatment: Analgesics, skin substitutes if large blistered areas are disrupted b) Deep partial-thickness burn: Extends further into the dermis (1) Excision and grafting may be necessary 3. Full-thickness burns: All layers of skin (epidermis, dermis, epidermal appendages), may extend into subcutaneous fat, connective tissue, muscle, and bone a) Require skin grafting to heal 4. Extension to deep tissue (formally called fourth degree burns) a) Extend to deep tissue; potentially life-threatening B. Extent of the burn 1. Expressed as percentage of total body surface area (TBSA) 2. Methods for calculating TBSA a) “Rule of nines” b) Lund and Browder method c) American Burn Association classification table: Use both extent and depth of burn to classify burns as minor, moderate, major III.

Burn Wound Healing A. Inflammation 1. Platelets in contact with damaged tissue aggregate 2. Thrombus forms, leading to hemostasis 3. Local vasodilation and increased capillary permeability follows 4. Monocytes convert into macrophages 5. Growth factors stimulate proliferation of fibroblasts; provisional wound matrix deposited B. Proliferation 1. Granulation tissue forms; complete reepithelialization occurs C. Remodeling 1. Collagen fibers reorganized into more compact area 2. Scars contract, fade 3. Excessive scar tissue may develop a) Hypertrophic scar b) Keloid

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

IV.

Minor Burns 1. Superficial burns that are not extensive 2. Superficial partial-thickness burns involving less than 15% TBSA 3. Full-thickness burns involving less than 2% TBSA, excluding special care areas A. The Patient with a Minor Burn B. Pathophysiology and manifestations 1. Sunburn a) Manifestations: Pain, nausea, vomiting, skin redness, chills, and headache b) Treatment: Apply mild lotions, increase liquid intake, administer mild analgesics, and maintain warmth 2. Scald burn a) Goals of therapy: Promote healing, prevent wound contamination b) Teach the patient to apply antibiotic solutions, light dressings, and maintain nutritional intake C. Interprofessional care 1. Wash wound with mild soap and water 2. Tetanus toxoid booster 3. Follow-up care: Wound cleansing with topical ointment, ROM exercises, weekly clinic appointments D. Nursing care 1. Take history, estimate extent and depth of the injury, cleanse the wound, apply topical agents, dress the wound, control pain, and establish follow-up care 2. Assessment a) Health history b) Determining the extent and depth of burn injury 3. Priorities of care a) Teach strategies for pain management, infection control and self-care, provide emotional support E. Transitions of care 1. How to identify and report manifestations of impaired wound healing 2. Wound care 3. Pain management

V.

Major Burns 1. >25% TBSA in adults less than 40 years of age 2. >20% TBSA in adults more than 40 years of age 3. >10% TBSA full-thickness burn 4. Injuries to the face, eyes, ears, hands, feet, or perineum

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

5. High-voltage electrical injuries 6. All burn injuries with inhalation injury or major trauma A. The Patient with a Major Burn B. Pathophysiology 1. Integumentary system a) Key mechanisms lost: Prevention of evaporative water loss and bacteria entry, maintenance of body warmth b) Burn zones (1) Outer zone of hyperemia: Unburned tissue, blanches on pressure, heals in 2 to 7 days postburn (2) Medial zone of stasis: Moist, red, blistered, blanches on pressure; may recover or become pale and necrotic on days 3 to 7 postburn (3) Inner zone of coagulation: Leathery, coagulated; may merge with the zone of stasis in 3 to 7 days postburn c) Eschar: Hard crust forms in acute stage of injury, covering the wound 2. Cardiovascular system a) Hypovolemic shock (burn shock): Continues until capillary integrity is restored (1) Early postburn phase in patients with >40% TBSA (a) Increase in microvascular permeability at the burn wound site (b) Generalized impairment of cell wall function, resulting in intracellular edema (c) Increase in osmotic pressure of the burned tissue, leading to extensive fluid accumulation (2) Vasoconstriction occurs as vascular system attempts to compensate fluid loss (3) Thrombosis occurs from abnormal platelet aggregation and WBC accumulation (4) Intravascular hypovolemia and edema at burn wound site from compromised lymphatic system (5) Burn shock reverses when fluid is reabsorbed from interstitium into intravascular compartment b) Cardiac rhythm alterations (1) Decrease in myocardial contractibility and cardiac output (2) Electrical burns often result in cardiac dysrhythmias or cardiopulmonary arrest c) Peripheral vascular compromise (1) Damage to blood vessels; impaired circulation to extremities from edema and peripheral vasoconstriction (2) Compartment syndrome 3. Respiratory system a) Damage results from direct inhalation injury or as part of systemic response to injury b) Ranges from mild respiratory inflammation to massive pulmonary failure c) Inflammation manifests as hyperemia d) Upper airway thermal injury: Inhalation of heated air or chemicals dissolved in water .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

4.

5.

6.

7.

e) Lower airway thermal injury: Rare, associated with inhalation of steam or explosive gases or aspiration of hot liquids f) Smoke poisoning: Toxic gases and particulate matter deposit directly onto pulmonary mucosa g) Carbon monoxide poisoning h) Cyanide poisoning Gastrointestinal system a) Directly related to size of burn wound b) Paralytic ileus: Secondary to burn trauma c) Curling’s ulcers (stress ulcers) d) Bacterial translocation: Can occur from ischemia of the intestine from splanchnic vasoconstriction increasing intestinal mucosal permeability Urinary system a) Urine output decreases, serum creatinine and BUN increase b) Myoglobinuria or hemoglobinuria: May result from underlying muscle damage or release of dead or damaged erythrocytes Immune system a) Capillary leak impairs active components of cell-mediated and humoral immune systems b) Serum levels of all immunoglobulins diminished c) Decrease in T-cell counts d) Acquired immunodeficiency creates risk for infection Metabolism a) Ebb phase: Decreased oxygen consumption, fluid imbalance, shock, and inadequate circulating volume b) Flow phase: Increase in cellular activity and protein catabolism, lipolysis, gluconeogenesis, basal metabolic rate (BMR) increases, body weight and heat drop, hypermetabolism persists

C. Interprofessional care 1. Stages of interprofessional care a) The emergent/resuscitative stage: Onset of injury through successful fluid resuscitation (1) Estimate extent of injury, institute first-aid measures, and implement fluid resuscitation (2) Determine if patient should be transported to a burn center b) Acute stage: Begins with start of diuresis, ends with closure of burn wound (1) Initiate wound care management, nutritional therapies, measures to control infectious processes c) Rehabilitative stage: Begins with wound closure, ends when patient returns to highest levels of health restoration (1) Primary focus is biopsychosocial adjustment of patient .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

2. Prehospital patient management a) Stop the burning process (1) Thermal burns (a) “Stop, drop, and roll” (b) Once flame is extinguished, cover body (2) Chemical burns (a) Remove clothing and use hose or shower to lavage area for 20 minutes (3) Electrical burns (a) Ensure source of current has been disconnected (b) Assess for presence of cardiac, respiratory function; begin CPR (c) Place person in cervical collar and transport on spinal board (4) Radiation burns (a) For severe burns: Render area safe, shield, establish distance, and limit time of exposure b) Support vital function (1) Begins with evaluation of ABC’s of care 3. Emergency and acute care a) Obtain history of injury, estimates of depth and extent of the burn b) Fluid resuscitation (1) Necessary in all burn wounds that involve ≥20% TBSA (2) Consensus formula (3) Indicators of effective fluid resuscitation: Hourly urine output and heart rate c) Respiratory management (1) Baseline assessment of respiratory status obtained: Chest x-ray study, ABGs, vital signs, and carboxyhemoglobin levels (2) Primary treatment plan: Prevent atelectasis and maintain alveolar oxygen exchange (3) Transfer to critical care unit or burn center after stabilization in ER D. Diagnosis 1. Urinalysis 2. Complete blood count 3. Serum electrolytes 4. Renal function 5. Total protein, albumin, transferrin, prealbumin, retinol binding protein, alpha 1-acid glycoprotein, and C-reactive protein 6. Creatine phosphokinase (CPK) 7. Blood glucose 8. Serial ABGs 9. Pulse oximetry 10. Serial chest x-ray studies .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

11. Serial 12 lead electrocardiograms (EKGs) E. Medications 1. Pain control a) Emergent stages: Intravenously administered narcotics (1) Meperidine is avoided b) Anxiolytics, especially 1 hour before wound care c) Acute stage: Opioids administered around-the-clock, patient-controlled analgesia (PCA) d) Rehabilitative stage: Alternative therapies for pain control added 2. Antimicrobial agents a) Diagnoses of infection: Burn wound biopsy b) Eliminate infection on surface of burn wound: Topical antimicrobial therapy 3. Tetanus prophylaxis: Administered if immunization status is in doubt 4. Preventing gastric hyperacidity: To prevent Curling’s ulcer F. Treatments 1. Surgery a) Escharotomy: To prevent circumferential constriction of the torso or extremity b) Surgical debridement: Removing thin slices of burn wound to level of viable tissue (1) Fascial excision (fasciectomy): Excising the wounds to level of fascia (2) Tangential excision: Removing thin slices of burn wound to level of viable tissue (3) Common technique: Electrocautery c) Autografting: Used to effect permanent skin coverage (1) Cultured epithelial autografting d) Biologic and biosynthetic dressings: Temporary material that rapidly adheres to wound bed, promotes healing, and/or prepares burn wound for permanent autograft coverage (1) Homograft (allograft): Human skin harvested from cadavers (2) Heterograft (xenograft): Skin obtained from an animal (3) Synthetic materials (a) Biobrane, Integra, and Alloderm (b) Temporary skin substitutes: TransCyte and Apligraf (c) Hydrocolloid dressings: DuoDerm, Aquacel, Acticoat, and Calcium alginate (d) Vacuum-assisted closure (VAC) device 2. Wound management a) Goals (1) Control microbial colonization and prevent wound infection (2) Prevent wound progression (3) Achieve wound coverage as early as possible (4) Promote function of healing skin b) Debriding the wound: Process of removing all loose tissue, wound debris, eschar from the wound .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Mechanical: Applying and removing gauze dressings, hydrotherapy, irrigation, or scissors and tweezers (2) Enzymatic: Use of topical agent to dissolve and remove necrotic tissue, lift eschar (3) Surgical c) Dressing the wound (1) Open method: Burn wound remains open to air, covered with topical antimicrobial agent (2) Closed method: Topical antimicrobial agent applied to the wound site, covered with dressing and wrapped with gauze roll bandage d) Positioning, splints, and exercise (1) Contractures: Common problem for burn injury patients (2) Early physical therapy: Maintain antideformity positions (3) Active and passive ROM exercises e) Support garments: Uniform pressure can prevent or reduce hypertrophic scarring 3. Nutritional support a) Major burn patient is in a hypermetabolic, catabolic state b) Total caloric needs 4000–6000 kcal per day c) Enteral feedings with nasointestinal feeding tube instituted (1) Contraindicated in Curling’s ulcer, bowel obstruction, feeding intolerance, pancreatitis, and septic ileus G. Nursing care 1. Assessment 2. Priorities of care a) Time of injury, cause of injury, first-aid treatment, past medical history, age, medications, and body weight H. Diagnoses, outcomes, and interventions 1. Maintain skin integrity a) Estimate the extent and depth of the burn wound and recalculate extent of unhealed burns weekly b) Provide daily wound care c) Elevate burned or newly skin grafted extremities at or above heart level d) Immobilize skin graft sites for 3–5 days or as ordered e) Provide special skin care to sensitive body areas 2. Maintain fluid balance a) Assess blood and heart rate frequently b) Monitor hemodynamic status, including CVP and PCWP c) Follow prescribed protocols for intravenous fluid resuscitation d) Monitor intake and output hourly e) Weigh daily .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

3.

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f) Test all stools and emesis for the presences of blood g) Maintain a warm environment h) Monitor for fluid volume overload Manage acute pain a) Measure patient’s level of pain using consistent measuring tool b) Medicate before painful procedures and determine PCA is appropriate c) Administer intravenous narcotic analgesics as prescribed d) Explain all procedures and expected levels of discomfort e) Use methods of nonnarcotic pain control in combination with medications for pain f) Allow patient to verbalize pain experience Reduce risk for infection a) Monitor daily for manifestations of wound infection, remove topical medications and wound exudate and examine entire wound b) Monitor for positive blood cultures c) Monitor for hyperermia, cough, chest pain, wheezing, rhonchi, decreased oxygen saturation, and purulent sputum d) Monitor for presence of bacteria in urine, fever, urgency, frequency, dysuria, and superpubic pain e) Obtain daily WBC counts f) Determine tetanus immunization status g) Maintain high kcal intake h) Maintain an aseptic environment i) Culture all wounds and body secretions per protocol j) Administer prescribed antimicrobial medications k) Indwelling catheter: Assess urine for cloudiness and foul odor, obtain urine culture and sensitivity weekly Assist with physical mobility a) Perform active or passive ROM exercises to joints every 2 hours b) Apply splints as prescribed c) Maintain limbs in functional alignment d) Anticipate need for analgesia e) Assess all patients, especially older adults, for pressure ulcer formation under a splint Promote appropriate nutrition a) Maintain nasogastric/nasointestinal tube placement b) Maintain enteral/parenteral nutritional support as prescribed c) Weigh patient daily d) Obtain daily laboratory values for protein, iron, CBC, glucose, and albumin Provide emotional support a) Allow patient as much control over the surroundings and routine as possible b) Keep needed items within reach c) Encourage patient to express feelings

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

d) Set short-term, realistic goals I. Continuity of care 1. Encourage family members to assume responsibility in providing care 2. Teach to assess findings, implement therapies, evaluate progress a) Long-term goals of rehabilitation care b) Avoid exposure to people with colds or infections; following aseptic technique c) The need for progressive physical activity d) How to apply splints, pressure support garments, and other assistive devices e) Dietary requirements with required kcal f) Alternative pain control therapies g) Care of the graft and donor sites h) Referral for occupational therapy, social service, clergy, and/or psychiatric services i) Helpful resources: American Burn Association, International Society for Burn Injuries, American Academy of Facial Plastic and Reconstructive Surgery

Chapter Highlights A. Four types of burn injuries are thermal, chemical, electrical, or radiation.

B. The depth of the burn injury determines whether it is classified as a superficial, partial-thickness, or full-thickness burn.

C. The “rule of nines” is a simple method to estimate the extent of a burn injury, but the Lund and Browder chart is considered the most accurate method as a compensates for changes in body shape with age.

D. There are three stages to burn wound healing: Inflammation, proliferation, and remodeling. Well the healing stages are similar to other wounds, in burns, these stages are longer in time.

E. Minor burn injuries consist of superficial burns that are not extensive. They involve less than 15% of the TBSA. Very limited full-thickness burns (less than 2% TBSA) are also considered minor burns.

F. This type of burn has not been associated with significant systemic sequelae and are commonly treated in the outpatient setting.

G. Major burns involve multiorgan pathophysiological alterations. Most critical is the fluid shift from the intracellular and intravascular compartments into the interstitium, resulting in a type of hypovolemic shock called burn shock. Other pathologic processes include an impaired immune system, disturbed functions of the skin, inhalation injury, gastrointestinal ulcerations and ileus, renal failure, and hypermetabolism.

H. Interprofessional care focuses on managing the patient during the emergent/resuscitative, acute, and rehabilitative stages. To counter the effects of burn shock, fluid resuscitation using guidelines such as the Consensus formula are initiated to replace fluid and electrolyte losses.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

I. Additional management for the patient with major burns includes preventing atelectasis, maintaining respiratory function, controlling pain, preventing infection and Curling’s ulcer, promoting nutrition, and providing wound care.

J. Extensive eschar of an extremity or the torso, called circumferential wounds, can potentially occlude arterial flow or decrease respiratory function. An escharotomy is used to release tension, preventing additional complications.

K. Surgical management of burn wounds include debridement and skin grafting.

Biologic and biosynthetic dressings provide temporary covering and prepare the wound for permanent autografts.

L. Continual psychological support of the patient and family is essential throughout convalescence and rehabilitation.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME ONE Ask students to list various types of burns and record these. Discuss causes for each type of burn.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME ONE Assign students to provide patient teaching appropriate for the prevention of various types of burns.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME TWO Discuss the “rule of nines.” Provide an image to reinforce verbal discussion.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME TWO Provide students with the opportunity to work with a patient requiring burn classification by determining depth and extent of injury.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME THREE Work with students to create a nursing care plan for all three stages of recovery from a major burn.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME THREE Have a burn nurse speak to the clinical group on treatment and nursing interventions for the three stages of burn wound healing.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME FOUR Discuss the scenario of an Emergency Department nurse working in a resort area and caring for patients with severe sunburns.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME FOUR If access to a burn unit or burn patients is available, assign students to provide care to patients with minor burns.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME FIVE Ask students to list emergent nursing interventions for a patient with severe burns

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Create a nursing care plan for a patient with a major burn over his legs and perineum.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME FIVE If access to a burn unit or burn patients is available, assign students to provide care to patients with major burns.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter 18 Assessing the Endocrine System

Learning Outcomes 1. Describe the anatomy, physiology, and functions of the endocrine glands and hormones, and identify abnormal findings that may indicate impairment of the endocrine system.

2. Outline the components of the assessment of the endocrine system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.

3. Differentiate considerations for assessing the endocrine system of older adults, veterans, individuals in the LGBTQI population, and adults with sequelae of childhood/ congenital conditions.

4. Summarize topics that nurses teach to promote healthy endocrine function across the lifespan.

Key Concepts I.

Anatomy, Physiology, and Functions of the Endocrine System A. Pituitary gland (hypophysis) 1. Anterior pituitary (adenohypophysis): Glandular tissue a) Promotes growth of body tissues b) Hormone secreted: Growth hormone (GH) c) Types of endocrine cells: Somatotropic cells, lactotropic cells, gonadotropic cells, thyrotropic cells, and corticotropic cells, 2. Posterior pituitary (neurohypophysis): Extension of hypothalamus, made of nervous tissue a) Stores and releases antidiuretic hormone (ADH) and oxytocin B. Thyroid gland 1. Maintains metabolic rate and growth and development of all tissues 2. Hormones secreted: Thyroid hormone (TH)—increases metabolism; calcitonin—decreases excessive levels of calcium in the blood C. Parathyroid glands 1. Maintains serum calcium levels 2. Hormone secreted: Parathyroid hormone (PTH) D. Adrenal glands 1. Two glands on top of kidneys 2. Adrenal medulla: Produces epinephrine, and norepinephrine 3. Adrenal cortex

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) Secretes corticosteroids; classified in two groups (1) Mineralocorticoids (2) Glucocorticoids: Cortisol, cortisone b) Renin–angiotensin–aldosterone system E. Pancreas 1. Both an endocine and exocrine gland 2. Cell types of pancreatic islets (islets of Langerhans) a) Alpha cells produce glucagon b) Beta cells produce insulin c) Delta cells secrete somatostatin d) F cells secrete pancreatic polypeptide F. Gonads 1. Testes in men, ovaries in women 2. Primary source of steroid sex hormones in the body G. An Overview of Hormones 1. Hormones: Chemical messengers secreted by endocrine organs and transported throughout the body to regulate tissue responses 2. Hormone transportation methods a) Endocrine glands release most hormones into the bloodstream (some require a protein carrier) b) Neuroendocrine route: Neurons release some hormones into the bloodstream c) Hypothalamus releases its hormones directly to target cells in the posterior pituitary by nerve cell extension d) Paracrine method: Released messengers diffuse through the interstitial fluid 3. Hormone levels are controlled by the pituitary gland and by feedback mechanisms. a) Positive feedback mechanisms (estradiol) b) Negative feedback mechanisms (TSH) 4. Classifications of stimuli for hormone release a) Hormonal b) Humoral c) Neural II.

Assessing Endocrine Function A. Health assessment interview 1. Analyze onset, characteristics, course, severity, precipitating and relieving factors, and associated symptoms of endocrine function 2. Health history: Patient’s medical history, family history, and social and personal history 3. Ask questions to identify changes in normal growth and development, height and weight, changes in size of extremities, and enlargement of neck

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

4. Other questions: Difficulty swallowing, increased or decreased thirst, appetite, and/or urination; visual changes; sleep disturbances; altered patterns of hair distribution; changes in menstruation; changes in memory or ability to concentrate; changes in hair and skin texture 5. Injury or surgery of the head, previous hospitalizations, chemotherapy, radiation, and the use of medications 6. Occupational and social history 7. Means of coping; use of alcohol, smoking, and drugs 8. Diet, exercise patterns, and sleep patterns B. Physical assessment 1. Palpate thyroid gland 2. Inspect skin, hair, nails, facial appearance, reflexes, and musculoskeletal system 3. Motor function assessment: Test deep tendon reflexes with reflex hammer 4. Sensory function assessment: Sensitivity to pain, temperature, vibration, light touch, stereognosis 5. Measure and monitor trends in height, weight, and vital signs 6. Assess hypocalcemic tetany a) Trousseau sign b) Chvostek sign C. Diagnostic tests 1. Pituitary tests a) Growth hormone (GH), human growth hormone (hGH) b) Magnetic resonance imaging (MRI) c) Somatomedin C (insulin-like growth factor or IGF-1) d) Water deprivation test 2. Thyroid tests a) MRI b) Radioactive iodine uptake (RIA) c) Thyroid antibodies (TA) d) Thyroid scan e) Thyroid stimulating hormone (TSH) f) Thyroid suppression test g) Thyrotropin-releasing hormone (TRH) stimulation test h) Thyroxine (T4) i) Triiodothyronine (T3) j) Triiodothyronine resin uptake (T3RU) 3. Parathyroid tests a) Calcium (Ca) b) MRI c) Parathyroid hormone (PTH) .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

4. Adrenal tests a) ACTH b) ACTH stimulation c) ACTH suppression d) Aldosterone e) Computerized tomography (CT) of the abdomen f) Cortisol g) Dexamethasone suppression test h) 17-Ketosteroids i) MRI adrenal glands j) MIBG scan 5. Pancreatic endocrine tests a) C-peptide b) Computed tomography (CT) of the abdomen c) Fasting Blood Sugar (FBS) d) Oral Glucose Tolerance Test (OGTT) e) Glycosylated Hemoglobin (Hb A1C) f) MRI pancreas III.

IV.

Assessment of Special Populations A. Older adult: Diabetes, deficient levels of vitamin D B. Posttraumatic stress disorder (PTSD): Veterans C. Gender identity: Biologic and hormone influences begin in childhood Health Promotion A. Promote health at various levels: Individual, family, and community

Chapter Highlights A. The endocrine system is comprised of several glands: The pituitary gland, thyroid gland, parathyroid glands, adrenal glands, pancreas, and gonads (reproductive glands).

B. The endocrine system is essential to the regulation of the body’s internal environment and affects a wide variety of human functions.

C. Endocrine glands release most hormones, including thyroid hormone and insulin, into the bloodstream. Hormone receptors are located on or inside target cells. They recognize a specific hormone and translate the message into a cellular response.

D. A targeted health history including genetic considerations and physical assessment will help to diagnose endocrine disorders.

E. Various diagnostic tests are employed to diagnose endocrine disorders and to monitor treatments such as hormone replacement.

F. Identifying and treating endocrine disorders such as type 2 diabetes can have a huge impact on the older adult’s quality and length of life.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

G. Veterans may have unique healthcare challenges such as PTSD. Understanding the endocrine component of PTSD is helpful in defining an effective plan of care.

H. LGBTQI patients require a scientific approach to their treatment that is nonjudgmental and inclusive of their healthcare needs.

I. Health promotion activities aimed at the individual, the family, and the community will be most effective in the prevention of endocrine dysfunction.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME ONE Separate the students into groups. Ask each group to research the functions of the hormones secreted by the endocrine glands.

SUGGESTIONS FOR CLINICAL ACTIVITY—LEARNING OUTCOME ONE Assign students to care for patients with endocrine disorders.

Assign students to provide patient teaching appropriate for the prevention of various types of burns.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME TWO Discuss the various labs for assessing endocrine function. Provide the students with abnormal lab results, and have them discuss the implications for the patient.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME TWO Role-play using nursing diagnoses and interventions for selected endocrine disorders.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME THREE Identify potential endocrine system disorders for older adults, veterans, LGBTQI individuals, and adults with sequelae of childhood/congenital conditions.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME THREE Review a patient’s laboratory results. Identify age-related endocrine changes and the significance of each.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME FOUR Ask students to identify patient education topics and to create a learning tool for use with patient education intended to promote healthy endocrine function.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME FOUR Assign students to care for patients with endocrine disorders and to provide patient education on the promotion of healthy endocrine function.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter 19 Nursing Care of Patients with Endocrine Disorders

Learning Outcomes 1. Describe the pathophysiology and manifestations of disorders of the thyroid gland, and outline the interprofessional care and nursing care of patients with these disorders.

2. Describe the pathophysiology and manifestations of disorders of the parathyroid glands, and outline the interprofessional care and nursing care of patients with these disorders.

3. Describe the pathophysiology and manifestations of disorders of the adrenal glands, and outline the interprofessional care and nursing care of patients with these disorders.

4. Describe the pathophysiology and manifestations of disorders of the pituitary gland, and outline the interprofessional care and nursing care of patients with these disorders.

Key Concepts I.

Disorders of the Thyroid Gland A. Altered thyroid hormone (TH) production or use in the adult this affects metabolism, cardiovascular function, gastrointestinal function, and neuromuscular function B. The patient with hyperthyroidism (thyrotoxicosis) 1. Caused by excessive delivery of TH to the tissues 2. Pathophysiology and manifestations a) Results from: Autoimmune stimulation, excess secretion of thyroid-stimulating hormone (TSH) by the pituitary gland, thyroiditis, neoplasms, side effect of certain drugs, and excessive intake of thyroid medications b) Increased appetite with possible weight gain, weight loss, hypermotile bowels, diarrhea, emotional liability, heat intolerance, insomnia, palpitations, increased sweating, smooth & warm skin, fine hair, hair loss in scalp, eyebrows, axilla, and pubic region c) Graves disease (1) Most common cause of hyperthyroidism (a) Goiter: Enlarged thyroid gland (b) Eye pathophysiology: Proptosis and visual dysfunction, exophthalmos (c) Other manifestations: Fatigue, difficulty sleeping, hand tremors, changes in menstruation; older patients may present atrial fibrillation, angina, and congestive heart failure d) Toxic multinodular goiter (1) Thyroid tumor of small, discrete independently functioning nodules in the thyroid gland tissue that secrete excessive amounts of TH (2) Usually affects older women; increases risk of thyroid malignancy

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

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e) Thyroiditis (1) Inflammation of the thyroid gland f) Thyroid crisis (thyroid storm) (1) Extreme state of hyperthyroidism; Rare due to improved diagnosis and treatment methods (2) Requires rapid treatment to preserve life Interprofessional care a) Goal: Reduce TH production to establish euthyroid (normal thyroid) and prevent/treat complications b) Diagnosis (1) Criteria: Elevated levels of TH (T3 and T4), increased radioactive iodine (RAI) uptake c) Medications (1) Administer antithyroid medications that reduce TH production (2) Initial treatment: Propranolol or esmolol d) Radioactive iodine therapy: Damages or destroys thyroid cells so they produce less TH e) Surgery (1) Thyroidectomy (a) Subtotal thyroidectomy and total thyroidectomy Nursing care a) Assessment (1) Health history: Other diseases, family history of thyroid disease, when manifestations began, severity of manifestations, intake of thyroid medications, menstrual history, changes in weight, and bowel elimination (2) Physical assessment: Muscle strength, tremors, vital signs, cardiovascular and peripheral vascular systems, integument, size of thyroid, presence of bruit over thyroid, and eyes and vision Priorities of care Diagnoses, outcomes, and interventions (1) Reduce risk for heart failure (a) Monitor blood pressure, pulse rate and rhythm, respiratory rate, and breath sounds (b) Suggest keeping environment cool and free from distraction (c) Encourage a balance of activity with rest periods (2) Monitor vision changes (a) Monitor visual acuity, photophobia, integrity of the cornea, and lid closure (b) Teach measures for protecting the eye from injury and maintaining visual acuity (3) Limit weight loss (a) Ask patient to weigh daily, keep a record

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(b) Teach patient the need for diet high in carbohydrates and protein, including between-meal snacks (c) Monitor nutrition status through laboratory data results (4) Monitor anxiety and mood disorders (a) Establish a trusting relationship; encourage patient to verbalize feelings about self, ask questions 7. Delegating nursing care activities (a) May delegate: Repositioning and activity, providing hygiene, assisting with feeding and dietary needs 8. Transitions of care a) Teach self-care at home; patient needs to know: (1) Oral medications: Understand the need for lifelong treatment (2) Thyroidectomy: Information about postoperative wound care (3) Radioactive iodine therapy: Manifestations of hypothyroidism (4) Referral to community healthcare agencies may be necessary (5) Resources: The American Thyroid Association, the Thyroid Foundation of Canada, and the Endocrine Society C. The patient with hypothyroidism 1. Hypothyroidism: Insufficient TH produced by the thyroid gland a) Common in women between ages 30 and 60, with increased incidence after age 50 b) Myxedema: Chronic, untreated hypothyroid state in adults 2. Pathophysiology and manifestations a) Primary hypothyroidism results from congenital defects in the gland, loss of thyroid tissue following treatment for hyperthyroidism with surgery or radiation, antithyroid medications, thyroiditis, or endemic iodine deficiency b) Secondary hypothyroidism results from pituitary TSH deficiency or peripheral resistance to thyroid hormones c) Multisystem effects of hypothyroidism (1) Characteristics: Goiter, fluid retention and edema, decreased appetite, weight gain, constipation, dry skin, dyspnea, pallor, hoarseness, muscle stiffness, decreased sense of taste and smell, menstrual disorders, anemias, cardiac enlargement, and slow pulse d) Iodine deficiency (1) Can result from goitrogenic drugs, lithium carbonate, antithyroid drugs, large consumption of gotrogenic compounds and living where the soil is deficient in iodine e) Hashimoto’s thyroiditis (1) Most common cause of goiter and primary hyperthyroidism f) Myxedema coma

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Characteristics: Severe metabolic disorders, hypothermia, cardiovascular collapse, impaired cognition, and coma (2) Treatment: Maintain patent airway; maintain fluid, electrolyte, and acid–base balance; maintain cardiovascular status; increase body temperature; increase TH levels 3. Interprofessional care a) Diagnosis (1) Clinical manifestations and decrease in TH (especially T4) (2) Same tests used as for hypothyroidism with opposite results (3) Other tests: Elevated serum LDL cholesterol, triglycerides, and lipoproteins b) Medications (1) Medications that replace TH: Levothyroxine c) Surgery: When goiter is large enough to cause respiratory difficulties or dysphagia (1) Subtotal thyroidectomy 4. Nursing care a) Assessment (1) Health history: Pituitary diseases, history of hyperthyroidism and treatment with medications or radioactive iodine, thyroid surgery, treatment of head or neck cancer with radiation, diet, use of iodized salt, bowel elimination, depression, muscle or joint aching, cold intolerance, respiratory difficulties, and heavy menstrual periods (2) Physical assessment: Muscle strength, deep tendon reflexes, vital signs, cardiovascular and peripheral vascular systems, integument, thyroid gland, and weight b) Priorities of care c) Diagnoses, outcomes, and interventions (1) Reduce risk of heart failure (a) Monitor blood pressure, rate, and rhythm of apical and peripheral pulses, respiratory rate, breath sounds (b) Suggest the patient avoid chilling (c) Explain the need to alternate activity with rest periods (2) Reduce risk of constipation (a) Encourage fluid intake of up to 2000 mL per day; discuss preferred fluids and the best times of day to drink fluids (b) Discuss ways to maintain a high-fiber diet (c) Encourage activity as tolerated (3) Maintain good skin integrity (a) Monitor skin surfaces for redness or lesions (b) Provide or teach the immobile patient measures to promote optimal circulation (c) Provide or teach the patient measures to maintain skin integrity .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

d) Delegating nursing care activities (1) Dietary teaching referred to dietician; skin care and hygiene referred to assistive personnel e) Transitions of care (1) Address the following since lifelong care, primarily at home, will be required (a) The need to take medications for the rest of one’s life (b) The need for periodic dosage reassessments (c) If the patient is older or does not have a support system, helpful community resources (d) Additional resources are the same as for the patient with hyperthyroidism D. The patient with cancer of the thyroid 1. Risk factors: Exposure to ionizing radiation to the head and neck during childhood 2. Common types: Papillary thyroid carcinoma, follicular thyroid cancer, and medullary thyroid cancer 3. Manifestations: Palpable, firm, non-tender nodule on thyroid 4. Diagnosis: Measure thyroid hormones (thyroid scans), fine-needle biopsy of nodule 5. Treatment: Subtotal or total thyroidectomy, TSH suppression therapy with levothyroxine prior to surgery, radioactive iodine therapy (131I), and chemotherapy II.

Disorders of the Parathyroid Glands A. The patient with hyperparathyroidism 1. Result of an increase in the secretion of parathyroid hormone 2. Pathophysiology and manifestations a) Older adults; three times more common in women b) Primary hyperparathyroidism: Occurs when hyperplasia or adenoma is in one of the parathyroid glands c) Secondary hyperparathyroidism: Compensatory response to chronic hypocalcemia d) Tertiary hyperparathyroidism: Seen in patients with chronic renal failure e) Manifestations: Many asymptomatic; symptoms related to hypercalcemia and musculoskeletal, renal, and gastrointestinal manifestations 3. Interprofessional care a) Diagnosis (1) Exclude all other possible causes of hypercalcemia by at least a 6-month history of manifestations (2) Laboratory analysis of levels of serum calcium and PTH levels b) Treatment: Decrease elevated serum calcium levels, drink fluids, and keep active (1) Severe hypercalcemia: Hospitalization and intensive intravenous saline treatment c) Medications (1) Short-term: Pamidronate, alendronate, and zoledronate

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(2) Calcitonin, calcimimetic d) Surgery: Removal of the parathyroid glands affected by hyperplasia or adenoma 4. Nursing care a) Focused on calcium balance B. The patient with hypoparathyroidism 1. Result of abnormally low PTH levels 2. Common causes: Damage to or inadvertent removal of all of the parathyroid glands during thyroidectomy 3. Pathophysiology and manifestations a) Impaired renal tubular regulation of calcium and phosphate b) Neuromuscular manifestations: Numbness, tingling around the mouth and fingertips; muscle spasms of hands and feet; convulsions; large laryngeal spasms c) Tetany: Primary symptom of hypocalcemia d) Integumentary system: Brittle nails, hair loss, dry, and scaly skin e) Gastrointestinal system: Abdominal cramps and malabsorption f) Cardiovascular system: Dysrhythmias g) Central nervous system: Paresthesias (lips, hands, and feet), mood disorders (irritability, depression, and anxiety), hyperactive reflexes, psychosis, and increased intracranial pressure 4. Interprofessional care a) Diagnosis: Low serum calcium levels and high phosphorous levels in the absence of renal failure, an absorption disorder, or nutritional disorder b) Treatment: Increase calcium levels (1) Long-term therapy: Supplemental calcium, increased dietary calcium, and vitamin D therapy III.

Disorders of the Adrenal Glands A. The patient with Cushing’s syndrome (hypercortisolism) a) Chronic disorder; caused by excessive amounts of circulating cortisol b) Most common cause: Long-term pharmacologic therapy with corticosteroids c) Cushing disease: Caused by adenoma or tumor on pituitary gland that causes overproduction of cortisol.

2. Pathophysiology a) The pituitary form, with ACTH hypersecretion by a benign tumor of the pituitary (called Cushing’s disease) 3. Manifestations a) Exaggerated cortisol actions, obesity and redistribution of body fat, changes in protein metabolism, glucocorticoid excess, altered glucose metabolism, electrolyte imbalances, changes in calcium absorption, hypokalemia, hypertension, inhibited immune responses, emotional changes, and increasing androgen levels in women

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

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b) Untreated Cushing’s syndrome: Electrolyte imbalances, hypertension, emotional disturbances, increased susceptibility to infections, and compression fractures Interprofessional care a) Diagnostic tests (1) Laboratory tests, late night salivary cortisol test, CT scan or MRI of abdomen to assess adrenal gland for tumors b) Medications (1) Mitotane, aminoglutethimide or ketoconazole, and somatostatin analog c) Surgery (1) Adrenalectomy: Done when Cushing’s syndrome is caused by adrenal cortex tumor (2) Hypophysectomy: Performed when Cushing’s syndrome is the result of a pituitary disorder Nursing care a) Assessment (1) Health history: History of pituitary, adrenal, pancreatic, or pulmonary tumor; frequent infections; gastrointestinal bleeding; stress fractures; pain; changes in weight distribution; change in height; fatigue; weakness; change in appearance; bruising; skin infections; menstrual history; sexual function (2) Physical assessment: Vital signs, behavior, appearance, fat distribution, face, skin, hair quantity and distribution, muscle size and strength, and gait Priorities of care Diagnoses, outcomes, and interventions (1) Manage fluid volume (a) Ask patient to weigh at the same time each day, and maintain a record of results (b) Monitor blood pressure, rate and rhythm of pulse, respiratory rate, breath sounds; assess for peripheral edema and jugular vein distention (c) Teach the patient and family the reasons for restricting fluid and importance of limiting fluids if ordered (2) Reduce risk for falls and fractures (a) Keep unnecessary clutter and equipment out of the way and off the floor (b) Ensure adequate lighting, especially at night (c) Use assistive devices for ambulation or to ask for help if needed (d) Be sure corrective lenses are available and clean (e) Use nonskid slippers or shoes (f) Watch for signs of fatigue; plan rest periods (3) Reduce risk for infection (a) Monitor vital signs and verbalizations of subjective manifestations every 4 hours

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(b) Use principles of medical and sterile asepsis when caring for the patient, conducting procedures, or providing wound care (c) If wounds are present, assess the color, odor, and consistency of wound drainage, and look for increased pain in and around the wound (d) Teach the importance of increasing intake of protein and vitamins C and A (e) Encourage recommended vaccinations (4) Discuss coping strategies (a) Encourage patients to express feelings and to ask questions about the disorder and its treatment (b) Discuss strengths and previous coping strategies (c) Discuss signs of progress in controlling manifestations 8. Delegating nursing care activities a) Blood glucose measurements, toileting, and repositioning 9. Transitions of care a) Safety measures to prevent falls if fatigue, weakness, and osteoporosis are present b) Taking medications as prescribed, with information about side effects c) Having regular health assessments d) Wearing a medical ID indicating the patient has Cushing’s syndrome e) Educate about signs of diabetes such as thirst, frequent urination, weight loss, and hunger f) Helping the patient with referrals to social services or community health services g) Providing helpful resources: The American Association of Clinical Endocrinologists and the Endocrine Society B. The patient with chronic adrenocortical insufficiency 1. Uncommon; result of destruction or dysfunction of the adrenal cortex 2. Pathophysiology a) Causes (1) Autoimmune destruction of the adrenals leads to primary adrenal insufficiency (Addison disease) (2) Adrenal gland destruction due to infection, sepsis, metastatic cancer, hemorrhage, or heparin-induced thrombocytopenia (3) Adrenoleukodystrophy (4) ACTH deficit (5) Abrupt withdrawal from long-term, high-dose steroid therapy, and tuberculosis or acquired immune deficiency syndrome (AIDS) b) Secondary adrenocortical insufficiency: Occurs from large doses or prolonged therapy with glucocorticoids 3. Manifestations a) Primary manifestations due to elevated ACTH levels and decreased aldosterone and cortisol .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

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b) Postural hypotension and tachycardia with syncope, hypovolemic shock, dizziness, confusion, neuromuscular irritability, cardiac dysrhythmias, weakness, and muscle pain c) Addisonian crisis (1) Triggers: Surgery, acute systemic illness, trauma, abrupt withdrawal of long-term corticosteroid therapy (2) Treatment: Rapid intravenous replacement of fluids and glucocorticoids Interprofessional care a) Diagnostic tests (1) Serum cortisol levels (2) Blood glucose levels (3) Serum sodium levels (4) Serum potassium levels (5) BUN levels (6) Urinary 17-hydroxycorticoids and 17-KS levels (7) Plasma ACTH levels (8) ACTH stimulation test (9) CT scans b) Medications (1) Replacement of corticosteroids and mineralocorticoids (2) Increased sodium in diet Nursing care a) Assessment (1) Health history: Weight loss, changes in skin color, nausea and vomiting, anorexia, diarrhea, abdominal pain, weakness, amenorrhea, changes in sexual desire, confusion, and intolerance of stress (2) Physical assessment: Height and weight, vital signs, skin, hair quality and distribution, muscle size and strength.

Priorities of care Diagnoses, outcomes, and interventions a) Maintain fluid volume (1) Monitor intake and output, assess for signs of dehydration (2) Monitor cardiovascular status (3) Weigh the patient daily, at the same time in the same clothing (4) Encourage oral fluid intake of 3000 mL per day and increased salt intake (5) Teach to sit and stand slowly b) Delegating nursing care activities c) Transitions of care (1) Risk for ineffective therapeutic regimen management (a) Teach the effects of illness and treatment (b) Self-administration of steroids

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(i) Importance of carrying an emergency kit containing parenteral cortisone and a syringe/needle (c) Medic-Alert bracelet that says “Adrenal insufficiency—takes hydrocortisone” (d) Increasing oral fluid intake and maintaining a diet high in sodium and low in potassium (e) The importance of continuing healthcare (f) The necessity of altering the medication dose when experiencing emotional or physical stressors (g) Refer to social worker, if appropriate (h) Refer to community agencies for continued education and support (i) Helpful resources: National Institute of Diabetes and Digestive and Kidney Diseases (Addison’s disease), Endocrine Society, and American Association of Clinical Endocrinologists C. The patient with pheochromocytoma 1. Pheochromocytomas: Tumors of chromaffin tissues in adrenal medulla 2. Dangerous effects: Peripheral vasoconstriction, increased cardiac rate, contractility with resultant paroxysmal hypertension 3. Diagnosis: Increased catecholamine levels in blood or urine by x-rays or surgical exploration 4. Treatment: Removal of tumors by adrenalectomy IV.

Disorders of the Pituitary Gland A. The patient with disorders of the anterior pituitary gland a) Hyperfunction (1) Causes: Pituitary tumor or pituitary hyperplasia b) Hypofunction (1) Causes: Pituitary tumor, surgical removal of the pituitary gland; radiation; and pituitary infarction, infection, or trauma c) Gigantism and acromegaly result from overstimulation d) Growth retardation and short stature result from deficient production of GH 2. Pathophysiology and manifestations a) Gigantism: GH hypersecretion begins before puberty and closure of epiphyseal plates b) Acromegaly: Sustained GH and IGF-1 hypersecretion begins during adulthood 3. Interprofessional and nursing care a) Acromegaly treatment: Surgical removal or irradiation of pituitary tumor b) Somatostatin receptor binding drugs (SRBDs) c) Growth hormone receptor antagonists d) Radiation therapy e) Help in coping with physical and emotional changes f) Prevent complications with other organs and endocrine system

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

B. The patient with disorders of the posterior pituitary gland 1. Pathophysiology and manifestations a) Syndrome of inappropriate ADH secretion (SIADH): High levels of ADH in the absence of serum hypo-osmolality (1) Manifestations caused by water retention, hyponatremia, serum hypoosmolality (2) Treatment: Teach the patient about restricting fluids to 1 L/day, diuretics used to decrease fluid volume, demeclocycline, lithium, vasopressin antagonists, and intravenous hypertonic solution of sodium chloride b) Diabetes insipidus: Result of ADH insufficiency (1) Types (a) Neurogenic diabetes insipidus (b) Nephrogenic diabetes insipidus (2) Causes: Brain tumors or infections, pituitary surgery, cerebral vascular accidents, renal and organ failure, and closed-head trauma with increased intracranial pressure c) Interprofessional and nursing care (1) SIADH treatment: Correct underlying causes, treat the hyponatremia with intravenous hypertonic saline, restrict oral fluids to less than 800 mL/day (2) Diabetes insipidus treatment: Correct underlying causes, administer intravenous hypotonic fluids, increase oral fluids, replace ADH hormone (3) Nursing care: Focus on patient problems with fluid and electrolyte balance

Chapter Highlights Thyroid disorders are the most common endocrine disorders. Occurring mainly among women, these diseases change body image and impose upsets to energy levels, creating fatigue and exhaustion.

B. Graves disease, an autoimmune disorder of the thyroid gland, is the most common cause of hyperthyroid disease. This disease causes the thyroid gland to enlarge, manifested with a goiter. Older patients with hyperthyroid are at risk for acute life-threatening cardiovascular complications.

C. Hypothyroidism results when thyroid hormone levels are insufficient. Myxedema coma is a lift-threatening form of hypothyroidism that results in hyponatremia, hypoglycemia, hypothermia, and lactic acidosis.

D. Diagnostic tests and therapies are available to identify and treat thyroid disorders.

Surgery, radiation therapy, and medications support good quality of life, but the medications must be used throughout the lifetime.

E. Hyperparathyroidism, though uncommon, usually occurs in older adults and results from increased parathyroid hormone (PTH). It manifests with hypercalcemia and hypophosphatemia. Metabolic acidosis and hypokalemia are complications.

A.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Hypoparathyroid results from low parathyroid hormone (PTH) and is often caused by damage or removal of the glands. It manifests with hypocalcemia and hyperphosphatemia.

G. Cushing syndrome is caused by taking glucocorticoids prescribed to treat chronic inflammatory conditions. Cushing disease is most commonly caused by adenomas (tumors) in the pituitary gland.

H. Addison disease, insufficient cortisol, is caused by destruction of the adrenal glands through autoimmune disease or infection or destruction of the pituitary gland (ACTH deficit). Corticosteroid replacements are critical for these patients.

I. The pituitary gland, in conjunction with the hypothalamus, is the master gland of the body. Pituitary disorders, therefore, can have wide-ranging effects.

J. Disorders of the anterior pituitary are manifested by the effects of excess growth hormone. Gigantism occurs when excess growth hormone occurs before closure of the epiphyseal plates, resulting in tall stature, whereas acromegaly occurs with excess growth hormone after puberty, resulting in larger hands, feet, and skull.

K. Disorders of the posterior pituitary include syndrome of inappropriate antidiuretic hormone (SIADH) and diabetes insipidus (DI). SIADH results from excess antidiuretic hormone (ADH), whereas DI results from inadequate ADH. Antidiuretic hormone affects fluid and electrolyte balance.

F.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME ONE Make a list (by body system) of the signs and symptoms of hypothyroid function. Do the same for hyperthyroid function. Compare the lists and discuss manifestations that will be difficult for the patient.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME ONE Have each student assess a client with thyroid disorder. Compare and contrast normal and abnormal assessment findings.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME TWO Break students into small groups. Assign each group a parathyroid disorder and ask them to research symptoms and treatment for the disorder. Discuss findings as a large group.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME TWO Have students shadow in the OR during surgical removal of a parathyroid gland.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTION FOR CLASSROOM ACTIVITY–LEARNING OUTCOME THREE Discuss the symptoms of Cushing’s syndrome and Addison’s disease. Develop a nursing care plan for patients with each of these.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME THREE Ask an endocrinologist to speak to the clinical group about pathophysiology, manifestations, and treatment for adrenal gland disorders.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME FOUR Ask students to anticipate why the patient with a diagnosis of closed head injury is at risk for pituitary injuries. What symptoms would the patient exhibit if this complication occurred?

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME FOUR Ask students to develop a teaching plan and to use it to educate a client about the changes associated with acromegaly.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter 20 Nursing Care of Patients with Diabetes Mellitus

Learning Outcomes 1. Describe the prevalence and incidence of diabetes mellitus (DM).

2. Distinguish the pathophysiology, risk factors, manifestations, and complications of type 1 and type 2 DM. 3. Differentiate the acute and chronic complications of DM and describe treatment plans for each.

4. Outline the diagnostic tests used for screening, diagnosing, and monitoring DM and the use of insulin and oral hypoglycemic agents to treat patients with DM. 5. Design best practices of self-care management of DM related to diet planning, sick-day management, and exercise.

Key Concepts I.

Overview of Diabetes Mellitus A. Characterized by inappropriate hyperglycemia caused by a relative or absolute deficiency of insulin or by cellular resistance to the action of insulin.

1. Type 1 (T1D): Result of pancreatic islet cell destruction and a total deficit of circulating insulin 2. Type 2 (T2D): Result of insulin resistance with a defect in compensatory insulin secretion B. Incidence and prevalence 1. 9.4% of the population in the United States has DM 2. Seventh leading cause of death by disease in the United States C. Blood glucose homeostasis 1. Hormones a) Isles of Langerhans (1) Types of cells: (a) Alpha cells: Produce hormone glucagon; primary function is to decrease glucose oxidation and increase blood glucose levels (i) Glycogenolysis (ii) Gluconeogenesis (b) Beta cells: Produce hormone insulin; facilitates the movement of glucose across cell membranes into cells (c) Delta cells: Produce hormone somatostatin; inhibits the production of glucagon and insulin

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(2) Additional hormones: Glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) b) Normal blood glucose is maintained through the actions of insulin and glucagon II.

Pathophysiology and Manifestations of Diabetes Mellitus 1. Four major types of DM: a) T1D b) T2D c) Gestational diabetes mellitus (GDM) d) Other specific types of DM 2. Type 1 diabetes a) Characterized by hyperglycemia and development of ketosis b) Risk factors (1) Genetic predisposition (2) Environmental factors c) Manifestations (1) Hyperglycemia, polyuria, glucosuria, polydipsia, polyphagia, weight loss, malaise, and fatigue 3. Type 2 diabetes a) Condition of fasting hyperglycemia b) Most common in middle age and older people c) Risk factors (1) Heredity (2) Lack of exercise, obesity d) Nonketotic form of DM e) Treatment: Weight loss, increased activity, and medications (1) Prediabetes and metabolic syndrome (a) Metabolic syndrome causes insulin resistance leading to T2D (i) Characteristics (ii) Central obesity, hypertension, abnormal lipid panel, fasting blood glucose greater than 100 mg/dl, and hyperinsulinemia (b) Prediabetes (i) Impaired glucose tolerance (ii) Defined by abnormal glucose tolerance test or elevated HbA1C f) Risk factors (1) History of DM in parents or siblings (2) Obesity (3) Physical inactivity (4) Race/ethnicity

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(5) Women: History of gestational DM, polycystic ovary syndrome, delivering a baby weighing more than 9 lb (6) Pre-diabetes and metabolic syndrome g) Manifestations (1) Mild hyperglycemia (polyuria, polydipsia), polyphagia, weight loss, blurred vision, fatigue, paresthesias, and skin infections B. Diabetes Mellitus in the Older Adult 1. Most often develop T2D as a result of increased insulin resistance and decreased production of insulin 2. Normal physiologic changes of aging may mask manifestations of the onset of DM III.

Complications of Diabetes Mellitus A. Acute complications 1. Hyperglycemia a) The dawn phenomenon, Somogyi phenomenon, and diabetes ketoacidosis (DKA) 2. Diabetic ketoacidosis a) Glucose deficiency at the cellular level, leading to break down of fat stores for energy and mobilization of fatty acids and ketosis (1) Metabolic problems (a) Hyperosmolarity (b) Metabolic acidosis (c) Extracellular volume depletion (d) Electrolyte imbalances (2) Manifestations (a) Dehydration, metabolic acidosis, abdominal pain, and Kussmaul’s respirations (3) Laboratory findings (a) Blood glucose higher than 250 mg/dL (b) Plasma pH less than 7.3 (c) Plasma bicarbonate less than 15 mEq/L (d) Presence of serum ketones (e) Presence of urine ketones and glucose (f) Abnormal levels of serum sodium, potassium, and chloride (4) Interprofessional care (a) Immediate medical attention required (b) DKA Treatment: Fluid replacement, regular intravenous insulin, and potassium replacement 3. Hyperosmolar Hyperglycemic State

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) Precipitating factors (1) Infection, therapeutic agents that cause hyperglycemia, therapeutic procedures, acute illness, and chronic illness b) Manifestations (a) Osmotic diuresis, decreased perfusion, GFR drops (can lead to renal failure), serum hyperosmolarity, and neurologic deficits c) Treatment (a) Correct fluid and electrolyte imbalances, lower blood glucose levels with insulin, and treat underlying conditions 4. Hypoglycemia a) Precipitating causes (1) Mismatch between insulin intake, physical activity, lack of carbohydrate availability, the intake of some alcohol and drugs b) Manifestations (1) Autonomic nervous system: Hunger, nausea, anxiety, pale cool skin, sweating, shakiness, irritability, rapid pulse, and hypotension (2) Impaired cerebral function: Strange or unusual feelings, headache, difficulty in thinking, inability to concentrate, change in emotional behavior, slurred speech, blurred vision, decreased levels of consciousness, seizures, and coma (3) Person with T1D may present with atypical manifestations c) Interprofessional care (1) Mild hypoglycemia: 15 g of rapid-acting sugar (2) Severe hypoglycemia: Seek medical attention (a) Hospitalization criteria: (i) Blood glucose less than 50 mg/dL and no recovery with prompt treatment (ii) Coma, seizures, or altered behavior (iii) Hypoglycemia has been treated but a responsible adult cannot be with the patient for the following 12 hours (iv) Hypoglycemia cause by a sulfonylurea drug (b) 10–15 g of an oral carbohydrate if patient is alert (c) Altered levels of consciousness: Parenteral glucose or glucagon, 50% dextrose B. Chronic complications 1. Alterations in the cardiovascular system a) Release of proinflammatory cytokines increases insulin resistance, increases hyperglycemia, and causes inflammatory damage in the endothelium 2. Macrovascular complications a) Coronary artery disease .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

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b) Hypertension c) Stroke (cerebrovascular accident) d) Peripheral vascular disease Microvascular complications a) Diabetic retinopathy b) Diabetic nephropathy Diabetic neuropathies a) Etiologies (1) Thickening of the walls of the blood vessels that supply nerves (2) Demyelinization of the Schwann cells that surround and insulate nerves (3) Formation and accumulation of sorbitol within the Schwann cells b) Peripheral neuropathies (somatic neuropathies) (1) Polyneuropathies (a) Manifestations: Distal paresthesias, impaired sensations of pain, light touch, two-point discrimination, and vibration (2) Mononeuropathies (a) Manifestations: Palsy of the third cranial nerve, radiculopathy, diabetic femoral neuropathy, entrapment or compression of the medial nerve at the wrist c) Visceral neuropathies (a) Manifestations: Sweating dysfunction, abnormal papillary function, cardiovascular dysfunction, gastrointestinal dysfunction, and genitourinary dysfunction Mood alterations a) Increased risk of depression Increased susceptibility to infection Periodontal disease Complications involving the feet a) Atherosclerosis of vessels in the legs b) Peripheral vascular insufficiency with intermittent claudication in the lower legs and ulcerations of the feet c) Foot trauma (1) Cracks and fissures caused by dry skin or infections such as athlete’s foot, blisters caused by improperly fitting shoes, pressure from stockings or shoes, ingrown toenails, and direct trauma d) Gangrene

C. Complications in Older Adults 1. Specific plan of care tailored to functional abilities 2. Complications a) Urinary incontinence .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

b) Disability c) Frailty d) Falls e) Depression f) Cognitive impairment g) Vascular disease IV.

Interprofessional Care of the Patient with Diabetes Mellitus A. Diagnosis 1. Diagnostic screening a) A hemoglobin A1C greater than or equal to 6.5% b) Fasting plasma glucose (FPG) greater than or equal to 126 mg/dL (7.0 mmol/L) c) Oral glucose tolerance test (OGTT) d) A random plasma glucose greater than or equal to 200 mg/dL 2. Prediabetes a) Risk factors: Hemoglobin A1C level of 5.7% to 6.4% b) Prevention: Weight loss, increased physical activity, annual monitoring for the onset of diabetes, and treatment with Metformin 3. DM management a) Fasting blood glucose (FBG) b) Glycosylated hemoglobin (A1C) c) Urine test for glucose, ketones, and albumin d) Serum cholesterol and lipid levels 4. Self-monitoring a) Urine testing for ketones and glucose b) Self-monitoring of blood glucose (SMBG) (1) Lancet device to perform a finger-stick (2) Blood glucose monitor (3) Test strips specific to the glucose monitor being used c) Continuous blood glucose monitoring (CGM) 5. Factors that affect glucose meter performance a) Hematocrit b) Other substances: Isopropyl alcohol, food residue, some lotions, uric acid, glutathione, and ascorbic acid c) Using correct supplies and sample volume 6. Medications for patients with diabetes mellitus a) Insulin

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Sources of insulin: Recombinant DNA technology (2) Insulin preparations (a) Rapid-acting, short-acting, intermediate-acting, and long-acting preparations (b) Insulin lispro, regular insulin, insulin detemir, and insulin glargine (i) Concentration of insulin (ii) Mixing insulin (3) Insulin administration (a) Routes of administration (b) Continuous subcutaneous insulin infusion (c) Correctional doses of insulin (d) Syringe and needle selection (i) Sterile, single-use needles and either disposable insulin syringes or a multiple dose insulin pen (e) Preparing the injection (f) Sites of injection (i) Abdomen: Most rapid absorption (ii) Subcutaneous tissue of upper arm, thigh, and hip (iii) Lipodystrophy (g) Insulin regimes (h) Hypersensitivity responses (i) Insulin may cause local and systemic hypersensitivity responses b) Hypoglycemic agents (1) Sulfonylureas, biguanides, alpha-glucoside inhibitors, meglitinides, incretin mimetics, DPP-4 inhibitors, and synthetic amylin hormone c) Aspirin therapy 7. Nutrition for patients with diabetes mellitus a) Promote and support healthy eating patterns that include a variety of nutrient-dense foods in appropriate portions b) Achieve and maintain blood glucose levels within HbA1C less than 7% or as individualized for the patient c) Achieve and maintain optimal serum lipid levels d) Achieve and maintain blood pressure levels in the normal range e) Achieve and maintain body weight goals f) Prevent or at least slow the rate of development of complications of DM g) Address individual nutrition needs, taking into account personal and cultural preferences, health literacy, access to helpful food choices, and willingness to change h) Limit food choices only when research-based evidence supports doing stuff i) Provide practical tools for meal planning j) Meal planning should follow the recommended daily allowance of all nutrients

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

8. Recommended intake of specific nutrients a) Carbohydrates: Choose healthy carbohydrates with higher fiber and nutrient value; majority of intake from vegetables, fruits, whole grains, legumes, and dairy b) Protein: Dietary goals individualized for the patient; two sources low in saturated fat and cholesterol such as fish, poultry, egg whites, beans c) Fats: Limit saturated fat; avoid trans fatty acids; consume healthful fat d) Fiber: Helpful in treating constipation and other gastrointestinal disorders e) Sodium: Recommended daily intake is 1000 mg per 1000 kcal f) Sweeteners: Restricted amount of refined sugars g) Alcohol: Not encouraged, but not restricted 9. Meal planning and diet plans (a) Consistent-carbohydrate DM meal plan (b) The exchange lists (c) Diet plan for insulin-dependent DM (d) Diet plan for T2D (e) Diet plan for the older adult 10. Exercise for patients with diabetes mellitus a) 150 minutes per week b) Patients with T1D (1) Factors that influence response to exercise (a) Type, intensity, and duration of the exercise (b) Timing of exercise in relation to meals and insulin injections (c) Time of day of the activity (2) Guidelines (a) Recognize and treat patterns of hyperglycemia or hypoglycemia during exercise (b) Risk of exercise induced hypoglycemia is lower before breakfast (c) Exercise should be moderate and regular (d) Exercising at peak insulin action time may lead to hypoglycemia (e) Self-monitoring blood glucose is essential before, during, and after exercise (f) Fluid intake, especially water, is essential c) Patients with T2D (1) Guidelines for exercise program (a) Medical screening before beginning program (b) Begin the program slowly, and gradually increase intensity and duration (c) Exercise at least 150 minutes a week in regular sessions (d) Include resistance exercise (muscle strengthening) and aerobic exercises 11. Surgery .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) Treating DM with surgery (1) Surgically revising the GI tract (2) Replace or transplant the pancreas, pancreatic cells, and beta cells b) Managing DM in the patient having surgery (1) Preoperative screening for complications and regular blood glucose monitoring (2) IV glucose and insulin infusion in an ICU for patients are critically ill in the perioperative period (3) Schedule surgery for earliest possible in the morning (4) Postoperatively glucose control will determine if the patient with T2D requires insulin or may resume oral medications V.

Nursing and Transition Care of the Patient with Diabetes Mellitus A. Assessment 1. Health history: Family history of DM; history of hypertension or other cardiovascular problems; history of any change in vision or speech, dizziness, numbness, or tingling in hands or feet; pain when walking; frequent voiding; change in weight, appetite, infections, and healing; problems with gastrointestinal function or urination; or altered sexual function 2. Physical assessment: Height/weight ratio, vital signs, visual acuity, cranial nerves, sensory ability of extremities, peripheral pulses, skin, and mucous membranes B. Priorities of care C. Diagnoses, outcomes, and interventions 1. Prevent skin breakdown a) Musculoskeletal assessment that includes foot and ankle joint range of motion, bone abnormalities, gait patterns, use of assistive devices for walking, and abnormal wear patterns on shoes b) Neurologic assessment that includes sensations of touch and position, pain, and temperature c) Vascular examination that includes assessment of lower-extremity pulses, capillary refill, color and temperature of skin, lesions, and edema d) Teach foot hygiene e) Discuss the importance of not smoking if patient smokes f) Discuss the importance of maintaining blood glucose levels through prescribed diet, medication, and exercise 2. Prevent infection a) Use and teach meticulous hand hygiene b) Monitor for manifestations of infection c) Discuss the importance of skin care

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

d) Teach dental health measures: (1) Obtain a dental examination every 4 to 6 months.

(2) Maintain careful oral hygiene (3) Be aware of the manifestations requiring dental care e) If dental surgery is necessary, monitor for need to make adjustments in insulin f) Teach women with DM about the manifestations and preventive measures for vaginitis caused by Candida albicans 3. Prevent injury a) Assess for the presence of contributing or causative factors that increase the risk of injury: Blurred vision, cataracts, decreased adaptation to dark, decreased tactile sensitivity, hypoglycemia, hyperglycemia, hypovolemia, joint immobility, and unstable gait b) Reduce environmental hazards in the healthcare facility, and teach the patient about safety in the home and in the community c) Monitor for and teach the patient and family to recognize and seek care for the manifestations of DKA in the patient with type 1 DM d) Monitor for and teach the patient and family to recognize and seek care for the manifestations of HHS in the patient with type 2 DM e) Monitor for and teach the patient and family to recognize and treat the manifestations of hypoglycemia f) Recommend that the patient wear a medical alert bracelet or necklace identifying self as a person with DM 4. Promote sexual function a) Include a sexual history as a part of the initial and ongoing assessment of the patient with DM b) Provide information about the actual and potential physical effects of DM on sexual function c) Provide counseling or make referrals as appropriate 5. Promote coping a) Assess the patient’s psychosocial resources, including emotional resources, support resources, lifestyle, and communication skills b) Explore with the patient and family the effects (actual and perceived) of the diagnosis and treatment of DM on finances, occupation, energy levels, and relationships c) Teach constructive problem-solving techniques d) Provide information about support groups and resources, such as suppliers of products, journals, books, and cookbooks for people with DM 6. Delegating nursing care activities

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

D. Transitions of care 1. Health promotion a) Plan of care b) Prevent complications c) Maintain or improve quality of life d) Health promotion e) Focuses on preventing the onset and complications of DM f) Lifestyle changes and medications g) Blood glucose screening at 3-year intervals beginning at age 45 2. Care of the newly diagnosed patient a) Information about the disease b) Diet information c) Exercise information d) Blood glucose monitoring e) Recognition of hypo and hyperglycemia and treatment f) Insulin teaching g) Traveling with diabetes h) Alcohol use i) Smoking cessation j) Stress and illness k) Potential complications and prevention 3. Care of the patient with diabetic complications a) Assess for knowledge and motivational deficits b) Foster resilience 4. Sick days a) Monitor blood glucose as often as every 2 to 3 hours b) Testing urine for ketones as often as every 4 hours c) Continue to take insulin or oral hypoglycemic agent and add to correctional insulin dose as prescribed d) Consume clear liquids e) Contact healthcare provider for fever longer than 2 days, vomiting and diarrhea for more than 6 hours, glucose way out of range, moderate or large ketones, and signs of dehydration 5. Teaching self-management a) Three levels of teaching (1) Survival skills (2) Home management .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(3) Improving lifestyle b) Teaching the older adult (1) Changes in diet maybe difficult to implement (2) Exercise is important and must be individualized (3) Money for medication and supplies may come from a fixed income (4) Visual deficits may impair safe self-care c) Home care teaching (1) Metabolism (2) Diet plan (3) Exercise (4) Self-monitoring of blood glucose (5) Medications (a) Insulin (b) Oral agents (6) Acute complications (7) Hygiene (8) Sick days (9) Helpful resources

Chapter Highlights A. Diabetes mellitus is a very common condition with continued increased incidence and prevalence in the United States. The long-term complications of diabetes, including cardiovascular disease, stroke, and kidney failure, are among the leading causes of death in this country.

B. Blood glucose homeostasis is maintained through constant feedback mechanisms that increase and decrease hormones. Insulin decreases blood glucose, whereas glucagon increases glucose. Stress hormones also increase blood glucose.

C. The onset, pathophysiology, and acute complications of T1D and T2D differ from one another. The development of T2D starts with insulin resistance (prediabetes) that may be asymptomatic for many years. The incidence of T2D is increasing in epidemic proportions in all racial and ethnic groups in the United States, often triggered by obesity and sedentary lifestyles.

D. T1D is the result of pancreatic islet cell destruction and a total deficit of circulating insulin. The autoantibodies that cause T1D are present for many years before the onset of the disease.

E. Acute complications of diabetes include hypoglycemia, hyperglycemia, and the hyperglycemic emergencies DKA and HHS. F. An estimated 50% of individuals newly diagnosed with T2D have already developed chronic complications secondary to hyperglycemia. Chronic complications are a result of vascular damage and hyperglycemia. They include retinopathy, nephropathy, wounds, infections, acute MI, stoke, and peripheral vascular disease, to name a few. .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

G. Older adults with diabetes may experience urinary incontinence, disability, frailty, falls, depression, cognitive impairment, and vascular disease. It is important to assess the older adult and prevent these complications to improve safety and quality of life.

H. Early diagnosis and tighter, intensive glycemic control is increasingly the focus of care of patients with hyperglycemia (patients with diabetes and prediabetes).

I. Self-monitoring blood glucose levels is an important aspect of care that results in better glucose control for the patient with diabetes.

J. Products to manage DM include insulins, noninsulin hypoglycemics, and blood glucose monitoring devices. Nurses must be familiar with these products and help patients become proficient in their use.

K. Nutrition, meal planning, and exercise are also important aspects of the management of diabetes and prevention of prolonged hyperglycemia.

L. Weight loss surgeries are an effective measure to aid in the treatment of T2D. When the patient with diabetes is experiencing surgery, careful management of glucose is important to prevent complications such as infection.

M. The nurse needs to understand sick-day management in order to teach the patient to prevent hyperglycemic emergencies during periods of illness.

N. Nursing care of the patient with diabetes is focused on assessment of problems and potential complications, developing accurate priorities of care, intervening and delegating care appropriately, and assessing outcomes.

O. Nurses have a great impact in caring, guiding, and teaching the patient with diabetes during acute and chronic complications and at the end of life.

SUGGESTIONS FOR CLASSROOM ACTIVITY—LEARNING OUTCOME ONE Ask students to describe how as a nurse they could impact the incidence of type 2 DM. Discuss the potential financial impact of normal weight among Americans. How would healthcare costs in the United States decrease?

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME ONE Invite an endocrinologist to speak to the clinical group on the prevalence and incidence of DM including how this has changed recently and what is projected for the future.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME TWO Compare and contrast the pathophysiology and risk factors for type 1 and type 2 diabetes.

Explain how the patient with diabetes can delay or prevent diabetic complications from occurring.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME TWO Assign students to patients who have been diagnosed with diabetes mellitus.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME THREE Develop a nursing care plan for the patient with DKA. Include nursing diagnoses and nursing implications.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME THREE Ask students to develop and implement a teaching plan to help the patient with DM prevent further complications of the disease.

SUGGESTIONS FOR CLASSROOM ACTIVITY—LEARNING OUTCOME FOUR Discuss how the tests used to detect DM and the tests used to determine the ability to manage diabetes differ.

Develop a care plan that incorporates an educational component to teach the patient about insulin administration and dietary control.

Review the choice of sites of administration of insulin.

SUGGESTIONS FOR CLINICAL ACTIVITY—LEARNING OUTCOME FOUR Review charts of a patient with diabetes. Note lab values. Ask students to explain if the patient is managing her diabetes well?

Practice administering insulin.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME FIVE Provide an example of and discuss a sick-day plan for the patient with DM.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTIONS FOR CLINICAL ACTIVITY—LEARNING OUTCOME FIVE Conduct a nursing assessment on a patient to decide what factors are involved in the patient’s ability to manage their diabetes.

Ask students to develop and implement a teaching plan for a patient, including dietary management, exercise, and a plan for sick-day management.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter 21 Assessing the Gastrointestinal System Learning Outcomes 1. Outline the nutrients absorbed in the gastrointestinal (GI) system.

2. Describe the anatomy, physiology, and functions of the GI system and identify abnormal findings that may indicate impairment of the GI system.

3. Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.

4. Differentiate considerations for assessing the GI system of older adults, veterans, and individuals in the LGBTQI population.

5. Summarize topics that nurses teach to promote a healthy GI system across the lifespan.

Key Concepts 1. Nutrition: Life process by which the body, via the gastrointestinal (GI) system and the accessory digestive organs, ingests, absorbs, transports, uses, and eliminates nutrients in food.

I.

Nutrients: Substances found in foods that are used by the body to promote growth, maintenance, and repair A. Carbohydrates 1. Plant foods: Primary source 2. Monosaccharides, disaccharides, and polysaccharides B. Proteins 1. Complete or incomplete 2. Used to build different structures (skin keratin, collagen and elastin in connective tissues, muscles, enzymes, hemoglobin, plasma proteins, and hormones) C. Fats (lipids) 1. Phospholipids, steroids, and neutral fats (triglycerides) 2. Unsaturated fats: Monounsaturated and polyunsaturated D. Vitamins 1. Organic compounds that facilitate the body’s use of carbohydrates, proteins, and fats 2. Fat soluble or water soluble 3. Dietary reference intakes (DRIs) 4. Tolerable upper intake limit (UL) E. Minerals

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

1. Maintain structure and function of the body II.

Anatomy, Physiology, and Functions of the GI System A. Digestive processes 1. Ingestion of food 2. Movement of food and wastes 3. Secretion of mucus, water, and enzymes 4. Mechanical and chemical digestion of food 5. Absorption of digested food B. The mouth 1. Lips, cheeks, palate, tongue, mucous membranes, 32 permanent teeth 2. Salivary glands: Parotid, submaxillary, and sublingual C. The pharynx 1. Consists of the oropharynx and the laryngopharynx 2. Provides passageways for foods, fluids, and air 3. Made of skeletal muscles and lined with mucous membranes D. The esophagus 1. Passageway for food from the pharynx to the stomach 2. Epiglottis 3. Gastroesophageal sphincter E. The stomach 1. Cardiac region, fundus, body, and pylorus 2. Functions a) Storage reserve for food b) Continues the mechanical breakdown of food c) Begins the process of protein digestion d) Mixes food with gastric juices into chime F. The small intestine 1. Begins at pyloric sphincter, ends at ileocecal junction 2. Three regions: The duodenum, the jejunum, and the ileum 3. Chemically digests and absorbs food 4. Enzymes a) Pancreatic amylase, dextrinase, glucoamylase, maltase, sucrase, lactase, trypsin, chymotrypsin, and pancreatic lipases G. The large intestine

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

1.

2.

3.

4.

5.

Begins at the ileocecal valve and terminates at the anus Cecum, appendix, colon, rectum, and anal canal Colon: Ascending, transverse, and descending Eliminates indigestible food residue from the body Defecation reflex a) Valsalva’s maneuver

H. The accessory digestive organs 1. The liver and gallbladder a) Liver: Produces bile b) Receives nutrients absorbed by the small intestine and metabolizes them so they are useable to cells of the body c) Gallbladder: Stores bile 2. The exocrine pancreas a) Produces enzymes necessary for digestion of fats, proteins, and carbohydrates b) Produces pancreatic juice which neutralizes acidic chyme and contains enzymes that aid in digestion I. GI Microbiota 1. Influenced by demographics, dietary intake, environmental exposures J. Metabolism 1. Process of biochemical reactions occurring in the body’s cells 2. Catabolic or anabolic 3. Biochemical reactions produce water, carbon dioxide, and ATP III.

Assessing Gastrointestinal Function A. Health assessment interview 1. Any family members with known abnormalities of copper accumulation in the body, hypercholesterolemia, abnormal cholesterol or fat metabolism, obesity, or cancer of the pancreas, colon, or rectum 2. Genetic gastrointestinal disorders a) Wilson’s disease b) Tangier disease c) Hypercholesterolemia d) Pancreatic cancer e) Obesity f) Colon cancer g) Familial adenomatous polyposis (FAP) and hereditary nonpolyposis colorectal cancer (HNPCC) h) Crohn’s disease

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

i) Celiac disease (CD) j) Gaucher disease 3. Nutrition history a) Interview to establish baseline dietary habits and preferences, identify problems with nutrition and GI function b) Food frequency questionnaire c) ADLs d) Medication use e) Family history f) Risk factors for cancer g) Health history: Prior surgeries or trauma of GI system, past history of medical conditions, and food allergies h) Culture and ethnicity: Nutritional diversity B. Physical assessment 1. Physical assessment: Palpation, inspection, and auscultation a) Gastrointestinal assessments (1) Anthropometric assessment (a) Measure weight and height (b) Measure BMI (c) Measure triceps skinfold thickness (TSF) (d) Measure midarm circumference (MAC) (e) Calculate midarm muscle circumference (MAMC) (f) Determine waist-to-hip ratio (2) Abnormal findings: Malnutrition, overweight, and obese b) Oral assessment (1) Inspect and palpate the lips, tongue, buccal mucosa, teeth, gums, throat, and tonsils (2) Note the patient’s breath (3) Abnormal findings: Cheilosis, cold sores, atrophic smooth glossitis, vertical fissures, black hairy tongue, leukoplakia, reddened, dry swollen mucosa, candidiasis, cavities, gingivitis, red and swollen tonsils, sweet fruity breath, acetone breath, and foul breath c) Abdominal assessment (1) Inspect abdominal contour, skin integrity, venous pattern, and aortic pulsation (2) Auscultate all four quadrants of the abdomen with the diaphragm of the stethoscope (3) Auscultate the abdomen for vascular sounds with the bell of the stethoscope (4) Percuss the abdomen in all four quadrants (5) Percuss the liver (6) Percuss the spleen .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(7) Percuss for shifting dullness (8) Palpate the abdomen in all four quadrants (9) Feel for masses, note tenderness or pain (10) Palpate for rebound tenderness (11) Palpate the liver (12) Abnormal findings (a) Generalized abdominal distention: Gas retention or obesity (b) Lower abdominal distention: Bladder distention, pregnancy, or ovarian mass (c) General distention and an everted umbilicus: Ascites and/or tumors (d) A scaphoid (sunken) abdomen: Malnutrition or when fat is replaced with muscle (e) Striae: Obesity and during or after pregnancy (f) Spider angiomas: Liver disease (g) Dilated veins: Cirrhosis of the liver, ascites, portal hypertension, or venocaval obstruction (h) Pulsation is increased in aortic aneurysm (i) Borborygmus: Diarrhea or at the onset of bowel obstruction (j) Bowel sounds may be absent later in bowel obstruction, with an inflamed peritoneum, and/or following surgery of the abdomen (k) Bruits: Constricted arteries (l) Venous hum: Cirrhotic liver (m) Friction rubs: Inflamed liver or spleen (n) Dullness: Bowel is displaced with fluid or tumors or filled with a fecal mass (o) The liver is greater than 6 to 10 cm in the MCL and greater than 4 to 8 cm in the midsternal line (MSL): Cirrhosis and/or hepatitis (p) A large area of dullness that extends to the left anterior axillary line on inspiration: Enlarged spleen (q) Level of dullness increases when the patient turns to the side: Ascites (r) Palpation causes abdominal pain and involuntary muscle spasms: Peritoneal inflammation (s) Abnormal masses: Aortic aneurysms, neoplastic tumors of the colon or uterus, and a distended bladder or distended bowel due to obstruction (t) A rigid, boardlike abdomen: Perforated duodenal ulcer (u) Peritoneal inflammation (v) Right upper quadrant pain: Acute cholecystitis (w) Upper middle abdominal pain: Acute pancreatitis (x) Right lower quadrant pain: Acute appendicitis (y) Left lower quadrant pain: Acute diverticulitis (z) Enlarged liver with a smooth, tender edge: Hepatitis or venous congestion (i) Enlarged, nontender liver: Malignant condition (ii) Murphy’s sign .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

d) Inguinal area assessment (1) Inspect the inguinal area for bulges (2) Palpate the inguinal (3) Abnormal findings: Bulges or masses may indicate a hernia e) Perianal assessment (1) Inspect the perianal area (2) Palpate the anus and rectum (3) Palpate in the anus for lesions or masses (4) Abnormal findings (a) Swollen, painful, longitudinal breaks in the anal area: Anal fissures (b) Dilated anal veins: Hemorrhoids (c) Red mass: Prolapsed internal hemorrhoids (d) Doughnut-shaped red tissue at the anal area: Prolapsed rectum (e) Movable, soft masses: Polyps (f) Hard, firm, irregular embedded masses: May indicate carcinoma f) Fecal assessment (1) Inspect the patient’s feces (a) Color, odor, and consistency (2) Test the feces for occult blood (3) Note the odor of the feces (4) Abnormal findings: Positive occult blood test needs further testing for colon cancer or GI bleeding, distinctly foul odors C. Diagnosis: Diagnostic tests 1. The esophagus and stomach a) Barium swallow or upper GI series b) Esophageal acidity, esophageal manometry, and acid perfusion (Bernstein test) c) Gastric analysis normal values d) Gastric emptying studies e) Magnetic Resonance Imaging (MRI)—Stomach f) Upper GI endoscopy (esophagogastroduodenoscopy [EGD]) and gastroscopy 2. The intestines a) Abdominal ultrasound b) Barium enema c) Colonoscopy d) Guaiac fecal occult blood test (G-FOBT) e) Immunochemical fecal occult f) Blood test (I-FOBT) g) Magnetic resonance imaging (MRI)—abdominal h) Sigmoidoscopy i) Small-bowel series .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

j) Stool specimen and stool culture k) Stool DNA test (sDNA) l) Virtual colonography (VC) 3. The gallbladder and pancreas a) Abdominal ultrasound, hepatobiliary ultrasound, and gallbladder ultrasound b) Cholangiography (1) Percutaneous transhepatic cholangiogram (PTC) (2) Surgical cholangiogram c) Cholecystography (oral) (GB series) d) Computed tomography (CT) e) Endoscopic retrograde cholangiopancreatography (ERCP) f) Magnetic resonance cholangiopancreatography (MRCP) g) Serum amylase h) Serum lipase 4. The liver a) Liver biopsy b) Liver function tests IV.

Assessments of Selected Populations A. Older adult 1. Age-related gastrointestinal changes a) Teeth: Increase in periodontal disease and tooth loss, fractures of teeth, and incidence of dentures b) Gums: Gingival retracts, increase in periodontal disease c) Taste: Less acute d) Saliva: Decrease in amount produced e) Esophageal motility: Decreased intensity of propulsive waves and slower emptying time f) Stomach: Mucosa atrophies, decreased production of hydrochloric acid and pepsin, increased incidence of gastric irritation g) Liver: Less efficient handling of cholesterol, increase in gallstones h) Small intestine: Decreased ability to absorb vitamins and minerals, slowed fat absorption i) Large intestine: Decrease in mucous secretion and elasticity of the wall of rectum B. Patients who identify as LGBTQI: Higher prevalence of eating disorders, anal cancer 17 times higher in men who have sex with men and increased risk of acquiring a sexually transmitted disease C. Adults with cystic fibrosis: Nutritional monitoring needs

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

V.

Health Promotion A. Maintain a healthy weight B. Reduce risk of cancer

Chapter Highlights A. The categories of nutrients are carbohydrates, proteins, fats, vitamins, minerals, and water and are found in food.

B. Overall health status is influenced by proper nutrition and a balanced diet.

C. The etiology of many common illnesses is influenced by diet and nutrition, thereby making the nurse’s role increasingly important in terms of conducting health assessments aimed at detecting early disease processes and teaching that promotes healthy dietary habits.

D. Describe the anatomy, physiology, and functions of the GI system and identify abnormal findings that may indicate impairment of the GI system.

E. The gastrointestinal system including the mouth, pharynx, esophagus, stomach, small intestine, large intestine, and the accessory digestive organs (liver, gallbladder, and pancreas) plays a critical role in providing nutrition to all other systems, thereby influencing homeostasis of the body.

F. After carbohydrates, fats, and proteins are ingested and digested, absorbed and transported across cell membranes, they must be metabolized to provide energy required to maintain life.

G. Manifestations of dysfunctions and disorders affecting the gastrointestinal system may be detected during a general health assessment as well as during focused assessment of the gastrointestinal system.

H. As a member of the interprofessional health care team, the nursing role involves preparing the patient for diagnostic tests and monitoring results.

I. Older adults can be at risk for malnutrition. Nurses should conduct a thorough assessment to determine nutritional status.

J. Veterans of the Persian Gulf wars should be assessed for diarrhea, constipation, and IBS. Vietnam veterans should be assessed for liver disorders.

K. Patients who identify as LGBTQI should be assessed for eating disorders, as needed, and MSM should be assessed, as needed, for anal cancer and STIs. L. Adults with cystic fibrosis will need continued monitoring of their nutrition.

M. Interventions aimed at assisting patients to maintain a healthy weight through diet and exercise are primary nursing responsibilities.

N. Health teaching should address behaviors and habits that increase the risk of esophageal cancer and chronic liver disease.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME ONE Discuss sources of nutrients for each of the food groups. .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME ONE Ask a gastroenterologist to speak to the clinical group about gastrointestinal disorders and management for the disorders.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME TWO Discuss the problems incurred with patients who have abnormal gallbladder and pancreatic studies.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME TWO Have each student assess their patient’s medical record for abnormal findings that might indicate alterations in gastrointestinal function.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME THREE Ask students to role-play taking a nutritional health history.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME THREE Ask students to perform a health assessment and physical assessment on the patient they are caring for.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME FOUR Discuss the different topics to consider when assessing and caring for the GI system of special population patients.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME FOUR Visit a gastroenterologist’s office, and assist in caring for various patients with gastrointestinal disorders.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME FIVE Ask the class to brainstorm topics that nurses should teach to promote a healthy GI system. Discuss responses.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME FIVE Have each student determine which diet the treating clinician has ordered for the patient for which they are caring.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter 22 Nursing Care of Patients with Nutritional Disorders

Learning Outcomes 1. Describe the pathophysiology, manifestations, and complications of obesity, and outline the intraprofessional care and nursing care of patients with obesity.

2. Describe the pathophysiology and manifestations of malnutrition, and outline the intraprofessional care and nursing care of patients with malnutrition.

3. Describe the pathophysiology and manifestations of eating disorders, and outline the intraprofessional care and nursing care of patients with these disorders.

Key Concepts I.

Obesity A. Obesity 1. Bariatrics: Healthcare science for the extremely obese 2. Body mass index (BMI): Indirect measure of the amount of body fat, or adipose tissue B. Incidence and prevalence 1. 39% of U.S. adult population is obese; over two-thirds are overweight 2. Obesity rate is higher in women and economically disadvantaged people of all races C. Risk factors 1. Genetic, physiologic, psychologic, environmental, and sociocultural factors D. Overview of normal physiology 1. Nutrients: Building blocks for growth and tissue repair 2. Basal metabolic rate (BMR): “Cost” of being alive 3. Adipocytes 4. Triglycerides E. The patient with obesity 1. Pathophysiology a) Obesity results from excess energy intake and/or decreased energy expenditure b) Appetite regulated by the central nervous system and emotional factors c) Major types of body fat distribution (1) Upper body obesity (central obesity) (2) Lower body obesity (peripheral obesity) d) Sarcopenic obesity

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

2. Complications of obesity a) Cardiovascular disease (1) Metabolic syndrome: Increased waist circumference, hypertension, elevated blood triglycerides and fasting blood glucose, low HDL cholesterol, and metabolic syndrome (2) Atherosclerosis, hypercholesterolemia, coronary heart disease, heart failure, hypertension, stroke, varicosities, and venous thrombosis b) Respiratory disorders (1) Asthma, COPD, and sleep apnea c) Diabetes mellitus d) Other disorders: Reproductive disorders, cancer, joint pain, and osteoarthritis 3. Interprofessional care a) Diagnosis (1) Body mass index (2) Waist circumference (3) Anthropometry (4) Underweight weighing (hydrodensitometry) (5) Bioelectrical impedance (6) Thyroid profile (7) Serum glucose (8) Serum cholesterol (9) Lipid profile (10) Electrocardiogram (ECG) b) Medications (1) Lipase inhibitors (2) Appetite suppressants c) Treatment (1) Exercise (a) Target heart rate (b) Aerobic activity, muscle-strengthening activities (2) Nutrition (a) Diet that creates 500- to 100-kcal deficit daily (b) Very low calorie diets (VLCDs): For patients with a BMI greater than 30 (3) Behavior modification (a) Controlling the environment (b) Controlling physiologic responses to food (c) Social support and group programs: Weight Watchers, Overeaters Anonymous, and Take Off Pounds Sensibly (TOPS) (4) Surgery (a) Bariatric surgery limited to extremely obese patients who have been unsuccessful at weight loss .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(b) Types of surgeries (i) Restrictive procedures: Vertical gastroplasty (VGB), adjustable gastric banding (AGB) (ii) Malabsorptive procedures: Roux-en-Y gastric bypass (RYGB), vertical sleeve gastrectomy (VSG) and biliopancreatic diversion with duodenal switch (BPD-DS) (iii) Combination of restrictive and malabsoprtive (iv) Most common procedures: Adjustable gastric banding, gastric bypass, gastric sleeve, and biliopancreatic bypass with duodenal switch (c) Postoperative complications (i) Anastomosis leak with peritonitis, abdominal wall hernia, gallstones, wound infections, deep venous thrombosis and pulmonary embolisnutritional deficiencies, and gastrointestinal symptoms, and dumping syndrome (5) Maintaining weight loss (a) Majority regain lost weight within 2-year period 4. Nursing care a) Assessment (1) Health history: Risk factors; current and usual weight; recent weight gains or losses; perception of weight and effect on health; usual diet and food intake; exercise/activity patterns; prior weight loss efforts and results; current medications; coexisting disorders such as cardiovascular disease and diabetes; tobacco use; family history of overweight conditions, diabetes, and weightrelated morbidity.

(2) Physical examination: Vital signs; weight (use a scale of adequate capacity) and height; skinfold measurements; waist-to-hip ratio; BMI; inspect skin under the breasts and abdominal folds. b) Priorities of care (a) Patient centered and holistic (b) Ensure maintenance of adequate nutrition participation in supportive interventions (c) Collaborate with interprofessional team (d) Monitor anthropometric measurements regularly (e) Monitor vital signs (f) Assess for clinical manifestations of nutritional deficiency (g) Monitor for side effects and drug interactions of weight loss medications c) Diagnoses, outcomes, and interventions (1) Support weight loss

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(a) Encourage the patient to identify the factors that contribute to excess food intake (b) Establish realistic weight loss goals and exercise/activity objectives (c) Assess the patient’s knowledge and discuss diet plan options (d) Discuss behavior modification strategies (e) Monitor weight loss, blood pressure, and laboratory data (2) Promote activity tolerance (a) Assess current activity level and tolerance of that activity; assess vital signs (b) After medical clearance, plan a program of regular, and gradually increasing exercise (3) Support adherence to treatment plan (a) Discuss ability and willingness to incorporate changes into daily patterns of diet, exercise, and lifestyle (b) Help the patient identify behavior modification strategies and support systems for weight loss and maintenance (c) Have the patient establish strategies for dealing with “stress” eating or interruptions in the therapeutic regime (4) Promote healthy self-esteem (a) Encourage the patient to verbalize the experience of being overweight, and validate the patient’s experience (b) Set small goals with the patient and offer positive feedback and encouragement (c) Refer for counseling as appropriate d) Transitions of care (1) Primary prevention—nutritional assessment and health and life style coaching (2) Secondary prevention—frequent monitoring for the development of metabolic syndrome and other complications (3) Tertiary prevention—monitoring for complications and the emergence of comorbidities associated with overweight/obesity (4) Topics to address with patient and family (a) Lifestyle changes are more effective than diets (b) Household should consume a nutritionally sound, low in fat, high in fiber diet (c) Establish realistic weight loss goals and a system of nonfood rewards (d) Identify an exercise buddy or support system to promote continued physical activity (e) Expect occasional failures (f) Community resources II.

Malnutrition A. Incidence and prevalence

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

1. At-risk groups in the United States: Young, poor, older adults, homeless, low-income women, and ethnic minorities 2. 1/3–1/2 of all hospitalized patients are malnourished B. Risk factors 1. Age—older adults are at greater risk 2. Poverty, homelessness, and inadequate food storage and preparation facilities 3. Functional health problems that limit mobility or vision 4. History of weight loss of more than 20% of usual weight 5. Oral or gastrointestinal problems that affect food intake, digestion, and absorption 6. Inability to eat for 5 or more days 7. Chronic pain or chronic diseases such as pulmonary, cardiovascular, renal, or endocrine disorders, or cancer 8. Dementia, mental health disorders, and eating disorders 9. Medications or treatments that affect appetite 10. Alcohol or drug addiction 11. Acute problems such as infection, surgery, or trauma C. The patient with malnutrition 1. Pathophysiology a) Starvation: Inadequate dietary intake; glycogen is used to provide energy b) Hypermetabolism: Increases energy expenditure and nutrient needs c) Catabolism: Cell and tissue breakdown d) Protein-calorie malnutrition (PCM) e) Severe malnutrition: Kwashiorkor and marasmus 2. Manifestations a) Weight loss, reduced body mass and skinfold thickness, wasted appearance, dry and brittle hair, pale mucous membranes, and peripheral or abdominal edema b) Older adults: General symptoms of frailty, weakness, slow walking speed, low physical activity level, unintentional weight loss, and exhaustion 3. Interprofessional care a) Diagnosis (1) Serum albumin (2) Prealbumin (3) Total lymphocyte count (4) Serum electrolytes and potassium levels (5) Bioelectric impedance analysis (6) Total daily energy expenditure b) Medications (1) Supplemental vitamins .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(2) Minerals c) Treatment (1) Fluid and electrolyte imbalances corrected (2) Protein and calories gradually reintroduced (3) Enteral nutrition (a) For patients with difficulty swallowing, unresponsiveness, oral or neck surgery or trauma, anorexia, or serious illness (b) Enteral feeding formulas: Complete, high-calorie complete, complete lactose-free, high-residue, and disease-specific formulas (c) Complications: Aspiration and diarrhea (4) Parenteral nutrition (PN) (a) Intravenous administration of amino acids, often with added carbohydrates, fats, electrolytes, vitamins, and minerals (b) Administered patient’s nutritional requirements cannot be met through diet or enteral nutrition (c) Complications: Fluid overload, infections, metabolic, and mechanical complications 4. Nursing care a) Assessment (1) Health history: Usual daily dietary pattern; usual weight and recent changes; appetite and food tolerance; specific food likes and dislikes; difficulty swallowing; problems such as anorexia, nausea, diarrhea, or constipation; history of surgery and/or chronic diseases and medications (2) Physical examination: Height, weight, skinfold thickness, BMI; vital signs; general appearance, muscle wasting, mobility; skin and mucous membranes; bowel sounds; and laboratory studies b) Priorities of care (a) Obtain and document baseline indicators of nutritional status (b) Collaborate with physician, dietician and pharmacy to develop an interprofessional treatment plan (c) Ensure patient is receiving supplemental nutrition support when appropriate c) Diagnoses, outcomes, and intervention (1) Promote weight gain and well-being (a) Provide an environment and nursing measures that encourage eating (b) Eliminate foul odors, provide oral hygiene before and after meals, make meals appetizing, and offer frequent, small meals including preferred foods Consult with the nutrition support team to provide adequate protein, calories, minerals, and vitamins (c) Provide a rest period before and after meals .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(d) Assess knowledge and provide appropriate teaching (e) Start specialized nutritional support when a patient cannot, should not, or will not eat adequately and if the benefits of nutrition outweigh the associated risks (2) Reduce risk for infection (a) Monitor temperature and assess for manifestations of infection every 4 hours (b) Maintain medical asepsis when providing care and surgical asepsis when carrying out procedures (c) Teach the signs and symptoms of infection, hand hygiene, and factors that increase the risk for infection (3) Reduce risk for insufficient fluid volume (a) Monitor oral mucous membranes, urine-specific gravity, level of consciousness, and laboratory findings every 4 to 8 hours (b) Weigh daily and monitor intake and output. Daily weights and intake and output measurements help monitor fluid balance (c) If allowed, offer fluids frequently in small amounts (4) Reduce risk for skin injury (a) Assess skin every 4 hours (b) Turn and reposition at least every 2 hours (c) Keep skin dry and clean, and minimize shearing forces d) Delegating nursing care activities e) Transitions of care (1) Teaching topics (a) Diet recommendations and use of nutritional supplements (b) Where to obtain recommended foods and nutritional supplements (c) If continuing enteral or parenteral nutrition: (i) How to prepare and/or handle solutions (ii) How to add them to either the feeding tube or central line (iii) How to manage infusion pumps (iv) How to care for the feeding tube or central catheter (v) How to recognize and manage problems and complications (vi) How and when to notify the healthcare provider of problems III.

Eating Disorders A. Anorexia nervosa 1. Typically begins during mid to late adolescence 2. Risk factors: History of sexual or physical abuse, family history of mood disorders, abnormal levels of neurotransmitters and other hormones, genetic factors, obsessive and perfectionist personalities, family, social, or occupational pressures

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

B. Bulimia nervosa 1. Develops in late adolescence or early adulthood 2. Weight is within normal or above range 3. Causes: Cultural, psychosocial, and biologic factors 4. Patient induces vomiting or excessive laxatives or diuretics after binging C. Binge-eating disorder (BED) 1. Share characteristics of bulimia, but do not purge 2. Commonly affects obese middle-aged adults 3. Psychosocial factors: Depressed, anxious, and personality disorder D. Interprofessional care 1. Diagnosis a) No specific diagnostic test b) BED: Elevated blood glucose and lipid levels c) Mental health evaluation 2. Treatment a) Anorexia nervosa (1) May require hospitalization (2) Intravenous feeding (3) Psychologic treatment (4) Cognitive-behavioral therapy or psychotherapy b) Bulimia (1) Nutritional counseling and therapy (2) Psychosocial interventions (3) Medications (antidepressants) (4) Cognitive-behavioral therapy c) Binge-eating (1) Establishing healthy eating patterns (2) Psychosocial therapy (cognitive-behavioral therapy and group counseling) E. Nursing care 1. Health promotion a) Nutritional education b) Promote healthy body imaging c) Identification of risk factors, early signs of disorders 2. Assessment a) Standard nutritional assessment b) History related to weight loss patterns and descriptions of psychological symptoms commonly associated with eating disorders 3. Priorities of care .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

4. Diagnosis, expected outcomes, and interventions a) Patient and family issues to consider (1) Adherence to therapeutic regimen (2) Chronic low self-esteem (3) Concerns with body image (4) Dysfunctional family process b) Nursing considerations (1) Regularly monitor weight, using standard conditions (2) Monitor food intake during meals, recording percentage of meal and snack consumed (3) Serve balanced meals, including all nutrient groups (4) Serve frequent, small feedings of cold or room-temperature foods (5) Administer a multivitamin and mineral supplement to replace losses c) Transitions of care (1) Health promotion interventions (2) Early identification of patients at risk

Chapter Highlights A. Obesity, defined as excess adipose tissue and a BMI greater than 30, is linked with many disorders, including type 2 diabetes, coronary heart disease, gallbladder disease, and osteoarthritis.

B. Exercise and reduced kilocalorie intake are the mainstays of obesity treatment.

Drugs that suppress the appetite or interfere with fat absorption in the gut may be used to facilitate weight loss in patients with multiple risk factors for obesity complications or people who have had difficulty achieving weight loss through diet and exercise.

C. Bariatric surgery is a treatment option for morbidly obese patients. The primary types of bariatric surgery used in the United States are restrictive procedures that limit stomach capacity and food consumption, and combination restrictive/malabsorptive procedures that limit both capacity and nutrient absorption.

D. Nursing care for obese patients focuses on health promotion, education, health coaching and support of the prescribed treatment plan.

E. In the United States, protein-calorie malnutrition is a common problem among hospitalized patients. Malnutrition increases the risk for complications and impairs healing.

Early identification and prevention are the primary focuses of treatment; nurses can be instrumental in identifying at-risk patients (e.g., the elderly, patients living alone, and people on extended NPO status).

F. Refeeding of malnourished patients is a gradual process. Enteral feedings (oral or by feeding tube) are preferred whenever possible. Parenteral nutrition may be required when enteral feeding is not possible or not tolerated by the patient.

G. Eating disorders, including anorexia nervosa, bulimia nervosa, and binge-eating disorder, can be difficult to effectively treat and maintain in remission. While patients with anorexia typically are underweight and malnourished, resisting efforts to achieve a normal .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

weight, patients with bulimia are more likely to be of normal weight and those with bingeeating disorder are more likely to be overweight or obese.

H. Treatment for eating disorders is multifaceted, including physical care to restore electrolyte balance and treat complications, nutritional counseling and therapy, psychosocial therapy, family support, and possibly medications.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME ONE Divide the class into two groups. One group will research obesity, causes, pathophysiology, and morbidity. The other group will research malnutrition, and will focus on eating disorders, pathophysiology, causes, morbidity. Both groups should cover care, treatment, and nursing interventions.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME ONE Ask a physician from the bariatric treatment program to speak to the clinical group regarding the care and treatment options for patients within the bariatric treatment program.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME TWO Create a nursing care plan for a patient with malnutrition. Include multidisciplinary methods for care.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME TWO Have each student assess their patient’s medical record for abnormal findings that might indicate malnutrition.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME THREE Have each student develop a list of departments in a hospital setting that could be part of the interdisciplinary care for patients with and eating disorder.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME THREE Assign patients to care for a patient with an eating disorder.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter 23 Nursing Care of Patients with Upper Gastrointestinal Disorders

Learning Outcomes 1. Describe the pathophysiology and manifestations of nausea and vomiting, and outline the interprofessional care and nursing care of patients with nausea and vomiting.

2. Describe the pathophysiology and manifestations of disorders of the mouth, and outline the interprofessional care and nursing care of patients with these disorders.

3. Describe the pathophysiology and manifestations of disorders of the esophagus, and outline the interprofessional care and nursing care of patients with these disorders.

4. Describe the pathophysiology and manifestations of disorders of the stomach and duodenum, and outline the interprofessional care and nursing care of patients with these disorders.

Key Concepts I. Nausea and Vomiting A. Nausea: Sensation of sickness or queasiness B. Vomiting: Forceful expulsion of contents of the upper GI tract C. The patient with nausea and vomiting 1. Pathophysiology a) Sources that stimulate the vomiting center (1) The GI tract, produced by distention, irritation, or infection (2) The vestibular system of the ear (3) Higher central nervous system centers (4) Chemoreceptors outside the blood–brain barrier (5) Disorders such as acute myocardial infarction and heart failure (6) Increased intracranial pressure b) Anorexia commonly precedes nausea; nausea frequently precedes vomiting c) Vomiting: Coordinated by the brainstem; stimulates the vagus nerve and parasympathetic nervous system 2. Manifestations a) Potential complications of vomiting: Dehydration, hypokalemia, metabolic alkalosis, and aspiration with resulting pneumonia, and rupture or tears of the esophagus b) Most often self-limited and requires no treatment c) Postoperative nausea and vomiting (PONV) d) Chemotherapy-induced nausea and vomiting (CINV) .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

3. Interprofessional care a) Diagnosis (1) Serum electrolytes (2) Pregnancy testing if indicated (3) Liver, pancreatic, and renal function studies (4) Imaging studies to detect gastrointestinal obstruction (5) Upper endoscopy (6) CT scan or MRI of the head (7) Gastrointestinal motility studies b) Medications (1) Serotonin receptor antagonists, phenothiazines and phenothiazine-like drugs, neurokinin receptor antagonist, anticholinergics and antihistamines, and cannabinoids, c) Integrative therapies (1) Biofeedback, guided imagery, music therapy, hypnosis, acupuncture, acupressure, and ginger 4. Nursing care a) Assessment (1) Health history: Determine if the patient has a past history with nausea and vomiting. Personal or family history of PONVV or motion sickness. Establish onset and duration of nausea and frequency, quantity and characteristics of emesis. Ask the patient what treatments they have used to control nausea and vomiting. Determine if the patient is experiencing signs and symptoms associated with dehydration or electrolyte balance (2) Physical examination: Focus on signs and symptoms of dehydration and electrolyte imbalance and include vital signs, skin turgor, mucous membranes, and weight b) Priorities of care c) Diagnosis, outcomes, and interventions (1) Manage nausea and vomiting (i) Monitor subjective complaints of nausea (ii) Monitor vital signs, skin turgor and condition, and weight. (iii) Maintain accurate intake and output records. Monitor amount, color, and specific gravity of urine (iv) Administer antiemetic medication as ordered, prior to meals and before treatments or procedures known to stimulate nausea (v) Instruct to deep breath to voluntarily suppress the vomiting reflex (vi) Instruct to consume small quantities of clear fluids and dry foods at separate times

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

5. Transitions of care a) Antiemetic administration b) Provide thorough discharge teaching and assure patients have access to followup care c) Instruct patient to restrict intake to small quantities of clear liquids and dry foods; avoid food prep odors d) Maintain fluid intake; provide information about electrolyte replacement solutions e) Chronic conditions and end of life can cause nausea and vomiting II.

Disorders of the Mouth A. Inflammations, infections, and neoplastic lesions of the mouth affect food ingestion and nutrition B. The patient with stomatitis 1. Stomatitis: Inflammation and ulcers of the oral mucosa 2. Causes: Viral infection, bacterial or fungal infections, mechanical trauma, irritants, nutritional deficiencies, chemotherapeutic agents 3. Risk factors: Immunocompromised, age > 65 years, impaired immune status, chronic renal failure or heart failure, chemotherapy, radiation therapy, stem cell transplant, oxygen therapy, mouth breathing, medications (antibiotics, phenytoin, anticholinergics, and corticosteroids), poor oral hygiene, ill-fitting dentures, and tobacco or alcohol use 4. Pathophysiology a) Stomatitis results from persistent damage to oral mucosal cells b) Damage is initially superficial, progressing to ulceration and involvement of the entire epithelium c) Healing begins within 2 to 4 weeks 5. Manifestations a) Potential complications: Malnutrition, fluid and electrolyte imbalance, sepsis, bacterial endocarditis 6. Interprofessional care a) Diagnosis (1) Direct physical examination, cultures, smears, and evaluation for systemic illness b) Medications (1) Topical oral anesthetics (mouthwash), topical antifungal agents, and antiviral agents c) Treatment

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Meticulous oral hygiene, solution of saline, sodium bicarbonate 7. Nursing care a) Assessment (1) Health history: Complaints of mouth pain, altered taste, lack of appetite, malaise; presence of dentures, regularity of dental care; current health status including chronic diseases; current medications; use of alcohol or tobacco.

(2) Physical assessment: Inspect lips, gums, teeth, interior cheeks, tongue and base of tongue, soft and hard palate; tonsils, and oral pharynx. Observe and assess general health status including temperature, weight. For patients undergoing chemotherapy and radiation therapy, expert groups recommend consistent use of an oral grading system to assess the oral cavity at regular intervals.

(3) Diagnostic tests: Conduct WBC, sedimentation rate, and serum albumin tests b) Priorities of care c) Diagnoses, outcomes, and interventions (1) Maintain intact oral mucous membrane (i) Assess and document oral mucous membranes and the character of any lesions every 4 to 8 hours (ii) Assist with thorough mouth care after meals, at bedtime, and every 2 to 4 hours while awake (a) Provide topical and systemic pain management, using “magic mouthwash” (iii) Assess knowledge and teach about condition, mouth care, and treatments (2) Promote balanced nutrition and hydration (i) Assess food intake as well as the patient’s ability to chew and swallow; weigh daily; provide appropriate assistive devices such as straws or feeding syringes (ii) Encourage a high-calorie, high-protein diet considerate of food preferences iii) Provide analgesics for pain relief as needed d) Delegating nursing care activities 8. Transitions of care a) Topics for teaching home care (1) Managing any underlying health conditions and ongoing treatments (2) Inspection of the oral cavity at regular intervals and report early signs of oral mucositis (3) The recommended diet and oral hygiene regime (4) Nutritional supplements to help meet nutritional requirements

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(5) Prescribed medication, its route, side effects, frequency of administration, and signs and symptoms to report (6) The importance of completing the full course of antibiotic, antiviral, or antifungal treatment (7) Manifestations to report and the importance of follow-up care C. The patient with oral cancer 1. Risk factors a) Smoking, drinking alcohol, chewing tobacco, marijuana use, occupational exposures to chemicals, and viruses such as human papilloma virus (HPV) 2. Pathophysiology a) More than 90% of oral and oropharyngeal tumors are squamous cell carcinomas b) Early cancers present as inflamed areas with irregular, ill-defined borders c) Advanced cancers present as deep ulcers fixed to deeper tissues 3. Manifestations a) Leukoplakia; erythroplakia; ulcers; neck mass; pigmented areas (brownish or black); fissures; lump or thickening in the throat or mouth; difficulty chewing, swallowing, or moving the tongue or jaws b) Earliest symptom is painless oral ulceration or lesion 4. Interprofessional care a) Eliminate causative factors b) TNM classification: Tumor staging determines therapy c) Stages I and II: Surgery or radiation therapy d) Stages III and IV: A treatment combination of surgery, radiation, and possibly chemotherapy e) Biopsy of oral lesion f) CT scans or MRI g) Radical neck dissection may be required for advanced carcinomas 5. Nursing care a) Assessment (1) Health history: Complaints of oral lesions that fail to heal; use (current or past) of tobacco products or excess alcohol (2) Physical examination: Inspect and palpate lips and oral mucosa for tumors or lesions. Lesions may appear as velvety red or white patches that do not scrape off, or as ulcers or areas of necrosis b) Priorities of care .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

c) Diagnoses, outcomes, and interventions (1) Manage risk for airway obstruction and problems with oxygenation (i) Initial postoperative period: Assess airway patency and respiratory status hourly (ii) Unless contraindicated, place in Fowler’s position, supporting arms; assist the patient to turn, cough, and deep breath at least every 2 to 4 hours (iii) Maintain adequate hydration and humidity of inspired air (2) Manage nutritional and fluid requirements (i) Weigh daily; assess oral intake for adequacy of protein, calories, and nutrients (ii) Offer soft, bland foods with supplements as indicated; provide small, frequent feedings (iii) Provide enteral feedings per gastrostomy tube as ordered (iv) Assess for gastric residual volume per facility protocol for the type of feeding (v) Consider a nutritional consultation to assess diet and plan appropriate supplements (3) Promote patient communication (i) Before surgery, establish and practice a communication plan (ii) Provide ample time for communication efforts and do not answer for the patient (iii) If indicated, refer to or consult with a speech therapist (4) Manage concerns with body image (i) Assess coping style, self-perception, and responses to altered appearance or function (ii) Encourage verbalization of feelings regarding perceived and actual changes (iii) Provide emotional support, encourage self-care, and provide decision-making opportunities (5) Plan discharge (i) Topics to discuss with patient and family (a) Diagnosis and prescribed care (b) Monitoring for new lesions or recurrences (c) Diet, nutrition, and activity (d) Pain management (e) Airway management, care of incision, and signs and symptoms to report d) Delegating nursing care activities 6. Transitions of care .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) Promote oral hygiene and regular dental care b) Smoking cessation c) Aggressive screening for patients at risk for developing mucositis d) Aggressive treatment for acute oral conditions e) Continuous attention to chronic oral conditions III.

Disorders of the Esophagus A. The patient with gastroesophageal reflux disease (GERD) 1. Pathophysiology a) May result from transient relaxation of the lower esophageal sphincter, an incompetent lower esophageal sphincter, and/or increased pressure within the stomach b) Contributing factors: Increased gastric volume, positioning that allows gastric contents to remain close to the gastroesophageal junction, increased gastric pressure, a hiatal hernia 2. Manifestations a) Heartburn, chest pain, regurgitation, belching, dysphagia, pain after eating, chronic cough, hoarseness, laryngitis, and pharyngitis 3. Interprofessional care a) Diagnosis (1) Barium swallow (2) Upper endoscopy (3) Bernstein test (4) 24-hour ambulatory pH monitoring (5) Esophageal manometry b) Medications (1) Antacids, proton-pump inhibitors (PPIs), histamine2-receptor (H2receptor) blockers, antiulcer agent, and promotility agent c) Nutrition and lifestyle management (1) Eliminate acidic and fatty foods, chocolate, peppermint, and alcohol from diet (2) Maintain ideal body weight, eat smaller meals, refrain from eating 3 hours before bedtime, and stay upright 2 hours after meals (3) Stop smoking and reduce alcohol consumption d) Surgery (1) Antireflux surgeries (2) Laparoscopic fundoplication (3) Nissen fundoplication (4) Other laparoscopic procedures (5) Ablation therapy

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

4. Nursing care a) Assessment (1) Health history: Manifestations such as frequent heartburn or atypical chest pain; intolerance of foods that are acidic, spicy, or fatty; regurgitation of acidic gastric juice; increased symptoms when bending over, lying down, or wearing tight clothing; difficulty swallowing; and possible hoarseness (2) Physical assessment: Epigastric tenderness b) Priorities of care c) Diagnosis, expected outcomes, and interventions (1) Manage acute and chronic pain (i) Provide small, frequent meals. Restrict intake of fat, acidic foods, coffee, and alcohol (ii) Instruct to stop smoking (iii) Administer antacids, H2-receptor blockers, and PPIs as ordered (iv) Discuss the long-term nature of GERD and its management 5. Transitions of care a) Teach the patient and family about management strategies B. The patient with hiatal hernia 1. Pathophysiology and manifestations a) Hiatal hernia: Part of the stomach protrudes through the esophageal hiatus of the diaphragm into the thoracic cavity (1) Sliding hiatal hernia (i) Contributing factors: Weakened anchors of the gastroesophageal junction to the diaphragm, shortening of the esophagus, and increased intra-abdominal pressure (2) Paraesophageal hiatal hernia b) Manifestations (1) Reflux, heartburn, feeling of fullness, substernal chest pain, dysphagia, occult bleeding, belching, and indigestion 2. Interprofessional and nursing care a) Diagnosis (1) Barium swallow (2) Upper endoscopy b) Treatment (1) Many patients require no treatment (2) If required, similar to GERD (3) Medications to address gastric reflux symptoms (4) Surgery: Nissen fundoplication .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

c) Nursing care Similar to that for patients with GERD C. The patient with impaired esophageal motility 1. Pathophysiology and manifestations a) Dysphagia, chest pain b) Achalasia 2. Interprofessional and nursing care a) Treatment (1) Endoscopically guided injection of botulinum toxin into the lower esophageal sphincter (2) Botulinum toxin injection (3) Balloon dilation of the LES (4) Laparoscopic myotomy D. The patient with esophageal cancer 1. Pathophysiology a) Types (1) Adenocarcinoma (2) Squamous cell carcinoma 2. Risk factors a) Excess alcohol consumption, cigarette smoking, ingested carcinogens such as nitrates and industrial chemicals, smoked opiates, physical mucosal damage, congenital disorders, and chronic gastric reflux 3. Manifestations a) Dysphagia, anemia, weight loss, GERD-like symptoms, regurgitation, anorexia, chest pain, and persistent cough 4. Interprofessional care a) Diagnosis (1) Barium swallow (2) Esophagoscopy (3) Chest x-ray, CT scans, or MRI (4) Complete blood count (CBC) b) Treatments (1) Combination of chemotherapy and radiation (2) Surgery to resect the tumor (a) Esophagectomy (3) Palliative therapy

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

5. Nursing care a) Assessment (1) Health history: Current symptoms such as chest pain, dysphagia, odynophagia (pain with swallowing), coughing or hoarseness; duration of symptoms; recent weight loss; smoking history; current and past patterns of alcohol consumption (2) Physical examination: Weight; general health status; skin color; and supraclavicular and cervical lymph nodes for lymphadenopathy b) Priorities of care c) Diagnoses, outcomes, and interventions (1) Promote balanced nutrition and hydration (2) Manage risk for airway obstruction and promote oxygenation (b) Assess mental and respiratory status at least every hour during the initial postoperative period (c) Provide aggressive pulmonary hygiene measures (d) If present, monitor chest tube function and drainage (e) Monitor cardiopulmonary status and hemodynamic pressures; administer intravenous fluids and fluid boluses as ordered (f) Do not move or manipulate the nasogastric tube; maintain low gastric suction as ordered (g) Verify enteral tube feeding placement by checking the pH of gastric aspirate (3) Help manage feelings of grief and loss d) Delegating nursing care activities 6. Transitions of care a) Topics to cover in teaching patients and family home care (1) Planned treatment options (2) Wound and follow-up care following surgery (3) Prevention and manifestations of complications such as wound or chest infection, anastomosis leak, and deep venous thrombosis (4) How to prepare, implement, and care for tube feedings or home parenteral nutrition IV. Disorders of the Stomach and Duodenum A. Overview of normal physiology 1. The stomach a) Gastric mucosal barrier: Protects the stomach from hydrochloric acid and pepsin (1) Substances that impact gastric mucosal barrier (i) Lipid-soluble substances (ii) Bile acids .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(iii) Aspirin and NSAIDs B. The patient with gastrointestinal bleeding 1. Primary disorders that lead to upper (UGI) hemorrhage a) Erosive gastritis b) Peptic ulcer disease c) Esophageal varices 2. Pathophysiology a) Blood in the GI tract leads to nausea and vomiting (hematemesis) b) Stools may be melena or hematochezia 3. Manifestations a) GI hemorrhage is a medical emergency b) Occult bleeding may be detected by chemical means 4. Interprofessional care a) Diagnosis (1) Complete blood count with hemoglobin and hematocrit (2) Blood type and crossmatch (3) Serum electrolytes, osmolality, and BUN (4) Liver function studies and a coagulation profile (5) An upper endoscopy (i) Treatments (6) Initial treatment: Stem bleeding and restore cardiovascular stability (7) Upper endoscopy (8) Sclerosing agent injected into the bleeding vessel or the vessel may be sealed with a heated probe, electrocautery, or laser (9) Emergency surgery to stop hemorrhage (rare) (10) Gastric lavage 5. Nursing care a) Assessment (1) Focused on immediate crisis (2) Identify possible contributing factors and presence of acute or chronic conditions (3) Identify all current medications and purposes, any allergies (4) Physical examination: Obtain vital signs and orthostatic vital signs; place the acutely ill patient on a cardiac monitor and obtain a rhythm strip; obtain oxygen saturation level; assess peripheral pulse strength, as well as color, temperature, and capillary refill of extremities; evaluate mental status; an indwelling catheter may be inserted to evaluate urine output

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

b) Priorities of care (1) Prevent GI bleeding by recognizing at-risk patients, institute regular gastric pH monitoring and maintenance of drug therapy to reduce gastric acidity c) Diagnoses, outcomes, and interventions (1) Monitor for early signs of shock (i) Frequently assess and document vital signs (ii) Monitor for and report changes in skin color, temperature, and moisture, or slow capillary refill (iii) Insert an indwelling urinary catheter and measure urine output hourly (iv) Unless contraindicated, insert a nasogastric tube and connect to low suction; measure gastric output hourly unless otherwise directed (v) Maintain two peripheral intravenous lines with large-bore catheters or a central venous catheter for fluid and blood administration as ordered (vi) Replace gastric drainage with balanced electrolyte intravenous solutions as ordered (2) Manage GI bleeding (i) Maintain gastric suction and drainage and patency of nasogastric tube (ii) Irrigate the nasogastric tube with room temperature saline or tap water as ordered; calculate intake and output, subtracting the amount of irrigant from gastric output (iii) Prepare for upper endoscopy or surgery as planned (iv) Following an acute bleed and in patients at risk for GI bleeding, monitor gastric pH as ordered and check vomitus and feces for the presence of occult blood (v) Maintain infusions of drugs to reduce gastric acidity as ordered 6. Transitions of care a) Focuses on resolving underlying disease process and preventing future episodes b) Minor or slow GI bleeding is often managed in the community C. Patient with peptic ulcer disease (PUD): Break in the mucous lining of the gastrointestinal tract where it comes in contact with gastric juice 1. Peptic ulcers a) Duodenal ulcers: Most common b) Gastric ulcers: More common in older patients 2. Risk factors a) Helicobacter pylori infection b) Older age c) Low socioeconomic status .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

d) Birth in a developing country e) Crowded, unsanitary living conditions f) Unclean food or water g) Other factors: Use of aspirin, history of ulcer, concurrent use of drugs such as glucocorticoids or NSAIDs, cigarette smoking, and family history of PUD 3. Pathophysiology a) Ulcer develops when the mucosal barrier is unable to protect the mucosa from damage by hydrochloric acid and pepsin b) H. pylori infection is found in 50% of people with PUD c) NSAIDs contribute through systemic and topical mechanisms d) Ulcers may affect esophagus, stomach, or duodenum e) Ulcers may be superficial or deep 4. Manifestations a) Pain, “pain-food-relief” system, heartburn, regurgitation, and vomiting b) Older adult: Poorly localized discomfort, perhaps chest pain or dysphagia, weight loss, or anemia, upper GI hemorrhage, and perforation of the stomach or duodenum 5. Complications: Hemorrhage, obstruction, and perforation a) Gastric outlet obstruction b) Perforation of the ulcer through the mucosal wall D. Zollinger–Ellison syndrome: PUD caused by a gastrinoma or gastrin-secreting tumor of the pancreas, stomach, or intestines 1. Interprofessional care a) Diagnosis (1) Upper GI series (2) Endoscopy (3) Biopsy specimens (4) Fecal H. pylori antigen tests, urea breath test (5) Gastric analysis (when Zollinger–Ellison syndrome is suspected) b) Medications (1) Proton-pump inhibitors (2) H2 receptor blockers (3) Sucralfate (4) Bismuth compounds (5) Antacids (6) Prostaglandin c) Treatments (1) Nutrition: Balanced meals at regular intervals (2) Surgery (i) May be required to treat a complication of PUD

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

d) Treatment of complications (1) Hemorrhage (i) Endoscopy with direct injection of a clotting or sclerosing agent into the bleeding vessel; laser photocoagulation, electrocoagulation (2) Gastrointestinal obstruction (i) Gastric decompression with nasogastric suction and administration of intravenous normal saline and potassium chloride; H2-receptor blockers; balloon dilation of the gastric outlet (3) Perforation and peritonitis (i) Intravenous fluids, nasogastric suction, Fowler or semi-Fowler position, intravenous antibiotics, laparoscopic surgery, or open laparotomy 2. Nursing care a) Assessment (1) Health history: Complaints of epigastric or left upper quadrant pain, heartburn, or discomfort; its character, severity, timing, and relationship to eating; measures used for relief; nausea or vomiting, presence of bright blood or “coffee-grounds” material in vomitus; current medications including use of aspirin or other NSAIDs; cigarette smoking and use of alcohol or other drugs (2) Physical examination: General appearance including height and weight relationship; vital signs including orthostatic measurements; abdominal examination including shape and contour, bowel sounds, and tenderness to palpation; presence of obvious or occult blood in vomitus and stool b) Priorities of care c) Diagnoses, outcomes, and interventions (1) Manage acute and chronic pain (i) Assess pain, including location, type, severity, frequency, and duration, and its relationship to food intake or other contributing factors (ii) Administer PPIs, H2-receptor antagonists, antacids, or mucosal protective agents as ordered; monitor for effectiveness and side effects or adverse reactions (iii) Teach relaxation, stress reduction, and lifestyle management techniques. Refer for stress management counseling or classes as indicate (2) Promote healthy sleep pattern (i) Stress the importance of taking medications as prescribed (ii) Instruct to limit food intake after the evening meal, eliminating any bedtime snack (iii) Encourage use of relaxation techniques and comfort measures such as soft music as needed to promote sleep (3) Promote balanced nutrition

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(i) Assess current diet, including pattern of food intake, eating schedule, and foods that precipitate pain or are being avoided in anticipation of pain (ii) Refer to a dietitian for meal planning to minimize PUD symptoms and meet nutritional needs (iii) Monitor for complaints of anorexia, fullness, nausea, and vomiting; adjust dietary intake or medication schedule as indicated (iv) Advise the patient to report increasing or persistent symptoms of anorexia, nausea and vomiting, or fullness to the healthcare provider (v) Monitor laboratory values for indications of anemia or other nutritional deficits (4) Monitor for bleeding (i) Monitor and record blood pressure and apical pulse every 15 to 30 minutes until stable; monitor CVP or PAP as indicated; Foley catheter for hourly urine output (ii) Monitor stools and gastric drainage for overt and occult blood; assess gastric drainage to estimate the amount and rapidity of hemorrhage (iii) Maintain intravenous therapy with fluid volume and electrolyte replacement solutions; administer whole blood or packed cells as ordered (iv) Insert a nasogastric tube and maintain its position and patency Monitor hemoglobin and hematocrit, serum electrolytes, BUN, and creatinine values (v) Assess abdomen, including bowel sounds, distention, girth, and tenderness every 4 hours and record findings (vi) Maintain bed rest with the head of the bed elevated; ensure safety 3. Transitions of care a) Provide the following information (1) Prescribed medication regimen, including desired and potential adverse effects (2) Importance of continuing therapy even when symptoms are relieved (3) Relationship between peptic ulcers and factors such as NSAID use and smoking (4) Manifestations of complications to report (5) Stress and lifestyle management techniques to prevent exacerbation E. The patient with gastritis 1. Pathophysiology a) Acute gastritis b) Chronic gastritis

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

2. Manifestations a) Acute: Anorexia, nausea and vomiting, hematemesis, melena, abdominal pain, and possible shock b) Chronic: Vague discomfort after eating, may be asymptomatic, anemia, and fatigue 3. Interprofessional care a) Diagnosis (1) Testing for H. pylori infection: Urea breath tests, serologic testing, and fecal antigen testing (2) Gastric analysis (3) Hemoglobin, hematocrit, and red blood cell (RBC) indices (4) Serum vitamin B12 levels (5) Upper endoscopy b) Medications (1) PPI, H2-receptor blocker, or sucralfate, combination therapy (antibiotics, bismuth compound, possibly a PPI) c) Treatments (1) Gastrointestinal tract rest (2) Gastric lavage (3) Complementary therapies: Herbal remedies, aromatherapy d) Integrative therapies (1) Chamomile tea or the essential oil used in aromatherapy (2) Garlic; one clove chopped fine and taken daily at bedtime (3) Ginger, powdered or in capsules or made into a tea taken before or after meals (4) Mint oil aromatherapy via a diffuser, in a bath, or diluted with a carrier oil and used for a soothing massage 4. Nursing care a) Assessment (1) Health history: Current symptoms and their duration; relieving and aggravating factors; history of ingestion of toxins, contaminated food, alcohol, aspirin, or NSAIDs; other medications (2) Physical examination: Vital signs including orthostatic vitals if indicated; peripheral pulses; general appearance; abdominal assessment including appearance, bowel sounds, and tenderness b) Priorities of care c) Diagnoses, outcomes, and interventions (1) Manage nausea (i) Monitor subjective complaints of nausea

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(ii) Acute gastritis: Monitor vital signs, skin turgor and condition, and weight (iii) Maintain accurate intake and output records (iv) Monitor amount, color, and specific gravity of urine (v) Administer antiemetic medication as ordered (vi) Instruct to consume small quantities of clear fluids and dry foods at separate times (2) Promote balanced nutrition and hydration (i) Monitor and record food and fluid intake and any abnormal losses (ii) Monitor weight and laboratory studies such as serum albumin, hemoglobin, and RBC indices (iii) Arrange for dietary consultation to determine caloric and nutrient needs and develop a dietary plan (iv) Provide nutritional supplements between meals or frequent small feedings as needed (v) Maintain tube feedings or parenteral nutrition as ordered (3) Delegating nursing care activities 5. Transitions of care a) Provide information on (1) How to maintain optimal nutrition (2) Helpful dietary modifications (3) Use of prescribed medications (4) How to avoid known gastric irritants, such as aspirin, alcohol, and cigarette smoking. Referral to smoking cessation classes or programs to treat alcohol abuse may be necessary F. The patient with cancer of the stomach 1. Risk factors a) H. pylori infection, genetic predisposition, chronic gastritis, pernicious anemia, gastric polyps, smoking, carcinogenic factors in the diet, achlorhydria, and partial gastric resection 2. Pathophysiology a) Adenocarcinoma: Most common form of gastric cancer b) Begins as localized lesion, progresses to involve mucosa or submucosa c) Lymph node involvement and metastasis occur early d) Metastatic lesions are often found in the liver, lungs, ovaries, and peritoneum 3. Manifestations

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) Early symptoms: Feelings of early satiety, anorexia, indigestion, and possibly vomiting b) Later stages: Weight loss, cachectic, palpable abdominal mass, and occult blood in the stool 4. Interprofessional care a) Diagnosis (1) CBC detecting anemia (2) Upper endoscopy (3) Upper GI x-ray with barium swallow (4) Ultrasound (5) Biopsy of the lesion b) Surgery (1) Partial gastrectomy: Gastroduodenostomy (Billroth I) and the gastrojejunostomy (Billroth II) (2) Total gastrectomy (3) Complications: Dumping syndrome, anemia, vitamin B12 deficiency, folic acid deficiency, and decreased absorption of calcium and vitamin D c) Other therapies: Combination chemotherapy, radiation therapy 5. Nursing care a) Assessment (1) Health history: Manifestations such as anorexia, early satiety, indigestion, or vomiting; epigastric pain after meals; recent unintentional weight loss (2) Physical assessment: General appearance, weight for height; abdominal distention or a palpable upper abdominal mass; occult blood in stool or vomitus b) Priorities of care c) Diagnoses, outcomes, and interventions (1) Promote balanced nutrition and hydration (i) Consult with dietitian for a complete nutrition assessment and diet planning (ii) Weigh daily; monitor laboratory values such as hemoglobin, hematocrit, and serum albumin levels (iii) Provide preferred foods (iv) Assess ability to consume adequate nutrients (v) Arrange for visitors to be present during meals (vi) Administer pain and antiemetic medications as needed before meals (2) Support the grieving the patient and family (i) Encourage family members to spend as much time as possible with the patient .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(ii) Do not negate denial if present (iii) Allow patients to talk openly if desired about their condition and the prognosis (iv) Actively listen to the patient’s and family’s expressions of grieving 6. Transitions of care a) Cover the following topics when preparing patient for home care (1) Care of incision and feeding tube (if present) or central venous line (2) Maintaining nutrition and preventing complications of surgery (3) Pain management (4) Provide referrals to home care agencies, hospice, and cancer support groups (5) Provide information about services available through the local chapter of the American Cancer Society

Chapter Highlights A. Nausea and vomiting, common GI symptoms, may be indicative of disorders affecting many organ systems, including the GI tract, inner ear, CNS, or heart. Nausea and vomiting are also frequently related to medical interventions, such as drugs and cancer therapies. Complications such as dehydration, electrolyte imbalance, and aspiration of gastric contents are primary concerns when treating nausea and vomiting.

B. Stomatitis and oral mucositis are common disorders of the mouth, potentially having a significant effect on comfort and nutrition. In most cases, management is symptomatic and supportive, directed toward promoting comfort and maintaining nutritional status.

C. Oral cancer is treatable when diagnosed in the early stages. Treatment can affect nutrition and body image. Management includes teaching the patient to alter diet to meet nutritional needs. Nursing interventions involve coordinating care and supporting the patient through the treatment phase.

D. GERD is common. While it often is considered to be a benign condition, prolonged exposure of the lower esophagus to gastric juices can lead to esophagitis, hemorrhage, and scarring. Treatment begins with pharmacologic agents for symptoms of gastric reflux.

E. Hiatal hernia and impaired esophageal motility create discomfort and lead to compromised nutritional status.

F. Both esophageal and gastric cancer are often diagnosed late in the disease because their symptoms may be vague. Cancers of the upper GI tract are serious and require multiple treatment and coordinated interprofessional care. Encourage patients with complaints of dysphagia, a sensation of gastric fullness, or heartburn to seek medical evaluation. Surgical resection of the cancerous portion of the esophagus or stomach is the treatment of choice when the tumor is diagnosed early.

G. Upper gastrointestinal bleeding can lead to significant blood loss and shock. Peptic ulcer disease accounts for the majority of UGI hemorrhage, although erosive gastritis and .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

esophageal varices are also common causes. Nursing care focuses on monitoring and promoting cardiovascular stability and preventing further hemorrhage.

H. Peptic ulcer disease is chronic erosion, destruction, and ulceration in the lining of the stomach and duodenum. The primary etiologies for PUD are H. pylori infection and use of NSAIDs. Proton-pump inhibitors or H2-receptor blockers are used to heal the damaged tissue. Antacids are used for symptom relief. Antibiotics are used to treat H. pylori.

I. Acute gastritis, often associated with aspirin or NSAID use, is generally benign and selflimited. Erosive gastritis, a complication of critical conditions such as shock, trauma, a major burn, or head injury, can lead to unexpected gastric hemorrhage. Prophylactic therapy with proton pump inhibitors or H2-receptor blockers is important to prevent erosive gastritis in at-risk patients. Chronic gastritis is an unrelated disorder usually associated with H. pylori infection.

J. H. pylori infection is also a major risk factor for peptic ulcer disease and gastric cancer.

Effectively treating the infection can reduce or eliminate the risk of future exacerbations of PUD. K. An acute change in the nature of abdominal pain in a patient with PUD, especially when accompanied by vomiting, guarding of the abdomen, or a change in bowel sounds, could indicate an obstruction or perforation and release of gastric contents into the peritoneal cavity.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME ONE Assist students with creating a plan of care for the patient with nausea and vomiting.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME ONE Ask a gastrointestinal nurse specialist to speak to the clinical group about nausea, vomiting, and common disorders of the mouth, esophagus, and stomach.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME TWO Discuss how the conditions of the mouth can affect nutritional status.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME TWO Assess assigned patients for disorders of the mouth.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME THREE Ask students to select a disorder of the esophagus and discuss the pathophysiology of the disease and the multidisciplinary treatment.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME THREE Shadow a gastroenterologist caring for a patient with a disorder of the esophagus.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME FOUR Develop a teaching plan for a patient with a disorder of the stomach or duodenum.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME FOUR Make rounds with the gastrointestinal nurse specialist. Observe how data are collected regarding disorders of the stomach and duodenum.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter 24 Nursing Care of Patients with Bowel Disorders Learning Outcomes 1. Describe the pathophysiology and manifestations of disorders of motility, and outline the interprofessional care and nursing care of patients with these disorders.

2. Describe the pathophysiology and manifestations of acute inflammatory and infectious bowel disorders, and outline the interprofessional care and nursing care of patients with these disorders.

3. Describe the pathophysiology and manifestations of chronic inflammatory bowel disorders, and outline the interprofessional care and nursing care of patients with these disorders.

4. Describe the pathophysiology and manifestations of malabsorption disorders, and outline the interprofessional care and nursing care of patients with these disorders.

5. Describe the pathophysiology and manifestations of neoplastic disorders, and outline the interprofessional care and nursing care of patients with these disorders.

6. Describe the pathophysiology and manifestations of structural and obstructive bowel disorders, and outline the interprofessional care and nursing care of patients with these disorders.

7. Describe the pathophysiology and manifestations of anorectal disorders, and outline the interprofessional care and nursing care of patients with these disorders.

Key Concepts I.

Disorders of Intestinal Motility A. The patient with diarrhea Acute or chronic 1. Pathophysiology (1) Types of diarrhea: Large volume, small volume, and antibiotic associated 2. Manifestations (1) Several large, watery stools daily, or frequent small stools that contain blood, mucus, or exudate 3. Complications (1) Dehydration, vascular collapse, hypovolemic shock, hypokalemia, hypomagnesemia, and metabolic acidosis 4. Interprofessional care a) Diagnosis (1) Stool specimen analysis and culture, sigmoidoscopy, and tissue biopsy

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(2) Laboratory tests: Serum electrolytes, serum osmolality, and ABGs b) Medications (1) Antisecretory, opium and opium derivatives, anticholinergics, absorbents, and demulcents c) Nutrition (1) Fluid replacement (oral glucose/balanced electrolyte solution) (2) BRAT diet d) Integrative therapies (1) Herbal or homeopathic therapies, lactase enzyme tablets or drops, and probiotics e) Fecal microbiota transplant (1) Fecal bacteriotherapy: Restores the colon homeostasis by instilling normal bacterial flora from a healthy person (donor) into the GI tract of the affected patient 5. Nursing care a) Assessment (1) Health history: Duration and extent of diarrhea; associated manifestations; dietary intake; recent travel out of the country or to wilderness areas; previous history of diarrhea; chronic diseases; prescription and nonprescription medications (2) Physical examination: Vital signs (including orthostatic blood pressure); peripheral pulses; skin temperature, moisture, turgor; color and moisture of mucous membranes; abdominal contour and girth; bowel sounds; stool for obvious or occult blood, pus, mucus, or steatorrhea (bulky, foulsmelling stool containing fat/grease) b) Priorities of care c) Diagnosis, outcomes, and interventions (1) Control diarrhea (a) Monitor and record the frequency and characteristics of bowel movements (b) Establish and document patient’s normal bowel elimination pattern (c) Measure abdominal girth and auscultate bowel sounds every 8 hours as indicated (d) Use standard precautions and contact precautions as needed, including gloves and hand hygiene (e) Provide ready access to bathroom, commode, or bedpan (f) Administer antidiarrheal medications as prescribed (g) Limit food intake if the diarrhea is acute (2) Promote balanced fluid and electrolyte status

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(a) Record intake and output; weigh daily; assess skin turgor, mucous membranes, and urine specific gravity every 8 hours (b) Assess skin turgor over the sternum in the older adult (c) Monitor vital signs, including orthostatic blood pressures (d) Provide fluid and electrolyte replacement solutions as indicated (3) Prevent injury to skin integrity (a) Assist with cleaning the perianal area as needed (b) Apply protective ointment to the perianal area d) Transitions of care (1) Causes of diarrhea (as directed by the diagnosis) (2) Importance of hand washing and other hygiene measures (3) Importance of maintaining adequate fluid intake (4) Use of a balanced electrolyte solution for fluid replacement (5) Recommendations to limit food intake during acute diarrhea (6) To avoid foods high in fiber, milk products, and caffeine (7) Ways to maintain nutrition if chronic diarrhea is a problem (8) Precautions and limitations of antidiarrheal preparations (9) Importance of seeking medical intervention if diarrhea continues or recurs B.

The patient with constipation Chronic constipation: 12 weeks in the last 12 months Affects older adults more than younger; 25 more frequent in women than men 1. Pathophysiology a) May be primary or secondary problem b) Acute or chronic c) Psychogenic factors: Postponing defecation when the urge is felt, and the perception of satisfaction with defecation d) Cathartic colon e) Melanosis coli 2. Manifestations and complications a) Bowel movements less often than usual, frequent flatus, abdominal discomfort, anorexia, straining to have a bowel movement, and the passage of hard, dry stools fecal impaction 3. Interprofessional care a) Diagnosis (1) Barium enema, sigmoidoscopy or colonoscopy, CTC b) Medications

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Laxatives and cathartics: Bulk-forming agents, wetting agents, osmotic and saline laxatives/cathartics, irritant or stimulant laxatives, and lubricants c) Nutrition: High-fiber foods and increased fluid intake d) Enemas: Saline, tap-water, soap-solutions, phosphate, and oil retention e) Integrative therapies (1) Herbal or homeopathic therapies, acupressure, massage, reflexology, aromatherapy, and stress management therapies, and exercise 4. Nursing care a) Assessment (1) Health history: Usual and current pattern of defecation, including time of day, amount, and stool consistency; usual diet, fluid intake, and activity pattern; possible contributing factors such as opioid analgesics, activity limitations, painful hemorrhoids, perianal surgery; chronic diseases such as endocrine or neurologic disorders; prescribed and nonprescription medications. Determine patients’ perspectives on their bowel function and establish toilet accessibility (2) Physical examination: Abdominal girth and shape, bowel sounds, tenderness, and percussion tone; digital exam of the rectum if impaction is suspected. An oral examination should be included to identify any difficulty with chewing or swallowing that can lead to a decrease in fiber intake. Assess musculoskeletal and functional level to determine patient’s capacity for accessing toileting facilities b) Priorities of care c) Diagnoses, outcomes, and interventions (1) Resolve constipation (a) Monitor pattern of defecation and stool consistency (b) Provide additional fluids to maintain an intake of at least 2500 mL per day (c) Encourage drinking a glass of warm water before breakfast (d) Consult with the dietitian to provide a diet high in natural fiber unless contraindicated (e) Encourage activities such as ambulation or chair exercises (f) If indicated, consult with primary care provider about the use of bulk laxatives, stool softeners, or other laxatives as needed 5. Transitions of care a) Increasing dietary fiber intake by including fresh fruits and vegetables, whole grains, high-fiber breakfast cereals, and unprocessed bran in the diet b) Maintaining fluid intake of 6 to 8 glasses of water per day (unless contraindicated) .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

c) Suggestions for remaining physically active d) Responding to the urge to defecate when perceived e) Appropriate use of laxatives f) Reporting any change in bowel habits to the primary care provider C.

The patient with irritable bowel syndrome (IBS) 1. Pathophysiology a) CNS regulation of the motor and sensory functions of the bowel is altered b) Motility disorder of the lower GI tract characterized by visceral hypersensitivity and hyperactivity of the GI tract 2.

Manifestations a) Abdominal pain, altered bowel elimination-frequency, stool form and/or passage, passage of mucous, abdominal bloating and flatulence, abdominal tenderness, especially over sigmoid colon, possible nausea, vomiting, anorexia, fatigue, headache, depression, and anxiety

3.

Interprofessional care a) Diagnosis (1) Examine stool for occult blood, ova and parasites, and WBCs (2) Sigmoidoscopy, colonoscopy, and/or small-bowel series and barium enema (3) CBC with differential and erythrocyte sedimentation rate b) Medications (1) Bulk-forming laxatives, anticholinergic drugs, loperamide or diphenoxykatem, antidepressant drugs, and serotonin receptor antagonists c) Nutrition (1) Additional dietary fiber, limiting lactose, fructose, or sorbitol intake, reducing the intake of gas-forming foods, and limiting intake of caffeinated drinks d) Integrative therapies (1) Herbal preparations, probiotic therapies, and hypnosis

4.

Nursing care a) Assessment (1) Health history: Current manifestations, their onset and duration; current treatment measures; effect of manifestations on lifestyle; careful exploration of history of emotional, physical, or sexual abuse. The accompanying nursing research box illustrates the importance of culture in how the patient may relate his or her symptoms

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(2) Physical examination: Apparent general state of health; abdominal shape and contour, bowel sounds, and tenderness b) Priorities of care c) Diagnoses, outcomes, and intervention (1) Primary nursing responsibility is education 5. Transitions of care a) The use and role of prescribed medications, their adverse effects, and when to contact the physician b) Stress and anxiety reduction techniques c) Dietary influences that may contribute to IBS and suggested dietary changes d) The importance of routine follow-up appointments and of notifying the primary care provider if manifestations change e) Fecal microbiota transplantation may improve IBS symptoms f) Increased physical activity reduces the severity of IBS symptoms D.

The patient with fecal incontinence 1. Pathophysiology a) Usually a symptom not a disease or disorder b) Causes: Neurologic, local trauma, inflammatory processes, diarrhea, stool impaction, pelvic floor relaxation or loss of sphincter tone, and tumors 2. Manifestations a) Inability to respond normally to the urge to defecate, resulting in soiling oneself 3. Interprofessional care a) Diagnosis (1) Patient’s history, physical examination, anorectal manometry, rectal motility test, and sigmoidoscopy b) Medications: Those that relieve diarrhea or constipation may be prescribed c) Nutrition: High-fiber diet, ample fluids d) Biofeedback therapy e) Surgery: When there is damage to sphincter or rectal prolapse 4. Nursing care a) Health promotion (1) Recommended dietary measure (2) Suggestions for regular exercise (3) Use of bulk-forming laxatives (4) Prescribed medications (5) Bowel training program, stimulants, dietary changes, and exercise

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(6) The importance of good skin care (7) The potential benefits and associated risk of biofeedback and surgical treatment (8) Provided referrals for home care or community health services as indicated b) Assessment (1) Health history: Extent, onset, and duration of incontinence; identified contributing factors; history of spinal cord or anorectal injury or surgery; chronic diseases such as diabetes, multiple sclerosis, or other neurologic disorders (2) Physical examination: Mental status; general health; examination of perianal tissues; and digital rectal examination c) Priorities of care d) Diagnoses, expected outcomes, and interventions (1) Manage bowel incontinence (a) Teach caregivers to place the patient on a toilet or commode and provide for privacy at a certain time of day (b) If necessary, insert a glycerin or bisacodyl (Dulcolax) suppository 15 to 20 minutes before positioning on the toilet or commode (c) Maintain a caring, nonjudgmental manner in providing care (2) Promote self-care and socialization (a) Provide room odor control with deodorizer tablets, sprays, or other devices (b) Assist patient with hygiene and grooming quickly when fecal incontinence occurs (3) Promote good skin care (a) Clean the skin thoroughly with mild soap and water after each bowel movement (b) Apply a skin barrier cream or ointment after each bowel movement (c) If incontinence pads or briefs are used, check frequently for soiling and change when feces is noted 5. Transitions of care a) Bowel training program b) Dietary changes II.

Acute Inflammatory and Infectious Bowel Disorders A. The patient with appendicitis 1.

Appendicitis: Inflammation of the vermiform appendix; most common cause of acute abdominal pain

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

2.

Pathophysiology a) Obstruction caused by a fecalith, calculus or stone, a foreign body, inflammation, a tumor, parasites, or edema of lymphoid tissue b) Classifications: Simple, gangrenous, or perforated

3.

Manifestations a) Continuous mild generalized or upper abdominal pain, localized and rebound tenderness at McBurney’s point, low-grade temperature, anorexia, nausea, and vomiting

4.

Complications: Perforation, peritonitis, abscess, and chronic appendicitis

5.

Interprofessional care a) Diagnosis (1) Abdominal ultrasound, abdominal x-rays, intravenous pyelogram, urinalysis, pelvic examination, and WBC count with differential b) Medications (1) Intravenous fluids prior to surgery, antibiotic therapy, and pain medications c) Surgery: Appendectomy (laparoscopic approach or laparotomy)

6.

Nursing care a) Assessment (1) Health history: Current manifestations, including onset, duration, progression, and aggravating or relieving factors; most recent food or fluid intake; known medication or other allergies; current medications; and history of chronic diseases (2) Physical examination: Vital signs including temperature; apparent general health; abdominal shape and contour, bowel sounds, and tenderness to light palpation b) Priorities of care c) Diagnoses, outcomes, and interventions (1) Monitor for signs and complications of infection (a) Monitor vital signs, including temperature (b) Maintain intravenous infusion until oral intake is adequate (c) Assess wound, abdominal girth, and postoperative pain (d) Keep the patient with suspected appendicitis NPO, and do not administer laxatives or enemas (e) No heat should be applied to the abdomen (2) Manage acute pain (a) Assess pain, including its character, location, severity, and duration

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(b) Administer analgesics as ordered (c)Assess effectiveness of medication 30 minutes after administration 7.

B.

Transitions of care a) Preoperative teaching: Explain why food and fluids are not permitted b) Postoperative teaching: Turning, coughing, deep breathing, pain management, wound or incision care, instructions to report signs of infection, and activity limitations

The patient with peritonitis 1. Inflammation of the peritoneum 2. Pathophysiology a) Chemical peritonitis: Often precedes bacterial peritonitis b) Bacterial peritonitis: Usually is caused by infection by Escherichia coli, Klebsiella, Proteus, or Pseudomonas bacteria 3. Manifestations a) Abdominal/gastrointestinal: Diffuse or localized pain, tenderness with rebound, boardlike rigidity, diminished or absent bowel sounds, distention, anorexia, nausea, and vomiting b) Systemic: Fever, malaise, tachycardia, tachypnea, restlessness, confusion or disorientation, and oliguria 4. Complications a) Abscess formation, fibrous adhesions in the abdominal cavity, septicemia and septic shock, and hypovolemic shock 5. Interprofessional care a) Diagnosis (1) WBC count, blood cultures, abdominal CT scan, liver and renal function studies, serum electrolytes, and paracentesis b) Medications (1) Broad-spectrum antibiotic (beta-lactam antibiotic), antibiotic therapy specific to organisms responsible c) Surgery (1) Laparotomy and peritoneal lavage d) Nutrition (1) Intravenous fluids and electrolyte replacements; parenteral nutrition e) Intestinal decompression

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

6. Nursing care a) Assessment (1) Health history: Pain, its onset, character, severity, location, aggravating and relieving factors; associated symptoms such as anorexia, nausea, and vomiting; current and previous history of peptic ulcer disease, gallbladder disease, and chronic diseases; current medications (2) Physical examination: Vital signs including temperature; level of consciousness; skin color, temperature, warmth, capillary refill and turgor; abdominal shape, contour, bowel sounds, tenderness, tympany, and guarding b) Priorities of care c) Diagnoses, outcomes, and interventions (1) Relieve acute pain (a) Assess pain, including its location, severity, and type; monitor analgesic effectiveness (b) Place in Fowler’s or semi-Fowler’s position with the knees and feet elevated (c) Administer analgesics as ordered on a routine basis or using patientcontrolled analgesia (PCA) (d) Teach and assist with adjunctive pain management techniques such as meditation, visualization, massage, and progressive relaxation (2) Restore vascular fluid volume (a) Maintain accurate intake and output records (b) Monitor vital signs and hemodynamic parameters every hour or as indicated (c) Weigh daily (d) Assess skin turgor, color, temperature, and mucous membranes at least every 8 hours (e) Measure or estimate fluid losses through abdominal drains and on dressings (f) Monitor laboratory values; report changes to the physician (g) Administer intravenous fluids and electrolytes as ordered (h) Provide good skin care and frequent oral hygiene (3) Promote surgical recovery (a) Monitor temperature, pulse rate, and for localized signs of infection (b) Obtain cultures of purulent drainage from any site (c) Monitor WBC and differential, serum protein, and albumin

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(d) Practice meticulous hand hygiene and use standard precautions at all times (e) Use strict aseptic technique for dressing changes, wound care, and irrigations (f) Maintain fluid balance and nutritional status through enteral or parenteral feedings (4) Provide discharge teaching and planning (a) Wound care procedures, including dressing changes or irrigations (b) Prescribed medications, including name and purpose of the drug, potential adverse effects, and their management (c) Manifestations of further infection and potential complications to be reported to the care provider (d) Prescribed activity restrictions (e) Instructions for a high-calorie, high-protein diet for healing, and optimal immune function 7. Transitions of care a) Ongoing assessment and management C.

The patient with gastroenteritis Inflammation of the stomach and small intestine 1.

Pathophysiology a) Two primary mechanisms: (1) The production of exotoxins (2) Invasion and ulceration of the mucosa 2.

Manifestations (1) Anorexia, nausea, vomiting, bowel distention, abdominal pain, cramping, borborygmi, diarrhea, dehydration, hypovolemia, orthostatic hypotension, fever, and hypovolemic shock

3.

Complications a) Electrolyte and acid–base imbalances, metabolic alkalosis, metabolic acidosis, hypokalemia, hyponatremia, headache, cardiac irregularities, changes in respiratory rate and pattern, malaise and weakness, muscle aching, and signs of neuromuscular irritability b) Specific types of gastrointestinal infections (1) Traveler’s diarrhea (2) Escherichia coli hemorrhagic colitis (3) Staphylococcal food poisoning

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(4) Cholera (5) Salmonellosis (6) Shigellosis (bacillary dysentery) (7) Clostridium difficile colitis (8) Norovirus 4.

Interprofessional care a) Diagnosis (1) Laboratory testing to assess fluid, electrolyte, and acid–base balance, stool specimen, sigmoidoscopy, serum osmolality, and electrolytes and ABGs b) Medications (1) Acute enteritis: Usually resolves spontaneously; no drug treatment required (2) Antibiotic therapy specific to the organism (3) Antidiarrheal drug c) Nutrition and fluids (1) Oral rehydration for replacing physiologic fluids (2) Intravenous rehydration with severe diarrhea and fluid loss d) Treatment (1) Gastric lavage (2) Plasmapheresis (plasma exchange therapy) (3) Dialysis

5.

Nursing care a) Assessment (1) Health history: Onset, duration, and severity of manifestations; recent activities such as attending a picnic or potluck, international travel, or camping; other affected members of the household; measures taken to relieve manifestations or replace fluids (2) Physical examination: Vital signs including temperature and orthostatic blood pressure; skin color, temperature, moisture, and turgor; peripheral pulses and capillary refill; abdominal shape, contour, bowel sounds, and tenderness b) Priorities of care c) Diagnoses, outcomes, and interventions (1) Nursing care is supportive and educational

6.

Transitions of care a) The importance of good hand hygiene

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

b) The need to wash clothing and linens contaminated with feces separately in hot water and detergent c) Oral solutions to replace lost fluids and electrolytes d) Appropriate use of antidiarrheal medications if recommended e) Manifestations of complications to report to the healthcare provider D.

The patient with a protozoal bowel infection 1.

Pathophysiology and manifestations a) Giardiasis: Protozoal infection of the upper small intestine caused by Giardia lamblia (1) May be asymptomatic, diarrhea, weight loss and weakness; anorexia, nausea, and vomiting; epigastric pain, abdominal cramping and distention, flatulence, belching; and malabsorption b) Amebiasis: Caused by the protozoan Entamoeba histolytica (1) Usually asymptomatic (2) Mild manifestations: Abdominal cramps, flatulence, and intermittent diarrhea containing blood and mucus (3) Severe manifestations: Frequent watery stools containing blood, mucus, and necrotic tissue; colic, tenesmus, and abdominal tenderness; nausea and vomiting; fever; and enlarged tender liver (4) Complications: Appendicitis, bowel perforation with peritonitis, and fulminating colitis c) Cryptosporidiosis: Sporadic mild diarrhea and traveler’s diarrhea in all age groups (1) Manifestations: Watery diarrhea, low-grade fever, nausea, vomiting, abdominal cramps, and general malaise 2.

Interprofessional care a) Diagnosis (1) Stool examination, serology testing, sigmoidoscopy, duodenal aspirate, and small bowel biopsy b) Medications (1) Local (gastrointestinal) agents and systemic agents c) Treatment: Usually on an outpatient basis; severe cases may require hospitalization for intravenous fluid and electrolyte replacements

3.

Nursing care a) Same interventions as those for the patient with a bacterial or viral infection 4.

Transitions of care a) Prevention of amebiasis and giardiasis

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Provision of safe water supplies (2) Appropriate disposal of human feces (3) Safe food storage, handling, and preparation (4) Adequate hand hygiene after defecating and before handling food E.

III.

The patient with a helminthic disorder 1.

Helminths: Parasitic worms a) Round worms (nematodes), flukes (trematodes), or tapeworms (cestodes) 2.

Pathophysiology and manifestations a) Organism enters through the GI tract in contaminated and inadequately cooked food b) Some remain in intestinal tract, others migrate to liver, lungs, or other structures c) Some can be asymptomatic, can impact pulmonary, GI, and skin 3.

Interprofessional care a) Diagnosis (1) Examination of the stool, CBC, presence of anemia, serum muscle enzyme levels, serologic testing, examination of blood, duodenal washings, and CSF, biopsies of inflamed muscles b) Medications (1) Single oral dose or 3-day course of pyrantel pamoate (Antiminth), albendazole (Albenza), or mebendazole (Vermox) c) Treatment: Stool culture at 2 weeks to examine effectiveness

4.

Nursing care a) Use standard precautions to minimize risk of spreading infection to other patients

5.

Transitions of care a) Measures to prevent spread of disease in household b) Hygiene measures c) Importance of not fertilizing food or grain crops with fecal matter d) Cook all meats and fish adequately e) Safe water supplies

Chronic Inflammatory Bowel Disorders A. The patient with inflammatory bowel disease (IBD) 1. Incidence and prevalence a) Genetic and environmental factors b) Risk factors: Abnormal immune response to microorganisms normally found in the gut, smoking, and oral contraceptive use

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

c) Peak incidence: The ages of 15 and 30 years 2. Ulcerative colitis: Chronic inflammatory bowel disorder that affects the mucosa and submucosa of the colon and rectum a) Pathophysiology (1) Begins at the rectosigmoid area of the anal canal and progresses proximally (2) May progress to involve the entire colon, stopping at the ileocecal junction b) Manifestations (1) Diarrhea, anemia, hypovolemia, malnutrition, rectal inflammation, urgency and tenesmus, left lower quadrant cramping, fatigue, anorexia, and weakness (2) Severe disease: Arthritis, skin and mucous membrane lesions, uveitis, thromboemboli with blood vessel obstruction, increased risk for gallstones, cirrhosis, kidney stones, and uretal obstruction c) Complications (1) Hemorrhage, toxic megacolon, colon perforation, peritonitis, and increased risk of colorectal cancer 3. Crohn disease: Chronic, relapsing inflammatory disorder affecting the gastrointestinal tract a) Pathophysiology (1) Begins as a small inflammatory aphthoid lesion of the mucosa and submucosa of the bowel. Disease progression results in fibrotic bowel changes with thickening and loss of flexibility b) Manifestations (1) Persistent diarrhea, abdominal pain and tenderness, palpable right lower quadrant mass, fever, fatigue, malaise, weight loss, anemia, anorectal lesions, nausea, vomiting, and epigastric pain c) Complications (1) Intestinal obstruction, abscess, and fistula, generalized peritonitis, massive hemorrhage, and increased risk of cancer of the small intestine or colon 4. Interprofessional care a) Diagnosis (1) Sigmoidoscopy, colonoscopy, barium upper and lower x-ray series (2) Laboratory tests: Stool examination for blood and mucus, stool cultures, CBC with hemoglobin and hematocrit, sedimentation rate and levels of C-reactive protein, serum albumin levels, folic acid and serum levels (3) Tests for renal and hepatic function b)

Medications

.

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Sulfasalazine (azulfidine), mesalamine (asacol rowasa) and olsalazine (dipentum), corticosteroids, immunosuppressive agents, and biologic therapies c)

Nutrition (1) Dietary management is individualized (2) Nutritional status is maintained using enteral or total parenteral nutrition (TPN)

d)

Surgery (1) Strictureplasty (2) Colectomy (a) Total colectomy with an ileal pouch-anal anastomosis (IPAA) (b) Temporary or loop ileostomy (3) Ostomy (4) Ileostomy (a) Total proctocolectomy with permanent ileostomy (b) Temporary or loop ileostomy (c) Continent ileostomy

e)

Integrative therapies (1) Peppermint tea, acupressure, body massage, reflexology, aromatherapy, and stress reduction therapies

5.

Nursing care a) Assessment (1) Health history: Current manifestations, including onset, duration, severity (number of stools per day, presence of blood or mucus in stool, abdominal pain or cramping, tenesmus); usual diet, ability to maintain weight and nutrition, food intolerances; associated manifestations such as arthralgias, fatigue, malaise; current medications; and previous treatment and diagnostic tests (2) Physical examination: General appearance; weight; vital signs including orthostatic vitals and temperature; abdominal assessment including shape, contour, bowel sounds, palpation for tenderness and masses, and presence of stoma or scars.

6.

Priorities of care a) Diagnoses, outcomes, and interventions (1) Control diarrhea (i) Record the frequency, amount, and color of stools using a stool chart (ii) Observe stools for obvious blood and test for occult blood as indicated

.

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(iii) Monitor vital signs every 4 hours (iv) Weigh daily and record (v) Assess for other indications of fluid deficit: Warm, dry skin, poor skin turgor, dry shiny mucous membranes, weakness, lethargy, and complaints of thirst (vi) Maintain bowel rest by keeping NPO or limiting oral intake to elemental feedings (vii) Administer prescribed anti-inflammatory and antidiarrheal medications as indicated (viii) Maintain fluid intake by mouth or intravenously as indicated (ix) Administer prescribed anti-inflammatory and antidiarrheal medications (2) Promote self-care and acceptance of change in body image (i) Accept feelings and perception of self (ii) Encourage discussion of physical changes and their consequences as they relate to self-concept (iii) Encourage discussion about concerns regarding the effect of the disease or treatment on close personal relationships (iv) Encourage the patient to make choices and decisions regarding care (v) Discuss possible treatment options and their effects openly and honestly (vi) Involve the patient in care, teaching and demonstrating as needed (vii) Provide care in an accepting, nonjudgmental manner (viii) Arrange for interaction with other patients or groups of people with IBD or ostomies (ix) Teach coping strategies (odor control, dietary modifications, and so on), and support their use (3) Maintain adequate nutrition (i) Monitor laboratory results (ii) Provide the prescribed diet (iii) Provide parenteral nutrition as necessary if the patient is unable to absorb enteral nutrients (iv) Arrange for dietary consultation (v) Provide or administer elemental enteral nutrition and supplements as ordered (vi) Include family members, the primary food preparer in particular, in teaching and dietary discussions 7.

Transitions of care (1) Home care instructions

.

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(2) Surgical topics (1) Ileal pouch-anal anastomosis or ileostomy care as indicated (2) Where to obtain ostomy supplies (3) Use of nonprescription drugs that may not be adequately absorbed before elimination through the ileostomy (4) Community and national ostomy support groups (3) Referrals to a dietary consultant or nutritionist, community healthcare agency, home care services, home intravenous care services (4) Teaching to include (1) The type of IBD affecting the patient, including the disease process, shortand long-term effects, the relationship of stress to disease exacerbations, and the manifestations of complications (2) Prescribed medications, including drug names, desired effects, schedules for tapering the doses if ordered, and possible side effects or adverse reactions and their management (3) The recommended diet and the rationale for any specific restrictions (4) Use of nutritional supplements to maintain weight and nutritional status (5) Indicators of malabsorption and impaired nutrition; recommendations for self-care and when to seek medical intervention (6) If discharged with a central catheter and home parenteral nutrition, written and verbal instructions on catheter care, troubleshooting, and parenteral nutrition administration (7) The importance of maintaining a fluid intake of at least 2 to 3 quarts per day, increasing fluid intake during warm weather, exercise, or strenuous work, and when fever is present (8) The increased risk for colorectal cancer and importance of regular bowel exams (9) Risks and benefits of various treatment options (10) Importance of informing interprofessional care team of complementary and alternative therapy use B. The patient with diverticular disease 1.

Contributing factors a) Diet, decreased activity levels, and delayed defecation 2. Pathophysiology a) Diverticula form when increased pressure within the bowel lumen causes bowel mucosa to herniate through defects in the colon wall (1) Diverticulosis: Indicates the presence of diverticula (2) Diverticulitis: Inflammation in and around the diverticular sac .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

3.

Manifestations: Pain, constipation or increased frequency of defecation, nausea, vomiting, low-grade fever, distended abdomen, and palpable mass in left lower quadrant 4.

Complications: Bowel obstruction, fistula formation, hemorrhage, obstruction of the large and small bowel, fistulas, urinary tract infection, and bleeding from perforation of a vessel wall 5. Interprofessional care a) Diagnosis (1) Barium enema, x-rays, flexible sigmoidoscopy or colonoscopy, and CT scan (2) Laboratory tests: Hemoccult or guaiac testing of stool, WBC count b) Medications (1) Systemic broad-spectrum antibiotics effective against usual bowel flora, oral antibiotics, and Rifixamin with fiber (2) Severe, acute attacks: Hospitalization and treatment with intravenous fluids and antibiotics effective against anaerobic and gram-negative bacteria (3) Stool softener may be prescribed, but laxatives are avoided c) Nutrition (1) High-fiber diet (2) Bowel rest: Feeding resumed gradually, clear liquid diet with gradual advancement to a soft, low-roughage diet with daily added psyllium seed (3) Foods to avoid: Wheat and corn bran, vegetable and fruit skins, nuts, and dry beans d) Surgery (1) Affected bowel segment is resected (2) Anastomosis of the proximal and distal portions (3) Two-stage Hartmann procedure (4) Temporary colostomy 6. Nursing care a) Assessment (1) Health history: Abdominal pain or cramping, chronic constipation or irregular bowel habits; nausea and vomiting; history of diverticular disease or irritable bowel syndrome (2) Physical examination: Bowel sounds, presence of abdominal tenderness of masses and location; stool for occult blood b) Priorities of care c) Diagnoses, outcomes, and interventions (1) Reduce risk of complication (i) Monitor vital signs, including temperature, at least every 4 hours .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(ii) Assess abdomen every 4 to 8 hours, or more often as indicated (iii)Assess for evidence of lower intestinal bleeding by visual examination and guaiac testing of stools for occult blood (iv) Maintain intravenous fluids, TPN, and accurate intake and output records 7. Transitions of care a) Topics for home-care: (1) Provide a referral to a dietitian for teaching as indicated (2) Prior to discharge of the patient with acute diverticulitis, discuss the following: (a) Food and fluid limitations, including recommendations for a lowresidue diet during the initial period of healing (b) Colostomy management (if a temporary colostomy has been created), including where to obtain supplies and dietary management (c) Planned procedure to reanastomose the colon and revise the colostomy (3) Prescribed high-fiber diet and the need to maintain the diet for life to reduce the incidence of complications, including ways to increase dietary fiber (4) Complications of diverticular disease and its manifestations IV.

Malabsorption Syndromes 1) Impaired absorption 2) Impaired digestion A.

The patient with celiac disease 1. Chronic T-cell-mediated autoimmune genetic disorder of the small intestine in which the absorption of nutrients, particularly fats, is impaired 2. Pathophysiology a) Provoked by the ingestion of gluten; affects a person who has a genetic predisposition for the disease b) Intestinal mucosa is damaged by immunologic response 3. Manifestations a) Local-abdominal bloating, cramps, diarrhea, and steatorrhea b) Systemic-weight loss, weakness and malaise, anemia, bone pain, muscle cramps, paresthesias, easy bruising and bleeding, glossitis, and cheilosis 4. Interprofessional care a) Diagnosis

.

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Enteroscopy (2) Genetic testing for the presence of HLA genes (3) Serologic testing for IgA endomysial antibodies and IgG and IgA antigliadin antibodies (4) Biopsy of the jejunum (5) Laboratory tests: Fecal fat; serum levels of protein, albumin, cholesterol, electrolytes, and iron; hemoglobin, hematocrit, and RBC indices; prothrombin time b) Medications: Vitamin and mineral supplements, corticosteroids c) Nutrition (1) Gluten-free diet that is high in calories and protein; fat content and lactose is usually restricted 5. Nursing care a) Assessment (1) Health history: Onset, duration, and severity of manifestations; number and character of stools; previous teaching related to disorder; current treatment and diet (2) Physical examination: Vital signs; abdominal shape, contour, bowel sounds; manifestations of malnutrition (e.g., anemia, small stature, muscle wasting, and signs of other nutrient deficiencies) b) Priorities of care c) Diagnoses, outcomes, and interventions (1) Control diarrhea (a) Assess and document the frequency and nature of stools (b) Weigh daily, monitor intake and output, and assess skin turgor and mucous membranes for indications of fluid balance (c) Assess and document perianal skin condition (d) Encourage a liberal fluid intake (2) Promote adequate nutrition (a) Maintain accurate dietary intake records (b) Monitor laboratory results, including hemoglobin and hematocrit, serum electrolytes, total serum protein, and albumin levels (c) Arrange for dietary consultation (d) Provide the prescribed high-kilocalorie, high-protein, low-fat, glutenfree diet for the patient with celiac sprue (e) Provide parenteral nutrition as ordered if the patient is unable to absorb enteral nutrients (f) Encourage nutritional supplements .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(g) Include family members, the primary food preparer in particular, in teaching and dietary discussions 6. Transitions of care a) Provide detailed list of foods that contain gluten as well as allowed foods b) Stress importance of taking medications as ordered B.

The patient with lactase deficiency 1. Pathophysiology and manifestations a) Many are asymptomatic b) Lower abdominal cramping, pain, diarrhea, bloating, and flatus 2. Interprofessional care a) Diagnosis (1) Lactose breath test b) Nutrition (1) Lactose-free or reduced lactose diet (2) Calcium supplements recommended 3. Nursing care a) Focuses on providing education and support

C.

The patient with short bowel syndrome (1) Result of resection of significant portions of the small intestine (2) Affects absorption of water, nutrients, vitamins, and minerals 1. Pathophysiology and Manifestations a) Bowel undergoes adaptive process in which villi enlarge and lengthen to increase absorptive surface b) Increased risk of kidney stones and gallstones 2.

3.

Interprofessional care a) Diagnosis (1) Total serum proteins and albumin levels (2) Serum levels of folate, iron, vitamins, minerals, and electrolytes (3) Anemia and a prolonged prothrombin time b) Medications (1) Multivitamin and mineral supplements, antidiarrheal medications, protonpump inhibitor Transitions of care

.

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) Provide instructions about the recommended diet and medication regimen b) Emphasize the importance of maintaining an adequate fluid intake c) Teach the patient to monitor his or her weight frequently and report changes d) Teach about possible manifestations of dehydration and nutrient deficiencies that should be reported to the physician e) Refer the patient to a dietitian or counselor V.

Neoplastic Disorders A. The Patient with polyps 1. Polyp: Mass of tissue that arises from the bowel wall and protrudes into the lumen 2. Familial adenomatous polyposis (FAP) is a syndrome 3. Pathophysiology a) Adenomas: Benign epithelial tumors (1) Tubular adenomas (pedunculated polyps) (2) Villous adenomas (sessile polyps) (3) Tubulovillous adenomas b) Sessile (raised nodules) or pedunculated (attached by a stalk) 4. Manifestations a) Most are asymptomatic, intermittent painless rectal bleeding (bright or dark red) b) Large polyp: Abdominal cramping, pain, or manifestations of obstruction; diarrhea and mucous discharge 5. Interprofessional care a) Diagnosis (1) Sigmoidoscopy or colonoscopy (2) Genetic testing and counseling b) Treatment (1) Removed using electrocautery snare or hot biopsy forceps (2) Total colectomy with ileorectal anastomosis (3) Follow-up colonoscopy recommended in 3 years and then every 5 years 6. Nursing care a) Assessment (1) Health history: Rectal bleeding; personal or family history of intestinal polyps or colorectal cancer b) Diagnoses, outcomes, and interventions

.

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Provide direct care and teaching about procedure, expected sensations during the procedure, and anticipated postoperative care (2) Cathartics and cleansing enemas prior to colonoscopy (3) Observe for evidence of fluid and electrolyte imbalance during preoperative preparation (4) Following polypectomy, observe closely for possible complications 7. Transitions of care a) The significance of polyps and their relationship to colorectal cancer b) The importance of keeping follow-up appointments and undergoing repeat colonoscopy c) Manifestations to report to the physician B.

The patient with colorectal cancer (1) Third most common form of cancer in the United States (2) Cultural: Higher among African Americans and lower among Hispanics 1.

Risk factors a) Age over 50 years b) Polyps of the colon and/or rectum c) Family history of colorectal cancer d) Personal history of colorectal, ovarian, endometrial, or breast cancer e) Inflammatory bowel disease f) Exposure to radiation g) Diet: High animal fat and kilocalorie intake h) Obesity, smoking, and alcohol use

2.

Pathophysiology a) Nearly all colorectal cancers that begin as adenomatous polyps are adenocarcinomas b) Tumor grows undetected, few manifestations c) Cancerous cells from the primary tumor may spread by way of the lymphatic system or circulatory system

3.

Manifestations a) Depend on location, type and extent, and complications b) Rectal bleeding, change in bowel habits, pain, anorexia, and weight loss, palpable abdominal or rectal mass, and anemia from occult bleeding

4.

Complications

.

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) Bowel obstruction due to narrowing of the bowel lumen by the lesion b) Perforation of the bowel wall by the tumor, allowing contamination of the peritoneal cavity by bowel contents c) Direct extension of the tumor to involve adjacent organs 5.

Interprofessional care a) Screening (1) Yearly fecal occult blood test (FOBT) or fecal immunochemical test (FIT) or stool DNA test (sDNA) (2) Flexible sigmoidoscopy every 5 years, or (3) Double-contrast barium enema every 5 years, or (4) CT colonography (virtual colonoscopy) every 5 years, or (5) Colonoscopy every 10 years b)

Diagnosis (1) Sigmoidoscopy or colonoscopy, tissue biopsy, current staging methods (TNM system), radiologic examinations, CT scan, MRI, or ultrasonic examination (2) Laboratory tests: Fecal occult blood (by guaiac or hemoccult testing), CBC, carcinoembryonic antigen (CEA) c)

Surgery (1) Surgical resection of the tumor, adjacent colon, and regional lymph nodes (2) Laser photocoagulation performed during endoscopy (3) Abdominoperineal resection with permanent colostomy (4) Local excision and fulguration (5) Colostomy (a) Ascending colostomy, transverse colostomy, descending colostomy, and sigmoid colostomy, double-barrel colostomy, transverse loop colostomy (b) Hartmann procedure (c) Radiation therapy: Used with surgical resection for treating rectal tumors (d) Chemotherapy: Used postoperatively as adjunctive therapy for colorectal cancer 6.

Nursing care a) Assessment (1) Health history: Usual bowel patterns and any recent changes; weight loss, fatigue, decreased activity tolerance; presence of blood in the

.

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

stool; pain with defecation, abdominal discomfort, perineal pain; usual diet; family history of colon cancer, other specific risk factors such as inflammatory bowel disease or colon polyps (2) Physical examination: General appearance; weight; abdominal shape, contour; bowel sounds, abdominal tenderness; and stool hemoccult or guaiac 7.

Priorities of care a) Diagnoses, outcomes, and interventions (1) Relieve acute pain (a) Monitor for adequate pain relief (b) Ask patient to rate pain using a 0 to 10 pain scale; document the level of pain (c) Monitor analgesic effectiveness 30 minutes after administration; monitor for pain relief and adverse effects (d) Assess the incision for inflammation or swelling; assess drainage catheters and tubes for patency (e) Assess the abdomen for distention, tenderness, and bowel sounds (f) Administer analgesia prior to an activity or procedure (g) Assist with adjunctive comfort measures (h) Splint incision with a pillow, and teach the patient how to selfsplint when coughing and deep breathing to prevent respiratory complications b) Ensure adequate nutrition (1) Assess nutritional status, using data such as height and weight, skinfold measurements, body mass index (BMI) calculation, and laboratory data (2) Assess readiness for resumption of oral intake after surgery or procedures using data such as statements of hunger, presence of bowel sounds, passage of flatus, and minimal abdominal distention (3) Monitor and document food and fluid intake (4) Weigh daily (5) Maintain PN and central intravenous lines as ordered (6) When oral intake resumes, help the patient develop a meal plan that incorporates food preferences and considers the patient’s schedule and environment c) Support adjustment to change in health status (1) Work to develop a trusting relationship with the patient and family

.

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(2) Listen actively, encouraging the patient and family to express their fears and concerns (3) Demonstrate respect for cultural, spiritual, and religious values and beliefs; encourage use of these resources to cope with losses (4) Encourage discussion of the potential impact of loss on individual family members, family structure, and family function (5) Refer to cancer support groups, social services, or counseling as appropriate d) Discuss changes in sexuality self-image and function (1) Provide opportunities for the patient and family to express feelings about the cancer diagnosis, ostomy, and effects of other treatments (2) Provide consistent colostomy care (3) Encourage expression of sexual concerns (4) Reassure the patient and significant other that the effect of physical illness and prescribed interventions on sexuality usually is temporary (5) Refer the patient and partner to social services or a family counselor for further interventions (6) Arrange for a visit from a member of the United Ostomy Association 2.

Transitions of care a) Instructions during the diagnostic and preoperative periods: (1) Tests to be performed and preparatory procedures (2) Recommended postprocedure care and potential adverse effects to report (3) Preoperative care, such as intestinal preparation and food and fluid restrictions b) Once treatment is initiated, teach the following for home care: (1) Pain management (2) Skin care and management of potential adverse effects of radiation therapy and/or chemotherapy (3) Incision and ostomy care (4) Recommended diet (5) Follow-up appointments and care

VI.

Structural and Obstructive Bowel Disorders A. The patient with a hernia 1. Causes: Trauma, surgery, and increased intra-abdominal pressure 2. Pathophysiology

.

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) b)

Congenital or acquired Inguinal hernia (1) Indirect: Improper closure of the tract that develops as the testes descend into the scrotum before birth (2) Direct: Acquired defects that result from weakness of the posterior inguinal wall (3) Femoral hernias: Acquired defects in which a peritoneal sac protrudes through the femoral ring c) Umbilical hernia (1) May be congenital or acquired (2) More common in women d) Incisional or ventral hernia (1) Occur at a previous surgical incision or following abdominal muscle tears 3.

Manifestations a) Abdominal contents protrude through the abdominal wall to form a sac covered by skin and subcutaneous tissues b) Reducible hernia

4.

Complications a) Incarcerated hernia b) Obstruction and strangulation c) Strangulated hernia: Severe abdominal pain and distention, nausea, vomiting, tachycardia, and fever

5.

Interprofessional care a) Diagnosis: Physical examination b) Surgery: Herniorrhaphy

6.

Nursing care a) Assessment (1) Health history: Manifestations of hernia, such as bulging in the groin or of the abdominal wall when coughing, straining, or moving from lying to standing; pain (abdominal, groin, or scrotal); history of hernia or abdominal surgery (2) Physical examination: Observe for bulging of the abdominal wall or around the umbilicus when raising head and shoulders from supine position; wearing gloves, palpate inguinal region for bulges when the patient coughs or bears down (Valsalva maneuver) while standing

.

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

b) Priorities of care c) Diagnoses, outcomes, and interventions (1) Reduce risk for lack of blood supply and infection (a) Assess bowel sounds and abdominal distention at least every 8 hours (b) Notify primary care provider if the hernia becomes painful or tender (c) If signs of possible obstruction or strangulation occur, notify the physician; place patient in supine position with the hips elevated and knees slightly bent; withhold all food and fluids (NPO), and begin preparations for surgery 7.

B.

Transitions of care a) Topics to teach patients about hernias and home care: (1) Rationale for examining the groin and abdomen for bulges (2) The nature of hernias, risk factors, and manifestations (3) Surgical intervention for hernias (4) How to reduce a hernia if necessary (5) The importance of seeking immediate medical intervention for signs of strangulation or obstruction (6) The need to notify the physician if upper respiratory infection and cough develop preoperatively (forceful coughing is not recommended postoperatively) (7) Postoperative pain management and activity restrictions

The Patient with Intestinal Obstruction 1.

Pathophysiology a) Mechanical obstruction b) Functional obstruction (1) Adynamic ileus (paralytic ileus or simply ileus): Most common functional obstruction after abdominal surgery c) Obstruction may be partial or complete d) Manifestations (1) Distended bowel, fluid accumulation, and vascular fluid losses e) Complications (1) Necrosis, sepsis, death, hypovolemia, hypokalemia, renal insufficiency, and shock 2.

Small-bowel obstruction a) Most common causes: Adhesions or bands of scar tissue and hernias

.

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

b) Less common causes: Intussusception, volvulus, foreign bodies, stricture, and IBD c) Usually produce a simple obstruction d) Manifestations: Abdominal pain, bowel sounds, vomiting, abdominal distention, hypovolemia, and electrolyte imbalance e) Complications: Hypovolemia and hypovolemic shock with multiple organ dysfunction, renal insufficiency, acute renal failure, impaired pulmonary ventilation, and strangulation 3.

Large-bowel obstruction a) Usually occurs in the sigmoid segment b) Causes: Cancer of the bowel, volvulus, diverticular disease, inflammatory disorders, and fecal impaction c) Manifestations: Constipation, colicky abdominal pain, vomiting, distended abdomen, high-pitched, tinkling bowel sounds, localized tenderness, and mass felt during palpation d) Complications: Closed-loop obstruction, gangrene, perforation, peritonitis, atelectasis, and impaired venous return

4.

Interprofessional care a) Diagnosis (1) Radiologic studies: X-rays, CT scan, and gastrografin (2) Laboratory tests: WBC, serum amylase, serum osmolality, electrolytes, and arterial blood gases b) Treatment: Gastrointestinal decompression c) Surgery: Required for complete mechanical obstructions as well as for strangulated or incarcerated obstructions of the small intestine (1) Laparoscopic surgery, laparotomy, anastomosis, colonoscopy, laser photocoagulation, colostomy, and ileostomy

5.

Nursing care a) Assessment (1) Health history: Complaints of abdominal pain and bloating, constipation; previous history of bowel obstruction or risk factors such as hernia, inflammatory bowel disease, diverticulosis, or previous abdominal surgery; and current medications (2) Physical examination: Vital signs including orthostatic blood pressure, temperature; skin color, temperature, texture, and turgor; color and moisture of mucous membranes; abdominal shape, contour, bowel sounds, and presence of tenderness or masses on palpation

.

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

b)

6.

VII.

Diagnoses, outcomes, and interventions (1) Ensure adequate hydration (a) Monitor vital signs, pulmonary artery pressures, cardiac output (CO), and central venous pressure (CVP) hourly (b) Measure urinary output hourly and nasogastric drainage every 2 to 4 hours (c) Maintain intravenous fluids and blood volume expanders as ordered (d) Evaluate for distention every 4 to 8 hours (e) Notify the physician of changes in status (2) Promote adequate blood and oxygen supply (a) Monitor vital signs hourly (b) Monitor urine output hourly (c) Monitor temperature at least every 4 hours (d) Frequently assess pain (e) Maintain NPO status until peristalsis resumes (3) Maintain effective breathing (a) Assess respiratory rate, pattern, and lung sounds at least every 2 to 4 hours (b) Monitor ABG results for possible effects of altered respiratory status (c) Elevate the head of the bed (d) Provide a pillow or folded bath blanket to use in splinting the abdomen while coughing postoperatively (e) Maintain nasogastric or intestinal tube patency (f) Encourage use of incentive spirometer or other assistive device hourly (g) Contact respiratory therapy as indicated (h) Provide good oral care at least every 4 hours

Transitions of care a) Wound care b) Activity level, return to work, and any other recommended restrictions c) Recommended follow-up care d) Care of temporary colostomy (if appropriate) and planned reanastomosis e) For recurrent obstructions, their cause, early identification of manifestations, and possible preventive measures

Anorectal Disorders A. Patient with Hemorrhoids 1.

Pathophysiology and Manifestations

.

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) Develop when venous return from the anal canal is impaired b) Causes: Straining to defecate, pregnancy, prolonged sitting, obesity, chronic constipation, and low-fiber diet c) Internal or external d) Prolapsed or protruding hemorrhoids can lead to thrombosis e) Thrombosed external hemorrhoid: Thrombosis of the subcutaneous external hemorrhoidal veins of the anal canal

B.

2.

Interprofessional care a) Diagnosis (1) Patient’s history, examination of anorectal area, Valsalva’s maneuver, anoscopic examination, testing of stool for occult blood and sigmoidoscopy, and liver function studies b) Medications (1) Bulk-forming laxatives, stool softeners, suppositories, local ointments, warm sitz baths, bed rest, and local astringent compresses c) Nutrition (1) High-fiber diet with increased water intake d) Sclerotherapy: Injecting a chemical irritant into tissues surrounding the hemorrhoid to induce inflammation and eventual fibrosis and scarring e) Hemorrhoidectomy: Hemorrhoids are surgically excised

3.

Diagnoses, outcomes, and interventions a) Relieving pain related to inflamed anal tissue b) Preventing constipation c) Reducing risk of infection d) Maintaining an adequate intake of dietary fiber, a liberal fluid intake, and regular exercise e) Teach manifestations of possible hemorrhoidal complications

4.

Transitions of care a) Prevention b) Potential complications

The patient with an anorectal lesion 1.

Anal fissure a) Occurs when the epithelium of the anal canal over the internal sphincter becomes denuded or abraded b) Typically has periods of exacerbation and remission c) Manifestations: Pain and bright red bleeding

.

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

d) Diagnosis: Gentle digital examination of the anal canal and anoscopy e) Treatment: Dietary changes to increase fiber intake, increased fluid intake, bulk-forming laxatives, and hydrocortisone cream f) Surgery: Internal sphincterotomy 2.

Anorectal abscess a) Caused by invasion of the pararectal spaces by pathogenic bacteria b) Manifestations: Pain, external swelling, redness, heat, and tenderness c) Treatment: Incision and drainage

3.

Anorectal fistula a) Tunnel or tubelike tract with one opening in the anal canal with the other usually found in perianal skin b) Manifestations: Intermittent or constant drainage or discharge (may be purulent); may be accompanied by local itching, tenderness, and pain associated with defecation c) Diagnosis: Digital and anoscopic examination with gentle probing of the fistula tract d) Treatment: Fistulotomy

4.

Pilonidal disease a) Acute abscess or chronic draining sinus in the sacrococcygeal area b) Manifestations: Pain, tenderness, redness, heat, swelling of the affected area, purulent discharge c) Treatment: Incision and drainage

5.

Nursing care a) Maintain high-fiber diet and liberal fluid intake b) Surgical teaching

Chapter Highlights A. Disorders of intestinal motility include diarrhea, constipation, irritable bowel syndrome, and fecal incontinence. Diarrhea is a manifestation of many other bowel disorders, including lactose intolerance, infections, and inflammatory diseases of the bowel. Constipation may be a primary problem (especially for the older adult) or a manifestation of another disorder. Irritable bowel syndrome (IBS) is a functional disorder without any identifiable organic cause. Fecal incontinence is usually considered to be the manifestation of a disorder rather than a disorder itself.

B. Nursing care involves treating the underlying etiology of problems with intestinal motility in collaboration with the interprofessional team. Managing symptoms is the focus of nursing care and assisting the patient to adapt to chronic symptoms while .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

promoting self-care and strategies that enhance quality of life are important nursing interventions.

C. Appendicitis is an acute inflammation of the vermiform appendix, manifested by abdominal pain that localizes in the right lower quadrant of the abdomen. On palpation, localized and rebound tenderness is present at McBurney’s point. It is treated most often with an appendectomy.

D. Peritonitis (inflammation of the peritoneum from infection or chemical irritant) is a serious complication of a wide variety of acute abdominal disorders, including perforated ulcer, ruptured appendix, abdominal trauma or surgery, or necrotic bowel. Complications may be life threatening; without prompt and effective treatment, septicemia and septic shock may occur.

E. Gastroenteritis, which may result from bacterial or viral infections, parasites, or toxins, is often the result of consuming contaminated water or food. Manifestations include nausea and vomiting, diarrhea, and abdominal discomfort.

F. Nurses provide education to help prevent protozoal infections (such as giardiasis, amebiasis, and coccidiosis) and helminthic infestations (roundworms, flukes, or tapeworms). Both types of bowel disorders are treated with medications.

G. Chronic inflammatory bowel disease (IBD) includes two separate but closely related conditions: Ulcerative colitis and Crohn disease. Ulcerative colitis affects the mucosa and submucosa of the colon and rectum. Crohn disease can affect any part of the GI tract, but usually involves the terminal ilium and ascending colon. Diarrhea is common to both disorders. A colectomy (removal of the large colon) may be performed to treat ulcerative colitis; an ileostomy (artificial opening from the abdomen to the ileum) may be performed to treat Crohn disease.

H. Diverticula are saclike projections of mucosa through the muscular layer of the colon. When these sacs become inflamed, the condition is labeled diverticulitis. A diet high in fiber is recommended for self-care.

I. Nursing care related to inflammatory bowel disease focuses on symptom management and adapting to issues related to chronic illness. Teaching the patient and family about medications, dietary modifications, and activity is an important role. Providing nursing actions in the acute care setting for patients with IBD includes postoperative care or actions that aim to restore fluids, electrolyte, and nutritional status. Pain control is a focus of care for the patient with IBD. IBD is a complex disease and likely involves multiple providers. The nursing role often involves coordinating care between providers and settings.

J. Malabsorption syndromes, in which the intestinal mucosa ineffectively absorbs nutrients, may be caused by a wide variety of diseases. However, three common malabsorption disorders in adults are celiac disease, lactase deficiency with resulting lactose intolerance of milk and milk products, and short bowel syndrome (a condition that can develop following resection of the small bowel).

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

K. Nursing care involves focus on promoting adequate nutrition and hydration.

Interprofessional care frequently involves working closely with a dietitian and reinforcing prescribed dietary teaching. Care coordination as a member of the interprofessional team is an important nursing role for many patients with malabsorption syndromes.

L. Malignant tumors of the lower bowel are the second leading cause of death from cancer. The risk of colon cancer may be reduced through health-related screenings and a diet high in fruits, vegetables, folic acid, and calcium. Rectal bleeding is the most common initial manifestation but may not occur until the cancer is well advanced. Surgical treatment is through resection of the bowel, accompanied by a colostomy for diversion of fecal contents.

M. Care of the patient of the patient with cancer will involve multiple disciplines and care will likely be delivered across settings. Care will also be complex and may include many forms of treatment including chemotherapy and radiation. Nursing actions include promoting adequate nutrition, hydration, and symptom control related to the disease and possible treatment. Coordinating care is an essential nursing role for patients with cancer of the GI tract.

N. A hernia is a defect in the abdominal wall that allows intra-abdominal contents to protrude out of the abdominal cavity. Hernias may follow trauma, surgery, and increased intra-abdominal pressure (as from pregnancy or obesity). Hernias may be congenital or acquired, and may be inguinal, umbilical, incisional, or ventral.

O. Intestinal obstructions occur when intestinal contents cannot move through the lumen of the bowel. They may occur in either the large or small intestine, may be partial or complete, and are caused by many factors, ranging from surgical ileus following abdominal surgery to adhesions or tumors.

P. Assessing general health and GI status, managing pain, and supporting fluid and electrolyte balance are priorities when caring for patients with structural and obstructive disorders. Postoperative care, nutritional and activity instructions, and teaching signs and symptoms of complications should also be included.

Q. Anorectal disorders include hemorrhoids, anorectal lesions (fissures, abscess, and fistula), and pilonidal disease. These disorders are painful and pose a risk for bleeding and infection.

R. Nursing care involves providing pharmacological and nonpharmacological strategies to reduce pain and reestablishment of normal bowel habits.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME ONE Discuss irritable bowel syndrome, diarrhea, and constipation. Ask students to identify manifestations of these conditions, and some of the causes.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME ONE Assign students to care for a patient with an intestinal motility disorder.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME TWO Create a teaching plan for patients and families with patients with and acute bowel disorder.

Incorporate over-the-counter (OTC) medications and diet.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME TWO Assign students to patients who are taking medication for an acute bowel disorder.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME THREE Create a teaching plan for patients and families with patients with a chronic bowel disorder.

Incorporate over-the-counter (OTC) medications and diet.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME THREE Assign students to patients who are taking medication for a chronic bowel disorder.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME FOUR Ask a dietitian to speak to the students about special diets for patients with malabsoprtive syndromes.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME FOUR Have each student review a patient’s medical record and find the type of diet the physician has ordered for the patient.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME FIVE Assign students to research a neoplastic disorder and discuss the results of their findings with the class. .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME FIVE Assign students to conduct a health history on assigned patients and screening to identify risk factors for neoplastic disorder.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME SIX Research various types of hernias. Share findings with the class.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME SIX Invite a GI specialist to speak to the clinical group on interventions and treatment of hernias.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME SEVEN Ask students to list health promotion interventions when caring for a patient with an anorectal disorder.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME SEVEN Ask students to create and implement a patient teaching program focused on health promotion interventions for the patient with an anorectal disorder.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter 25 Nursing Care of Patients with Gallbladder, Liver, and Pancreatic Disorders Learning Outcomes 1. Describe the pathophysiology and manifestations of gallbladder disorders, and outline the interprofessional care and nursing care of patients with these disorders.

2. Describe the pathophysiology and manifestations of liver disorders, and outline the interprofessional care and nursing care of patients with these disorders.

3. Describe the pathophysiology and manifestations of exocrine pancreas disorders, and outline the interprofessional care and nursing care of patients with these disorders.

Key Concepts I.

Gallbladder Disorders A. The patient with gallstones 1. Cholelithiasis: Formation of stones (calculi or gallstones) within the gallbladder or biliary duct system 2. Risk factors a) Age, family history of gallstones, race or ethnicity, obesity, hyperlipidemia, rapid weight loss (e.g., following bariatric surgery), female gender (use of oral contraceptives), biliary stasis, diseases or conditions (diabetes mellitus; cirrhosis; ileal disease or resection; sickle cell disease) 3. Pathophysiology review 4. Pathophysiology and manifestations a) Cholelithiasis (1) Gallstone formation occurs due to a combination of abnormal bile composition, biliary stasis, and inflammation of the gallbladder (2) Most gallstones are formed in the gallbladder (a) Epigastric fullness or mild gastric distress, distention and increased pressure behind the stone, biliary colic, nausea, vomiting, pain, possible liver damage (b) Common bile duct obstruction with possible jaundice and liver damage; common duct obstruction with pancreatitis b) Cholecystitis: Inflammation of the gallbladder (1) Acute cholecystitis (2) Chronic cholecystitis (3) Manifestations: Pain, anorexia, nausea, vomiting, RUQ tenderness and guarding, chills, and fever

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(4) Complications: Empyema, gangrene and perforation with resulting peritonitis or abscess formation; formation of a fistula into an adjacent organ; and gallstone ileus 5. Interprofessional care a) Diagnosis (1) Serum bilirubin, total (serum) bilirubin, direct (conjugated) bilirubin levels, indirect (unconjugated) bilirubin levels, CBC, alkaline phosphate, ultrasonography of the gallbladder, gallbladder scans b) Medications (1) Ursodeoxycholic acid, statins, antibiotics, cholestyramine, opioid analgesics, and antiemetic c) Nutrition (1) Limited food intake during an acute attack of cholecystitis (2) Limited dietary fat, administration of fat-soluble vitamins and bile salts d) Surgery (1) Laparoscopic cholecystectomy (2) Laparotomy, cholecystostomy, and choledochostomy 6. Nursing care a) Assessment (1) Health history: Current manifestations, including RUQ pain, its character and relationship to meals, duration, and radiation, nausea and vomiting, or other symptoms; duration of symptoms; risk factors or previous history of symptoms; chronic diseases such as diabetes, cirrhosis, or inflammatory bowel disease; current diet; use of oral contraceptives or possibility of pregnancy (2) Physical assessment: Current weight; color of skin and sclera; abdominal assessment including light palpation for tenderness; color of urine and stool (3) Diagnostic tests: Monitor results of WBC, serum bilirubin, liver enzymes, and pancreatic enzymes (amylase and lipase) b) Priorities of care c) Diagnoses, outcomes, and interventions (1) Relieve pain (i) Discuss the relationship between fat intake and the pain; teach ways to reduce fat intake (ii) Withhold oral food and fluids during episodes of acute pain (iii) For severe pain, administer morphine, fentanyl, or other narcotic analgesia as ordered (iv) Place in Fowler position (2) Promote balanced nutrition and hydration (i) Assess nutritional status, including diet history, height and weight, and skinfold measurements .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(ii) Evaluate laboratory results; report abnormal results to the primary care provider (iii) Refer to a dietitian or nutritionist for diet counseling to promote healthy weight loss and reduce pain episodes (iv) Administer vitamin supplements as ordered (3) Monitor for infection (i) Monitor vital signs including temperature every 4 hours (ii) Assess abdomen every 4 hours and as indicated (iii) Assist to cough and deep breath or use incentive spirometer every 1 to 2 hours while awake (iv) Place in Fowler position and encourage ambulation as allowed (v) Administer antibiotics as ordered 7. Transitions of care a) Teach about medications that dissolve stones b) Teach about maintaining low-fat, low-carbohydrate diet c) Provide appropriate preoperative teaching for the planned procedure d) Teach postoperative self-care measures to manage pain and prevent complication

B. The patient with gallbladder cancer 1. Spread to liver, metastasize via the blood and lymph system 2. Intense pain, palpable mass in the RUQ of the abdomen, jaundice, and weight loss 3. Radical and extensive surgical intervention 4. Poor prognosis regardless of treatment 5. Nursing care is Palliative, focuses on maintaining comfort and independence II.

Liver Disorders A. Essential functions of liver 1. Metabolism of proteins, carbohydrates, and fats; metabolism of steroid hormones and most drugs; synthesizes essential blood proteins; detoxifies alcohol and other toxic substances; converts ammonia to urea; produces bile; stores minerals, fat-soluble vitamins, and glycogen B. Common manifestations of liver disorders 1. Hepatocellular failure a) Results of impaired function (1) Impaired protein metabolism with decreased production of albumin and clotting factors (2) Disrupted glucose metabolism and storage with resulting alterations in blood glucose levels (either hyperglycemia or hypoglycemia)

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(3) Reduced bile production that impairs the absorption of lipids and fat-soluble vitamins (4) Impaired metabolism of steroid hormones (including estrogen and testosterone) leads to feminization in men and irregular menses in women 2. Jaundice: Yellow staining of tissues a) Prehepatic/hemolytic jaundice b) Intrahepatic/hepatic jaundice c) Posthepatic/obstructive jaundice 3. Portal hypertension a) Effects of prolonged portal hypertension: (1) Dilation of veins in the gastrointestinal tract and the abdominal wall, leading to formation of collateral vessels in the distal esophagus, stomach, and rectum (esophageal varices, hemorrhoids, caput medusae) (2) Splenomegaly, or enlargement of the spleen (3) Ascites, accumulation of fluid in the peritoneal cavity (4) Portal systemic encephalopathy (or hepatic encephalopathy) (5) Cerebral edema (6) Hepatorenal syndrome C. The patient with hepatitis 1. Inflammation of the liver 2. Pathophysiology and manifestations a) Caused by virus, toxin, or other mechanism b) Acute or chronic c) Viral hepatitis (1) Hepatitis A virus (HAV) (a) Transmitted by fecal–oral route (2) Hepatitis B virus (HBV) (a) Can cause acute hepatitis, chronic hepatitis, fulminant (rapidly progressive) hepatitis, or a carrier state (b) Spread through contact with infected blood and body fluids (3) Hepatitis C virus (HCV) (a) Primary worldwide cause of chronic hepatitis, cirrhosis, and liver cancer (4) Hepatitis B-associated delta virus (HDV) (a) Causes infection in people who are also infected with HBV (5) Hepatitis E virus (HEV) (a) Transmitted by fecal contamination of water supplies in developing areas d) Chronic hepatitis (1) Primary cause of liver damage leading to cirrhosis, liver cancer, and liver transplantation .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(2) Manifestations: Malaise, fatigue, and hepatomegaly e) Fulminant hepatitis (1) Rapidly progressive disease f) Toxic hepatitis (1) Hepatotoxins: Alcohol, acetaminophen, benzene, carbon tetrachloride, halothane, chloroform, and poisonous mushrooms g) Autoimmune hepatitis (1) Chronic disorder (2) Cell-mediated immune response directed against liver cells causes persistent inflammation and necrosis with fibrosis and scarring 3. Interprofessional care a) Diagnosis (1) Alanine aminotransferase (ALT) levels (2) Aspartate aminotransferase (AST) levels (3) Alkaline phosphatase (ALP) levels (4) Serum bilirubin levels, including conjugated and unconjugated (5) Laboratory tests for viral antigens and their specific antibodies (6) Liver biopsy b) Medications (1) Prevention vaccines: Hepatitis A and B (2) Postexposure prophylaxis: Hepatitis A and B c) Disease treatment (1) Severe acute HBV: Antiretroviral drugs (2) Chronic HCV: Combination therapy with peginterferon and ribavirin (3) Acute HCV: Interferon alpha, long-acting interferon (peginterferon or Pegasys) combined with the antiviral drug ribavirin (4) Most with acute viral hepatitis recover fully without pharmacologic treatment d) Integrative therapies (1) Milk thistle, silymarin, licorice root, ginger, and St. John’s wort 4. Nursing care a) Assessment (1) Health history: Current manifestations, including anorexia, nausea, vomiting, abdominal discomfort, changes in bowel elimination or color of stools; muscle or joint pain, fatigue; changes in color of skin or sclera; duration of symptoms; known exposure to hepatitis; high-risk behaviors such as injection drug use or multiple sexual partners; previous history of liver disorders; current medications, prescription and over the counter (2) Physical assessment: Vital signs including temperature; color of sclera and mucous membranes; skin color and condition; abdominal contour and tenderness; color of stool and urine .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(3) Diagnostic tests: Serum bilirubin, liver function tests, serologic antibody–antigen levels b) Priorities of care c) Diagnoses, outcomes, and interventions (1) Prevent transmission of disease (i) Use standard precautions (ii) For patients with HAV or HEV, use standard precautions and contact isolation if fecal incontinence is present (iii) Encourage prophylactic treatment of all members of household and intimate sexual contacts (iv) If the patient diagnosed with HAV is employed as a food handler or child care worker, contact the local health department to report possible exposure of patrons (2) Teach energy conservation strategies (i) Encourage planned rest periods throughout the day (ii) Assist to identify essential activities and those that can be deferred or delegated to others (iii) Suggest using level of fatigue to determine activity level, with gradual resumption of activities as fatigue and sense of well-being improves (3) Promote adequate nutrition (i) Help plan a diet of appealing foods that provides a high-kilocalorie intake of approximately 16 carbohydrate kilocalories per kilogram of ideal body weight (ii) Encourage planning food intake according to symptoms of the disease (iii) Instruct to avoid alcohol intake and diet drinks (iv) Encourage use of nutritional supplements such as Ensure or instant breakfast drinks to maintain calorie and nutrient intake 5. Transitions of care a) Recommended prophylactic treatment b) Infection control measures c) Managing fatigue and limited activity d) Managing pruritus and maintaining skin integrity e) Promoting nutrient intake f) Avoiding hepatic toxins; encourage to alert all care providers to presence of infection g) Recommended follow-up h) If chronic hepatitis B or C is being treated with medications, teach how to administer the drug, its dosing schedule, precautions, and management of adverse effects D. The patient with cirrhosis 1. Cirrhosis: Fibrosis of liver tissue leading to decreased mass, impaired liver function, and altered blood flow .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

2. Pathophysiology a) Alcoholic cirrhosis: End result of alcoholic liver disease b) Posthepatic cirrhosis: Advanced progressive liver disease resulting from chronic hepatitis B or C, autoimmune hepatitis, or from nonalcoholic fatty liver disease c) Biliary cirrhosis: Results from obstructed bile flow within the liver or biliary system 3. Manifestations and complications a) Edema, ascites, bleeding, bruising, esophageal varices, hemorrhoids, gastritis, anorexia, diarrhea, abdominal wall vein distention (caput medusae), jaundice, malnutrition, muscle wasting, anemia, leukopenia, increased risk for infection, asterixis, encephalopathy, gynecomastia, infertility, and impotence b) Portal hypertension: Contributes to the formation of ascites c) Splenomegaly: Can lead to anemia, leucopenia, and thrombocytopenia d) Ascites: Accumulation of plasma-rich fluid in abdominal cavity (1) Contributing factors: Hypoalbuminemia and hyperaldosteronism e) Esophageal varices: Enlarged, thin-walled veins that form in the submucosa of the esophagus f) Portal systemic encephalopathy: Results from accumulation of neurotoxins in the blood and cerebral edema (1) Early manifestations: Asterixis (liver flap), changes in personality and mentation develop; agitation, restlessness, impaired judgment, and slurred speech g) Hepatorenal syndrome: Results from imbalanced blood flow, leading to constriction of vessels leading to and within the kidneys h) Spontaneous bacterial peritonitis: Inflammatory response to peritonitis 4. Interprofessional care a) Diagnosis (1) Liver function studies include ALT, AST, and ALP (2) CBC with platelets (3) Coagulation studies (4) Serum electrolytes, bilirubin levels, serum albumin levels, serum ammonia levels, serum glucose, and cholesterol levels (5) Abdominal ultrasound, Doppler studies (6) Esophagoscopy (upper endoscopy) (7) Liver biopsy b) Medications (1) Diuretics, laxatives, anti-infective agents, beta-blocker, ferrous sulfate and folic acid, antacids, benzodiazepine antianxiety/sedative c) Nutrition and fluid management (1) Sodium intake is restricted to less than 2 g/day .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(2) Fluids are often limited to 1500 mL/day (3) Unless serum ammonia levels are high, a palatable diet with adequate calories and protein is recommended (4) Vitamin and mineral supplements are ordered based on laboratory values d) Management of complications (1) Ascites (a) Paracentesis: Diagnostic or therapeutic procedure (2) Esophageal varices (b) Screening with endoscopy, beta-blocker therapy, variceal ligation or banding, endoscopic sclerosis (c) Bleeding esophageal varices: Intensive care management required; stabilize blood pressure and cardiac output; upper endoscopy, gastric lavage, balloon tamponade (3) Portal hypertension (a) Transjugular intrahepatic portosystemic shunt (TIPS) e) Surgery: Liver transplantation 5. Nursing care a) Assessment (1) Health history: Current manifestations, including abdominal pain or discomfort, recent weight loss, weakness, and anorexia; altered bowel elimination; excess bleeding or bruising; abdominal distention; jaundice, pruritus; altered libido or impotence; duration of symptoms; history of liver or gallbladder disease; pattern and extent of alcohol or injection drug use; use of other prescription and nonprescription drugs (2) Physical assessment: Vital signs; mental status; color and condition of skin and mucous membranes; peripheral pulses and presence of peripheral edema; abdominal assessment including appearance, shape and contour, bowel sounds, abdominal girth, percussion for liver borders, and palpation for tenderness and liver size b) Priorities of care c) Diagnosis, outcomes, and interventions (1) Monitor and restore normal fluid volume (a) Weigh daily (b) Assess urine specific gravity (c) Monitor for signs of impaired renal function (d) Provide a low-sodium diet (500 to 2000 mg/day) and restrict fluids as ordered (2) Monitor mentation and respond to confusion (a) Assess neurologic status, including level of consciousness and mental status .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(b) Closely monitor patients who have experienced gastrointestinal bleeding for signs of portal systemic encephalopathy (c) Avoid factors that may precipitate portal systemic encephalopathy (d) If possible, plan for consistent nursing care assignments (e) Administer medications or enemas as ordered to reduce nitrogenous products (f) Monitor bowel function and provide measures to promote regular elimination and prevent constipation (g) Orient to surroundings, person, and place; provide simple explanations and reassurance (3) Prevent hypovolemia due to initial and recurrent bleeding (a) Monitor vital signs (b) Institute bleeding precautions (c) Monitor coagulation studies and platelet count; report abnormal results (d) Monitor the patient who has had bleeding esophageal varices for evidence of rebleeding: Hematemesis, hematochezia or tarry stools, signs of hypovolemia or shock (4) Prevent skin breakdown (a) Use warm water rather than hot water when bathing (b) Use measures to prevent dry skin (c) If indicated, apply mittens to the hands to prevent scratching (d) Institute measures to prevent skin and tissue breakdown (e) Administer prescribed antihistamine (to relieve pruritus) cautiously (5) Promote adequate nutrition (a) Weigh daily (b) Provide small meals with between-meal snacks (c) Unless protein is restricted due to impending portal systemic encephalopathy, promote protein and nutrient intake by providing nutritional supplements (d) Arrange for consultation with a dietitian for diet planning while hospitalized and at home 6. Transitions of care a) The absolute necessity of avoiding alcohol and other hepatotoxic drugs b) Diet and fluid intake restrictions and recommendations c) Prescribed medications, their timing, intended and adverse effects, and manifestations to report to the primary care provider d) Bleeding precautions e) Manifestations of potential complications to be reported to the primary care provider f) Skin care techniques to reduce pruritus and the risk of damage g) Ways to manage fatigue and conserve energy .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

h) Referrals for home health services, dietary consultation, social services, and counseling as needed E. The patient with cancer of the liver 1. Pathophysiology a) 80% of primary hepatic cancers arise from liver’s parenchymal cells b) Etiologic factors: Chronic hepatitis C infection, chronic hepatitis B infection, cirrhosis, regardless of type, aflatoxin (a toxin produced by Aspergillus molds) exposure, chronic ethanol consumption, and nonalcoholic fatty liver (steatohepatitis or NASH) c) Underlying pathophysiology of primary liver cancer is damage to hepatocellular DNA 2. Manifestations a) Malaise, anorexia, lethargy, weight loss, fever of unknown origin, jaundice, feeling of abdominal fullness, painful right upper quadrant mass, and manifestations of liver failure 3. Interprofessional care and nursing care a) Ultrasound of the liver, CT scan with contrast and MRI, liver biopsy, and serum alpha-fetoprotein (AFP) levels b) Treatment (1) Radio-frequency ablation (2) Injection of an agent (such as ethanol) directly into the tumor (3) Liver transplantation for stage I or II tumors (4) Radiation therapy, chemotherapy (5) Direct continuous hepatic arterial infusion with an implanted pump 4. Transitions of care a) Health promotion (1) At-risk patients should avoid alcohol and other substances that might damage liver (2) Regular screening for liver tumors F. The patient with liver trauma 1. Pathophysiology and manifestations a) Causes bleeding due to vascularity of the organ b) Surface hematoma, hematoma within the liver parenchyma, laceration of liver tissue, disruption of vessels leading to or from the liver, and shock 2. Interprofessional care a) Diagnosis .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Diagnostic peritoneal lavage, CT scan b) Treatment (1) Administration of intravenous fluids, fresh frozen plasma, platelets, and other clotting factors (2) Surgical intervention to control hemorrhage c) Postoperative care: Prevent pulmonary complications, detect and prevent infection 3. Nursing care a) Manage hypovolemia related to hemorrhage b) Prevent infection c) Monitor for hemorrhage G. The patient with liver abscess 1. Pathophysiology and manifestations a) Bacterial or amoebic in origin b) Healthy tissue is destroyed, leaving an area of necrosis, inflammatory exudate, and blood c) Etiologies: Cholangitis, or distant or intra-abdominal infections (peritonitis or diverticulitis), Escherichia coli d) Infection pathway for amoebic hepatic abscesses is usually the portal venous circulation from the right colon e) Fever, malaise, vomiting, hyperbilirubinemia, and pain in the right upper abdomen 2. Interprofessional care a) Diagnosis (1) Biopsy, hepatic aspirate, blood and fecal cultures, and CT scan and ultrasound studies b) Medications (1) Antibiotics, pharmacologic agents, combination therapy, metronidazole (Flagyl), and iodoquinol (Diquinol) c) Treatment (1) Antibiotic therapy, percutaneous aspiration, or surgical drainage (percutaneous closed-catheter drain) 3. Nursing care a) Prevent hypovolemia due to prolonged fever and vomiting b) Provide patient education related to transmission of amoebic abscess c) Support activities of daily living due to pain and weakness

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

III.

Exocrine Pancreas Disorders A. The patient with pancreatitis 1. Risk factors: Alcoholism and gallstones 2. Physiology review a) Pancreatic enzymes (1) Proteolytic enzymes (trypsin, chymotrypsin, carboxypolypeptidase, ribonuclease, and deoxyribonuclease) which break down dietary proteins (2) Pancreatic amylase, which breaks down starch (3) Lipase, which breaks down fats into glycerol and fatty acids 3. Pathophysiology and manifestations a) Acute pancreatitis: Self-destruction of the pancreas by its own enzymes through autodigestion (1) Types: Interstitial edematous pancreatitis and necrotizing pancreatitis (2) Precipitating factors: Gallstones may obstruct the pancreatic duct or cause bile reflux; alcohol causes duodenal edema, and may increase pressure and spasm in the sphincter of Oddi, obstructing pancreatic outflow; tissue ischemia or anoxia; trauma or surgery; pancreatic tumors; third-trimester pregnancy; infectious agents (viral, bacterial, or parasitic); elevated calcium levels; hyperlipidemia; some medications b) Chronic pancreatitis: Characterized by chronic inflammation, fibrosis, gradual destruction of functional pancreatic tissue (1) Irreversible process (2) Risk factors: Alcoholism, malnutrition, and genetic mutation on a gene associated with cystic fibrosis 4. Manifestations a) Acute pancreatitis (1) Abrupt onset of severe epigastric and left upper quadrant pain, may radiate to back; nausea, vomiting; fever; decreased bowel sounds; abdominal distention and rigidity; tachycardia, hypotension; cold, clammy skin; possible jaundice; positive Turner’s sign (flank ecchymosis) or Cullen’s sign (periumbilical ecchymosis) b) Acute pancreatitis (1) Systemic complications (i) Intravascular volume depletion with shock, acute tubular necrosis and renal failure, acute respiratory distress syndrome (ARDS), hypovolemic shock, and acute renal failure (2) Localized complications (ii) Pancreatic necrosis, abscess, pseudocysts, and pancreatic ascites c) Chronic pancreatitis

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Recurrent epigastric and LUQ pain, radiates to back; anorexia, nausea, and vomiting, weight loss; flatulence, constipation; steatorrhea d) Chronic pancreatitis (1) Malabsorption, malnutrition, possible peptic ulcer disease, pancreatic pseudocyst or abscess, or stricture of the common bile duct, diabetes mellitus, and increased risk for pancreatic cancer 5. Interprofessional care a) Diagnosis (1) Ultrasonography, endoscopic ultrasonography (2) Contrast-enhanced CT scan (3) Magnetic resonance cholangiopancreatography (MRCP) (4) Endoscopic retrograde cholangiopancreatography (ERCP) (5) Percutaneous fine-needle aspiration biopsy (6) Laboratory tests: Serum amylase, serum lipase, urine amylase, serum glucose, serum bilirubin, serum alkaline phosphatase (ALP), serum calcium, and white blood cells b) Medications (1) Pancreatic enzyme replacement, opioid analgesics, prophylactic antibiotics, H2blockers, and proton-pump inhibitors, and octreotide c) Treatment (1) Nutrition (i) Oral food and fluids are withheld (ii) Intravenous fluids administered, total parenteral nutrition (TPN) initiated (2) Surgery (i) Endoscopic transduodenal sphincterotomy, cholecystectomy, surgical procedures to promote drainage of pancreatic enzymes into the duodenum or resection of all or part of the pancreas b) Integrative therapies (i) Fasting, use of low-salt, low-fat vegetarian diets; Qigong; magnetic field therapy 6. Nursing care a) Assessment (1) Health history: Current manifestations; abdominal pain (location, nature, onset and duration, identified precipitating factors); anorexia, nausea, or vomiting; flatulence, diarrhea, constipation, or stool changes; recent weight loss; history of previous episodes or gallstones; alcohol use (extent and duration); current medications (2) Physical assessment: Vital signs including orthostatic vitals and peripheral pulses; temperature; skin temperature and color, presence of any flank or

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

periumbilical ecchymoses; abdominal assessment including bowel sounds, presence of distention, tenderness, or guarding b) Priorities of care c) Diagnoses, outcomes, and interventions (1) Relieve acute pain (i) Using a standard pain scale, assess pain, including location, radiation, duration, and character (ii) Regularly assess respiratory status (at least every 4 to 8 hours) (iii) Maintain NPO status and nasogastric tube patency as ordered (iv) Maintain bed rest in a calm, quiet environment (v) Assist to a comfortable position, such as a side-lying position with knees flexed and head elevated 45 degrees (vi) Remind family and visitors to avoid bringing food into the patient’s room (2) Support adequate nutrition (i) Monitor laboratory values (ii) Weigh daily or every other day (iii) Maintain stool chart; note frequency, color, odor, and consistency of stools (iv) Monitor bowel sounds (v) Administer prescribed intravenous fluids and/or TPN (vi) Provide oral and nasal care every 1 to 2 hours (vii) When oral intake resumes, offer small, frequent feedings (viii) Provide oral hygiene before and after meals (3) Promote adequate fluid balance (i) Assess cardiovascular status every 4 hours or as indicated (ii) Monitor renal function (iii) Monitor neurologic function 7. Transitions of care a) Avoid alcohol entirely b) Smoking and stress stimulate the pancreas and should be avoided c) If pancreatic function has been severely impaired, discuss appropriate use of pancreatic enzymes d) A low-fat diet is recommended e) Report symptoms of infection f) Refer to a dietitian or nutritionist for diet teaching as needed g) If appropriate, refer to community agencies, or to an alcohol treatment program B. The patient with pancreatic cancer 1. Risk factors .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) Cigarette smoking, chronic pancreatitis, diabetes mellitus, cirrhosis, obesity, high-fat diet; possibly red meat consumption, genetic predisposition 2. Pathophysiology and manifestations a) Most occur in the exocrine pancreas, are adenocarcinomas, and are fatal within 1 to 3 years after diagnosis b) Early manifestations: Nonspecific, including anorexia, nausea, weight loss, flatulence, and dull epigastric pain c) Cancer of the head of the pancreas: Jaundice, clay-colored stools, dark urine, pruritus d) Cancer of the body of the pancreas: Pain that increases when the person eats or lies supine e) Cancer of the tail of the pancreas: No symptoms until it has metastasized f) Other late manifestations: Palpable abdominal mass, ascites 3. Interprofessional care and nursing care a) Treatment (1) Pancreatoduodenectomy (Whipple procedure) (2) Radiation and chemotherapy

Chapter Highlights A. Gallstones (cholelithiasis) are common and are often unrecognized until the patient develops manifestations of biliary colic or acute cholecystitis. Laparoscopic cholecystectomy is the treatment of choice for symptomatic gallbladder disease.

B. Cancer of the gallbladder is rare and mimics the signs and symptoms associated with liver and pancreatic cancer. Survival rate depends on the stage of cancer at diagnosis.

C. Common manifestations of liver disorders are jaundice, malnutrition, weakness and fatigue, neurological changes, abnormal coagulation of the blood, and portal hypertension.

D. Hepatitis, inflammation of functional liver tissue, is usually a viral disease and requires longterm treatment and monitoring. Preventing the spread of hepatitis through use of standard and body substance precautions is an important nursing responsibility.

E. Hepatitis A, commonly transmitted via the fecal–oral route, is generally a self-limiting disease with few long-term sequelae. Some types of viral hepatitis, most notably hepatitis B and C, can become chronic and ultimately lead to liver failure and an increased risk for liver cancer. Hepatitis B and C can result in a carrier state in which the infected patient has no symptoms of the disease, but can spread it to others.

F. Alcohol abuse is a significant risk factor for liver and pancreatic disorders. Prevention, early identification, and treatment of alcohol abuse reduce the risk of these disorders. Absolute

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

abstinence from alcohol is an important part of the treatment plan for patients with liver and pancreatic disorders.

G. Cirrhosis leads to portal hypertension and liver failure, which in turn account for most of the manifestations and complications of the disorder. Complications such as ascites, splenomegaly, esophageal varices, and portal systemic encephalopathy affect multiple body systems and significantly contribute to the mortality and morbidity associated with cirrhosis.

H. Bleeding from esophageal varices may be massive, resulting in a medical emergency and requiring prompt control to maintain cardiac output.

I. Liver cancer has a poor survival rate; early symptoms are often vague, delaying diagnosis.

Weakness, weight loss, and abdominal bloating are early signs that are often ignored.

Treatment depends of the size of the tumor and stage of the cancer.

J. Acute pancreatitis often develops as a complication of gallstones. Acute pancreatitis often resolves with no long-term consequences. Chronic pancreatitis is more frequently related to alcohol abuse and can lead to continuing pain and digestive disruptions.

K. All of the accessory organs of digestion (the gallbladder, liver, and pancreas) can be primary sites of malignancy. Cancer of the gallbladder is uncommon; hepatocellular and pancreatic cancers are more common, and their incidence is increasing. These cancers often are advanced when diagnosed, reducing treatment options and the chance for a cure.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME ONE Discuss the multidisciplinary approach for care of patients with disease conditions of the gallbladder.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME ONE Assign students to patients who are experiencing manifestations of biliary disorders.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME TWO Discuss alcohol consumption in patients with liver disease.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME TWO Assign students to patients who are undergoing diagnostic tests for liver conditions.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME THREE Ask students to select a disorder of the pancreas and discuss the pathophysiology of the disease and the multidisciplinary treatment.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME THREE Have a pain management specialist speak to the clinical group regarding pain management in patients with a pancreas disorder.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter 26 Assessing the Renal System

Learning Outcomes 1. Describe the anatomy, physiology, and functions of the kidney and urinary tract, and identify abnormal findings that may indicate impairments of the renal system.

2. Outline the components of the assessment of the renal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.

3. Differentiate considerations for assessing the renal systems of older adults, veterans, individuals in the LGBTQI population, and adults with sequelae of childhood/congenital conditions.

4. Summarize topics that nurses teach to promote healthy tissue integrity across the lifespan.

Key Concepts I.

Anatomy, Physiology, and Functions of the Renal System A. The kidneys 1. Regions: The cortex, medulla, and pelvis 2. Formation of urine a) 1 million nephrons process the blood to make urine b) Nephron: Glomerulus, a tuft of capillaries, and a renal tubule 3. Glomerular filtration: Passive process in which hydrostatic pressure forces fluid and solutes out of glomerular capillaries and into the surrounding capsule a) Glomerular filtration rate (GFR) 4. Tubular reabsorption: Occurs as the filtrate moves through the tubules and into the collecting ducts 5. Tubular secretion: Final process in urine formation; reabsorption in reverse B. Maintaining normal composition and volume of urine 1. Urea: Nitrogenous waste product formed in the liver from the breakdown of amino acids 2. Countercurrent exchange system 3. Renal clearance a) Process of kidneys excreting water-soluble waste products and other chemicals or substances from the body b) Kidneys clear urea, creatinine, uric acid, ammonia, and bacterial toxins and watersoluble drugs 4. Renal hormones a) Active form of vitamin D, erythropoietin, and natriuretic hormone

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

C. The ureters, urinary bladder, and urethra 1. Ureters a) Transport urine from the kidney to the bladder through peristaltic waves originating in the renal pelvis b) Layers of the wall of the ureter: Inner epithelial mucosa, a middle layer of smooth muscle, and an outer layer of fibrous connective tissue 2. Urinary bladder a) Holds 300 to 500 mL of urine b) Micturition (urination) 3. Urethra a) Thin-walled muscular tube that channels urine to the outside of the body II.

Assessing Renal System Function A. Health assessment interview 1. May focus on a chief complaint or may be part of a total health assessment 2. Assess the patient’s current urinary elimination status 3. Assess changes in patterns of urination 4. Assess changes in the urine 5. Ask the patient about temperature elevations, chills, and general malaise 6. If the patient reports pain, explore its location, duration, and intensity 7. Information about surgeries or other treatment of previous renal problems 8. Family history of altered structure or function 9. Questions about lifestyle, diet, and work history B. Genetic considerations 1. Renal system disorders: Adult polycystic kidney disease (APKD), chronic kidney disease, and bladder cancer C. Physical assessment 1. Skin assessment a) Inspect the skin and mucous membranes, noting color, turgor, edema, and excretions b) Abnormal findings: Anemia, dehydration, edema, and uremic frost 2. Abdominal assessment a) Inspect the abdomen, noting size, symmetry, masses or lumps, swelling, distention, glistening, or skin tightness b) Abnormal findings: Hernia or superficial mass, distended urinary bladder, fluid retention, ascites 3. Urinary meatus assessment a) Male patient: With the patient in a sitting or standing position, compress the tip of the glans penis with the gloved hand to open the urinary meatus b) Female patient: With the patient in the dorsal lithotomy position, spread the labia with your gloved hand to expose the urinary meatus

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

c) Abnormal findings: Urinary tract infection, sexually transmitted infection, hypospadias, and epispadias 4. Kidney assessment a) Auscultate the renal arteries b) Percuss the kidneys for tenderness or pain c) Palpate the kidneys d) Abnormal findings: Renal artery stenosis, kidney disease, tumors, cysts, or hydronephrosis 5. Bladder assessment a) Percuss the bladder for tone and position b) Abnormal findings: Urinary retention D. Diagnostic tests 1. Blood urea nitrogen (BUN) 2. Creatinine (serum) 3. Creatinine clearance 4. CT scan of kidneys 5. Cystatin C 6. Cystometrogram (CMG) (voiding cystogram) 7. Cystoscopy, cystography 8. Estimated GFR (eGFR) 9. Intravenous pyelogram (IVP), retrograde pyelogram 10. MRI of the kidneys 11. Portable ultrasonic bladder scan 12. Renal arteriogram or angiogram 13. Renal biopsy 14. Renal scan 15. Renal ultrasound 16. Residual urine (postvoiding residual urine) 17. Urinalysis (UA) 18. Urine culture (midstream, clean-catch) 19. Uroflowmetry III.

Assessment of Special Populations A. Age-related changes in kidney function 1. Kidney a) Decreased size of renal cortex and number of nephrons b) Decreased growth of renal tissue c) Increased risk of atherosclerosis 2. Renal tubules a) Decreased function, with less effective exchange of substances b) Water and sodium

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

3. Bladder a) Decreased bladder capacity b) Difficulty emptying bladder c) Delayed micturition reflex B. Chronic kidney disease in older adults a) Hemodialysis, peritoneal dialysis, and renal transplant C. Assessing for home care 1. Reasonable access to dialysis or outpatient unit 2. Appropriateness of home dialysis 3. Appropriateness of ambulatory peritoneal dialysis 4. Support available if needed D. Resources for home care IV.

Health Promotion A. Maintain optimal function and reduce risk for infection 1. Measures to prevent UTI 2. Measures to prevent urinary incontinence

Chapter Highlights A. The renal system, including the kidneys, ureters, urinary bladder, and urethra, plays a critical role in maintaining homeostasis of the body.

B. Manifestations of dysfunction and disorders affecting the renal system may be detected during a general health assessment as well as during a focused assessment of renal system organs.

C. Older adults have increased risk for urinary dysfunction related to age-related changes of the urinary system.

D. Health promotion of the urinary system focuses on patient teaching to promote normal function and to reduce risk of infection. Health promotion includes teaching good hygiene, teaching women to void before and after sex, encouraging consumption of lots of fruits and vegetables, and encouraging smoking cessation.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME ONE Have students review a case study history for findings that are significant to patients with urinary elimination disorder.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME ONE Have students review their assigned patient’s history for indications of possible renal dysfunction.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME TWO Have students trace the formation of urine, starting with blood flow into the kidney and ending with urine exit from the body.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME TWO Assign students to perform a renal assessment on a patient.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME THREE Ask students to state renal changes in the older adult. Discuss assessment findings indicative of these changes.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME THREE Have students review their patient’s chart. Ask them to identify renal findings and to label them as normal or abnormal in the older adult.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME FOUR Discuss communication methods that help to make the patient more comfortable when discussing sensitive information.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME FOUR Provide patient teaching on UTI prevention.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter 27 Nursing Care of Patients with Urinary Tract Disorders

Learning Outcomes 1. Describe the pathophysiology and manifestations of a urinary tract infection, and outline the interprofessional care and nursing care of patients with this disorder.

2. Describe the pathophysiology and manifestations of urinary calculi, and outline the interprofessional care and nursing care of patients with this disorder.

3. Describe the pathophysiology and manifestations of urinary tract tumors, and outline the interprofessional care and nursing care of patients with such disorders.

4. Describe the pathophysiology and manifestations of disorders of urinary elimination (urinary retention, neurogenic bladder, and urinary incontinence), and outline the interprofessional care and nursing care of patients with these disorders.

Key Concepts I.

Urinary Tract Infection A. Pathophysiology 1. Urinary tract is normally sterile above the urethra B. Risk factors 1. Congenital or acquired factors 2. Female: Sexual activity, pregnancy, use of spermicide with a diaphragm, cervical cap, or condom 3. Males: Prostatic hypertrophy, bacterial prostatitis, and unprotected anal intercourse 4. Instrumentation of the urinary tract 5. Increased age C. Manifestations 1. Sources of infection: Bacteria that have colonized the urethra, vagina, or perineal area into the lower urinary tract 2. Categories of UTIs a) Lower urinary tract infections (1) Urethritis (2) Prostatitis (3) Cystitis (a) Manifestations: Dysuria, pyuria, frequency, hematuria, urgency, suprapubic discomfort, nocturia b) Upper urinary tract infections

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Pyelonephritis D. Complications a) Catheter-associated UTI (1) Often asymptomatic (2) Complications: Gram-negative bacteremia b) Pyelonephritis: Acute or chronic (1) Acute pyelonephritis (a) Risk factors: Pregnancy, urinary tract obstruction, congenital malformation, urinary tract trauma, scarring, calculi (stones), kidney disorders, chronic diseases, vesicoureteral reflux (b) Manifestations: Rapid onset chills, fever, malaise, vomiting flank pain, costovertebral tenderness, urinary frequency; older adult: Change in behavior, acute confusion, incontinence, general deterioration in condition (2) Chronic pyelonephritis (a) Common cause of chronic kidney disease (b) Manifestations: May be asymptomatic, mild manifestations such as urinary frequency, dysuria, and flank pain; hypertension E. Interprofessional care 1. Diagnosis a) Urinalysis b) Gram stain of the urine c) Urine culture and sensitivity tests d) WBC with differential e) Imaging studies such as intravenous pyelography (IVP) or CT scan f) Voiding cystourethrography g) Cystoscopy, tissue biopsy h) Manual pelvic or prostate examinations 2. Medications a) Urinary anti-infectives, urinary analgesic, and antibiotic therapy 3. Surgery a) Surgery: Surgical removal of a large calculus from the renal pelvis; cystoscopic removal of bladder calculi; percutaneous ultrasonic pyelolithotomy or extracorporeal shock wave lithotripsy; and ureteroplasty (1) Indwelling urinary catheter and a ureteral stent 4. Integrative therapies (1) Homeopathy, aromatherapy, or herbal preparations F. Nursing care 1. Assessment .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) Health history: Current symptoms, including frequency, urgency, burning on urination, voidings per night; color, clarity, and odor of urine; other manifestations such as lower abdominal, back, or flank pain; nausea or vomiting; fever; duration of symptoms and any treatment attempted; history of previous UTIs and their frequency; possibility of pregnancy and type of birth control used; chronic diseases such as diabetes; current medications and any known allergies b) Physical examination: General health; vital signs including temperature; abdominal shape, contour, tenderness to palpation (especially suprapubic); percuss for costovertebral tenderness; observe color, clarity, and odor of urine 2. Priorities of care 3. Diagnoses, outcomes, and interventions a) Relieve acute pain (1) Assess pain: Timing, quality, intensity, location, duration, and aggravating and alleviating factors (2) Teach or provide comfort measures (3) Increase fluid intake unless contraindicated (4) Instruct to notify primary care provider if pain and discomfort continue or intensify after therapy is initiated b) Restore normal urinary elimination (1) Monitor (or instruct the patient to monitor) color, clarity, and odor of urine (2) Instruct to avoid caffeinated drinks; citrus juices; drinks containing artificial sweeteners; and alcoholic beverages (3) Use strict aseptic technique and a closed urinary drainage system when inserting a straight or indwelling urinary catheter (4) When possible, use intermittent straight catheterization to relieve urinary retention; remove indwelling urinary catheters as soon as possible (5) Maintain the closed urinary drainage system, and use aseptic technique when emptying the catheter drainage bag (6) Provide perineal care on a regular basis and following defecation; use antiseptic preparations only as ordered c) Promote self-management through education (1) Teach how to obtain a midstream clean-catch urine specimen (2) Assess knowledge about the disease process, risk factors, and preventive measures (3) Discuss the prescribed treatment plan and the importance of taking all prescribed antibiotics (4) Help the patient develop a plan for taking medications (5) Instruct to keep appointments for follow-up and urine culture (6) Teach measures to prevent future UTI 4. Delegating nursing care activities

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

G. Transitions of care 1. Risk factors for UTI and how to minimize or eliminate these factors through increased fluid intake, regular elimination, and personal hygiene measures 2. Early manifestations of UTI and the importance of seeking medical intervention promptly 3. Maintaining optimal immune system function by attending to physical and psychosocial stressors 4. The importance of completing the prescribed treatment and keeping follow-up appointments 5. Minimizing the risk of UTI catheterization is necessary.

6. Teach perineal care, managing and emptying the collection chamber, maintaining a closed system, and bladder irrigation or flushing if ordered II.

Urinary Calculi A. Pathophysiology 1. Contributing factors: Supersaturation, nucleation, and lack of inhibitory substances in the urine 2. When fluid intake is adequate, no stone growth occurs 3. Types of kidney stones a) Calcium stones: Due to high concenteration of calcium in the blood or urine b) Uric acid stones: Develop when the urine concentration of uric acid is high c) Struvite stones: Associated with UTI caused by urease-producing bacteria d) Cystine stones: Rare, associated with a genetic defect B. Risk factors: A prior personal or family history of urinary calculi; dehydration with resultant increased urine concentration; immobility; excess dietary intake of calcium, oxalate, or proteins; gout; hyperparathyroidism; and urinary stasis or repeated infections C. Manifestations 1. Kidney stones: Often asymptomatic; dull, aching flank pain, microscopic hematuria, manifestations of UTI 2. Ureteral stones: Renal colic; acute, severe flank pain on affected side; often radiates to suprapubic region, groin, and external genitals; nausea, vomiting, pallor, and cool, clammy skin 3. Bladder stones: May be asymptomatic; gross hematuria D. Complications 1. Obstruction a) Can lead to renal failure b) The degree of obstruction, location, duration of impaired urine flow determine the effect on renal function 2. Hydronephrosis

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) Acute hydronephrosis (1) Manifestations: Acute, colicky pain; may radiate into groin; hematuria, pyuria; fever; nausea, vomiting, abdominal pain b) Chronic hydronephrosis (1) Manifestations: Dull, aching flank pain; hematuria, pyuria; fever; palpable flank mass 3. Infection a) Upper or lower UTI may develop.

E. Interprofessional care 1. Diagnosis a) Urinalysis to assess for hematuria and the presence of WBCs and crystal fragments b) Chemical analysis of any stones passed in the urine c) Urine calcium, uric acid, and oxalate levels d) Serum calcium, phosphorus, and uric acid levels e) KUB (kidneys, ureters, and bladder) x-ray of the lower abdomen f) Renal ultrasonography g) Spiral computed tomography (CT) scan of the kidney, with or without contrast medium h) Cystoscopy 2. Medications a) Narcotic analgesics, NSAIDs, oral alpha-adrenergic blockers, oral or intravenous fluids, thiazide diuretic, potassium citrate 3. Nutrition a) Increased fluid intake of 2.5 to 3.0 L per day b) Dietary changes: Low-sodium, restricted-protein diet; limiting foods containing oxalate; diet low in purines 4. Treatments a) Lithotripsy (1) Extracorporeal shock wave lithotripsy (ESWL) (2) Percutaneous nephrolithotomy (3) Ureteroscopy b) Integrative therapy (1) Positioning, moist heat, relaxation techniques, guided imagery, diversion (2) Good hydration F. Nursing care 1. Assessment a) Health history: Complaints of flank, back, or abdominal pain, radiation, characteristics and timing, aggravating or relieving factors; nausea and vomiting; possible contributing factors such as dehydration; previous or family history of kidney stones; current or previous treatment measures .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

b) Physical examination: General appearance including position, vital signs; skin color, temperature, moisture, turgor; abdominal, flank, or costovertebral tenderness; amount, color, and characteristics of urine (presence of hematuria, bacteria, pyuria, pH) 2. Priorities of care a) Relieve acute pain (1) Assess output (2) Monitor for complications (3) Promote comfort 3. Diagnoses, outcomes, and interventions a) Relieve acute pain (1) Assess pain using a standard pain scale and its characteristics; administer analgesia as ordered and monitor its effectiveness.

(2) Unless contraindicated, encourage fluid intake and ambulation in the patient with renal colic (3) Use nonpharmacologic measures such as positioning, moist heat, relaxation techniques, guided imagery, and diversion as adjunctive therapy for pain relief b) Promote normal urinary elimination (1) Monitor amount and character of urine output; if catheterized, measure output hourly; document any hematuria, dysuria, frequency, urgency, and pyuria; strain all urine for stones, saving any recovered stones for laboratory analysis (2) Maintain patency and integrity of all catheter systems c) Teach self-care (1) Assess understanding and previous learning (2) Present all material in a manner appropriate to knowledge base, developmental and educational level, and current needs (3) Teach about all diagnostic and treatment procedures (4) If the patient will be managed in the community, teach to (a) Collect and strain all urine, saving any stones (b) Report stone passage to the physician and bring the stone in for analysis (c) Report any changes in the amount or character of urine output to physician (5) Teach measures to prevent further urolithiasis (6) Teach about the relationship between urinary calculi and UTI, emphasizing preventive measures and the importance of prompt treatment G. Delegating nursing care activities H. Transitions of care 1. Importance of maintaining a fluid intake adequate to produce 2.0 to 2.5 quarts of urine per day 2. Prescribed medications, their management, and potential adverse effects .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

3.

4.

5.

6.

III.

Dietary recommendations Prevention, recognition, and management of UTI Any further diagnostic or treatment measures planned When discharged with dressings, a nephrostomy tube, or a catheter, teach about the following: a) How to change dressings, maintaining aseptic technique b) Assessment of the wound and skin for healing and possible complications such as infection or skin breakdown c) How to manage drainage systems and maintain their patency d) Emptying drainage bags and assessing urine output e) When to contact the physician and recommendations for follow-up care

Urinary Tract Tumors A. Pathophysiology 1. Most urinary tract malignancies arise from epithelial tissue 2. Tumors begin as nonspecific cellular alterations that develop into flat or papillary lesions a) Lesions may be superficial or invasive b) Papillary lesions c) Carcinoma in situ (CIS) 3. Tumor, node, metastasis (TNM) system B. Risk factors 1. Contributing factors: The presence of carcinogens in the urine and chronic inflammation and infection of bladder mucosa 2. Risk factors: Cigarette smoking, environmental hazards, residence in urban areas, chronic UTIs, bladder calculi C. Manifestations 1. Painless hematuria, manifestations of UTI, colicky pain from obstruction D. Interprofessional care 1. Diagnosis a) Urinalysis b) Urine cytology c) Ultrasound of the bladder d) Cystoscopy and ureteroscopy e) CT scan or MRI 2. Medications a) Immunologic or chemotherapeutic agents administered by intravesical instillation b) Bacille Calmette-Guérin (BCG; BCGLive, TheraCys) 3. Radiation therapy

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) Palliative treatment for inoperable tumors and patients who cannot tolerate surgery b) May be used in combination with systemic chemotherapy 4. Surgery a) Transurethral resection of bladder tumor b) Cystectomy (1) Partial cystectomy (2) Complete or radical cystectomy c) Urinary diversion procedures (1) Ileal conduit (2) Cutaneous urostomy (3) Continent urinary reservoir E. Nursing care 1. Assessment a) Health history: Risk factors; history of hematuria or manifestations of UTI (dysuria, frequency, urgency, pyuria); lower abdominal discomfort or flank pain b) Physical examination: General health; abdominal tenderness; urine for analysis 2. Priorities of care 3. Diagnosis, outcomes, and interventions a) Promote normal urinary elimination (1) Monitor urine output from all catheters, stents, and tubes for amount, color, and clarity hourly for the first 24 hours postoperatively, then every 4 to 8 hours (2) Label all catheters, stents, and their drainage containers; maintain separate closed gravity drainage systems for each (3) Secure ureteral catheters and stents with tape; prevent kinking or occlusion; and maintain gravity flow by keeping drainage bag below level of kidneys (4) Encourage fluid intake of 3000 mL per day (5) Monitor urine output closely for first 24 hours after stents or ureteral catheters are removed (6) Encourage activity to tolerance b) Reduce risk for impaired skin integrity (1) Assess peristomal skin for redness, excoriation, or signs of breakdown; assess for urine leakage from catheters, stents, or drains; keep the skin clean and dry (2) Ensure gravity drainage of urine collection device or empty bag every 2 hours (3) Change urine collection appliance as needed, removing any mucus from stoma c) Promote healthy body image (1) Use therapeutic communication techniques, actively listening and responding to the patient’s and family’s concerns (2) Recognize and accept behaviors that indicate use of coping mechanisms, encouraging adaptive mechanism

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(3) Encourage looking at, touching, and caring for the stoma and appliance as soon as possible (4) Discuss concerns about returning to usual activities, perceived relationship changes, and resumption of sexual relations d) Reduce risk for infection (1) Maintain separate closed drainage systems, keeping drainage bags lower than the kidney, and prevent loops or kinks in drainage tubing (2) Monitor for signs of infection (3) Teach signs and symptoms of infection and self-care measures to prevent UTI (4) Teach about impaired immune function F. Delegating nursing care activities G. Transitions of care 1. Teach about changes in urinary elimination 2. Teach about signs for tumor recurrence 3. Urinary diversion: Teach about care of the stoma and surrounding skin, prevention of urine reflux and infection, signs and symptoms of UTI and renal calculi, and selfcatheterization using clean technique 4. Information about urinary tract tumor, expected prognosis, and planned treatment strategies IV.

Disorders of Urinary Elimination A. The patient with urinary retention 1. Pathophysiology a) Bladder emptying is controlled by the interaction of muscle tone and the autonomic nervous system b) Causes: Mechanical obstruction of the bladder outlet, functional problem, benign prostatic hypertrophy (BPH), fecal impaction, acute inflammation, scarring from repeat UTI, bladder calculi, surgery, drugs (anticholinergic medications) 2. Manifestations a) Overflow voiding or incontinence b) Severe urinary retention: Hydroureter and hydronephrosis 3. Interprofessional care a) Bladder scan or insertion of a urinary catheter and measuring urine output b) Indwelling urinary catheter or intermittent straight catheterization c) Cholinergic medications d) Mechanical obstruction: Removed or repaired e) Resection of the prostate gland f) Bladder calculi removed 4. Nursing care

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) Promote urination: Place patient in normal voiding position; provide privacy; run water; place the patient’s hands in warm water; pour warm water over the perineum; take a warm sitz bath b) Acute urinary retention: Catheterization c) Perform repeated bladder scans in at-risk patients d) Avoid OTC drugs that affect micturition e) Double-voiding, scheduled voiding f) Indwelling catheter: Teach clean techniques, report signs of UTI to primary care provider 5. Transitions of care a) Teach intermittent self-catheterization b) Evaluate drug regimens for medications known to interfere with detrusor muscle function B. The patient with neurogenic bladder 1. Pathophysiology, risk factors, and manifestations a) Neurologic control of bladder filling and emptying can be disrupted by: (1) The cerebral cortex (voluntary impulses) (2) The micturition center of the midbrain (3) The spinal cord tracts (4) The peripheral nerves of the bladder b) Spastic bladder dysfunction: Caused by disruption of CNS transmission above the sacral spinal cord segment c) Flaccid bladder dysfunction: Caused by damage to the sacral spinal cord at the level of the reflex arc, the cauda equina, or the sacral nerve roots (1) Peripheral neuropathies (a) Causes: Diabetes mellitus, multiple sclerosis, chronic alcoholism, and prolonged overdistention of the bladder 2. Interprofessional care a) Diagnosis (1) Urine culture (2) Urinalysis and eGFR, serum creatinine and BUN to evaluate renal function (3) Postvoid bladder scan to measure residual urine (4) Cystometrography b) Medications (1) Anticholinergic drugs, cholinergic drugs c) Nutrition (1) Moderate to high fluid intake, diet that acidifies the urine, cranberry juice d) Bladder retraining

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Using trigger points; pulling pubic hairs; tapping the suprapubic region; inserting a gloved finger into the rectum and stretching the anal sphincter; Credé method; manual pressure on the abdomen; the Valsalva maneuver; catheterization e) Surgery (1) Injection of botulinum toxin A into the detrusor muscle via cystoscopy; rhizotomy; urinary diversion; implantation of an artificial sphincter 3. Nursing care a) Assessment (1) Health history: Obtain a complete nursing history, focusing on information related to CNS or spinal cord injury or disease, as well as disorders that affect the peripheral nervous system (e.g., diabetes); ask about measures used to stimulate or control urination (2) Physical examination: Inspect and palpate the lower abdomen and suprapubic region; evaluate the volume of urine in the bladder using a portable bladder scanner; percuss the suprapubic region; assess urine for color, clarity, and odor b) Priorities of care (1) Impaired urinary elimination related to impaired bladder innervation (2) Toileting self-care deficit related to neurologic injury (3) Risk for impaired skin integrity related to urinary incontinence (4) Risk of infection related to impaired urination reflex 4. Transitions of care a) Measures to stimulate reflex voiding and promote bladder emptying b) Measures that trigger urination and treat urge incontinence C. The Patient with urinary incontinence (UI) a) 25 million in the United States have some degree of UI b) Especially common among older patients 1. Pathophysiology a) Urinary continence requires: (1) Input from the CNS (2) A bladder able to expand and contract (3) Sphincters that can maintain a urethral pressure higher than that in the bladder (4) Intact cognition, mobility, motivation, and manual dexterity b) Contributing factors: Relaxation of the pelvic musculature, disruption of cerebral and nervous system control, and disturbances of the bladder c) May be acute, self-limited, or chronic disorder d) Causes may be congenital or acquired, reversible or irreversible e) Types of incontinence: Stress incontinence, urge incontinence, overflow incontinence, and functional incontinence (1) Mixed incontinence (2) Total incontinence .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

2. Interprofessional care a) Complete history, voiding diary, information about chronic or acute illnesses, previous surgeries, and current medication b) Physical assessment: Abdominal, rectal, and pelvic assessment as well as evaluation of mental and neurologic status, mobility, and dexterity c) Diagnosis (1) Urinalysis and urine culture using a clean-catch specimen (2) Postvoiding residual (PVR) volume (3) Bladder stress testing (4) Cystometrography (5) Uroflowmetry (6) Cystoscopy or ultrasonography 3. Medications a) Stress incontinence: Duloxetine b) Incontinence associated with postmenopausal atrophic vaginitis: Estrogen therapy c) Urge incontinence: Anticholinergic drugs 4. Treatments a) Surgery: Suspension of the bladder neck, prostatectomy, implantation of an artificial sphincter, formation of a urethral sling to elevate and compress the urethra, and augmentation of the bladder with bowel segments to increase bladder capacity 5. Integrative treatments a) Biofeedback and relaxation techniques D. Nursing care 1. Assessment a) Health history: Voiding diary; frequency of incontinent episodes, amount of urine loss and activities associated with incontinence; methods used to deal with incontinence; use of Kegel exercises or medications; any chronic diseases, related surgeries, and so on; effects of incontinence on usual activities, including social activities b) Physical examination: Physical and mental status, including any physical limitations or impaired cognition; inspect, palpate, and percuss abdomen for bladder distention; inspect perineal tissues for redness, irritation, or tissue breakdown; observe for bulging of bladder into vagina when bearing down; assess pelvic muscle tone as indicated 2. Reducing the risk for UI a) Inquire about frequency, urgency, and burning on urination b) Identify medications and the time of day each is taken c) Assess patterns of fluid intake and output d) Assess abdomen for evidence of bladder distention or tenderness e) Assess the home environment f) Health promotion .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(a) Generous fluid intake (b) Wear comfortable clothing that is easy to remove to void (c) Perform Kegel exercises (d) Reduce consumption of caffeine-containing beverages, citrus juices, and artificially sweetened beverages (e) Behavioral techniques to reduce frequency of incontinence (f) Routine pelvic and prostate exams (g) Advise women to seek advice about using topical hormonal therapy during menopause (h) Report changes in urine to care provider 3. Priorities of care 4. Diagnoses, interventions, and outcomes a) Enhance urinary elimination (1) Instruct to keep a voiding diary (2) Teach pelvic floor muscle exercises (3) Using the patient’s voiding diary, suggest dietary and fluid intake modifications to reduce stress and urge incontinence b) Promote self-care toileting (1) Assess physical and mental abilities and limitations, usual voiding pattern, and ability to assist with toileting (2) Provide assistive devices as needed to facilitate independence (3) Plan a toileting schedule based on the patient’s normal elimination patterns to achieve approximately 300 mL of urine output with each voiding (4) Position for ease of voiding and provide privacy (5) Adjust fluid intake so that the majority of fluids are consumed during times of the day when the patient is most able to remain continent (6) Assist with clothing that is easily removed c) Reduce social isolation due to urinary demands (1) Assess reasons for and extent of social isolation (2) Refer patient for urologic examination and incontinence evaluation (3) Explore alternative coping strategies with patient, significant other, staff, and other healthcare team members 5. Delegating nursing care activity 6. Transitions of care a) Address possible causes of incontinence and appropriate treatment measures b) Refer for urologic examination if not already completed c) Discuss fluid intake management, perineal care, and products for clothing protection

Chapter Highlights A. Urinary tract infections (UTIs) are common among adult women and patients in hospitals and long-term care facilities. In the untreated or immunocompromised patient, .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

UTI can lead to sepsis or chronic kidney disease. Preventing UTI through patient and caregiver teaching and use of evidence-based guidelines is a major nursing responsibility.

B. Short-course antibiotic therapy is appropriate for uncomplicated infections of the lower urinary tract that are not associated with the presence of an indwelling urinary catheter.

C. Teach patients about perineal hygiene and the importance of maintaining adequate fluid intake as measures to help prevent UTI. D. The urinary tract can be affected by obstructive processes such as stones and tumors. Early recognition of obstructive processes and maintaining unobstructed urinary output are critical to maintain kidney function.

E. Urinary stones (most commonly kidney stones in the United States) can obstruct the urinary tract at any level and cause significant pain as they move from the kidney through the ureter. Instruct patients who have had a kidney stone to maintain a generous fluid intake, particularly during exercise and warm weather, to reduce the risk of further stone formation.

F. Bladder cancer is the most commonly occurring malignancy of the urinary tract.

When identified and treated early, bladder function can be preserved and the prognosis is good. Invasive bladder cancer may necessitate removal of the bladder and urinary diversion, altering patterns of urinary elimination and body image.

G. The risk for bladder cancer is greater among men than women, and cigarette smoking is the most significant risk factor for bladder cancer. Most tumors can be resected transurethrally if diagnosed early, before spreading to deeper layers of the bladder wall, the lymph nodes, and adjacent tissue.

H. When resection of the urinary bladder is necessary, a urinary diversion is created to collect urine. A collection appliance must be worn constantly on an ileal conduit; when a continent urinary diversion is created, the pouch is emptied by intermittent catheterization of the stoma.

I. Changes in muscle tone can affect the ability to effectively empty the urinary bladder and/or maintain urinary continence. Urinary incontinence, while treatable and rarely life-threatening, can lead to embarrassment, social isolation, and institutionalization.

J. Urinary retention may occur as a result of some medications, neurologic damage or disease, or obstruction (e.g., an enlarged prostate gland). If the underlying condition cannot be treated, medications or intermittent catheterization are used to promote bladder emptying.

K. Older adults in particular are at risk for urinary incontinence, a treatable condition. A health history, voiding diary, and diagnostic testing are used to establish the type of urinary incontinence and direct treatments such as surgery, pelvic floor muscle exercises, medications, and scheduled toileting.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTIONS FOR CLASSROOM ACTIVITY—LEARNING OUTCOME ONE Have students develop urinary tract health-promotion teaching plans.

Have students research integrative therapies for prevention and treatment of urinary tract infection.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME ONE Have students review clinical patient health histories for evidence of risk factors for development of urinary disorders.

SUGGESTIONS FOR CLASSROOM ACTIVITY—LEARNING OUTCOME TWO Have students develop a nursing plan of care for patients experiencing urinary calculi.

Have students develop a teaching plan to assist patients in compliance with diet modifications necessary for various stone compositions.

SUGGESTIONS FOR CLINICAL ACTIVITY—LEARNING OUTCOME TWO Arrange a registered nurse who works in a lithotripsy unit to speak to clinical students about care of that patient population.

Arrange for students to observe in a lithotripsy unit.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME THREE Arrange a guest lecture by a patient who has undergone cystectomy.

SUGGESTIONS FOR CLINICAL ACTIVITY—LEARNING OUTCOME THREE Discuss the nursing care implications of cystectomy.

Arrange for students to attend a meeting of a support group for patients who have undergone cystectomy.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTIONS FOR CLASSROOM ACTIVITY—LEARNING OUTCOME FOUR Ask the students to list the risk factors for urinary elimination disorders.

Discuss the possible results of prostate gland resection.

SUGGESTIONS FOR CLINICAL ACTIVITY—LEARNING OUTCOME FOUR Have students review patient charts for possible manifestations of urinary elimination disorders.

Have students review clinical patient medication records for medications that might have side effects that affect the urinary tract. Discuss alternative medications or treatments.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter 28 Nursing Care of Patients with Kidney Disorders

Learning Outcomes 1. Describe the pathophysiology and manifestations of kidney disorders, including polycystic kidney disease, glomerular disorder, vascular kidney disorder, kidney trauma, and renal tumor, and outline the interprofessional care and nursing care of patients with these disorders.

2. Describe the pathophysiology and manifestations of kidney failure (i.e., acute kidney injury and chronic kidney disease), and outline the interprofessional care and nursing care of patients with these disorders.

Key Concepts I.

Kidney Disorders A. The patient with polycystic kidney disease 1. Forms: Autosomal dominant (ADPKD) and autosomal recessive 2. Pathophysiology a) Cysts arise from tubular epithelial cells b) Kidneys enlarge as cysts enlarge c) People often develop cysts in other parts of the body d) Complications: Liver cysts, diverticular disease of the colon, cardiac valve abnormalities, and subarachnoid or cerebral hemorrhage 3. Risk factors a) Genetic: 90% autosomal dominant 4. Manifestations a) Slowly progressive onset (1) Flank pain, microscopic or gross hematuria, proteinuria, polyuria and nocturia, UTIs, renal calculi, hypertension, enlarged kidneys, and symptoms of renal insufficiency and chronic renal failure 5. Interprofessional care a) Diagnosis (1) Renal ultrasonography (2) Computed tomography (CT) scan or MRI of the kidney (3) Genetic testing for ADPKD type 1 and type 2 b) Management

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Largely supportive, fluid intake of 2000 to 2500 mL per day (2) Control hypertension using multidrug regimen (3) Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) (4) Dialysis or renal transplantation 6. Nursing care a) Genetic counseling and screening of family members b) Discuss measures to maintain optimal renal function c) Teach how to prevent UTI and early manifestations of UTI d) Avoid drugs that are toxic to kidneys 7. Transitions of care a) Lifestyle changes b) Dietary and fluid management B. The patient with a glomerular disorder 1. May be either primary or secondary to a multisystem disease or hereditary condition 2. Pathophysiology a) Affects both the structure and function of the glomerulus, disrupting glomerular filtration b) Acute postinfectious glomerulonephritis (1) Inflammation of the glomerular capillary membrane (2) Etiologies: Infection of the pharynx or skin with group A beta-hemolytic streptococci (3) Manifestations and complications: Hematuria, cola-colored urine; proteinuria; salt and water retention; edema, periorbital and facial, dependent; hypertension; azotemia; fatigue, anorexia, nausea, and vomiting; headache (a) Less apparent symptoms in older adult (4) Prognosis less favorable for adults than children c) Antiglomerular basement membrane glomerulonephritis (1) Autoantibodies to antigens in the glomerular basement membrane and manifestations of severe glomerular injury (2) Goodpasture’s syndrome (3) Manifestations: Weakness, nausea and vomiting, possible abdominal or flank pain, hematuria, proteinuria, edema, moderate hypertension, oliguria, pulmonary hemorrhage, cough, shortness of breath, and hemoptysis d) Nephrotic syndrome (1) A group of clinical findings as opposed to a specific disorder (2) Manifestations: Massive proteinuria, hypoalbuminemia, hyperlipidemia, and edema .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(3) Etiologies: Minimal change disease (MCD), membranous glomerulonephropathy, focal sclerosis, and membranoproliferative glomerulonephritis (4) Complications: Thromboemboli e) Chronic glomerulonephritis (1) Typically, the result of progressive glomerular disorders such as anti-GBM glomerulonephritis, lupus nephritis, or diabetic nephropathy (2) Symptoms develop insidiously, and the disease is often not recognized until signs of renal failure develop f) Diabetic nephropathy (1) Leading cause of chronic kidney disease in North America (2) Manifestations: Microproteinuria, overt proteinuria, nephropathy, glomerulosclerosis, and thickening of the glomerular basement membrane g) Lupus nephritis (1) Manifestations: Microscopic hematuria to massive proteinuria 3. Interprofessional care 4. Diagnosis a) Urinalysis b) Blood urea nitrogen (BUN) c) Serum creatinine d) Urine creatinine levels e) eGFR (estimated GFR) f) Creatinine clearance g) Serum electrolytes h) Antistreptolysin O (ASO) titer and other tests to detect antigenic proteins or antibodies i) Renal ultrasound j) Kidney scan k) Biopsy 5. Medications a) No drugs can cure disorder b) Nephrotoxic antibiotics, aggressive immunosuppressive therapy, glucocorticoid, corticosteroids, ACE inhibitors or angiotensin-receptor blockers (ARBs), and antihypertensives 6. Treatments a) Restricted activity, restricted sodium and protein intake b) Plasma exchange therapy c) Dialysis

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

7. Nursing care a) Assessment (1) Health history: Complaints of facial or peripheral edema or weight gain, fatigue, nausea and vomiting, headache, general malaise, abdominal or flank pain; cough or shortness of breath; changes in amount, color, or character of urine (e.g., frothy urine); history of skin or pharyngeal streptococcal infection, diabetes, SLE, or kidney disease; current medications (2) Physical assessment: General appearance; vital signs; weight; presence of periorbital, facial, or peripheral edema; inspect skin for lesions, infection; inspect throat, obtain culture as indicated; obtain urine specimen for color, character, and odor b) Priorities of care (1) Monitor renal function and fluid volume status c) Diagnoses, outcomes, and interventions (1) Balance fluid volume (a) Monitor vital signs at least every 4 hours (b) Record intake and output every 4 to 8 hours, or more frequently as indicated (c) Weigh daily, using consistent technique (d) Monitor serum electrolytes, hemoglobin and hematocrit, BUN, creatinine, and eGFR (e) Maintain fluid restriction as ordered (f) Arrange dietary consultation regarding sodium or protein restricted diets (g) Monitor for desired and adverse effects of prescribed medications (h) Provide frequent position changes and good skin care (2) Manage fatigue (a) Document energy level (b) Schedule activities and procedures to provide adequate rest and energy conservation (c) Assist with ADLs as needed (d) Discuss the relationship between fatigue and the disease process (e) Reduce energy demands with frequent, small meals and short periods of activity; limit the number of visitors and visit length (3) Reduce risk for infection (a) Monitor vital signs, temperature, and mental status every 4 hours (b) Assess frequently for signs of infection (c) Monitor CBC, focusing on the WBC and differential (d) Perform effective hand hygiene (e) Avoid or minimize invasive procedures (f) If catheterization is required, use sterile intermittent straight catheterization or maintain a closed drainage system for an indwelling catheter

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(g) Prevent urine reflux from the drainage system to the bladder or the bladder to the kidneys by ensuring a patent, gravity flow system (h) Provide a nutritionally sound diet with complete proteins (i) Teach measures to prevent infection (4) Support the need to modify responsibilities (a) Encourage self-care and active participation in decision making (b) Provide time for verbalization of thoughts and feelings (c) Teach coping skills, helping the patient identify personal strengths (d) When possible, enlist the support of family, other patients, and friends (e) Discuss the effect of the disease and treatments on roles and relationships, helping identify potential changes in roles, relationships, and lifestyle (f) Evaluate the need for additional support and social services for the patient and family d) Delegating nursing care activities 8.

Transitions of care a) Discuss importance of treating streptococcal infections b) Discuss the importance of completing the full course of antibiotic therapy c) Teach patients with diabetes mellitus and SLE about potential renal effects d) Discuss measures to reduce the risk of associated nephritis e) Topics for home care: (1) Information about the disease and the prognosis (2) Prescribed treatment, including activity and diet restrictions; the use and potential effects, both beneficial and adverse, of all medications (3) Risks, manifestations, prevention, and management of complications such as edema and infection (4) Signs, symptoms, and implications of improving or declining renal function (5) Measures to prevent further kidney damage, such as nephrotoxic drugs to avoid (6) Community resources, such as home care providers and support groups

C. The patient with a vascular kidney disorder 1. Hypertension: Sustained elevation of systemic blood pressure a) Malignant hypertension: Diastolic pressure is in excess of 120 mmHg and may be as high as 150 to 170 mmHg b) Secondary hypertension: Manifestation of an underlying disease 2. Renal artery stenosis (RAS) a) Causes: Atherosclerosis, coronary heart disease or peripheral vascular disease, and fibromuscular dysplasia b) Diagnosis (1) Doppler ultrasonography

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(2) Magnetic resonance angiography (MRA) and computed tomography (CT) angiography c) Treatment (1) ACE inhibitors or angiotensin-receptor blockers (ARBs) along with other antihypertensive drugs (2) Stains, low-dose aspirin (3) Percutaneous transluminal angioplasty d) Nursing care (1) Achieve target blood pressures (2) Monitor renal function (3) Implement measures to preserve remaining renal function (4) Teach the patient and family about the prescribed treatment 3. Renal artery occlusion a) Risk factors: Severe abdominal trauma, vessel trauma from surgery or angiography, aortic or renal artery aneurysms, and severe aortic or renal artery atherosclerosis b) Manifestations: May be asymptomatic; sudden, severe localized flank pain; nausea and vomiting; fever; hypertension; hematuria; and oliguria c) Diagnosis (1) Leukocytosis (elevated WBC) and elevated renal enzyme levels d) Treatment: Surgery to restore blood flow to affected kidney, anticoagulant therapy, intrarenal fibrinolysis, hypertension control, and supportive treatment 4. Renal vein occlusion a) Predisposing factors: Nephritic syndrome, pregnancy, oral contraceptive use, and certain malignancies b) Manifestations: Gradual or acute deterioration of renal function c) Diagnosis: Visualizing the thrombus through renal venography d) Treatment: Fibrinolytic drugs, anticoagulant therapy D. The patient with kidney trauma 1. Pathophysiology a) Causes: Blunt force 2. Manifestations a) Hematuria, flank or abdominal pain, oliguria or anuria, localized swelling, tenderness, or ecchymoses in the flank region, Turner’s sign, and signs of shock 3. Interprofessional care a) Diagnosis (1) Hemoglobin and hematocrit levels (2) Urinalysis (3) AST levels .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(4) Renal ultrasonography (5) CT scan with contrast b) Treatments (1) Bed rest and observation (2) Surgery to stop bleeding: Partial nephrectomy or total nephrectomy 4. Nursing care a) Obtain urine specimen for analysis b) Monitor level of consciousness, vital signs, skin color and temperature, and urine output for possible signs of shock E. The patient with a renal tumor 1. May be benign or malignant, primary or metastatic 2. Pathophysiology a) 92% are renal cell carcinomas b) Metastases tend to occur in the lungs, bone, lymph nodes, liver, and brain 3. Risk factors a) Males affected 2:1 more than females b) Highest incidence in those over age 55 c) Smoking, obesity, hypertension, occupational exposure to chemicals, and ESRD 4. Manifestations a) Microscopic or gross hematuria, flank pain, palpable abdominal mass, fever, fatigue, weight loss, and anemia or polycythemia 5. Interprofessional care a) Diagnosis (1) Renal ultrasonography (2) CT scan of the abdomen and pelvis (3) Chest x-ray, bone scan, MRI, and liver function studies b) Medications (1) Antiangiogenesis agents, interferon-, interleukin-2, and targeted therapy with monoclonal antibodies c) Surgery (1) Stage I or II: Radical nephrectomy (2) Regional lymph node resection 6. Nursing care a) Assessment (1) Renal function, tumor type, size, and location .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(2) Preoperative assessment as appropriate b) Diagnoses, outcomes, and interventions (1) Relieved surgical pain (a) Assess frequently for adequate pain relief (b) Assess the incision for inflammation or swelling and drainage catheters and tubes for patency (c) Assess for abdominal distention, tenderness, and bowel sounds (d) Use adjunctive pain relief measures such as positioning, diversional activities, management of environmental stimuli, guided imagery, and relaxation techniques (2) Reduce risk of breathing pattern that increases risk for postoperative respiratory complications (a) Position to promote respiratory excursion, using semi-Fowler position and side-lying positions as allowed and tolerated (b) Change position frequently; ambulate as soon as possible (c) Encourage frequent (every 1 to 2 hours) deep breathing, spirometer use, and coughing (3) Maintain fluid balance (a) Monitor vital signs, CVP, and urine output every 1 to 2 hours initially, then every 4 hours (b) Frequently assess the amount and nature of drainage on surgical dressings and from drainage tubes, stents, and catheters; measure and record output from each drain or catheter separately (c) Maintain fluid intake with intravenous fluids until oral intake is resumed (d) Use strict aseptic technique in caring for all urinary catheters, tubes, stents, drains, and incisions (e) Following catheter removal, assess frequently for urinary retention (f) Monitor laboratory results, including urinalysis, BUN, serum creatinine, and serum electrolytes; report abnormal findings to the physician (4) Support grieving patient and family (a) Work to develop a trusting relationship with the patient and family (b) Listen actively, encouraging the patient and family to express fears and concerns (c) Assist the patient and family to identify strengths, past experiences, and support systems (d) Demonstrate respect for cultural, spiritual, and religious values and beliefs; encourage use of these resources to cope with losses (e) Encourage discussion of the potential impact of loss on the patient and the family structure and function (f) Refer to cancer support groups, social services, or counseling as appropriate 7. Delegating nursing care activities .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

8. Transitions of care a) Maintain a fluid intake of 2000 to 2500 mL per day, increasing the amount during hot weather or strenuous exercise b) Urinate when the urge is perceived, and before and after sexual intercourse c) Properly clean the perineal area d) Watch for manifestations of UTI and understand the importance of early and appropriate evaluation and intervention e) If the patient is an older adult male, he should watch for manifestations of prostatic hypertrophy, a major cause of urinary tract obstruction. Stress the importance of routine screening examinations f) Avoid contact sports such as football or hockey; use measures to prevent motor vehicle accidents and falls, which could damage the kidney II. Kidney Failure A. Kidneys are unable to remove accumulated metabolites from the blood, leading to altered fluid, electrolyte, and acid–base balance 1. Cause may be primary or secondary 2. Onset may be acute or chronic B. The patient with acute kidney injury (AKI); previously known as acute renal failure (ARF) 1. AKI: Rapid decline in renal function with azotemia and fluid and electrolyte imbalances 2. Causes: Ischemia, sepsis, and nephrotoxins 3. Pathophysiology a) Prerenal AKI: Results from conditions that affect renal blood flow and perfusion (1) Causes: Hypovolemia, low cardiac output, and altered vascular resistance b) Postrenal AKI: Results from obstructive causes of acute renal failure (1) Causes: Ureteral and urethral obstruction c) Intrinsic AKI: Acute damage to the renal parenchyma and nephrons (1) Causes: Sepsis, ischemia, nephrotoxins, infectious disease, immunologic disorders (a) Acute tubular necrosis (ATN): Destruction of tubular epithelial cells (b) Nephrotoxins associated with ATN: Radiologic contrast agents, the aminoglycoside antibiotics, amphotericin B, NSAIDs, some chemotherapy drugs, heavy metals such as mercury and gold, and some common chemicals such as ethylene glycol (c) Rhabdomyolysis: Caused by release of excess myoglobin from injured skeletal muscles (d) Hemolysis: Red blood cell destruction 4. Risk factors

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) Major trauma or surgery, infection and sepsis, hemorrhage, severe heart failure, severe liver disease, urinary tract obstruction, drugs and radiologic contrast media, and aging process 5. Manifestations a) Initial phase: May last hours to days, and may be seen as a continuum from prerenal azotemia to intrinsic AKI b) Maintenance phase: Characterized by a significant fall in GFR and tubular necrosis (1) Manifestations: Azotemia, edema and hypertension, confusion, disorientation, agitation or lethargy, hyperreflexia, possible seizures or coma due to azotemia, electrolyte and acid–base imbalances, anorexia, nausea, vomiting, decreased or absent bowel sounds, and uremic syndrome if AKI is prolonged c) Recovery phase: Characterized by a process of tubule cell repair and regeneration and gradual return of the GFR to normal or pre-AKI levels 6. Complications a) Uremia, hypervolemia, hyperkalemia, metabolic acidosis, infections, bleeding, cardiac complications, and malnutrition 7. Interprofessional care a) Treatment goals: Identify and correct underlying cause, prevent additional kidney damage, restore the urine output and kidney function, compensate for renal impairment until kidney function is restored b) Staging: Used to guide treatment decisions for AKI (1) RIFLE: Risk, injury, failure, loss, and end-stage kidney disease (2) AKIN: Stages 1 to 3 c) Diagnosis (1) Urinalysis (2) Serum creatinine, BUN, BUN/creatinine ratio, and eGFR (3) Serum electrolytes (4) Arterial blood gases (5) CBC (6) Renal ultrasonography (7) CT scan or MRI (8) Kidney biopsy d) Medications (1) To restore renal perfusion: Dopamine, norepinephrine, fenoldopam, and atrial natriuretic peptide (ANP) (2) Loop diuretics, osmotic diuretics, electrolytes, and electrolyte modifiers (3) To control arterial pressures: ACE inhibitors, ARBs, or other antihypertensive medications

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(4) To prevent GI hemorrhage: Antacids, histamine H2-receptor antagonists, or a proton-pump inhibitor (5) To manage hyperkalemia: Calcium chloride, bicarbonate, insulin and glucose, nebulized albuterol, and sodium polystyrene sulfonate (6) To manage hyperphosphatemia: Aluminum hydroxide e) Fluid management (1) Fluid intake is restricted once vascular after volume and renal perfusion restored f) Nutrition (1) Adequate nutrients and calories needed (between 25 and 45 calories/kg/day) to prevent catabolism g) Renal replacement therapy (1) Dialysis: Removes excess fluid and metabolic waste products in acute kidney injury and renal failure (a) Hemodialysis: Blood passes through a semipermeable membrane filter outside the body (b) Peritoneal dialysis: Uses the peritoneum surrounding the abdominal cavity as the dialyzing membrane (i) Poses less risk for unstable patient, increased risk for developing peritonitis (c) Intermittent hemodialysis: Most commonly used for the patient with AKI in the United States (i) Ultrafiltration, convection (ii) 3 to 4 hours per day, 3 to 4 times per week (iii) Complications: Hypotension, bleeding related to altered platelet function, infection (local or systemic) related to WBC damage and immune system suppression (2) Continuous renal replacement therapy: Allows more gradual fluid and solute removal (a) Continuous venovenous hemofiltration (CVVH) (b) Continuous venovenous hemodialysis (CVVHD) (c) Continuous venovenous hemodiafiltration (CVVHDF) (3) Vascular access: Gained by inserting a double-lumen catheter into the subclavian, jugular, or femoral vein (a) Long term: Arteriovenous fistula (AVF) is created (b) Arteriovenous graft (c) Complications: Infection and clotting or thrombosis, aneurysms, systemic complications (septicemia and embolization), depression, and low-self esteem (4) Peritoneal dialysis (a) Increases risk of developing peritonitis (b) Avoid with recent abdominal surgery, significant lung disease or peritonitis .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

8. Nursing care a) Assessment (1) Health history: Complaints of anorexia, nausea, weight gain, or edema; recent exposure to a nephrotoxin such as an aminoglycoside antibiotic or radiologic procedure using an injected contrast medium; previous transfusion reaction; chronic diseases such as diabetes, heart failure, or kidney disease (2) Physical examination: Vital signs including temperature; urine output (amount, color, clarity, specific gravity, and presence of blood cells or protein); weight; skin color, peripheral pulses; presence of edema (periorbital or dependent); lung sounds, heart sounds, and bowel tones b) Priorities of care c) Diagnoses, outcomes, and interventions (1) Restore fluid and electrolyte balance (a) Maintain hourly intake and output records (b) Weigh daily or more frequently, as ordered (c) Assess vital signs at least every 4 hours (d) If not contraindicated, place in semi-Fowler position (e) Report abnormal serum electrolyte values and manifestations of electrolyte imbalance. The patient with AKI is at particular risk for the following electrolyte imbalances: (i) Hyperkalemia due to impaired potassium excretion (ii) Hyponatremia due to water retention (iii)Hyperphosphatemia due to decreased phosphate excretion (f) Restrict fluids as ordered; provide frequent mouth care and encourage using hard candies to decrease thirst (g) Administer medications with meals (h) Turn frequently and provide good skin care (2) Maintain adequate nutrition (a) Monitor and record food intake, including the amount and type of food consumed (b) Weigh daily (c) Arrange for dietary consultation to plan meals within prescribed limitations that consider the patient’s food preferences (d) Engage the patient in planning daily menus (e) Allow family members to prepare meals within dietary restrictions; encourage family members to eat with the patient (f) Provide frequent, small meals or between-meal snacks (g) Administer antiemetics as ordered and provide mouth care prior to meals

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(3)

(h) Administer parenteral nutrition as ordered if the patient is unable to eat or tolerate enteral nutrition Promote patient learning (a) Assess anxiety level and ability to comprehend instruction (b) Assess knowledge and understanding (c) Teach about diagnostic tests and therapeutic procedures (d) Discuss dietary and fluid restrictions (e) If the patient is discharged prior to the recovery phase of AKI, teach the signs and symptoms of complications (f) Teach how to monitor weight, blood pressure, and pulse (g) Instruct to avoid nephrotoxic drugs and chemicals for up to 1 year following an episode of AKI

(4) Delegating nursing care activities (5) Transitions of care (a) Avoiding exposure to nephrotoxins, particularly those in over-the-counter products (b) Preventing infection and other major stressors that can slow healing (c) Monitoring weight, blood pressure, and pulse (d) Manifestations of relapse (e) Continuing dietary restrictions (f) Knowing when to contact the physician C. The patient with chronic kidney disease 1. CKD: Kidney damage with resulting dysfunction (GFR less than 60 mL/min) that persists for 3 or more months 2. Incidence increasing in people 65 and older a) Pathophysiology 3. Glomerulosclerosis and interstitial inflammation and fibrosis are characteristic of CKD 4. Early stages: Nephron units gradually destroyed, remaining functional nephrons hypertrophy 5. Progresses over a period of months to many years 6. ESRD: Final stage of CKD; GFR is less than 15 mL/min and renal replacement therapy is necessary to sustain life a) Risk factors

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Risk factors: Diffuse, bilateral disease of the kidneys with progressive destruction and scarring of the entire nephron, AKI, autoimmune disease, proteinuria, or a family history of kidney disease 7. Manifestations a) May not be identified until final, uremic stage (uremia occurs) (1) Early manifestations of uremia: Nausea, apathy, weakness, and fatigue 8. Complications a) Fluid and electrolyte effects (1) Proteinuria, hematuria, decreased urine-concentrating ability, risk for dehydration increases, polyuria, nocturia, sodium and water retention, hyperkalemia, hyperphosphatemia, hypocalcemia, hypermagnesemia, and metabolic acidosis b) Cardiovascular effects (1) Cardiovascular disease is leading cause of death in CKD patients (2) Accelerated atherosclerosis, hypertension, hyperlipidemia, inflammation, cerebral and peripheral vascular manifestations of atherosclerosis, systemic hypertension, pericarditis, and cardiac tamponade c) Hematologic effects (1) Anemia, impaired platelet function, increasing the risk of bleeding disorders such as epistaxis and GI bleeding d) Immune system effects (1) Uremia increases the risk for infection, decreased WBC, impaired humoral and cell-mediated immunity, defective phagocyte function, acute inflammatory response, and delayed hypersensitivity responses affected e) Gastrointestinal effects (1) Anorexia, nausea, vomiting, hiccups, gastroenteritis, ulcerations, increased risk of GI bleeding, and uremic fetor f) Neurologic effects (1) CNS manifestations: Changes in mentation, difficulty concentrating, fatigue, and insomnia, psychotic symptoms, seizures, and coma (2) Peripheral neuropathy, restless leg syndrome, paresthesias and sensory loss typically occur in a “stocking-glove” pattern, impaired motor function g) Musculoskeletal effects (1) Renal osteodystrophy, bone cysts, increased risk for spontaneous fractures 9. Endocrine and metabolic effects a) Elevated serum creatinine and BUN levels, increased risk of gout, glucose intolerance, accelerated atherosclerotic process, and reproductive function affected

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

10. Dermatologic effects a) Pallor and yellowish hue to skin, dry skin with poor turgor, bruising and excoriations, itching and pruritus, and uremic frost 11. Interprofessional care a) Eliminating or controlling factors that cause additional kidney damage b) Slow progression to ESRD c) Diagnosis (1) Urinalysis (2) Urine culture (3) BUN and serum creatinine (4) eGFR (5) Serum electrolytes (6) CBC (7) Renal ultrasonography (8) Kidney biopsy d) Medications (1) Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs), diuretics, diuretic therapy, antihypertensive agents (calcium channel blockers diltiazem and verapamil), and statin drugs (2) Drugs to manage electrolyte imbalances and acidosis: Sodium bicarbonate or calcium carbonate, oral phosphorus binding agents (3) Folic acid and iron supplements, multivitamins e) Nutrition (1) Daily protein intake of 0.6 to 0.75 g/kg of body weight, or approximately 40 to 50 g/day (2) Carbohydrate and fat intake is increased (3) Sodium intake regulated (4) In stages 4 and 5, potassium and phosphorous intake are restricted f) Renal replacement therapies (1) Dialysis (a) 70% of people treated for ESRD in the United States are receiving dialysis (b) Peritoneal dialysis is choice for at-home treatment (c) Patients on long-term dialysis have a higher risk for complications and death (d) Manages symptoms but doesn’t cure it (e) Dialysis dose determined by body size and residual renal function, dietary intake, and concurrent illness (f) Continuous ambulatory peritoneal dialysis (CAPD): Most common form of peritoneal dialysis (i) Continuous cyclic peritoneal dialysis (CCPD) (2) Kidney transplant: Treatment of choice for ESRD .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(a) Most are from deceased donors, transplants from living donors are increasing (b) Match of ABO blood is necessary (c) Requirements for deceased donor: Meet the criteria for brain death, are less than 60 years old, and are free of systemic disease, malignancy, or infection, including HIV and hepatitis B or C (d) Immunosuppressive drugs minimize the immune response stimulated by grafted organ (e) Acute rejection: Develops within months of transplant (f) Chronic rejection: May develop months to years following the transplant (g) Complications of transplant: Hypertension, glomerular lesions, manifestations of nephrosis, infection, tumors, increased risk of congenital anomalies in infants whose mothers have undergone immunosuppressive therapy, bone problems, gastrointestinal disorders, and cataract formation 12. Nursing care a) Assessment (1) Health history: Complaints of anorexia, nausea, weight gain, or edema; current treatment (if any), including type and frequency of dialysis or previous kidney transplant; chronic diseases such as diabetes, heart failure, or kidney disease (2) Physical examination: Mental status; vital signs including temperature, heart and lung sounds, and peripheral pulses; urine output (if any); weight; skin color, moisture, condition; presence of edema (periorbital or dependent); bowel tones; presence and location of an AV fistula, shunt, graft, or peritoneal catheter b) Priorities of care c) Diagnoses, outcomes, and interventions (1) Monitor and support kidney function (a) Monitor intake and output, vital signs including orthostatic blood pressures, and weight (b) Monitor respiratory status, including lung sounds, every 4 to 8 hours (c) Monitor BUN, serum creatinine, eGFR, pH, electrolytes, and CBC; report significant changes (d) Report manifestations of electrolyte imbalances (e) Administer medications to treat electrolyte imbalances as ordered (f) Collaborate with the patient who has diabetes to maintain the blood glucose within a range of 90 to 130 mg/dL (g) Administer antihypertensive medications as ordered (h) Time activities and procedures to allow rest periods (2) Maintain adequate nutritional intake .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(a) Monitor food and nutrient intake as well as episodes of vomiting (b) Weigh daily before breakfast (c) Administer antiemetic agents 30 to 60 minutes before eating (d) Assist with mouth care prior to meals and at bedtime (e) Serve small meals and provide between-meal snacks (f) Arrange for a dietary consultation (g) Monitor nutritional status by tracking weight, laboratory values such as serum albumin and BUN, and anthropometric measurements (h) Administer enteral or parenteral nutrition as prescribed; routinely monitor blood glucose levels, and use strict aseptic technique when handling parenteral nutrition solutions and the venous access site (3) Reduce risk for infection (a) Use standard precautions and good hand hygiene technique at all times (b) Monitor temperature and vital signs at least every 4 hours (c) Monitor WBC count and differential (d) Culture urine, peritoneal dialysis fluid, and other drainage as indicated (e) Monitor clarity of dialysate return (f) Provide good respiratory hygiene (g) Restrict visits from obviously ill people; teach the patient and family about the risk for infection and measures to reduce the spread of infection (4) Promote healthy body image (a) Involve the patient in care, including meal planning, dialysis, and catheter, port, or incision care to the extent possible (a) Encourage expression of feelings and concerns, accepting perceptions and feelings without criticism (a) Include the patient in decision making and encourage self-care (a) Support positive gains, but do not support denial (a) Help the patient develop and achieve realistic goals (a) Provide positive reinforcement and feedback (a) Reinforce effective coping strategies (a) Facilitate contact with a support group or other community members affected by renal failure (a) Refer for mental health counseling as indicated or desired (5) Delegating nursing care activities 13. Transitions of care a) Promote early and effective treatment of all infections b) Discuss measures to reduce the risk for urinary tract infections and stress the importance of prompt treatment to eradicate the infecting organism c) Discuss the relationship between diabetes, hypertension, and kidney disease .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

d) Emphasize that maintaining blood glucose levels and the blood pressure within the recommended ranges reduces the risk of adverse effects on the kidneys e) Ensure that all patients with less than optimal renal function are well-hydrated f) Encourage the patient with CKD to investigate options for early transplantation to avoid long-term dialysis g) Teach for home care: (1) Nature of chronic kidney disease and renal failure, including expected progression and effects (2) Monitoring weight, vital signs, and temperature (3) Prescribed medications, including purpose, intended effect, and potential adverse effects and their management (4) Prescribed dietary restrictions (5) How to assess and protect a fistula or shunt for hemodialysis (6) Peritoneal catheter care and the procedure for peritoneal dialysis as indicated (7) Following kidney transplant, prescribed medications, adverse effects and their management, infection prevention, graft protection, and manifestations of organ rejection (8) The benefits of, and strategies for, incorporating physical activity into daily life and the treatment plan

Chapter Highlights A. Congenital and acquired disorders of the kidneys can profoundly affect urinary elimination and ultimately all body systems.

B. Glomerulonephritis, inflammation of the glomerulus of the kidney, leads to loss of proteins and blood cells in the urine, a decrease in the glomerular filtration rate, and severe edema.

C. The renal and cardiovascular systems are closely interrelated. Vascular disorders, such as hypertension, renal artery stenosis, or obstruction of the renal artery or vein, can have serious consequences in terms of renal function.

D. Renal cell malignancies, while uncommon, are often not evident until the cancer is advanced and has metastasized to other sites.

E. Acute kidney injury is a frequent complication of hospitalization and critical illness that increases mortality, length of stay, costs, and the risk for subsequent chronic kidney disease. Nurses play a key role in preventing and recognizing acute kidney injury, thus minimizing its negative consequences.

F. Ischemic and nephrotoxic damage to the kidney are the most common precipitating factors for AKI. G. Diabetes mellitus and hypertension are the leading causes of chronic kidney disease and kidney failure. Aggressive glycemic control and blood pressure management reduce the risk of kidney disease; likewise, early identification and effective management of chronic kidney disease can delay the onset of kidney failure.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

H. When the kidneys fail, renal replacement therapies are necessary to eliminate metabolic waste products and sustain life. Dialysis and kidney transplant are the primary renal replacement therapies used.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME ONE Have students develop a teaching plan for patients that will help the patient manage risk factors for kidney disorders.

SUGGESTIONS FOR CLINICAL ACTIVITY—LEARNING OUTCOME ONE Assign students to care for patients with a kidney disorder.

Review patient medical records, health histories, and assessments for indications of kidney disorder. Help students relate those manifestations to the specific disorder.

Review patient labs. Help students identify results that are considered normal and abnormal. Have students identify when normal results might indicate kidney disorder and when abnormal results might indicate improving kidney function.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME TWO Arrange for a registered nurse who works on a dialysis unit to speak to the class.

Arrange for a hemodialysis patient to speak to the class.

SUGGESTIONS FOR CLINICAL ACTIVITY—LEARNING OUTCOME TWO Arrange for clinical students to visit a dialysis unit.

Have students document on an assessment documentation flow sheet for patients undergoing routine hemodialysis.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter 29 Assessing the Cardiovascular and Lymphatic Systems Learning Outcomes 1. Describe the anatomy, physiology, and functions of the cardiovascular and lymphatic systems.

2. Describe the anatomy, physiology, and functions of the peripheral vascular system.

3. Outline the components of the assessment of the cardiovascular and lymphatic systems including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.

4. Differentiate considerations for assessing the cardiovascular and lymphatic systems of older adults, veterans, individuals in the LGBTQI population, and adults with sequelae of childhood/congenital conditions.

5. Summarize topics that nurses teach to promote cardiovascular and lymphatic health across the lifespan.

Key Concepts I.

Anatomy, Physiology, and Functions of the Heart A. Pericardium: Double layer of fibroserous membrane that encases heart, forms pericardial sac 1.

Parietal pericardium: Outermost layer 2.

Visceral pericardium: Adheres to heart surface 3.

Pericardial cavity: Small space between visceral and parietal layers, contains serous lubricating fluid B.

Heart wall layers: Epicardium, myocardium, and endocardium

C.

Chambers and valves of the heart 1.

Two atria and two lower ventricles a) Right atrium receives deoxygenated blood b) Blood travels to right ventricle, into pulmonary capillary beds for oxygenation c) Left atrium receives oxygenated blood from pulmonary veins d) Blood travels into left ventricle, into circulation 2.

Valves: Separate chambers and allow for unidirectional blood flow a) Atrioventricular (AV) valves: Separate atria from the ventricles (1) Tricuspid on the right; bicuspid (mitral) on the left b) Chordae tendineae: Control movement of valves c) Semilunar valves: Connect ventricles to vessels (1) Pulmonary valve on the right; aortic valve on the left

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

D.

Systemic, pulmonary, and coronary circulation 1.

Systemic circulation: Supplies blood to body a) Left side of the heart, the aorta and its branches, the capillaries that supply the brain and peripheral tissues, the systemic venous system, and the vena cava 2.

Pulmonary circulation: Right side of the heart, the pulmonary artery, the pulmonary capillaries, and the pulmonary vein 3.

Coronary circulation: Network of vessels that supply heart with blood a) Left and right coronary arteries from the base of the aorta b) Anterior descending and circumflex arteries from the left coronary artery c) Posterior descending artery from the right coronary artery d) Coronary arteries fill with oxygenated blood during ventricular relaxation

E.

The cardiac cycle and cardiac output 1.

Cardiac cycle: Ventricular filling, ventricular systole (ventricles contract), and diastole (ventricles refill, atria contract, myocardium is perfused) a) Normally occurs 70 to 80 times per minute 2.

Stroke volume (SV): Difference between end-diastolic volume and end-systolic volume a) Normally, ranges from 60 to 100 mL/beat 3.

Cardiac output (CO): Amount of blood pumped by ventricles into circulation in 1 minute, measure of heart’s function as pump a) Normally, ranges from 4 to 8 L/min b) CO is determined by heart rate, contractility, preload, and afterload. c) Heart rate (1) Increase usually leads to increase in CO (2) Rapid heart rate decreases amount of time for ventricular filling during diastole, may decrease CO d) Contractility: Ability of cardiac muscle fibers to shorten (1) Poor contractility reduces flow from heart (2) Increased contractility may stress heart and increase SV e) Preload: Amount of cardiac muscle fiber tension at the end of diastole (1) Starling law of the heart: The greater the volume of blood in ventricles, the greater the stretch of cardiac muscle fibers, and the greater the force of contraction (2) Sodium and water retention and vasoconstriction increase preload f) Afterload: Pressure in arterial system ahead of ventricles (1) Pulmonary vascular resistance: Measures right ventricle afterload (2) Systemic vascular resistance: Measures left ventricle afterload (3) Left ventricle pumps against greater pressure. g) Clinical indicators of cardiac output (1) Changes in organ function indicate compromised blood flow (2) Cardiac index (CI): The CO adjusted for body size

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(3) Adequate index: Ranges within 2.5–4.2 L/min/m2 F.

II.

The conduction system of the heart 1.

Cardiac muscle cells can self-excite without stimulus 2.

Sinoatrial (SA) node: “Pacemaker” of the heart 3.

Electrical transmission produces changes in ion concentration across cardiac cell membranes. a) Increases permeability of cell membrane and creates an action potential b) Electrocardiogram (ECG) measures action potential

The Peripheral Vascular System A. Arterial and venous network 1.

Oxygen and nutrients exchanged for metabolic waste in capillary beds B.

Structure of blood vessels 1.

Wall layers a) Tunica intima: Innermost layer, made of endothelium b) Tunica media: Made of smooth muscle in arteries (1) Arterioles contain more smooth muscle, constrict and dilate more. c) Tunica adventitia: Made of connective tissue 2.

Blood pressure in veins is much lower than in arteries.

3.

Veins: Thinner walls, larger lumen, and greater capacity; many have valves for unidirectional flow.

4.

Tiny capillaries connect arterioles and venules, and have only tunica intima

C.

Arterial circulation 1.

Peripheral vascular resistance (PVR): Opposing forces to blood flow in channels far from heart a) Affected by blood viscosity, length of vessel, and diameter of vessel 2.

Blood pressure (BP): Force exerted against walls of arteries as it is pumped from heart a) MAP: Mean arterial pressure b) Systolic BP: Highest pressure, at peak of contraction c) Diastolic BP: Lowest pressure, during relaxation

D.

Factors influencing arterial blood pressure 1.

Sympathetic and parasympathetic nervous systems 2.

Baroreceptors and chemoreceptors in large vessels 3.

Kidney excretion/conservation of water and sodium 4.

Temperature 5.

Chemicals, hormones, and drugs 6.

Dietary factors

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

7.

Race, gender, age, weight, time of day, position, exercise, and emotional state

E.

The Lymphatic System 1.

Consists of lymph, lymph nodes, spleen, thymus, tonsils, and the Peyer patches of the small intestine 2.

Lymph nodes: Aggregates of specialized cells and removes foreign material from lymph 3.

Spleen a) Filters blood, breaks down old red blood cells, stores, and releases their byproducts to the liver b) Synthesizes lymphocytes c) Stores platelets for blood clotting d) Reservoir of blood 4.

Lymphatic vessels: Network around blood vessels 5.

Lymph: Excess tissue fluid

F.

The hematologic system 1.

Blood: Plasma, solutes, red blood cells, white blood cells, and platelets 2.

Hematopoietic system a) Bone marrow: Where blood cells forms b) Lymphoid tissues of lymph nodes: Where blood cells mature 3.

Red blood cells a) Transport oxygen b) Contain hemoglobin molecules, transport oxygen (1) Rate of synthesis depends on availability of iron c) Red blood cell production and regulation (1) Erythroblasts begin forming hemoglobin in bone marrow (2) Cells enter circulation as reticulocytes, mature in 48 hours (3) Stimulated by kidney release of erythropoietin d) Red blood cell destruction (hemolysis) (1) Destroyed by phagocytes in spleen, liver, bone marrow, and lymph nodes (2) Phagocytes reuse amino acids and iron by lysed RBCs (3) Most converted to bilirubin in the bile (4) Jaundice: Bilirubin accumulation in serum

G.

White blood cells 1.

Defense against microorganisms 2.

Originate in bone marrow 3.

Types of granular leukocytes/granulocytes a) Neutrophils: Active phagocytes b) Eosinophils

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

c) Basophils 4.

Nongranular leukocytes a) Monocytes b) Lymphocytes

III.

H.

Platelets 1.

Produce ATP and release mediators for clotting 2.

Production controlled by thrombopoietin

I.

Hemostasis: Control of bleeding 1.

Vessel spasm a) Vessel constricts when damaged b) Thromboxane A2 (TXA2) released 2.

Formation of the platelet plug a) Platelets change from smooth disks to spiny spheres, bind with von Willebrand factor, and expose collagen fibers 3.

Development of the fibrin clot a) Fibrinogen converts to fibrin, forms a meshwork, and stabilizes plug 4.

Clot retraction a) Platelets contract and pull ruptured vessel together. b) Growth factors stimulate repair of vessel.

5.

Clot dissolution/fibrinolysis a) Plasminogen converts to plasmin and dissolves fibrin strands.

Assessing Cardiovascular and Lymphatic Function A. Health assessment interview 1.

Analyze onset, characteristics, course, severity, precipitating and relieving factors, and associated symptoms 2.

Genetic considerations: a) Familial hypercholesterolemia b) Marfan syndrome c) Hypertrophic cardiomyopathy d) Long QT syndrome e) Sickle cell disease f) Gaucher disease g) Hemophilia A h) Chronic myeloid leukemia i) Thalassemia 3.

History of any cardiovascular disorders such as Angina, heart attack, congestive heart failure, stroke, hypertension, peripheral vascular disease, other chronic illness, heart surgery, rheumatic fever, scarlet fever, recurrent streptococcal throat infections, and radiation treatment for breast cancer

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

4.

Ask about cardiovascular symptoms, bleeding patterns, swelling, and recurrent infections 5.

Review personal habits and nutrition history 6.

Consider socioeconomic factors may aggravate circulatory problems.

B.

Physical assessment 1.

Assess heart: Inspection, palpation, and auscultation over precordium a) Apical impulse: Normal visible pulsation, seen in half adult population b) Retraction: Visible retraction in some adults c) Pulsations: Abnormal, from enlarged ventricle 2.

Assess cardiac rate and rhythm 3.

Assess heart sounds 4.

Murmur assessment 5.

Blood pressure and pulse pressure assessment 6.

Skin assessment 7.

Artery and vein assessment 8.

Upper extremity assessment 9.

Lower extremity assessment 10.

Abdominal assessment 11.

Lymph node assessment 12.

Spleen assessment

C.

Diagnosis 1.

Results of diagnostic tests used to: a) Support the diagnosis of a specific cardiovascular disease b) Monitor or alter prescribed medications c) Monitor patient response to treatment d) Plan nursing care

D.

Diagnostic tests 1.

Heart and peripheral vascular system a) Blood pool imaging (gated scan or multigated acquisition scan [MUGA]) b) Cardiac catheterization (coronary angiography and coronary arteriography) c) Cardiolite scan d) Cardiac computed tomography (CT) scan e) Chest x-ray f) Echocardiogram g) Electrocardiogram (ECG) (1) Leads (2) Waveforms (3) Steps to interpretation (a) Determine rate

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(b) Determine regularity (c) Assess P wave (d) Assess P to QRS relationship (e) Determine interval durations (f) Identify abnormalities h) Lipids i) Magnetic resonance imaging (MRI) j) Nuclear dobutamine stress test k) Nuclear dipyridamole (Persantine) stress test l) Pericardiocentesis m) Positron emission tomography (PET) n) Thallium/technetium stress test o) Treadmill tests (stress test) p) Transesophageal echocardiography (TEE) 2.

Lymphatic system a) Abdominal or thoracic CT scan b) Lymph node biopsy c) Lymphangiography (lymphangiogram) d) Magnetic resonance imaging (MRI): Liver, spleen, and lymph nodes 3.

Hematologic system a) Bone marrow examination b) Complete blood count (CBC) c) Erythrocyte sedimentation rate (ESR) d) Magnetic resonance angiography (MRA) IV. Assessment of Special Populations A. Age-related cardiovascular changes and significance B. Relationship of posttraumatic stress disorder and cardiovascular disease C. LGBTQI population: No significant risk of developing cardiovascular disease V. Health Promotion A. Preventing heart disease 1. Modifiable risk factors: a) Lifestyle b) Disease conditions 2. Hypertension 3. Diabetes 4. Abnormal blood lipids 5. Cigarette smoking 6. Obesity 7. Physical inactivity 8. Diet .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

9. Other risk factors 10. Metabolic syndrome 11. Risk factors unique to women B. Maintaining appropriate blood pressure 1. Lifestyle modifications a) Diet b) Physical activity c) Alcohol and tobacco use d) Stress reduction

Chapter Highlights A. Normal anatomy, physiology, and functions of the heart, blood vessels, and lymphatic system are the basis for assessment.

B. The peripheral vascular system includes arteries, veins, and the capillary beds.

C. Factors that affect arterial circulation are blood flow, peripheral vascular resistance, and blood pressure.

D. The lymph system is made up of small aggregates of specialized cells that assist the immune system by removing foreign material, infectious organisms, and tumor cells via lymph nodes and lymphatic vessels. The blood consists of plasma, solutes (e.g., proteins, electrolytes, and organic constituents), red blood cells, white blood cells, and platelets (which are fragments of cells).

E. Both general health and focused cardiovascular and lymphatic system assessments can detect dysfunction, injury, and disorders.

F. Assessment of the cardiovascular and lymphatic systems includes diagnostic tests, genetic considerations, a health interview, and a physical assessment.

G. Veterans who have developed PTSD are at higher risk for developing heart disease.

H. Patients with sequelae from childhood congenital conditions are at increased risk for hematologic or vascular comorbidities.

I. Management of modifiable risk factors can prevent the development of heart disease.

J. Maintaining normal blood pressure is essential to cardiovascular health. Based on the latest guidelines, hypertension is now considered when blood pressure measures 130/80 mmHg and higher.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME ONE Bring anatomical models to the classroom to demonstrate the size and structure of the heart.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME TWO Bring anatomical models to the classroom to demonstrate the size and structure of the great vessels.

SUGGESTIONS FOR CLASSROOM ACTIVITY—LEARNING OUTCOME THREE Have students work in pairs, and present each pair with a disease. Practice interview techniques.

Have students work in pairs and present each pair with a disease. Practice assessment techniques.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME THREE Have the students complete a health history and assessment of a client’s cardiovascular and lymphatic systems.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME FOUR Have students categorize areas to expect age-related changes when conducting an assessment of an older client.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME FOUR Have students assess an older adult to identify normal age-related changes

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME FIVE Have the students create a teaching tool, identifying the modifiable risk factors for cardiovascular disease.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter 30 Nursing Care of Patients with Coronary Heart Disease

Learning Outcomes 1. Describe the pathophysiology and manifestations of disorders of myocardial perfusion, and outline the interprofessional care and nursing care of patients with these disorders.

2. Describe the pathophysiology and manifestations of cardiac dysrhythmias, and outline the interprofessional care and nursing care of patients with these disorders.

Key Concepts I. Disorders of Myocardial Perfusion A. The Patient with Coronary Heart Disease (CHD) 1. Coronary arteries a) Left and right: Supply blood, oxygen, and nutrients to the myocardium and originate in the root of the aorta, just outside the aortic valve b) Left main: Divides to form the anterior descending and circumflex arteries c) Anterior descending: Supplies the anterior interventricular septum, the left ventricle, including the apex of the heart d) Circumflex branch: Supplies the lateral wall of the left ventricle e) Right coronary: Supplies the right ventricle and forms the posterior descending artery f) Posterior descending: Supplies the posterior portion of the heart 2. Pathophysiology a) Atherosclerosis: Most common cause of reduced coronary blood flow (1) Atheroma formation; unknown precipitating factors = lipoproteins/fibrous tissue accumulate in arterial wall; apoprotein increases risk (2) Abnormal lipid metabolism; injury to or inflammation of endothelial cells (3) Potential mechanisms of vessel injury: Hyperlipidemia, arterial hypertension, cigarette smoke, infections, and inflammation (4) Endothelial damage = platelet adhesion and aggregation; attracts leukocytes to area Atherogenic lipoproteins collect; impairs vessel dilation; severe stenosis or total occlusion of artery are possible (5) Atheromas (final stage): Complex lesions; calcified lesions can ulcerate or rupture; thrombosis; vessel lumen occluded by thrombus, or embolize/occlude a distal vessel (6) Plaque formation: Eccentric or concentric (7) Manifestations after about 75% of arterial lumen has been occluded b) Myocardial ischemia (1) Mechanisms that affect coronary perfusion: .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(a) One or more vessels may be partially occluded by large, stable areas of plaque. (b) Platelets can aggregate in narrowed vessels, forming a thrombus. (c) Normal or already narrowed vessels may spasm. (d) A drop in blood pressure may lead to inadequate flow through coronary vessels. (e) Normal autoregulatory mechanisms that increase flow to working muscles may fail.

(2) Classifications: Chronic ischemic heart disease and acute coronary syndromes 3. Incidence and prevalence a) Risk factors: 1) Modifiable risk factors (a) Lifestyle: Cigarette smoking, obesity, physical inactivity, atherogenic diet; women only: Oral contraceptives/hormone replacement therapy (b) Disease conditions: Hypertension, diabetes mellitus, and hyperlipidemia 2) Nonmodifiable risk factors (a) Age, sex, and genetic factors (chromosome p 921.3) (b) Men affected at an earlier age than women; until menopause, women have lower homocysteine levels than men: May partially explain their lower risk 3) Emerging risk factors (a) Elevated homocysteine levels, thrombogenic factors, inflammatory factors, impaired fasting glucose 4. Interprofessional care a) Assesses for risk factors b) Diagnosis (1) Laboratory testing (a) Blood lipid profile: Triglyceride, HDL, and LDL levels/enables calculation of ratio of HDL to total cholesterol (ideal ratio = 1:3) (i) Total serum cholesterol is elevated (b) C-reactive protein: Elevated levels may predict CHD (c) Ankle-brachial blood pressure index (ABI) (d) Exercise ECG testing (e) Electron beam computed tomography (EBCT) (i) Can reveal calcification and other abnormalities (f) Myocardial perfusion imaging: Costly; not recommended for routine CHD risk assessment c) Risk factor management (1) Modification including smoking, diet, exercise, and management of comorbidities (2) Smoking cessation: Reduces CHD risk within months (3) Diet .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(a) Reduced saturated fat and cholesterol intake; good fats vs. bad fats; increased intake of insoluble and soluble fiber; folic acid, and vitamins B6 and B12 affect homocysteine metabolism, reducing serum levels (b) Increased intake of antioxidant nutrients (vitamin E, in particular) and foods rich in antioxidants (fruits and vegetables) appears to increase HDL levels and has a protective effect on CHD; moderate alcohol intake for middle-aged and older adults (4) Regular exercise: Reduces the risk for CHD, lowers VLDL, LDL, and triglyceride levels, and raises HDL levels. Unless contraindicated, all patients are encouraged to exercise (5) Hypertension (a) Hypertension control (maintaining a blood pressure lower than 130/80 mmHg) is vital to reduce atherosclerosis-promoting effects and to reduce heart workload (b) Reducing sodium intake, increasing calcium intake, regular exercise, stress management, and medications (6) Diabetes: Accelerates the atherosclerotic process (a) Weight loss (if appropriate), reduced fat intake, and exercise (b) Because hyperglycemia apparently contributes to atherosclerosis, consistent blood glucose management is vital d) Medications: Lowering total serum cholesterol and LDL levels and raising HDL levels is an integral part of CHD management (1) Cholesterol-lowering drugs (a) Statins (i) Inhibit enzyme HMG-CoA reductase in the liver, lower LDL synthesis and serum levels (ii) Lovastatin (Mevacor), pravastatin (Pravachol), simvastatin (Zocor), and others (iii) Can cause myopathy and increase liver enzyme levels; rhabdomyolysis is a rare side effect causing breakdown of muscle fibers (b) Bile acid sequestrants, nicotinic acid, and fibrates: When combination therapy is required; for younger adults, women who wish to become pregnant, and to specifically lower triglyceride levels (2) Low-dose aspirin therapy e) Nutrition (1) Diet (a) Low-fat, rich in antioxidants and exercise; red wine or grape juice, foods containing bioflavonoids, green tea, nuts (b) Pritikin diet; Ornish diet; DASH (Dietary Approaches to Stop Hypertension)

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

f) Integrative therapies (1) Supplements of vitamins C, E, B6, B12, folic acid; herbs and garlic (for hypertension) (2) Behavioral therapies: Relaxation and stress management; guided imagery; treatment of depression; anger/hostility management; meditation, tai chi, yoga 5. Nursing care a) Assessment: Identifying risk factors (1) Health history; physical examination b) Priorities of Care (1) Ensure adequate treatment of the underlying process while providing care that supports the physical and psychologic responses to the disorder c) Diagnoses, outcomes, interventions (1) Maintain appropriate weight (a) Encourage assessment of food intake and eating patterns; discuss AHA and therapeutic lifestyle change (TLC) dietary recommendations, emphasizing the role of diet in heart disease (b) Refer to clinical dietitian for diet planning and further teaching; encourage gradual but progressive dietary changes; discourage use of high-fat, low-carbohydrate, or other fad diets for weight loss (c) Encourage reasonable goals for weight loss (2) Manage risk factors for CHD (a) Discuss risk factors for CHD, stressing that changing or managing those factors reduces patient’s risk; discuss immediate benefits of smoking cessation (b) Identify specific sources of psychosocial and physical support for smoking cessation, dietary, and lifestyle changes (c) Discuss the benefits of regular exercise for cardiovascular health and weight loss (d) Provide information and teaching about prescribed medications d) Transitions of care (1) Discuss: Smoking cessation, cardiac rehabilitation programs, monitored exercise and information about risk factors; the importance of regular follow-up appointments (2) Assist the patient to make healthy choices and reinforce positive changes B. The Patient with Angina Pectoris 1. Pathophysiology a) Imbalance between myocardial blood supply and demand: Temporary and reversible myocardial ischemia; cellular processes are compromised as ATP stores are depleted b) Cells go from aerobic metabolism to anaerobic metabolism Lactic acid builds up in cells; affects cell membrane permeability, releasing histamine, kinins, and specific enzymes that cause pain c) Return of adequate circulation provides the nutrients needed by cells; clears waste products; more than 30 minutes of ischemia irreversibly damages myocardial cells .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

d) Stable angina—most common/predictable form (1) Usual causes: Physical exertion, exposure to cold, stress; relieved by rest and nitrates e) Prinzmetal’s (variant) angina—atypical/unpredictable (1) Often occurs at night; caused by coronary artery spasm with or without anatherosclerotic lesion (2) Exact mechanism of coronary artery spasm unknown: May result from hyperactive sympathetic nervous system responses, altered calcium flow in smooth muscle, or reduced prostaglandins f) Unstable angina: Occurs with increasing frequency, severity, and duration (1) Unpredictable pain: Occurs with decreasing levels of activity or stress, or at rest g) Silent myocardial ischemia (asymptomatic ischemia) (1) Common in people with CHD; may occur with either activity or mental stress; increased chance of myocardial infarction and death 2. Course and manifestations a) Chest pain: Substernal or precordial (across the chest wall); may radiate to neck, arms, shoulders, or jaw b) Quality: Tight, squeezing, heavy pressure, or constricting sensation, burning, aching, choking, dull, or constant c) Associated manifestations: Dyspnea, pallor, tachycardia, anxiety, and fear d) Atypical manifestations: Indigestion, nausea and vomiting, upper back pain e) Precipitating factors: Exercise or activity, strong emotion, stress, cold, and heavy meal f) Relieving factors: Rest, position change, and nitroglycerin g) Severity graded by degree to which it limits activity (1) Class I: Does not occur with ordinary physical activities (2) Class II: May develop with rapid or prolonged walking or stair climbing (3) Class III: Significantly limits ordinary physical activities (4) Class IV: Angina at rest, as well as with physical activity 3. Interprofessional care a) Diagnosis: Based on medical/family history, comprehensive description of the chest pain, and physical assessment findings (1) Electrocardiography (ECG) (2) Stress electrocardiography (3) Radionuclide testing: Evaluates myocardial perfusion and left ventricular function (4) Echocardiography: Ultrasound to evaluate cardiac structure and function (a) Transesophageal echocardiography (TEE): Identifies abnormal blood flow patterns and cardiac structures (5) Coronary angiography: Visualization of main coronary branches (a) Ergonovine maleate induces coronary artery spasm to diagnose Prinzmetal’s angina .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

b) Medications—goal: Reduce oxygen demand/increase oxygen supply to myocardium (1) Nitrates: Treat acute anginal attacks and prevent angina (a) Sublingual nitroglycerin, nitroglycerine spray to treat acute attacks (b) Longer-acting nitroglycerin preparations (oral tablets, ointment, or transdermal patches) to prevent attacks of angina, not to treat an acute attack (c) Common side effects: Headache, nausea, dizziness, hypotension (2) Beta-blockers (a) Propranolol, metoprolol, nadolol, and atenolol are considered first-line drugs (b) Block the cardiac-stimulating effects of norepinephrine and epinephrine, preventing anginal attacks, reducing myocardial oxygen demand (c) Contraindicated for patients with asthma or severe COPD; may exacerbate Prinzmetal’s angina (3) Calcium channel blockers (a) Verapamil, diltiazem, and nifedipine: Reduce myocardial oxygen demand and increase myocardial blood and oxygen supply; for long-term prophylaxis, not acute attack of angina (b) Not usually prescribed in the initial treatment of angina: May increase ischemia and mortality in patients with heart failure or left ventricular dysfunction (4) Aspirin: Low-dose often prescribed to reduce the risk of platelet aggregation and thrombus formation 4. Nursing care a) Assessment (1) Health history (2) Physical examination b) Priorities of care (1) Circulatory support (2) Strategies to identify early signs and symptoms of acute cardiac events (3) Optimize safe home and work environments (4) Promote comfort and prevention of cardiac event recurrence c) Diagnoses, outcomes, and interventions (1) Promote effective cardiac tissue perfusion (a) Keep prescribed nitroglycerin tablets at the patient’s side so one can be taken at the onset of pain; start oxygen at 4 to 6 L/min per nasal cannula or as prescribed; space activities to allow rest; teach about prescribed to maintain myocardial perfusion and reduce cardiac work; emphasize difference between drugs used to treat acute attacks versus drugs used to prevent anginal attacks (b) Instruct to take sublingual nitroglycerin before engaging in activities that precipitate angina (e.g., climbing stairs, sexual intercourse): Encourage exercise; refer to a smoking cessation program as indicated (2) Promote adherence to therapeutic regimen

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(a) Assess knowledge and understanding of angina; teach where appropriate; provide written and verbal instructions about prescribed medications and their use; stress the importance of taking chest pains seriously while maintaining a positive attitude; refer to a cardiac rehabilitation program or other organized activities and support groups 5. Transitions of care a) Topics for teaching home care (1) Coronary heart disease and the processes that cause chest pain, including the relationship between the pain and reduced blood flow to the heart muscle (2) Use and effects (desired and adverse) of prescribed medications (3) Importance of not discontinuing medications abruptly (4) Nitroglycerine use for acute angina/appropriate storage (5) Importance of calling 911 or going to the emergency department immediately for unrelieved chest pain (6) Appropriate storage of nitroglycerine (7) Respiratory care, activity, and pain management; importance of actively participating in rehabilitation (8) Manifestations of infection or other potential complications and their management C. The Patient with Acute Coronary Syndrome (ACS) 1. Pathophysiology a) Rupture or erosion of atherosclerotic plaque with formation of a blood clot that does not fully occlude the vessel; coronary artery spasm (e.g., Prinzmetal’s angina) b) Progressive vessel obstruction by atherosclerotic plaque or restenosis following a percutaneous revascularization (PCR) procedure; inflammation of a coronary artery c) Increased myocardial oxygen demand and/or decreased supply (e.g., acute loss or anemia); increased SNS activity is often the trigger for plaque rupture; higher incidence within first hour of rising from bed d) When atherosclerotic plaque ruptures or erodes, exposed lipid core of plaque stimulates platelet aggregation and extrinsic clotting pathway; cells become ischemic due to thrombin and fibrin deposits forming clot that impairs blood flow to tissue distal to rupture e) Inversion of the T wave and possibly elevation of the ST segment may be seen on the ECG 2. Manifestations a) Chest pain, usually substernal or epigastric; often radiates to neck, left shoulder, and/or left arm; at rest and longer than 10–20 min; more severe than previously experienced by patient b) Dyspnea, diaphoresis, pallor, and cool skin may be present; tachycardia and hypotension may occur; nausea or light-headedness

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

3. Interprofessional care a) Diagnosis (1) ECG and serum cardiac markers: To differentiate between unstable angina and acute myocardial infarction (a) Cardiac muscle troponins: Cardiac-specific troponin T (cTnT) and cardiac-specific troponin I (cTnI): Sensitive indicators of myocardial damage (b) Creatine kinase (CK) and CK-MB (specific to myocardial muscle) levels likely within normal limits or demonstrate transient elevation, returning to normal levels within 12 to 24 hours b) Medications: Reduce myocardial ischemia and reduce the risk for blood clotting (1) Fibrinolytic drugs: Restore blood flow to ischemic cardiac muscle—can prevent permanent damage (2) Nitrates and beta blockers: Restore blood flow to the ischemic myocardium and reduce the workload of the heart (3) Aspirin, other antiplatelet drugs, and heparin: To inhibit blood clotting/risk of thrombus formation (aspirin and clopidogrel increase risk of serious hemorrhage) (4) Intravenous antiplatelet drugs: Abciximab (ReoPro), eptifibatide (Integrilin), or tirofiban (Aggrastat)—used when an invasive coronary revascularization procedure is anticipated in the immediate or near future c) Revascularization procedures (1) Percutaneous coronary angioplasty: Opens area of narrowing and pushes plaque against artery wall; typically is accompanied by placement of a stent (a) Intracoronary stents: Metallic scaffolds used to maintain an open arterial lumen (i) Reduce the rate of restenosis following angioplasty by about one-third (ii) Antiplatelet medications are given following stent insertion to reduce the risk of thrombus formation at the site (2) Coronary atherectomy: Removes plaque from the lesion (3) Coronary artery bypass grafting (CABG) (a) Creates a connection (or bypass) between the aorta and the coronary artery beyond the obstruction; angina is totally relieved or significantly reduced in 90% of patients; median sternotomy commonly is used to access the heart; heart is usually stopped during surgery; cardiopulmonary bypass (CPB) pump is used to maintain perfusion to the rest of the organs during open-heart surgery.

(4) Minimally invasive coronary artery surgery: Potential future alternative to CABG (a) Port-access coronary artery bypass—several small holes to connect to CPB pump (b) Alternatively, the femoral artery and femoral vein may be used (c) Minimally invasive coronary artery bypass (MIDCAB) does not require CPB— performed while heart continues to beat .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(5) Transmyocardial laser revascularization (TMLR): Patients whose coronary artery obstructions are too diffuse to bypass are candidates for this new surgical treatment 4. Nursing care a) Patient having a coronary artery bypass graft (CABG) (1)Preoperative care (a) Verify presence of laboratory and diagnostic test results in the chart, including CBC, coagulation profile, urinalysis, chest x-ray, and coronary angiogram; type and crossmatch four or more units of blood as ordered; patient/family teaching (2) Postoperative care (3) Monitor cardiac output (a) Monitor vital signs, oxygen saturation, and hemodynamic parameters, skin color and temperature, peripheral pulses, and level of consciousness every 15 minutes; continuously monitor and document cardiac rhythm; note trends; monitor hemoglobin, hematocrit, and serum electrolytes (b) Initial hypothermia and bradycardia are expected; the heart rate should return to the normal range with rewarming (c) Auscultate heart and breath sounds on admission, then at least every 4 hours (d) A ventricular gallop, or S3, is an early sign of heart failure; an S4 may indicate decreased ventricular compliance (e) Assess skin color and temperature, peripheral pulses, and level of consciousness with vital signs (f) Continuously monitor and document cardiac rhythm (g) Measure intake and output hourly. Report urine output less than 30 mL/h for 2 consecutive hours; record chest tube output hourly (h) Monitor hemoglobin, hematocrit, and serum electrolytes (i) Administer medications, intravenous fluids, fluid boluses, and blood transfusions as ordered (j)Keep a temporary pacemaker at the bedside; initiate pacing as indicated (4) Manage rewarming (a) Monitor core body temperature for first 8 hours following surgery (b) Institute rewarming measures (5) Manage acute pain (a) Frequently assess for pain (6) Promote adequate gas exchange (b) Evaluate respiratory status frequently (c) Monitor and maintain endotracheal tube (ETT) placement on chest (d) Maintain ventilator settings as ordered (e) Suction as needed (f) After extubation, teach use of incentive spirometer, cough pillow (7) Reduce risk for infection (a) Assess sternal incision and leg wounds frequently .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(b) Maintain sterile dressing for first 48 hours, then leave incision open to air (c) Report signs of wound infection (d) Culture wound drainage as indicated (e) Collaborate with dietician to promote nutrition and fluid intake (8) Promote mental clarity (a) Frequently reorient during initial recovery period, involve family members in reorienting (b) Explain all procedures before performing them; speak in calm clear voice (c) Secure all IV lines, catheters, and tubes (d) Note verbal responses to questions (e) Maintain calendar and clock within patient’s view (f) Promote patient participation in decision making when appropriate (g) Report signs of hallucinations, delusions, depression, and agitation; administer sedatives with caution (h) Administer sedatives cautiously (i) Reevaluate cardiac status every shift D. The Patient with Acute Myocardial Infarction (AMI) 1. Pathophysiology a) Atherosclerotic plaque may form stable or unstable lesions (1) Stable: Progress gradually; often cause angina (2) Unstable lesions: Prone to rupture/thrombus formation; often lead to acute coronary syndromes or acute ischemic heart diseases b) Myocardial infarction: Blood flow to a portion of cardiac muscle is completely blocked, resulting in prolonged tissue ischemia and irreversible cell damage (1) Coronary occlusion usually caused by ulceration/rupture of a complicated atherosclerotic lesion; upon rupture, substances are released that stimulate platelet aggregation, thrombin generation, and local vasomotor tone; vessel constricts, a thrombus forms, occluding the vessel and interrupting blood flow to myocardium distal to obstruction c) With prolonged ischemia lasting more than 20 to 45 minutes, irreversible hypoxemia causes cellular death and tissue necrosis d) Within 20 minutes of injury, the subendocardium suffers the initial damage (1) If blood flow is restored at this point, infarction is limited to tissue (a subendocardial or non-Q-wave infarction) e) Within 1 to 6 hours, damage progresses to the epicardium (1) Transmural infarction: All layers of the myocardium are affected (Q-wave MI) (a) Heart failure is more frequently associated with Q-wave MIs; however, non-Q wave MI patients frequently experience recurrent ischemia or subsequent MI within weeks or months of the event f) Surrounding tissue may be stunned or hibernating

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

g) Myocardial remodeling may occur, with cellular hypertrophy and loss of contractility in regions distant from the infarction: Rapid restoration of blood flow limits these changes h) MIs are described by the damaged area of the heart i) AMI may develop due to cocaine intoxication 2. Manifestations a) Chest pain (substernal or precordial) more severe than angina pain; onset sudden; not associated with activity; duration and continuity distinguishes MI from angina and acute coronary syndrome; pain lasts more than 15 to 20 minutes and is not relieved by rest or nitroglycerin; up to 25% of patients with acute MI deny chest discomfort; compensatory mechanisms cause many of the other symptoms of MI b) Women and older adults often experience atypical chest pain, presenting with complaints of indigestion, heartburn, nausea, and vomiting c) Tissue necrosis causes an inflammatory reaction that increases the white blood cell (WBC) count and elevates the temperature d) Typical manifestations: Chest pain, tachycardia, tachypnea, dyspnea, shortness of breath, nausea, vomiting, anxiety, sense of impending doom, diaphoresis, cool, mottled skin; diminished peripheral pulses, hypotension or hypertension, palpitations, dysrhythmias, signs of left heart failure, and decreased consciousness 3. Complications a) Dysrhythmias: Most frequent complication of MI (1) Infarcted tissue is arrhythmogenic, increasing risk of dysrhythmias; premature ventricular contractions (PVCs) are common following an MI (2) Ventricular fibrillation (VF) is a frequent cause of sudden cardiac death—greatest risk in first hour after MI (3) Atrioventricular (AV) block may occur following anterior wall infarction; first-degree and Mobitz I (Wenckebach) blocks are most common, although complete heart block can occur; bradydysrhythmias (abnormal slow rhythms) may develop b) Pump failure (1) Severity of heart failure is dependent on the location and amount of myocardial damage; hemodynamic monitoring is often initiated for patients with evidence of heart failure (2) Cardiogenic shock: Functioning myocardial muscle mass decreases by > 40% (3) Heart unable to meet organ function needs; mortality > 70% c) Infarct extension (1) Extension or reinfarction: Area of original infarction first 10 to 14 days after an MI (2) Characterized by increased myocardial necrosis from continued blood flow impairment and ongoing injury d) Structural defects

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Necrotic muscle replaced by scar tissue that is thinner than ventricular muscle mass; can lead to ventricular aneurysm, rupture of the interventricular septum or papillary muscle, and myocardial rupture (2) Myocardial rupture is a risk between 4 and 7 days after MI, when injured tissue is soft/weak e) Pericarditis: Tissue necrosis prompts inflammatory response, often within 2–3 days (1) Dressler’s syndrome (a) Thought to be a hypersensitivity response to necrotic tissue or an autoimmune disorder, may develop days to weeks after AMI; symptom complex characterized by fever, chest pain, and dyspnea 4. Interprofessional care a) Immediate treatment goals for the MI patient = relieve chest pain, reduce extent of myocardial damage, maintain cardiovascular stability, decrease cardiac workload, and prevent complications b) Slowing the process of CHD and reducing the risk of future MI is major long-term management goal c) Rapid assessment and early diagnosis is important in treating AMI (1) “Time is muscle”: The quicker the artery is reopened = more myocardium salvaged (2) Every minute of delay in treating patients with AMI affects the mortality risk during the first year; major problem = delay in seeking treatment d) Diagnosis (1) Serum cardiac markers (a) Creatine kinase (CK) (b) CK-MB (CK specific to cardiac muscle) (c) Cardiac-specific troponin T (cTnT) and cardiac-specific troponin I (cTnI) (2) Myoglobin: One of 1st cardiac markers detectable in blood after an MI (3) CBC shows an elevated WBC count due to inflammation of injured myocardium (4) Arterial blood gases (ABGs): Assess blood oxygen levels and acid–base balance (5) Electrocardiography (ECG) (a) Ischemic changes in the heart = depression of the ST segment or inversion of the T wave; elevation of the ST segment = myocardial injury; transmural infarction = significant Q-wave development (6) Echocardiography: Evaluates cardiac wall motion and left ventricular function (7) Radionuclide imaging: Evaluates myocardial perfusion; helps identify specific area of myocardial ischemia and damage (8) Hemodynamic monitoring: May be initiated when AMI significantly affects cardiac output and hemodynamic status e) Medications (1) Aspirin: Platelet inhibitor (2) Analgesia: Vital in maintaining low myocardial workload

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(a) Nitroglycerin: Pain relief, decreases myocardial oxygen demand; may increase the supply of oxygen to the myocardium; peripheral and arterial vasodilator that reduces afterload; dilates coronary arteries/collateral channels in heart/increasing coronary blood flow to save myocardial tissue at risk (b) Can cause reflex tachycardia or excessive hypotension; use of sildenafil (Viagra) within previous 24 hours before administering nitroglycerin—combination can cause significant drop in blood pressure (c) Morphine sulfate when nitroglycerin is ineffective in pain relief (3) Fibrinolytic therapy: Drugs that dissolve or break up blood clots (a) First-line drugs to treat acute MI when no access to a cardiac catheterization lab (b) Streptokinase: Risk of a severe hypersensitivity reaction, including anaphylaxis (c) Tissue plasminogen activator (t-PA), tenecteplase (TNK), and reteplase (rPA) are more effective in reestablishing myocardial perfusion, especially when the pain developed more than 3 hours previously (4) Antidysrhythmics (a) Treat or prevent dysrhythmias; ventricular dysrhythmias—class I or class III antidysrhythmic drugs; symptomatic bradycardia—intravenous atropine, 0.5 to 1 mg; atrial fibrillation or other supraventricular tachydysrhythmias— intravenous verapamil or the short-acting beta blocker esmolol (Brevibloc) (5) Other medications (a) Beta blockers: Pain, limit infarct size, decrease serious ventricular dysrhythmias (b) Angiotensin: Converting enzyme (ACE) inhibitors reduce ventricular remodeling following an MI (c) Anticoagulants and antiplatelet medications often are prescribed to maintain coronary artery patency following thrombolysis or a revascularization procedure (d) Abciximab (ReoPro) suppresses platelet aggregation and reduces risk of reocclusion after angioplasty; improves vessel opening with fibrinolytic therapy, permitting lower doses of fibrinolytic drugs (e) Intravenous dopamine used for pump failure and hypotension (f) Heparin helps establish/maintain patency of affected coronary artery (i) Used along with long-term warfarin, to prevent systemic or pulmonary embolism in patients with significant left ventricular impairment or atrial fibrillation following AMI (g) Antilipemic agents are used for the patient with hyperlipidemia (h) Stool softener such as docusate sodium f) Treatments (1) Continuous monitoring; intensive coronary care unit for the first 24 to 48 hours, possibly followed by telemetry; bed rest is prescribed for first 12 hours to reduce the cardiac workload; activities gradually increased as tolerated; a quiet, calm environment with limited outside stimuli is preferred; oxygen is administered by nasal cannula at 2 to 5 L/min .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(2) Diet (a) Liquid first 4–12 hours to reduce gastric distention and myocardial work (b) Followed by low-fat, low-cholesterol, and reduced-sodium diet (c) Small, frequent feedings are often recommended (3) Revascularization procedures (a) PCR may follow fibrinolytic therapy or be used in place of fibrinolytic therapy to restore blood flow to ischemic myocardium (b) Procedure depends on the patient’s age and immediate condition, time elapsed from onset of manifestations, and extent of myocardial disease and damage (4) Other invasive procedures (a) The intra-aortic balloon pump (IABP) (b) (Intra-aortic balloon counterpulsation); mechanical circulatory support device temporarily supports cardiac function allowing heart recovery; widely used to augment cardiac output; ventricular assist devices for patients requiring longerterm artificial support (c) Catheter inflates during diastole, increasing perfusion of the coronary and renal arteries; deflates just prior to systole, decreasing afterload and cardiac workload (d) Inflation–deflation sequence triggered by the ECG pattern (e) Ventricular assist devices (VADs) (i) Temporarily takes partial or complete control of cardiac function; uses: Bridge to heart transplant, temporary or complete assist in AMI/cardiogenic shock when there is chance for recovery to normal heart function (ii) Considerable risk for infection; strict aseptic technique is used with all invasive catheters and dressing changes; pneumonia a risk due to immobility and ventilatory support; mechanical failure of the VAD is lifethreatening (5) Cardiac rehabilitation (a) Long-term program of medical evaluation, exercise, risk-factor modification, education, and counseling; goal: Limit physical/psychological effects of cardiac illness and improve quality of life (b) Phase 1—inpatient phase: Assessment, activity progression, subjective/objective response to increased activity evaluated (c) Phase 2—immediate outpatient cardiac rehabilitation: Within 3 weeks of cardiac event; increase activity level, participation, capacity; improve psychosocial status/treat anxiety and depression; educate/support to reduce risk factors (d) Phase 3—continuation programs: Transition to independent exercise and exercise maintenance; patient check-in every 3 months for evaluation 5. Nursing care

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) Focus on reducing cardiac work, identifying and treating complications in a timely manner, and preparing the patient for rehabilitation b) Assessment—timely and ongoing: Health history, physical examination c) Priorities of care: (1) Adequate treatment of the underlying process while providing care that supports the physical and psychologic responses to the acute cardiac event d) Diagnoses, outcomes, and interventions (1) Manage acute pain (a) Titrate intravenous nitroglycerin as ordered to relieve chest pain, maintaining a systolic blood pressure greater than 100 mmHg; administer oxygen at 2 to 5 L/min per nasal cannula; intravenous push morphine 2 to 4 mg as needed for chest pain (2) Promote effective cardiac tissue perfusion (a) Assess vital signs, assess for changes in level of consciousness (LOC); auscultate heart and breath sounds; decreased urine output; moist, cool, pale, mottled or cyanotic skin; dusky or cyanotic mucous membranes and nail beds; diminished/absent peripheral pulses; delayed capillary refill (b) Monitor ECG rhythm continuously; monitor oxygen saturation levels; administer oxygen as ordered; obtain and assess ABGs as indicated; plan for invasive hemodynamic monitoring (3) Promote effective coping (a) Accept denial as a coping mechanism, but do not reinforce it; note aggressive behaviors, hostility, or anger. Document any failure to comply with treatments (b) Provide opportunities for patient to make decisions about plan of care, as possible; provide privacy for patient and significant others to share their questions/concerns (4) Manage fear (a) Acknowledge the patient’s perception of the situation; encourage questions and provide consistent, factual answers; encourage self-care; teach nonpharmacologic methods of stress reduction 6. Transitions of care a) Assessing readiness to learn is important first step in preparing for home-care; provide written material to supplement teaching and encourage questions; include in home-care teaching: The normal anatomy and physiology of the heart, and specific area of heart damage; CHD process and implications of MI; purposes and side effects of prescribed medications; complying with medical regimen; community resources II. Cardiac Rhythm Disorders A. The Patient with a Cardiac Dysrhythmia 1. Physiology review

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) Properties of cardiac cells: Automaticity, excitability, conductivity, refractoriness, and contractility 2. Pathophysiology a) Disturbance or irregularity in the electrical system of the heart; not all are pathologic b) Tachydysrhythmias, bradydysrhythmias, and ectopic rhythms (1) Reentry phenomenon is a major cause of tachydysrhythmias c) Result from a change in the automaticity of cardiac cells; aberrant impulses may originate outside normal conduction pathways, causing ectopic beats d) Ischemia, injury, and infarction of myocardial tissue affect its excitability and ability to conduct and respond to an electrical stimulus (1) Conduction abnormalities cause varying degrees of heart block; bundle branch blocks are common in acute myocardial infarction e) Cardiac rhythms are classified by site of impulse formation or site and degree of conduction block (1) Supraventricular rhythms: Sinus, atrial, and junctional (2) Ventricular rhythms: May prove fatal if left untreated; AV conduction blocks result from a defect in impulse transmission from the atria to the ventricles f) Supraventricular rhythms (1) Normal sinus rhythm (NSR)—normal heart rhythm; rate: 60 and 100 bpm (2) Sinus node dysrhythmia (a) Occur as a normal compensatory response (e.g., to exercise) or because of altered automaticity (b) Initiating impulse is from the sinus node (c) Include sinus arrhythmia, sinus tachycardia, and sinus bradycardia.

(3) Sinus arrhythmia (a) Rate: 60 to 100 bpm; rhythm: Irregular, varying with respirations; common in the very young and very old; can be caused by an increase in vagal tone, by digitalis toxicity, or by morphine administration (4) Sinus tachycardia (a) Rate: 101 to 150 bpm; rhythm: Regular; has all of the characteristics of NSR, except that the rate >100 bpm; arises from enhanced automaticity in response to changes in the internal environment (b) Common causes: Exercise, excitement, anxiety, pain, fever, hypoxia, hypovolemia, anemia, hyperthyroidism, myocardial infarction, heart failure, cardiogenic shock, pulmonary embolism, caffeine intake, certain drugs, such as atropine, epinephrine (Adrenalin), or isoproterenol (Isuprel) (c) Manifestations: Rapid pulse rate, feeling of racing heart, shortness of breath, dizziness; if heart disease present, can cause chest pain (5) Sinus bradycardia (a) Rate: < 60 bpm; rhythm: Regular; has all of the characteristics of NSR, but the rate is less than 60 bpm; may be normal (e.g., in patients with athletic heart .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

syndrome); heart rate normally slows during sleep because parasympathetic nervous system is dominant at this time (b) Other causes: Pain, increased intracranial pressure, sinus node disease, acute myocardial infarction (especially with inferior wall damage), hypothermia, acidosis, and certain drugs; may be asymptomatic (6) Sick sinus syndrome (a) Results from SA node disease or dysfunction that causes problems with impulse formation, transmission, and conduction (b) May be caused by direct injury to sinus tissue, fibrosis of conduction fibers associated with aging, and digitalis, beta-blockers, and calcium channel blockers. (c) ECG characteristics include sinus bradycardia, sinus arrhythmia, sinus pauses or arrest, and atrial tachydysrhythmias such as atrial fibrillation, atrial flutter, or atrial tachycardia (d) Manifestations include fatigue, dizziness, lightheadedness, and syncope g) Supraventricular dysrhythmias (1) Premature atrial contractions (PAC) (a) Rate: Variable; rhythm: Irregular, with normal rhythm interrupted by early beats arising in the atria; usually asymptomatic and benign, but they may initiate paroxysmal supraventricular tachycardia in susceptible individuals (b) Common causes: Strong emotions, excessive alcohol intake, tobacco, stimulants (c) Also may be associated with MI, heart failure and other cardiac disorders, hypoxemia, pulmonary embolism, digitalis toxicity, acid–base imbalances (d) Few manifestations: Palpitations or a fluttering sensation in the chest (2) Paroxysmal supraventricular tachycardia (PSVT) (a) Rate: 100 to 280 bpm (usually 150 to 200 bpm); rhythm: Regular; sudden onset and termination; PSVT occurs more frequently in women (b) Causes: Sympathetic nervous system stimulation and stressors: Fever, sepsis, hyperthyroidism; also may be associated with heart diseases such as CHD, MI, rheumatic heart disease, myocarditis, or acute pericarditis (c) Wolff-Parkinson-White (WPW) or Lown-Ganong-Levin (LGL) (d) Manifestations: Complaints of palpitations and a racing heart, anxiety, dizziness, dyspnea, anginal pain, diaphoresis, extreme fatigue, and polyuria (3) Atrial flutter (a) Rate: Atrial 240 to 360 bpm; ventricular rate depends on degree of AV block, usually is < 150 bpm; rhythm: Atrial: Regular; ventricular: Usually regular (b) Causes: Sympathetic nervous system stimulation due to anxiety, caffeine/alcohol intake, thyrotoxicosis, CHD or MI; pulmonary embolism, and abnormal conduction syndromes such as WPW or LGL (c) Manifestations of decreased cardiac output, such as decreased level of consciousness, hypotension, decreased urinary output, and cool clammy skin (d) ECG characteristics: Sawtooth appearance of P waves (flutter (F) waves) .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(4) Atrial fibrillation (a) Rate: Atrial: 300 to 600 bpm (too rapid to measure); ventricular: 100 to 180 bpm in untreated patients; rhythm: Irregularly irregular; disorganized atrial activity without discrete atrial contractions (b) Commonly associated with heart failure, rheumatic heart disease, CHD, hypertension, and hyperthyroidism (c) Manifestations relate to the rate of the ventricular response (d) Rapid response rates: Decreased cardiac output: Hypotension, shortness of breath, fatigue, and angina; patients with extensive heart disease may develop syncope or heart failure (e) Increases risk of thromboemboli. Organ infarction may occur as a result; incidence of stroke is high h) Junctional dysrhythmias: Rhythms that originate in AV nodal tissue (1) Junctional escape rhythm (a) Rate: 40 to 60 bpm; junctional tachycardia: 60 to 140 bpm; rhythm regular; retrograde conduction (b) Causes: Drug toxicity, hypoxemia, hyperkalemia, increased vagal tone or damage to the AV node, MI, and heart failure (2) Premature junctional contractions (PJCs) (3) Junctional tachycardia: Rate > 60 bpm i) Ventricular dysrhythmias (1) Premature ventricular contractions (PVC) (a) Rate: Variable; rhythm: Irregular, with PVC interrupting underlying rhythm and followed by a compensatory pause; often have no significance in people without heart disease (b) Causes: Anxiety or stress; tobacco, alcohol/caffeine use; hypoxia, acidosis, electrolyte imbalances; sympathomimetic drugs; coronary heart disease; heart failure; mechanical stimulation of heart or reperfusion after fibrinolytic therapy (c) Incidence and significance of PVCs is greatest after MI; couplet or paired PVCs; triplet or salvo PVCs is a short run of ventricular tachycardia (d) Ventricular bigeminy: PVC following each normal beat; ventricular trigeminy: PVC every third beat; unifocal vs. multifocal PVCs (e) Risk for a lethal dysrhythmia: Warning signs in patient with acute heart disease (2) Ventricular tachycardia (VT or V tach) (a) Rate: 100 to 250 bpm; rhythm: Regular; patient may experience a fluttering sensation in the chest or complain of palpitations and brief shortness of breath (b) Patients in sustained VT: Decreased cardiac output and hemodynamic instability, including severe hypotension, a weak or nonpalpable pulse, loss of consciousness; medical emergency requiring immediate intervention (c) Torsades de pointes and long QT syndrome .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(i) Genetic or acquired, occurring secondarily to electrolyte disruptions, MI, cocaine use, liquid protein diets, medications, or other conditions (3) Ventricular fibrillation (VF, V fib)(cardiac arrest) (a) Rate: Too rapid to measure; rhythm: Grossly irregular; medical emergency requiring immediate intervention with CPR (b) Causes: Severe myocardial ischemia or infarction; occurs without warning 50% of the time; termination of many disease processes or traumatic conditions; other causes: Digitalis toxicity, reperfusion therapy, antidysrhythmic drugs, hypokalemia and hyperkalemia, hypothermia, metabolic acidosis, mechanical stimulation, and electric shock; loss of ventricular contractions results in absence of a palpable or audible pulse; ECG shows grossly irregular, bizarre complexes j) Atrioventricular conduction blocks (1) Conduction defects that delay or block transmission of the sinus impulse through the AV node (2) First-degree AV block (a) Rate: Usually 60 to 100 bpm; rhythm regular; benign, generally poses no threat, has no symptoms, requires no treatment (3) Second-degree AV block, type I (Mobitz type I, Wenckebach phenomenon) (a) Rate: 60 to 100 bpm; rhythm: Atrial regular; ventricular irregular; often: Acute anterior wall MI and a high rate of mortality (4) Second-degree AV block, type II (Mobitz type II) (a) Rate: Atrial: 60 to 100 bpm; ventricular: < 60 bpm; rhythm: Atrial regular; ventricular irregular; often: Acute anterior wall MI and a high rate of mortality; manifestations depend on the ventricular rate (5) Third-degree AV block (complete heart block) (a) Rate: Atrial: 60 to 100 bpm; ventricular: 15 to 60 bpm; rhythm: Atrial regular; ventricular regular; atrial impulses completely blocked a AV node/fail to reach ventricles: Atria and ventricles controlled by different and independent pacemakers, with separate rates and rhythms; often associated with an inferior or anteroseptal myocardial infarction; other causes: Congenital conditions, acute or degenerative cardiac disease or damage, drug effects, and electrolyte imbalances (b) Manifestations: Stokes-Adams attack, dizziness, fatigue, exercise intolerance, and heart failure (life threatening); AV dissociation—complete dissociation of atrial/ventricular rhythms can occur (6) AV dissociation (a) Complete dissociation from atrial and ventricular rhythms (b) Caused by severe sinus bradycardia or slower pacemaker that exceeds NSR k) Intraventricular conduction blocks .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Bundle branch block (a) Prolonged QRS complex (b) No clinical manifestations associated 3. Interprofessional care a) Cardiac dysrhythmias may be either benign or critical: Recognizing lethal dysrhythmias is a matter of life and death b) Major goals of care: Identifying dysrhythmia, evaluating its effect on physical and psychosocial well-being, treating underlying causes c) Diagnosis (1) Electrocardiogram, cardiac monitoring, and continuous cardiac monitoring; Serum electrolytes, drug levels, and arterial blood gases to help id cause; continuous cardiac monitoring; telemetry (2) Home monitoring (a) Ambulatory or Holter monitoring: ID intermittent dysrhythmias, detect silent ischemia, monitor effects of treatment, assess pacemaker or automatic cardioverter-defibrillator function (b) Electrophysiology studies (i) Electrode catheters are guided by fluoroscopy into the heart through femoral or brachial vein (ii) Electrical stimulation may be used to induce dysrhythmias similar to patient’s clinical dysrhythmia (iii) May be used to treat dysrhythmia: Overdrive pacing to break the dysrhythmia’s cycle, or ablative therapy to destroy ectopic site d) Medications: Goal of drug therapy is to suppress dysrhythmia formation (1) Antidysrhythmic drugs are primarily used for acute treatment of dysrhythmias, although may also be used to manage chronic conditions; virtually all antidysrhythmic drugs also have prodysrhythmic effects (2) Class I: Fast sodium channel blockers—slows impulse conduction in atria and ventricles (3) Class II: Beta blockers—decrease SA node automaticity, AV conduction velocity, and myocardial contractility (4) Class III: Potassium channel blockers—delays repolarization and prolongs relative refractory period (5) Class IV: Calcium channel blockers—effect similar to beta blockers (6) Outside major classifications (7) Adenosine and digoxin reduce SA node automaticity and slow AV conduction e) Countershock (1) Synchronized cardioversion

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(a) Delivers direct electrical current synchronized with patient’s heart rhythm; an elective procedure to treat supraventricular tachycardia, atrial fibrillation, atrial flutter, or hemodynamically stable ventricular tachycardia (b) Patients in atrial fibrillation are at high risk for thromboembolism following cardioversion; increased risk of clot formation (2) Defibrillation (a) Emergency procedure delivers direct current without regard to cardiac cycle; early defibrillation shown to improve survival in patients experiencing VF f) Pacemaker therapy (1) Pulse generator provides electrical stimulus to the heart when the heart fails to generate or conduct its own at a rate that maintains cardiac output (2) Leads sense intrinsic electrical activity of heart and provide an electrical stimulus to heart when necessary (pacing) (3) Temporary vs. permanent pacemakers (4) Single-chamber vs. dual-chamber (atrioventricular sequential) pacing (5) Pacing is detected on the ECG strip by the presence of pacing artifact (6) Care of patient focuses on monitoring for pacemaker malfunctioning, maintaining safety, preventing infection and postoperative complications g) Implantable cardioverter/defibrillator (1) Detects life-threatening dysrhythmias and delivers an electric shock to convert the rhythm (2) Battery must be replaced every 5 years (3) Care and complications the same as the patient have a pacemaker inserted h) Cardiac mapping and catheter ablation: Used to locate and destroy an ectopic focus (1) Cardiac mapping used to ID site of earliest impulse formation in atria or ventricles (2) Catheter ablation destroys, removes, or isolates an ectopic focus; treats supraventricular tachycardias, atrial fibrillation/flutter; in some cases, paroxysmal ventricular tachycardia (3) Anticoagulant therapy may be started after catheter ablation to reduce risk of clot formation at ablation site i) Other therapies (1) Vagal maneuvers that stimulate the parasympathetic nervous system may be used to slow heart rate in supraventricular tachycardias (2) Carotid sinus massage: Performed only by a physician during continuous cardiac monitoring (3) Valsalva maneuver increases intrathoracic pressure/vagal tone, slowing pulse rate 4. Nursing care for the patient having a permanent pacemaker implant .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) Preoperative care (1) Assess knowledge, understanding of the procedure, clarifying, expand on existing knowledge; place ECG monitor electrodes away from potential incision sites; teach range-of-motion (ROM) exercises for the affected side b) Postoperative care (1) Provide postoperative monitoring, analgesia, care; obtain a chest x-ray as ordered; assist with gentle ROM exercises at least three times daily, beginning 24 hours after pacemaker implantation; monitor pacemaker function with cardiac monitoring or intermittent ECGs; report pacemaker problems to the physician; assess for dysrhythmias and treat as indicated; immediately report signs of potential complications; provide a pacemaker identification card including the manufacturer’s name, model number, mode of operation, rate parameters, expected battery life c) Home-care—provide teaching: (1) Use of pacemaker; signs of pacemaker malfunction to report; avoid tight-fitting clothing over the pacemaker site to reduce irritation and avoid skin breakdown; carry pacemaker identification card at all times, wear a MedicAlert bracelet or tag; do not hold or use certain electrical devices over the pacemaker site 5. Nursing care a) Assessment (1) Health history (2) Physical examination b) Priorities of care (1) Promote comfort and prevent recurrence of the cardiac event c) Diagnoses, outcomes, and interventions (1) Monitor cardiac output (a) Assess for decreased cardiac output (b) Monitor ECG (c) Assess for underlying causes of dysrhythmias (d) Assess serum electrolytes, digitalis, antidysrhythmic drug levels as indicated (e) Administer antidysrhythmic medications as indicated (f) Perform Valsalva maneuver as appropriate (g) Assist with cardioversion (h) Transfer to critical care in case of cardiac arrest (i) Notify family in case of changes in condition or cardiac arrest 6. Transitions of care .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) Significant physical and psychologic impact on patient/all family members b) Patient/family: Stress from frequent hospitalizations, experimentation with therapies, frustration, and the fear of sudden cardiac death c) Major teaching effort: Coping strategies, lifestyle changes, management of prescribed therapies; importance of follow-up visits with the cardiologist; options for CPR training for patient/family members; discuss fears/inform about implanted devices d) Assess and teach home care needs B. The Patient with Sudden Cardiac Death (SCD) 1. Definition: Unexpected death occurring within 1 hour of the onset of cardiovascular symptoms 2. Pathophysiology a) Usually is caused by ventricular fibrillation and cardiac arrest; ventricular fibrillation is the most common dysrhythmia associated with SCD, accounting for 65% to 80% of cardiac arrests; risk factors for SCD are those associated with CHD; evidence of CHD with significant atherosclerosis and narrowing of two or more major coronary arteries is found in 75% of SCD victims b) Causes (1) Cardiac causes: Coronary heart disease; reperfusion following ischemia; myocardial hypertrophy; cardiomyopathy; inflammatory myocardial disorders; valve disorders; primary electrical disorders; dissecting or ruptured aortic or ventricular aneurysm; cardiac drug toxicity (2) Noncardiac causes: Pulmonary embolism; cerebral hemorrhage; autonomic dysfunction; choking; electrical shock; electrolyte and acid–base imbalances (3) Structural causes: Abnormalities include infarction, hypertrophy, myopathy, electrical anomalies; caused by ischemia followed by reperfusion, altered homeostasis, autonomic nervous system and hormone interactions, toxic effects 3. Manifestations a) SCD may be preceded by typical manifestations of ACS or MI; severe chest pain, dyspnea or orthopnea, and palpitations or light-headedness b) Event itself: Abrupt, complete loss of consciousness; death within minutes; if VT precedes cardiac arrest, consciousness and mentation may be impaired prior to collapse and loss of consciousness 4. Interprofessional care a) Goal: Restore cardiac output and tissue perfusion b) Treatment initiates as soon as clinical cardiac arrest is verified by: Absence of respirations and carotid or femoral pulses; basic and advanced cardiac life support measures must be instituted within 2 to 4 minutes of cardiac arrest to prevent permanent neurologic damage and ischemic injury to other organs c) Basic life support (BLS) .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Automated external defibrillator (AED) used immediately; after shock, CPR immediately initiated; after about 2 minutes or five cycles of CPR, rhythm evaluated/circulation checked; sequence of analysis, shock, CPR is continued/ACLS protocols initiated (2) Cardiopulmonary resuscitation (CPR): Mechanical attempt to maintain tissue perfusion using external cardiac compressions d) Advanced life support (ALS)—specially trained healthcare personnel (1)Includes advanced airway support (insertion of a laryngeal mask airway [LMA], esophageal-tracheal Combitube, or endotracheal intubation); use of intravenous drugs following specific protocols; additional interventions: Repeated defibrillation procedures and cardiac pacing (2) Drugs used to restore effective cardiac rhythm: Epinephrine, vasopressin, sodium bicarbonate; antidysrhythmic drugs: Amiodarone, bretylium, lidocaine, procainamide, magnesium sulfate, and atropine e) Postresuscitation care (1) Patients with SCD associated with ventricular fibrillation/acute MI: Best prognosis (2) Patient transferred to a coronary care unit, MI treatment measures instituted (3) Significant risk of recurrent SCD: Extensive diagnostic testing (a) Interventions: Angioplasty or surgical revascularization of the myocardium, ablation, or an implantable cardioverter-defibrillator 5. Nursing care a) Requires prompt recognition of the event and immediate initiation of BLS and ALS protocols b) Important concepts: Recognize signs/symptoms early; continually assess the effectiveness of emergency interventions; defibrillate pulseless VT or VF as soon as possible; initiate ALS protocols early c) The family is not forgotten during resuscitation (1) If present: Usually offered private consultation room in which to await outcome (2) If not present: Notified/asked to come to hospital as soon as possible (3) The situation is presented in a careful manner d) Teaching needs (1) Risk factor reduction for CHD; planned diagnostic studies to identify cause of SCD, possible interventions; risks and benefits of an ICD if appropriate (2) Planned diagnostic studies (3) Risks and benefits of an ICD (4) Importance of carrying a card at all times listing current medications and healthcare provider information (5) Early manifestations or warning signs of cardiac arrest (6) Importance of CPR training and maintaining proficiency .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(i) Provide referral to local CPR training providers (7) Nurses can impact death rates from cardiac arrest through community teaching (i) Promote CPR training in the community

Chapter Highlights A. Atherosclerosis is the primary underlying process in coronary heart disease, impaired perfusion of myocardial tissue.

B. The risk factors for coronary heart disease are those for atherosclerosis: Age, gender, and genetic factors; hypertension, diabetes, abnormal blood lipids; cigarette smoking, obesity, physical inactivity, and diet; and emerging risk factors such as the metabolic syndrome and homocysteine levels.

C. Smoking cessation, exercise, diet modification, weight loss, medications to achieve desired blood lipid values, and effective hypertension and diabetes management are the primary treatment measures for coronary heart disease.

D. Atherosclerosis of coronary vessels impairs the supply of blood, oxygen, and nutrients to the myocardium. Myocardial ischemia results in the manifestations of coronary heart disease, angina pectoris, acute coronary syndrome, and myocardial infarction.

E. Stable angina develops with a predictable amount of activity or stress, and typically follows an activity–pain, rest–relief pattern. Stable angina often can be managed effectively by medications and risk factor modification. The nursing focus is on education.

F. Acute coronary syndrome or unstable angina is characterized by increasingly severe chest pain that occurs unpredictably. Acute coronary syndrome often requires aggressive interventions such as percutaneous coronary revascularization or coronary artery bypass surgery.

G. Myocardial infarction, necrosis of myocardial tissue, results from complete blockage of a coronary artery, usually due to atherosclerotic plaque rupture and thrombus formation.

Prompt restoration of blood flow through a revascularization procedure or administration of a fibrinolytic drug to dissolve the blood clot is necessary to preserve functional muscle tissue.

H. The nursing focus for patients with acute coronary syndrome and myocardial infarction is on reducing myocardial work through measures such as pain relief and activity limitation, promoting blood flow and oxygenation through medication and oxygen administration and positioning, and early recognition and treatment of complications.

I. Cardiac dysrhythmias may arise anywhere in conductive tissue of the myocardium.

Dysrhythmias may be either benign or fatal, depending on their effect on cardiac output.

J. Tachycardias increase the workload of the heart and may interfere with cardiac output if ventricular filling is impaired by the rapid rate.

K. Bradycardias can affect cardiac output when the rate is too slow to meet the metabolic needs of the body.

L. Atrial fibrillation is a common dysrhythmia that can lead to formation of blood clots within the heart and subsequent stroke if these clots lodge in cerebral blood vessels.

M. Frequent ventricular dysrhythmias may indicate an increased risk for ventricular fibrillation and cardiac arrest.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

N. AV conduction blocks interfere with conduction of the sinus or atrial impulse through the AV node and to the ventricles.

O. Although many antidysrhythmic medications are available, all increase the risk of dysrhythmia development, so they are used sparingly.

P. The nurse’s role in caring for patients with cardiac dysrhythmias focuses on prompt identification of the rhythm disruption, assessment of its effect on the patient, administration of medications and other treatment measures, and institution of life support procedures as indicated.

SUGGESTIONS FOR CLASSROOM ACTIVITY—LEARNING OUTCOME ONE Using anatomic models, review the structure and blood flow through the heart.

Have students develop a plan of care for the patients experiencing a cardiac event.

Have students develop case studies of patients who have undergone cardiac procedures. Have students present those case studies to other students who have not cared for similar patients.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME ONE Assign students to care for patients with a cardiac perfusion problem.

SUGGESTIONS FOR CLASSROOM ACTIVITY—LEARNING OUTCOME TWO Assign students to a cardiac monitor unit where they can observe monitor strip interpretation Have students develop a plan of care for the patients experiencing a cardiac dysrhythmia.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME TWO Have students provide care to a patient with a cardiac dysrhythmia.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter 31 Nursing Care of Patients with Cardiac Disorders

Learning Outcomes 1. Describe the pathophysiology and manifestations of heart failure, and outline the interprofessional care and nursing care of patients with these disorders.

2. Describe the pathophysiology and manifestations of inflammatory heart disorders, and outline the interprofessional care and nursing care of patients with these disorders.

3. Describe the pathophysiology and manifestations of disorders of cardiac structure, and outline the interprofessional care and nursing care of patients with these disorders.

Key Concepts I.

Heart Failure A. The Patient with heart failure 1. Congestive heart failure a) Compensatory mechanisms activated may cause vascular congestion.

2. Incidence, prevalence, and risk factors a) Incidence, prevalence increase with age b) African Americans at higher risk because of higher rates of hypertension c) Prognosis depends on underlying cause and precipitating factors d) Most die within 8 years of diagnosis 3. Physiology review a) Cardiac output depends on adequate functional muscle mass and ability of ventricles to work together. b) Cardiac reserve is the ability of the heart to increase CO to meet metabolic demands. c) Heart rate influenced by autonomic nervous system, catecholemines, and thyroid hormones.

(1) Increased heart rate generally increases cardiac output, but rapid heart rate can reduce cardiac output. d) Stroke volume, preload and afterload, influenced by compliance of ventricles (1) Hypertension increases afterload. e) Contractility is the natural ability of cardiac muscle fibers to shorten during systole. f) Ejection fraction (EF): Percentage of blood in the ventricle that is ejected during systole; normal EF is approximately 60%.

4. Pathophysiology a) Compensatory mechanisms triggered by failure

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Frank–Starling mechanism (2) Activation of sympathetic nervous system and the RAAS (3) Ventricular hypertrophy (4) Norepinephrine released (a) Increases heart rate and contractility (b) Causes arterial and venous vasoconstriction (5) Renin released from kidneys, triggers renin–angiotensin–aldosterone system (a) Additional vasoconstriction (b) Aldosterone promotes water retention (c) Antidiuretic hormone (ADH) inhibits water excretion and causes vasodilation.

(6) Increase in vascular volume (7) Atrial natriuretic factor (ANF) released from increased atrial pressures (a) Balances effects of other hormones to some extent, promotes sodium and water excretion (8) Ventricular remodeling: Heart chambers and myocardium adapt to increased fluid and pressure.

(9) Ventricular hypertrophy: Existing cardiac muscle cells enlarge.

5. Classifications and manifestations of heart failure a) Systolic versus diastolic failure (1) Many patients have components of both systolic and diastolic failure (2) Systolic failure (a) Ventricle fails to contract adequately to eject sufficient blood (b) Manifestations of decreased cardiac output: Weakness, fatigue, and decreased exercise tolerance (3) Diastolic failure (a) Diastole filling disrupted by heart not fully relaxing (b) Manifestations of increased pressure and congestion behind the ventricle: Shortness of breath, tachypnea, respiratory crackles if left ventricle is affected; distended neck veins, liver enlargement, anorexia, and nausea if right ventricle is affected b) Left-sided versus right-sided failure (1) One side is primarily affected; however, components of failure in both sides may be present in chronic failure (2) Left-sided failure (a) Commonly caused by coronary heart disease, hypertension (b) Manifestations from pulmonary congestion and decreased cardiac output: Fatigue and activity intolerance, dizziness and syncope, dyspnea, shortness of breath, cough, orthopnea, cyanosis, inspiratory crackles may be heard, and S3 gallop (3) Right-sided failure

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(a) Caused by conditions that restrict blood flow to lungs (e.g., chronic pulmonary disease) (b) Increased venous pressures cause abdominal organs to become congested and prompt peripheral tissue edema. (c) Edema in feet and legs, anorexia, nausea, right upper quadrant pain from liver engorgement, and distended neck veins c) Low-output vs. high-output failure (1) Low output: From coronary heart disease, hypertension, cardiomyopathy, and primary cardiac disorders (2) High output: From hypermetabolic states from hyperthyroidism, infection, anemia, and pregnancy d) Acute vs. chronic failure (1) Acute: Abrupt onset of myocardial injury (2) Chronic: Progressive deterioration e) Other manifestations (1) Manifestations of increased sodium and water retention: Weight gain, edema, nocturia, paroxysmal nocturnal dyspnea (PND), and dyspnea even at rest 6. Complications a) Congestive hepatomegaly and splenomegaly results in increased abdominal pressure, ascites, and gastrointestinal problems b) Liver function impairment from right-sided failure c) Pleural effusions and pulmonary problems d) Major complications: Cardiogenic shock and acute pulmonary edema 7. Interprofessional care a) Diagnosis (1) B-type natriuretic peptide (BNP) (2) Serum electrolytes (3) Urinalysis, blood urea nitrogen (BUN), and serum creatinine (4) Liver function tests: ALT, AST, LDH, serum bilirubin, and total protein and albumin (5) Thyroid function tests: TSH and TH (6) Arterial blood gases (7) Chest x-ray (8) Electrocardiography (9) Echocardiography with Doppler flow studies (10) Radionuclide imaging b) Hemodynamic monitoring (1) Parameters: Heart rate, arterial blood pressure, central venous of right-atrial pressure, pulmonary pressures, and cardiac output .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(2) Invasive procedure used in critically ill patients (3) Converts signal into electrical waveform (4) Complications: Bleeding, hematoma, pneumothorax, hemothorax, arterial puncture, dysrhythmias, venospasm, infection, air embolism, thromboembolism, brachial nerve injury, and thoracic duct injury (5) Intra-atrial pressure monitoring (a) Indwelling arterial line with direct and continuous monitoring of blood pressures in ventricles and vessel, access for arterial blood sampling (b) Systolic blood pressure: Pressure generated during ventricular systole (c) Diastolic blood pressure: Pressure in ventricles during diastole (d) Mean arterial pressure (MAP): Average pressure throughout cycle (6) Venous pressure monitoring (a) Central venous pressure (CVP) and right atrial pressure (RAP) measure blood volume, venous return, and right heart filling pressures. (b) Monitor fluid volume status (c) Catheter insert in internal jugular or subclavian vein (d) Water manometer: Fluid level reflects CVP (7) Pulmonary artery pressure monitoring (a) Evaluates left ventricle and overall cardiac function (b) Inserted into central vein, measures pulmonary artery wedge pressure (PAWP) (c) Can also measure cardiac output c) Medications (1) Angiotensin-converting enzyme (ACE) inhibitors (a) Interrupt conversion of angiotensin I to angiotensin II (b) Block RAAS activity, decrease cardiac workload, and increase cardiac output (c) Reduce progression and manifestations (d) Used with caution in African Americans because of increased risk for developing angioedema (2) Angiotensin II receptor blockers (ARBs) (a) Block action of angiotensin II (b) Pharmacologic effect similar to ACE inhibitors (3) Beta blockers (a) Inhibit SNS activity (4) Diuretics (a) Relieve symptoms related to fluid retention (b) Risks of electrolyte imbalance (c) Loop diuretics for severe cases (d) Thiazide diuretics for less severe cases (5) Inotropic medications (6) Direct vasodilators .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(a) Relax smooth muscle in blood vessels (b) Nitrates produce arterial and venous vasodilation (7) Digitalis glycosides (a) Positive inotropic effect on the heart and increases strength of myocardial contraction (b) Narrow therapeutic index; risk may outweigh benefits (8) Antidysrhythmic drugs (a) May depress left-ventricular function (b) Premature ventricular contractions (PVCs) often left untreated d) Nutrition and activity (1) Sodium-restricted diet recommended (2) Bed rest during acute episodes of heart failure (3) Prolonged bed rest is not recommended (4) Moderate, progressive activity program prescribed e) Other treatments (1) Circulatory assistance (a) Intra-aortic balloon pump and left-ventricular assist device used when patient is expected to recover or before transplant (b) Newer devices under development (2) Cardiac transplantation (a) Treatment of choice for end-stage heart disease (b) Survival rates are good. (c) Most frequent method leaves posterior walls of the atria, the superior and inferior vena cava, and the pulmonary veins intact. (d) Nursing care: Similar to other cardiac surgery (i) Bleeding: Major concern (ii) Monitor: Chest tube drainage, cardiac output, pulmonary artery pressures, and CVP (iii) Aggressive care against infection (3) Other procedures (a) Cardiomyoplasty: Wrapping of latissimus dorsi muscle around heart for more forceful contraction (b) Ventricular reduction surgery: Portion of anteriolateral left-ventricular wall is removed f) Integrative therapies (1) Hawthorn: Increases force of contraction, dilates blood vessels, and has natural ACE inhibitor (2) Coenzyme Q10, magnesium, and thiamine may be used with other treatments.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

8. Nursing care a) Assessment (1) Health history (a) Complaints of manifestations, history of cardiac disease or cardiac failure, risk factors, current medications, usual diet and activity and recent changes (2) Physical assessment (a) General and cardiac physical assessment; assessment of activity tolerance and breathing, noting edema, and other manifestations b) Priorities of care (1) Ensure adequate treatment of the underlying process (2) Provide care that supports the physical and psychologic responses to the disorder c) Diagnoses, outcomes, and interventions (1) Monitor cardiac output (a) Monitor vital signs and oxygen saturation (b) Auscultate heart and breath sounds (c) Administer supplemental oxygen and prescribed medications (d) Encourage rest, elevate head, provide bedside commode, and assist with ADLs (2) Monitor fluid volume (a) Monitor intake and output, weigh daily (b) Record abdominal girth frequently and note complaints of GI discomfort (c) Monitor and record hemodynamic measurements (d) Restrict fluids as ordered (3) Balance activity and rest (a) Allow for rest periods (b) Assist with ADLs (c) Plan and implement progressive activities, ROM exercises (d) Provide written and verbal information after discharge (4) Promote a low-sodium diet (a) Explain sodium restriction (b) Consult with dietician to teach, if necessary, and provide American Heart Association materials (c) Teach how to check sodium levels in food labels (d) Assist the patient in creating 2-day meal plan (e) Encourage small, frequent meals 9. Transitions of care a) Teach patient and family: (1) Disease process .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(2) Warning signs of cardiac decompensation (3) Desired and adverse effects of prescribed drugs (4) Prescribed diet and sodium restriction (5) Exercise recommendations (6) Importance of keeping follow-up appointments b) Provide referrals for home healthcare and household assistance as indicated B. The patient with pulmonary edema 1. Abnormal accumulation of fluid in interstitial tissue and alveoli of lung a) Due to cardiac and noncardiac causes b) Medical emergency: Patient is drowning in fluid in lungs.

2. Pathophysiology a) Contractility of left ventricle severely impaired b) Fluid leaks from pulmonary capillaries, congests interstitial tissues, decreases lung compliance, and interferes with gas exchange. c) Fluid, red blood cells, and protein molecules enter alveoli.

3. Manifestations a) Respiratory: Tachypnea, labored respirations, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, cough, productive of pink frothy sputum, and crackles and wheezes b) Cardiovascular: Tachycardia, hypotension, cyanosis, cool, clammy skin, hypoxemia, and ventricular gallop c) Neurologic: Restlessness, anxiety, and feeling of impending doom 4. Interprofessional care a) Goals: Restoring effective gas exchange and reducing fluid and pressure in pulmonary vascular system b) Diagnosis: Based on assessment and limited tests because of acuteness (1) Arterial blood gases (a) Oxygen tension (PaO2): Low (b) Carbon dioxide levels (PaCO2): Low at first, may rise later (c) Oxygen saturation levels (2) Chest x-ray (3) Hemodynamic monitoring: PAWP often elevated c) Medications (1) Morphine: For anxiety and improved breathing and cardiac function (2) Oxygen: Administered with CPAP, intubation, or mechanical ventilation (3) Loop diuretics: Administered with IV for rapid diuresis (4) Vasodilators: Reduce afterload to heart (5) Dopamine or dobutamine to improve myocardial contractility

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

5. Nursing care a) Assessment: (1) Similar to the patient with acute pulmonary edema b) Priorities of care (1) Ensure adequate treatment of the underlying process (2) Provide care that supports the physical and psychologic responses to the disorder c) Diagnoses, outcomes, and interventions (1) Improve gas exchange (a) Ensure airway patency (b) Assess effectiveness of respiratory efforts and airway clearance (c) Assess respiratory status frequently (d) Place in high-Fowler position with legs dangling (e) Administer oxygen as ordered (f) Encourage patient to cough up secretion and provide nasotracheal suctioning if necessary (2) Monitor cardiac output (a) Monitor vital signs, hemodynamic status, and cardiac rhythm (b) Assess heart sounds for possible S3, S4, or murmurs (c) Initiate IV line for medication administration, administer medications (d) Insert indwelling catheter as ordered (e) Keep accurate intake and output records (3) Manage fear (a) Provide emotional support for family and patient; explain all procedures and maintain close contact (b) Answer questions and provide accurate information 6. Transitions of care a) During acute period, teaching is limited because of emergency situation. b) Once acute episode is resolved, teach about underlying cause and prevention.

II.

Inflammatory Heart Disorders A. The patient with rheumatic fever and rheumatic heart disease 1. Rheumatic fever: Systemic inflammatory disease from abnormal immune response to pharyngeal infection by group A beta-hemolytic streptococci a) Usually self-limiting, may be recurrent or chronic 2. 10% of rheumatic fever cases develop rheumatic heart disease 3. Incidence, prevalence, and risk factors a) Rare in industrialized nations (1) Scattered outbreaks in recent years b) Peak incidence between ages 5 and 15 c) Significant problems in developing countries

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

d) Risk factors: Crowded living conditions, malnutrition, immunodeficiency, poor access to healthcare, and potentially unknown genetic factor 4. Pathophysiology a) Receptors in group A beta-hemolytic streptococcal bacteria cause autoimmune response by binding to cells in heart, muscles, brain, and synovial joints b) Inflammatory response in tissues containing proteins from bacteria (1) Inflammatory lesions develop c) Antibodies remain in serum up to 6 months d) Cardiac factors (1) Carditis: Inflammation of the heart, develops in 50% of cases (2) Aschoff bodies: Localized area of tissue necrosis surrounded by immune cells, develop in cardiac tissues (3) Pericardial and myocardial inflammation is mild and self-limiting (4) Endocardial inflammation harms valves with fibrous scarring e) Rheumatic heart disease (RHD): Slowly progressive valvular deformity (1) Stenosis: Narrowed fused valve obstructs blood flow (2) Regurgitation: Valve fails to close properly, blow flows back through it 5. Manifestations a) Follow streptococcal infection by 2 to 3 weeks b) Initially: Fever and joint pain c) Cardiac: Chest pain, friction rub, heart murmur d) Musculoskeletal: migratory polyarthritis e) Skin: Erythema marginatum, subcutaneous nodules f) Neurologic: Sydenham chorea 6. Interprofessional care a) Diagnosis (1) Complete blood count (CBC) and erythrocyte sedimentation rate (ESR): Indicate inflammatory process (2) C-reactive protein (CPR): Positive (3) Antistreptolysin O (ASO) titer: For streptococcal antibodies (4) Throat culture b) Medications (1) Antibiotics to eliminate infection (a) Penicillin first choice (b) Erythromycin or clindamycin if patient is allergic (2) Salicylates, ibuprofen, or other NSAIDs, corticosteroids for pain 7. Nursing care a) Assessment .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Health history (a) Manifestations of streptococcal throat infection (2) Physical examination (a) Vital signs, skin color, presence of rash, mental status, inflamed joints, heart and lung sounds b) Priorities of care (1) Ensure adequate treatment of the underlying process (2) Provide care that supports the physical and psychologic responses to the disorder c) Diagnoses, outcomes, and interventions (1) Control acute pain (a) Administer anti-inflammatory drugs (b) Provide warm, moist compress on inflamed joints (c) Auscultate heart sounds (2) Promote activity tolerance (a) Explain importance of activity limitations (b) Encourage social and diversional activities (c) Encourage gradual increases in activity as appropriate 8. Transitions of care a) Importance of completing antibiotic course b) Preventative dental care and good oral hygiene to prevent recurrence via gingival infections c) Early recognition of streptococcal sore throat d) Manifestations of heart failure e) Prescribed medications f) Sodium restriction if recommended B. The patient with infective endocarditis 1. Incidence and risk factors a) Risk factor: Previous heart damage, intravenous drug use, invasive catheters, dental procedures or poor dental health, and recent heart surgery b) Prosthetic valve endocarditis (PVE) in patients with mechanical or tissue valve replacement (1) Usually affects males over 60, most often with aortic valve prosthesis 2. Pathophysiology a) Pathogens enter into bloodstream through oral lesions, during dental work or invasive procedures, IV drug use, or from infectious process b) Initial lesion: Sterile platelet-fibrin vegetation on endothelium (1) Acute ineffective endocarditis: Lesions on healthy valve structures (2) Subacute endocarditis: On already damaged valves or endocardial tissue .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

c) Organisms colonize lesions. d) May break off and travel to other organ systems e) Scar and deform valves, adversely affect function f) Classifications (1) Acute ineffective endocarditis (a) Abrupt onset, rapidly progressive (2) Subacute ineffective endocarditis (a) More gradual onset (b) Predominant systemic manifestations 3. Manifestations a) Chills and fever, general malaise, fatigue, arthralgias, cough, dyspnea, heart murmur, anorexia, abdominal pain, petechiae, splinter hemorrhages, and splenomegaly b) Peripheral manifestations: Petechiae, splinter hemorrhage, Osler nodes, Janeway lesions, and Roth spots 4. Complications a) Embolization of vegetative fragments can affect any organ system. b) Heart failure, abscesses, and aneurysms are common. c) Universally fatal without treatment 5. Interprofessional care a) Diagnosis (1) No definitive test (2) Blood cultures: Positive for pathogens (3) Echocardiography: To visualize vegetations (4) Serologic immune testing for antigens b) Medications (1) Antibiotics given prophylactically to those at high risk (2) Antibiotics usually effective treatment (a) Extended IV dose (b) Initial regimen: Nafcillin or oxacillin; penicillin or ampicillin; or gentamicin (c) Therapy tailored when organism is identified (3) Prosthetic valve endocarditis requires extended treatment. c) Surgery (1) Replace severely damaged valves (2) Remove large vegetations at risk for embolization (3) Remove valve that is a continuing source of infection and does not respond to antibiotics 6. Nursing care a) Assessment .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Health history: Manifestations (2) Physical examination b) Priorities of care (1) Ensure adequate treatment of the underlying process (2) Provide care that supports the physical and psychologic responses to the disorder c) Diagnoses, outcomes, and interventions (1) Monitor body temperature (a) Record temperature every 2–4 hours (b) Obtain blood cultures as ordered (c) Provide anti-inflammatory and/or antipyretic agents (d) Administer antibiotics (2) Promote adequate tissue perfusion (a) Assess for manifestations of decreased organ system perfusion (neurologic, renal, pulmonary, cardiovascular) (b) Assess skin color and temperature, quality of peripheral pulses, and capillary refill (3) Promote effective health maintenance (a) Demonstrate IV catheter site care and administration of antibiotics (b) Explain desired and adverse effects of medications, provide information about risk of superinfection (c) Teach about heart valve function and manifestations of heart failure (d) Encourage good dental hygiene, avoidance of people with upper respiratory conditions 7. Transitions of care a) Teach home care b) Discuss severity of condition and effectiveness of treatment; importance of reporting unusual manifestations; rationale for all treatments and procedures; and preventing recurrences C. The patient with myocarditis 1. Inflammation of heart muscle 2. Usually from infectious process, also from immunologic response, radiation, toxins, or drugs a) Most common viral cause in the United States: Coxsackievirus B 3. Incidence and risk factors a) Any age, more common in men than in women b) Immunocompromised patients c) HIV, rheumatic fever, and pericarditis .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

4. Pathophysiology a) Infectious agents infiltrate myocardial interstitial tissues, form abscesses b) Autoimmune injury may occur from destroying myocardial cells c) Usually self-limited, may become chronic and lead to dilated cardiomyopathy d) Can lead to heart failure 5. Manifestations a) May be asymptomatic b) Nonspecific manifestations of inflammation c) Nonspecific febrile illness or upper respiratory infection may precede specific manifestations. d) Abnormal heart sounds such as muffled S1 and S3, murmurs, and pericardial friction rub may be heard.

6. Interprofessional care a) Diagnosis (1) Electrocardiography (2) Cardiac markers (3) Endomyocardial biopsy b) Medications (1) Antimicrobial therapy when appropriate (2) Immunosuppressive therapy with corticosteroids to minimize inflammatory response (3) Heart failure treated as needed (4) Antidysrhythmic agents and anticoagulants as needed 7. Nursing care a) Directed at decreasing myocardial work and maintaining cardiac output b) Diagnoses (1) Poor activity and exercise tolerance (2) Reduced cardiac function (3) Fatigue (4) Anxiety (5) Fluid overload c) Interventions (1) Assess activity tolerance, urine output, heart and breath sounds 8. Transitions of care a) Teach about (1) Activity restriction, dietary modifications (2) Treatment and medications, importance of adhering .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(3) Manifestations to report D. The patient with pericarditis 1. Inflammation of pericardium 2. May be primary disorder or from another cardiac or systemic disorder 3. Causes: a) Infectious: Viruses, bacteria, tuberculosis, syphilis, and parasites b) Noninfectious: Myocardial and pericardial injury; rheumatic fever, uremia, neoplasms, radiation, trauma or surgery, myxedema, autoimmune disorders, connective tissue diseases, prescription and nonprescription drugs, and postcardiac injury 4. Pathophysiology a) Pericardial tissue damage triggers inflammatory response. b) Capillary permeability increases, plasma proteins and white blood cells fill pericardial space. c) Exudate is formed. d) Inflammatory process may resolve without long-term effects. e) Scar tissue formation causes exudate collection in pericardial sac. f) Chronic inflammation causes pericardium to become rigid.

5. Manifestations a) Abrupt and sharp chest pain, a pericardial friction rub, and fever 6. Complications a) Pericardial effusion (1) Abnormal collection of fluid between pericardial layers that threatens cardiac function b) Cardiac tamponade: Compression of heart (1) Medical emergency from pericardial effusion, trauma, cardiac rupture, or hemorrhage (2) Manifestations: From rising intracardiac pressures, decreased diastolic filling, decreased cardiac output (a) Hallmark manifestation: Paradoxical pulse, or pulsus paradoxus c) Chronic constrictive pericarditis (1) Scar tissue formation contracts and restricts diastolic filling (2) Manifestations: Progressive dyspnea, fatigue, weakness, ascites, peripheral edema may develop, distended neck veins.

7. Interprofessional care a) Diagnosis: Tests to differentiate from myocardial infarction (1) CBC .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(2) Cardiac enzymes (3) Electrocardiography (4) Echocardiography (5) Hemodynamic monitoring (6) Chest x-ray (7) Computed tomography b) Medications (1) Address manifestations (2) Aspirin and acetaminophen to reduce fever (3) NSAIDs to reduce inflammation and pain (4) Corticosteroids for severe inflammation c) Pericardiocentesis (1) Excess fluid withdrawn with large gauge needle (2) Diagnostic or therapeutic purposes; emergency procedure for cardiac tamponade d) Surgery (1) For recurrent cases (a) Piece of pericardium removed for fluid to drain into pleural space (2) For constrictive cases (a) Partial or total pericardiectomy 8. Nursing care a) Assessment (1) Health history (2) Physical examination b) Priorities of care: (1) Ensure adequate treatment of the underlying process (2) Provide care that supports the physical and psychologic responses to the disorder c) Diagnoses, outcomes, and interventions (1) Manage acute pain (a) Assess chest pain (b) Auscultate heart sounds every 4 hours (c) Administer NSAIDs, document effectiveness (d) Maintain a quiet, calm environment, and position of comfort (2) Promote effective breathing pattern (a) Document respiratory status (b) Encourage deep breathing and use of incentive spirometer (c) Administer oxygen (d) Place in Fowler or High Fowler position .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(3) Reduce risk for decreased cardiac output (a) Document vital signs hourly during acute inflammatory process (b) Report changes in hemodynamic status, signs of decreased cardiac output (c) Maintain at least one patent IV access site (d) Prepare for pericardiocentesis and/or surgery as necessary (4) Promote activity tolerance (a) Document vital signs, cardiac rhythm, skin color, and temperature before and after activity (b) Collaboratively develop realistic progressive activity plan. (c) Allow for rest and sleep 9. Transitions of care a) Teach about importance of adhering to prescribed medications, monitoring weight, maintaining fluid intake, restricted activity, manifestations of recurrent pericarditis III.

Disorders of Cardiac Structure A. The Patient with valvular heart disease 1. Interferes with blood flow to and from the heart 2. Result from acute or chronic conditions 3. Physiology review a) Atrioventricular (AV) valves: Mitral on left, tricuspid on right, separate atria from ventricles (1) Fully open during diastole, closed during systole b) Semilunar valves: Aortic and pulmonic, separate ventricle from great vessels (1) Open during systole and close during diastole 4. Pathophysiology a) Stenosis: Valve leaflets fuse together, cannot fully open or close (1) Scarring from endocarditis or infarction, or calcium deposits (2) Decrease cardiac output, some backflow occurs b) Regurgitation (1) Valves do not completely close, causes backflow of blood (2) From bacterial endocarditis, scarring or tearing from myocardial infarction, cardiac dilation c) Hemodynamic changes: Blood volume and pressures reduced in front of affected valve, increase behind affected valve d) May lead to pulmonary complications or heart failure e) Remodeling and hypertrophy of heart muscle occur f) Cardiac output falls, and heart begins to fail g) Ischemia and chest pain from workload of heart exceeding blood supply h) Necrosis occurs, functional muscle is lost.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

i) j) k) l)

Pulmonary edema, pulmonary failure and right-ventricular failure occur.

Increased risk for ineffective endocarditis Murmurs occurs Mitral stenosis (1) Mitral valve narrows, reduces end-diastolic pressure and volume, and decreases stroke volume (2) Leads to left-atrial hypertrophy and eventual heart failure (3) Causes: Rheumatic heart disease, bacterial endocarditis, congenital defects (4) Manifestations (a) Asymptomatic or causes severe impairment (b) Dyspnea on exertion, cough, hemoptysis, frequent pulmonary infections, paroxysmal nocturnal dyspnea, orthopnea, weakness, fatigue, and palpitation (c) More severe: Manifestations of right heart failure, cyanosis of the face, and extremities (d) On auscultation, a loud S1, a split S2, and a mitral opening snap may be heard (5) Complications (a) Atrial dysrhythmias, particularly atrial fibrillation, are common. (b) Thrombi may form and embolize to the brain, coronary arteries, kidneys, spleen, and extremities. (c) Women may be asymptomatic until pregnancy. m) Mitral regurgitation (1) Rheumatic heart disease common cause (2) Other causes: Processes that dilate the mitral annulus or affect the supporting structures, papillary muscles, or the chordae tendineae (3) Manifestations (a) Asymptomatic or symptoms of fatigue, weakness, exertional dyspnea, and orthopnea (b) Severe cases: Manifestations of left-sided heart failure (c) Murmur usually loud, high pitched, rumbling, and holosystolic n) Mitral valve prolapse (1) Cause often unclear, can result from rheumatic damage, ischemic heart disease, or other cardiac disorders (2) Most common in women ages 14–30, people with connective tissue disorders (3) Manifestations and complications (a) Usually asymptomatic (b) Midsystolic ejection click or murmur, or a high-pitched late systolic murmur, may be audible. (c) Atypical chest pain (d) Tachydysrhythmias may cause palpitations, lightheadedness, and syncope. (e) Complications: Bacterial endocarditis, heart failure, transient ischemic attacks .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

o) Aortic stenosis (1) Idiopathic, or due to a congenital defect, rheumatic damage, or degenerative changes (2) Increases myocardial oxygen consumption, can precipitate myocardial ischemia (3) Coronary blood flow may decrease.

(4) Left-atrial pressure increases.

(5) Pulmonary vascular congestion and pulmonary edema may result.

(6) Course and manifestations (a) May be asymptomatic for many years (b) Manifestations of left-ventricular failure (c) Dyspnea on exertion, angina pectoris, and exertional syncope (d) Harsh systolic murmur p) Aortic regurgitation (1) Causes: Rheumatic heart disease, congenital disorders, infective endocarditis, blunt chest trauma, aortic aneurysm, syphilis, Marfan syndrome, and chronic hypertension (2) Workload of the right ventricle increases; right-sided heart failure may develop.

(3) Manifestations (a) May be asymptomatic for many years (b) Persistent palpitations, throbbing pulse in arteries of the neck; characteristic head bob (Musset sign), dizziness, and exercise intolerance (c) Fatigue, exertional dyspnea, orthopnea, and paroxysmal nocturnal dyspnea, anginal pain (d) Murmur: “Blowing,” high-pitched sound during diastole q) Tricuspid valve disorders (1) Tricuspid stenosis (a) Usually from rheumatic heart disease; mitral stenosis often occurs concurrently (b) Stroke volume, cardiac output, and tissue perfusion fall (c) Manifestations related to systemic congestion and right-sided failure (i) Increased central venous pressure, jugular venous distention, ascites, hepatomegaly, peripheral edema, fatigue and weakness (ii) Low-pitched, rumbling diastolic murmur (2) Tricuspid regurgitation (a) Usually occurs secondarily to right-ventricular dilation (b) Causes: Right-ventricular overload, pulmonary hypertension, rheumatic heart disease, infective endocarditis, inferior MI, trauma, or other conditions (c) Manifestations of right-sided heart failure, and atrial fibrillation (d) High-pitched, blowing systolic murmur r) Pulmonic valve disorders (1) Pulmonic stenosis

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(a) Usually is a congenital disorder; also caused by rheumatic heart disease or cancer (b) Typically asymptomatic unless severe (c) Dyspnea on exertion and fatigue are early signs. (d) Manifestations of right-sided heart failure, with peripheral edema, ascites, hepatomegaly, and increased venous pressures (e) Harsh, systolic crescendo–decrescendo murmur (2) Pulmonic regurgitation (a) Causes: Pulmonary hypertension, infective endocarditis, pulmonary artery aneurysm, syphilis (b) Right-sided heart failure develops (c) Murmur: High-pitched, decrescendo, and blowing sound 5. Interprofessional care a) Diagnosis (1) Echocardiography (2) Chest x-ray (3) Electrocardiography (4) Cardiac catheterization (5) Exercise testing b) Medications (1) Treat manifestations and complications (2) Heart failure treated with diuretics, ACE inhibitors, vasodilators, and digitalis glycosides (3) Atrial fibrillation treated with digitalis or beta blockers, anticoagulants (4) Antibiotics prescribed prophylactically c) Percutaneous balloon valvotomy (1) Balloon catheter inserted into heart with balloon straddling the stenotic valve, inflated to divide fused leaflets and enlarge valve orifice d) Surgery (1) Repair generally safer than replacement (2) Reconstructive surgery (valvuloplasty) (a) Open commissurotomy: Division of fused valve leaflets (b) Annuloplasty: Repairs a narrowed or an enlarged or dilated valve annulus (3) Valve replacement (a) Many different prosthetic valves available: Mechanical and biologic tissue valves (b) Selection depends on the valve hemodynamics, resistance to clot formation, ease of insertion, anatomic suitability, patient acceptance, age, underlying condition, and contraindications to anticoagulation (c) Biological: Allow more normal blood flow and have a low risk of thrombus formation, but are less durable and often need to be replaced. .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(d) Mechanical: Durable, but require lifelong anticoagulation therapy 6. Nursing care a) Assessment (1) Health history (2) Physical examination b) Priorities of care (1) Ensure adequate treatment of the underlying process (2) Provide care that supports the physical and psychologic responses to the disorder c) Diagnoses, outcomes, and interventions (1) Monitor cardiac output (a) Monitor vital signs and hemodynamic parameters (b) Monitor intake and output, oxygen saturation, and arterial blood gases (c) Restrict fluids as ordered (d) Elevate the head of the bed, administer oxygen and medications (e) Provide for rest (2) Promote activity tolerance (a) Monitor vital signs (b) Encourage self-care (c) Gradually increase activities and assist when needed (d) Discuss energy conservations (3) Reduce risk for infection (a) Use aseptic technique for invasive procedures (b) Record temperature every 4 hours (c) Assess wounds and catheter sites (d) Administer antibiotics (e) Monitor WBC and differential (4) Prevent bleeding (a) Test stools and vomitus for occult blood (b) Instruct to avoid aspirin and NSAIDs (c) Advise safe measures for fragile skin 7. Transitions of care a) Usually chronic condition, patient manages care b) Teach: Symptom management, importance of rest, diet restrictions, prescribed medications, importance of following up with healthcare providers, and manifestations to report c) Provide referrals to community resources

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

B. The patient with cardiomyopathy 1. Diverse group of disorders that directly affect the heart muscle 2. May be primary and idiopathic or result of other processes 3. Pathophysiology and manifestations a) Dilated cardiomyopathy (1) Causes (a) Usually idiopathic, may be secondary to chronic alcoholism or myocarditis (2) Pathophysiology (a) Scarring and atrophy of myocardial cells (b) Thickening of ventricular wall (c) Dilation of heart chambers (d) Impaired ventricular pumping (e) Increased end-diastolic and end-systolic volumes (f) Mural thrombi common (3) Manifestations and course (a) Heart failure, cardiomegaly, and dysrhythmias (b) S3 and S4 gallop; murmur of mitral regurgitation b) Hypertrophic cardiomyopathy (1) Causes (a) Hereditary; may be secondary to chronic hypertension (2) Pathophysiology (a) Hypertrophy of ventricular muscle mass (b) Small left-ventricular volume (c) Septal hypertrophy may obstruct left-ventricular outflow (d) Left-atrial dilation (3) Manifestations and course (a) Dyspnea, anginal pain, and syncope (b) Left-ventricular hypertrophy and dysrhythmias (c) Loud S4 (d) Sudden death c) Restrictive cardiomyopathy (1) Causes (a) Usually secondary to amyloidosis, radiation, or myocardial fibrosis (2) Pathophysiology (a) Excess rigidity of ventricular walls restricts filling (b) Myocardial contractility remains relatively normal (3) Manifestations and course (a) Dyspnea and fatigue (b) Right-sided heart failure (c) Mild to moderate cardiomegaly (d) S3 and S4, mitral regurgitation murmur

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

4. Interprofessional care a) Treatment of underlying cause, to manage heart failure, or dysrhythmias b) Diagnosis (1) Electrocardiography (2) Ambulatory ECG monitoring (3) Chest x-ray (4) Hemodynamic studies (5) Radionuclear scans (6) Cardiac catheterization and coronary angiography (7) Myocardial biopsy c) Medications (1) Drugs for heart failure: ACE inhibitors, vasodilators, digitalis, beta blockers, and anticoagulants (2) For anginal symptoms and syncopal episodes: Beta blockers (3) Vasodilators, digitalis, nitrates, and diuretics are contraindicated. d) Surgery (1) Cardiac transplant for dilated cases (a) Not viable for restrictive cases (2) Ventricular assist devices before surgery (3) Symptomatic hypertrophic cases: Excess muscle may be removed from aortic valve outflow tract (4) Implantable cardioverter defibrillator (ICD) inserted to treat lethal dysrhythmias (5) Dual chamber pacemakers for hypertrophic cases 5. Nursing care a) Assessment similar to that for heart failure b) Teaching about disease process is vital (1) Activity restriction, energy conservation, and coping skills c) Similar interventions to heart failure d) Nursing diagnoses (1) Monitor cardiac function (2) Reduce fatigue (3) Promote effective breathing (4) Manage fear (5) Manage ADLs (6) Support grieving 6. Transitions of care a) Chronic disorders, managed in home and community b) Teach: (1) Activity restriction, dietary changes (2) Intended and adverse effects of drugs .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(3) Disease process (4) Manifestations to report (5) Cardiopulmonary resuscitation procedures c) Refer patient to community resources

Chapter Highlights A. Heart failure is the most common cardiac disorder, a condition in which the heart is unable to pump effectively to meet the body’s need to provide blood and oxygen to the tissues.

B. Heart failure is due to impaired myocardial contraction and is most commonly caused by coronary heart disease and myocardial ischemia or infarct.

C. Heart failure can also occur due to long standing excessive workload of the heart muscle such as in hypertension or valvular disorders.

D. When the heart starts to fail, compensatory mechanisms are activated to help maintain tissue perfusion. Although these mechanisms, including increased contractile force, vasoconstriction, sodium and water retention, and remodeling of the heart, effectively maintain cardiac output in the short term, in the long term they hasten deterioration of heart function.

E. Goals of heart failure management are to reduce the workload and improve its function.

Medical management includes medication use including ACE inhibitors, beta blockers, diuretics, and vasodilators to reduce cardiac workload.

F. Digitalis is no longer recommended as a first-line therapy due to the risk for digitalis toxicity outweighing the benefit due to the narrow therapeutic window.

G. Nursing care of the patient with heart failure is primarily supportive and educative, providing the patient and family with the necessary knowledge and resources to manage this chronic condition.

H. Cardiogenic pulmonary edema, a manifestation of severe cardiac decompensation, is a medical emergency, requiring immediate and effective treatment to preserve life. The nurse’s role in managing pulmonary edema focuses on supporting respiratory and cardiac function through careful assessment and early intervention, administering prescribed medications, and providing reassurance to the patient and family.

I. Inflammatory and infectious processes, such as rheumatic fever, endocarditis, myocarditis, and pericarditis, can affect any layer of the heart. While some, such as myocarditis and pericarditis, are typically mild and self-limiting, others can have long-term effects on cardiac structure and function.

J. Processes such as rheumatic heart disease, endocarditis, and congenital conditions can affect the structure and function of the heart valves, resulting in either stenosis (narrowing) of the valve and restricted flow through it, or regurgitation, backflow of blood through a valve that does not fully close. The mitral and aortic valves are commonly affected due to the higher pressures and increased workload of the left side of the heart.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

K. Valve disorders may be mild, producing a heart murmur but no functional impairment for the patient, or severe, causing symptoms of heart failure even at rest. Repair or replacement of the valve may ultimately be required.

L. Cardiomyopathies affect the heart muscle and its ability to stretch during filling and to contract effectively. Dilated cardiomyopathy, the most common type, is progressive, ultimately necessitating heart transplant. Hypertrophic cardiomyopathy affects both ventricular filling and outflow through the aortic valve. Surgical resection of excess tissue may relieve its manifestations.

SUGGESTIONS FOR CLASSROOM ACTIVITY—LEARNING OUTCOME ONE Have students develop a chart that outlines the etiology, pathophysiology, and manifestations of common cardiac disorders.

Arrange for a registered nurse who has extensive hemodynamic monitoring experience to discuss the use of this equipment in practice.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME ONE Assign students to care for a patient with heart failure or other cardiac health problem.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME TWO Have students develop a community outreach teaching plan regarding the importance of taking prophylactic antibiotic therapy before invasive procedures, such as a visit to the dentist.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME TWO Assign students to care for a patient with an inflammatory cardiac health problem.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME THREE Arrange for a heart transplant recipient to speak to the class.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME THREE Assign students to care for a patient with a structural cardiac health problem.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter 32 Nursing Care of Patients with Vascular and Lymphatic Disorders

Learning Outcomes 1. Describe the pathophysiology and manifestations of disorders of blood pressure, and outline the interprofessional care and nursing care of patients with these disorders.

2. Describe the pathophysiology and manifestations of disorders of the aorta and its branches, and outline the interprofessional care and nursing care of patients with these disorders.

3. Describe the pathophysiology and manifestations of disorders of the peripheral arteries, and outline the interprofessional care and nursing care of patients with these disorders.

4. Describe the pathophysiology and manifestations of disorders of venous circulation, and outline the interprofessional care and nursing care of patients with these disorders.

5. Describe the pathophysiology and manifestations of disorders of the lymphatic system, and outline the interprofessional care and nursing care of patients with these disorders.

Key Concepts I.

Disorders of Blood Pressure Regulation A. Blood pressure: Pressure exerted by blood against arterial walls 1.

Affected by blood volume, vascular resistance, cardiac output, and other factors B.

Physiology review 1.

Arteries have relatively high pressures from elastic walls 2.

Veins have relatively low pressure from thin and distensible walls 3.

Blood flows from high pressure to low pressure in capillaries 4.

Systolic blood pressure: During systole, is highest a) Average in healthy adults: <120 mmHg 5.

Diastolic blood pressure: During diastole, is lowest a) Average is less than <80 mmHg 6.

Pulse pressure: Difference between systolic and diastolic pressure a) Normally about 40 mmHg 7.

Mean arterial pressure (MAP): Average pressure throughout cycle a) [systolic BP + 2 (diastolic BP)] / 3 8.

Vascular resistance determined by vessel length, blood viscosity, vessel diameter, and compliance, affected by: a) Sympathetic nervous system (SNS) stimulation b) Circulating epinephrine and norepinephrine from adrenal cortex c) Renin–angiotensin–aldosterone system from kidneys

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

d) Atrial natriuretic peptide from atrial cells e) Adrenomedullin f) Vasopressin or antidiuretic hormone g) Local factors: Inflammatory mediators and metabolites h) Extent of arteriosclerosis and atherosclerosis C.

The Patient with Primary Hypertension 1.

Essential hypertension: Persistently elevated systemic blood pressure a) Affects 1 in 3 people in U.S. 2.

Primary hypertension: 90% of cases have hypertension, no identified cause a) Systolic blood pressure 140 mmHg of higher, or diastolic pressure of 90 mmHg 3.

Risk factor for coronary heart disease, heart failure, stroke, and renal failure

4.

Pathophysiology a) Diverse group of pathophysiologic mechanisms b) Excess sympathetic nervous system with overstimulation of - and -adrenergic receptors c) Altered function of the renin–angiotensin–aldosterone system (1) In 20% of cases, renin levels are lower than normal d) Other chemical mediators such as atrial natriuretic peptide (factor) and endothelin-1 e) Interaction between insulin resistance, hyperinsulinemia, and endothelial function (1) Excess insulin causes (a) Sodium retention by the kidneys (b) Increased sympathetic nervous system activity (c) Hypertrophy of vascular smooth muscle (d) Changes in ion transport across cell membranes

5.

Incidence and risk factors a) Risk factors: (1) Family history (2) Age (3) Race (4) Mineral intake (5) Obesity (6) Insulin resistance (7) Excess alcohol consumption (8) Stress

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

6.

Manifestations a) Early stages typically asymptomatic b) Headache upon awakening, nocturia, confusion, nausea and vomiting, visual disturbances

7.

Complications a) Rate of atherosclerosis accelerates, increasing risk for coronary heart disease and stroke b) Ventricular hypertrophy, can lead to coronary heart disease, dysrhythmias, and heart failure c) Hypertensive encephalopathy: Syndrome of extremely high blood pressure; altered level of consciousness, increased intracranial pressure, papilledema, and seizures d) Nephrosclerosis and renal insufficiency, proteinuria and microscopic hematuria, signs of chronic renal failure

8.

Interprofessional care a) Diagnosis: Tests to determine causes, cardiovascular risk factors, presence of organ damage (1) Electrocardiogram (2) Urinalysis (3) Blood glucose (4) Hematocrit (5) Serum potassium, creatinine, and calcium (6) Cholesterol and lipoprotein profile b) Lifestyle modifications (1) Diet (a) Reducing sodium intake, maintaining adequate potassium and calcium intake (b) DASH diet focuses on whole foods, rich in fruits and vegetables, and low in total and saturated fats (2) Physical activity (a) Regular aerobic exercise for weight loss, stress reduction, and feelings of overall well-being (b) Isometric exercise may not be appropriate c) Medications (1) Drug classes (a) Diuretics: Preferred treatment for systolic hypertension in older adults (i) Thiazide diuretics are widely used (ii) Promote sodium and water excretion

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(iii) Adverse effects: Hypokalemia, abnormal levels of glucose, triglycerides, uric acid, low-density lipoproteins, and insulin (b) Beta-adrenergic blockers: For patients with heart failure, coronary heart disease, or diabetes (i) Reduce peripheral vascular resistance, may reduce amount of renin released from kidneys (c) Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs): Often used initially, particularly for patients who are diabetic, have heart failure, history of MI, or chronic kidney disease (i) Reduces vasoconstriction and sodium and water retention (d) Centrally acting sympatholytics (e) Vasodilators: Alpha blockers and calcium channel blockers (i) Adverse effects: Reflex tachycardia, suppress heart function (2) Drug regimens (a) Start at low dose, increase until effective, may decrease slowly after 1 year (b) More aggressive for stage 2 hypertension d) Integrative therapies (1) Yoga, Tai chi, meditation, and guided imagery 9.

Nursing care a) Assessment (1) Health history (a) Manifestations and risk factors (2) Physical examination (a) Manifestations (3) Laboratory data (a) Serum electrolytes, glucose, and creatinine; (b) Cholesterol and lipoprotein profile; (c) Urinalysis b) Priorities of care (1) Ensure adequate treatment of the underlying process (2) Provide care that supports the physical and psychologic responses to the disorder c) Diagnoses, outcomes, and interventions (1) Promote a healthy lifestyle and behaviors (a) Assist with identifying current behaviors that contribute and in developing realistic health maintenance plan .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(2) Monitor adherence to therapeutic plan (a) Inquire about reasons for noncompliance (b) Assess factors, such as adverse drug effects (c) Evaluate knowledge of hypertension and treatment (d) Assist to develop goals for lifestyle changes (e) Assist to develop system of reminders (f) Reassure that relapse into old behaviors common (3) Promote balanced nutrition (a) Assess usual daily food intake (b) Mutually determine realistic target weight, monitor weight (c) Refer to dietician (d) Recommend participating in approved weight loss program (4) Monitor fluid volume (a) Monitor blood pressure and other vital signs as indicated (b) Monitor fluid intake and output, weight daily, monitor for peripheral edema (c) Refer to dietician for low-sodium diet (d) Monitor lab values (e) Discuss importance of adhering to treatment plans 10.

D.

Transitions of care a) Teach about: Exercise, healthy eating patterns; smoking cessation; alcohol in moderation; stress-reducing techniques; desired and adverse medication effects; importance of continual monitoring and following up with provider b) Refer to community resources

The Patient with Secondary Hypertension 1.

Elevated blood pressure from identifiable underlying process 2.

Pathophysiology a) Kidney disease: Most common cause (1) Stimulation of renin–angiotensin–aldosterone system (2) Vasoconstriction and sodium and water retention b) Coarctation of the aorta (1) Narrowing of aorta (2) Stimulation of renin–angiotensin–aldosterone system (3) Manifestations: Marked difference between pressures in the upper and lower extremities; weak pulses and poor capillary refill in the lower extremities c) Endocrine disorders (1) Adrenal gland disorders: Cushing syndrome and primary aldosteronism

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(2) Pheochromocytoma: Rare tumor of the adrenal medulla (3) Other endocrine disorders: Hyperthyroidism and pituitary disorders d) Neurologic disorders (1) Increased intracranial pressure (2) Disorders that interfere with autonomic nervous system regulation e) Drug use (1) Estrogen and oral contraceptive use (2) Stimulant drugs f) Pregnancy (1) 10% of pregnant women (2) Significant cause of maternal and fetal morbidity and mortality g) Primary aldosteronism

E.

3.

Interprofessional care a) Diagnosis: Tests to differentiate from primary hypertension (1) Renal function studies and urinalysis (2) Serum potassium (3) Blood chemistries (4) Intravenous pyelography (IVP), renal ultrasonography, renal arteriography, CT or MRI scan

4.

Nursing care a) Same as for primary hypertension, with care for underlying cause

The Patient with Hypertensive Crisis 1.

Rapid, significant elevations in blood pressure 2.

Systolic pressure greater than 180 mmHg and diastolic pressure higher than 120 mmHg 3.

Immediate treatment vital to prevent cardiac, renal, and vascular damage 4.

Manifestations a) Rapid onset, blurred vision (papilledema), restlessness, systolic pressure >180 mmHg, diastolic pressure >120 mmHg, headache, confusion, and motor and sensory deficits

5.

Risk factors a) Sudden cessation of medications can trigger b) Ages 30–50 c) African American men d) Pregnant women with pre-eclampsia e) Collagen and/or renal disease

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

II.

6.

Interprofessional care a) Goal to decrease blood pressure by no more than 25% within minutes to 1 hour, then toward 160/100 within 2–6 hours b) Monitor: Blood pressure, BUN, serum creatinine, calcium, total protein levels c) Medications: Rapidly acting antihypertensive (1) Vasodilators (2) Calcium channel blockers (3) ACE inhibitors (4) ARBs

7.

Nursing care a) Continuously monitor blood pressure and titrating drugs b) Avoid excessive or rapid blood pressure reduction c) Provide reassurance and support d) Teach management of hypertension and prevention of future crisis

Disorders of the Aorta and Its Branches A. The Patient with an Aneurysm 1.

Abnormal dilation of a blood vessel or ventricular wall 2.

Pathophysiology a) Due to weakness of arterial wall (1) Often from destruction of structural proteins collagen and/or elastin b) True aneurysms: From slow weakening of arterial wall from atherosclerosis and hypertension (1) Affect all three layers of vessel wall (2) Fusiform: Spindle-shaped and tapers at both ends (3) Circumferential: Involve entire diameter of vessel c) False aneurysms / traumatic aneurysms: From traumatic break in vessel wall (1) Saccular: Shaped like small outpouchings (a) Berry aneurysm: Type of saccular aneurysm caused by congenital weakness in tunica media of artery (2) Dissecting: Tear in tunica intima and media, blood dissects layers of vessel wall, usually contained by adventitia, forms saccular and longitudinal aneurysm

3.

Manifestations and complications a) Thoracic aortic aneurysms (1) Causes: Arteriosclerosis, hypertension, trauma, coarctation of the aorta, tertiary syphilis, fungal infections, Marfan syndrome, and syphilis (2) Manifestations

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(a) May be asymptomatic (b) Back, neck, or substernal pain (c) Dyspnea, stridor, or brassy cough if pressing on trachea (d) Hoarseness and dysphagia if pressing on esophagus or laryngeal nerve (e) Edema of the face and neck (f) Distended neck veins b) Abdominal aortic aneurysms (1) Causes and risk factors: Arteriosclerosis, hypertension, increasing age, smoking (2) Over 90% develop below the renal arteries (3) Manifestations (a) Pulsating abdominal mass (b) Aortic calcification noted on x-ray (c) Mild to severe midabdominal or lumbar back pain (d) Cool, cyanotic extremities if iliac arteries are involved (e) Claudication (ischemic pain with exercise, relieved by rest) c) Popliteal and femoral aneurysms (1) Causes: Arteriosclerosis (2) Manifestations (a) Popliteal: Intermittent claudication, rest pain, numbness, pulsating mass may be palpable in the popliteal fossa (b) Femoral: Same as popliteal but with pulsating mass in the femoral area d) Aortic dissections (1) Life-threatening emergency: A tear in the intima of the aorta with hemorrhage into the media (a) Hemorrhage dissects or splits the vessel wall, forming a bloodfilled channel between its layers (2) Risk factors: Hypertension, cystic medial necrosis, male gender, advancing age, pregnancy, congenital defects of the aortic valve, coarctation of the aorta, and inflammatory aortitis (3) Pressure may prevent the aortic valve from closing or may occlude the branches of the aorta (4) May extend into the renal, iliac, or femoral arteries (5) Manifestations: Sudden, excruciating pain; syncope, dyspnea, and weakness; peripheral pulse becomes inaudible 4.

Interprofessional care a) Diagnosis (1) Chest x-ray

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(2) Abdominal ultrasonography (3) Transesophageal echocardiography (4) Contrast-enhanced CT or MRI (5) Angiography b) Medications (1) Thoracic aortic: Long-term beta blockers and other hypertensive drugs (2) Aortic dissection: IV beta blockers concurrently with sodium nitroprusside infusion, and sometimes calcium channel blockers (a) Direct vasodilators avoided (3) Anticoagulant therapy following surgery c) Surgery: For symptomatic or rapidly expanding cases (1) Endovascular stent grafts (EVSG): Metal sheath covered with polyester fabric or a woven polyester tube placed percutaneously via the femoral artery (a) Fewer pulmonary, renal, and cardiovascular complications than open surgery (b) Complication: Persistent perfusion of the aneurysm (endoleak) (2) Open surgical procedure: Aneurysm excised and replaced with a synthetic fabric graft 5.

Nursing care a) Assessment (1) Health history (2) Physical examination b) Priorities of care (1) Ensure adequate treatment of the underlying process (2) Provide care that supports the physical and psychologic responses to the disorder c) Diagnoses, outcomes, and interventions (1) Promote effective tissue perfusion (a) Interventions to reduce risk of aneurysm rupture: Maintain bed rest with legs flat; maintain calm environment, reducing stress; prevent straining during defecation and instruct not to hold breath while moving; administer beta blockers and antihypertensives (b) Report manifestations of arterial thrombosis or embolism; changes in mental status or symptoms of peripheral neurologic impairment (c) Continuously monitor cardiac rhythm (2) Reduce risk for injury (a) Use an infusion control device for all drug infusions

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(b) Monitor arterial pressure and hemodynamic parameters and urine output (3) Reduce anxiety (a) Explain all procedures and treatments; respond to all questions honestly, using a calm, empathetic, but matter-of-fact manner (b) Spend as much time as possible with the patient and allow supportive family members to remain with the patient when possible 6.

III.

Transitions of care a) Discussion topics when surgery is not immediately planned: (1) Measures to control hypertensions; benefits of smoking cessation; manifestations of increasing aneurysm size or complications b) Preoperative care c) Postoperative care d) Discussion topics following surgery: (1) Wound care and infection prevention; manifestations of infection (2) Medications: Intended and adverse effects (3) Importance of rest and good nutrition (4) Measures to prevent constipation (5) Importance of avoiding prolonged sitting, lifting heavy objects, engaging in strenuous exercise, having sex until approved

Disorders of the Peripheral Arteries A. Physiology review 1.

Arterial wall layers: a) Intima: Includes endothelium and basement layer b) Media: Composed of smooth muscle and elastic fibers c) Adventitia: Connective tissue containing collagen and elastic fibers 2.

Muscle of media controls blood flow 3.

Arterioles: Less than .5 mm in diameter, mostly smooth muscle 4.

Capillary beds: Where gas, nutrient, and waste product exchange occurs 5.

Resistance opposes blood flow: Friction, diameter, and length of blood vessel B.

The Patient with Peripheral Vascular Disease 1.

Pathophysiology a) Atherosclerotic lesions form at arterial bifurcations (1) Vessel lumen is progressively obstructed, decreasing blood flow to lower extremities (2) Tissue hypoxia and anoxia results

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(3) Collateral circulation develops, but is not adequate to supply tissue needs 2.

Incidence and risk factors a) Ages 60–70, men more often affected than women b) Risk factors same as those for atherosclerosis and coronary heart disease

3.

Manifestations and complications a) Pain (1) Intermittent claudication, cramping or aching in the calves of the legs, the thighs, and the buttocks with a predictable level of activity (2) Rest pain during periods of inactivity b) Peripheral pulses may be decreased or absent; bruit may be heard; skin is thin, shiny, and hairless, with discolored areas; toenails thickened; areas of skin breakdown c) Edema in severe cases

4.

Interprofessional care a) Diagnosis: To evaluate extent (1) Segmental pressure measurements (2) Stress testing (3) Doppler ultrasound (4) Duplex Doppler ultrasound (5) Transcutaneous oximetry (6) Angiography or magnetic resonance angiography b) Medications (1) Aspirin, clopidogrel, and cilostazol: To inhibit platelet aggregation (2) Pentoxifylline: To increase blood flow to the microcirculation and tissues of the extremities (3) Parenteral vasodilator prostaglandins: To decrease pain and facilitate healing in patients with severe limb ischemia c) Treatments (1) Smoking cessation; foot care to prevent ulceration and infection; elevation of head; and regular exercise (2) Controlling precipitating causes d) Revascularization: If symptoms are progressive, severe, or disabling (1) Nonsurgical procedures: Percutaneous transluminal angioplasty (PTA), stent placement, and atherectomy (2) Surgical options: Endarterectomy to remove occlusive plaque from the artery and bypass grafts e) Integrative therapies

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Aromatherapy with rosemary or vetiver (2) Biofeedback (3) Healing or therapeutic touch and massage (4) Herbs such as ginko, garlic, cayenne, hawthorn, and bilberry (5) Exercise, including yoga 5.

Nursing care a) Assessment (1) Health history (2) Physical examination b) Priorities of care (1) Ensure adequate treatment of the underlying process (2) Provide care that supports the physical and psychologic responses to the disorder c) Diagnoses, outcomes, and interventions (1) Promote effective perfusion of peripheral tissues (a) Assess peripheral pulses, pain, color, temperature, and capillary refill (b) Position with extremities dependent (c) Instruct to avoid smoking (d) Discuss benefits of regular exercise (e) Keep extremities warm (f) Encourage frequent position changes (2) Manage pain (a) Assess pain every 4 hours (b) Keep extremities warm (c) Teach pain relief and stress reduction techniques (3) Promote skin integrity (a) Assess and document skin condition frequently (b) Provide daily skin care (c) Apply a bed cradle (d) Provide egg crate mattress, flotation pad, and heel protectors (4) Promote activity tolerance (a) Assist with care activities (b) Encourage gradual increases in duration and intensity of exercise (c) Provide diversional activities during periods of prescribed bed rest (d) Encourage position changes and ROM exercises d) Caring for older adults with PVD (1) Visual deficits and osteoarthritis make foot care difficult

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(2) Smoking habits (3) Impaired mobility 6.

C.

Transitions of care a) Discuss: Smoking cessation, medications, signs of excess bleeding, skin surveillance and foot care, recommended diet and exercise b) Post revascularization or surgery discussion topics: (1) Incision care, manifestations of complications, and activity limitations

The Patient with Thromboangitis Obliterans 1.

Pathophysiology and course a) Occlusive vascular disease, small and midsize peripheral arteries become inflamed and spastic, causing clots to form b) As the disease progresses, affected vessels become scarred and fibrotic c) Course is intermittent with dramatic exacerbations and marked remissions d) Collateral vessels increasingly involved 2.

Incidence and risk factors a) Primarily men under 40 who smoke b) More prevalent in Asians and Eastern Europeans

3.

Manifestations and complications a) Manifestations: Pain in affected extremities; claudication and rest pain; thin, shiny skin; and thickened, malformed nails b) Digital pulses difficult to locate or absent c) Risk for tissue ulceration and gangrene in fingers and toes

4.

Interprofessional care a) Diagnosis: By history and physical examination (1) Doppler studies to locate and determine extent (2) Angiography and magnetic resonance imaging b) Management: Smoking cessation most important (1) Also: Keeping extremities warm, managing stress, keeping affected extremities in a dependent position, preventing injury to affected tissues, and regular exercise c) Medications: No specific drugs (1) Calcium channel blocker may provide symptom relief d) Surgery (1) Sympathectomy: Interrupts sympathetic nervous system input to affected vessels

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(2) Arterial bypass graft: Useful when larger vessels are affected by the disease (3) Amputation of digit sometimes necessary for gangrene 5.

Nursing care a) Health promotion (1) Smoking prevention b) Focus on promoting arterial circulation and preventing prolonged tissue hypoxia, relieving acute symptoms c) Postsurgical care, in case of surgery 6.

Transitions of care a) Smoking cessation absolutely necessary; foot care; protection from injury; medication information; manifestations to report D.

The Patient with Raynaud’s Disease 1.

Raynaud’s disease and Raynaud’s phenomenon a) Episodes of intense vasospasm in the small arteries and arterioles of the fingers and sometimes the toes 2.

Pathophysiology a) Disease: No identifiable cause (1) Primarily affects women ages 20–40 b) Phenomenon: Occurs secondarily to another disease, known causes, or longterm exposure to cold or machinery c) Manifestations: (1) Pain becomes more severe and prolonged as disease progresses (2) “Blue-white-red” changes in color of hands with accompanying changes in skin temperature (3) Numbness, stiffness, and decreased sensation during attacks d) With progression: Fingertips thicken and the nails become brittle e) Complications: Ulceration and gangrene, rarely occur

3.

Interprofessional care a) Diagnosis: History and physical examination b) Medications: Vasodilators, calcium channel blockers, beta-adrenergic blocker prazosin (Minipress), oral nitrates to help hands return to normal after attack c) Treatment: Keep hands warm, avoidance of hand injury, smoking cessation, stress reduction measures, lifestyle habits to improve overall vascular health

4.

Nursing care a) Protect the hands and feet from exposure

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

b) Nursing diagnoses similar to those for atherosclerosis c) Continuity of care (1) Teach measures to reduce attacks 5.

E.

Transitions of care a) Teaching topics: (1) Dress warmly (2) Avoid exposure to cold (3) Stop smoking or do not start (4) Use of medications and adverse effects

The Patient with Acute Arterial Occlusion 1.

Pathophysiology a) Acute thrombosis: Thrombus adheres to vessel wall (1) Thrombus formation prompted by: Damaged vessel wall from atherosclerosis, infection, inflammation, and pooling of blood (2) Lead to ischemia of tissues supplied by affected artery (3) Collateral vessels develop in gradual cases b) Arterial embolism: Sudden obstruction of blood vessel by debris (1) Thromboembolus: Thrombus broken loose from wall (2) Other substances: Atherosclerotic plaque, masses of bacteria, cancer cells, amniotic fluid, bone marrow fat, and foreign objects (e.g., air bubbles, broken IV catheters) (3) Associated with myocardial infarction, valvular heart disease, leftsided heart failure, atrial fibrillation, or infectious heart diseases 2.

Manifestations a) Tissue ischemia: Painful, pale, and cool or cold tissues (1) Absent distal pulses; paresthesias in the extremity; cyanosis and mottling are common

3.

Interprofessional care a) Diagnosis: By signs and symptoms (1) Arteriography: To confirm, locate, and determine extent of occlusion b) Medications: Anticoagulation with IV heparin (1) Intra-arterial thrombolytic therapy (a) Streptokinase, urokinase, or tissue plasminogen activator (t-PA) c) Surgery (1) Immediate embolectomy: For acute arterial occlusion by an embolus (2) Emergency laparotomy: For embolus in mesenteric circulation

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(3) Complications: Compartment syndrome, acute respiratory distress syndrome, and acute renal failure

IV.

4.

Nursing care a) Assessment (1) Health history (2) Physical examination b) Priorities of care (1) Ensure adequate treatment of the underlying process (2) Provide care that supports the physical and psychologic responses to the disorder c) Diagnoses, outcomes, and interventions (1) Promote effective peripheral tissue perfusion (a) Monitor extremity perfusion, comparing affected and unaffected extremities (b) Maintain IV fluids as needed (c) Protect extremity, keeping it horizontal or lower than heart, with specific care after surgery (2) Reduce anxiety (a) Spend as much time with patient, allow to vocalize anxiety (b) Perform required measures in expedient but calm manner (c) Assess anxiety level often (d) Decrease sensory stimuli as much as possible (e) Speak slowly and clearly and avoid unnecessary interruptions when listening (3) Reduce risk for injury and bleeding (a) Monitor activated partial thromboplastin time (APTT) during heparin therapy (b) Monitor prothrombin time (PT) or international normalized ratio (INR) during oral anticoagulant therapy (c) Protect from injury

5.

Transitions of care a) Discuss: Care of incision; manifestations of complications to be reported; longterm anticoagulant therapy; activity restrictions or dietary modifications b) Control of atherosclerosis and hypertension, measures to promote peripheral circulation and maintain tissue integrity

Disorders of Venous Circulation A. Physiology review

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

1.

Veins: Thin-walled, distensible, contain much less muscle than arteries, contain valves to prevent retrograde blood flow 2.

Blood return to heart relies on skeletal muscle contractions and pressure B.

The Patient with Venous Thrombosis 1.

Blood clot forms on wall of vein, vein inflames, and blood flow is obstructed 2.

Pathophysiology a) Virchow’s triad: Stasis of blood, vessel damage, and increased blood coagulability b) Thrombus forms in same way as in arterial thrombosis c) Vein wall is scarred and venous valves are permanently destroyed d) Risk factors: Immobilization, surgery, cancer, trauma, pregnancy, hormone therapy, and coagulation disorders e) Manifestations of deep venous thrombosis (1) Deep veins of legs and pelvis most common areas (2) Manifestations (a) May be asymptomatic (b) Due to inflammation: Tenderness, swelling, warmth, erythema, and cyanosis and edema of affected extremity (3) Complications (a) Chronic venous insufficiency and pulmonary embolism f) Manifestations of superficial venous thrombosis (1) Risk factors: Venous catheter and infusions, thromboangiitis obliterans, varicose veins, deep vein thrombosis, pregnancy (2) Manifestations: Pain and tenderness; palpable reddened, warm, tender cord extending along the affected vein; swelling and redness in area

3.

Interprofessional care a) Diagnosis (1) Duplex venous ultrasonography (2) Plethysmography (3) Magnetic resonance imaging (4) Ascending contrast venography b) Prophylaxis (1) Low-molecular-weight heparins for risk from surgery, acute medical illness or prolonged bed rest (2) Oral anticoagulant therapy for fractures or orthopedic surgery c) Medications (1) Anticoagulants: To prevent clot extension and reduce risk of pulmonary embolism

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(a) Heparin or low-molecular-weight (LMW), heparin, and warfarin (b) Initial bolus and subsequent infusion d) Treatments (1) Superficial vein thrombosis: Warm, moist compress; extremity rest, anti-inflammatory agents (2) Deep vein thrombosis: Bed rest; elevation of foot of bed; leg exercises; pneumatic compression devices; and elastic stockings e) Surgery (1) Venous thrombectomy: When thrombi lodge in the femoral vein, removal is necessary to prevent pulmonary embolism or gangrene (2) Filter inserted into vena cava to capture emboli (a) When condition is recurrent and anticoagulant therapy is contraindicated (b) Inserted under fluoroscopy with local anesthesia (3) Ligation and division of saphenous vein where it joins femoral vein: For extensive thrombosis of saphenous vein, to prevent clot extension 4.

Nursing care a) Assessment (1) Health history (2) Physical examination b) Priorities of care (1) Ensure adequate treatment of the underlying process (2) Provide care that supports the physical and psychologic responses to the disorder c) Diagnoses, outcomes, and interventions (1) Manage pain (a) Regularly assess pain (b) Measure calf and thigh diameter daily (c) Apply warm, moist heat (d) Maintain bed rest as ordered (2) Promote effective peripheral tissue perfusion (a) Assess peripheral pulses, skin integrity, capillary refill times, color of extremities every 8 hours (b) Elevated extremities at all times with knees slightly bent and legs above heart (c) Use mild soaps and lotions to clean leg and foot daily (d) Use weight-dispersion device on mattress (e) Encourage frequent position changes (3) Reduce risk for bleeding

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(a) Avoid injury (b) Monitor laboratory results (4) Promote mobility (a) Encourage ROM exercises and provide passive ROM as needed; encourage frequent position changes, deep breathing, coughing; and ambulation (b) Encourage increased fluid and dietary fiber intake (c) Encourage diversional activities (5) Promote effective cardiopulmonary tissue perfusion (a) Frequently assess respiratory status (b) Administer oxygen therapy 5.

C.

Transitions of care a) Discuss: Disease process, treatment measures, appropriate methods of heat application, prescribed activity restrictions, and importance of follow-up visits

The Patient with Chronic Venous Insufficiency 1.

Pathophysiology a) Large veins remain occluded following DVT, pressure increases in other veins of extremity, become distended, and valve closure impaired b) Venous blood collects and stagnates in the lower leg c) Eventually: Cells die, skin atrophies, subcutaneous fat deposits necrose, venous stasis ulcers develop and enlarge, inflammatory and immune responses impaired 2.

Manifestations a) Lower extremity edema b) Itching, dull leg discomfort or pain that increases with standing c) Thin, shiny, atrophic skin; cyanosis and brown skin pigmentation of lower leg d) Possible weeping dermatitis e) Thick, fibrous subcutaneous tissue f) Recurrent ulcerations of medial or anterior ankle

3.

Interprofessional care a) Diagnosis: No specific test to confirm diagnosis, based on history and physical exam b) Conservative management to reduce edema and treat ulcerations c) Treatment (1) Weeping dermatitis: Wet compresses of boric acid, buffered aluminum acetate (Burrow’s solution), or isotonic saline solution followed by topical corticosteroid

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(2) Stasis dermatitis: Topical corticosteroid, zinc oxide ointment, or a topical broad-spectrum antifungal cream (3) Large, chronic ulcer: May require surgical excision and skin graft 4.

D.

Nursing care a) Patient teaching: Elevate legs while resting and sleeping; walk but avoid prolonged standing and sitting; do not cross legs or wear things that pinch legs; wear elastic hose; keep skin clean and dry

The Patient with Varicose Veins 1.

Irregular, tortuous veins with incompetent valves 2.

Pathophysiology a) Primary: No involvement of deep veins b) Secondary: Caused by obstruction of deep veins c) Increased venous pressure stretches vessel wall, impairs valves’ ability to close

3.

Incidence and risk factors a) Most often seen in: Women, over 35 years of age; white race b) Risk factors: Prolonged standing, potential genetic link, obesity, venous thrombosis, congenital arteriovenous malformations, or sustained pressure on abdominal veins

4.

Manifestations and complications a) Severe, aching pain, itching, and feelings of warmth in the leg b) Leg fatigue and heaviness c) Visibly dilated veins d) Thin, discolored skin above the ankles e) Stasis ulcers f) Venous insufficiency, stasis ulcers, chronic stasis dermatitis, and superficial venous thrombosis

5.

Interprofessional care a) Diagnosis: Often by history and physical exam (1) Doppler ultrasonography or duplex Doppler ultrasound (2) Trendelenburg test b) Treatments (1) Conservative management: Graduated compression stockings, daily walking and elevating legs c) Compression sclerotherapy: For small, symptomatic vessels

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Sclerosing solution injected into varicose vein, compression bandage applied: Obliterates vein and blood is rerouted (2) Complications: Phlebitis, tissue necrosis, and infection d) Surgery: For patients who are very symptomatic, experience recurrent superficial venous thrombosis, and/or develop stasis ulcers; sometimes done for cosmetic reasons (1) Usually involves extensive ligation and stripping of the greater and lesser saphenous veins (2) Postoperative care: Pressure bandages for 6 weeks, elevate extremities, gradually increase amounts of ambulation 6.

Nursing care a) Assessment (1) Health history (2) Physical examination b) Priorities of care (1) Ensure adequate treatment of the underlying process (2) Provide care that supports the physical and psychologic responses to the disorder c) Diagnoses, outcomes, and interventions (1) Manage chronic pain (a) Assess pain and inquire about measures patient uses to manage pain (b) Teach nonpharmacologic pain management strategies (c) Collaborate with patient to establish pain control plan (d) Regularly evaluate effectiveness of planned interventions (2) Promote effective peripheral tissue perfusion (a) Assess peripheral pulses, capillary refill, skin color and temperature, and extent of edema (b) Teach application and use of elastic graduated compression stockings (c) Encourage regular exercise and frequent elevation of legs for 15–20 minutes (3) Reduce risk for skin breakdown (a) Assess lower extremity color, temperature, moisture, and evidence of pressure or breakdown (b) Teach foot and skin care measures (c) Discuss importance of adequate nutrition and fluid intake (4) Reduce risk for neurologic dysfunction (a) Assess circulation, sensation, and movement of lower extremities (b) Instruct to report signs of neurovascular dysfunction .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(c) Teach measures to protect extremities from injury 7.

Transitions of care a) Discuss: Leg elevation and exercise program; elastic graduated compression stockings; foot and leg care; measures to avoid injury; and symptoms to report V.

Disorders of the Lymphatic System A. Lymphatic system: Filters plasma out of interstitial tissues, returns it to bloodstream 1.

Lymphatic vessels: Contain smooth muscle and one-way valves 2.

Phagocytes in lymph nodes remove foreign material from lymph fluid B.

The Patient with Lymphadenopathy 1.

Localized or generalized enlarged lymph nodes 2.

Localized: From inflammatory response or minor trauma a) Phagocytes and monocytes increase in node 3.

Generalized: From malignancy or disease a) Abnormal cells invade node 4.

Lymphangitis: Inflammation of lymph vessels draining infected area a) Characterized by red streak along inflamed vessels, pain, heat, and swelling 5.

Treatment: Identify and treat underlying condition

C.

The Patient with Lymphedema 1.

Primary: Uncommon disorder, may be associated with genetic disorder 2.

Secondary: Acquired, resulting from damage, obstruction, and removal of lymphatic vessels a) Filariasis: Infestation of lymphatic vessel by filarial, a nematode worm b) Also from bacterial lymphangitis, tumors, and surgical or radiation treatment for breast cancer 3.

Pathophysiology and risk factors a) Osmotic pressure in interstitial tissues increases, causes edema in soft tissues

4.

Manifestations a) Initial edema is soft and pitting b) Brawny edema: Subcutaneous tissues become fibrotic, causing thick, rough skin and a woody texture of the limb

5.

Interprofessional care a) Diagnosis (1) Abdominal or pelvic ultrasound and computed tomography (CT) scan to detect lesions (2) MRI to show edema and identify lymph nodes

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(3) Lymphangiography: Injected contrast media illustrate lymphatic vessels on x-rays (4) Lymphoscintigraphy: Injected radioactively tagged substance into distal subcutaneous tissues b) Treatments (1) Meticulous foot care (2) Wear shoes (3) Exercise (4) Elevate legs (5) Wear compression stockings c) Medications (1) Antibiotics (2) Diuretics may be used intermittently d) Surgery: For those who do not respond to conservative treatment, for recurrent cases 6.

Nursing care a) Assessment b) Priorities of care (1) Ensure adequate treatment of the underlying process (2) Provide care that supports the physical and psychologic responses to the disorder c) Diagnoses, outcomes, and interventions (1) Promote tissue integrity (a) Frequently inspect skin of affected extremity (b) Apply elastic graduated compression stockings or pressure devices (c) Instruct to elevate extremities while seated and during rest (d) Instruct skin and foot care (2) Monitor fluid volume (a) Monitor fluid intake and output and weigh daily (b) Discuss rationale for restricted sodium intake (c) Assess affected extremity daily for increased edema (3) Teach coping strategies (a) Discuss perception of self and coping patterns (b) Encourage active participation in self-care

7.

Transitions of care a) Discuss: Exercise; foot and skin care; graduated elastic compression devices; measures to prevent infection; signs and symptoms to report; sodium-restricted diet if ordered; desired and adverse effects of medications

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter Highlights A. Essential hypertension, blood pressure of 130/80 or higher with no clearly identified cause, rarely causes symptoms but is a major risk factor for coronary heart disease, heart failure, stroke, and renal insufficiency.

B. Patients with prehypertension are advised to make lifestyle changes indicated for hypertension (weight loss, exercise, dietary changes, limited alcohol intake, and stress reduction), but generally are not treated with medications unless other risk factors such as diabetes or kidney disease are present.

C. Systolic hypertension, an elevated systolic blood pressure without elevation of the diastolic pressure, is common in older adults and contributes to complications such as coronary heart disease and stroke.

D. Medications to treat hypertension include diuretics, alpha- and beta-adrenergic blockers, ACE inhibitors and angiotensin II blockers, calcium channel blockers, and vasodilators. A combination of two or more drugs often is required for effective blood pressure control.

E. Aneurysms, abnormal dilation of a blood vessel, commonly affect the aorta and the iliac arteries, particularly in older men. A slowly expanding abdominal aortic aneurysm that does not produce symptoms or impair flow through the renal arteries may not be repaired, particularly in an older patient. Percutaneously inserted endovascular splints provide an alternative to surgery for abdominal aortic aneurysms.

F. Peripheral vascular disease, obstruction or occlusion of peripheral arteries by atherosclerotic plaque, is common and a leading cause of disability and amputation.

G. Smoking cessation and regular daily exercise are key components of treatment for peripheral vascular disorders such as atherosclerosis, thromboangiitis obliterans, and Raynaud disease.

H. Venous thrombosis, particularly of the deep veins of the legs and pelvis, develop as a result of venous stasis, blood vessel damage, and increased coagulability of the blood. The developing clot may fragment or break loose, becoming an embolus that typically lodges in the pulmonary circulation (pulmonary embolus). Chronic venous insufficiency and venous stasis may develop as a result of deep venous thrombosis.

I. Prophylactic anticoagulation and mobilization of the patient are the primary preventive measures for venous thrombosis. Monitoring coagulation studies and assessing for evidence of bleeding (overt or covert) are important nursing measures for the patient on anticoagulant therapy.

J. Lymphadenopathy (enlarged lymph nodes), lymphangitis (inflammation of the lymph vessels), and lymphedema are the most common disorders affecting the lymph system.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME ONE Have students practice blood pressure measurement in the learning lab.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME ONE Assign students to care for patients with hypertension/hypotension. Have the students analyze prescribed medication for the disorder and explain the effectiveness of the medication during post conference.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME TWO Have the students prepare a teaching tool to prevent disorders of the aorta and other major vessels.

SUGGESTIONS FOR CLINICAL ACTIVITY—LEARNING OUTCOME TWO Assign students to care for patients with disorders of the aorta and major vessels.

Assign students to observe surgery to correct an arterial disorder.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME THREE Compare and contrast the differences between peripheral arterial and peripheral venous disorders during class.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME THREE Assign the students to care for patients with a peripheral arterial disorder.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME FOUR Have the students prepare a teaching tool to help prevent the development of peripheral venous disorders.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME FOUR Assign the students to provide care to a patient with a peripheral venous disorder.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME FIVE Discuss the manifestations of lymph disorders during class.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME FIVE Assign students to care for patients with a disorder of the lymphatic system.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter 33 Nursing Care of Patients with Hematologic Disorders Learning Outcomes 1. Describe the pathophysiology and manifestations of red blood cell disorders, and outline the interprofessional care and nursing care of patients with these disorders.

2. Describe the pathophysiology and manifestations of white blood cell disorders, and outline the interprofessional care and nursing care of patients with these disorders.

3. Describe the pathophysiology and manifestations of lymphoid tissue disorders, and outline the interprofessional care and nursing care of patients with these disorders.

4. Describe the pathophysiology and manifestations of platelet and coagulation disorders, and outline the interprofessional care and nursing care of patients with these disorders.

Key Concepts I.

Red Blood Cell Disorders A. The Patient with Anemia 1. Abnormally low number of circulating RBCs, low hemoglobin concentration, or both 2. Physiology review a) Oxygen binds to hemoglobin for travel, releases from hemoglobin in capillaries to reach cells b) Amount of oxygen that reaches tissues depends on: (1) Available oxygen in the alveoli (2) The diffusing surface and capacity of the lungs (3) The number of RBCs and the amount and type of hemoglobin they contain (4) The ability of the cardiovascular system to transport blood and oxygen to the tissues 3. Pathophysiology and manifestations a) Depend on severity, may be asymptomatic b) Pallor of the skin, mucous membranes, conjunctiva, nail beds; heart and respiratory rates rise; angina, fatigue, dyspnea on exertion, night cramps; possible bone pain, headache, dizziness, and dim vision c) Heart failure may develop in severe anemia d) Blood loss anemia (1) Circulating blood volume decreases, cardiac output falls (2) Compensatory mechanisms: Heart rate increases; peripheral blood vessels and liver vessels constrict; fluid shifts from the interstitial to vascular compartment

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

e)

f)

(3) Acute: With sufficient iron, number of circulating RBCs and hemoglobin return to normal within 3 to 4 weeks after the bleeding episode (4) Chronic: Depletes iron stores; RBCs are microcytic and hypochromic Nutritional anemias (1) Nutrients necessary for erythropoiesis: Iron, protein, vitamins (particularly B, C, and E vitamins), other minerals (particularly folate) (2) Nutrient deficit from inadequate diet, malabsorption problems, or increased need for the nutrient (3) Iron-deficiency anemia: Most common type (a) Results in fewer numbers of RBCs, microcytic and hypochromic RBCs, as well as malformed RBCs (poikilocytosis) (b) Causes: Chronic bleeding, menstrual blood loss, inadequate intake, malabsorption, pregnancy and lactation (c) Particularly common in older adults (d) General manifestations of anemia: Brittle, spoon-shaped nails; cheilosis; a smooth, sore tongue; and pica (a craving for unusual substances, such as clay or starch) (4) Megaloblastic anemia: B12 and folic acid anemia; enlarged nucleated RBCs (a) Vitamin B12–deficiency anemia (i) B12 almost entirely from food derived from animals (ii) Pernicious anemia: Failure to absorb dietary vitamin B12 (a) Lack of intrinsic factor (iii) Manifestations: Pallor or slight jaundice and weakness; paresthesias in the extremities; problems with proprioception; difficulty maintaining balance (iv) Pernicious: Smooth, sore, beefy red tongue; diarrhea (b) Folic acid–deficiency anemia (i) Folic acid is found in green leafy vegetables, fruits, cereals, meats (ii) Risk factors: Older age, alcoholism, drug use, parenteral nutrition, pregnancy, rapid growth, hemodialysis, celiac sprue, and neural tube defects (iii) Manifestations: Pallor; progressive weakness and fatigue; shortness of breath; heart palpitations; glossitis, cheilosis, and diarrhea Hemolytic anemias: Premature destruction of RBCs (1) Lysis occurs in circulatory system and spleen (2) Leads to more immature RBCs (reticulocytes)

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(3) May be intrinsic, from disorders of blood cells, or extrinsic, from drugs, infection, toxins, and trauma (4) Sickle cell anemia: Autosomal recessive genetic defect of abnormally crescent-shaped RBCs (a) Most common in people of African descent (b) In hypoxia, low temperatures, excessive exercise, anesthesia, dehydration, infection, or acidosis: HbS crystallizes into rodlike structures that clump together and impair blood flow (c) Return to normal when normal conditions are restored (d) Repeated sickling and unsickling weaken cell membranes (e) Manifestations and complications (i) Pallor, fatigue, jaundice, and irritability. (ii) Sickle cell crisis: Occluded circulation, impaired erythropoiesis, or sequestration of large amounts of blood in the liver or spleen (a) Cause pain, swelling, and fever; may cause priapism (iii) Complications: Infarction of abdominal organs and structures, aseptic necrosis of affected bones, stroke, skin ulcers, Acute chest syndrome, pneumonia, pulmonary infarction, and pulmonary embolism (iv) Can affect structure and function of nearly every organ system (5) Thalassemia: Inherited disorders of hemoglobin synthesis (a) Fragile, hypochromic, microcytic RBCs called “target cells” (b) Different varieties affect different ethnic populations (c) Children with cases of thalassemia major rarely reach adulthood (d) Manifestations and complications (i) Minor: Often asymptomatic; mild splenomegaly; bronze skin coloring; and bone marrow hyperplasia (ii) Major: Heart failure; liver and spleen enlargement; bone marrow expansion and thinning; jaundice; hepatomegaly and splenomegaly; failure of heart, liver, pancreas (6) Acquired hemolytic anemia (a) Causes: Mechanical trauma from prosthetic heart valves, severe burns, hemodialysis, or radiation; autoimmune disorders; bacterial or protozoal infection; immune system–mediated responses; drugs, toxins, chemicals (b) Manifestations: Those of anemia, enlarged spleen, jaundice, deformed or pathologic fractures of bones in severe cases (7) Glucose-6 phosphate dehydrogenase (G6PD) anemia (a) Hereditary defect in RBC metabolism (b) Common in people of African and Mediterranean descent, more common in males

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

g)

(c) Manifestations when under stress: Pallor, jaundice, hemoglobinuria, elevated reticulocyte count Aplastic anemia (1) Bone marrow fails to produce all types of cells, leads to pancytopenia (2) Number of stem cells in the bone marrow is significantly reduced (3) Fanconi anemia: Rare aplastic anemia caused by defects of DNA repair (a) Some cases have unknown cause (b) Other cases follow exposure to radiation or certain chemical substances, antibiotics, chemotherapeutic drugs, viral infections (4) Manifestations: Fatigue, pallor, progressive weakness, exertional dyspnea, headache, and ultimately tachycardia and heart failure (a) Low platelets: Bleeding gums, bruising, nose bleeds (b) Low WBCs: Increased risk of infection

4. Interprofessional care a) Priority to ensure adequate tissue oxygenation b) Diagnosis (1) Complete blood count: Helps determine cause, type (2) Iron level and total iron-binding capacity (3) Serum ferritin (4) Sickle cell test (5) Hemoglobin electrophoresis (6) Schilling test: Measures B12 absorption (7) Bone marrow examination (8) Quantitative assay of G6PD c)

d) e) f)

Medications (1) Iron-deficiency: Oral and parenteral iron supplements (2) Vitamin B12 deficiency: Oral and parenteral B12 supplements (3) Folic acid deficiency: Oral folic acid supplements (4) Sickle cell: Hydroxyurea (a) Hydroxyurea (b) Sickle cell crisis: Oxygen therapy, narcotic analgesia (c) Acute chest syndrome: Oxygen therapy, folic acid (5) Thalassemia: Folic acid (6) Aplastic: Causative agent, other treatments Nutrition (1) Dietary modifications for nutritional deficiency anemias Blood transfusion (1) For cases from major blood loss or severe cases regardless of cause Integrative therapies

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Specific enzymes for nutritional anemias 5. Nursing care a) Assessment (1) Health history (2) Physical examination b) Priorities of care (1) Ensure adequate treatment of the underlying process (2) Provide care that supports the physical and psychologic responses to the disorder c) Diagnoses, outcomes, and interventions (1) Promote activity tolerance (a) Help identify ways to conserve energy (b) Help establish priorities (c) Encourage 8–10 hours of sleep at night (d) Monitor vital signs before and after activity (e) Discontinue activity in the case of: Chest pain, breathlessness, vertigo; palpitations or tachycardia; bradycardia; tachypnea or dyspnea; decreased systolic blood pressure (f) Instruct patient to abstain from smoking (2) Promote oral membrane health (a) Monitor condition of lips and tongue daily (b) Use mouthwash every 2–4 hours, avoid alcohol-based mouthwash (c) Provide frequent oral hygiene (d) Apply petroleum-based lubricating jelly to lips after oral care (e) Instruct to avoid hot, spicy, or acidic foods (f) Encourage eating four to six small meals daily (3) Reduce risk for decreased cardiac output (a) Monitor vital signs, breath sounds, and apical pulse (b) Assess for pallor, cyanosis, and dependent edema (c) Monitor for manifestation of anaphylaxis when administering parenteral iron preparations (4) Manage ADLs (a) Assist with ADLs (b) Discuss importance of rest periods 6. Transitions of care a) Discuss: Nutritional strategies; appropriate use of prescribed medications and supplements; energy conservation strategies; other treatment measures and followup b) Refer to community resources

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

B. The Patient with Myelodysplastic Syndrome 1. Group of blood disorders characterized by abnormal-appearing bone marrow and cytopenia (low numbers of circulating blood cells) 2. At least five variations of the disorder have been identified 3. Idiopathic: Affects older adults, men slightly more than women 4. Secondary risk factors: Environmental toxins, radiation therapy, chemotherapy, anemias 5. Chronic, progressive, eventually fatal 6. Pathophysiology a) Stem cells fail to reproduce and differentiate into the various types of blood cells b) Dysplastic (abnormal) blood cells produced 7. Manifestations a) May be asymptomatic b) Manifestations of anemia c) Manifestations of splenomegaly and hepatomegaly; abnormal bleeding tendencies, increased risk for infection 8. Interprofessional care a) Diagnosis (1) CBC reveals anemia (2) Bone marrow: May appear normal or contain increased myeloblasts (3) Serum erythropoietin, vitamin B12, serum iron, total iron-binding capacity, ferritin levels, and RBC folate levels b) Treatment (1) Classification systems to guide therapy (2) RBC blood transfusions (3) Iron chelation therapy: Deferoxamine (Desferal) (4) Blood cell growth factors (5) Platelet transfusion (6) Antibiotic therapy (7) Chemotherapy in cases on leukemia (a) Azacitidine may be more effective than other antileukemic drugs (8) Stem cell transplant: Only hope for cure (a) High risk 9. Nursing care a) Priorities of care (1) Ensure adequate treatment of the underlying process

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

b)

(2) Provide care that supports the physical and psychologic responses to the disorder Diagnoses, outcomes, and interventions (1) Promote activity intolerance (a) Monitor vital signs, breath sounds, and apical pulse (b) Help identify energy-conserving strategies (c) Help the patient and family establish priorities for activities (d) Suggest planning recreational activities following a transfusion (e) Encourage 8 to 10 hours of sleep (f) Discontinue activity in case of: Complaints of chest pain; palpitations, bradycardia, tachycardia, dyspnea; decreased systolic blood pressure; instruct patient not to smoke (g) Instruct the patient not to smoke (2) Teach health maintenance (a) Assess knowledge of disorder and the related treatments (b) Provide information about the disorder (c) Provide emotional support (d) Provide supervised learning and practice opportunities for administering parenteral medications

10. Transitions of care a) Discuss treatment options: Timing of and options for stem cell transplant, help patient evaluate the potential benefits and risks of treatment options C. The Patient with Polycythemia 1. Excess of RBCs, hematocrit higher than 55% 2. Pathophysiology a) Primary polycythemia (1) Cause unknown (2) Colonies of endogenous erythroid stem cells develop, produce RBCs in absence of erythropoietin (3) Complications: Thrombosis, hemorrhage, hypertension b) Secondary polycythemia (1) Abnormally high erythropoietin levels from kidney disease; erythropoietin-secreting tumors; chronic hypoxia; living at high altitudes; chronic heart or lung disease; smoking (2) Manifestations: Similar to those of primary, except splenomegaly does not develop 3. Manifestations a) Primary polycythemia:

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Hypertension; plethora; painful itching of fingers and toes; engorged retinal and cerebral vessels; weight loss and night sweats; drowsiness or delirium b) Secondary polycythemia: (1) Hypertension, headache, tinnitus, blurred vision, plethora, splenomegaly, severe pruritus, extremity pain, weight loss, night sweats, GI bleeding, intermittent claudication, symptoms from thrombosis within various organs 4. Interprofessional care a) Diagnosis (1) Primary (a) Serum erythropoietin levels: Low (b) Bone marrow studies: Hyperplasia of all hematopoietic elements (2) Secondary (a) Erythropoietin levels: Low (b) Bone marrow: Red stem cell hyperplasia b) Treatments (1) Phlebotomy: Periodic removal of blood (2) PV: Chemotherapeutic agents may be used (3) Hydroxyurea may be used to suppress marrow function (4) Antihistamines, interferon alpha, or other treatments for pruritus (5) Aspirin for thrombosis 5. Nursing care a) Health promotion: Dangers of smoking b) Patient teaching: Hydration; measures to prevent blood stasis; importance to report manifestations of thrombosis or bleeding c) Clinical issues (1) Ambivalence regarding smoking cessation (2) Discomfort from altered blood flow in the extremities (3) Potential poor tissue perfusion II. White Blood Cell Disorders A. The Patient with Leukemia 1. Ratio of red to white blood cells is reversed 2. Replacement of bone marrow by malignant immature WBCs; abnormal immature circulating WBCs; and infiltration of these cells into liver, spleen, and lymph nodes 3. Physiology review a) WBC precursor cells: Myeloblasts, monoblasts, and lymphoblasts b) WBC function: Immune system c) Neutrophils: Active phagocytes

.

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

d) Monocytes and macrophages: Phagocytes that dispose waste material from tissues e) Eosinophils: Involved in allergic response and parasitic infections f) Basophils: Involved in inflammatory response g) Lymphocytes: B cells and T cells (1) B, involved in humoral response: Produce antibodies to specific antigens (2) T, involved in cell-mediated response 4. Pathophysiology a) Leukemic cells are ineffective in inflammatory and immune processes b) Replace hematopoietic elements in the marrow c) Severe anemia, splenomegaly, and bleeding difficulties result d) Leukemic cells travel through circulatory system, infiltrate other body tissues 5. Incidence and risk factors a) Diagnosed 10 times more often in adults than in children b) Risk factors: Men more than women, certain genetic disorders, environmental risk factors (smoking, benzene), ionizing radiation, human T-cell leukemia/lymphoma virus-1 6. Manifestations a) Manifestations from: Anemia, infection, and bleeding b) Leukemic cell infiltration: Increase metabolism, increase leukocyte destruction, pain and tissue swelling, manifestations of increased intracranial pressure, impaired renal function, increased uric acid into circulation c) Without treatment, usually fatal d) With treatment, survival rates vary due to type 7. Classifications a) Acute myeloid leukemia (1) Uncontrolled proliferation of myeloblasts and hyperplasia of the bone marrow and spleen (2) Most common form of acute cases in adults, treatment induces remission in 66% cases (3) Manifestations: (a) From neutropenia and thrombocytopenia (i) Recurrent severe infections, petechiae, purpura, ecchymoses (bruising), epistaxis (nosebleeds), hematomas, hematuria, and GI bleeding (b) Bone pain and anemia b) Chronic myeloid leukemia .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

c)

d)

(1) Abnormal proliferation of all bone marrow elements (2) Associated with a chromosome abnormality called the Philadelphia chromosome (3) Manifestations: Often asymptomatic in early stages (a) Those of anemia, abdominal discomfort, hypermetabolism, bleeding and bruising (b) Terminal blast crisis phase: Constitutional manifestations, splenomegaly, and infiltration of leukemic cells into the skin, lymph nodes, bones, and central nervous system (i) 2–4 months survival Acute lymphocytic leukemia (1) Most common type in children and young adults (2) Most cases from malignant transformation of B cells (3) Lymphoblasts accumulate in the bone marrow, lymph nodes, and spleen (4) Usually rapid onset (5) Manifestations (a) Infections, bleeding, and anemia, bone pain, lymphadenopathy, liver enlargement (b) With infiltration of CNS: Headaches, visual disturbances, vomiting, seizures Chronic lymphocytic leukemia (1) Proliferation and accumulation of small, abnormal, mature lymphocytes in the bone marrow, peripheral blood, and body tissues (2) Slow onset (3) Manifestations (a) Vague complaints of weakness or malaise (b) Diagnosed by clinical findings

8. Interprofessional care a) Diagnosis (1) CBC with differential (2) Platelet count (3) Bone marrow examination b) Chemotherapy: Treatment of choice for most types (1) Single agent or combination (2) Induction phase: Doses are high, interfere with production of normal blood cells, too (a) Circulating mature blood cells are not affected (3) Colony-stimulating factors (CFSs): Following induction phase, stimulate bone marrow function

.

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

c)

d)

e)

f)

g)

(a) Granulocyte-macrophage CSF (GM-CSF) and granulocyte CSF (GCSF) (4) Postremission phase: To eradicate any remaining cells and prevent relapse Radiation therapy (1) Damages cellular DNA (2) Affects bone marrow and cancer cells more than normal cells Bone marrow transplant (1) Follows chemo or radiation (2) Allogeneic BMT: Bone marrow of healthy donor (a) Marrow is aspirated and infused through a central venous line into the recipient (3) Autologous BMT: Patient infused with own marrow (a) Marrow is aspirated during period of remission, frozen, and stored, used after other treatment (4) Prior to transplant, patient is susceptible to infection Stem cell transplant (1) Donor takes hematopoietic growth factors prior to harvesting (2) Peripheral blood removed, white cells separated, and administered to the patient (3) Similar risks as bone marrow transplant (4) Graft-versus-host disease (a) Immune cells of donated marrow/stem cells attack patient’s tissue (b) Acute: Within days or weeks of transplant, pruritic, maculopapular rash that begins on the palms and soles of the feet, and may extend over the entire body (c) Vaso-occlusive disease of the liver may follow (d) Treated with antibiotics, steroids, and sometimes immunosuppressive drugs Biologic therapy (1) Administration of cytokines such as interferons and interleukins (2) Moderate immune function and inhibit abnormal cell proliferation (3) Interferon-α may be used to treat some leukemias, particularly CML Integrative therapies (1) None proven to have sustained benefit in treating leukemia (2) Reduction of oral discomfort demonstrated with coping skills and hypnosis

9. Nursing care a) Assessment (1) Health history (2) Physical examination .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

b)

Priorities of care (1) Ensure adequate treatment of the underlying process (2) Provide care that supports the physical and psychologic responses to the disorder

c)

Diagnoses, outcomes, and interventions (1) Reduce risk for infection (a) Promptly report manifestations of infection (b) Institute infection protection measures (c) Monitor vital signs and oxygen saturation every 4 hours (d) Monitor neutrophil levels for relative risk of infection (e) Explain infection precautions, restrictions, and their rationale (2) Promote good nutrition (a) Weigh regularly and evaluate weight loss over time (b) Address causative/contributing factors to inadequate food/fluid intake (provide mouth care; consider texture and taste preferences; assist to sit; provide appetizing environment; provide medication and rest before meals; offer small frequent meals) (3) Promote oral membrane health (a) Inspect buccal region, gums, sublingual area, throat daily for swelling or lesions; ask about oral pain (b) Culture any oral lesions (c) Assist with mouth care (d) Administer medications to treat infection or relieve pain (e) Instruct to avoid: Alcohol-based mouthwashes, citrus fruit juices, spicy foods, very hot and very cold foods, alcohol, crusty foods (4) Reduce risk of bleeding (a) Assess vital signs every 4 hours and body systems every shift for bleeding (petechiae, ecchymoses, and purpura; mucous membrane bleeding; stool and urine; vaginal; neurologic and GI manifestations of blood loss) (b) Avoid invasive procedures when possible (c) Apply pressure to injection sites for 3–5 minutes and to arterial punctures for 15–20 minutes (d) Instruct to avoid forcefully blowing or picking the nose, forceful coughing or sneezing, straining to have a bowel movement (e) Monitor and report blood and urine tests (f) Maintain adequate hydration and administer medications (5) Support the grief process

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

d)

(a) Discuss roles of the patient and family and stress management in the past; assess coping skills and effectiveness; evaluate cultural factors that affect grief reactions (b) Use therapeutic communication skills to facilitate open discussion of losses and provide permission to grieve (c) Provide information about agencies that may help in resolving grief Transitions of care (1) Encourage self-care (2) Provide information about the disease and treatment (3) Prevent infection and injury (4) Promote nutrition

III. Lymphoid Tissue Disorders A. The Patient with Malignant Lymphoma 1. Malignancies of lymphoid tissue 2. Proliferation of lymphocytes, histiocytes (resident monocytes or macrophages), and their precursors or derivatives 3. Closely related to lymphocytic leukemias 4. Pathophysiology a) Hodgkin disease (1) Most often between ages 15–35 and over 50; more common in men than women (2) Cause unknown; genetic factors and Epstein-Barr virus may contribute (3) One of the most curable cancers (4) Reed-Sternberg cells in lymph nodes, may invade other body tissues (a) Spleen, liver, lungs, digestive tract, CNS may be affected (5) Immune response impaired (6) Classifications: Classic and nodular lymphocyte-predominant Hodgkin’s b) Non-Hodgkin lymphoma (1) Malignancies do not contain Reed-Sternberg cells (2) More common type (3) Older adults more often affected; more often affects men (4) Cause unknown; genetic and environmental factors play a role (5) Extranodal spread may involve the nasopharynx, GI tract, bone, CNS, thyroid, testes, and soft tissue (6) Prognosis varies 5. Incidence and risk factors a) Risk factors: Genetic factors, immunosuppression, infectious agents, chemical exposure .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

6. Manifestations: a) Hodgkin disease (1) One or more painlessly enlarged lymph node(s) (2) Systemic manifestations: Persistent fever, night sweats, fatigue, and weight loss (3) Malaise, pruritus, and anemia indicate spread of the disease b) Non-Hodgkin lymphoma: (1) Early: Similar to Hodgkin’s (2) Systemic manifestations: Less common than in Hodgkin’s (3) Organ system involvement: abdominal pain, nausea, vomiting (a) CNS: Headaches, peripheral or cranial nerve symptoms, altered mental status, or seizures 7. Interprofessional care a) Diagnosis (1) CBC (2) Erythrocyte sedimentation rate (ESR) (3) Chemistry studies of major organ function (4) Chest x-ray (5) CT scans of chest, abdomen, and pelvis (6) PET or gallium scans (7) Biopsy of the largest, most central enlarged lymph node and of bone marrow to establish diagnosis based on presence or lack of ReedSternberg cells b) Staging (1) Ann Arbor Staging System (a) I: Single lymph node region or lymphoid structure (b) II: Two or more lymph node regions on the same side of diaphragm (c) III: Lymph node regions on both sides of diaphragm (d) IV: Extranodal site (e) A: No systemic symptoms; and B: Systemic symptoms c) Chemotherapy (1) Combination chemo choice based on stage and patient condition (a) CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone), ABVD (doxorubicin, bleomycin, vinblastine, and dacarbazine), MOPP (nitrogen mustard, vincristine, procarbazine, and prednisone), and ChlVPP (chlorambucil, vinblastine, procarbazine, and prednisone) d) Immunotherapy (1) Rituximab (Rituxan): Monoclonal antibody used to destroy the CD20 antigen in B lymphocytes e) Radiation therapy .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

f) g)

(1) Sometimes used in early-stage Hodgkin’s (2) Used in combination with chemo in later stages and in non-Hodgkin’s Stem cell transplant (1) Autologous, for patients who experience remission Complications of treatment (1) Permanent sterility, immunosuppression, anemia, bleeding, secondary cancers and cardiac injury, leukemia, coronary heart diseases, hypothyroidism

8. Nursing care a) Assessment (1) Health history (2) Physical examination b) Priorities of care (1) Ensure adequate treatment of the underlying process (2) Provide care that supports the physical and psychologic responses to the disorder c) Diagnoses, outcomes, and interventions (1) Manage fatigue (a) Inquire about fatigue and malaise (b) Encourage enjoyable but quiet activities (c) Encourage establishing priorities, including rest periods (d) Encourage delegation of some responsibilities to others (e) Encourage use of energy-saving devices (f) Encourage diet high in carbohydrates and fluids (2) Manage nausea (a) Assess precipitating factors and relief measures (b) Teach measures to prevent or relieve nausea (c) Provide small frequent meals (d) Assist with oral care, general hygiene, and environmental control (e) Identify and provide preferred foods (f) Assist to sit following meals (3) Manage feelings about changes to appearance (a) Assess perception of body image (b) Discuss the risk for and measures to cope with alopecia; teach proper scalp care; eye protection (c) Discuss available resources for financial assistance with purchase of wigs (4) Promote sexual function (a) Encourage discussion of actual or potential sexual dysfunction or sterility with the patient and significant other

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

d)

(b) Assess knowledge, provide information, clarify misconceptions; discuss measures for coping (c) Refer for counseling as needed (5) Reduce risk for injury to skin (a) Assess skin, especially in areas undergoing radiation (b) Provide and teach measures to promote comfort and relieve itching Transitions of care (1) Discuss: Illness, treatment, and side effects of treatment; skin care; symptoms to report; use of analgesics and alternate relief strategies; respiratory care; planning ADLs with time for rest; measures to relieve nausea (2) Refer to local chapter of the American Cancer Society

B. The Patient with Multiple Myeloma 1. Plasma cells multiply uncontrollably and infiltrate the bone marrow, lymph nodes, spleen, and other tissues 2. Pathophysiology a) Malignant plasma cells produce abnormally large amounts of immunoglobulin M protein b) Interferes with normal antibody production and impairs humoral immune response c) Infiltrates and weakens bones first, then other tissues via bloodstream 3. Incidence and risk factors a) Increases with age b) Most diagnosed after age 65 4. Manifestations a) Develops slowly b) Bone pain is most common symptom c) With progression: Pain increases in severity, hypercalcemia, and manifestations of neurologic dysfunction (lethargy, confusion, weakness); recurrent infections; Bence Jones proteins may lead to renal failure with azotemia and uremia d) 15% of patients die within 3 months of diagnosis e) Disease is usually chronic and progressive f) Acute terminal stage: Pancytopenia, widespread organ infiltration 5. Interprofessional care a) Diagnosis and staging (1) X-rays and other radiologic studies of the bone .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

b)

(2) Bone marrow examination (3) CBC shows anemia, elevated ESR (4) Protein electrophoresis shows spike of antibody (5) Serum calcium, creatinine, uric acid, BUN levels: Elevated (6) Urinalysis: Bence Jones protein (7) Biopsy of myeloma lesions (8) Staging based on the hemoglobin and serum calcium levels, amount of abnormal protein, degree of bone involvement Treatment (1) No cure (2) Induction chemo followed by stem cell transplant and maintenance chemo (3) Localized radiation may be used (4) Hypercalcemia treated with hydration, bisphosphonate therapy, calcium, vitamin D, and fluoride supplements (5) Acute renal failure: Plasma exchange therapy

6. Nursing care a) Assessment (1) Health history (2) Physical examination b) Priorities of care (1) Ensure adequate treatment of the underlying process (2) Provide care that supports the physical and psychologic responses to the disorder c) Diagnoses, outcomes, and interventions (1) Manage chronic pain (a) Assess pain (b) Determine position of greatest comfort, assist into position, support with pillows (c) Provide uninterrupted rest periods (d) Teach adjunctive pain relief strategies, analgesic use (e) Report unrelieved pain to healthcare provider (2) Promote physical mobility (a) Assist to change position every 2 hours (b) Provide trapeze and assist in repositioning (3) Reduce risk for injury (a) Place needed items close at hand (b) Provide safety measures to prevent falls from bed (c) Provide environment as free as possible of obstacles with adequate lighting d) Transitions of care .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Discuss: Strategies for home management; potential complications and manifestations to report (2) Refer to community support resources C. The Patient with Neutropenia 1. Leukopenia: Decrease in total circulating WBC count 2. Neutrophils most often affected 3. May be either congenital or acquired 4. Risk factors: Prolonged infection, hematologic disorders, starvation, autoimmune disorders, chemotherapy, and other drugs 5. Agranulocytosis: Severe neutropenia; less than 200 cells/µm a) Aplastic anemia is a risk factor 6. Pathophysiology a) Neutrophils: Phagocytes, engulf and degrade invading organisms (1) Lifespan in peripheral blood is less than 1 day (2) When granulopoiesis is suppressed, numbers fall rapidly 7. Manifestations a) Opportunistic infections develop, commonly affect respiratory tract, mouth mucosa, GI tract, and vagina (1) Manifestations: Malaise, chills, and fever with extreme weakness, fatigue 8. Interprofessional care a) Diagnosis: Based on manifestations, risk factors, and CBC b) Medications: Hematopoietic growth factors (1) Antibiotics for infections c) Protective isolation to prevent exposure to antigens d) When related to chemo, chemo is halted, at least temporarily 9. Nursing care a) Early identification of condition b) Protection of the patient from infection D. The Patient with Infectious Mononucleosis 1. Invasion of B cells into oropharyngeal lymphoid tissues by the Epstein-Barr virus (EBV) 2. Usually benign and self-limiting 3. Most common in ages 15–30 4. Saliva is primary mode of transmission 5. Associated with some cancers .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

6. Pathophysiology a) Infected B cells are destroyed as virus replicates b) Incubation period: 4–8 weeks, insidious onset 7. Manifestations a) Headache, malaise, fatigue, fever, sore throat, cervical lymphadenopathy, sometimes an enlarged spleen 8. Interprofessional and nursing care a) Diagnosis (1) Increased and abnormal lymphocytes and monocytes (2) Platelet count often is low b) Treatment: Bed rest and analgesic agents c) Nursing care (1) Educational for prevention of disease spread IV. Platelet and Coagulation Disorders A. The Patient with Thrombocytopenia 1. Platelet count under 100,000/mL of blood 2. Can lead to abnormal bleeding 3. Can be primary or secondary 4. Secondarily from: Aplastic anemia, bone marrow malignancy, infection, radiation therapy, drug therapy, enlarged spleen, disseminated intravascular coagulation (DIC) 5. Physiology review a) Thrombopoietin: Controls platelet production in bone marrow b) Platelets activate clotting process in case of damaged vessel wall 6. Pathophysiology and manifestations a) Immune thrombocytopenic purpura (1) Autoimmune disorder in which platelet destruction is accelerated (2) Manifestations (a) Petechiae and purpura; bruising; frequent bleeding from mucous membranes (b) Spontaneous intracranial bleeding is rare but possible (c) Associated symptoms: Weight loss, fever, and headache (3) Incidence and course (a) Acute: Follows viral illness, lasts 1–2 months, resolves (b) Chronic: Most often affects adults between 20 and 50, often in people with other autoimmune disorders b) Thrombotic thrombocytopenic purpura (1) Thrombi occlude arterioles and capillaries of the microcirculation (2) Incidence is increasing and cause is unknown (3) Manifestations .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(a) May be acute or chronic (b) Purpura and petechiae; headache, seizures, and altered consciousness c) Heparin-induced thrombocytopenia (1) Abnormal response to heparin therapy (2) Type I: Platelets clump and are removed by phagocytosis (3) Type II: Heparin and platelets form platelet factor 4, acts as foreign antigen, stimulates antibody production (a) Platelets aggregate, are removed, leads to thrombocytopenia (4) Manifestations (a) Bleeding (b) Manifestations of an arterial or venous thrombosis (c) Rarely, inflammatory response creates manifestations of acute pulmonary embolism and cardiopulmonary arrest 7. Interprofessional care a) Diagnosis (1) CBC with platelet count (2) Antinuclear antibodies (ANA) (3) Serologic studies for hepatitis viruses, cytomegalovirus (CMV), Epstein-Barr virus, toxoplasma, and HIV (4) Bone marrow examination for aplastic anemia and megakaryocyte production b) Medications (1) Oral glucocorticoids to suppress autoimmune response (2) Immunosuppressive drugs may be used (3) Prompt withdrawal of heparin therapy, substitute with nonheparin anticoagulant c) Treatments (1) Platelet transfusions may be used (2) Plasmapheresis or plasma exchange therapy for acute thrombotic thrombocytopenic purpura d) Surgery (1) Splenectomy: For ITP relapse after discontinuation of glucocorticoids 8. Nursing care a) Assessment (1) Health history (2) Physical examination b) Priorities of care (1) Ensure adequate treatment of the underlying process

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

c)

d)

(2) Provide care that supports the physical and psychologic responses to the disorder Diagnosis, outcomes, and interventions (1) Reduce risk of bleeding (a) Monitor vital signs, heart and breath sounds every 4 hours and assess for other manifestations of bleeding (b) Apply pressure to puncture sites for 3–5 minutes or arterial puncture sites for 15–20 minutes (c) Instruct to avoid forcefully blowing the nose or picking nose, straining to have a bowel movement, and forceful coughing or sneezing (2) Promote oral membrane health (a) Frequently assess for mouth bleeding, inquire about oral pain (b) Encourage use of soft toothbrush, rinsing with saline every 2–4 hours (c) Instruct to avoid alcohol-based mouthwashes, foods of extreme temperature, alcohol, and crusty foods Transitions of care (1) Discuss: Nature of the disorder, usual course, and the treatment plan; desired and adverse effects of medications; risks and benefits of treatment options; importance of follow-up visits; measures to reduce the risk of bleeding

B. The Patient with Hemophilia 1. Group of hereditary clotting factor disorders that lead to persistent and sometimes severe bleeding 2. Physiology review a) Clotting process 3. Pathophysiology a) Hemophilia A: Deficiency or dysfunction of clotting factor VIII (1) X-linked recessive disorder (2) Severity varies b) Hemophilia B: Deficiency in clotting factor IX (1) About 15% of cases (2) Clinically the same as type A c) Von Willebrand’s disease: Deficit of, or defective, von Willebrand (vW) factor (1) Most common bleeding disorder (2) Bleeding is rarely severe d) Hemophilia C: Deficiency in clothing factor XI (1) Usually mild 4. Manifestations .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) Hemarthrosis b) Easy bruising and cutaneous hematoma formation with minor trauma c) Bleeding from the gums and prolonged bleeding following minor injuries or cuts d) GI bleeding, with hematemesis, occult blood in the stools, gastric pain, or abdominal pain e) Spontaneous hematuria or epistaxis (nosebleed) f) Pain or paralysis due to the pressure of hematomas on nerves 5. Interprofessional care a) Diagnosis (1) Serum platelet levels (2) Coagulation studies: APTT, bleeding time, and prothrombin time (3) Factor assays (4) Amniocentesis or chorionic villus sampling to identify genetic defect b) Medications (1) Clotting factors replaced prophylactically before surgery and dental procedures, and used in severe cases for treatment (a) Fresh-frozen plasma, cryoprecipitates, or concentrates (b) Desmopressin acetate (2) Aspirin is avoided 6. Nursing care a) Assessment (1) Health history (2) Physical examination b) Priorities of care (1) Ensure adequate treatment of the underlying process (2) Provide care that supports the physical and psychologic responses to the disorder c) Diagnosis, outcomes, and interventions (1) Reduce risk for bleeding (a) Monitor for signs of bleeding (b) Avoid invasive procedures (c) If bleeding occurs, control blood loss with gentle pressure, ice, or a topical hemostatic agent, such as absorbable gelatin sponge, microfibrillar collagen hemostat, or topical thrombin (d) Instruct to avoid activities that increase risk of trauma (2) Promote health maintenance (a) Assess knowledge of disorder and related treatments (b) Provide information, emotional support, instruction on administering clotting factors, and topical hemostatic agents d) Transitions of care .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Discuss: Recognizing manifestations of internal bleeding; self-care for hemarthrosis; ensuring safe home environment; practicing good dental hygiene; following safer-sex practices; preparing and administering IV medications (2) Refer patient to community resources C. The Patient with Disseminated Intravascular Coagulation 1. Widespread intravascular clotting and bleeding 2. Clinical syndrome that develops as a complication of a wide variety of other disorders 3. Pathophysiology a) Triggered by endothelial damage, release of tissue factors into the circulation, or inappropriate activation of the clotting cascade by an endotoxin b) Extensive thrombin leads to unrestricted clot formation c) Widespread clotting occurs within the microvasculature d) Thrombi and emboli impair tissue perfusion, leading to ischemia, infarction, and necrosis e) Clotting activates fibrinolytic processes that begin to break down clots f) Hemorrhage occurs 4. Manifestations a) Frank hemorrhage from incisions b) Oozing of blood from punctures, intravenous catheter sites c) Purpura, petechiae, bruising d) Cyanosis of extremities e) GI bleeding or hemorrhage f) Dyspnea, tachypnea, bloody sputum g) Tachycardia, hypotension h) Hematuria, oliguria, acute renal failure i) Manifestations of increased intracranial pressure: Decreased level of consciousness, papillary, motor, and sensory changes j) Mental status changes 5. Interprofessional care a) Diagnosis (1) CBC and platelet count (2) Coagulation studies (3) Fibrin degradation products analysis b) Treatments (1) Fresh frozen plasma and platelet concentrations for bleeding

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(2) Heparin when bleeding not controlled with plasma and platelets, and with manifestations of thrombotic problems 6. Nursing care a) Assessment (1) Health history (2) Physical examination b) Priorities of care (1) Ensure adequate treatment of the underlying process (2) Provide care that supports the physical and psychologic responses to the disorder c) Diagnoses, outcomes, and interventions (1) Promote effective tissue perfusion (a) Assess extremity pulses, warmth, and capillary refill (b) Monitor level of consciousness and mental status (c) Reposition every 2 hours (d) Discourage crossing and elevating legs and minimize use of tape, binders, nonadhesive dressings (2) Promote adequate tissue perfusion (a) Monitor oxygen level and administer oxygen therapy (b) Place in Fowler’s or semi-Fowler’s position (c) Maintain best rest (d) Encourage deep breathing and effective coughing (e) Institute cautious nasotracheal suctioning if cough is ineffective (f) Administer analgesics and antianxiety drugs as needed (3) Manage pain (a) Assess pain and analgesic effectiveness (b) Handle extremities gently (c) Apply cool compresses to painful joints (4) Manage fear (a) Encourage the patient and family to vocalize concerns (b) Answer questions truthfully (c) Help with coping strategies and teach relaxation techniques (d) Provide emotional support (e) Maintain calm environment (f) Respond quickly when the patient asks for help d) Transitions of care (1) Discuss patient’s specific needs, medication administration, manifestations of excessive bleeding (2) Provide referral to community resources

Chapter Highlights .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

A. Anemia is the most common disorder of the red blood cells; nutritional deficiencies are the most common causes of anemia. Its manifestations relate to the function of RBCs and hemoglobin, transporting oxygen to the cells: Fatigue, increased respiratory and heart rates, shortness of breath with activity, and pallor.

B. Genetically transmitted disorders such as sickle cell disease and thalassemia can cause significant anemia and associated problems in affected populations. These patients require teaching and episodic acute care for crises such as a vaso-occlusive crisis in sickle cell disease.

C. Nursing care related to anemia is primarily educational to prepare the patient for effective self-care, including diet, prescribed medications, and measures to prevent sickling episodes (for patients with sickle cell disease).

D. Manifestations of the leukemias reflect the altered ability of abnormal WBCs to perform effective immune surveillance and crowding of the bone marrow and other organs by rapidly proliferating cells. Frequent sore throats, increased risk for infection, and manifestations of anemia and thrombocytopenia are seen, as well as an enlarged spleen and abdominal pain.

E. Four major subgroups of leukemia are identified: Acute and chronic myeloid leukemias and acute and chronic lymphocytic (or lymphoblastic) leukemias. The primary population affected differs for each of these leukemias, as does their course.

F. Genetic alterations and certain viruses are linked to the development of leukemia, as are exposure to chemotherapy drugs, environmental toxins, and ionizing radiation.

G. Lymphocytic leukemias and lymphomas are closely related disorders.

H. Nursing care for patients with leukemia and lymphoma focuses on reducing the risk for infection and bleeding, managing the effects of chemotherapy and radiation therapy, and, in some cases, caring for patients before and after bone marrow or stem cell transplant.

I. The major risks associated with bone marrow and stem cell transplant are infection prior to and immediately following the transplant and graft-versus-host disease, a potentially fatal condition. A pruritic rash and desquamation of the palms and soles; abdominal pain, nausea, and diarrhea; and jaundice and elevated liver enzymes are common early manifestations of GVHD. J. The treatment of and nursing care for patients with lymphomas (including Hodgkin disease and non-Hodgkin lymphoma) is similar to that provided for patients with leukemia.

K. Multiple myeloma is a malignancy of plasma cells, B lymphocytes that produce antibodies.

L. Circulating M proteins and Bence Jones proteins in the urine are seen in multiple myeloma. The usual presenting manifestation is bone pain. Pathologic fractures and hypercalcemia are common complications of multiple myeloma as bone is destroyed.

M. Bleeding and clotting disorders can result from either inadequate platelets (thrombocytopenia) or disruption of the clotting mechanisms (hemophilia, disseminated intravascular coagulation). Petechiae and purpura are common manifestations of bleeding/clotting disorders.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

N. Hemophilias are genetically transmitted disorders. Hemophilia A and B are transmitted on the X chromosome (sex-linked) from mother to son. Von Willebrand’s disease, the most common bleeding disorder, is transmitted as an autosomal dominant disorder and affects men and women equally.

O. Hemophilias are treated by replacement of the missing clotting factor and measures to prevent injury and bleeding.

P. Disseminated intravascular coagulation is a disorder of widespread microvascular clotting. It is commonly precipitated by sepsis, but also may occur with conditions such as major trauma, malignancy, or as an obstetric emergency.

Q. In DIC, platelets and clotting factors are consumed by the abnormal clotting processes, leading to manifestations of bleeding, including frank hemorrhage, hematuria, oozing blood from parenteral and intravenous injection sites, and GI bleeding. Blood flow to organs and tissues is compromised by clot formation, leading to manifestations such as cyanosis of extremities, abdominal pain, renal failure, and changes in mental status and level of consciousness. Nursing care is supportive, focusing on administering prescribed treatments and monitoring and supporting cardiovascular, respiratory, and renal function.

SUGGESTIONS FOR CLASSROOM ACTIVITY- LEARNING OUTCOME ONE Assign each major hematologic disorder to a small group of students. Have the students explain how the disorder relates to the pathophysiology of the hematological system as if they were explaining it to a lay audience.

In the same groups, have the student groups explain the pathophysiology of their assigned disorders

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTION FOR CLINICAL ACTIVITY- LEARNING OUTCOME ONE Assign the students to care for patients with a red blood cell disorder.

SUGGESTION FOR CLASSROOM ACTIVITY- LEARNING OUTCOME TWO Have students list the possible sources of nosocomial infection that are of danger to a patient undergoing bone marrow or stem cell transplantation. Help students relate common nursing interventions to the development of those infections, focusing on prevention.

SUGGESTION FOR CLINICAL ACTIVITY- LEARNING OUTCOME TWO Assign students to care for patients with a white blood cell disorder.

SUGGESTION FOR CLASSROOM ACTIVITY- LEARNING OUTCOME THREE Assign the different classifications of leukemia to small groups of students. Have each group explain the pathophysiology of the disease and the nursing care required.

SUGGESTION FOR CLINICAL ACTIVITY- LEARNING OUTCOME THREE Assign students to care for patients with a lymph tissue disorder.

SUGGESTIONS FOR CLASSROOM ACTIVITY- LEARNING OUTCOME FOUR Have the students create a teaching tool that focuses on the types and pathophysiology of the different types of hemophilia.

Invite a Critical Care nurse to explain the care required for a patient with disseminating intravascular coagulation.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter 34 Assessing the Respiratory System

Learning Outcomes 1. Describe the anatomy, physiology, and functions of the nose and sinuses, pharynx, larynx, trachea, lungs, pleura, bronchi and alveoli, and rib cage and intercostal muscles, and identify abnormal findings that may indicate impairment of the respiratory system.

2. Outline the components of the assessment of the respiratory system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.

3. Differentiate considerations for assessing the respiratory system of older adults, veterans, individuals in the LGBTQI population, and adults with sequelae of childhood/congenital conditions.

4. Summarize topics that nurses teach to promote healthy tissue integrity across the lifespan.

Key Concepts I.

Anatomy, Physiology, and Functions of the Respiratory System A. Events in respiration: ventilation, perfusion, diffusion B. The upper respiratory system 1. Nose and sinuses a) Nose (1) Nasal hairs filter air (2) Mucus traps dust and bacteria, contains lysozyme that destroys bacteria (3) Mucosal ciliated cells move accumulated mucus to pharynx to be swallowed (4) Mucosa warms air b) Paranasal sinuses (1) Located in frontal, spheoid, ethmoid, and maxillary bones (2) Lighten skull, assist in speech, produce mucus c) Mouth: alternate airway 2. Pharynx a) Nasopharynx: passageway for air (1) Tonsil and adenoids: masses of lymphoid tissues (a) Trap and destroy infectious agents entering with the air (2) Eustachian tubes connect nasopharynx with middle ear b) Oropharynx: passageway for air and food (1) Behind oral cavity, from soft palate to hyoid bone c) Laryngopharynx: passageway for air and food

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) From hyoid bone to larynx 3. Larynx: passageway for air, routes food and air to proper passageways, contains vocal cords a) Inlet open for air, closes during swallowing b) Framed by throid, cricoid, and epiglottis cartilages c) Cough reflex to keep substances other than air out 4. Trachea a) Begins at inferior larynx, descends anteriorly to the esophagus, enters mediastinum, divides to become primary bronchi of lungs b) Seromucous glands produce mucus C. The lower respiratory system 1. Lungs a) Hilus: on mediastinal surface of each lung (1) Where blood vessels enter and exit lungs b) Stroma: elastic connective tissue c) Left lung: smaller, has two lobes d) Right lung: has three lobes e) Vascular system: (1) Pulmonary arteries: deliver blood for oxygenation (a) Within lungs, branch in capillary network, surround alveoli (2) Pulmonary veins: oxygenated blood to heart (3) Bronchial arteries, bronchia and pulmonary veins: take blood to and from lungs 2. Pleura a) Parietal pleura: lines thoracic wall and mediastinum b) Visceral pleura: covers external lung surfaces c) Pleural fluid: lubricating, serous fluid for lung movement 3. Bronchi and alveoli a) Trachea divides into right and left primary bronchi b) Bronchial tree: bronchi subdivide into smaller bronchi, into bronchioles, end in terminal bronchioles c) Terminal bronchioles branch into alveolar ducts, lead to alveolar sacs, to alveoli d) Alveoli: location of oxygen and carbon dioxide exchange by simple diffusion (1) Walls covered with layer of squamous epithelia cells over thin basement membrane (2) External surface covered with pulmonary capillaries e) Alveoli cluster around alveolar sacs, open into atrium

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

4. Rib cage and intercostal muscles a) 12 pairs of ribs, which articulate with the thoracic vertebrae b) Sternum: manubrium, body, and xiphoid process c) Intercostal spaces: spaces between ribs d) Inspiratory muscles: intercostal muscles between ribs and diaphragm D. Factors Affecting Respiration 1. Respiratory volume and capacity a) Pulmonary function tests determine (1) Total lung capacity (TLC): volume at maximum inflation of lungs (a) Calculated from: tidal volume (TV), inspiratory reserve volume (IRV), expiratory reserve volume (ERV), residual volume (RV) (2) Vital capacity: amount that can be exhaled after maximal inspiration (a) Calculated from: inspiratory capacity, functional residual capacity (FRC), forced expiratory volume (FEV1), forced vital capacity (FVC), minute volume (MV) 2. Air pressures a) Inspiration: diaphragm and intercostal muscles contract, create pressure gradient, air fills lungs b) Expiration: primarily passive process from elasticity of lungs when inspiratory muscles relax c) Intrapulmonary pressure: pressure within the alveoli, changes constantly with inhalation and exhalation d) Intrapleural pressure: within pleural space, also rises and falls with breathing, but is always less than intrapulmonary pressure e) Pressures necessary for breathing and to prevent lung collapse 3. Oxygen, carbon dioxide, and hydrogen ion concentrations a) Rate and depth of respirations controlled by respiratory center in medulla oblongata and pons of brain and chemoreceptors in medulla and carotid and aortic bodies b) Respond to changes in oxygen, carbon dioxide, and hydrogen ion concentrations in arterial blood 4. Airway resistance, lung compliance, and elasticity a) Respiratory passageway resistance: from friction of gases moving, and by constriction of passageways by mucus, infectious materials, and tumors b) Lung compliance: depends on elasticity of lung tissue and flexibility of rib cage 5. Alveolar surface tension a) Surface tension on liquid film of alveolar walls b) Surfactant, produced by alveolar cells, reduces surface tension .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

E. Oxygen and Carbon Dioxide Transport 1. Arterial blood gases reflect gas exchange function of alveoli 2. Oxygen transport and unloading a) Blood carries oxygen in dissolved state (1–2%) and combined with hemoglobin (99%) b) Hemoglobin: made of 4 polypeptide chains, each bound to iron-containing heme group c) Oxygen affinity to hemoglobin affected by: temperature, blood pH, PO2, PCO2, serum concentration of 2,3-DPG d) Blood dissociates from hemoglobin in capillaries, diffuses into cells 3. Carbon dioxide transport a) CO2: product of cell metabolism b) CO2 transported in blood to lungs as bicarbonate ions in plasma, dissolved in plasma, and bound to hemoglobin c) Amount of CO2 transported in blood depends on oxygenation of blood II.

Assessing Respiratory Function A. Health assessment interview 1. Analyze manifestations: onset, characteristics, course, severity, precipitating and relieving factors, and associated symptoms 2. History of allergies, asthma, bronchitis, emphysema, pneumonia, tuberculosis, congestive heart failure, surgery or trauma to the respiratory structures, chronic illnesses, selftreatment of manifestations 3. Lifestyle, environmental, and occupation factors B. Genetic considerations 1. Deficiency of alpha1-antitrypsin 2. Asthma 3. Cystic fibrosis 4. Family history of lung cancer C. Physical assessment 1. Nasal assessment a) Size, shape, color, nasal cavity health, and ability to smell 2. Sinus assessment a) Comfortable to palpation 3. Thoracic assessment a) Respiratory rate, anteroposterior diameter/transverse diameter ratio, intercostal retraction or bulging, chest expansion, trachea position, lung sounds, and diaphragmatic excursion 4. Breath sound assessment a) Auscultate for sounds, crackles, wheezes, friction rubs D. Diagnosis

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

1. Diagnostic tests a) Arterial blood gases (ABGs), biopsy of the lung, bronchoscopy, chest x-ray, CT scan of the thorax, MRI of the thorax, pulmonary angiography, pulmonary ventilation scan, pulse oximetry, positron emission tomography (PET), sputum studies, acid-fast smear and culture, cytology, and thoracentesis III.

Assessment of Special Populations A. Age-related changes 1. Decrease elastic recoil of lungs during expiration because of less elastic collagen and elastin 2. Calcification of the costal cartilage and weakening of the intercostal muscles 3. Loss of skeletal muscle strength in the thorax and diaphragm; flattening of the diaphragm 4. Alveoli are less elastic, more fibrotic, and have fewer functional capillaries 5. Cough is less effective 6. PO2 reduces as much as 15% by age 80 B. Veterans 1. Agent orange exposure C. LGBTQI community 1. No differences have been noted for LGBTQI persons related to pulmonary disease and risk D. Congenital 1. Respiratory sequelae of congenital conditions primarily occur in four conditions: a) Restrictive lung disease b) Pulmonary hypertension c) Pulmonary hemorrhage d) Plastic bronchitis

IV.

Health Promotion A. Stop smoking or never start B. Use good hand hygiene C. Use good cough technique D. Consider environmental changes to promote lung health E. Participate in healthy activities F. Get vaccinated

Chapter Highlights A. Correct structure and function of the respiratory system is vital to ventilation, resulting in oxygenation of all body tissues.

B. Normal anatomy, physiology, and functions of the upper and lower respiratory systems are the basis for assessment. .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

C. Manifestations of dysfunction, injury, and disorders affecting the respiratory system may be detected during a general health assessment as well as during a focused respiratory system assessment.

D. Both general health and focused pulmonary system assessments can detect dysfunction, injury, and disorders.

E. Assessment of the pulmonary system includes diagnostic tests, genetic considerations, a health interview, and a physical assessment.

F. In older adults, physiological changes of the respiratory system lead to changes in pulmonary function that reduce efficiency. However, in the absence of chronic lung disease, these changes do not impact function.

G. Respiratory sequelae of congenital conditions primarily occur in four conditions: H. Restrictive lung disease, pulmonary hypertension, pulmonary hemorrhage, and plastic bronchitis.

I. Preventing lung disease focuses on avoidance of noxious inhalants, infection control, and healthy lifestyle choices.

SUGGESTION FOR CLASSROOM ACTIVITY- LEARNING OUTCOME ONE Using anatomic models, demonstrate the anatomy of the respiratory system.

SUGGESTION FOR CLASSROOM ACTIVITY- LEARNING OUTCOME TWO In groups of two, have the students practice conducting a respiratory health history.

SUGGESTIONS FOR CLINICAL ACTIVITY- LEARNING OUTCOME TWO Assign the students to complete a respiratory health history on assigned clinical patients.

Have students identify factors that impact respiration in their clinical patients.

Have students complete respiratory physical assessments on clinical patients.

SUGGESTION FOR CLASSROOM ACTIVITY- LEARNING OUTCOME THREE Have students identify assessment changes associated with aging.

SUGGESTION FOR CLINICAL ACTIVITY- LEARNING OUTCOME THREE Assign students to assess an older patient’s respiratory system.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTION FOR CLASSROOM ACTIVITY- LEARNING OUTCOME FOUR Have the students create a teaching tool to promote health lung function.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter 35 Nursing Care of Patients with Upper Respiratory Disorders

Learning Outcomes 1. Describe the pathophysiology and manifestations of infectious and inflammatory upper respiratory disorders and outline the interprofessional care and nursing care of patients with these disorders.

2. Describe the pathophysiology and manifestations of disorders of upper respiratory trauma or obstruction and outline the interprofessional care and nursing care of patients with these disorders.

3. Describe the pathophysiology and manifestations of upper respiratory tumors and outline the interprofessional care and nursing care of patients with upper respiratory tumors.

Key Concepts I. Infectious and Inflammatory Disorders A. Rhinitis: Most common respiratory disorder 1. Acute viral rhinitis (common cold) 2. Chronic rhinitis a) Allergic (hay fever) (1) Sensitivity reaction to allergens such as plant pollens b) Vasomotor (1) Similar symptoms to allergic rhinitis, but not linked to allergens c) Atrophic rhinitis (1) Changes in mucus membrane of nasal cavities B. The Patient with Viral Upper Respiratory Infection 1. Pathophysiology a) Associated viral strains: Rhinoviruses, adenoviruses, parainfluenza viruses, coronaviruses, and respiratory syncytial virus (1) Occasionally more than one virus is present b) Modes of infection (a) Hands bring virus from contaminated surfaces to the eyes and mucous membranes c) Immune response to infection (1) Immunity built only to current strain 2. Manifestations a) Nasal mucus membranes appear red and boggy .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

b) Swollen mucous membranes, local vasodilation, and secretions cause nasal congestion c) Sneezing, sore throat, and coughing are common d) Coryza (1) Nasal inflammation and profuse nasal discharge (2) Caused by clear watery secretions e) Infrequent symptoms: Low-grade fever, headache, malaise, and muscle aches 3. Complications a) URI effects on upper-respiratory immune system has potential to make patient vulnerable to more serious bacterial infections 4. Interprofessional care a) Diagnosis (1) Possible testing if bacterial infection suspected b) Treatments c) Medications (1) Treat symptoms (2) Experimental vaccines in development d) Integrative therapies (1) Echinacea (2) Vitamin C (3) Aromatherapy (4) Acupressure (5) Acupuncture 5. Nursing care a) Assessment (1) Health history (2) Physical assessment (3) Laboratory data 6. Priorities of care a) Symptom management, surveillance for complications, teaching for selfcare, and on identification of complications such as pneumonia, sinusitis, and prevention of viral spread 7. Diagnoses, outcomes, and interventions a) Promote effective breathing b) Promote airway clearance and patency c) Assess sleep quality d) Reduce .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

8. Transitions of care a) Primary nursing role for patients with URIs is education b) Teach home care C. The Patient with Respiratory Syncytial Virus (RSV) 1. Pathophysiology a) Primary cause of respiratory illness in infants and children 2. Risk factors a) Common in older children and adults, but milder, presenting as common cold b) Risk of severe pneumonitis in immunocompromised and elderly patients 3. Manifestations a) Rhinorrhea, sore throat, and cough, headache, malaise, and low-grade fever b) In older adults, RSV may present as lower respiratory infection with fever or pneumonia 4. Complications a) Progress to pneumonia, bronchiolitis, and tracheobronchiolitis in adults 5. Interprofessional care a) Diagnosis (1) Based on history and clinical findings (2) Chest x-ray (3) WBC count may be done to rule out pneumonia b) Medications (1) Aerosolized ribavirin (Virazole) c) Integrative therapies (1) None specific for RSV 6. Nursing care a) Assessment (1) Health history (2) Physical assessment (3) Laboratory data 7. Priorities of care a) Teaching for self-care b) Identify complications c) Provide care similar to pneumonia 8. Diagnoses, outcomes, and interventions a) Promote effective breathing b) Promote airway clearance and patency c) Assess sleep quality d) Reduce risk for infection .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

9. Transitions of care a) No vaccine b) Focus on hand hygiene c) Educate on self-care d) Increase rest e) Increase fluids D. The Patient with Influenza 1. Pathophysiology a) Three major strains: Influenza A, B, and C b) Influenza A is most common and causes most outbreaks (1) Avian influenza is type A H5N1 c) Incubation period: 18–72 hours d) Inflammation, necrosis, and shedding of serous/ciliated cells of respiratory tract e) Humoral and cell-mediated immune response to infection 2. Risk factors a) Age—highest risk in those under 5 or adults > 65 years) b) Chronic illness—impaired immune or respiratory systems c) Pregnant and early postpartum women d) Residents of nursing homes e) Obese persons (BMI >40) 3. Manifestations a) Infection produces one of three syndromes: Uncomplicated nasopharyngeal inflammation, viral upper respiratory infection followed by bacterial infection, and viral pneumonia b) Systemic manifestations: Abrupt onset of chills and fever, malaise, muscle aches, and headache c) Respiratory manifestations: Dry, nonproductive cough, sore throat, and substernal burning and coryza 4. Complications a) Respiratory epithelial necrosis increases risk for secondary bacterial infections b) Sinusitis and otitis media are frequent, tracheobronchitis may develop c) Increased risk of pneumonia, particularly in older adults d) Reye’s syndrome e) Other uncommon, potential complications of influenza: Myositis, myocarditis, and encephalitis and Guillain-Barré syndrome.

5. Interprofessional care .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) Diagnosis (1) Based on history, clinical findings, and knowledge of an influenza outbreak in the community (2) Chest x-ray and white blood cell (WBC) count to rule out complications b) Medications (1) Yearly immunization (2) Amantadine (Symmetrel) or rimantadine (Flumadine) may be used for prophylaxis in unvaccinated people who are exposed to the virus (3) Antiviral drugs zanamivir (Relenza), oseltamivir (Tamiflu), and peramivir (Rapiva) (4) Symptomatic relief with acetaminophen, aspirin, or NSAIDs c) Integrative therapies (1) None specific for influenza 6. Nursing care a) Assessment (1) Health history (2) Physical assessment (3) Laboratory data b) Priorities of care (1) Treat underlying disease process (2) Supports the physical and psychologic responses to the disorder c) Diagnoses, outcomes, and interventions (1) Promote effective breathing Monitor respiratory rate and pattern; pace activities to provide for periods of rest; elevate head of the bed (2) Promote airway clearance and patency (a) Monitor effectiveness of cough and ability to mobilize secretions; maintain adequate hydration; use bedside humidifier; teach effective cough techniques; administer analgesics as ordered (3) Promote sleep and rest (a) Assess sleep patterns; provide antipyretic and analgesic medications (4) Reduce risk for infection (a) Use standard precautions 7. Transitions of care a) Discuss home-care: Rest, fluids, OTC medications, good hygiene, and recognize complications E. The Patient with Sinusitis

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

1. Common causative organisms include viruses, streptococci, S. pneumoniae, Haemophilus influenzae, and staphylococci 2. Higher risk to patients with HIV 3. Pathophysiology a) Obstructed sinus openings due to swollen mucous membranes, polyps, tumors, or impaired drainage of mucus b) Mucus collects in sinus cavity, serving as a medium for viral or bacterial growth c) The inflammatory response draws serum and leukocytes to the area, increasing swelling and pressure d) Sinusitis may be acute or chronic 4. Risk factors a) Nasal allergies b) Hay fever c) Deviated septum d) Nasal polyps e) Nasal tumors 5. Manifestations a) Pain and tenderness, headache, fever, and malaise (1) Pain in different places depending on affected area (a) Frontal, maxillary, ethmoid, and sphenoid b) Other symptoms: Nasal congestion, purulent nasal discharge, bad breath, and red and swollen nasal mucous membrane 6. Complications a) Periorbital abscess, or cellulitis, cavernous sinus thrombosis, meningitis, brain abscess, sepsis, and eustachian tube edema 7. Interprofessional care a) Diagnosis (1) Acute: History and physical exam (2) Sinus x-rays (3) CT scan (4) Magnetic resonance imaging (MRI) b) Medications (1) Antibiotics: Amoxicillin (possibly combined with clavulanate [Augmentin]), trimethoprim-sulfamethoxazole (Bactrim, Septra), cefuroxime (Ceftin), cefaclor (Ceclor), ciprofloxacin (Cipro), or clarithromycin (Biaxin) (2) Topical steroids (fluticasone), nasal decongestants or oral decongestants (pseudoephedrine or phenylephrine) (3) Antihistamines .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(4) Saline nose drops or sprays (5) Inhalation of warm steam (6) Systemic mucolytic agents (guaifenesin) (7) Aerobic exercise c) Surgery (1) Fiberoptic nasal endoscope (a) Most effective for local disease, recurrent acute sinusitis, and for removing anatomic obstructions (b) Antral irrigation procedure (c) Caldwell-Luc procedure (d) External sphenoethmoidectomy d) Integrative therapies (1) High-volume, low-pressure nasal irrigation (2) Aromatherapy, herbal tea, and steam inhalation 8. Nursing care a) Assessment (1) Health history (2) Physical assessment (3) Laboratory data b) Priorities of care (1) Treat underlying process (2) Provide care that supports the physical and psychologic responses to the disorder c) Diagnoses, outcomes, and interventions (1) Manage pain (a) Assess pain, apply ice packs, place in Fowler’s or high-Fowler’s position after surgery (2) Promote balanced nutrition (a) Clear liquid diet progressing to soft foods; monitor intake, output and weight; elevate head of bed during meals d) Transitions of care (1) Following through with appropriate treatment and promoting comfort (2) Educating patient and family on medications, prevention, fluid intake, postoperative care F. The Patient with Pharyngitis or Tonsillitis 1. Pharyngitis: Acute inflammation of the pharynx a) Usually viral in origin, but may also be caused by bacterial infection b) Group A beta-hemolytic streptococcus (GABHS) (strep throat), most common cause of bacterial pharyngitis c) Other bacterial causes .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Neisseria gonorrhea, a gram-negative diplococcus (sexually transmitted), mycoplasma, and Chlamydia trachomatis d) Other causes (1) Post-nasal drip from allergic rhinitis (2) Gastroesophageal reflux into the throat 2. Tonsillitis: Acute inflammation of the palatine tonsils a) Sometimes viral in origin, but usually caused by streptococcal infection 3. Pathophysiology a) Spread by droplet nuclei b) Incubation varies 4. Risk factors a) Prior colonization with group A Streptococcus (GAS) b) Exposure to someone who is colonized or immunocompromised c) Use of inhaled corticosteroids d) Ingestion of non-domestic meats.

5. Manifestations a) Streptococcal pharyngitis (1) Abrupt onset, fever, severe sore throat with dysphagia, headache, malaise, absence of cough, anterior lymph nodes enlarged, exudate may be seen on pharynx and tonsils b) Viral pharyngitis (1) Gradual onset, with low-grade fever, sore throat, mild hoarseness, headache, and rhinorrhea, pharyngeal membranes appear mildly red with vascular congestion (2) Infectious mononucleosis, caused by the Epstein-Barr virus, often presents as acute pharyngitis, with visible patches of exudate on the pharynx or tonsils (3) Cervical lymph nodes are enlarged and tender c) Tonsillitis (1) Tonsils appear bright red and edematous; the uvula may also be reddened and swollen, white exudate may be present on the tonsils; pressing on a tonsil may produce purulent drainage; tonsillar lymph nodes are usually tender and enlarged; sore throat; difficulty swallowing; general malaise; fever; and otalgia (2) Often more severe in adolescents and adults than children (3) Risk of acute otitis media 6. Complications

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) GABHS pharyngitis can lead to abscess, scarlet fever, and toxic shock syndrome, rheumatic fever, or acute poststreptococcal glomerulonephritis b) Tonsillitis can lead to peritonsillar abscess (quinsy) c) Rare but serious complications of group A beta-hemolytic streptococcal pharyngitis and tonsillitis include acute glomerulonephritis and rheumatic fever, abnormal immune responses to the infection d) Acute glomerulonephritis e) Hematuria, proteinuria, and less commonly, hypertension and edema 7 to 10 days after the acute infection f) Rheumatic fever (1) Fever, painful or swollen joints, rash, and heart murmur 3 to 5 weeks after acute infection g) Other complications of bacterial infection include sinusitis, otitis media, mastoiditis, and cervical adenitis 7. Interprofessional care a) Diagnosis (1) Test for GABHS sore throat (2) Throat swab (a) If test is negative, swab is cultured to ensure proper diagnosis (3) Complete blood count (CBC) b) Medications (1) Antipyretics and mild analgesics for throat pain (2) Penicillin for A streptococci (a) If patient is allergic to penicillin, erythromycin, amoxicillin, or cefuroxime (Ceftin, Kefurox) may be used (3) Antibiotic therapy is continued for at least 10 days c) Surgery (1) A peritonsillar abscess is drained by needle aspiration or incision/drainage, followed by tonsillectomy either immediately or 6 weeks after incision and drainage of peritonsillar abscess (2) Tonsillectomy (a) Indicated for recurrent or chronic infections unresponsive to antibiotic therapy, hypertrophy of the tonsils with risk of airway obstruction, peritonsillar abscess, repeated attacks of purulent otitis media, and tonsil malignancy (b) Adenoid tissue usually removed simultaneously 8. Nursing care a) Assessment (1) Health history (2) Physical assessment .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

b) Priorities of care (1) Supportive (2) Adult care: Close surveillance for complications and teaching for selfcare and prevention of causative organism spread.

(3) Post-surgical care: Perioperative care and close observation for postoperative complications c) Diagnoses, outcomes, and interventions (1) Promote airway clearance and patency (a) Ice packs to neck (b) Cold oral fluids (2) Manage acute pain (a) Analgesics as prescribed 9. Transitions of care a) Postoperative care: (1) Avoid use of aspirin for 2 weeks to reduce the risk of postoperative bleeding (2) Manifestations of bleeding because (delayed hemorrhage may occur for up to 1 week postsurgery). b) Home care teaching: (1) Completing the full course of antibiotic therapy, if prescribed (2) Using warm saline gargles or throat lozenges for symptomatic relief (3) Signs and symptoms of possible complications of GABHS streptococcal infection such as glomerulonephritis or rheumatic fever (4) Monitoring temperature in the morning and evening until well to ensure that the infection has not spread to deeper tissues (5) Proper use and disposal of tissues and frequent hand hygiene to prevent spreading the infection to others G. The Patient with Laryngeal Infection 1. Epiglottitis: Medical emergency a) Pathophysiology (1) Swelling and edema threatens airway (2) Most common cause: H. influenza b) Assessment (1) Sore throat, odynophagia, dyspnea, and possibly drooling and stridor (2) Using a tongue blade to view the oropharynx is avoided; this may precipitate laryngospasm and airway obstruction (3) The epiglottis is visualized using a flexible fiberoptic laryngoscope c) Diagnosis (1) The epiglottis appears red, swollen, and edematous (2) Treatment .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(a) Patient admitted to critical care unit (b) Intravenous antibiotic therapy initiated (c) Ceftriaxone (Rocephin), cefuroxime (Ceftin), or ampicillin/sulbactam (Unasyn) may be prescribed (d) If allergic to penicillin, a combination of clindamycin (Cleocin) and either trimethoprim-sulfamthoxazole (TMP-SMZ) or ciprofloxacin (Cipro) may be used. Dexamethasone, a systemic corticosteroid, is also given to suppress the inflammatory response and rapidly reduce swelling of the epiglottis d) Nursing care (1) Maintain a calm, reassuring manner (2) Focus on monitoring and maintaining airway patency (a) If the patient is not intubated, supplies for emergency intubation should be kept in the unit 2. Laryngitis a) Pathophysiology (1) Commonly associated with viral URI such as influenza (2) May also occur with bronchitis, pneumonia, other respiratory infections, or due to a tumor or polyp on the vocal cord (3) Non-infectious causes include excessive use of the voice, sudden changes in temperature or exposure to dust, irritating fumes, smoke, or other pollutants (4) Primary symptom: Change in the voice (5) The throat is often sore and scratchy, and a dry, harsh cough may be present; hoarseness or aphonia may occur b) Treatment (1) Any identified precipitating factors should be eliminated, voice rest, abstinence from tobacco and alcohol, inhaling steam or spraying the throat with antiseptic solutions c) Nursing care (1) Encourage speaking in short sentences or using alternate methods of communication (2) Advise to use soothing throat lozenges, sprays, or other comfort measures such as gargling with a warm antiseptic solution (3) Help identify potential irritants H. The Patient with Diphtheria 1. Easily spread in areas where sanitation is poor, living conditions are crowded, and access to health care is limited a) Pathophysiology b) C. diphtheriae infects the mucous membranes of the respiratory tract and can invade skin lesions .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

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c) Toxins released by the organism inflame mucosal surfaces of the pharynx d) Exudate from inflamed tissues forms a thick, grayish, and rubbery pseudomembrane over the posterior pharynx and sometimes into the trachea e) Impairs eating, drinking, and breathing f) Can fully obstruct breathing, necessitating tracheostomy Risk factors a) Lack of or incomplete immunization against diphtheria b) Overcrowded or unsanitary environments c) Immunocompromise Manifestations a) Fever, malaise, sore throat, and malodorous breath b) Severe cases may present lymphadenopathy Complications a) Airway occlusion b) Pulmonary infection that can progress to respiratory failure c) Myocarditis d) Polyneuropathy that can progress to paralysis Interprofessional care a) Diagnosis (1) Throat culture, Gram stain or immunofluorescent antibody stains (2) Strict patient isolation procedures (a) All contacts are screened and immunized b) Medication (1) Diphtheria antitoxin via IV over 1 h or IM (2) A skin test for sensitivity to horse serum should precede immunization (3) Due to risk of anaphylaxis, epinephrine must be readily available (4) Antibiotics such as penicillin or erythromycin

6. Nursing care a) Assessment (1) Health history (2) Physical assessment (3) Laboratory data b) Priorities of care (1) Bedrest (2) Monitored for airway obstruction, cardiac manifestations, and CNS complications (3) Nutrition and fluid balance (4) Keep equipment for suction, emergency intubation, and tracheostomy at the bedside.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(5) Symptomatic patients are isolated and treated until two negative throat cultures are obtained (6) Nasopharyngeal and throat cultures from all close contacts (7) Asymptomatic disease carriers are confined to home until at least 3 days of antibiotic therapy have been completed.

(8) All contacts, including hospital personnel, receive tetanus and diphtheria toxoids (Td).

7. Diagnoses, outcomes, and interventions a) Promote airway clearance and patency (1) Monitor cough and expectoration of excretions (2) Adequate hydration b) Promote effective breathing (1) Provide for rest periods (2) Elevate the head of the bed c) Assess sleep quality (1) Assess and monitor sleep patterns d) Reduce risk for infection (1) Droplet isolation (2) Frequent hand hygiene 8. Transitions of care a) Acute, life-threatening illness b) Patient may require continued nursing care to regain function, strength, and endurance I. The Patient with Pertussis 1. Pathophysiology a) Highly contagious acute upper respiratory infection caused by Bordetella pertussis (1) B. pertussis is spread by respiratory droplets b) Effects are due to toxins produced by the bacteria c) Risk of pneumonia d) Immunization does not guarantee lifetime protection, but the disease tends to be milder in people who have been immunized e) Complications in adolescents and adults (a) Pneumothorax, weight loss, inguinal hernia, rib fracture, and cough syncope (fainting due to hypoxia) 2. Risk factors a) Not being immunized b) Close contact with an infected person 3. Manifestations a) Typical URI symptoms appear 7 to 10 days after exposure

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

b) After 1 to 2 weeks frequent cough, paroxysms, often ending with an audible whoop c) Vomiting following coughing d) Disease gradually resolves over a period of up to 3 months (1) Catarrhal phase: Coryza, malaise, low-grade fever, sneezing, and cough (2) Paroxysmal phase: Frequent spasms of sometimes violent coughing, worse at night; characteristic whoop on inspiration following cough paroxysm; vomiting, fatigue, and weight loss resulting from severe cough (3) Convalescent phase: Gradually decreasing frequency and severity of coughing episodes e) Atypical (often seen in adolescents and adults) (1) Severe, prolonged cough that may not be paroxysmal; whoop uncommon, vomiting with cough, and cough at night 4. Complications a) Infants (1) Pneumonia (2) Neurologic complications caused by hypoxia b) Adolescents and adults c) Pneumothorax d) Weight loss e) Inguinal hernia f) Rib fracture g) Cough syncope 5. Interprofessional care a) Diagnosis (1) Culture of nasopharyngeal secretions (2) Blood tests for antibodies to the organism (3) Lymphocytosis (elevated lymphocyte count) may be present b) Medication (1) Erythromycin (2) Trimethoprim-sulfamethoxazole (TMP-SMZ) may be used as an alternate; respiratory isolation is instituted for 5 days after antibiotic therapy is started; hospitalization is rare (3) Prophylactic erythromycin or TMP-SMZ is prescribed for all in the household and close contacts of the infected patient c) Hospitalization (1) Children are hospitalized to prevent neurologic complications 6. Nursing care .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) Assessment (1) Health history (2) Physical assessment (3) Laboratory data b) Priorities of care (1) Close surveillance for complications (2) Teaching for self-care c) Diagnoses, outcomes, and interventions (1) Promote effective breathing (2) Promote airway clearance and patency (3) Assess sleep quality (4) Reduce risk for infection 7. Transitions of care a) Teach respiratory isolation measures, heightened hygienic measures, prescribed antibiotics, and potential adverse effects and how to mitigate them, maintaining fluid and nutrient intake II. Upper Respiratory Trauma or Obstruction A. The Patient with Epistaxis: Nosebleed 1. Pathophysiology a) Causes include: Trauma, drying of nasal mucous membranes, infection, substance abuse, arteriosclerosis, or hypertension, and treatment with an anticoagulant or antiplatelet drug b) May also indicate a bleeding disorder related to acute leukemia, thrombocytopenia, aplastic anemia, or severe liver disease c) Anterior and posterior epistaxis 2. Risk factors a) Nasal perforation, nasal septum deviation, rhinitis, sinusitis, and upper respiratory tract infection b) Significant risk factors for recurrent epistaxis include congestive heart failure, diabetes mellitus, hypertension, and a history of anemia 3. Manifestations a) Obvious bleeding b) Blood draining into the posterior pharynx c) Nausea and vomiting 4. Complications a) Anemia b) Hypovolemic shock .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

5. Interprofessional care a) Identify and treat the source of bleeding (1) Applying pressure (pinching the nose toward the septum) for 5 to 10 minutes (2) Applying ice packs to the nose and forehead (3) Sitting position (4) Leaning forward (5) Instruct to spit out the blood (6) Medications, nasal packing, or surgery may be necessary b) Diagnosis (1) History and physical exam c) Medications (1) Topical vasoconstrictors: Cocaine, phenylephrine (Neo-Synephrine), or adrenaline (2) Chemical cauterization: Silver nitrate or Gelfoam (3) Topical anesthetic prior to nasal packing (4) Tetracaine, lidocaine, or cocaine (5) If posterior nasal packing is required, prophylactic antibiotic therapy is initiated to prevent sinusitis or possible toxic shock syndrome d) Nasal packing (1) Nasal tampon, packing (anterior, posterior) (2) Posterior nosebleeds require both anterior and posterior packing (a) Hypoxemia is common; supplementary oxygen is administered.

Endotracheal intubation may be necessary to maintain adequate ventilation and gas exchange (b) Possible complications 1. Hypertension, dysrhythmias, acute myocardial infarction may occur in patients with severe cardiovascular disease 2. Toxic shock syndrome 3. Pack may occlude the eustachian tube and sinus openings, resulting in ear discomfort, possible otitis media, or sinusitis 4. Oral and nasal dryness e) Surgery (1) Chemical or surgical cautery (2) Surgical procedures for posterior bleeding (a) Potential complications: Facial paralysis, paresthesias, facial pain, and dental injury 6. Nursing care a) Assessment (1) Health history (2) Physical exam .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

b) Estimated amount of bleeding; presence of blood in oropharynx; vital signs; evidence of facial or nasal trauma c) Laboratory data (1) Hemoglobin, hematocrit, platelets, and WBC as indicated; oxygen saturation; tests of organ function such as liver function tests (bilirubin, AST, ALT, LDH) or kidney function tests (serum creatinine, BUN) d) Diagnoses, outcomes, and interventions (1) Manage anxiety (a) Maintain calm attitude, instruct patient to pinch nares together at bridge of nose, encourage slow breathing through mouth, and provide basin and tissues (2) Reduce risk for aspiration (a) Position upright with head forward, apply ice to nose 7. Transitions of care a) Teaching for home care to prevent further episodes of bleeding B. The Patient with Nasal Trauma or Surgery 1. Pathophysiology a) Broken nose (1) Unilateral, bilateral, and complex fractures (2) Soft-tissue trauma commonly accompanies nasal fracture b) Potential complications: Septal hematoma and abscess formation, septal perforation or deviation, and cerebrospinal fluid (CSF) leakage 2. Manifestations a) Epistaxis, deformity or displacement to one side, crepitus, periorbital edema and ecchymosis, and nasal bridge instability 3. Complications a) Septal hematoma and abscess formation, septal perforation or deviation, cerebrospinal fluid (CSF) leakage, complete and bilateral nasal obstruction. Risk of staphylococcal abscess, necrosis of septal cartilage, and saddle nose deformity 4. Interprofessional care a) Diagnosis (1) Head and facial x-rays (2) Intranasal cavity is examined using a nasal speculum to rule out septal hematoma b) Fracture reduction (1) Nasal fractures heal rapidly; early reduction is ideal (2) Padded splint, ice packing, and nasal packing c) Surgery: Rhinoplasty with concurrent septoplasty procedure .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Rhinoplasty (2) Septoplasty (3) Submucous resection 5. Nursing care a) Assessment (1) Health history (a) Nature and circumstances of the injury; pain; ability to breathe through the nose; complications from prior head injury (2) Physical examination (a) Evident trauma, swelling, ecchymosis, or deformity of the nose; vital signs, respiratory rate and ease; gently palpate nose and facial bones for crepitus; inspect oropharynx for drainage; test nasal discharge for glucose b) Diagnoses, outcomes, and interventions (1) Promote airway clearance and patency (a) Monitor airway patency, cough effectiveness and ability to clear airway secretions; maintain adequate hydration; assess patency of both nares before inserting a nasogastric tube or feeding tube (2) Reduce risk for infection (a) Avoid suctioning if possible; monitor vital signs every 4 hours (b) Administer antibiotics c) Transitions of care (1) Prepare patient for home care (a) Elevate head (b) Ice packs on nose for 20 minutes, 4 times per day (c) Care for CSF leakage C. The Patient with Laryngeal Obstruction or Trauma 1. Laryngeal obstruction—life-threatening emergency a) Pathophysiology (1) The larynx may be partially or fully obstructed by aspirated food or foreign objects, laryngospasm or edema due to inflammation, injury, anaphylaxis, or a tumor (2) Most common cause of obstruction: Ingested meat that lodges in the airway (3) Laryngeal trauma: (a) Trauma may fracture thyroid and/or cricoid cartilage, resulting in loss of airway patency (b) Soft-tissue injuries can cause swelling that further impairs the airway b) Risk factors .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Risk factors for food aspiration: Ingesting large boluses of food and chewing them insufficiently, consuming excess alcohol, and wearing dentures (2) Risk factor for laryngeal trauma: Prolonged intubation or difficult intubation c) Manifestations (1) Coughing, choking, gagging; obvious difficulty breathing with use of accessory muscles, and inspiratory stridor; asphyxia signs become apparent (2) Respirations are labored and noisy with wheezing and stridor (3) Cyanosis may develop (4) Respiratory arrest and death may result without prompt treatment (a) Laryngeal trauma manifestations: May include subcutaneous emphysema or crepitus, voice change, dysphagia and pain with swallowing, inspiratory stridor, hemoptysis, and cough 2. Interprofessional care a) Diagnosis and treatment (1) Heimlich maneuver (2) CT scan is used to identify laryngeal fractures (3) Intravenous fluids, antibiotics, and corticosteroids to reduce edema b) Nursing care (1) Assessment (2) Priorities of care (a) Establish a patent airway (b) Heimlich maneuver (c) Emergency intubation or tracheostomy c) Diagnosis, outcomes, and interventions (1) Promote airway clearance and patency (2) Promote communication (3) Reduce risk for choking (4) Promote balanced nutrition d) Transitions of care (1) Caution patients who wear dentures to take small bites, chewing each bite carefully before swallowing (2) Patients with a known risk for anaphylaxis should carry a MedicAlert tag and bee-sting kit D. The Patient with Obstructive Sleep Apnea 1. Obstructive sleep apnea: Respiratory drive remains intact, but airflow ceases due to occlusion of the oropharyngeal airway 2. Central sleep apnea rare neurologic disorder 3. Pathophysiology .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

4.

5.

6.

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a) Loss of normal pharyngeal muscle tone permits the pharynx to collapse b) Obesity or decreased inspiratory tone contribute c) Airflow obstruction causes the oxygen saturation, PO2, and pH to fall, and the PCO2 to rise. Progressive asphyxia causes brief arousal from sleep, which reestablishes patency. Sleep can be severely fragmented Risk factors a) Male gender, increased age, obesity, large neck circumference, and use of alcohol and other central nervous system depressants Manifestations a) Loud, cyclic snoring, excessive daytime sleepiness, headache, irritability, and restless sleep, gasping or choking during sleep, morning headache, depression, intellectual impairment, impotence, and hypertension Complications a) Recurrent nocturnal asphyxia and negative intrathoracic pressure b) Myocardial ischemia, angina, and dysrhythmias c) Systemic hypertension (1) Occurs in 50% of people with obstructive sleep apnea d) Sudden cardiac death e) Risks for morbidly obese patients after gastric bypass surgery Interprofessional care a) Diagnosis (1) Polysomnography: Overnight monitor b) Treatments (1) Mild to moderate obstructive sleep apnea (a) Weight reduction, alcohol abstinence, improving nasal patency, and avoiding the supine position for sleep (2) More severe cases (a) Nasal continuous positive airway pressure (CPAP) (b) The newer BiPAP ventilator c) Surgery (1) Tonsillectomy and adenoidectomy (2) Uvulopalatopharyngoplasty (UPPP) (3) Tracheostomy Nursing care a) Assessment (1) Health history (2) Physical assessment b) Diagnoses, outcomes, and interventions (1) Promote sleep quality (2) Promote effective breathing (3) Promote adequate ventilation (4) Reduce risk for injury (5) Promote sexual function

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

9. Transition of care a) Education of patient and family on equipment use and strategies to decrease contributing factors such as obesity and alcohol intake III. Upper Respiratory Tumors A. The Patient with Nasal Polyps 1. Pathophysiology a) Allergic rhinitis may cause slow polyp formation b) Polyps may enlarge to the size of a grape 2. Risk factors a) Nasal infections b) Allergies c) Asthma 3. Manifestations a) May be asymptomatic, but can cause nasal obstruction, rhinorrhea, and loss of sense of smell; sinusitis may develop; voice may have nasal tone; asthmatics who have nasal polyps may have an associated aspirin allergy of which they are not aware 4. Complications a) Chronic sinus infections b) Sleep apnea 5. Interprofessional care a) Treatment (1) Diagnosis (a) Physical exam (b) Nasal endoscopy (c) CT scan b) Medications (1) Polyps may regress with resolution of infection (2) Topical corticosteroid nasal sprays or low-dose oral corticosteroids c) Surgery (1) May be required to restore normal breathing (2) Procedure typically done with local anesthesia (3) Multiple surgeries may be needed 6. Nursing care a) Assessment (1) Health history (2) Physical assessment .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(3) Laboratory data b) Diagnoses, outcomes, and interventions (1) Manage pain (2) Promote balanced nutrition 7. Transitions of care a) Apply ice pack, increase fluid intake, clean mouth frequently; avoid blowing nose, straining at stool, vigorous coughing, and strenuous exercise b) Discuss manifestations of possible bleeding and preventative measures such as resting after surgery for 2 to 3 days B. The Patient with Laryngeal Tumor 1. Pathophysiology a) Benign tumors include papillomas, nodules, and polyps (1) Risk factors: Chronic shouting, projecting, or vocalizing, cigarette smoking and chronic irritation from industrial pollutants b) Laryngeal cancer (1) Squamous cell carcinoma is most common form (2) Leukoplakia appear: White, patchy, and precancerous lesions (3) Erythroplakia: Red, velvety patches, later stage of carcinoma (4) Carcinoma in situ (CIS): Initial cancerous lesion 2. Risk factors a) Men are affected more than four times as often as women. b) Develops between ages 50 and 70 c) Tobacco use is the major risk factor d) Alcohol consumption e) Poor nutrition, human papillomavirus (HPV) infection, exposure to asbestos and other occupational pollutants, and race 3. Manifestations a) Hoarseness b) Change in the voice c) Painful swallowing d) Dyspnea e) Foul breath f) Palpable lump in neck g) Earache 4. Interprofessional care a) Benign tumors may resolve with correction of underlying issue. Early detection of malignant tumors is critical to survival; 80% to 95% of early .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

stage tumors can be cured; 50% to 80% of people with advanced laryngeal cancer die of the disease b) Diagnosis (1) Direct or indirect laryngoscopy when cancer is suspected (2) Biopsy (3) Imaging studies such as CT scan, MRI, and chest x-ray, PET (4) Laryngeal cancer staging c) Treatments (1) Vocal cord polyps: Inhaled steroid spray; some cases call for surgery (2) Chemotherapy (a) Cisplatin (Platinol) / 5-fluorouracil (5-FU) (b) Other drugs that may be used include methotrexate (Mexate), bleomycin sulfate (Blenoxane), carboplatin (Paraplatin), and cisplatin (Platinol) (3) Radiation therapy (a) External radiation commonly used (b) Extremely effective in early stages (c) Can affect tone or timbre of voice (d) Can be used in conjunction with chemotherapy (4) Surgery (a) Type based on site, size, and invasiveness of the tumor (b) Goals: Remove malignancy, maintain airway patency, and achieve optimal cosmetic appearance (c) Laryngoscopy (d) Laryngectomy 1. Partial laryngectomy (hemilaryngectomy, vertical partial laryngectomy) 2. Total laryngectomy (e) Radical or modified neck dissection (5) Speech rehabilitation (a) Tracheoesophageal puncture (TEP); external tracheostoma valve (b) Esophageal speech (c) Speech generators (electrolarynx): Neck vibrations—transmitted vibrations are formed into words using the normal muscles of speech; mouth tube vibrations: Lips, tongue, and mouth muscles are used to form the sound into words 5. Nursing care a) Assessment (1) Health history (a) Current symptoms, including voice change, difficulty swallowing, throat pain, weight loss; risk factors such as voice abuse family

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

history of cancer, occupational exposures smoking, use of alcohol and amount (2) Physical examination (a) Voice character; general appearance and apparent state of health, weight loss; swallowing ability; visible or palpable mass in neck b) Diagnoses, outcomes, and interventions (1) Promote airway clearance and patency (especially immediately postoperation) 1. Withhold food and fluids until the cough and gag reflexes have returned (2) Promote communication (a) Introduce nonverbal communication strategies. Arrange consultation with a speech therapist (b) Assess the importance of verbal communication to self-concept, occupation, and lifestyle. Maintain a positive attitude about postoperative communication (3) Promote swallowing (a) Maintain intravenous fluids and enteral feedings or parenteral nutrition until adequate food and fluids can be ingested orally (b) Postoperatively, initiate oral intake with soft foods, not liquids (c) Following total laryngectomy, reassure that choking is not possible, Swallowing is no longer an automatic function and needs to be relearned (d) Provide for privacy during initial attempts at eating (4) Promote balanced nutrition (a) Assess nutritional status; monitor food and fluid intake and urinary output; weigh daily; evaluate current and preferred eating habits and foods, as well as understanding of nutrition; refer to a dietitian for further evaluation; encourage small meals and dietary experimentation; recommend liquid supplements (b) Provide an antiemetic 30 minutes before eating as needed to relieve nausea; provide mouth care before meals and supplemental feedings; provide a topical anesthetic such as viscous lidocaine before eating for stomatitis or esophagitis related to radiation or chemotherapy; suggest enteral (tube) feedings via nasogastric or gastrostomy tube (5) Promote healthy grief responses (a) Provide opportunities for expressing feelings of grief, anger, or fear about the diagnosis of cancer, the impending surgery, and the anticipated loss of speech. (b) Provide a calm, supportive environment with adequate privacy and emotional support for the patient and family

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(c) Help the patient and family discuss the potential impact of the loss on family structure and function. (d) Refer for psychologic or spiritual counseling (e) Help identify coping strategies 6. Transitions of care a) Teach management of contributing factors, stress importance of not screaming or yelling, refer singers to speech therapist for training, and emphasize need to maintain normal range of voice b) Teach treatment options, importance of early intervention, options for postoperative communication if surgery is necessary c) Tracheostomy care d) End of life care

Chapter Highlights A. Upper respiratory infections (the common cold) are caused by a multitude of different viruses. Most are mild, self-limiting infections, appropriate for self-care.

Some viruses, however (such as RSV) can cause serious lower respiratory illness in the very young or very old.

B. Three different strains of influenza virus are identified; type A causes most outbreaks of influenza. Because this disease increases the risk of pneumonia in older adults, people with chronic diseases, and people who are immunocompromised, annual immunization is important for these populations and their caregivers.

C. Influenza is differentiated from URI primarily by the presence of systemic manifestations, the duration and degree of fever, and the presence of a persistent cough.

D. Pharyngitis (sore throat) may be either viral or bacterial in origin; manifestations are similar. Patients with persistent or severe symptoms that include fever, enlarged lymph nodes, and myalgias should be evaluated to rule out GABHS pharyngitis, which can have significant complications such as rheumatic fever or poststreptococcal glomerulonephritis.

E. The incidence of pertussis, a highly contagious reportable disease, is increasing due to waning immunity, decreased rates of childhood pertussis immunizations, and improved identification of the infection among adults. In adults, it is often recognized by prolonged and persistent coughing spells. Pertussis is treated in community settings with antibiotic therapy (usually erythromycin or sulfamethoxazole-trimethoprim [SMZ-TMP]).

F. Epistaxis (nosebleed) and nasal fracture are relatively common, and pose a risk only when airway clearance is impaired. Emergency care for epistaxis includes pinching the nares or bridge of the nose, sitting upright, leaning forward, and .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

applying ice to the nose. When nasal packing is required to control bleeding, close monitoring of the respiratory status (respiratory rate and effort, oxygen saturation) is critical.

G. Persistent voice hoarseness is the primary manifestation of laryngeal cancer.

When identified and treated early, the rate of cure for laryngeal cancer is high.

Some laryngeal tumors, however, have few manifestations until advanced. They may be treated by radiation therapy, chemotherapy, or surgery (laryngectomy and neck dissection).

H. Following total laryngectomy, a permanent tracheostomy is created and the upper trachea and esophagus are separated, preventing aspiration when feedings are resumed. A tracheoesophageal puncture (TEP) may be created to allow verbal communication following total laryngectomy.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME ONE Discuss the difference between infectious and inflammatory upper respiratory disorders.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME ONE Assign students to care for a patient with an infectious or inflammatory upper respiratory disorder.

SUGGESTIONS FOR CLASSROOM ACTIVITY—LEARNING OUTCOME TWO Have the students develop a chart that lists common upper respiratory tract disorders and their manifestations. Using the chart, look for commonalities among and differences between these disorders.

Have students list medications commonly prescribed for patients with an upper respiratory disorder. List the nursing implications of each of those medications. Have students relate the action of the medication to the pathophysiology of the disorder.

Provide an opportunity for the students to practice the Heimlich maneuver.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME TWO Assign students to care for patients with upper respiratory trauma or obstruction

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME THREE Have students develop teaching materials to address the risk factors for development of upper respiratory tumors.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME THREE Assign students to care for patients with upper respiratory tumors.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter 36 Nursing Care of Patients with Ventilation Disorders

Learning Outcomes 1. Describe the pathophysiology and manifestations of infectious and inflammatory ventilation disorders, and outline the interprofessional care and nursing care of patients with these disorders.

2. Describe the pathophysiology and manifestations of disorders of the pleura, and outline the interprofessional care and nursing care of patients with these disorders.

3. Describe the pathophysiology and manifestations of trauma of the chest or lung, and outline the interprofessional care and nursing care of patients with these injuries.

4. Describe the pathophysiology and manifestations of lung cancer, and outline the interprofessional care and nursing care of patients with this disease.

Key Concepts I.

Infections and Inflammatory Disorders A. The patient with acute bronchitis 1. Pathophysiology a) Infectious bronchitis: Caused by viruses or bacteria b) Inflammatory bronchitis: Inhalation of toxic gases/chemicals (1) Inflammatory cells infiltrate the affected mucosa, leading to exudate formation and increased mucus production 2. Risk factors a) Close exposure to someone with acute bronchitis b) Lack of current immunizations c) Exposure to smoke, fumes, and pollution 3. Manifestations a) Inflammatory response to infection or tissue damage b) Capillary dilation and edema of the mucosal lining of the bronchi c) Ciliated epithelium is damaged; ciliary function is impaired. d) Nonproductive coughing paroxysms (later productive), substernal chest pain, moderate fever, and general malaise 4. Complications a) Pneumonia b) Recurrent infection 5. Interprofessional care a) Diagnosis

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Based on history and clinical presentation (2) Chest x-ray to rule out pneumonia b) Medications (1) Broad-spectrum antibiotic (2) Daytime: Expectorant cough medication (3) Nighttime: Cough suppressant c) Priorities of care (1) Supportive (2) Monitor for complications (3) Teach self-care 6. Nursing care a) Assessment (1) Health history (2) Physical assessment b) Diagnoses, outcomes, and interventions (1) Promote airway clearance and patency c) Transitions of care (1) Increased fluid intake (2) Over-the-counter analgesics and cough preparations, and prescribed medications (3) Smoking cessation B. The patient with pneumonia 1. Pathophysiology a) Infectious causes: Bacteria, viruses, fungi, protozoa, and other microbes (1) Community acquired (a) Most common: Streptococcus pneumoniae (b) Other leading causes: Mycoplasma pneumoniae, Haemophilus influenza, influenza virus, Chlamydia pneumoniae, Legionella pneumophila (2) Healthcare associated (a) Staphylococcus aureus, Pseudomonas aeruginosa, Klebsiella pneumoniae, and Escherichia coli (3) Opportunistic (a) Pneumocystis carinii, Mycobacterium tuberculosis, Cytomegalovirus (CMV), atypical mycobacteria, and fungi b) Noninfectious causes: Aspiration of gastric contents and inhalation of toxic or irritating gases (1) Sneezing, swallowing, expectoration, reflex closure of epiglottis and bronchial tree help maintain sterility of lower respiratory tract.

(2) Organisms that make it past the barriers are rapidly phagocytized by macrophages, then attacked by the inflammatory and immune defenses. .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(3) Aging impairs these immune responses, increases risk. c) Causes: Inhalation of air or water, bloodstream from infection elsewhere, aspiration of oropharyngeal secretions containing microbes d) Pathologic process, anatomic location, and manifestations vary by organism. e) Acute bacterial pneumonia (Streptococcus pneumoniae) (1) Inflammatory response causes alveolar edema and exudate (2) Consolidation (solidification) of lung tissue (a) Lobar pneumonia: Large portion consolidation (b) Bronchopneumonia: Patchy consolidation (c) Interstitial pneumonia (d) Miliary pneumonia (3) Manifestations (a) Acute bacterial pneumonia (i) Onset: Acute, rapid (ii) Respiratory: Productive cough; chest aching or pleuritic pain; limited breathing sounds; and audible pleural friction rub (iii) Systemic: Shaking chills, fever (4) Complications (a) Infection of pleura (b) Extensive parenchymal damage with necrosis, lung abscess, and empyema or pleural effusion (c) Progressive destruction of lung tissue and functional impairment (d) Lung abscess (e) Empyema (i) Identified by chest x-ray or CT scan (ii) Bacteremia can lead to meningitis, endocarditis, or peritonitis, thus increasing the risk of mortality f) Legionnaires’ disease (1) Onset: Gradual (2) Respiratory manifestations: Dry cough, dyspnea (3) Systemic manifestations: Chills and fever; general malaise; headache; confusion; anorexia and diarrhea; myalgias; and arthralgias g) Primary atypical pneumonia (1) Mycoplasma pneumonia (2) Onset: Gradual (3) Respiratory manifestations: Pharyngitis or bronchitis, dry, hacking, and nonproductive cough (4) Systemic manifestation: Fever, headache, myalgias, and arthralgias h) Viral pneumonia (1) Influenza and adenovirus (2) Cytomegalovirus (CMV) pneumonia is increasing in immunocompromised people. .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(3) Onset: Sudden or gradual (4) Respiratory manifestations: Dry cough (5) Systemic manifestations: Flu-like symptoms i) Pneumocystis pneumonia (1) Opportunistic: People with AIDS and immunocompromise are at risk.

(2) Abrupt onset with fever, tachypnea, shortness of breath, dry, nonproductive cough (3) Can lead to intercostal retractions and cyanosis j) Aspiration pneumonia (1) Gastric contents in lungs (2) Risk factors: Emergency surgery, depressed coughing reflexes, impaired swallowing 2. Interprofessional care a) Diagnosis (1) Chest x-ray, sputum gram stain, sputum culture and sensitivity (2) Sputum gram stain (3) Sputum culture and sensitivity (4) Complete blood count (CBC) with white blood cell (WBC) differential (5) Serology: When blood and sputum tests are negative.

(6) Pulse oximetry: Continuously monitor gas exchange (7) Arterial blood gases (ABGs) (8) Fiberoptic bronchoscopy b) Immunization (1) Pneumococcal vaccine usually imparts lifetime immunity with single dose (2) Recommended for: People over age 65; those with chronic cardiac or respiratory conditions, diabetes mellitus, alcoholism, or other chronic diseases; and immunocompromised people c) Medications (1) Antibiotics to eradicate the infection (a) Specific medications for particular bacteria (2) Bronchodilators to improve ventilation and reduce hypoxia (3) Mucus “break up” agent d) Treatments (1) Increased fluid intake (2) Incentive spirometry to promote clearance of respiratory secretions (3) Oxygen therapy (a) For patient who is tachypneic or hypoxemic (b) Increasing percentage of inspired oxygen (c) Low-flow or high-flow systems (d) Venturi mask; Vapotherm (4) Chest physiotherapy .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(a) Percussion: Rhythmically striking or clapping the chest wall with cupped hands, using rapid wrist flexion and extension (b) Vibration: Repeatedly tensing the arm and hand muscles while maintaining firm but gentle pressure over the affected area with the flat of the hand (c) Postural drainage: Uses gravity to facilitate removal of secretions from a particular lung segment e) Integrative therapies (1) Echinacea (2) Ma huang or ephedra (banned in the United States for safety risks) 3. Nursing care a) Assessment (1) Health history (2) Physical examination: Presentation, apparent distress, level of consciousness; skin color, temperature; respiratory excursion, use of accessory muscles of respiration; and lung sounds b) Diagnoses, outcomes, and interventions (1) Promote airway clearance and patency (a) Assess respiratory status and cough frequently (b) Monitor arterial blood gas results (c) Place in Fowler or high-Fowler position and encourage frequent position changes and ambulation as allowed (d) Assist to cough, deep breathe, and use assistive devices (e) Perform pulmonary hygiene measures c) Promote effective breathing (a) Assess respiratory status (b) Assess for pleuritic discomfort (c) Provide analgesics as ordered (d) Teach slow abdominal breathing, meditation, and visualization (2) Reduce energy demands (a) Assess activity tolerance (b) Assist with self-care, bathing (c) Schedule activities, planning for rest periods (d) Provide assistive devices d) Transitions of care (1) Discuss medication, activity level and rest, fluid and nutritional intake, avoiding smoking, manifestations to report to healthcare provider (2) Refer to community support services C. The patient with severe acute respiratory syndrome 1. Pathophysiology a) Coronavirus, spreads primarily by contact with respiratory secretions .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

b) Infects cells of respiratory tract c) Alveolar damage and inflammation of interstitial pulmonary tissues 2. Manifestations a) 2–7 day average incubation period b) Fever above 100.4°F (38°C) c) Nonproductive cough, shortness of breath, dyspnea, and hypoxemia 3. Complications a) In second week, respiratory symptoms may progress to respiratory distress.

4. Interprofessional care a) Report cases of SARS b) Infection control (1) Standard precautions along with contact and airborne precautions (2) Healthcare setting: Hand hygiene, gown, gloves, eye protection, and an N95 respirator (3) Community setting: (a) Patient advised to stay home for 10 days after the fever has resolved; cover the mouth and nose when coughing/sneezing; wear a surgical mask (b) Family members are advised to wash hands frequently. c) Treatments (1) Supportive (2) Oxygen if hypoxemia is present (3) Intubation/mechanical ventilation for respiratory failure or acute respiratory distress syndrome (ARDS) D. The patient with lung abscess 1. Lung abscess—local area of lung destruction 2. Pathophysiology a) Forms after lung tissue becomes consolidated b) In up to 89% of patients, anaerobic organisms are the cause. c) Consolidated tissue becomes necrotic: (1) Can spread to involve entire bronchopulmonary segment (2) Can progress proximally until it ruptures into a bronchus (3) Can lead to diffuse pneumonia or a syndrome similar to acute respiratory distress syndrome 3. Risk factors a) Abuse alcohol b) Post-pneumonia patients c) Immunocompromised 4. Manifestations .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) Typically 2 weeks after precipitating event b) Early symptoms are those of pneumonia. c) When the abscess ruptures, the patient may expectorate large amounts of foulsmelling, purulent, and possibly blood-streaked sputum. d) Breathing sounds diminish; crackles in the region of abscess; and a dull percussion tone is also present.

5. Interprofessional care a) Diagnosis (1) Based on history and presentation (2) CBC may indicate leukocytosis (3) Sputum culture may not show organism unless rupture occurs (4) Chest x-ray b) Treatment (1) Antibiotic therapy: Intravenous clindamycin (Cleocin), amoxicillin-clavulanate (Augmentin), or penicillin (2) Treatment for at least 1 month 6. Nursing care a) Assessment (1) Same as for lung abscess b) Priorities of care (1) Patent airway (2) Adequate gas exchange c) Diagnoses, outcomes, and interventions (1) Promote airway clearance and patency (2) Effective gas exchange (3) Reduce hyperthermia (4) Reduce anxiety (5) Promote comfort, sleep, and rest 7. Transitions of care a) Patient and family teaching (1) Importance of completing antibiotic therapy (2) Risk of sepsis (3) For surgery: Preoperative teaching and instruction on postoperative care E. 1.

2.

3.

4.

The patient with tuberculosis Chronic, recurrent infectious disease, that usually affects lungs Bacteria: Mycobacterium tuberculosis Transmitted through droplet nuclei Incidence and prevalence

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) Significant problem worldwide b) In the United States, affects immigrants, those infected with HIV, and disadvantaged populations 5. Pathophysiology a) Disease process (1) Pulmonary (a) Bacteria implants in alveolus or respiratory bronchiole, cause local inflammatory response. Bacteria is isolated but not destroyed. (b) Tubercle (sealed-off colony of bacilli) forms (c) Caseation necrosis: Infected tissue in tubercle dies (d) If immune response adequate, patient may not develop TB. (e) Primary tuberculosis: Severe and uncommon in adults (f) Reactivation tuberculosis: Previously healed lesion may be reactivated. (i) Occurs when immune system is suppressed (ii) Risk of death if untreated (iii) HIV patients at high risk (2) Miliary tuberculosis (a) Hematogenous spread (through the blood) of the bacilli throughout the body (b) Causes chills and fever, weakness, malaise, and progressive dyspnea (c) Sputum rarely contains organisms. (d) Causes anemia, thrombocytopenia, and leukocytosis (3) Genitourinary tuberculosis (a) Organism spreads to the kidney through the blood. (b) Manifestations (i) Symptoms of a urinary tract infection and flank pain (ii) Men: Perineal, sacral, or scrotal pain and tenderness; difficulty voiding; and fever (iii) Women: Manifestations of pelvic inflammatory disease, impaired fertility, or ectopic pregnancy (4) Tuberculosis meningitis (a) TB spreads to the subarachnoid space (b) Reactivation of latent disease (c) Manifestations: Listlessness, irritability, anorexia, fever, headache, behavior changes, vomiting, convulsions, and coma (5) Skeletal tuberculosis (a) Kyphosis and spinal cord compression 6. Risk factors a) Poor ventilation, less-than-optimal immune function, prolonged contact, injection drug use, HIV infection, and alcoholism

.

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

7. Manifestations a) Initial infection typically goes unnoticed b) Fatigue, weight loss, anorexia, low-grade afternoon fever, and night sweats; dry cough, which later becomes productive of purulent and/or blood-tinged sputum 8. Complications a) Tuberculosis empyema and bronchopleural fistula 9. Interprofessional care a) Focus: Early detection, accurate diagnosis, effective treatment, preventing TB spread b) Hospitalization is rarely required. c) Screening (1) Methods for tuberculin testing (a) Intradermal PPD (Mantoux) and multiple-puncture (tine) test (2) Tuberculin test (a) Positive response indicates that infection and a cellular (T-cell) response have developed; does not mean that active disease is present or that the patient is infectious to others. (b) Screen those with: (i) HIV infection or risk (ii) Exposed to TB (iii) With medical risk factors (iv) Born in countries with high prevalence of TB (v) Alcoholics and injection drug users (vi) Residents and staff of long-term residential facilities, such as longterm care and mental health facilities, correctional institutions d) Diagnosis (1) A positive tuberculin test alone does not indicate active disease.

(2) Sputum smear is microscopically examined for acid-fast bacilli.

(3) Sputum culture positive for M. tuberculosis provides the definitive diagnosis.

(4) Sensitivity testing: To determine appropriate drug therapy (5) Polymerase chain reaction (PCR): Rapid detection of M. tuberculosis DNA. (6) Chest x-ray (7) Liver function tests (8) Vision exam (9) Audiometric testing e) Medications (1) Chemotherapeutic medications both to prevent and treat (2) Prophylactic treatment: Isoniazid (INH), bacilli Calmette-Guérin (BCG) vaccine (3) Initial regimen of four oral antitubercular drugs for 2 months (a) Isoniazid (INH), rifampin, pyrazinamide, and ethambutol (4) Four additional months of therapy with isoniazid and rifampin .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(5) In the presence of HIV infection, treatment is continued for at least 9 months.

(6) Many adverse and toxic effects (7) Patients often do not comply with prescriptions. f) Nutrition (1) Supplements may be required.

10. Nursing care a) b) Assessment (1) Health history (2) Physical examination (3) Diagnostic tests c) Priorities of care (1) Physical and psychologic recovery from the infection d) Diagnoses, outcomes, and interventions (1) Provide patient teaching (a) Assess knowledge about the disease process; identify misperceptions and emotional reactions (b) Assess ability and interest in learning, developmental level, and obstacles to learning (c) Identify support systems, and include significant others in teaching (2) Promote adherence to the treatment plan (3) Assess self-care abilities and support systems (a) Work collaboratively to identify barriers to managing the prescribed treatment; assist in developing a plan for managing prescribed regimen; and provide verbal and written instructions that are clear and appropriate (b) Active intervention for homeless people (c) Refer patients who are unlikely to comply with treatment regimen to public health department for management and follow-up (4) Reduce risk for infection (a) Use standard precautions and TB isolation techniques e) Transitions of care (1) Discuss with patient and family: (a) Screening and prevention of spread (b) Medication regiment (c) Nutrition and dietary guidelines (d) Manifestations of complications to report (e) Community support services F. The patient with inhalation anthrax 1. Pathophysiology a) Bacillus anthracis, the spore-forming rod responsible for causing anthrax .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Potential biologic weapon threat 2. Manifestations a) Flu-like symptoms, followed by an abrupt onset of severe dyspnea, stridor, and cyanosis b) Lymph nodes in the mediastinum and thorax become inflamed and enlarged. c) Septic shock and/or meningitis may develop d) Untreated, death results from hemorrhagic thoracic lymphadenitis and hemorrhagic mediastinitis e) 45% mortality rate 3. Diagnosis a) Blood culture/chest x-ray b) Because of risk of death, people suspected of exposure are treated prophylactically 4. Treatments a) Ciprofloxacin (Cipro) is used to both prevent and treat inhalation anthrax. b) Doxycycline (Vibramycin) is an alternative to ciprofloxacin. c) Vaccine is considered experimental.

G. The patient with a fungal infection 1. Pathophysiology a) Histoplasmosis: Most common fungal lung infection in the United States (1) Found in soil, bird droppings, and bats (2) Most infections lead to latent asymptomatic disease, or primary acute histoplasmosis, a mild, self-limiting influenza-like illness (3) Chronic progressive disease, usually seen in older adults (4) Immunocompromised host: Macrophages remove the fungi but are unable to destroy them, resulting in disseminated histoplasmosis (often fatal) b) Coccidioidomycosis: Coccidioides immitis mold grows in arid soil of Southwest, Mexico, Central/South America (1) Typically causes an acute, self-limiting pulmonary infection that often is asymptomatic and goes unrecognized c) Blastomycosis: Blastomyces dermatitidis fungus grow in Midwestern United States/Canada (1) Lungs are primary site for disease.

(2) Pulmonary symptoms include fever, dyspnea, pleuritic chest pain, and cough, which may become productive of bloody or purulent sputum (3) Fatal if untreated d) Paracoccidioidomycosis (1) Also known as Brazilian blastomycosis or Lutz-Spendore-de Almeida disease (2) Caused by Paracoccidioides brasiliensis fungus

.

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(3) The pulmonary presentation includes lobar pneumonia or pleurisy that continues past the ninth day. e) Aspergillus (1) Aspergillus spores are common in the environment, but rarely cause disease except in the immunocompromised.

(2) When infection occurs, Aspergillus species invade blood vessels and produce hyphae that branch at acute angles, frequently causing venous or arterial thrombosis.

(3) Dyspnea, nonproductive cough, pleuritic chest pain, chills, and fever (4) If the organism invades a pulmonary blood vessel, hemoptysis or massive pulmonary hemorrhage can occur.

2. Interprofessional care a) Microscopic examination of a sputum specimen b) Blood cultures, cerebrospinal fluid cultures, chest x-ray c) Acute pulmonary histoplasmosis and acute pulmonary coccidioidomycosis (1) Usually resolve without treatment (2) Antifungal drugs may shorten the disease course. (a) Oral itraconazole (Sporanox) for histoplasmosis d) Intravenous amphotericin B for other fungal infections e) Surgery (lobectomy) for severe hemoptysis associated with aspergillosis 3. Nursing care a) Education (1) Antifungal drugs (2) Pregnancy and birth control b) Monitor carefully during infusion and therapy II.

Disorders of the Pleura A. The patient with pleuritis (pleurisy) 1. Pleura: Thin membrane of two layers overlying lungs and chest wall 2. Pleural cavity: Between layers of the pleura, contains serous fluid 3. Pathophysiology and manifestations a) Inflammation of pleura b) Abrupt onset, unilateral, well localized, sharp or stabbing pain c) Often occurs following a viral respiratory illness, pneumonia, or rib injury 4. Interprofessional care a) Diagnosis based on manifestations b) Chest x-ray/ECG to rule out other causes of chest pain c) Treatment (1) Symptomatic

.

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

d) Care focused on promoting comfort 5. Nursing care a) Teach patient and family (1) Pleuritis is generally self-limited and of short duration.

(2) Discuss symptoms to report to the healthcare provider: Increased fever, productive cough, difficulty breathing, or shortness of breath B. The patient with a pleural effusion 1. Pathophysiology a) Excess pleural fluid may be either transudate or exudate. b) Precipitating factors: Heart failure, renal failure, nephrosis, liver failure, malignancy 2. Manifestations a) Large pleural effusion compresses adjacent lung tissue. b) Manifestation of dyspnea; pain may develop c) Breath sounds are diminished or absent d) Dull percussion tone heard over affected area; chest wall movement may be limited 3. Complications a) Lung scarring, pneumothorax (secondary to thoracentesis), empyema, or sepsis 4. Interprofessional care a) Diagnosis (1) Chest x-rays, CT scan, ultrasonography used to localize and differentiate effusions (2) Thoracentesis: Fluid removed from pleural space (a) Analyzed for appearance, cell counts, protein and glucose content, the presence of enzymes such as LDH and amylase, abnormal cells, and culture b) Treatment (1) Focuses on underlying disorder (2) An empyema may require repeated drainage, as well as high doses of parenteral antibiotics.

(3) Thoracotomy and surgical excision may be necessary.

5. Nursing care a) Supporting respiratory function and assisting with procedures to evacuate collected fluid b) Teaching for home care: Symptoms of recurrent effusion or complications following thoracentesis to report to healthcare provider (increasing dyspnea or shortness of breath, cough, and hemoptysis) C. The patient with pneumothorax 1. Pathophysiology

.

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) When either the visceral or parietal pleura is breached, air enters the pleural space, equalizing this pressure b) Lung expansion is impaired; recoil tendency collapses lung c) Spontaneous pneumothorax (1) Primary (simple) pneumothorax: Affects previously healthy people, usually tall, slender men between ages 16 and 24; cause unknown (2) Secondary (complicated) pneumothorax: Generally caused by overdistention and rupture of an alveolus and is more serious and potentially life threatening d) Traumatic pneumothorax (1) Blunt or penetrating trauma of the chest wall and pleura, fracture of the trachea and a ruptured bronchus or esophagus can lead to closed pneumothorax (2) Open pneumothorax (sucking chest wound): Penetrating chest trauma (3) Iatrogenic pneumothorax: Results from puncture or laceration of the visceral pleura during central-line placement, thoracentesis, or lung biopsy (a) Alveoli can become overdistended and rupture during anesthesia, resuscitation procedures, or mechanical ventilation e) Tension pneumothorax (1) Air enters the pleural space but is prevented from escaping.

(2) Ventilation is severely compromised, and venous return to the heart is impaired.

(3) Medical emergency requiring immediate intervention to preserve respiration and cardiac output 2. Risk factors a) COPD, cystic fibrosis, pulmonary tuberculosis, pneumonia, or asthma 3. Manifestations a) Spontaneous pneumothorax (1) Depends on size of pneumothorax, extent of lung collapse, and any underlying lung disease (2) Pleuritic chest pain, shortness of breath, heart rate and respiratory increase, and asymmetrical chest-wall movement (affected side is hyperresonant to percussion, and breath sounds may be diminished or absent) (3) Hypoxemia may develop (more pronounced in secondary).

(4) Decreased breath sounds and hyperresonant percussion tone on affected side, unequal lung excursion, tachypnea, tachycardia b) Traumatic pneumothorax (1) Pain and dyspnea (2) Chest wall movement on the affected side is diminished, and breath sounds are absent; if penetrating wound is present, air may be heard and felt moving through it with respiratory efforts.

(3) Pain, dyspnea, tachypnea, tachycardia, decreased respiratory excursion, absent breath sounds in affected area (4) Hemothorax frequently accompanies traumatic pneumothorax. .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(5) The manifestations of iatrogenic pneumothorax are similar to those of spontaneous pneumothorax. c) Tension pneumothorax (1) Hypotension, shock, distended neck veins, severe dyspnea, tachypnea, tachycardia, decreased respiratory function, absent breath sound on affected side, tracheal deviation toward unaffected side 4. Interprofessional care a) Treatment depends on severity b) Thoracostomy may be necessary. c) Diagnosis (1) Oxygen saturation measurements, chest x-rays, and ABGs d) Treatments (1) Chest tubes (closed-chest catheter) allows lung to reexpand. (a) Protocol and systems of chest tubes (2) Pleurodesis: Adhesions between the parietal and visceral pleura (a) To prevent recurring pneumothorax (3) Surgery: For patients at high risk of recurrence (a) Thoracostomy 5. Nursing care a) Assessment (1) Health history (2) Physical assessment (3) Diagnostic tests: Chest x-rays, arterial blood gases b) Diagnosis, outcomes, and interventions (1) Promote effective gas exchange (a) Assess and document vital signs and respiratory status (b) Evaluate chest wall movement, position of the trachea, and neck veins frequently; place in Fowler or high-Fowler position (c) Administer oxygen (d) Assess chest tube, system function, and drainage at least every 2 hours (2) Reduce risk for injury (a) Secure a loop of drainage tubing to the sheet or gown (b) When turning to the affected side, ensure that neither the chest tube nor drainage tubing is kinked or occluded under the patient (c) Teach the patient how to ambulate with the drainage system (d) Ensure all tubing connections are taped per hospital policy or provider preference 6. Transitions of care a) Education about future risk .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

b) Stress the importance of follow-up care and monitoring c) Teach manifestations to report to healthcare provider D. The patient with hemothorax (blood in pleural space) 1. Pathophysiology and manifestations a) Causes: Chest trauma, tumors, pulmonary infarction, infections such as TB b) With significant hemorrhage, a risk of shock exists c) Symptoms similar to pneumothorax or pleural effusion d) Chest x-ray confirms diagnosis 2. Treatment a) Thoracentesis or thoracostomy with chest tube drainage is used to remove blood from the pleural space 3. Nursing care a) Focuses on maintaining adequate respiratory function and cardiac output b) When hemothorax develops rapidly and hemorrhage is significant, cardiac output and fluid volume become additional priorities for care c) Fluid volume III.

Trauma of the Chest or Lung 1. Chest injury is a leading cause of death from trauma.

2. Traumatic injury to the chest may involve both the chest wall and underlying thoracic structures, including the lungs, heart, great vessels, and esophagus.

A. The patient with a thoracic injury 1. Pathophysiology a) Most common: Acceleration–deceleration injury and direct mechanisms of injury (e.g., crush injuries) b) Rib fracture (1) Generally well tolerated (2) Complications can occur for older adult or person with lung disease.

(3) Displaced fractured ribs can penetrate the pleura, leading to pneumothorax and possible hemothorax.

(4) Intrathoracic vessels may be damaged or torn with fractures of the first and second ribs; fractures of the seventh through tenth ribs may cause liver or spleen injuries. c) Flail chest (1) Paradoxic movement (2) Significantly affects ventilation, and consequently, gas exchange d) Pulmonary contusion (1) May occur unilaterally or bilaterally

.

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(2) Alveoli and pulmonary arterioles rupture, causing intra-alveolar hemorrhage, and interstitial and bronchial edema; resulting inflammatory response increases capillary permeability, leading to local or general edema (3) Manifestations of pulmonary contusion may not be apparent until 12 to 24 hours after the injury.

(4) Even with appropriate treatment, pulmonary contusion can lead to acute respiratory distress and potential death.

2. Manifestations a) Rib fracture (1) Pain on inspiration and coughing b) Flail chest (1) Dyspnea and pain, especially on inspiration; unequal chest expansion; palpable crepitus; breath sounds diminished; crackles may be heard on auscultation c) Pulmonary contusion (1) Increasing shortness of breath, restlessness, apprehension, and chest pain are early signs; copious sputum, which may be blood tinged, is present.

(2) Later manifestations: Tachycardia, tachypnea, dyspnea, and cyanosis 3. Interprofessional care a) Diagnosis (1) Chest x-ray b) Medications (1) Rib fracture: Providing adequate analgesia to promote breathing, coughing, and movement is primary intervention.

(2) Flail chest: Intercostal nerve blocks or continuous epidural analgesia to manage the pain associated c) Treatments (1) Intubation and mechanical ventilation (2) Pulmonary contusion patients often are critically ill, requiring intensive care management. (a) Treatment is supportive, directed at maintaining adequate ventilation and alveolar gas exchange. (b) Endotracheal intubation and mechanical ventilation (c) Although adequate hydration is necessary to prevent shock, overhydration can increase pulmonary edema. (d) Unilateral pulmonary contusion—unique management problem (i) Mechanical ventilation with positive end-expiratory pressure (PEEP) to maintain open alveoli and adequate gas exchange can damage the unaffected lung (ii) Intubation with a double-lumen endotracheal tube that permits independent ventilation of each lung may be used .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

4. Nursing care a) Assessment (1) Health history (2) Physical examination b) Diagnoses, outcomes, and interventions (1) Manage pain (a) Frequently assess pain; administer analgesics by patient-controlled analgesia or on a schedule (2) Promote airway clearance and patency (a) Assess lung sounds and respiratory rate, depth, and effort frequently (b) Encourage to cough, deep breathe, and change position every 1 to 2 hours, and use the incentive spirometer (c) Teach splinting with pillow when coughing (d) Elevate the head of the bed (3) Promote effective gas exchange (a) Expected outcomes: Improved ventilation and adequate oxygenation as evidenced by blood gas levels within normal limits for the individual patient (b) Monitor vital signs, color, oxygen saturation, and arterial blood gases (c) Assess for manifestations such as anxiety or apprehension, restlessness, confusion or lethargy, or complaints of headache (d) Maintain oxygen therapy and mechanical ventilation as ordered.

Hyperoxygenate prior to suctioning 5. Transitions of care a) Teaching for home care includes: Pain management and its importance in preventing respiratory complications; importance of coughing and deep breathing; reasons for not taping or wrapping the chest continuously b) Symptoms to report to the healthcare provider; importance of avoiding respiratory irritants B. The patient with inhalation injury 1. Pathophysiology a) Smoke inhalation: Pulmonary injury due to inhalation of hot air, toxic gases, or particulate matter is the leading cause of death in burn injury.

(1) Three mechanisms significantly impair normal respiratory function (a) Thermal damage to the airways, leading to impaired ventilation (b) Carbon monoxide or cyanide poisoning, resulting in tissue hypoxia (c) Chemical damage to the lung from noxious gases, which can impair gas exchange (d) Asphyxiation (e) Carbon monoxide or cyanide inhalation—immediate threat to life

.

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(2) Hemoglobin bound to carbon monoxide reduces the oxygen-carrying capacity of blood and oxygen delivery to cells of the body (3) Suspected if the burn occurred in a closed space, if there is evidence of inhalation injury, or if dyspnea develops b) Near-drowning (1) Asphyxiation and aspiration are primary problems.

(2) Laryngeal spasm causes asphyxia.

(3) Most often asphyxia and hypoxemia are the result of fluid aspiration.

(4) The dive reflex may prolong survival.

(5) Water aspiration can cause delayed death from near-drowning.

(6) Respiratory and systemic effects differ between freshwater and saltwater.

2. Manifestations a) Smoke inhalation: Depend on level of carboxyhemoglobin saturation (1) When hemoglobin is 10–20% saturated with carbon monoxide, symptoms include headache, dizziness, dyspnea, and nausea (2) A characteristic “cherry-red” skin color (3) With increasing levels, confusion, visual disturbances, irritability, hallucinations, hypotension, seizures, and coma develop (4) Permanent neurologic deficit can occur in survivors of severe acute carbon monoxide poisoning b) Near drowning (1) Altered level of consciousness, restlessness, and apprehension (2) Headache or chest pain (3) Vomiting, cyanosis, apnea, tachypnea, and wheezing (4) Pink frothy sputum if pulmonary edema present (5) Tachycardia, dysrhythmias, hypotension, shock, and cardiac arrest (6) Hypothermia may be present.

3. Interprofessional care a) Safety and prevention b) Administering effective cardiopulmonary resuscitation (1) Hypoxemia progresses rapidly until breathing is restored; reversal of tissue hypoxia depends on adequate circulation c) Diagnosis (1) ABGs (2) Carboxyhemoglobin levels are drawn in suspected carbon monoxide poisoning (3) Serum electrolytes and osmolality levels vary in near-drowning, depending on the type of water aspirated.

(4) Chest x-ray (5) Bronchoscopy may be ordered to inspect damaged lung tissue, particularly with smoke inhalation and possible thermal injury. .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

d) Treatments (1) Supportive (2) Endotracheal intubation and mechanical ventilation (3) Supplemental oxygen (4) Hyperbaric oxygen therapy may be used for carbon monoxide poisoning. (a) Risks include: Oxygen toxicity and potential trauma to lung tissues, sinuses, and ears due to the increased pressures (5) Bronchodilator therapy to manage bronchospasm (6) Intravenous fluids may be ordered; if significant hemolysis has occurred, packed red blood cells may be given.

(7) With near-drowning victims, measures such as inducing hypothermia or barbiturate-induced coma and administering corticosteroids and osmotic diuretics may be employed to help prevent neurologic damage.

(8) Careful monitoring for complications such as pneumonia and acute respiratory distress syndrome is vital throughout the course of treatment.

4. Nursing care a) Assessment (1) Health history (2) Physical examination (3) Diagnostic tests (4) Diagnoses, outcomes, and interventions (5) Promote airway clearance and patency (i) Assess lung and breath sounds and respiratory rate, depth, and effort (ii) Assist to cough frequently; suction the intubated patient as needed to remove secretions; elevate head of bed (b) Promote effective gas exchange (i) Monitor vital signs, color, oxygen saturation, mental status (ii) Monitor exhaled carbon monoxide, arterial blood gases, and pulmonary artery pressures (c) Promote cerebral tissue perfusion (i) Monitor vital signs and neurologic status frequently (ii) A change in level of consciousness or behavior is typically the earliest sign of increased intracranial pressure (IICP) (iii) Maintain effective ventilation and oxygenation; hypercapnia and hypoxemia increase cerebral edema (iv) Administer sedation, osmotic diuretics, or corticosteroids as ordered to reduce cerebral edema 5. Transitions of care a) Teach non-hospitalized patients about symptoms that may indicate a complication b) Provide resources for patients who have neurologic damage .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

IV.

Lung Cancer A. The patient with lung cancer 1. Pathophysiology a) Damaged bronchial epithelial cells mutate over time to become neoplastic b) Bronchogenic carcinoma: Vast majority of primary lung lesions (1) Types: Small-cell carcinomas, non-small-cell carcinomas c) Each cell type differs in its incidence, presentation, and manner of spread 2. Risk factors a) Cigarette smoking b) Dose–response relationship between smoking and lung cancer 3. Manifestations a) Related to the location and spread of the tumor b) Chronic cough, hemoptysis, wheezing, shortness of breath c) Dull chest pain with spread to mediastinum d) Pleuritic pain with pleura invasion e) Systemic and paraneoplastic manifestations (1) Weight loss, anorexia, fatigue, and weakness (2) Bone pain, tenderness, and swelling; clubbing of the fingers and toes (3) Various endocrine, neuromuscular, cardiovascular, and hematologic symptoms 4. Complications and course a) Superior vena cava syndrome: Obstruction of superior vena cava b) Paraneoplastic syndromes (1) Syndrome of inappropriate ADH secretion (SIADH) with fluid retention, hyponatremia, edema, Cushing syndrome related to abnormal ACTH production, and hypercalcemia c) Procoagulation factors, increasing the risk for venous thrombosis, pulmonary embolism, and thrombotic endocarditis 5. Interprofessional care a) Diagnosis (1) Chest x-ray, sputum specimen, bronchoscopy; CT scan (2) Cytologic examination and biopsy (3) CBC, liver function studies, serum electrolytes (4) Tuberculin test (5) Pulmonary function tests (PFTs) (6) Arterial blood gases (7) Lung cancer is staged by the tumor size, location, degree of invasion of the primary tumor, and the presence of metastatic disease.

(8) Stage 0 to Stage IV b) Medications

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Combination chemotherapy, often combined with radiation therapy and/or surgery (2) Bronchodilators to reduce airway obstruction (3) Analgesics and pain management c) Surgery (1) Can cure non-small-cell lung cancer (2) Most types inoperable at time of diagnosis (3) Laser bronchoscopy: Bronchoscopy-guided laser used to resect tumor (4) Mediastinoscopy: Visualization of the mediastinum using an endoscope passed through a suprasternal incision (5) Thoracotomy: Incision into the chest wall (6) Wedge resection: Removal of a small section of peripheral lung tissue (7) Segmental resection: Removal of an individual bronchovascular segment of a lobe (8) Sleeve resection: Resection of a section of a major bronchus with reconstruction of remaining normal bronchus (9) Lobectomy: Removal of a single lung lobe (10) Pneumonectomy: Removal of an entire lung d) Radiation therapy (1) Used alone or in combination with surgery or chemotherapy (2) Treatment goal may be either cure or symptom relief (palliative).

(3) Prior to surgery, radiation therapy is used to “debulk” tumors.

(4) Complications of lung cancer may be treated with radiation.

6. Integrative therapies a) Herbal medicines, medicinal teas, homeopathy, animal extracts, and aromatherapy 7. Nursing care a) Assessment (1) Health history (2) Physical examination (3) Laboratory tests and diagnostic studies b) Diagnoses, outcomes, and interventions (1) Promote effective breathing (a) Assess and document respiratory status every 4 hours; more frequently postoperatively or as needed (b) Frequently assess and document pain level (c) Elevate head of bed to 60°; assist to turn, cough, and deep breathe and use incentive spirometry; help splint the chest with a pillow or blanket when coughing (2) Promote physical activity as tolerated (a) Assess activity tolerance .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(b) Assist postoperative patient to increase activities gradually (c) Teach measures to conserve energy while performing ADLs (3) Manage pain (a) Assess and document pain (b) Maintain medication schedule using narcotic, nonsteroidal anti-inflammatory drugs, and other medications as ordered (c) Provide or assist with comfort measures (d) Spend as much time with the patient as possible; allow family members to remain with the patient (4) Promote healthy grief responses (a) Spend time with the patient and family (b) Answer questions honestly (c) Encourage the patient and family to express their feelings, fears, and concerns 8. Transitions of care a) Discuss the disease, expected prognosis, and planned treatment strategies b) Importance of quitting smoking c) Strategies to cope with noxious effects of radiation or chemotherapy d) Activities and exercises to improve strength and regain function for the postoperative patient e) The need to continue coughing and deep-breathing exercises at home f) Symptoms to report to the healthcare provider g) Use of analgesics and other pain relief measures for postoperative or cancer pain h) Information about hospice services, home health, local cancer support groups for patients and caregivers, and American Cancer Society services

Chapter Highlights A. Pneumonia, inflammation of the respiratory bronchioles and alveoli, is usually bacterial in origin. Different organisms are commonly found in healthcare-associated pneumonia than in community-acquired pneumonia. Nursing care focuses on promoting airway clearance, supporting effective gas exchange, and promoting rest.

B. Infection control measures, including standard, airborne, and contract precautions, are vital to prevent the spread of viral severe acute respiratory syndrome (SARS) or related novel respiratory viruses.

C. Tuberculosis affects many people worldwide. In the United States, the primary affected populations are immigrants, people with compromised immunity, and people living in crowded or unsanitary conditions.

D. The tuberculin test (PPD) detects a cellular immune response to M. tuberculosis, indicating infection, but not necessarily active disease.

E. Effective tuberculosis treatment is a public health concern, requiring therapy and compliance monitoring, contact follow-up, and assessment for adverse treatment effects. .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

F. Fungal lung infections tend to have a geographic pattern of distribution. People with compromised immune status are more likely to be affected. Their manifestations resemble those of pneumonia or tuberculosis.

G. Disorders of the pleura, such as pleural effusion and pneumothorax, can affect lung expansion, ventilation, and gas exchange when significant.

H. Tension pneumothorax develops when air enters the pleural space but is unable to escape, collapsing the lung on the affected side and placing pressure on the unaffected lung and mediastinum. Ventilation, gas exchange, venous return, and cardiac output can be significantly affected.

I. Trauma may affect the chest wall or the airways and alveoli. Flail chest and pulmonary contusion often occur concurrently; hemothorax also frequently develops with chest trauma. Chest trauma can endanger effective ventilation and gas exchange.

J. Lung cancer, the leading cause of cancer deaths, typically is advanced when diagnosed. Surgery, radiation therapy, and chemotherapy are used to treat lung cancer, often in combination.

K. Superior vena cava syndrome and paraneoplastic syndromes may complicate lung cancer.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME ONE Have students identify clinical patients who might be at risk for the development of ventilation disorder. Discuss the care necessary for these patients.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME ONE Assign students to care for patients with lung infections. Have the students discuss the difference in care required for these patients and those with an upper respiratory infection.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME TWO Divide the class into small groups and assign each group one of the major categories of disorders discussed in this chapter. Have each group work through the nursing process as it would be associated with that disease process.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME TWO Assign students to care for patients with pleural disorders (if available). Have the students observe a thoracentesis (if available). Have the students outline the care needed for patient recovering from a thoracentesis.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME THREE Ask an RN with trauma training to come to post-conference to discuss emergency nursing treatment of the patient with chest wall trauma.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME THREE Assign the students to care for a patient with a chest tube. Have the students discuss the role of the chest tube to inflate the lung and the emergency precautions needed when caring for this patient.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME FOUR Have students identify medications that are commonly used for treatment of ventilation disorders.

Have the students group the medications by class and identify major nursing implications in administration.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME FOUR Have the students develop a plan of care for a patient with lung cancer. Include actions to support the patient having surgery and radiation. If possible, assign students to care for patients with this health problem.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter 37 Nursing Care of Patients with Gas Exchange Disorders Learning Outcomes 1. Describe the pathophysiology and manifestations of reactive airway disorders, and outline the interprofessional care and nursing care of patients with these disorders.

2. Describe the pathophysiology and manifestations of interstitial lung disease, and outline the interprofessional care and nursing care of patients with this disorder.

3. Describe the pathophysiology and manifestations of pulmonary vascular disorders, and outline the interprofessional care and nursing care of patients with these disorders.

4. Describe the pathophysiology and manifestations of respiratory failure, and outline the interprofessional care and nursing care of patients with this condition.

Key Concepts I.

Reactive Airway Disorders A. Airways narrow in response to stimulus, limits airflow B. The Patient with Asthma 1. Chronic inflammatory disorder of the airways characterized by recurrent episodes of wheezing, breathlessness, chest tightness, coughing 2. Pathophysiology a) Airways in lungs consist of smooth muscle that controls diameter b) Parasympathetic stimulation leads to bronchoconstriction c) Sympathetic stimulation leads to bronchodilation d) Inflammatory mediators produce bronchoconstriction e) Airways in persistent state of inflammation f) Attack triggers (1) Inhalation of allergens, environmental pollutants, agents found in the workplace (a) Exposure to secondhand smoke associated with higher risk and increased severity (2) Respiratory infections, viral in particular, are common internal stimulus (3) Exercise, emotional stress (4) Pharmacologic triggers: Aspirin and other NSAIDs, beta blockers, sulfites g) Responses (1) Acute/early response: Develops in hyperreactive airway

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(a) Sensitized mast cells and inflammatory cells release inflammatory mediators, stimulate parasympathetic receptors and increase capillary permeability (b) Bronchoconstriction and mucosal edema develops (2) Late-phase response (a) Develops 4–12 hours after exposure (b) Inflammatory cells activated, damage airway epithelium, produce mucosal edema, impair mucociliary clearance (c) Produce or prolong bronchoconstriction (d) Degree of hyperreactivity depends on the extent of inflammation (3) Air trapped distal to the spastic, narrowed airways mixes with inspired air in alveoli, reduces oxygen tension and gas exchange across alveolar-capillary membrane (4) Hypoxemia develops 3. Risk factors a) Risk factors: Allergies, strong genetic component, exposure to environmental factors (e.g., air pollution and industrial compounds) 4. Manifestations a) Subjective sensation of chest tightness, cough, dyspnea with wheezing b) Onsets are either abrupt or insidious c) During attack: Tachycardia, tachypnea, prolonged expiration, diffuse wheezing on auscultation, use of accessory muscles of respiration, intercostal retractions, loud wheezing, distant breath sounds, fatigue, anxiety, apprehension, severe dyspnea d) Frequency and severity of symptoms vary greatly 5. Complications a) Status asthmaticus: Severe, prolonged asthma that does not respond to routine treatment (1) Can lead to respiratory failure with hypoxemia, hypercapnia, and acidosis b) Cough-variant asthma (1) Have persistent cough without wheezing or dyspnea 6. Interprofessional care a) Diagnosis (1) Pulmonary function tests: Residual volume (RV), forced expiratory volume (FEV1), and peak expiratory flow rate (PEFR) (2) Challenge or bronchial provocation testing: To confirm diagnosis .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(3) ABGs: During attack to evaluate severity (4) Skin testing: To identify allergens (5) Serum immunoglobulin E (6) Eosinophil count b) Disease monitoring (1) Peak expiratory flow rate (PEFR) on day-to-day basis to establish baseline and evaluate severity in time of attack c) Medications (1) Long-term disease control (a) Long-acting bronchodilators (i) Adrenergic stimulants: Affect receptors on smooth muscle cells of respiratory tract; cause smooth muscle relaxation and bronchodilation (ii) Anticholinergic agents: Block parasympathetic input to bronchial smooth muscle; inhibit bronchoconstriction (iii) Methylxanthines: Relaxes bronchial smooth muscle, may also inhibit release of chemical mediators of inflammatory response (b) Anti-inflammatory agents (i) Corticosteroids: Block the late response to inhaled allergens and reduce bronchial hyperresponsiveness (ii) Nonsteroidal anti-inflammatory agents: Prevent acute attacks by reducing airway hyperreactivity and inhibiting release of mediator substances (a) Cromolyn sodium and nedocromil (c) Leukotriene modifiers (i) Reduce inflammatory response, appear to improve lung function, diminish symptoms, reduce need for short-acting bronchodilators (ii) Taken orally (iii) Montelukast (Singulair), zafirlukast (Accolate), and zileuton (Zyflo Filmtab) (2) Quick relief medications (a) Short-acting adrenergic stimulants (b) Anticholinergic drugs (c) Methylxanthines (3) Stepwise approach based on severity (4) Administration methods: Metered-dose inhaler (MDI), dry powder inhaler (DPI), and nebulizer (a) Rapid onset, reduced systemic effects of drugs d) Integrative therapies

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Nutritional: Elimination of certain foods or food additives; some evidence for intake of ascorbic acid, zinc, magnesium, omega-3 polyunsaturated fatty acids (2) Herbal preparations: Atropa belladonna, capsaicin, quercetin, grape seed extract (a) Ephedra: Banned because of dangers (b) Herbs not to be used in combination with certain medications (3) Biofeedback, yoga, breathing techniques, acupuncture, homeopathy, and massage 7. Nursing care a) Assessment (1) Health history (2) Physical examination (3) Laboratory data b) Diagnoses, outcomes, and interventions (1) Promote airway clearance and patency (a) Monitor skin color and temperature and level of consciousness (b) Assess arterial blood gas results and pulse oximetry readings (c) Assess cough (d) Place in Fowler’s, high-Fowler’s or orthopneic position (e) Administer oxygen and nebulizer treatments as needed (f) Provide humidification, fluids, and endotracheal suctioning as needed (g) Assist with chest physiotherapy (2) Promote effective breathing pattern (a) Frequently assess respiratory status, not manifestations of ineffective breathing (b) Monitor vital signs and laboratory results (c) Assist with ADLs as needed (d) Provide rest periods between scheduled activities and treatments (e) Teach and assist to use techniques to control breathing pattern (f) Administer medications (3) Reduce anxiety (a) Assess level of anxiety (b) Assist to identify coping skills (c) Provide physical and emotional support (d) Listen actively to concerns (e) Provide clear, concise explanation (4) Promote adherence to the treatment plan (a) Assess level of understanding about disease and the treatment (b) Discuss patient’s perception of illness and its effect on lifestyle .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(c) Assist to identify problems integrating the treatment into lifestyle (d) Provide verbal and written instructions (e) Refer to counseling, support groups, self-help organizations 8. Transitions of care a) Discuss: Lifestyle changes to avoid triggers; using PEFR meter to monitor airway status; using prescribed medications C. The Patient with Chronic Obstructive Pulmonary Disease 1. Pathophysiology a) Slowly progressive obstruction of the airways b) Periodic exacerbations with increased symptoms of dyspnea and sputum production c) Three separate processes usually involved: (1) Small airways disease: Narrowing of small bronchioles (2) Chronic bronchitis with persistent airway edema, excessive mucous production, and impaired airway clearance (3) Emphysema with loss of alveolar walls, capillary bed, and airway support tissue resulting in airway collapse and reductions in gas exchange d) Increased work of breathing, impaired expiration with air trapping, and impaired gas exchange 2. Risk factors a) More common in Whites than Blacks and in men than in women b) Risk factors: Middle and older age, cigarette smoking, air pollution, occupational exposure to noxious dusts and gases, airway infection, familial and genetic factors 3. Manifestations a) Varies from simple bronchitis without disability to chronic respiratory failure and severe disability b) Manifestations typically absent early in disease c) Chronic bronchitis: Productive cough, cyanosis, evidence of right-sided heart failure, adventitious sounds prominent on auscultation d) Emphysema: Progressive dyspnea, minimal or absent cough, barrel chest; patient is thin, tachypneic, often sits leaning forward; expiratory phase of respiratory cycle is prolonged; breath sounds diminished, hyperresonant percussion tone 4. Interprofessional care a) Diagnosis (1) Pulmonary function testing: (a) Total lung capacity, residual volume: Increased (b) Forced expiratory volume, forced vital capacity: Decreased .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(2) Ventilation–perfusion screening (3) Serum alpha1-antitrypsin levels (4) ABGs (5) Pulse oximetry (6) Exhaled carbon dioxide (7) CBC with WBC differential (8) Chest x-ray b) Smoking cessation (1) Can prevent COPD from developing and improve lung function once disease has been diagnosed c) Medications (1) Immunization against pneumococcal pneumonia and a yearly influenza vaccine recommended (2) Broad-spectrum antibiotic if infection is suspected, in cases with purulent sputum and increased dyspnea, for those who experience four or more exacerbations per year (3) Bronchodilators: Improves dyspnea and exercise tolerance (a) Anticholinergic agent ipratropium bromide often prescribed (4) Corticosteroids: Used when asthma is major component (a) Improves symptoms and exercise tolerance, may reduce the severity of exacerbations and need for hospitalization (5) Alpha1-antitrypsin replacement therapy: For patients with emphysema due to a genetic deficiency of the enzyme d) Treatments (1) Avoidance of allergens and airway irritants (2) Pulmonary hygiene measures (3) Maintaining adequate systemic hydration to keep secretions thin (4) Leaning forward and repeatedly “huffing” (5) Percussion and postural drainage (6) Pulmonary rehabilitation: Exercise, education, and psychological support (a) Improves exercise, functional capacity, and quality of life (b) Offered in the outpatient settings (7) Breathing exercises e) Oxygen: For severe and progressive hypoxemia (1) Improves energy tolerance, mental functioning, quality of life; reduces rates of hospitalization, increases length of survival in advanced cases (2) May be used intermittently, at night, or continuously (3) Supplied as liquid oxygen, compressed gas cylinders or oxygen concentrators .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(4) Acute exacerbations may call for oxygen with face mask and mechanical ventilation f) Surgery (1) When medical therapy is no longer effective (2) Both single and bilateral transplants are options (3) 1-year survival rate of 87.2% (4) Lung reduction surgery: Experimental intervention for advanced diffuse emphysema and lung hyperinflation g) Integrative therapies (1) Dietary measures: Minimizing intake of dairy products and salt (2) Herbal teas: Peppermint and yarrow, coltsfoot, comfrey, and licorice root (3) Acupuncture, hypnotherapy, and guided imagery 5. Nursing care a) Assessment (1) Health history (2) Physical examination (3) Laboratory data b) Diagnoses, outcomes, and interventions (1) Promote airway clearance and patency (a) Assess respiratory status every 1 to 2 hours or as indicated (b) Promptly report changes in oxygen saturation, skin color or mental status (c) Monitor ABGs (d) Weigh daily, monitor intake and output, and assess mucous membranes and skin turgor (e) Encourage fluid intake of at least 2000 to 2500 mL per day (f) Place in Fowler, high-Folwer, or othopneic position; encourage movement and activity to tolerance (g) Assist with cough, deep breathing, percussion, postural drainage; perform endotracheal suctioning; provide rest periods between treatments and activities (h) Administer medications and oxygen as ordered (i) Refer to a respiratory therapist (2) Promote balanced nutrition (a) Assess nutritional status; observe eating habits; monitor laboratory values (b) Consult with a dietitian to plan meals and nutritional supplements (c) Provide frequent, small meals with supplements between meals (d) Place seated or in high-Fowler position for meals (e) Assist to choose preferred meals .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(f) Keep snacks at bedside (g) Consult with physician about enteral or parenteral feeding (3) Promote healthy family coping (a) Assess interactions between patient and family (b) Assess effect of the illness on the family (c) Help the patient and family identify strengths for coping (d) Provide information and teaching about COPD (e) Encourage expression of feelings; family participation in care (f) Help family members recognize behaviors that may hinder effective treatment (g) Initiate a interprofessional care conference with patient, family, and healthcare team (h) Advocate for the patient in cases of dysfunctional family relationships (i) Refer the family to support groups, pulmonary rehabilitation programs, social services, and other community resources (4) Encourage smoking cessation (a) Assess knowledge and understanding of choices and consequences involved (b) Acknowledge concerns, values, and beliefs without judgement (c) Spend time with patient, encourage expression of feelings (d) Help plan a course of action for quitting smoking, adapt as necessary (e) Demonstrate respect for decisions and the right to choose (f) Provide referral to a counselor or other professional as needed 6. Transitions of care a) Teach effective coughing and breathing techniques, measures to prevent exacerbations, and managing prescribed therapies b) Discuss fluid intake, respiratory irritants, preventing exposure to infection, exercise, diet, wearing ID band, and carrying list of medications in case of emergency c) Provide referrals to community resources D. The Patient with Cystic Fibrosis 1. Autosomal recessive disorder that leads to abnormal exocrine glad secretions 2. Pathophysiology a) Lack or abnormality of CFTR protein causes abnormal electrolyte transport across epithelial cell membranes b) Excessive mucus production in the respiratory tract and impaired ability to clear secretions, progressive COPD

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Results in atelectasis, infection, bronchiectasis, dilation of distal airways (2) Damage to lung parenchyma causes tissue loss, scarring, and fibrosis (3) Severe airway obstruction leads to pulmonary hypertension, right ventricular hypertrophy, cor pulmonale (4) Death results from cardiovascular changes and respiratory failure c) Pancreatic enzyme deficiency and impaired digestion d) Abnormal elevation of sodium and chloride concentrations in sweat 3. Complications a) Diabetes mellitus, liver failure, males are usually sterile, females have difficulty conceiving 4. Manifestations a) Pulmonary: Recurrent pneumonia, exercise intolerance, chronic cough, clubbing of fingers and toes, barrel chest, hyperresonant percussion tone, basilar crackles on auscultation b) Cardiac: Manifestations of right-sided heart failure c) Abdominal: Manifestations of pancreatic insufficiency d) Small stature common 5. Interprofessional care a) Diagnosis (1) Analysis of Cl− concentration in sweat (a) Pilocarpine and small electric current used to increase sweat production (2) ABGs and oxygen saturation levels show hypoxemia b) Medications (1) Immunization against respiratory infections (2) Bronchodilators to control airways constriction (3) Antibiotics for infections (4) Dornase alfa: Breaks down excess DNA in sputum c) Nutrition (1) Pancreatic enzyme replacement therapy (2) Diet high in protein, fat, and calories with supplemental vitamins and minerals for loss in sweat and stools d) Treatments (1) Chest physiotherapy with percussion and postural drainage (2) Huff cough technique with specified breathing cycles or patterns (a) Valved mask maintains positive expiratory pressure (b) Autogenic drainage technique (biofeedback) (c) Oscillating positive expiratory pressure uses a flutter valve device .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(3) Oxygen therapy for hypoxemia (4) Liberal fluid intake e) Surgery (1) Lung transplantation increases quality of life, lengthens life span (2) Donor lungs do not develop CF related complications (3) Other defects characteristic of CF remain, are manageable with medications 6. Nursing care a) Assessment (1) Health history (2) Physical assessment (3) Laboratory data b) Diagnoses, outcomes, and interventions (1) Promote airway clearance and patency (a) Assess respiratory status; cough and sputum; ABG results (b) Place in Fowler or high-Fowler position and encourage frequent position changes (c) Assist to cough, deep breath, use assistive devices (d) Provide endotracheal suctioning, sufficient fluid intake (e) Work with physician and respiratory therapist to provide pulmonary hygiene measures (f) Administer medications as ordered (2) Promote healthy grief response (a) Spend time with patient and family; answer questions honestly; encourage expression of feelings (b) Assist with understanding the grieving process (c) Help patient and family make treatment decisions (d) Encourage use of other support systems and refer to community resources (e) Discuss advance directives and power of attorney laws 7. Transitions of care a) Discuss: Respiratory care techniques and specific breathing and cough exercises; the importance of avoiding respiratory irritants; measures to prevent respiratory infection b) Refer to a dietician c) Discuss genetic transmission with people with a family history of CF E. The Patient with Atelectasis 1. Condition of partial or total lung collapse and airlessness 2. Causes .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) Obstruction of bronchus ventilating a segment of lung tissue, compression of lung by pneumothorax, pleural effusion or tumor; loss of pulmonary surfactant and inability to maintain open alveoli 3. Manifestations: Depend on size a) Diminished breath sounds over affected area, tachycardia, dyspnea, cyanosis, other signs of hypoxemia; chest expansion; manifestations of infection 4. Diagnosis a) Chest x-ray and CT scan 5. Therapy a) Prevention and early detection for those at risk b) Treatment focuses on underlying cause (1) Bronchoscopy may be necessary (2) Antibiotics to treat infections 6. Nursing care a) Directed toward airway clearance (1) Position on unaffected side to promote drainage (2) Encourage frequent position changes, ambulation, cough, deep breathing (3) Encourage fluids b) Teach at-risk patients about pulmonary care measures F. The Patient with Bronchiectasis 1. Permanent abnormal dilation of one or more large bronchi with destruction of bronchial walls 2. Causes a) Inflammation from infection, cystic fibrosis, lung abscess, exposure to toxic gases, abnormal lung or immunologic defenses, localized airway obstruction from a foreign body or tumor 3. Manifestations and complications a) Chronic productive cough, hemoptysis, recurrent pneumonia, wheezing and shortness of breath, malnutrition, right-sided health failure, cor pulmonale 4. Diagnosis: Based on history and physical examination a) Chest x-ray and CT scan may be ordered for confirmation 5. Treatments a) Antibiotics for infection and prophylactically b) Inhaled bronchodilators c) Chest physiotherapy d) Percussion and postural drainage e) Oxygen may be prescribed f) Bronchoscopy or lung resection may be used 6. Nursing care a) Similar to that for patients of other obstructive lung disorders .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

b) Diagnoses: Ineffective airway clearance; ineffective breathing pattern; impaired gas exchange; imbalanced nutrition: Less than body requirements; self-care deficit II.

Interstitial Lung Diseases A. Damage connective tissue of the lung B. The Patient with an Occupational Lung Disease 1. Disorders directly related to inhalation of noxious substances in the work environment 2. Classifications: a) Pneumoconiosis: Chronic fibrotic lung diseases from inhalation of inorganic dusts and particulate matter (1) For example, silicosis, coal worker’s pneumoconiosis, asbestosis b) Hypersensitivity pneumonitis: Allergic pulmonary diseases from exposure to inhaled organic dusts (1) For example, farmer’s lung, hot tub lung, pigeon-breeder’s lung 3. Pathophysiology a) Lung compliance affected by: Elastin fibers, collagen fibers, water content, and surface tension of tissues b) Response to noxious substance inhalation depends on (1) Size of particulates (2) Nature (organic or inorganic) (3) Where it deposits in respiratory tract (4) Susceptibility of individual c) Inhaled substances damage alveolar epithelium, lead to inflammatory process of the alveoli and interstitial lung tissue d) Fibrotic scarring replaces elastin fibers, leads to hypoxemia e) Asbestosis: Inhalation of asbestos (1) Diffuse interstitial fibrotic disease involving terminal airways, alveoli, pleurae (2) Symptoms may not be apparent until 20 years after exposure, tend to progress (3) Associated with increased risk for bronchogenic carcinoma and mesothelioma f) Silicosis: Inhalation of silica dust (1) Nodular pulmonary fibrosis (2) Simple silicosis: Asymptomatic with no respiratory impairment (3) Complicated silicosis: Large conglomerate densities in upper lungs g) Coal worker’s pneumoconiosis: Ingestion of coal dust (1) Coal macules form (2) Simple cases: Asymptomatic

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(3) Small percentage: Develop massive fibrosis with symptoms similar to complicated silicosis h) Hypersensitivity pneumonitis (1) Allergic pulmonary disease affecting airways and alveoli 4. Manifestations a) Asbestosis (1) Exertional dyspnea, exercise intolerance, and inspiratory crackles (2) Diffuse, small, irregular, or linear opacities appear on chest x-ray (3) Respiratory failure and marked hypoxemia may develop b) Silicosis (1) Severe dyspnea and productive cough, restrictive and obstructive changes in lungs (2) Can lead to severe disability, cor pulmonale, and death c) Coal worker’s pneumoconiosis (1) Black lung disease d) Hypersensitivity pneumonitis (1) Acute: Sudden onset of malaise, chills and fever, dyspnea, cough, nausea (2) Subacute: Insidious onset of chronic cough, progressive dyspnea, anorexia, and weight loss (3) Diffuse fibrosis can lead to respiratory insufficiency 5. Interprofessional care a) Diagnosis (1) Chest x-ray, pulmonary function studies, bronchoscopy, possibly lung biopsy, ABGs, specialized lung scans b) Disease management: Limiting exposure to offending agent (1) Corticosteroids may slow progression (2) Preventing exposure to other damaging substances (3) Vaccinations for respiratory infections 6. Nursing care a) Assessment b) Diagnoses, outcomes, and interventions (1) Similar to those for COPD (2) Other diagnoses to consider: Ineffective breathing pattern, anticipatory grieving, and low self-esteem 7. Transitions of care a) Discuss: Prevention of further damage, pulmonary hygiene measures, use and care of oxygen equipment if required, use and effects of medications .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

C. The Patient with Sarcoidosis 1. Chronic, multisystem disease of exaggerated cellular immune response 2. Granuloma formation in lungs, lymph nodes, liver, eyes, skin and other organs 3. Unknown cause 4. Incidence a) Primarily adults ages 20‒40; highest incidence in African Americans; women more often affected than men 5. Manifestations a) Vary depending on organ system affected; may be asymptomatic b) Anorexia, fatigue, weight loss, fever, dyspnea, arthralgias, myalgias, skin lesions, uveitis, lymphadenopathy, and hepatomegaly 6. Diagnosis a) Leukopenia, eosinophilia, elevated erythrocyte sedimentation rate noted b) Chest x-ray c) Biopsy of granulomatous lesion to confirm d) Pulmonary function tests 7. Treatment a) Often resolves spontaneously b) Corticosteroids or other anti-inflammatory or immune-modifier medications 8. Nursing care a) Supportive respiratory care b) Teach patients with limited symptoms about disease and manifestations to report c) Teach importance of taking corticosteroids as prescribed III.

Pulmonary Vascular Disorders A. The Patient with a Pulmonary Embolism 1. Emboli: Thromboemboli, tumors, fat or bone marrow due to trauma, amniotic fluid after childbirth, IV injection of air or other foreign substances 2. Medical emergency: 50% of deaths occur within first 2 hours 3. Pathophysiology a) Right heart receives deoxygenated blood from venous circulation b) Right ventricle outputs to pulmonary circulation via pulmonary artery c) Local factors regulate ventilation and perfusion to maintain match d) Thrombi from popliteal and iliofemoral veins may break loose e) Impact ranges from occlusion of large pulmonary artery and sudden death to lung tissue infarction to no permanent lung injury (1) If infarction does not occur, fibrinolytic system dissolves the clot

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(2) Infarcted tissues becomes fibrotic 4. Risk factors a) Same as those for deep vein thrombosis (most common cause) 5. Manifestations a) Usually develop abruptly b) Common: Dyspnea, chest pain, anxiety, cough, tachycardia, tachypnea, crackles, low-grade fever c) Less common: Diaphoresis, hemoptysis, syncope, cyanosis, S3 and/or S4 gallop 6. Interprofessional care a) Diagnosis (1) Plasma D-diner levels (2) Lung scans (3) Pulmonary angiography (4) Chest x-ray (5) Electrocardiogram (ECG) (6) ABGs (7) Exhaled carbon dioxide (8) Coagulation studies b) Medications (1) Anticoagulation therapy for prevention for high-risk patients (2) Heparin therapy: IV bolus followed by continuous infusion (3) Oral anticoagulant therapy with warfarin sodium (Coumadin) initiated at same time as heparin (a) Vitamin K for bleeding associated with Coumadin (4) Thrombolytic therapy for massive pulmonary embolus and hypotension (a) Streptokinase, urokinase, or tissue plasminogen activator (t-PA) (b) Significantly increases risk for bleeding c) Surgery (1) Umbrella-like filter inserted percutaneously into inferior vena cava to trap large emboli 7. Nursing care a) Assessment (1) Health history (2) Physical examination (3) Laboratory data b) Diagnoses, outcomes, and interventions (1) Promote effective gas exchange (a) Frequently assess respiratory status, level of consciousness, ABG test results (b) Place in Fowler or high-Fowler position (c) Maintain bed rest .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(2) Promote adequate cardiac output (a) Auscultate heart sounds every 2 to 4 hours (b) Record intake and output hourly (c) Assess skin color and temperature, cardiac rhythm, pulmonary artery pressures, neck vein distention, and peripheral edema (d) Administer medications as ordered (e) Maintain IV and arterial access sites as well as central lines (f) Provide frequent skin care (g) Instruct to report chest pain and other manifestations (3) Reduce risk for bleeding and hemorrhage (a) Assess for signs of bleeding, coagulation study results (b) Keep protamine sulfite available during heparin therapy and vitamin K available for warfarin therapy (c) Avoid invasive procedures, injections, and venous punctures when possible (d) Maintain firm pressure on injection and venipuncture sites (e) Maintain adequate fluid intake (4) Reduce anxiety (a) Assess anxiety level (b) Provide reassurance and emotional support (c) Remain with patient as much as possible (d) Explain procedures and treatments clearly (e) Reduce environmental stimuli and use and calm manner (f) Allow supportive family members to be with patient as much as possible (g) Administer morphine sulfate as ordered 8. Transitions of care a) Discuss: Use of prescribed anticoagulant, measures to reduce the risk of bleeding, avoiding aspiring, importance of wearing MedicAlert tag for anticoagulant use, health promotion measures to reduce recurrent cases b) Symptoms of pulmonary embolism for high-risk patients B. The Patient with Pulmonary Hypertension 1. Pathophysiology a) Smooth muscle cells and fibroblasts cause vasoconstriction and fibrosis of pulmonary vessels b) Vasoconstrictive substances produced in excess: Endothelin 1 and thromboxane A2 c) Vasodilating substances reduce: Nitric oxide d) Development of plexiform lesions e) Changes are progressive and irreversible .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

f) Leads to right ventricular failure g) Primary pulmonary hypertension (1) Uncommon, no identified cause, in familial and sporadic patterns (2) Primarily affects women in 30s or 40s h) Secondary pulmonary hypertension (1) Due to: HIV; collagen diseases; hypoxemia from chronic lung diseases, sleep apnea, or obesity; widespread vessel destruction or obstruction; emphysema; left ventricular failure or mitral stenosis 2. Manifestations a) Both forms: Progressive dyspnea, fatigue, angina, and syncope with exertion b) Secondary: Manifestations often masked by those of underlying disorder (1) Dull, retrosternal chest pain may occur c) Primary: Generally causes death within 3 to 4 years 3. Complications a) Cor pulmonale: Right ventricular hypertrophy and failure from long-standing pulmonary hypertension 4. Interprofessional care a) Diagnosis (1) CBC shows polycythemia (2) ABGs and oxygen saturation show hypoxemia (3) Chest x-ray (4) ECG changes (5) Echocardiogram (6) Doppler ultrasonography b) Treatment (1) Oxygen for hypoxemia (2) Phlebotomy for polycythemia c) Medications (1) Calcium channel blockers to reduce pulmonary vascular resistance (2) Short-acting direct vasodilators for patients who do not respond to calcium channel blockers (3) Oral anticoagulant to prevent clotting d) Surgery (1) Bilateral lung or heart transplant most effective for long-term primary cases (2) Salt and water restrictions and diuretics for cor pulmonale 5. Nursing care a) Diagnosis and interventions .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

b) Impaired gas exchange (a) Monitor breath sounds, respiratory rate, skin color, use of accessory muscles (b) Position for optimal lung expansion (c) Coughing, deep breathing, chest physiotherapy (d) Administer medications as ordered (e) Assess for fatigue and dyspnea, plan rest periods, assist with self-care (2) Primary: Anticipatory grieving and hopelessness (3) Cor pulmonale: Decreased cardiac output, excess fluid volume, ineffective individual coping 6. Transitions of care a) Teach about underlying disease and resulting hypertensive process b) Teach manifestations to report, importance of rest periods, importance of not smoking, medication use IV.

Respiratory Failure A. The Patient with Acute Respiratory Failure 1. Due to: COPD, other lung diseases, chest injury, inhalation trauma, neuromuscular disorders, and cardiac conditions 2. Pathophysiology a) Characterized by primary hypoxemia or combination of hypoxemia and hypercapnia (1) Hypoxemia without a corresponding rise in carbon dioxide levels indicates a failure of oxygenation (2) Hypoxemia with hypercapnia is the result of lung hypoventilation 3. Manifestations a) Caused by hypoxemia and hypercapnia and underlying disease process b) Hypoxemia: Dyspnea and neurologic symptoms, cardiac rhythm irregularities c) Hypercapnia: Manifestations of depressed CNS function and vasodilation d) Prognosis: Depends on underlying disease process, may resolve quickly with no long-term effects or cause death 4. Interprofessional care a) Diagnosis (1) Exhaled carbon dioxide (2) Arterial blood gases b) Medications (1) Beta-adrenergics, anticholinergics, or methylxanthine bronchodilators for bronchodilation

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(2) Corticosteroids to reduce airway edema (3) Antibiotics for underlying infections (4) Sedation and analgesia during mechanical ventilation (a) Sometimes sedation decreases effectiveness of ventilation (i) Neuromuscular blocking agent used in combination with sedation in these cases c) Oxygen therapy: To reverse hypoxemia (1) Caution to not induce oxygen toxicity (2) Venturi mask or CPAP used d) Airway management (1) Endotracheal tube from mouth or nose into trachea in cases of upper airway obstruction or need for positive pressure mechanical ventilation (a) Cuffed with air-filled or foam sac to prevent air escaping back (2) Tracheostomy may be performed if long-term ventilator support is required (a) More comfortable but increased complication risk (3) Extubation: Tube is removed e) Mechanical ventilation: When alveolar ventilation is inadequate to maintain blood oxygen and carbon dioxide levels (1) Types of ventilators (a) Negative-pressure: Create negative pressure externally to draw chest outward and air into lungs (i) For neuromuscular disorders, ventilator support during sleep (b) Positive-pressure: Push air into lungs (2) Modes of ventilation (a) Noninvasive ventilation (NIV) uses tight-fitting mask, avoids intubation (b) Continuous positive airway pressure (CPAP) (c) Assist-control mode ventilation (d) Synchronized intermittent mandatory ventilation (e) Positive-end expiratory pressure (f) Pressure support ventilation (g) Pressure-control ventilation (h) Independent lung ventilation (i) High-frequent ventilation (3) Ventilator settings (a) Mode, rate, tidal volume, oxygen concentration, I:E ratio, flow rate, sensitivity, and pressure limit (4) Complications (a) Ventilator-assisted pneumonia .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(b) Barotrauma (c) Pneumothorax (d) Pneumomediastinum (e) Cardiovascular effects (f) Gastrointestinal complications (5) Nutrition and fluids (a) Swan-Ganz catheter monitors pulmonary artery pressures, cardiac output, serum electrolytes (b) Enteral or parenteral nutritional provided (i) Nasogastric, gastrostomy, jejunostomy feeding tube used (6) Weaning (a) Process of removing ventilator support and reestablishing spontaneous, independent respirations (b) Process and time required depend on lung condition, duration of mechanical ventilation, general health (c) T-piece, CPAP, SIMV, PSV used (d) Terminal weaning: Gradual withdrawal of mechanical ventilation when survival without it is not expected (i) Occurs in intensive care unit (ii) Sedation and analgesia may be used 5. Nursing care a) Assessment (1) Health history (2) Physical examination (3) Laboratory data b) Diagnoses, outcomes, and interventions (1) Promote adequate ventilation (a) Assess and document respiratory rate, vital signs, and oxygen saturation every 15 to 30 minutes (b) Administer oxygen as needed (c) Place in Fowler or high-Fowler position (d) Minimize activities and energy expenditures (e) Avoid sedatives and respiratory depressants unless mechanically ventilated (f) Prepare for endotracheal intubation and mechanical ventilation (g) Explain procedures and purpose (2) Promote airway clearance and patency (a) Suction as needed to maintain patent airway (b) Obtain sputum for culture .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(c) Perform percussion, vibration, and postural drainage (d) Firmly secure endotracheal or tracheostomy tube (e) Assess fluid balance and maintain hydration (3) Reduce risk for injury (a) Assess level of consciousness, condition of mucosa, respiratory status, vital signs, skin color, bowel sounds, urine output, daily weight (b) Turn and reposition frequently, using caution with endotracheal tube (c) Keep skin and linens clean, dry, and wrinkle-free (d) Perform passive ROM exercises every 4 to 8 hours (e) Keep side rails up and use soft restraints as needed (f) Administer histamine H2-blockers and sucralfate as ordered (4) Reduce anxiety (a) Frequently monitor anxiety level (b) Remain with the patient as much as possible (c) Explain all monitors, procedures, sounds, and machinery (d) Provide a simple means of communication (e) Encourage family visits (f) Explain to the family that the patient can hear and understand (g) Provide distraction with TV or radio, if allowed (h) Attend physical needs promptly and completely (i) Reassure that intubation and mechanical ventilation are temporary measures 6. Transitions of care a) Prior to discharge, discuss: Measures to prevent future respiratory failure; effective coughing and pulmonary hygiene measures b) In cases of terminal weaning, discuss: What to expect, use of sedation, presence of nurses, family, other supporters during weaning B. The Patient with Acute Respiratory Distress Syndrome 1. Noncardiac pulmonary edema with progressive refractory hypoxemia 2. Severe form of acute respiratory failure 3. Occurs secondarily from diverse conditions 4. Pathophysiology a) Acute lung injury from systemic inflammatory response to acute injury or inflammation b) Alveolar-capillary membrane damage, plasma and blood go into interstitial space and alveoli, causes alveolar collapse with atelectasis c) Fibrotic changes occur in lungs .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

5.

Tissue hypoxia, metabolic and respiratory acidosis, sepsis and multiple organ system dysfunction occurs and can cause death 6. Manifestations a) Early: Dyspnea, tachypnea, and anxiety b) Progressive respiratory distress, cyanosis, mental status changes develop c) Breath sounds initially clear, crackles, and rhonchi later 7. Interprofessional care a) Diagnosis (1) Refractory hypoxemia is hallmark (2) ABGs (3) Chest x-ray (4) Pulmonary function testing (5) Pulmonary artery pressure monitoring b) Berlin definition (1) Onset: <7 days from the predisposing clinical insult (2) Imaging: Bilateral opacities on chest x-ray or CT that is not fully explained by effusion, atelectasis, or nodules (3) Noncardiac pulmonary edema (4) Oxygen requirements: (a) PaO2/FiO2 ratio with ≥5 cm (b) H2O positive end-expiratory pressure (c) Mild ARDS: 201–300 (d) Moderate ARDS: 101–200 (e) Severe ARDS: <100 (5) Predisposing conditions (a) Echocardiogram may be ordered to rule out cardiac problem c) Medications (1) Inhaled nitric oxide: Dilates blood vessels (2) Surfactants: Helps maintain open alveoli (3) Under investigation: NSAIDs and corticosteroids to block inflammatory response (4) Corticosteroids: To improve oxygenation in fibrotic lungs d) Mechanical ventilation (1) Mainstay of management (2) Caution for oxygen toxicity e) Treatments (1) Prone positioning and mechanical ventilation for atelectasis (2) Fluid replacement, attention to nutrition, treatment of infection, correction of underlying condition .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

8. Nursing care a) Very similar to that for any patient with acute respiratory failure b) Diagnoses, outcomes, and interventions (1) Promote adequate cardiac output (a) Monitor and record vital signs, urine output, level of consciousness, pulmonary artery pressures, daily weight, heart and lung sounds (b) Provide skin care (c) Maintain IV fluids as ordered (d) Administer medications and ordered (e) Reduce risk for dysfunctional ventilatory weaning response Assess vital signs every 15 to 30 minutes following changes in ventilator settings and during T-piece trials (f) Place in Fowler or high-Fowler position (g) Explain all weaning procedures and expected changes in breathing (h) Remain with patient during changes and trials (i) Limit procedures and activities during weaning (j) Begin weaning in morning, may be discontinued at night (k) Keep oxygen at bedside following weaning and extubation (l) Provide pulmonary hygiene 9. Transitions of care a) Discuss: ARDs develops from serious illness; respiratory function usually returns within 6 months but may be impaired; avoid smoking and environmental pollutants; obtain immunization for respiratory infections b) Provide referrals to community resources

Chapter Highlights A. Obstructive disorders of the lower respiratory system, including asthma, COPD, and cystic fibrosis impair airflow into and out of the lungs, often affecting the outflow of air to a greater extent than inflow. As a result, air trapping in the alveoli increases the residual volume of the lungs and reduces functional residual capacity. Alveolar ventilation is reduced as well. The net result is less available oxygen in the alveoli and impaired gas exchange.

B. In many instances, acute episodes of asthma can be avoided through the use of inhaled steroids to reduce airway inflammation, inhaled long-acting bronchodilators, and frequent self-monitoring of expiratory flow rate. Nursing care focuses on teaching for selfmanagement, and providing care during acute episodes of airway constriction.

C. Chronic obstructive pulmonary disease (COPD) is a long-term process of progressive lung dysfunction. COPD involves two different disease processes: Chronic bronchitis, characterized by airways edema and excessive mucus production, and emphysema, .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

characterized by destruction of supporting tissue with enlargement of respiratory bronchioles and alveolar spaces and loss of surface area for gas exchange.

D. Smoking and exposure to tobacco smoke is the single greatest risk factor for COPD. A small percentage of cases result from an inherited deficiency of alpha1-antitripsin, an enzyme that inhibits lung tissue destruction. Although smoking cessation does not reverse COPD, it does slow the progress of the disease.

E. Cystic fibrosis, inherited as an autosomal recessive disorder, causes thick, viscous secretions in affected organs, primarily the lungs, pancreas, sweat glands, and reproductive tract. In the lungs, small airway clearance is impaired, leading to atelectasis, bronchiectasis, infection, and dilation of distal airways with air trapping and impaired gas exchange. Chest physiotherapy and early treatment of respiratory infections are key components of disease management. Ultimately, lung or heart-lung transplant may be required.

F. Occupational lung diseases, pneumoconiosis and hypersensitivity pneumonitis, damage interstitial tissues of the lungs, leading to fibrosis and scarring that causes the lungs to become stiff and noncompliant. Lung volumes decrease, the work of breathing increases, and gas diffusion is impaired. Most occupational lung diseases are progressive and nonreversible. Interprofessional care is similar to that provided for patients with COPD. G. Pulmonary vascular disorders affect blood flow through the pulmonary vascular system and gas exchange. Pulmonary embolism, obstruction of pulmonary blood flow, is a potentially critical condition usually resulting from deep venous thrombosis. Sudden onset of chest pain and dyspnea with changes in hemodynamic status are possible manifestations of pulmonary embolism. Prevention through early ambulation, lower extremity exercises, and sequential compression devices is the most effective treatment for pulmonary embolism.

H. In primary and secondary forms of pulmonary hypertension, constriction of pulmonary vessels and remodeling of the pulmonary vascular bed increase pressure in the pulmonary system and right heart, ultimately leading to right-sided heart failure (cor pulmonale). Treatment focuses on slowing disease progression through oxygen therapy, administration of vasodilators and anticoagulants, and supporting patient function.

I. Hypoventilation, impaired gas exchange and significant ventilation–perfusion mismatch (e.g., pulmonary embolism) can lead to respiratory failure. Hypoventilation leads to hypoxemia and hyercapnia, whereas in impaired gas exchange or ventilation–perfusion mismatch, hypoxemia dominates.

J. The manifestations of respiratory failure relate directly to the effects of hypoxemia and hypercapnia.

K. Respiratory support often is required, using positive pressure ventilators. Variables of mechanical ventilation include the mode or cycle of ventilation, the flow rate and amount, pressures delivered, and the oxygen concentration. Either invasive or noninvasive techniques may be used.

L. Complications of mechanical ventilation include lung and mucous membrane trauma and infection, reduced cardiac output, gastric dilation, impaired communication, and stress.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

M. ARDS is noncardiac pulmonary edema caused by a diffuse inflammatory response with increased pulmonary capillary permeability leading to interstitial and alveolar edema and impaired gas exchange. As the process continues, lung compliance decreases, increasing the work of breathing, and atelectasis and consolidation of lung tissue develop.

Respiratory failure with refractory hypoxemia result.

N. Mechanical ventilation and measures to support physiologic function are the primary treatments for ARDS. The mortality rate, however, remains high at about 40%.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME ONE Have the students identify risk factors that are common to the disorders covered in this chapter.

Identify how those risk factors manifest in vulnerable populations. Discuss health-promotion implications of the presence of these risk factors.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME ONE Assign clinical students to the care of a patient with one of the disorders discussed in this chapter.

Have the students identify the assessment findings that are expected with the disorder and contrast those findings to those manifested in the patient.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME TWO Divide the students into small groups. Assign each group a nursing diagnosis problem statement that is frequently appropriate for patients who have ventilatory disorders. Have students investigate how the nursing diagnosis applies to the various disorders covered in this chapter.

Share the work.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME TWO Assign students to care for patients with reactive airway or interstitial lung disorders. Have the students discuss the care needs for this type of patient.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME THREE Divide the students into small groups. Assign each group a nursing diagnosis problem statement that is frequently appropriate for patients who have ventilatory disorders. Have students investigate how the nursing diagnosis applies to the various disorders covered in this chapter.

Share the work.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME THREE Assign students to care for patients at risk for pulmonary vascular problems (if possible). Have the students create a plan of care for a patient with a pulmonary vascular problem.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME FOUR Invite a respiratory therapist to the class to explain and demonstrate the different ventilator settings.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME FOUR Assign students to observe care provided to patients in intensive care areas. Have the students document type of ventilatory support, settings, medications, and fluids prescribed for the patient.

Have the students discuss the types of care in post-clinical conference.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter 38 Assessing the Musculoskeletal System Learning Outcomes 1. Describe the anatomy, physiology, and functions of the musculoskeletal system, and identify abnormal findings that may indicate impairments of the musculoskeletal system.

2. Outline the components of the assessment of the musculoskeletal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.

3. Differentiate considerations for assessing the musculoskeletal systems of older adults and veterans.

4. Summarize topics that nurses teach to promote a healthy musculoskeletal system across the lifespan.

Key Concepts I.

Anatomy, Physiology, and Functions of the Musculoskeletal System A. Bones 1. Axial skeleton: Skull, thorax, and vertebrae 2. Appendicular skeleton: Shoulder, arms, pelvic girdle, and legs 3. Functions a) Body structure b) Protect organs c) Movement of body parts d) Store minerals e) Site for hematopoiesis 4. Bone structure a) Bone cells: Osteoblasts, osteocytes, osteoclasts, and osteoprogenitor cells b) Bone matrix: Collagen fibers, minerals, proteins, carbohydrates, and ground substance c) Periosteum: Double layer connective tissue that covers bones d) Osseous tissue: Rigid connective tissues (1) Laminar bone and woven bone e) Mature bone: Compact outer shell and spongy interior f) Haversian system (osteon): Structural unit of laminar bone g) Hematopoiesis: In spongy sections of certain long bones and flat bones 5. Bone shapes a) Long bones b) Short bones c) Flat bones d) Irregular bones

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

6. Bone remodeling in adults a) Bone resorption and bone deposit at periosteal and endosteal surfaces b) Increased osteoblastic activity and ossification with stress c) Increased osteoclast activity and resorption with inactivity d) Hormone regulation: Interaction of parathyroid hormone (PTH) and calcitonin e) Bones regulate calcium levels B. Cartilage 1. Types: Elastic, hyaline, and fibrocartilage C. Muscles 1. Skeletal muscles function: Body movement, posture, and produce heat 2. Anatomy a) Muscle fibers composed of myofibrils. b) Myofibrils composed of sarcomeres. c) Sarcomeres consist of myosin and actin (proteins).

3. Functional properties: Excitability, contractibility, extensibility, and elasticity 4. Movement triggered by acetylcholine and sodium 5. Muscle fatigue from buildup of lactic acid D. Joints, ligaments, and tendons 1. Joints, by functional classifications: Synarthroses, amphiarthroses, diarthroses 2. Joints, by structural classifications: Fibrous, cartilaginous, and synovial 3. Synovial fluid: Filtrate of blood plasma, in cavity that surrounds synovial joints (1) Bursae: Small sacs of synovial fluid that protect against friction E. Ligaments and tendons 1. Ligaments: Fibers that bind bones together 2. Tendons: Fibers that connect muscles to periosteum of bones II.

Assessing the Musculoskeletal System A. Health assessment interview 1. Analyze manifestations: Onset, characteristics, course, severity, precipitating and relieving factors, and associated symptoms 2. Significant information: Fever, fatigue, changes in weight, rash, and/or swelling 3. History: Lifestyle, employment, ability to carry out ADLs, exercise, use of drugs and alcohol, nutrition, past injuries, and measures to self-treat pain B. Physical assessment 1. Gait and body posture assessment 2. Joint assessment

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

3. Rang-of-motion assessment 4. Special assessments a) Phalen test b) Bulge sign c) Ballottement d) McMurray test e) Thomas test C. Genetic considerations 1. Myotonic dystrophy 2. Marfan syndrome 3. Duchenne muscular dystrophy 4. Other a) Rheumatoid arthritis, osteoarthritis, gout, muscular dystrophy, ankylosing spondylitis, lupus erythematosus, and scleroderma.

D. Diagnosis 1. Diagnostic tests a) Arthrocentesis, arthroscopy, blood chemistry, bone mineral density, bone absorptiometry, dual-energy x-ray absorptiometry (DEXA), quantitative ultrasonography(QUS), bone scan, CT scan, EMG, MRI, musculoskeletal ultrasound, skeletal x-ray 2. Blood tests: Alkaline phosphatase (ALP), calcium (Ca), creatine kinase (CK), creatinine phosphokinase (CPK), human leukocyte antigen (HLA), phosphorus (P), phosphate (PO 4), rheumatoid factor (RF), and uric acid III.

Assessment of Special Populations A. Age-related changes B. Effects of military service

IV.

Health Promotion A. Prevent trauma 1. Safety equipment B. Screenings 1. Older adults a) Osteoporosis, cognitive and affective disorders, vision, and risk of falls C. Regular exercise D. Nutritional support 1. Vitamin D supplements and calcium

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter Highlights A. Intact structure and function of the musculoskeletal system is vital to the ability to independently perform usual activities of daily living and other activities.

B. Manifestations of dysfunction, injuries, and disorders affecting the musculoskeletal system may be detected during a general health assessment as well as during focused and functional musculoskeletal assessments.

C. Musculoskeletal disorders are diagnosed primarily using a targeted medical history, physical assessment, and functional assessments of the musculoskeletal system. Diagnostic tests help to identify and diagnose musculoskeletal injuries and disorders.

D. There are many musculoskeletal impacts found in the older adult patient. Changes related to aging and chronic illness are the most common changes.

E. All patients should be assessed for military service. If the patient had served, determination of VA involvement in care helps to maintain coordination of care.

F. Musculoskeletal health promotion focuses on two overarching topics: Trauma prevention (especially with young adults) and the importance of regular exercise and maintenance of normal body weight.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME ONE Discuss the various types of joints and the movement that is expected of each joint.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME TWO Have students in groups of two and practice completing a health history.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME TWO Have students complete a musculoskeletal health history with a patient.

Have students complete a physical assessment of a client with a musculoskeletal disorder.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME THREE Have the students research myotonic dystrophy, Marfan syndrome, Duchenne muscular dystrophy, and amyotrophic lateral sclerosis and present their findings to the class.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME THREE Have students assess an older adult and identify age-related changes.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME FOUR Have students prepare a teaching tool to promote the health of the musculoskeletal system.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter 39 Nursing Care of Patients with Musculoskeletal Trauma

Learning Outcomes 1. Describe the pathophysiology and manifestations of traumatic injuries of the muscles, ligaments, and tendons, and outline the interprofessional care and nursing care of patients with these injuries.

2. Describe the pathophysiology and manifestations of traumatic injuries of bones, and outline the interprofessional care and nursing care of patients with these injuries.

Key Concepts I.

Traumatic Injuries of the Muscles, Ligaments, and Tendons A. The patient with a contusion, strain, or sprain 1. Pathophysiology and manifestations a) Contusion: Least serious form of musculoskeletal injury; bleeding into soft tissue that results from blunt force (1) Skin remains intact.

(2) Hematoma: Contusion with large amount of bleeding b) Strain: Stretching injury of muscle or muscle–tendon unit caused by mechanical overloading (1) Microscopic tears in fibers develop (2) Common sites: Lower back and the hamstring muscle in the back of the thigh c) Sprain: Stretch and/or tear of one or more ligaments surrounding a joint (1) Common sites: Ankle and knee 2. Manifestations a) Contusion (1) Swelling, discoloration of skin, and bruising b) Strain (1) Pain, limited motion, muscle spasms, swelling, and possible muscle weakness c) Sprain (1) Loss of functional ability of the joint, feeling of a “pop” or tear, discoloration, pain, and rapid swelling 3. Interprofessional care a) Diagnosis:

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Musculoskeletal ultrasound or x-rays rule out fracture, determine damage extent b) Medications c) Nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce pain, swelling, inflammation; acetaminophen alternatively for pain relief d) Treatment (1) PRICE for the first 24 to 48 hours (a) Protection (b) Rest (c) Ice (d) Compression (e) Elevation (2) Ankle and knee sprains immobilized with a cast or splint; slings for upper extremity e) Surgery (1) Repair torn ligaments, muscles, and tendons may be required 4. Nursing care a) Diagnoses, outcomes, and interventions (1) Manage acute pain (a) Teach patient to use PRICE (protection, rest, ice compression, elevation) measures (b) Teach effective use of prescription and over-the-counter (OTC) drugs (2) Promote physical mobility (a) Teach correct use of crutches, walkers, canes, or slings if prescribed (b) Encourage follow-up care B. The patient with joint trauma 1. Pathophysiology a) Rotator cuff injuries (1) Common in shoulders (2) Includes tendinitis, bursitis, partial and complete muscle tears (3) Injuries can be acute or may result from repetitive injury or degenerative changes b) Knee injuries (1) Vulnerable to ligament tears, meniscal injury, patellar discoloration c) Joint dislocation (1) Injury in which ends of bones are displaced out of their normal position and joint articulation is lost (2) Usually follow trauma and can result from some pathologic conditions .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(3) May occur in any joint and are most common in shoulder, acromioclavicular joints, and the patella (4) Subluxation: Partial dislocation, bones remain in partial contact 2. Risk factors a) Participation in athletic events b) Joint overuse c) Females of childbearing age have an increased risk of anterior cruciate ligament (ACL) injury due to laxity in the ligaments d) Underlying issue (1) Osteoarthritis (2) Rheumatoid arthritis e) Systemic disease processes (1) Osteoporosis (2) Diabetes mellitus (3) Systemic lupus erythematous 3. Manifestations a) Rotator cuff injuries (1) Shoulder pain, limited range of motion b) Knee injuries (1) Acute injury, immediate pain, a tearing or popping sensation, knee “giving out,” edema, pain with ambulation, and a locking sensation of the joint (with large tears) c) Joint dislocation (1) Pain, deformity, and the limited motion of the affected joint d) Complications (1) Pain, a frozen (immovable) shoulder and functional limitations, mobility difficulties, and nerve impingement 4. Interprofessional care a) Diagnosis (1) Identification: Based on history and physical examination, specific maneuvers may be performed; x-rays and MRIs are performed. b) Treatment (1) Dislocation: Reduced using manual traction, or surgery to realign joint and prevent complications such as neurovascular injury (2) Rotator cuff injuries: Conservative treatment of rest, NSAIDs, moist heat, and physical therapy; surgery sometimes required (3) Knee injuries: Joint rest with compression, ice, elevation, and restricted weight bearing c) Surgery .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Realign the joint (2) Reattach tendon to the bone 5. Nursing care a) Assessment (1) Health history (2) Physical assessment b) Diagnoses, outcomes, and interventions (1) Reduce risk for peripheral neurovascular dysfunction (a) Monitor neurovascular status by assessing pain, pulses, pallor, paralysis, and paresthesia (b) Maintain immobilization as ordered after reduction (2) Mange acute pain (a) Encourage use of appropriate splint or joint immobilizer (b) Teach safe application of ice or heat to affected joint as indicated (c) Instruct about using NSAIDs (d) Teach use of assistive devices (3) Promote mobility and self-care (a) Refer to physical therapy for appropriate exercises (b) Suggest occupational therapy 6. Continuity of care a) Discuss: Importance of complying with prescribed length of immobilization; skin care; prescribed rehabilitation exercises; and alternative to activities that precipitate recurrent trauma b) Refer to physical therapy, occupational therapy, and/or home health services C. The patient with a repetitive use injury 1. Pathophysiology a) Carpal tunnel syndrome (1) Carpal tunnel: Canal through which flexor tendons and median nerve pass from the wrist to the hand (2) Syndrome: Synovial lining of tendon sheaths become inflamed, compress the median nerve (3) Believed to be directly related to extended use of computers b) Bursitis (1) Bursa: Enclosed sac between muscles, tendons, and bony prominences in certain joints (2) Inflammation of bursa from constant friction, causes irritation, edema, and inflammation c) Tendonitis .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Inflammation of the tendon at its point of origin 2. Risk factors a) Carpal tunnel syndrome (1) Obesity, pregnancy, diabetes, rheumatoid arthritis, hypothyroidism, connective tissue disorders, genetic predisposition, workplace factors, being female, and preexisting median mononeuropathy and aromatase inhibitor use b) Bursitis (1) Aging, occupations or hobbies that have repetitive motion or place pressure on a specific bursae (2) Rheumatoid arthritis, gout, and diabetes c) Tendonitis (1) Age and repetitive motion occupations and hobbies 3. Manifestations a) Carpal tunnel syndrome (1) Numbness, tingling and/or pain of thumb, index finger, lateral ventral surface of middle finger; affected hand may become weak and lack precision b) Bursitis (1) Area around the sac is tender, and extension and flexion of the joint near the bursa produce pain.

(2) Inflamed bursa is hot, red, and edematous.

(3) Joint is guarded to decrease pain. c) Tendonitis (1) Point tenderness, pain radiating down dorsal surface of forearm 4. Complications a) Ongoing pain and reduced mobility 5. Interprofessional care a) Diagnosis (1) Carpal tunnel: History, physical examination, and tests to confirm (a) Phalen test, ultrasound or MRI, electromyography (2) Bursitis and epicondylitis: History and physical examination b) Medications (1) NSAIDs common (2) Narcotics may be given for acute flare-ups.

(3) Corticosteroids may be injected into joint for epicondylitis or carpal tunnel. c) Treatments .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Conservative management: Immobilize and rest the joint (a) Splints and ice may be used.

(2) Surgery: For patient for whom conservative management doesn’t work (a) Carpal tunnel: Resection of carpal ligament to enlarge tunnel (b) Epicondylitis and bursitis: Removal of calcified deposits d) Integrative therapies (1) Acumoxa therapy 6. Nursing care a) Assessment (1) Health history (2) Physical assessment b) Diagnoses, outcomes, and intervention (1) Manage acute pain (a) Assess pain before and after any intervention (b) Encourage use of immobilizers (c) Teach patients to apply ice and/or heat as prescribed (d) Encourage use of NSAIDs (e) Explain why treatment should not be abruptly discontinued (2) Promote mobility and self-care (a) Suggest interventions to alleviate pain (b) Refer to physical therapist and/or occupational therapist 7. Transitions of care a) Discuss: Causes and treatments for repetitive use injury; rehabilitation; ways to avoid unnecessary exposure to activities that increase risk of recurrent injury; information about braces and other assistive devices II.

Traumatic Injuries of Bones A. The patient with a fracture 1. Pathophysiology a) Bone is subjected to more kinetic energy than it can absorb. b) Classifications (1) Closed (simple): Skin is intact; open (compound) fracture: skin is interrupted (2) Complete: Involves entire width of bone; incomplete: only a part of the width (3) Oblique: At an angle to the bone; spiral: curves around the bone; avulse: pulls bone away from other tissues; comminuted: bone breaks

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

into many pieces; compressed: bone is crushed; impacted: bone ends forced into each other; depressed: broken bone is forced inward (4) Stable: Bones maintain anatomic alignment; unstable: bones move out of correct anatomic alignment 2. Risk factors a) Trauma, falls, osteoporosis, smoking, alcohol abuse, chronic steroid use, diabetes mellitus, a history of low-impact fractures, and a family history of hip fractures.

3. Fracture healing a) Phases: Hematoma formation, fibrocartilaginous callus formation, bony callus formation, and remodeling b) Influential factors: Age, physical condition, type of fracture, and other local factors 4. Etiology and manifestations a) Fracture of the skull (1) Patient assessed for neurologic changes (2) Depressed fracture may press on brain and cause neurologic damage. b) Fracture of the face (1) Monitored to ensure airway is not compromised.

(2) Observed for neurologic deficits (3) Nursing care: Maintain airway, clear secretions from oropharynx; body image disturbances are addressed c) Fracture of the spine (1) Most severe complication: Injury to the spinal cord, which can cause ischemia and permanent paralysis (2) Immobilized with cervical collar or halo brace (3) Manual or skeletal traction performed (4) Surgical plates and screws applied d) Fracture of the clavicle (1) Displaced fractures may damage subclavian vessels and lead to hemorrhage, or damage lung and lead to pneumothorax.

(2) Malunion may result in shoulder asymmetry.

(3) Immobilized with clavicular strap or surgical repair e) Fracture of the humerus (1) Complications: Nerve and ligament damage, frozen or stiff joints, and malunion (2) Immobilization for simple nondisplaced cases (3) Surgical intervention for complicated displaced cases (4) Rehabilitative measures with range of motion (ROM) exercises .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(5) Hanging arm cast and skeletal traction used f) Fracture of the elbow (1) Complications: Nerve or artery damage, hemarthrosis, Volkmann contracture (2) Immobilized with splint or cast g) Fracture of the radius and/or ulna (1) Nondisplaced: Sling (2) Displaced: Surgical repair (3) Complications: Compartment syndrome, delayed healing, and decreased wrist and finger movement h) Fractures in the wrist and hand (1) Metacarpals and phalanges often involved (2) Complications: Compartment syndrome, nerve damage, ligament damage, and delayed union (3) Treatment: Closed reduction, cast application, and elevation i) Fracture of the ribs (1) May damage the subclavian artery or vein, spleen, and liver; cause pulmonary contusion, pneumothorax and/or hemothorax (2) Flail chest: Fracture of two or more ribs in two or more places, formation of free-floating segment that moves in opposite direction of rib cage (a) Surgical stabilization of flail segment and supported respirations (3) Simple fraction: Pain medication, instructions for coughing, deep breathing, and splinting j) Fracture of the pelvis (1) Complications: Significant blood loss and damage to organs in pelvis and extrapelvic organs (2) Simple: Analgesia and activity limitation (3) Unstable: Pelvic sling, surgical reduction and fixation k) Fracture of the hip (1) Intracapsular: Involve head or neck of femur (2) Extracapsular: Involve the trochanteric region (3) Most common injury in older adults (4) Can result in serious health problems and increase risk of dying for those over 65 (5) Initially treated with traction followed by surgery or immediate surgery to increase mobility, decrease pain, and prevent complications (a) ORIF for trochanteric area (b) Replacement of femoral head with prosthesis for disrupted blood supply

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(c) Total hip arthroplasty: Replacement of femoral head and acetabulum l) Fracture of the femoral shaft (1) Complications: Hypovolemia due to blood loss, fat embolism, dislocation of hip or knee, muscle atrophy, and ligament damage (2) Treatment: Skeletal traction, surgical restriction, weight bearing restriction, and partial weight bearing after some healing m) Fracture of the tibia and/or fibula (1) Complications: Damage to peroneal nerve or tibial artery, compartment syndrome, hemarthroses, and ligament damage (2) Nondisplaced: Closed reduction and casting allowing for partial weight bearing (3) Complex: External fixation or ORIF with intermedullary rod n) Fracture of the ankle and/or foot (1) Ankle (a) Nondisplaced: Closed reduction and casting (b) Multiple or displaced surgery and splinting (2) Foot (a) Most are nondisplaced: Closed reduction and casting (b) More severe: Surgery and placement of wires 5. Interprofessional care a) Emergency care (1) Immobilizing the fracture, maintaining tissue perfusion, and preventing infection (2) Assessment for instability or deformity of the bone (3) Fracture is splinted. b) Diagnosis (1) X-ray and bone scans (2) Blood chemistry studies, CBC, and coagulation studies to assess blood loss, renal function, muscle breakdown, and the risk for clotting c) Medications (1) Analgesia: Opioids and NSAIDs (2) Antibiotics sometimes used prophylactically (3) Anticoagulants to prevent deep venous thrombosis (DVT) (4) Antiulcer or antacids for sustained trauma d) Nutrition (1) High-protein diet, calcium, vitamin D, and hydration e) Treatments (1) Reduction (a) Closed reduction: Bone repositioned using external manipulation .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(b) Open reduction: Bone repositioned during surgery (2) Traction: Straightening or pulling force to return or maintain bones in anatomical alignment (a) Manual traction: Physically pulling on extremity (b) Skin traction (straight traction): Buck traction—uses traction tape or foam boot on lower leg to immobilize leg (c) Balanced suspension traction: Extremity raised and supported off the bed to maintain alignment (d) Skeletal traction: Pulling force applied through pin inserted into bone (3) Casts (a) Immobilize bones during healing (b) Must be allowed to dry before any pressure is applied (4) Surgery (a) External fixator device: Frame connected to pins that are inserted into bone (b) Applied via open reduction and internal fixation (ORIF), or through closed reduction followed by percutaneous intramedullary (IM) fixation (5) Electrical bone stimulation (a) Electrical current applied to fracture site that is not healing appropriately (b) Electrical stress increases migration of osteoblasts and osteoclasts to fracture site, promotes healing (c) Can be applied invasively or noninvasively 6. Nursing care a) Assessment (1) Health history (2) Physical assessment: Pain, pulses, pallor, paralysis/paresis, and paresthesia b) Diagnoses, outcomes, and interventions (1) Manage acute pain (a) Monitor vital signs (b) Ask patient to rate pain on 0 to 10 scale before and after any intervention (c) For hip fracture: Apply Buck traction as ordered (d) Move patient gently and slowly (e) Elevate injured extremity above the level of heart (f) Encourage distraction or other adjunctive measures of pain relief (g) Administer medications as prescribed .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(2) Reduce risk for peripheral neurovascular dysfunction (a) Support injured extremity above and below fracture site when moving the patient (b) Assess: Five Ps every 1–2 hours; nail beds for capillary refill; and ability to differentiate between sharp and dull touch and presence of paresthesias (c) Monitor for edema and hematoma, tightness of cast; and assist with bivalving if cast is too tight (d) Assist in measuring compartment pressure (e) Administer anticoagulant as prescribed (3) Reduce risk for infection (a) Follow guidelines for skeletal pin site care (b) Monitor vital signs and WBC reports (c) Use sterile technique for dressing changes (d) Assess for wound size, color, and the presence of drainage (e) Administer antibiotics as ordered (4) Promote physical mobility (a) Teach or assist patient with ROM and isometric exercises (b) Encourage ambulation while able; provide assistance as necessary (c) Turn patient on bed every 2 hours 7. Complications a) Compartment syndrome: Increased pressure of fibrous muscle or fascia that enclose muscles, nerves, and blood vessels (1) Compromises circulation and tissue function (2) Due to hemorrhage and edema following: Fracture, crash injury, surgery, and tight cast or dressing (3) Manifestations (a) Early: Pain, normal or decreased peripheral pulse (b) Later: Cyanosis, tingling, paresthesias, weakness, and severe pain (4) Interventions (a) Removal or dressing of cast (b) Fasciotomy: Incision of the muscle fascia to relieve pressure (5) Volkmann contracture (ischemia, degeneration, and contracture of forearm muscles) can result from elbow or forearm compartment syndrome. b) Fat embolism syndrome (1) Fat emboli released from adipose tissue or bone marrow after long bone fracture, usually are asymptomatic .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(2) Mechanical theory versus biochemical theory of development (3) Syndrome: Neurologic dysfunction, pulmonary insufficiency, petechial rash on chest, axilla, and upper arms (4) Treatment (a) Early immobilization and surgery reduce risk (b) Severe cases: Intubation and mechanical ventilation to prevent hypoxemia, corticosteroid therapy c) Deep venous thrombosis (1) Blood clot forms along intimal lining of large vein accompanied by inflammation of vein wall (2) Injury to vessel and venous stasis are risk factors (3) May dislodge, become embolus, lead to pulmonary embolism (4) Manifestations and diagnosis (a) Swelling, pain, tenderness, or cramping (b) Doppler ultrasonography, MRI, or a venogram (5) Treatment: Prevention with ambulation, anticoagulation, and antiembolism stockings d) Infection (1) May occur at time of injury or during surgery (2) Can delay healing or cause osteomyelitis e) Delayed union and nonunion (1) Delayed: Prolonged healing (2) Nonunion may require surgical intervention, electrical or ultrasonic stimulation, and biologic agents such as growth hormone or parathyroid hormone f) Complex regional pain syndrome (1) Characterized by intense pain in the affected limb, as well as sensory, autonomic, motor, skin, and bone changes of the extremity (2) Pain receptors in affected extremity are sensitized to catecholamines (3) Cause is unclear, may be related to peripheral nervous system damage, an inflammatory process, disrupted healing, or an autoimmune response (4) Diagnosis: History, physical examination, x-rays and bone scans (5) Treatment: Analgesics, nerve blocks, and occupational, physical, psychological therapies 8. Continuity of care a) Discuss: Type of fracture, treatment, activity and position, wound care, and where to find resources b) Encourage independence in ADLs, well-balanced meals, and proper use of medications c) Avoid: Scratching under cast with sharp objects, and getting plaster cast wet .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

d) Follow orders for weight-bearing and physical therapy exercises B. The patient with an amputation 1. Pathophysiology a) Peripheral vascular disease, peripheral neuropathy, untreated infection leading to gangrene, and traumatic events (accidents involving machinery, combat-related trauma, frostbite, burns, or electrocution) b) Result from or are necessitated by interruption in blow flow c) Replantation of fingers, small body parts, and entire limbs have been successful in acute injuries d) Levels of amputation (1) Local factors: Ischemia, gangrene (2) Systemic factors: Cardiovascular status, renal function, and severity of diabetes mellitus e) Amputation site healing (1) Compression dressing applied to prevent infection and minimize edema (2) Splint sometimes applied to mold extremity to fit prosthesis; elastic bandage to form conical shape or “stump shrinker” sheath (3) Patient encouraged to toughen stump skin by pushing it into surfaces 2. Risk factors and causes a) Peripheral vascular disease b) Peripheral neuropathy c) Trauma 3. Manifestations a) Injury that may be life threatening b) Significant loss of blood and tissue c) Shock d) Completely amputated portion may be intact and brought to the hospital on ice for potential replantation. e) Wound may be a clean cut or severely damaged, mangled and completely or partially separated from the area.

4. Complications a) Infection (1) Especially high risk: Traumatic amputation, older patient, diabetes mellitus, and peripheral neurovascular compromise (2) May be local or systemic b) Delayed healing

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Occurs when infection is present, circulation remains compromised, preexisting conditions in older patients, or electrolyte imbalances in anyone interfere (2) Smoking and DVT compromises healing c) Chronic stump pain and phantom limb pain (1) Chronic stump pain: From neuroma formation (a) Treated with medications, nerve blocks, transcutaneous electrical nerve stimulation (TENS), and surgical stump reconstruction (2) Phantom limb sensation: Common early in postoperative period, is usually self-limited, but may last for decades (3) Phantom limb pain: More often occurs in those who had pain in the limb prior to amputation, cause is known with several theories (a) Management is challenging. d) Contractures: Abnormal flexion and fixation of a joint caused by muscle atrophy and shortening (1) Most common in joint above amputation (2) Prevention by ROM and muscle-strengthening exercises 5. Interprofessional care a) Diagnosis (1) Postoperatively: CBC for hemorrhage, WBC for infection, blood chemistries for electrolyte and fluid balance; and a vascular Doppler ultrasonography if DVT is suspected (2) Preoperative to assess circulation: Doppler flowmetry, segmental blood pressure determination, transcutaneous partial pressure oxygen readings, and angiography b) Medications (1) Antibiotics and analgesics (2) Steroids to decrease swelling (3) Histamine H2 agonist to decrease risk for peptic ulcer formation c) Surgery (1) Replantation may be possible (2) Open (guillotine) or closed (flap) d) Prosthesis (1) Type depends on level of amputation, patient’s occupation and lifestyle (2) Custom-made, mostly of foam and plastic materials (3) Lower extremity: Often fitted with early walking aids before prosthesis (4) Upper: May be fitted immediately after surgery

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

6. Nursing care a) Assessment (1) Health history (2) Physical assessment b) Diagnoses, planning, and interventions (1) Manage acute pain (a) Ask patient to rate pain on scale of 0 to 10 before and after interventions (b) Splint and support injured area (c) Elevate stump on pillow for first 24 hours following surgery (d) Move and turn patient gently and slowly, reposition frequently (e) Administer pain medications as prescribed (f) Encourage deep breathing and relaxation exercises (2) Reduce risk of infection (a) Assess wound for redness, drainage, temperature, edema, and suture line approximation (b) Take patient’s temperature every 4 hours (c) Monitor WBC count (d) Use aseptic technique to change dressing and teach patient stump-wrapping techniques (e) Administer antibiotics as needed (3) Reduce risk of impaired skin integrity (a) Wash stump with soap and warm water and dry thoroughly each day (b) Massage the end of the stump, beginning 3 weeks after surgery (c) Expose any open areas of skin on limb intermittently throughout the day (d) Change stump socks and elastic wraps each day and wash c) Reduce risk for psychosocial issues (a) Encourage verbalization of feelings, using open-ended questions; listen and make eye contact; reflect on patient’s feelings (b) Allow patient to have unlimited visiting hours, if possible (c) If desired by patient, provide spiritual support by encouraging prayer, meditation, visits from a spiritual leader (2) Promote health body image (a) Encourage verbalization of feelings (b) Allow patient to wear clothing from home (c) Encourage patient to look at stump

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(d) Encourage patient to care for stump and active participation in rehabilitation (e) Offer to have fellow amputees visit the patient (3) Promote physical mobility (a) Perform ROM exercises on all joints (b) Maintain postoperative stump shrinkage devices (c) Turn and reposition every 2 hours (d) Reinforce teaching by the physical therapist (e) Encourage active participation in physical therapy 7. Transitions of care a) Discuss: Stump care, prosthesis fitting and care, medications, assistive devices, exercises, rehabilitation, counseling, support services, and follow-up appointments b) Refer to the Amputee Coalition of America and Amputee Resource Foundation of America

Chapter Highlights A. Musculoskeletal injuries, including strains, sprains, fractures, and joint injuries are common, often associated with recreational activities or trauma. Nursing care includes assessing the circumstances and impact of the injury as well as neurovascular status distal to the injury and teaching prescribed treatment and rehabilitation.

B. Immediate treatment for contusions, strains, and sprains includes PRICE (protection, rest, ice, compression, elevation) therapy.

C. Joint trauma may damage soft tissue, cartilage, or even result in joint dislocation.

Monitor neurovascular status, assessing the affected extremity for increased pain, decreased or absent pulses, pale skin, inability to move the extremity, and changes in sensation.

D. Repetitive use injuries, especially common in the workplace, include carpal tunnel syndrome, bursitis, and tendonitis.

E. Fractures are usually uncomplicated, but place the patient at risk for both acute and longterm complications and may necessitate surgery or other invasive procedures for healing.

Nurses must promptly recognize complications and initiate appropriate care.

F. Fractures are closed or simple (skin is intact) or open or compound (skin integrity is interrupted); open fractures are at risk for infection. Other fracture descriptors include oblique or spiral, avulsed, comminuted, compressed, impacted, or depressed.

G. Fractures heal through four phases: Hematoma, fibrocartilaginous callus, bony callus, and remodeling. Healing is influenced by the age and physical condition of the patient and by the type of fracture.

H. Fracture complications include compartment syndrome, fat embolism syndrome, deep venous thrombosis, infection, delayed union and nonunion, and complex regional pain syndrome.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

I. Fractures are treated with surgery—both internal and external fixation, traction, and/or casts/splints to stabilize the fractured bone, maintain bone alignment and immobilization, prevent complications, and restore function.

J. Fractures of the hip, most often sustained by older adult women, are usually the result of a fall. Hip fractures present a serious health problem for people aged 65 years and older, potentially impacting the patient’s independence and even shortening the lifespan.

K. Nursing care for the patient with a fracture focuses on interventions for acute pain, risk for impaired peripheral neurovascular function, risk for infection, and impaired physical mobility.

L. Amputation, the partial or total removal of an extremity, has significant physical and psychosocial effects on the patient and on the family. In addition to providing care and support for the patient and family, the nurse is actively involved in coordinating the interprofessional team for optimal patient care and rehabilitation.

M. The most common cause for amputation of a lower extremity is peripheral vascular disease. Trauma is the most common cause for upper extremity amputation.

N. Complications that may follow an amputation include infection, delayed healing, chronic stump pain, phantom pain, and contractures. Stump care is necessary to prevent complications and to prepare the stump for a prosthesis.

O. Nursing care for the patient with an amputation is focused on a return to functional health, with interventions to meet needs for acute pain, impaired skin integrity, grieving, disturbed body image, and impaired physical mobility.

SUGGESTIONS FOR CLASSROOM ACTIVITY—LEARNING OUTCOME ONE Divide the students into small groups. Assign each group a set of conditions that are covered in this chapter. Have the students prepare a chart that lists the common causes and risk factors for the development of the disorders assigned. Share the findings and look for commonalities Use anatomic models to demonstrate the pathophysiology of repetitive use injuries. Using the same models, demonstrate treatment options

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME ONE Assign the students to care for a patient with a traumatic injury of the muscles, ligaments, or tendons. Have the students observe the patient learn to use assistive devices if appropriate.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTIONS FOR CLASSROOM ACTIVITY—LEARNING OUTCOME TWO Using anatomical models, demonstrate the phases of bone healing. Compare these structures with those of an uninjured bone.

Discuss the psychologic support of a patient who is undergoing amputation.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME TWO Assign clinical students to an orthopedic unit. Have students identify how the RN prepares for cast application, how he assists during cast application, and what activities are important after the cast is applied. Focus both on patient care and the care of equipment.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter 40 Nursing Care of Patients with Musculoskeletal Disorders

Learning Outcomes 1. Describe the pathophysiology and manifestations of metabolic musculoskeletal disorders, and outline the interprofessional care and nursing care of patients with these disorders.

2. Describe the pathophysiology and manifestations of degenerative musculoskeletal disorders, and outline the interprofessional care and nursing care of patients with these disorders.

3. Describe the pathophysiology and manifestations of autoimmune and inflammatory musculoskeletal disorders, and outline the interprofessional care and nursing care of patients with these disorders.

4. Describe the pathophysiology and manifestations of infectious musculoskeletal disorders, and outline the interprofessional care and nursing care of patients with these disorders.

5. Describe the pathophysiology and manifestations of neoplastic musculoskeletal disorders, and outline the interprofessional care and nursing care of patients with these disorders.

6. Describe the pathophysiology and manifestations of other musculoskeletal disorders, including low back pain, fibromyalgia, spinal deformity, and common foot disorders, and outline the interprofessional care and nursing care of patients with these disorders.

Key Concepts I.

Metabolic Musculoskeletal Disorders A. Interrupt bone remodeling process B. The Patient with Osteoporosis 1. Characterized by loss of bone mass, increased bone fragility, and increased risk of fractures 2. Pathophysiology a) Involves imbalance of activity of osteoblasts that form new bone and osteoclasts that resorb bone b) After age 30, bone resorption exceeds formation c) Rate of bone loss varies among individuals and at different skeletal sites 3. Risk factors a) Nonmodifiable risk factors: Increasing age, female gender, Caucasian and Asians more than African Americans, endocrine disorders, and malabsorption disorders b) Modifiable risk factors: Calcium deficiency, acidosis from a high-protein diet, high intake of diet soda can deplete calcium stores, low estrogen levels, cigarette smoking, excess alcohol intake, sedentary lifestyle, long-term glucocorticoid medication, anticonvulsants, immunosuppressants, and some other drugs

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

c) ACCESS: Alcohol, Corticosteroids, Calcium low, Estrogen low, Smoking, and Sedentary lifestyle.

4. Manifestations a) Loss of height, progressive curvature of the spine (“dowager’s hump”), low back pain, and fractures of the forearm, spine, or hip 5. Complications a) Fractures are most common 6. Interprofessional care a) Diagnosis (1) Bone mineral density (BMD) tests to estimate skeletal mass or density (2) Dual-energy x-ray absorptiometry: Measures bone density in lumbar spine or hip (3) Quantitative ultrasonography (4) CT scanning of spine, hip, forearm, or tibia used to evaluate for fracture risk (5) CBC, serum and urine calcium, vitamin D levels, and liver and renal function studies to determine cause (6) Biochemical markers of bone turnover b) Medications (1) Prevention and treatment: Calcium and vitamin D (2) Biophosphonates: Inhibit bone resorption (3) Alendronate, risedronate, and oral ibandronate: For postmenopausal cases or glucocorticoid-induced cases (4) Denosumab (Prolia) for postmenopausal cases (5) Estrogen replacement therapy: Reduces bone loss, increases bone density in spine and hip, and reduces risk of fractures in postmenopausal women (6) Selective estrogen receptor modulators (SERMs): Prevent bone loss in postmenopausal women by mimicking estrogen’s effects (7) Calcitonin: Increases bone formation and decreases bone resorption c) Nutrition (1) Calcium and vitamin D supplements d) Surgery (1) Fracture rep e) Integrative therapies (1) Yoga and tai chi 7. Nursing care a) Assessment .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Health history (2) Physical examination (a) FRAX assessment b) Diagnoses, outcomes, and interventions (1) Promote self-health management (a) Assess patient’s health habits (b) Teach importance of calcium intake, exercise (c) Refer patients to smoking-cessation programs and alcohol treatment programs (d) Refer patients with risk for bone-density evaluation (2) Reduce risk for injury (a) Implement safety precautions as necessary (b) Avoid using restraints if possible (c) Teach patients weight-bearing exercises (d) Encourage older adults to use assistive devices to maintain independence in ADLs (e) Teach older patients about fall precautions (3) Promote good nutrition (a) Teach adolescents, pregnant or lactating women, adults, and older adults importance of calcium (b) Teach proper time and side effects for calcium (4) Relieve acute pain (a) Suggest anti-inflammatory pain medications for treatment of both acute and chronic phases (b) Suggest the application of heat to relieve pain 8. Transitions of care a) Discuss: Resources for medical supplies and assistive devices; diet, exercise, and medications; pain management; maintaining good posture to help prevent stress on spine C. The Patient with Paget Disease of Bone 1. Progressive metabolic skeletal disorder from localized excessive bone formation 2. Affected bones are larger and softer, causing bone pain, arthritis, obvious skeletal deformities, and fractures 3. Genetic and environmental factors play a role 4. Pathophysiology a) Hyperactive bone resorption followed by very active bone formation b) Formed bone is not as structurally sound as normal bone, can bow and fracture more easily c) Normal bone marrow may be replaced with fibrous connective tissue .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

5. Risk factors a) Occurs slightly more in men than in women b) Affects1.5 to 8% of the population over the age of 40 c) More common in people of European and Greek descent d) Less common in people from Scandinavia and Asia e) Appears to be a genetic link 6. Manifestations a) Most patients are asymptomatic for years b) Musculoskeletal: Local pain, headache, deformity, abnormal gait, pathologic fractures, collapse of the vertebrae, kyphosis and loss of height, and muscle weakness c) Metabolic: Symptoms of hypercalcemia in immobilized patients; hypercalciuria and renal calculi; increased skin temperature over affected bone 7. Complications a) Pathologic fractures b) Involvement of the skull and vertebrae can cause neurologic complications c) Cardiovascular disease from increased vascularity of affected bones d) Sarcomas may develop 8. Interprofessional care a) Diagnosis (1) X-rays, bone scans for identification (2) CT scans and MRI to identify possible causes of pain (3) Serum alkaline phosphatase may be elevated b) Medications (1) Bisphosphonates: Inhibit bone resorption (a) Calcium and vitamin D supplements for patients taking bisphosphonates (2) Calcitonin: For patients who do not tolerate bisphosphonates (3) Acetaminophen and NSAIDs for pain due to complications c) Nutrition (1) No link found between nutrition and Paget disease (2) Suggest adequate intake of calcium and vitamin D d) Surgery (1) To repair fractures or replace knee and/or hip (2) Excessive operative bleeding is a risk 9. Nursing care a) Assessment

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Patient’s complaints, complete pain assessment, assessment of range of motion, nutrition assessment, and review of medications b) Diagnoses, outcomes, and interventions (1) Manage chronic pain (a) Assess location and extent of pain (b) Explain relationship between pain and disease activity (c) Teach patient proper NSAID use (d) Ensure proper placement of brace or corset (2) Promote physical mobility (a) Provide assistive device for ambulation (b) Teach good body mechanics (c) Reinforce information about exercise protocols and activity regimens 10. Transitions of care a) Discuss: Importance of following treatment even if noticeable response takes weeks; importance of taking calcium with bisphosphonates; importance of remaining active; safety in home and outdoor environment; recognizing pathologic fractures D. The Patient with Gout 1. Excess of uric acid in blood causes deposition of urate crystals in synovial fluid and other tissues 2. Acute inflammation of the joint 3. Deposits in kidneys can form urate kidney stones and result in kidney failure 4. Pathophysiology a) Hyperuricemia results from either an underexcretion of uric acid by the kidneys or an overproduction of uric acid b) Monosodium urate crystal form in synovial fluid, synovial membrane, cartilage, other joint connective tissues, and/or in kidneys c) Neutrophils ingest crystals, release phagolysosomes, perpetuate inflammation d) Inflammatory process destroys joint cartilage and underlying bone 5. Risk factors a) Obesity, metabolic syndrome, diet rich in meat and seafood, excessive alcohol intake, excessive soda intake, diuretics, aspirin 6. Manifestations a) Acute gouty arthritis: Usually monoarticular; acute pain; red, hot, swollen, and tender joint; fever, chills, malaise; elevated WBC and sedimentation rate

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

b) Advanced gout: Tophi evident on joints, bursae, tendon sheaths, pressure points, helix of ear; joint stiffness, limited ROM, and deformity; ulceration of tophi with chalky discharge 7. Complications a) Kidney disease, particularly when hypertension is also present (1) Uric acid crystals form stones, can obstruct urine flow 8. Interprofessional care a) Diagnosis (1) Serum uric acid: Elevated, but may be low or normal during acute attack (2) WBC count: Elevated (3) Eosinophil sedimentation rate: Elevated during acute attack (4) Serum creatinine: To evaluate kidneys (5) 24-hour urine specimen (6) Analysis of fluid aspirated from acutely inflamed joint: Definitive diagnosis b) Medications (1) Acute attack (a) NSAID: Very effective (b) Systemic corticosteroids (c) Colchicine: Interrupts cycle of urate crystal deposition (a) Significant GI side effects cause discomfort in many (2) Prophylactic therapy: For patients with gout, to prevent acute attack (a) Xanthine oxidase inhibitors, lower plasma uric acid levels, facilitate mobilization of tophi (a) Allopurinol (Zyloprim) or febuxostat (Uloric) (b) Uricosuric drugs: Promote uric acid excretion and reduce serum levels (a) Probenecid (Benemid) and sulfinpyrazone (Aprazone, Anturane, Zynol) (c) Pegloticase (Krystexxa): An enzyme that facilitates uric acid excretion (a) Newer therapy (b) Risk for anaphylaxis (3) Nutrition (a) Limited intake: Purine-rich foods such as organ meats and certain seafoods; high-fructose corn syrup; alcohol (b) Intake of: Low-fat or nonfat dairy products and vegetables; fluids (c) Obese patient advised to lose weight .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(4) Treatment (a)

Rest (a)

During acute attack, rest is prescribed 9. Nursing care a) Diagnoses, outcomes, and interventions (1) Relieve acute pain (a) Position the affected joint for comfort, protect it from pressure (b) Administer drugs as prescribed, avoid aspirin (c) Maintain joint rest 10. Transitions of care a) Discuss: Disease and manifestations; rationale for medications; importance of high intake of fluids and avoiding alcohol E. The Patient with Osteomalacia 1. Inadequate or delayed mineralization of bone matrix in mature compact and spongy bone, resulting in softening of bones 2. Calcium and/or phosphate deficiency impairs mineralization of bone matrix 3. Pathophysiology a) Causes: (1) Insufficient calcium absorption in the intestine due to a lack of calcium intake or vitamin D deficiency or resistance (a) Vitamin D deficiency: Inadequate dietary intake, lack of sun exposure, malabsorption, drug effects from isoniazid, rifampin, and anticonvulsants (b) Calcium malabsorption b) Decreased phosphate absorption or increased losses of phosphate through the urine (a) Chronic antacid use, impaired renal reabsorption (2) Systemic acidosis (3) Bone mineralization inhibitors (4) Chronic renal failure c) Abnormal buildup of demineralized bone leads to gross deformities of the long bones, spine, pelvis, and skull 4. Risk factors a) Diet low in vitamin D, inadequate sun exposure, impaired intestinal absorption of fats (vitamin D is a fat-soluble vitamin), liver or kidney disorders that interfere with the metabolism of vitamin D, and certain drugs b) Aging c) Hypophosphatemia: Alcohol abuse the most common cause .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Ingesting large amounts of nonabsorbable antacids (2) Genetic disorders 5. Manifestations a) Muscle fatigue and weakness, manifestations of vitamin D deficiency may be noted early b) Bone pain (most frequently in the pelvis; long bones of the extremities, spine, and ribs); muscle weakness; difficulty changing from lying to sitting position and sitting to standing position; waddling gait; dorsal kyphosis may occur in severe cases; pathologic fractures 6. Interprofessional care a) Diagnosis (1) History and physical examination (2) Serum calcium, parathyroid hormone, phosphate, vitamin D hydroxy, and alkaline phosphate levels b) Nutrition (1) Calcium and vitamin D supplements, sometimes phosphate supplements (2) Metabolite of vitamin D for malabsorption cases 7. Nursing care a) Diagnoses, outcomes, and interventions (1) Provide patient teaching (a) Causes and consequences (b) Specific teaching for older clients to reduce the risk of developing the disorder (c) Discuss safety measures to prevent falls, use of assistive devices (d) Refer to physical therapy and supervised low-impact exercise program II. Degenerative Disorders A. The Patient with Osteoarthritis 1. Characterized by progressive loss of joint cartilage, synovitis, joint pain, stiffness, and loss of joint motion 2. Pathophysiology a) Proteoglycans and collagen are lost from cartilage as a result of enzymatic degradation b) Cartilage loses tensile stretch, develops surface ulcerations and deep layer fissures, eventually degenerates .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

c) Underlying bone is exposed, and thickens d) Osteophytes: Cartilage-coated bony outgrowths (1) Small pieces may break off and lead to synovitis 3. Risk factors a) Increasing age is primary factor b) Strong genetic linkage for hand and hip, less clear for knee c) Excessive weight contributes to weight bearing on joints and metabolic risk factor (also associated with hands) d) Inactivity e) Repetitive joint use, particularly occupational 4. Manifestations a) Onset is usually gradual, course progressive b) Early: Pain and stiffness in one or more joints, may be accompanied with paresthesias (1) ROM exercises to relieve stiffness and slow progression c) Joint enlargement form bony overgrowth that are hard and cool to palpation d) Flexion contractures may occur e) In younger adults, risk of debilitation is higher, disease progresses faster 5. Complications a) Pain, stiffness, limited mobility, and destruction of the articulation surfaces of the joint.

6. Interprofessional care a) Diagnosis (1) History, physical examination, and x-rays (2) MRI and examination of synovial fluid in some cases b) Medications (1) Acetaminophen or NSAIDs (a) Use proton-pump inhibitor simultaneously with longterm NSAIDs to reduce risk for GI bleeding (2) Topical NSAIDs: Reduce systemic effects; proper use important (3) Intra-articular corticosteroids injected into joint: Provides marked pain relief, but may be short-lived (4) Intra-articular hyaluronic acid (HA) for knee joint (5) Opioid analgesics for those with advanced cases c) Treatments (1) ROM exercises, muscle strengthening exercises, low-impact aerobic exercises (2) Heat and ice .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(3) Use of a cane, crutches, or a walker as needed (4) Weight loss, if indicated d) Surgery (1) Anthroscopy (a) Thin tube with light and camera on end is inserted into a joint (b) To diagnose type, or perform debridement (2) Osteotomy (a) Incision or transection of bone, performed to realign the joint (3) Joint anthroscopy (a) Reconstruction or replacement of a joint (b) Total joint replacement: Joint removed, replaced with prosthetic parts (a) Prosthetics may be cemented or uncemented (b) Total hip replacement: Articular surfaces of acetabulum and femoral head replaced (a) Lasts 10–15 years; a revision must then be performed (c) Total knee replacement: Several prosthetic devices involve removing varying amounts of bone (a) Vigorous rehabilitation needed to achieve best results (d) Total shoulder replacement: For limited ROM in both humeral and glenoid surfaces (e) Total elbow replacement: Replacement of humeral and ulnar surfaces of elbow (c) Complications for total join replacement: Infection, circulatory impairment of affected limb, thromboembolism, nerve damage, dislocation of the joint e) Physical therapy and rehabilitation (1) Postoperatively for all types of joint replacement (2) Regiment of exercise, rest, and medication f) Integrative therapies (1) Biomagnetic therapy, acupuncture, eliminating nightshade foods, herbal therapy, massage therapy, osteopathic manipulation, vitamin therapy, yoga (2) Nutritional supplements: Glucosamine, chondroitin, boron, zinc, copper, selenium, manganese, flavonoids, and/or SAM-e 7. Nursing care a) Assessment .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Health history (2) Physical assessment b) Diagnoses, outcomes, and interventions (1) Manage chronic pain (a) Monitor the level and quality of pain (b) Teach patients to take medications as directed (c) Encourage rest of painful joints (d) Suggest applying heat to joints (e) Emphasize importance of proper posture and good body mechanics (f) Encourage weight loss for overweight patient (g) Encourage nonpharmacologic pain relief measures (2) Promote physical mobility (a) Assess ROM of affected joints (b) Perform function mobility assessment (c) Teach active and passive ROM, isometric, progressive resistance, and low-impact aerobic exercises (d) Collaborate with physical and/or occupational therapists to recommend braces or mobility aids (3) Promote self-care (a) Perform functional assessment of upper and lower extremities (b) Assess home setting to determine need for assistive devices and assist in obtaining helpful assistive devices 8. Transitions of care a) Discuss: Safeguard against home hazards to safe mobility; disease process and chronic degenerative nature; exercise techniques; use of pain relief measures and analgesics; use of assistive devices; possible complications b) Avoid: Overuse of affected joints, soft chairs, recliners, and mattresses c) Make referrals to community resources and agencies B. The Patient with Muscular Dystrophy 1. Group of inherited muscle diseases that cause progressive muscle degeneration and wasting 2. Pathophysiology a) Genetic defect and cellular pathology differ among different muscular dystrophies b) Fat and connective tissues replace muscle fibers, increase size of muscle and cause progressive weakness c) Duchenne muscular dystrophy (DMD): Most common, mutation of gene that codes for dystrophin .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

d) Other types: Myotonic, Becker, facioscapulohumeral, limb-girdle 3. Manifestations and complications a) Muscle weakness leads to difficulty ambulating; patient can become wheelchair-bound, bed-bound; can cause cardiac abnormalities; mental retardation may occur 4. Interprofessional care a) Diagnosis (1) Creatine kinase: Elevated (2) Muscle biopsy: Fibrous tissues and fatty deposits (3) Electromyogram (EMG): Decrease in amplitude (4) Genetic testing b) Medications (1) Omigapil (Callisto), to combat the muscle “floppiness” that occurs in children 5 to 16 years old with congenital MD 5. Nursing care a) Diagnoses, outcomes, and interventions (1) Promote balance of independence and acceptance (a) Provide patients and family with supportive care during process of disease (b) Promote independence; encourage tasks that can be accomplished 6. Transitions of care a) Discuss: Prescribed exercises; skin care for braces; prevention of respiratory infections b) Refer to community resources: For example, Muscular Dystrophy Association III. Autoimmune and Inflammatory Musculoskeletal Disorders A. The Patient with Rheumatoid Arthritis 1. Chronic systemic autoimmune disease, causes inflammation of connective tissues, particularly in joints 2. Pathophysiology a) Cause is unknown; genetic and environmental factors contribute b) Exposure to virus causes aberrant immune response; autoantibodies form, attack host tissues c) Autoantibodies have: Rheumatoid factors (RFs) and anti-CCP antibodies d) Antibodies bind with target antigens, form immune complexes, activate complementary and inflammatory response in synovial and other involved tissues e) Joint damage occurs from: .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Inflammatory pannus spreads to cover joint cartilage and produces enzymes that promote tissue damage (2) Cytokines activate chondrocytes to attack joint cartilage; also activate osteoclasts, leading to resorption and demineralization of underlying bone 3. Risk factors a) Genetic links, cigarette smoking, viral or bacterial triggers, and occupational exposure to silica and asbestos 4. Manifestations 5. Joint manifestations a) Often preceded by systemic manifestations of inflammation b) Joint swelling with associated stiffness, warmth, tenderness, and pain (1) Joints: Sponge-like on palpation, limited ROM and sometimes weakness c) Pattern of joint involvement is typically polyarticular and symmetric d) Without treatment, deformities of joint, ligaments, tendons, muscles, cartilage e) Hands and fingers: Ulnar deviation of fingers, subluxation of MCP joints, inability to pinch f) Swan-neck deformity and boutonnière deformity g) Wrists and elbows: Limited movement, deformity, carpal tunnel, flexion contracture h) Knees: Valgus (knock-knee) deformities i) Ankles and feet: Limit ambulation, subluxation, hallux valgus, lateral deviation of toes, cock-up toes j) Spine: Neck pain, neurologic complications 6. Extra-articular manifestations a) Fatigue, weakness, anorexia, weight loss, and low-grade fever, anemia resistance to iron therapy, and skeletal muscle atrophy b) Rheumatoid nodules in subcutaneous tissue in areas subject to pressure c) Pleural effusion, vasculitis, pericarditis, and splenomegaly 7. Complications a) Cardiovascular disease, myocardial infarction, stroke, and death b) Infection and lymphoma 8. Interprofessional care a) Diagnosis: History, physical examination, and tests

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Blood tests: Autoantibodies, C-reactive protein levels, and the ESR: Typically elevated; anti-CCP test; CBC to identify anemia (2) Synovial fluid examination: Increased turbidity, decreased viscosity, increased protein, and WBC levels (3) X-rays of joints b) Medications (1) NSAIDs and mild analgesics for pain and inflammation (2) Low-dose oral corticosteroids for pain and inflammation; may slow progression; for acute flares, too (3) Disease-modifying antirheumatic drugs (DMARDs): Slow or prevent joint damage (a) Synthetic (or nonbiologic): Methotrexate, sulfasalazine, and antimalarial agents (b) Biologic: Anti-tumor necrosis factor-α, abatacept, and rituximab c) Nutrition (1) Well-balanced diet (2) Omega-3 fatty acids may be helpful d) Treatments (1) Rest and exercise (a) Physical and occupational therapists develop plan (b) Dynamic strength training: Improve muscle strength without increasing joint stress (c) Low-impact aerobic exercises (2) Heat and cold (a) Moist heat effective with muscles (b) Some patients prefer cold for joint pain (3) Assistive devices and splints (a) Cane, walker, raised toilet seat for hip or knee involvement (b) Night splints for hand and/or wrists (c) Splints should be easily removed to perform ROM exercises (4) Surgery (a) Arthrodesis: Joint fusion (b) Arthroplasty: Joint replacement 9. Nursing care a) Assessment (1) Health history (2) Physical examination b) Diagnoses, outcomes, and interventions (1) Promote self-help management .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(a) Assess the patient’s understanding of disease (b) Initiate an interprofessional care conference with patient and family (c) Encourage the patient and family to discuss effect of disease on their lives (d) Refer the patient and family to community resources and support groups (2) Manage chronic pain (a) Monitor level of pain and duration of morning stiffness (b) Teach use of heat and cold applications for relief (c) Teach about use of anti-inflammatory medications prescribed (3) Reduce fatigue (a) Encourage a balance of periods of activity and rest (b) Help in prioritizing activities (c) Encourage dynamic physical activity and ROM exercises (d) Refer counseling or support groups (4) Facilitate role changes (a) Discuss effects of disease on patient’s career and other life roles (b) Encourage the patient and family discussion of feelings; listen actively and acknowledge concerns (c) Help patient and family identify coping strengths (d) Encourage patient to make decisions and assume personal responsibility for disease management 10. Transitions of care a) Discuss: Disease process and treatments; medications; management of stiffness and pain; energy conservation; use of assistive devices; skin care with assistive devices; home and equipment modifications b) Refer to physical therapy, occupational therapy, home health services, and other community resources B. The Patient with Ankylosing Spondylitis 1. Chronic inflammatory arthritis that primarily affects the axial skeleton, leading to pain and progressive stiffening and fusion of the spine 2. Onset typically between 17 and 35 3. Incidence: Greater in men than women; men have more severe cases 4. Cause: Unknown, strong genetic component; enteric bacteria may play a role a) Inherited HLA-B27 antigen

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

5. Pathophysiology a) Sacroiliac joints and spine joints: Cartilage erodes, joint margins ossify and are replaced by scar tissue b) Gradual calcification and ossification that leads to ankylosis, or joint consolidation and immobility 6. Manifestations and complications a) Onset usually gradual and insidious b) Persistent or intermittent bouts of low back pain, worse at night, may radiate to buttocks, hips, and legs c) Back motion becomes limited, lumbar curve is lost, and thoracic curvature is accentuated d) In severe cases, entire spine becomes fused, preventing any motion e) Systemic manifestations: Anorexia, weight loss, fever, fatigue, uveitis, inflammatory bowel disease, psoriasis, and, uncommonly, pulmonary or cardiac dysfunction f) Most patients: Disease is intermittent with mild to moderate acute episodes g) Complications (1) Osteopenia, vertebral fractures, neurologic changes secondary to changes in the spinal structure, and rarely renal compromise 7. Interprofessional care a) Diagnosis (1) ESR and CRP: Elevated (2) X-ray of sacroiliac joints and spine (3) MRI for earlier identification of sacroiliitis b) Medications (1) NSAIDs (2) Biologic DMARD that targets tumor necrosis factor-alpha (TNF-α) (a) Infliximab (Remicade), etanercept (Enbrel), and adalimumab (Humira) or golimumab (Simponi) c) Treatment (1) Physical therapy d) Surgery (1) Total hip arthroplasty 8. Nursing care a) Diagnoses, outcomes, and interventions (1) Teach therapeutic regime (a) NSAIDs with food, milk, or antacid (b) Exercises in the shower (c) Follow prescribed exercise program

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(d) DMARD: Education about adverse effects, manifestations to report (e) Proper posture, firm mattress or bed board with small or no pillow (f) Weight loss, smoking cessation when appropriate (g) Occupational counseling C. The Patient with Reactive Arthritis (Reiter’s syndrome) 1. Pathophysiology a) Acute, nonpurulent inflammatory arthritis that is believed to be a response to an exposure to or infection from certain types of bacteria b) In people with inherited HLA-B27 antigen c) Typically self-limited, although it can be recurrent or progressive 2. Manifestations and complications a) Nonbacterial urethritis in men; urethritis and cervicitis in women b) Fatigue, malaise, fever, weight loss; conjunctivitis and acute inflammatory arthritis follow; tendinitis, fasciitis, and back pain; mouth ulcers, inflammation of the glans penis, and skin lesions c) Heart and aorta may be affected d) May develop chronic arthritis or spondylitis 3. Interprofessional care a) Diagnosis (1) History and presenting symptoms (2) Urethral or cervical cultures to rule out gonococcal infection b) Medications (1) Antibiotics for infections (2) NSAIDs, DMARDs, or immunosuppressive agents (3) Biologic TNF inhibitor for severe cases (a) Adalimumab (Humira) or etanercept (Enbrel) 4. Nursing care a) Discuss: Association between disease and precipitating infection and importance of treating infection; STIs; self-limiting nature of disease; NSAIDs; symptomatic relief measures D. The Patient with Systemic Lupus Erythematosus 1. Chronic inflammatory autoimmune disease that affects almost all body systems, including the musculoskeletal system 2. Cell and tissue damage caused by deposition of antigen–antibody complexes in connective tissues 3. Cause unknown; genetic, environmental, and hormonal factors contribute .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

4. Course: Usually mild, periods of remission and exacerbation a) Sometimes virulent disease with significant organ system involvement b) Systemic disease, kidney failure, infections, and thromboembolic events are leading causes of death 5. Pathophysiology a) Hyperreactivity of B cells because of disordered T-cell function b) Autoantibody production against nucleic acids, erythrocytes, coagulation proteins, lymphocytes, and platelets c) Immune complexes deposited in connective tissues, trigger inflammatory response, damage local tissues d) Medications can induce syndrome that mimics lupus; manifestations resolved when medication is discontinued 6. Risk factors a) Women of childbearing age but it can occur at any age, affect either gender, and is found in all ethnic groups b) Drugs that can cause a syndrome that mimics lupus in patients include procainamide, hydralazine, and isoniazid.

7. Manifestations a) Early ones resemble rheumatoid arthritis (1) Synovitis may be present, but joints are rarely deformed b) Characteristic red butterfly rash across the cheeks and bridge of the nose, photosensitivity, discoid lesions, hives, erythematous fingertip lesions, splinter hemorrhages, alopecia, mucous membrane ulcerations c) 50% experience renal manifestations: Proteinuria, cellular casts, and nephrotic syndrome d) Hematologic, vascular, cardiac: Anemia, leukopenia, and thrombocytopenia; pericarditis, myocarditis; vascular disorders, thrombotic events e) Pulmonary: Pleuritis, pleural effusions, and lupus pneumonitis 8. Complications a) Osteoporosis and infections 9. Interprofessional care a) Diagnosis: Health history, physical examination, tests (1) Antinuclear antibody (ANA): Positive (2) Anti-DNA antibody testing (3) ESR: Typically elevated (4) Serum complement levels: Usually decreased

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(5) CBC: Moderate to severe anemia, leukopenia, lymphocytopenia, thrombocytopenia (6) Urinalysis: Mild proteinuria, hematuria, blood cell casts during exacerbations (7) Renal function tests: Creatinine, blood urea nitrogen (BUN), eGFR (8) Kidney biopsy to assess severity of renal lesions b) Medications (1) Acetaminophen, aspirin or NSAIDs (2) Antimalarial drugs for skin and arthritic manifestations (3) Corticosteroids for severe and life-threatening manifestations (4) Immunosuppressive agents in combination with corticosteroids for active SLE or lupus nephritis c) Nutrition (1) Vitamin D supplements because of the need to avoid sunlight d) Treatments (1) Caution to avoid sun exposure (2) Topical corticosteroids for skin lesions (3) Some physicians recommend avoiding use of oral contraceptives (4) Dialysis and kidney transplantation for end-stage renal disease 10. Nursing care a) Diagnoses, outcomes, and interventions (1) Promote skin integrity (a) Assess knowledge of SLE and effects on skin (b) Discuss relationship between sun exposure and disease activity; suggest methods to limit sun exposure (c) Keep skin clean and dry; apply therapeutic creams to lesions as prescribed (2) Reduce risk for infection (a) Wash hands before and after providing direct care (b) Use strict aseptic technique in caring for IV lines and indwelling urinary catheters or performing wound care (c) Assess frequently for infection (d) Monitor lab results and report significant changes to physician (e) Initiate reverse or protective isolation procedures as indicated by the patient’s immune status (f) Ensure an adequate nutrient intake (g) Monitor for potential adverse effects of medications (3) Promote self-health management (a) Assess ability to maintain optimal health (b) Provide care and teaching in a nonjudgmental manner .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(c) Encourage the patient and family to discuss the effect of the disease on their lives (d) Initiate interprofessional care conference with the patient and family (e) Refer the patient and family to counseling as needed and to community resources 11. Transitions of care a) Discuss: The disease and potential effects; importance of skin care; importance or avoiding exposure to infection; need to follow treatment plan; importance of wearing medical alert tag identifying condition and therapy; family planning with patient and spouse; the need for preventive healthcare for both men and women E. The Patient with Systemic Sclerosis (Scleroderma) 1. Chronic disease characterized by deposition of excess collagen tissue in the skin and internal organs 2. Higher incidence noted in those exposed to silica and certain chemicals 3. Pathophysiology a) Functional and structural abnormalities of small arteries and arterioles that lead to progressive vessel obstruction, increased permeability, and fibrosis b) Progressive replacement of normal tissue with dense connective tissue in skin, blood vessels, lungs, GI tract, and other organs c) Raynaud’s phenomenon: Vascular disorder with reversible arterial vasospasm d) May be limited, with limited visceral organ involvement, or diffuse with both skin and visceral organ involvement e) Common causes of death: Infections; diseases of the cardiovascular, renal, pulmonary, and CNS 4. Risk factors a) Genetic predisposition after exposure to viruses or environmental toxins 5. Manifestations a) Skin thickens; diffuse, nonpitting swelling occurs b) Skin atrophies, becomes taut, shiny, hyperpigmented; telangiectasias and calcium deposits may be noted c) Raynaud’s phenomenon: Pallor of the fingers followed by cyanosis, and then reactive hyperemia with redness d) Other manifestations vary depending on visceral organ involvement 6. Complications

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) Dysphagia, impaired gas exchange, right-sided heart failure due to pulmonary hypertension, pericarditis, dysrhythmias, diarrhea or constipation, abdominal cramping, malabsorption, proteinuria, hematuria, hypertension, and renal failure 7. Interprofessional care a) Diagnosis (1) Antinuclear antibody (ANA) (2) ESR: Typically elevated (3) CBC: Demonstrates anemia (4) Skin biopsy to confirm diagnosis b) Medications (1) Immunosuppressive agents and corticosteroids to slow or prevent pulmonary fibrosis (2) Cyclophosphamide (Cytoxan) or methotrexate: May slow disease progression (3) Sildenafil (Viagra): For symptomatic pulmonary hypertension (4) Calcium channel blockers: For Raynaud’s phenomenon (5) H2-receptor blockers: For esophagitis (6) Broad-spectrum antibiotic to suppress intestinal flora, relieve symptoms of malabsorption (7) Angiotensin-converting enzyme (ACE) inhibitors: For kidney disease c) Therapies (1) Particularly important for hands and face (2) Stretching and strengthening facial muscles is essential to maintain oral food intake 8. Nursing care a) Measures to maintain supple skin b) Measures to maintain adequate nutrition in cases of weak facial muscles and/or esophagitis c) Approach psychological effects of disease, assess, and aid in patient coping 9. Transitions of care a) Discuss: Disease and management; skin care; physical therapy; avoid chilling; smoking cessation b) Refer to helpful resources F .The Patient with Sjögren’s Syndrome 1. Pathophysiology a) Chronic, progressive autoimmune disorder that causes inflammation and dysfunction of exocrine glands

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

b) Lymphocytes and deposits of immune complexes infiltrate and destroy exocrine glands c) Can occur primarily but is often associated with other rheumatic disease 2. Risk factors a) Occurs more in women 3. Manifestations and complications a) Dry eyes, dry mouth; potential dry nose, throat, larynx, bronchi, vagina, and skin; parotid gland enlargement is common b) Systemic effects: Arthritis, dysphagia, pancreatitis, pleuritis, migraine, vasculitis, and nephritis c) Complications: Increased risk for malignant lymphoma 4. Interprofessional care a) Diagnosis: Based on history and clinical presentation (1) Schirmer’s test: Measures tears secreted in response to irritation (2) Biopsy of lip: Evidence for lymphoid foci b) Treatment: Supportive (1) Artificial tears, intake of fluids, saliva substitute, or chewing gum 5. Nursing care a) Teach measures to protect eyes and oral mucosa G. The Patient with Inflammatory Myopathy 1. Pathophysiology and risk factors a) Polymyositis: Systemic connective tissue disorder characterized by inflammation of connective tissue and muscle fibers leading to muscle weakness and atrophy b) Dermatomyositis: Fiber inflammation is accompanied by skin lesions c) Affects all ages 2. Manifestations a) Initial: Muscle pain, tenderness, and weakness; rash; arthralgias; fatigue; fever; and weight loss b) Others: Raynaud’s phenomenon, dysphagia, dyspnea, and cough c) Risk for malignancy is increased 3. Complications a) Interstitial lung disease, malignancy, esophageal disease, and myocarditis 4. Interprofessional care .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) Diagnosis (1) Autoantibodies in blood serum (2) Muscle enzymes elevated (3) Biopsy of involved muscle b) Medications (1) Corticosteroids to reduce inflammatory response (2) Immunosuppressive agents may be used in combination with corticosteroids to induce remission 5. Nursing care a) Provide alternate methods of communication as needed b) Observe while eating, risk for aspiration c) Modify diet to maintain nutrition and safety 6. Transitions of care a) Education for the patient and family (1) Need to balance rest and activity (2) Skin care (3) Prescribed medications (4) Information about safety measures (5) Heimlich maneuver and CPR for family (6) Signs of respiratory infection and other complications H. The Patient with Lyme Disease 1. Inflammatory disorder caused by the spirochete Borrelia burgdorferi, which is transmitted primarily by ticks 2. Pathophysiology a) Borrelia burgdorferi enters skin at tick bite b) Incubation period of about 30 days, migrates to skin, and/or spreads via lymph or blood to other skin sites, nodes, or organs c) Inflammatory joint changes closely resemble those of rheumatoid arthritis 3. Manifestations a) Flulike manifestations and a skin rash followed weeks or months later by neurologic symptoms, including facial nerve palsy and meningitis, and months to years later, by arthritis b) Progression is highly individualized c) Erythema migrans: Flat or slightly raised red lesion at the site of the tick bite expands over several days, with the central area clearing as it expands d) Systemic symptoms such as fatigue, malaise, fever, chills, and myalgias

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

4. Complications a) Chronic recurrent arthritis, meningitis, encephalitis, neuropathies, myocarditis, and heart block 5. Interprofessional care a) Diagnosis: Manifestations and tests (1) Culture of organism is difficult and slow (2) Enzyme-linked immunosorbent assay (ELISA) or Western blot methods: To detect antibodies to B. burgdorferi b) Medications (1) Antibiotics: Doxycycline (Doxy-Caps, Vibramycin), amoxicillin (Amoxil), cefuroxime axetil (Ceftin), or erythromycin (a) May be continued for up to 1 month (2) Aspirin or NSAIDs for arthritic symptoms (3) Affected joint may be splinted, or weight bearing is restricted 6. Nursing care a) Discuss measures of prevention: (1) Avoid tick infected areas, or cover exposed skin, tuck pants into socks, use insect repellents, and inspect skin after exposure (2) Remove attached ticks with fine-tipped tweezers IV. Infectious Musculoskeletal Disorders A. The Patient with Osteomyelitis 1. Infection of the bone 2. Pathophysiology a) Usually bacterial b) Pathogen lodges and multiplies in bone, causes immune and inflammatory response c) Enzymes release by phagocytes destroy bone tissue d) Infection travels to other segments of bone e) If it reaches outer margin of bone, it spreads along the surface and disrupts blood vessels that enter the bone, eventually leads to ischemia and necrosis of bone f) Hematogenous osteomyelitis: Caused by pathogens that are carried in the blood from other infection sites (1) Primarily affects older adults, people with sickle cell anemia, and IV drug users (2) Spine is usual site of infection for older adults

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(3) Acute onset of pain, tenderness, fever; soft tissue swelling over the affected bone may be noted (4) For IV users: Subacute onset, with vague, dull pain in affected region, normal or low-grade fever g) Osteomyelitis from a contiguous infection: Spread from infection of adjacent soft tissues (1) Complication of: Direct penetrating wounds, joint replacements, decubitus ulcers, and neurosurgery (2) Manifestations may be masked by local tissue inflammation 3. Risk factors a) Over age 50, chronic circulatory disease, diabetes, peripheral vascular disease 4. Manifestations a) Local: Acute or chronic bone pain of increasing intensity; low back pain; drainage and ulceration, swelling, erythema, and warmth at involved site; localized tenderness b) Systemic: Lymph node involvement, especially in the involved extremity; high temperature with chills; malaise; tachycardia; nausea and vomiting; anorexia 5. Complications a) Sinus tracts, which can cause osteolysis and lead to pathologic fractures, sepsis, squamous cell carcinoma 6. Interprofessional care a) Diagnosis (1) X-rays, bone scans, MRI, blood tests, and biopsy b) Medications (1) Antibiotics: To prevent progression to chronic phase (a) Penicillinase-resistant semisynthetic penicillin or a cephalosporin used first, more definitive antibiotics prescribed from test results (b) Course 4 to 6 weeks c) Surgery (1) Debridement to remove necrotic tissue and ID organism: For chronic cases and early in course of infection (2) Musculocutaneous flap: Moves muscles and skin into the cavity that was created during surgery 7. Adjuvant therapies a) Hyperbaric oxygen (HBO) therapy and negative-pressure wound therapy (NPWT)

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

8. Nursing care a) Diagnoses, outcomes, and interventions (1) Promote tissue integrity (a) Maintain strict hand hygiene practices (b) Administer antimicrobial therapy (c) Monitor site of infection, surgical wound, and systemic manifestations for evidence of desired therapeutic effect and for adverse effects (d) Maintain nutrition and protein (2) Promote physical mobility (a) Maintain rest, avoid subjecting extremity to weightbearing exercises (b) Assist with ROM exercises (3) Relieve acute pain (a) Apply splint or immobilizer when appropriate; maintain affected limb in functional position when immobilized (b) Use nonpharmacologic strategies for pain management (c) Handle the affected area gently 9. Transitions of care a) Discuss: Hand hygiene; finishing antibiotics course; pain medications on a regular basis; wound care; rest of affected area; nutrition B. The Patient with Septic Arthritis 1. Infection of a joint space 2. Pathophysiology a) Inflammation with resulting synovitis and joint effusion b) Abscesses may form in synovial tissues or joint cartilage c) Without proper treatment, can destroy affected joint 3. Risk factors a) Persistent bacteremia, previous joint damage, impaired immunity, loss of skin integrity, arthroscopic surgery, and total joint replacement 4. Manifestations and complications a) Onset: Abrupt b) Local: Pain and stiffness of the infected joint; joint is red, swollen, hot, tender; effusion c) Systemic: Manifestations of infection d) Complications .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Destruction of the joint or severe joint dysfunction, leading to the need for amputation, arthrodesis, or joint replacement 5. Interprofessional care a) Diagnosis: Fluid from joint is aspirated, sent from Gram stain and culture b) Medications (1) Antibiotics c) Surgery (1) Needle aspiration or arthroscopy or arthrotomy (2) Physical therapy during recovery period 6. Nursing care a) Interventions (1) Monitor patient’s response to therapy (2) Position affected joint appropriately, use warm compresses (3) Assist with ROM exercises 7. Transitions of care a) Patient education (1) Disease process and treatment (2) Discuss STI and IV drug use (3) Emphasize importance of complying with treatment V. Neoplastic Musculoskeletal Disorders A. The Patient with a Bone Tumor 1. Benign are much more common than malignant a) Benign grow slowly, malignant grow rapidly 2. Pathophysiology a) Etiology unknown; frequently occur during peak bone growth or overstimulation from disease b) Cause osteolysis, results in bone fractures c) Malignant: Invade and destroy adjacent bone tissue 3. Risk factors a) Genetic disorders b) Paget disease c) Exposure to radiation d) Bone marrow transplant 4. Manifestations a) Benign: Pain, a mass, impaired function .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

5. Interprofessional care a) Diagnosis (1) X-rays, CT scans, and MRI (2) Percutaneous needle biopsy or needle biopsy (3) Alkaline phosphatase, calcium: Elevated b) Treatment (1) Chemotherapy: To shrink malignant tumor before surgery, to control recurrence after surgery, and to treat metastasis of the tumor (2) Radiation therapy: May be used in combination with chemo (3) Surgery: Excision of tumor or amputation of limb 6. Nursing care a) Diagnoses, outcomes, and interventions (1) Reduce risk for injury (a) Teach to avoid injury to tumor site (b) Provide referral to physical or occupation therapy (2) Manage acute and chronic pain (a) Develop strategies for controlling pain (b) Provide assistive devices for ambulation (3) Promote physical mobility (a) Muscle strengthening and ROM after surgery 7. Transitions of care (1) Discuss: Disease, progression, consequences, treatment options (2) Teach: Methods to limit side-effects; wound care; activity and weightbearing restrictions (3) Refer to community resources VI. Other Musculoskeletal Disorders A. The Patient with Low Back Pain 1. Pathophysiology a) Causes and types: (1) Local pain from compression or irritation of sensory nerves (2) Referred pain originates from abdominal or pelvic viscera (3) Pain associated with pathology of the spine (4) Radicular pain radiates from back to the leg along a nerve root (5) Muscle spasm pain associated with spine disorders 2. Risk factors

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) Smoking, obesity, age, female gender, physically strenuous work, sedentary work, psychologically strenuous work, low educational attainment, job dissatisfaction, somatization disorder, anxiety, and depression 3. Manifestations a) Pain ranges from mild discomfort to chronic debilitating pain b) Acute pain thought to be injury related, but specific event often difficult to identify 4. Complications a) Chronic back pain 5. Interprofessional care a) Diagnosis (1) Radiography, CT scans, and MRI: If serious underlying condition is suspected or patient doesn’t respond to conservative treatment b) Medications (1) NSAIDs and acetaminophen (2) Muscle relaxants and opioid analgesics may be used c) Treatment (1) Limited rest with resumption of normal activity (2) Application of heat (3) Physical therapy: Diathermy (deep heat therapy), ultrasonography, hydrotherapy, and transcutaneous electrical nerve stimulation (TENS) units d) Integrative therapy (1) Chiropractic, acupuncture, and massage 6. Nursing care a) Assessment (1) Health history (2) Physical assessment b) Diagnoses, outcomes, and interventions (1) Teach self-health management (a) Teach appropriate comfort measures (b) Discuss NSAIDs (c) Encourage patients to stay active (d) Instruct about use of heat (e) Teach appropriate body mechanics in lifting and reaching (f) Discuss modifications of home or work space (g) Encourage weight loss

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(h) Discuss complementary and alternative therapy options 7. Transitions of care a) Discuss: Body mechanics, using a firm mattress, body weight, and physical fitness B. The Patient with Fibromyalgia 1. Pathophysiology a) Pathogenesis involves several levels of the central nervous system, as well as the autonomic and somatic peripheral nervous systems and the endocrine system b) Disordered central processing, abnormal CSF levels of neurotransmitters, abnormal hypothalamic–pituitary–adrenal (HPA) axis responses (1) Patients perceive pain at a lower level of stimulation 2. Manifestations a) Onset may be chronic or acute b) Pain may be localized or involve entire body c) Pain exacerbated by weather changes, disrupted sleep, exercise, and stress d) Systemic: Fatigue, sleep disruptions, headaches, morning stiffness, painful menstrual periods, and problems with thinking and memory 3. Complications a) Increased risk of suicide; problems with employment 4. Interprofessional care a) Diagnosis: Based on history and physical assessment (1) No diagnostic tests b) Medications (1) Tricyclic or selective serotonin reuptake inhibitor (SSRI) antidepressants (2) Mixed reuptake inhibitors: Duloxetine (Cymbalta) and milnacipran (Savella) (3) Pregabalin (Lyrica): Was developed to treat neuropathic pain c) Integrative therapy (1) Aerobic exercise, stretching (2) Heated pool treatments (3) Cognitive behavioral therapy, hypnotherapy, biofeedback, and acupuncture 5. Nursing care a) Acknowledge symptoms .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

b) Teach patients about disorder, reassure that course is not progressive c) Teach about pain relief measures d) Refer to community resources C. The Patient with Spinal Deformity 1. Pathophysiology a) Scoliosis: Lateral curvature of the spine (1) Postural: The small curve corrects with bending (2) Structural: The curve does not correct with bending (3) Progressive deformities of the vertebral column and ribs, cause onesided compression of the vertebral bodies b) Kyphosis: Excessive angulation of the normal posterior curve of the thoracic spine (1) Postural: Caused by slumping posture (2) Structural: From congenital malformations or disorders, or surgical removal of intervertebral disks (3) Manifestations: Moderate back pain, increased curvature of thoracic spin as viewed from the side 2. Risk factors a) Scoliosis: Genetics b) Kyphosis: Vertebral fractures, low bone density, short vertebral height, degenerative disk disease, poor posture, muscle weakness, loss of elastic tissue in intervertebral ligaments, and genetic or metabolic conditions 3. Manifestations a) Scoliosis (1) Asymmetry of the shoulders, scapulae, and waist creases; prominence of the thoracic ribs or paravertebral muscles on forward bend; and lateral curvature and vertebral rotation on posteroanterior xray (2) Pain is present in severe cases, usually in the lumbar region (3) Pain from pressure on the ribs or the crest of the ilium (4) Shortness of breath and GI disturbances because of crowding of the abdominal organs b) Kyphosis (1) Moderate back pain, posterior rounding at the thoracic level as viewed from the side (hunchback), and a kyphotic curve of over 45 degrees on x-ray 4. Complications

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) Pain, impaired mobility, respiratory problems, increased risk of falls, fractures, and GI issues 5. Interprofessional care a) Diagnosis (1) Upright posteroanterior and lateral x-rays (2) Scoliosis: Degree measured by lateral deviation (3) Kyphosis: Wedging of vertebrae b) Treatments (1) Conservative treatment (a) Braces: For younger patients who still are growing (b) For adults: Weight reduction, exercises, braces for support (2) Surgery (a) Attachment of metal rods to the vertebrae with bilateral rods, wire hoods, or screws (b) Decision depends on curvature, patient’s overall health 6. Nursing care a) Minimize risk for injury: Assess environment for safety hazards b) Teach patient proper brace usage, ways to reduce skin irritation and promote comfort 7. Transitions of care a) Reassure that condition is not caused by poor posture b) Provide verbal and written instructions for brace c) Postsurgical patients: Teaching of site care and limited activity d) Importance of not smoking if disorder restricts respiratory excursion D. The Patient with a Common Foot Disorder 1. Causes: Congenital, related to systemic disorder, confining shoes, physical stress on the foot 2. Types: Hallux valgus (bunion), hammertoe, Morton’s neuroma, Plantar fasciitis 3. Interprofessional care a) Diagnosis: History, inspection (1) X-rays in case of surgery b) Medications (1) Analgesics or injected corticosteroids for pain and inflammation c) Surgery (1) Intractable toe deformities or pain d) Integrative therapies .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Conservative treatment: Corrective shoes or orthotic devices (2) Metatarsal pads (3) Exercises 4. Nursing care a) Pain relief: Teach about appropriate footwear, use of protective pads, importance of inspecting foot b) Post-surgery: Teach care of exposed pins c) Importance of well-fitting footwear d) Safety measures to prevent falling, when appropriate

Chapter Highlights A. Metabolic bone and joint disorders arise from disrupted processes or impaired elimination of wastes. As a result, bones may be weak, and easily fractured, leaving the patient at risk for fractures. Metabolic wastes such as urate crystals may accumulate, damaging joints and other tissues and causing acute pain.

B. Metabolic bone disorders, including osteoporosis, Paget disease, and osteomalacia, begin in the bone remodeling process. Aging, calcium and phosphate imbalances, genetics, and changes in hormone levels contribute to these disorders.

C. Osteoporosis is a major health problem in the United States, with fractures being the most common complication. Health promotion activities to prevent osteoporosis include a calcium-rich diet, weight-bearing exercises, and a healthy lifestyle.

D. Gout is characterized by hyperuricemia and urate crystal formation in the joint synovium.

Attacks of the disease typically begin with an acutely painful inflammation of the first joint of the great toe, although other joints such as the knee or elbow may be affected.

E. Degenerative disorders of the joints and muscles can lead to impaired mobility and chronic pain. These problems may in turn cause disability, especially in the performance of daily living activities.

F. Osteoarthritis (OA) is the most commonly occurring of all forms of arthritis and a leading cause of pain and disability in older adults. The disease is characterized by loss of cartilage in articulating joints and hypertrophy of bone at the articular margins. Pain and inflammation are most often conservatively managed with mild analgesics and NSAIDs. G. Significant pain and disability not controlled with analgesics, NSAIDs, exercise, and physical therapy may necessitate total joint replacement.

H. Muscular dystrophy is a degenerative musculoskeletal disorder that mostly affects children.

However, with increased knowledge of the pathophysiology of the disorder, these children are living into adulthood and nurses will encounter them in both inpatient and outpatient settings.

I. Knowledge of the disease processes and potential complications will assist the nurse in caring for the patient with this disorder in their history.

J. Autoimmune and inflammatory disorders of the musculoskeletal system are systemic in nature and often chronic, potentially leading to significant disability. Care is .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

multidimensional, involving pharmacologic and nonpharmacologic strategies to maintain optimal function.

K. Autoimmune and inflammatory musculoskeletal disorders include rheumatoid arthritis (RA), ankylosing spondylitis (AS), reactive arthritis (ReA), systemic lupus erythematosus (SLE), polymyositis, and Lyme disease.

L. Although the cause of RA is unknown, it is believed to involve a combination of genetic and environmental factors. RA is a systemic disease, affecting one or many joints and also causing fatigue, weakness, anorexia, weight loss, and fever. The primary objectives of treatment and care are to reduce pain and inflammation, preserve function, and prevent deformity.

M. Connective tissue is the most abundant and widely distributed body tissue. It connects body parts and provides support; forms bones, cartilage, and the walls of blood vessels; and attaches muscles to bones. Disorders that affect connective tissue have diverse manifestations, and patients need interprofessional team support for effective disease management.

N. SLE is a chronic inflammatory connective tissue disease, affecting almost all body systems, including the musculoskeletal system. Skin lesions are a common manifestation, exhibited by a characteristic rash on the face. The patient with SLE is at increased risk for infection.

O. Systemic sclerosis is a chronic disease characterized by the formation of excess connective tissue and diffuse fibrosis of the skin and internal organs. It may be either localized or generalized.

P. Lyme disease is caused by the spirochete B. burgdorferi, carried and transmitted primarily by ticks. The disease can be treated effectively with antibiotics.

Q. Infectious disorders of bone and joints are caused by a pathogen, and are often difficult to treat. Effective treatment is vital, however, to prevent chronic pain, deformity, and disability. The nurse coordinates, provides, and monitors treatment measures and responses in acute care and the home, and provides patient, family, and caregiver education.

R. Osteomyelitis and septic arthritis are infectious musculoskeletal disorders. Osteomyelitis may be the result of a bloodborne pathogen, a contiguous infection, or a complication of vascular insufficiency. Septic arthritis is a medical emergency, requiring immediate treatment to preserve joint function.

S. Bone tumors may be benign or malignant, primary or metastatic. The primary manifestations of a bone tumor are pain, a mass, and impaired function. Nursing care is directed toward teaching to prevent injury and interventions to relieve pain.

T. Musculoskeletal disorders characterized by chronic pain and discomfort can have significant physical and psychosocial effects on the patient. The nursing role in caring for these patients focuses on providing support and educating the patient about his or her condition so the patient can be an active partner in managing the condition.

U. Low back pain is among the most common problems causing adults to seek medical care.

Unless risk factors or manifestations indicating a secondary origin (e.g., a tumor or infection) are present, this condition is appropriate for conservative management with mild .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

analgesics, NSAIDs, or chiropractic measures. Patients are encouraged to stay active, avoiding only strenuous lifting or activity.

V. Fibromyalgia is characterized by chronic widespread musculoskeletal pain and tenderness that has a significant negative impact on physical and psychosocial functioning. A combination of physical conditioning, cognitive-behavioral strategies, and pharmacologic treatment is commonly employed to treat fibromyalgia.

W. Structural musculoskeletal disorders include scoliosis, kyphosis, hallux valgus, hammertoe, and Morton neuroma. Plantar fasciitis is a common cause of foot pain in adults.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME ONE Discuss modifications in assessment and intervention that would be necessary for patients with musculoskeletal disorders. Help students practice these modified techniques.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME ONE Assign students to care for clients with a metabolic disorder. Have the students discuss the care needs of these clients during post-clinical conference.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME TWO Have a person who has had a joint replacement come to the classroom to speak about her experience of the surgery and recovery.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME TWO Assign students to care for clients with a degenerative musculoskeletal disorder including joint replacement surgery. Have the students accompany the client to physical therapy so that postoperative physical care can be discussed during post-clinical conference.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME THREE Use anatomic models to demonstrate the pathologic changes associated with the disorders covered in this section.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME THREE If possible, assign students to care for clients with an autoimmune or inflammatory musculoskeletal disorder. Have the students create a teaching tool to help these clients reduce symptoms and potential complications.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTION FOR CLASSROOM ACTIVITY–LEARNING OUTCOME FOUR Have students identify specific drugs that are common in the care of patients with specific musculoskeletal disorders. Have students review the nursing implications of these medications.

Share the information found, and look for commonalities and differences.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME FOUR Assign students if possible to care for clients with infectious musculoskeletal disorders. Have the students discuss the pathophysiology of the disorder and their individual client predisposing factors for the disorder.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME FIVE Have students identify treatments appropriate for a patient with a neoplasm of the bone

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME FIVE Have the students create a teaching tool appropriate for a client with a neoplastic musculoskeletal disorder.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME SIX Ask a podiatrist to the classroom to discuss the different disorders of the feet.

SUGGESTIONS FOR CLINICAL ACTIVITY—LEARNING OUTCOME SIX Assign the students to attend grade schools to observe the school nurse screen students for scoliosis.

Assign the students to observe surgical procedures to correct disorders of the spine or feet.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter 41 Assessing the Nervous System

Learning Outcomes 1. Describe the anatomy, physiology, and functions of the nervous system and identify abnormal findings that may indicate impairments of the nervous system.

2. Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.

3. Differentiate considerations for assessing the nervous systems of older adults and veterans.

4. Summarize topics that nurses teach to promote healthy tissue integrity across the lifespan.

Key Concepts I.

Anatomy, Physiology, and Functions of the Nervous System A. Neurons, action potentials, and neurotransmitters a) Neurons: Receive and send impulses (1) Gray matter (a) Dendrite: Conducts impulses toward cell body (b) Cell body: Clustered in ganglia or nuclei (2) White matter (a) Axon: Conducts impulses away from cell body (b) Covered with myelin sheath (c) Nodes of Ranvier: Unmyelinated areas that allow movement of ions between axon and ESF (3) Afferent neurons: Sensory neurons, have receptors in skin, muscles, and other organs (4) Efferent neurons: Motor neurons, transmit impulses to cause action b) Action potentials: Impulses of electrical charge—how neurons communicate (1) Polarized state: Resting state, not involved in impulse conduction (2) Sodium and potassium regulate membrane potential (a) Sodium: Positive ion in extracellular fluid (b) Potassium: Major positive ion in the intracellular fluid (3) Depolarized state: Sodium moves into cell, stimulates action potential c) Neuralgia: Protect and nourish neurons 2.

Neurotransmitters: Chemical messengers a) When action potential reaches end of axon, neurotransmitter is released and travels to bind with receptors

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

b) Excitatory or inhibitory c) Acetylcholine (ACh), usually excitatory, is degraded by acetylcholinesterase (1) Cholinergic nerves: Transmit impulses with ACh d) Norepinephrine (NE): Either excitatory or inhibitory (1) Adrenergic nerves: Transmit impulses with norepinephrine (a) Alpha-adrenergic: Help control varied functions, including arterial vasoconstriction and pupil dilation (b) Beta-adrenergic: Regulate rate and force of heart contractions, bronchial diameter, arterial diameter and glycogenesis e) Gamma aminobutyric acid (GABA): Inhibits CNS function f) Dopamine: Helps control fine movement and emotions g) Serotonin: Helps control sleep, hunger, behavior, and consciousness B.

The central nervous system 1.

The brain a) Cerebrum (1) Two hemispheres, divided into frontal parietal, temporal, and occipital lobes (a) Left: Control of language (b) Right: Control over nonverbal perceptual functions (2) Corpus callosum: Nerve fibers, communicate between two lobes (3) Cerebral cortex: Outer surface (4) Functions (a) Interprets sensory input (b) Controls skeletal muscle activity (c) Processes intellect and emotions (d) Contains skills memory (5) Diencephalon (a) Embedded in cerebrum superior to the brainstem (b) Thalamus, hypothalamus, and epithalamus (c) Functions (i) Conducts sensory and motor impulses (ii) Regulates autonomic nervous system (iii) Regulates and produces hormones (iv) Mediates emotional responses b) Brainstem (1) Midbrain, pons, and medulla oblongata (2) Functions (a) Serves as a conduction pathway (b) Serves as site of decussation of tracts

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(c) (d) (3) Cerebellum (a) (b)

Contains respiratory nuclei Helps regulate skeletal muscles

Connected to brainstem Functions (i) Processes information (ii) Provides information necessary for balance, posture, and coordinated muscle movement c) Ventricles: 4 chambers filled with cerebrospinal fluid (CSF) (1) Linked by ducts, allow CSF to circulate d) Cerebrospinal fluid (1) Formed by choroid plexus, derived from blood plasma (2) Contains 99% water, with protein, sodium, chloride, potassium, bicarbonate, and glucose (3) Functions: Cushions brain tissue, protects brain and spinal cord from trauma, helps provide nourishment for brain, removes waste products of cerebrospinal cellular metabolism e) Meninges (1) Connective tissue membranes, cover and protect brain and spinal cord (2) Dura mater: Outermost layer, attached to inner surface of skull (3) Arachnoid mater: Encloses CNS, forms subarachnoid space that contains CSF (4) Pia mater: Clings to brain, spinal cord, segmental nerves, filled with small blood vessels f) Cerebral circulation and blood–brain barrier (1) Blood flow to brain controlled by autoregulatory mechanisms, maintains constant blood flow despite changes in systemic blood pressure (2) Metabolic factors: Carbon dioxide, hydrogen ion, and oxygen concentrations (3) 2 internal carotid arteries: Supply anterior brain, branch into ophthalmic, posterior communicating, anterior choroidal, anterior cerebral, and middle cerebral (4) Vertebral arteries: Supply posterior brain (5) Basilar artery: Supplies brainstem and cerebellum (6) Circle of Willis: Connected blood vessels, provides alternative routes for brain tissues to receive blood supply (7) Brain capillaries: Low permeability, allows lipids, glucose, some amino acids, water carbon dioxide, and oxygen to pass through

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(a) Substances that cannot normally pass through: Urea, creatinine, proteins, some toxins, and most antibiotics g) The limbic system and reticular formation (1) Limbic: Ring of tissue in medial side of each hemisphere (a) Provides emotional and behavioral responses to environmental stimuli (2) Reticular: Located through central core of medulla oblongata, pons, and midbrain (a) Relays sensory input for all body systems to all levels of brain (b) Reticular activating system (RAS): Stimulating center for cerebral cortex (c) Motor nuclei: Help maintain muscle tone and coordinated movements 2.

C.

The spinal cord a) Center for conducting messages to and from the brain, and the reflex center b) Surrounded by vertebrae: Cervical, thoracic, lumbar, sacral, and coccyx c) Vertebral foramen: Enclosed space in vertebrae through which spinal cord passes d) Intervertebral disks: Between vertebrae, made of thick capsule surrounding gelatinous core (nucleus pulposus) e) Functions of the spinal cord and spinal roots (1) Ascending (sensory) pathways: Lateral and anterior spinothalamic tracts (2) Descending (motor) pathways: Pyramidal tracts (a) Mediate voluntary movements f) Upper and lower motor neurons (1) Carry impulses from cerebral cortex to anterior gray column of spinal cord

The peripheral nervous system 1.

Spinal nerves a) 31 pairs, named by their location b) Cauda equina: Nerve roots that travel inferiorly through vertebral canal before exiting c) Dorsal root: Contains sensory fibers d) Ventral root: Contains motor fibers e) Rami: Branches of nerve, further out f) Dermatome: Area of skin innervated by cutaneous branches of a single spinal nerve

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

2.

Cranial nerves a) Twelve pairs, originate in forebrain and brainstem b) Most are mixed nerves, 3 pairs (olfactory, optic, and acoustic) are solely sensory 3.

Reflexes a) Rapid, involuntary, predictable motor response to a stimulus b) Somatic: Skeletal muscle contraction c) Reflex arc: Pathway for reflex, contain a receptor and integration center in spinal cord or brain, a motor neuron and an effector d) Spinal reflexes: Mediated by spinal cord, most do not travel to or from the brain e) Deep tendon reflexes: Occur in response to muscle contraction, cause muscle relaxation and lengthening f) Flexor reflexes: Caused by actual or perceived painful stimuli, result in withdrawal or threatened body part g) Superficial responses: From gentle stimulation of skin D.

II.

The autonomic nervous system 1.

Innervate cardiac muscle, smooth muscle, and glands 2.

Primarily controlled by reticular formation in the brainstem 3.

Sympathetic division a) Norepinephrine is primary neurotransmitter b) Prepares body for stress, harm, and strenuous activity 4.

Parasympathetic division a) Acetylcholine is primary neurotransmitter b) Operates during nonstressful situations

Assessing Neurologic Function A. Health assessment interview 1.

Glasgow coma scale: Assesses level of consciousness 2.

Analyze onset, characteristics, course, severity, precipitating and relieving factors, associated symptoms, time and circumstances of manifestations 3.

Ask about: Numbness, tingling sensations, tremors, problems with coordination or balance, loss of movement in any part of the body; sensory deficit; memory, feeling state, recent changes in sleep patterns, ability to perform self-care and activities of daily living, sexual activity, and weight 4.

History of seizures, fainting, dizziness, headaches, and any trauma, tumors, or surgery of the brain, spinal cord, or nerves 5.

Occupational hazards, self-care habits B.

Genetic considerations

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

1.

Parkinson disease, multiple sclerosis (MS), narcolepsy, Huntington disease, Friedreich ataxia, essential tremor, epilepsy, Charcot-Marie-Tooth syndrome, Alzheimer disease, amyotrophic lateral sclerosis (ALS), Tay-Sachs disease C.

Physical assessment 1.

AVPU scale a) Alert: Is the patient fully alert (not necessarily oriented)? b) Verbal: Does the patient make some kind of response when verbally addressed? c) Pain: Does the patient respond to painful stimuli? d) Unresponsive 2.

Abbreviated neurologic assessment a) Level of consciousness b) Obtain vital signs c) Check pupillary response to light d) Assess strength of hand grip and movement of extremities bilaterally e) Determine ability to sense touch/pain in extremities

3.

Mental status assessment a) Assess appearance, behavior, cognitive function, attention span, recent and remote memory, thought processes, ability to understand what is said and express thoughts, ability to make logical and safe judgments b) Abnormal findings (1) Unilateral neglect with some strokes (2) Poor hygiene with dementing disorders (3) Abnormal gait with transient ischemic attacks, strokes, Parkinson disease (4) Emotional swings with strokes (5) Masklike fact with Parkinson disease (6) Apathy in dementing disorders (7) Aphasia in TIAs and stroke (8) Dysphonia in stroke (9) Dysarthria with lesions (10) LOC alterations, drowsiness, disorientation in time, memory deficits, perceptual deficits, impaired cognition: With damage to brainstem, stroke, and brain tumors

4.

Cranial nerve assessments a) Olfactory, optic, oculomotor, trochlear, abducens, trigeminal, facial, acoustic, glossopharyngeal, vagus, spinal accessory, and hypoglossal nerves b) Abnormal findings

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Anosmia: With lesions of frontal lobe, impaired blood flow (2) Blindness in one eye or both eyes, impaired vision, double vision, nystagmus, constricted pupils: Stroke, TIAs, brain tumors, multiple sclerosis, and medications/drug use (3) Ptosis: Strokes, myasthenia gravis, and palsy of CN III (4) Changes in facial sensations: Impaired blood flow (5) Decreased sensations on one side: Stroke (6) Loss of facial sensation, impaired corneal reflex: Lesions of CN V or VII (7) Severe facial pain: Trigeminal neuralgia (8) Loss of ability to taste: Brain tumors and nerve impairment (9) Asymmetry, decreased facial movement, loss of gag reflex: Lesions (10) Paralysis of lower neurons: Injury to CN VII (11) Paralysis of upper neurons: Stroke (12) Pain, paralysis, sagging of facial muscles: Bell’s palsy (13) Decreased hearing: Stroke and tumors of CN VIII (14) Dysphagia: Impaired blood flow to brain (15) Muscle weakness and atrophy and fasciculations of tongue: Lower motor neuron disease 5.

Sensory function assessments a) Assess ability to feel touch, kinesthesia, ability to discriminate fine touch b) Abnormal findings (1) Decreased sensation of pain: Injury to spinothalamic tract (2) Decreased vibratory sensations: Injury to posterior column tract (3) Transient numbness of face, arm, and hand: TIAs (4) Unilateral sensory loss: Lesions of higher pathways to the spinal cord (5) Bilateral sensory loss: Polyneuropathy, strokes, brain tumors, spinal cord trauma or compression (6) Impaired sense of position: Lesions of posterior column (7) Inability to discriminate fine touch: Injury to posterior columns or sensory cortex

6.

Motor function assessments a) Assess: Bilateral symmetry of muscles, movement at rest and with activity b) Abnormal findings (1) Atrophy of muscles and flaccidity: Disease of lower motor neurons (2) Tremors: Multiple sclerosis, diseases of cerebellar system, and Parkinson disease (3) Fasciculations: Disease or trauma to lower motor neurons, medications, during fever, sodium deficiency, and uremia

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(4) Spasticity: Disease of corticospinal motor tract and incomplete spinal cord injury (5) Muscle rigidity: Disease of extrapyramidal motor tract (6) Weakness of arms, legs, hands: TIAs (7) Hemiplegia, flaccid paralysis: Strokes (8) Paralysis or decreased movement: Multiple sclerosis, myasthenia gravis

D.

7.

Cerebellar function assessments a) Assess gait, coordination b) Abnormal findings: (1) Ataxia: Strokes, cerebellar tumors, and disease of upper motor neurons (2) Spastic hemiparesis: Strokes, upper motor neuron disease (3) Steppage gate: Disease of lower motor neurons (4) Sensory ataxia: Polyneuropathy, damage to posterior columns (5) Parkinsonian gait: Parkinson disease (6) Positive Romberg’s test: Cerebellar ataxia (7) Ataxic movements: Cerebellar disease

8.

Reflex assessments a) Assess patellar, biceps, brachioradialis, triceps, Achilles deep tendon reflexes, and superficial abdominal and cremasteric reflexes b) Abnormal findings (1) Hyperactive reflexes: Lesions of upper motor neurons (2) Decreased reflexes: Lower motor neurons involvement (3) Clonus: Upper motor neuron disease (4) Absent superficial reflexes: Disease of lower and upper motor neurons (5) Dorsiflexion of big toe and fanning of the other: Upper motor neuron disease of the pyramidal tract

Special neurologic assessments 1.

Brudzinski sign a) Abnormal: Pain, resistance, flexion of hips and knees: Meningeal irritation 2.

Kernig’s sign a) Abnormal: Resistance and pain with multiple sclerosis 3.

Abnormal postures in patients who are unconscious a) Abnormal (1) Decorticate posturing: In lesions of corticospinal tracts (2) Decerebrate posturing: Lesions of midbrain, pons, and diencephalon

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

E.

III.

Diagnostic tests 1.

Carotid duplex study/transcranial Doppler study: Velocity of blood flow through carotid arteries identifies occlusive disease 2.

Cerebral angiogram: For aneurysms, arteriovenous malformations, blood vessel patency and stenosis, thrombosis, vasospasm, aneurysm, and space-occupying lesions 3.

Computed tomography (CT) scan: For intracerebral hemorrhage, tumors, cysts, aneurysms, edema, ischemia, atrophy, tissue necrosis, and shift in intracranial contents 4.

Electrocephalogram (EEG)/magnetoencephalogram (MED): Brain disease and brain death; MEG identifies area of the brain affected by a stroke, brain disorders or trauma, or seizures 5.

Electromyogram (EMG): Neuromuscular diseases 6.

Evoked potentials: Neuromuscular diseases and nerve damage 7.

Lumbar puncture (LP): Multiple sclerosis, or increased intracranial pressure from meningitis, subarachnoid hemorrhage, brain tumor, brain abscess, encephalitis, and viral infections 8.

Magnetic resonance imaging (MRI): Stroke, tumors, trauma, seizures, and multiple sclerosis a) More sensitive than CT scan to subtle vascular changes seen in Alzheimer’s disease 9.

Functional MRI: Evaluate metabolic or blood flow responses of the brain to specific tasks 10.

Magnetic resonance angiography (MRA): Vascular lesions 11.

Magnetic resonance spectroscopy (MRS): Alzheimer’s disease, extent of injury from trauma or stroke, and causes of coma 12.

Myelogram: Lesions of the spinal cord 13.

Positron emission tomography (PET): Differentiates different types of dementia; identifies stages of brain tumors 14.

Single-photon emission computed tomography (SPECT): Strokes, brain tumors, and seizure disorders 15.

X-rays of skull and spine: Identify fractures, displacement of vertebrae, spinal curves, and tissue displacement

Assessment of Special Populations A. Age-related neurologic system changes 1.

Onset of epilepsy 2.

Memory problems 3.

Parkinson disease 4.

Psychologic disorders 5.

Heat stroke

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

B. IV.

Military effects

Health Promotion A. Injury prevention B. Healthy behavior maintenance C. Correct use of safety equipment 1.

Helmets when bicycling or riding a motorcycle and using vehicular safety and seat belts D. Screenings for neurological disorders or memory changes if symptoms appear E. General health promotion 1.

Physical activity, healthy diet, and sufficient sleep

Chapter Highlights A. Correct structure and function of the nervous system are vital to enervate, regulate, and integrate all of the body’s functions.

B. Manifestations of dysfunction, injury, and disorders affecting the nervous system may be detected during a general health assessment as well as during a focused nervous system assessment.

C. Several age-related changes are noted for the neurological system. Neurological diseases such as AD and PD and other disorders are more prevalent in the older adult.

D. All patients should be assessed for military service. If the patient had served, determination of VA involvement in care helps to maintain coordination of care.

E. Neurological health promotion focuses on two overarching topics: Trauma prevention and healthy behaviors (regular exercise, good nutrition, and adequate sleep).

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME ONE Provide the students with an unlabeled chart of the nervous system. Give the students 5 minutes to label as many parts as they can.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME TWO Have students assume the decorticate and decerebrate postures.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTIONS FOR CLINICAL ACTIVITY—LEARNING OUTCOME TWO Have students assess the reflexes of clinical patients. In postconference, have students compare findings from patients of different ages who have different disorders.

Assign the students to care for patients with alterations in the nervous system. During postconference, ask the students to share their assessment findings with the entire group.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME THREE Provide the students with a list of various assessment findings. Ask the students to identify which of these findings would be normal and which would be abnormal in the older adult.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME THREE Assign the students to assess an older client’s neurologic system. Prepare to discuss the findings during postclinical conference.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME FOUR Have the students create a teaching tool identifying actions to ensure the health of the neurologic system.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter 42 Nursing Care of Patients with Intracranial Disorders

Learning Outcomes 1. Describe the pathophysiology and manifestations of altered level of consciousness, and outline the interprofessional care and nursing care of patients with this condition.

2. Describe the pathophysiology and manifestations of increased intracranial pressure, and outline the interprofessional care and nursing care of patients with this condition.

3. Describe the pathophysiology and manifestations of seizures, and outline the interprofessional care and nursing care of patients with seizures.

4. Describe the pathophysiology and manifestations of stroke, and outline the interprofessional care and nursing care of patients with stroke.

5. Describe the pathophysiology and manifestations of intracranial vascular disorders, and outline the interprofessional care and nursing care of patients with these disorders.

6. Describe the pathophysiology and manifestations of traumatic brain injuries, and outline the interprofessional care and nursing care of patients with this condition.

7. Describe the pathophysiology and manifestations of brain tumors, and outline the interprofessional care and nursing care of patients with brain tumors.

8. Describe the pathophysiology and manifestations of headaches, and outline the interprofessional care and nursing care of patients with headache.

Key Concepts I. Altered Level of Consciousness A. Consciousness 1. Aware of self and environment, appropriate response to stimuli 2. Arousal/alertness: Depends on the RAS, a diffuse system of neurons in the thalamus and upper brainstem 3. Cognition: Complex process involving all mental activities controlled by the cerebral hemispheres including thought processes, memory, perception, problem solving, and emotion 4. Changing LOC corresponds to patterns of respiration, pupillary, oculomotor responses, and motor function (Table 42.1) 5. Altered level of consciousness (LOC) (Table 42.2) a) Full consciousness, confusion, disorientation, obtundation, stupor, semicomatose, coma, and deep coma b) Major causes of altered consciousness (1) A-E-I-O-U = Alcohol, Epilepsy, Insulin, Opium, Uremia (2) TIPSS = Tumor, Injury, Psychiatric, Stroke, Sepsis

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

B. The Patient with Altered Level of Consciousness 1. Pathophysiology a) Arousal and cognition (1) Reticular formation: Most important part of the reticular activating system (RAS) (a) Mass of nerve cells and fibers making up the core of the brainstem (b) Neurons pass impulses through the thalamic relays, stimulating wakefulness (2) Damage to RAS (a) Most commonly caused by stroke (b) Other causes: Demyelinating diseases (multiple sclerosis, tumors, abscesses, and head injury) (3) May be difficult to assess cognitive functioning when RAS damage is due to impairment of arousal (4) Cerebral hemisphere (dis)functioning (a) Any process that affects the flow of blood, oxygen, and glucose to the brain or alters cell membranes can also alter LOC (5) Progression of deterioration of brain functioning b) Patterns of respiration (1) Normal respirations: Maintained pons and medulla responding to oxygen and carbon dioxide levels (2) Damage can result in lower brainstem regulation of breathing, which only responds to changes in carbon dioxide (3) Yawning and sighing: Initial manifestations of deteriorating brain functioning (4) Progressive respiratory changes include: (a) Cheyne-Stokes respirations (damage to diencephalon) (b) Neurogenic hyperventilation (damage to the midbrain) (c) Apneustic respirations (damage to the pons) (d) Ataxic/apneic respirations (damage to the medulla) c) Pupillary and oculomotor responses (1) Localized damage to brain (ipsilateral pupil) vs. generalized or systemic process entire pupil (2) Small pupils, equally reactive: Metabolic processes (3) Pupils oval or eccentric: Compression of CN III (4) Pupils become increasingly fixed and dilated (5) Blown pupils: Sudden appearance of fixed and dilated pupils (6) Ocular movement: Spontaneous eye movement is lost and reflexive movements are altered (a) Cranial nerve nuclei injury impairs normal movement (b) Doll’s eye movement: Oculocephalic reflex, lessens to fixation with deterioration

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

d) Motor responses (1) Most accurate identifier of changes in mental status (2) As function declines, movements become more generalized (withdrawal, grimacing) and less purposeful (3) Reflexive responses: Decorticate posturing, then decerebrate posturing, eventually flaccid e) Coma states and brain death (1) Full recovery or recovery with residual damage including learning deficits, emotional difficulties, impaired judgment, and cerebral death (2) Persistent vegetative state (PVS) (a) Permanent unawareness of self and environment and loss of all cognitive functions (b) Caused by severe brain trauma or global ischemia (c) Death of cerebral hemispheres with continued function of brainstem and cerebellum (d) Sleep–wake cycles, chew, swallow, and cough (e) Eyes may wander but cannot track objects or people (f) Diagnosis requires that the condition lasts for 1 month (3) Locked-in syndrome (a) Intact cognitive abilities, alert and fully aware of environment (b) Unable to communicate through speech or movement because of blocked efferent pathways from the brain (c) Patient may be able to communicate through eye movements and blinking (4) Brain death (a) Cessation and irreversibility of all brain functions, including the brainstem (b) Criteria for establishing brain death varies state to state (usually 6–24 hours) (i) Unresponsive coma with absent motor and reflex movements (ii) No spontaneous respirations, apnea test performed (iii) Pupils fixed (unresponsive to light) and dilated (iv) Absent ocular responses to head turning and caloric stimulation (v) Flat electroencephalogram (EEG) in patient who is not hypothermic or under the influence of drugs that depress the central nervous system (vi) No cerebral blood flow on angiography (vii) Persistence of manifestations for 30 minutes to 1 hour and 6 hours after onset of coma and apnea (5) Prognosis (a) Varies with underlying cause and pathologic process (b) Poor when pupillary reaction or reflex eye movements are lacking 6 hours after the onset of coma 2. Interprofessional care .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) Diagnosis (1) Patient history and physical exam (2) Diagnostic tests (a) CT and MRI scanning: Hemorrhage, tumor, cyst, edema, myocardial infarction, brain atrophy, and displacement of brain structures (b) Radioisotope brain scan: Abnormal lesions in the brain and evaluate cerebral blood flow (c) Cerebral angiography: Radiographic visualization of the vascular system (i) Aneurysms, occluded vessels, or tumors (ii) Cessation of cerebral blood flow and brain death (d) Transcranial Doppler: Assess cerebral blood flow (e) Lumbar puncture with cerebrospinal fluid (CSF) analysis: Infection or meningitis are suspected (f) EEG: Electrical activity of the brain (3) Laboratory tests (a) Blood glucose: Suspected hypoglycemia (b) Serum electrolytes (c) Serum osmolality (hyperosmolality, hypo-osmolality) (d) Arterial blood gases (ABGs) (e) Liver function tests (f) Toxicology screening b) Medications (1) Fluid balance is maintained via intravenous catheter using isotonic or slightly hypertonic solutions (e.g., normal saline or lactated Ringer’s solution) (2) Response to fluid administration is monitored for evidence of increased cerebral edema (3) Hypoglycemia: 50% glucose is administered (4) Hyperglycemia: Insulin is administered (5) Narcotic overdose: Naloxone is administered (6) Thiamine administered if patient is malnourished or known to abuse alcohol (Wernicke’s encephalopathy) (7) Fluid and electrolyte imbalance is corrected by administering medications or appropriate electrolytes (8) Hyponatremic, low-serum osmolality: Furosemide (Lasix) or an osmotic diuretic such as mannitol may be administered (9) Meningitis: Antibiotics are administered c) Nutrition: Long-term alterations in consciousness (1) Enteral feedings (2) Total parenteral nutrition (TPN)

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

d) Surgery (1) If coma is caused by intracerebral tumor, hemorrhage, or hematoma (2) When there is a risk of IICP, the patient is monitored continuously e) Other treatments (1) Support of the airway and respirations: Oral pharyngeal airway, endotracheal intubation, mechanical ventilation (2) AGBs monitored to determine adequacy of ventilation 3. Nursing care a) Support of the family b) Assessment (1) Assess for manifestations or LOC (2) Interprofessional care for the assessment of the patient with altered LOC c) Diagnoses, outcomes, and interventions (1) Maintain adequate airway clearance (a) Monitor breath sounds, rate and depth of respirations, dyspnea, pulse oximeter, and the presence of cyanosis (b) If patient is unconscious of does not have an intact cough reflex: Maintain an open airway by periodic suctioning, to clear mucus, blood, etc.

(2) Reduce risk for aspiration (a) Drainage, mucus, or blood may obstruct the airway, interfering with oxygenation (b) Secretions may pool in lungs, increasing risk of pneumonia (3) Reduce risk for impaired skin integrity (a) Ischemia and pressure ulcers (b) Interventions for skin, lips, and mucous membranes (4) Promote physical mobility (a) Passive ROM exercises; collaborate with a physical therapist (b) Support devices to maintain functional positions of extremities (5) Promote adequate nutritional intake (6) Assess the need for alternative methods of nutrition with collaboration with dietitian (a) Increased nutritional needs during trauma or infection recovery 4. Transitions of care a) Reinforce teaching b) Explain the purpose of tubes and drains c) Encourage family self-care

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

II. Increased Intracranial Pressure A. Increased intracranial pressure (IICP) 1. Results in ischemia and damage to neural tissue 2. Cerebral edema is most frequent cause, other causes: Head trauma, tumors, abscesses, stroke, inflammation, and hemorrhage 3. Dynamic equilibrium: Brain (80%), cerebrospinal fluid (8%), and blood (12%) B. The Patient with Increased Intracranial Pressure 1. Pathophysiology a) Autoregulation (1) Increase in intracranial contents: Space-occupying lesion, hydrocephalus, cerebral edema, excess cerebrospinal fluid, and intracranial hemorrhage (2) Compensatory mechanisms: CSF is displaced and absorbed, low-pressure venous system is compressed, and cerebral arteries constrict (3) Compliance: Relationship between the volume of components and pressure (4) Autoregulation can fail, then cerebrovascular tone is reduced, and blood flow becomes dependent on changes in blood pressure b) Cerebral edema (1) Vasogenic edema: Extracellular edema of the white matter; brain tumors (locally), cerebral trauma and meningitis (globally) (2) Cytotoxic edema: Increase in fluid in neurons, glia, and endothelial cells; events causing anoxia or hypoxia (e.g., cardiac arrest), hypo-osmolar conditions (hyponatremia) c) Hydrocephalus: Abnormal overproduction, circulation, or reabsorption of CSF (1) Noncommunicating: Drainage from ventricular system is obstructed (2) Communicating: CSF not reabsorbed through the arachnoid villi d) Brain herniation: Displacement of brain tissue (1) Supratentorial herniation (a) Cingulate herniation (b) Central or transtentorial herniation (c) Uncal or lateral transtentorial herniation (d) Infratentorial 2. Manifestations a) Changes in LOR b) Motor responses c) Vision and pupils d) Vital signs (1) Other manifestations (2) Headache (3) Papilledema (4) Vomiting .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

3. Interprofessional care a) Diagnosis: Identifying presence of IICP and underlying cause (1) CT or MRI (2) Serum osmolality (3) ABGs (4) Additional tests used for altered LOC b) Medications (1) Chemical restraints (2) Osmotic diuretics (a) Nursing responsibilities (i) Monitor vital signs, urinary output, central venous pressure (CVP), and pulmonary artery pressures (PAP) (ii) Assess for manifestations of dehydration, muscle weakness, numbness, tingling, paresthesia, confusion, and excessive thirst (iii) Assess for pulmonary edema while administering the medication (iv) Monitor neurologic status and intracranial pressure readings (v) Monitor renal function and serum electrolytes throughout therapy (vi) Check medication solution for crystals, use an in-line filter, and observe site frequently for infiltration (vii) Do not administer mannitol solution with blood (3) Loop diuretics (a) Nursing responsibilities (i) Monitor vital signs and electrolyte values closely (ii) Assess fluid status throughout therapy (iii) Monitor blood pressure and pulse before and during administration (iv) Monitor renal laboratory studies closely (v) Use infusion pump to ensure accurate dosage (4) Intravenous fluids (a) Nursing responsibilities (i) Monitor fluid and neurologic status closely (ii) Avoid administering solutions that become hypo-osmolar (5) Other pharmacologic interventions for ICP (a) Antipyretics are used in conjunction with a hypothermia blanket to reduce hyperthermia (b) Antiulcer drugs are used in patients with ICP to decrease the development of stress ulcers (c) Antihypertensive agents and vasopressors may be used to adjust high and low MAP (d) Vasopressors may be used if the mean arterial pressure is low (e) Anticonvulsants may be given to prevent or treat seizures c) Surgery (1) Infarcted or necrotic tissue may be resected .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(2) Drainage catheter or shunt for CSF d) ICP monitoring (1) Measure cerebral blood flow, cerebral perfusion pressure, and oxygen levels (2) In general, patients who are comatose and have a Glasgow Coma Score of 8 or less should be monitored e) Basic monitoring systems (a) Epidural probe (b) Subarachnoid bolt or screw (c) Intraventricular catheter (d) Transcranial Doppler studies (TCD) (e) Cerebral perfusion pressure (CPP) (f) Jugular bulb oxygen saturation monitor (g) LICOX system: Oxygen and temperature status within brain tissue (h) Cerebral microdialysis catheters f) Mechanical ventilation 4. Nursing care a) Diagnoses, outcomes, and interventions (1) Maintain normal ICP (a) Maintain patency of the airway for the patient on a ventilator (b) Monitor ABGs (c) Elevate head to 30 degrees or keep flat, as prescribed; maintain alignment of head and neck (d) Teach the patient to avoid actions that increase ICP: Coughing, blowing nose, and muscle contracting exercises (e) Monitor bladder distention and bowel constipation (f) Assist patient to move up in bed to prevent the initiation of the Valsalva maneuver (g) Schedule nursing care to provide rest between procedures (h) Provide a quiet environment, limiting stimuli both physical and emotional (i) Maintain fluid limitations if prescribed (2) Reduce risk for infection (a) Keep dressings over catheter dry (b) Monitor the insertion site for leaking CSF, drainage, or infection, and monitor for physical and vital signs of infection (c) Use strict aseptic technique when in contact with the device 5. Transitions of care a) Encourage the family to talk to the patient, but to maintain low stimuli in environment b) Family must carry out decisions about treatment if patient is unable to give informed consent

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

III. Seizures A. Pathophysiology 1. Seizure: “A single event of abnormal electrical discharge in the brain resulting in an abrupt and temporary altered state of cerebral function” (Hickey, 2013) a) Precipitating factors for seizures are unknown in 70% of all cases 2. Epilepsy: A chronic disorder of abnormal, recurring, excessive, and self-terminating electrical discharge from neurons a) Affects people of all ages, races, and ethnic background b) Fourth most common neurological disorder in the United States; affects 2.2 million people in the United States 3. Excessive imbalance in excitation and inhibition in cerebral cortex 4. Alterations in membrane potentials that increase the risk of hypersensitive neurons responding abnormally to changes in the cellular environment 5. Epilepsy in older adults a) By age 75, 3% of the population will have been diagnosed with epilepsy, 10% will have experienced a seizure b) Caused by arteriosclerosis of the cerebrovascular system and stroke c) Complex partial seizure is most common type d) Longer postseizure manifestations than young adults e) Epilepsy beginning in older adults is often easier to control with antiepileptic drugs (AEDs) 6. Seizure thresholds 7. Epileptogenic focus: Neurons that initiate seizure activity 8. Triggers: Music, odors, lights, fatigue, hypoglycemia, fever, alcohol, menstruation, constipation, and hyperventilation B. Risk factors 1. Birth defects, trauma, brain tumors, IICP, metabolic disorders, Alzheimer’s disease, and cardiovascular diseases 2. Cause is unknown in 70% of all cases 3. Isolated seizure episodes may occur in otherwise because of fever, infection, metabolic or endocrine disorder, or exposure to toxins C. Manifestations 1. Seizure types a) Focal seizures (1) Simple partial seizures: Manifestations depend on involved area of the brain (2) Complex partial seizure: Consciousness is impaired, may be preceded by an aura b) Generalized seizures (1) Absence seizures: Brief cessation of motor activity, automatisms

.

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

2.

3.

4.

5.

(2) Tonic–clonic seizures: Most common type in adults, aura may precede, loss of consciousness, tonic phase, opisthotonic posture, clonic phase, and postictal period c) Unknown Onset (1) Seizures when the onset is not determined Epilepsy types a) Focal b) Generalized c) Combined generalized and focal d) Unknown Epilepsy syndrome a) Cluster of features including seizure type, EEG, and imaging features Terms no longer used in epilepsy classification a) Simple partial seizures b) Complex partial seizures c) Partial seizures d) Psychic seizures e) Dyscognitive seizures f) Secondarily generalized tonic–clonic seizures Status epilepticus: Repetitive seizures, usually tonic–clonic a) Cumulative effect, can interfere with respirations, requires immediate intervention b) Airway is a priority

D. The Patient with Seizures 1. Interprofessional care a) Diagnosis (1) MRI or CT scan: Determine abnormalities in brain (2) Skull x-ray: Bony abnormalities (3) EEG: Helps localize brain lesions and confirm diagnosis (4) Lumbar puncture: CNS infections (increased WBCs) or tumors (increased protein levels) (5) Blood studies: Blood count, electrolytes, blood urea, and blood glucose b) Medication administration c) Antiseizure drugs (1) Potentiate GABA Action (Barbiturates, Benzodiazepines, and Other Drugs) (a) clonazepam (Klonopin) (b) diazepam (Valium) (c) gabapentin (Neurontin) (d) lorazepam (Ativan) (e) phenobarbital (Luminol) (f) pregabalin (Lyrica) (g) primidone (Mysoline) .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(h) topiramate (Topramax) (2) Suppress Sodium Influx (Hydantoins and Related Drugs) (a) carbamazepine (Tegretol) (b) fosphenytoin (Cerebrex) (c) lamotrigine (Lamictal) (d) levetiracetam (Keppra) (e) phenytoin (Dilantin) (f) valproic acid (Depakene) (g) zonisamide (Zonegran) (3) Suppress Calcium Influx (a) ethosuximide (Zarontin) (b) methsuximide (Celontin) (4) Nursing Responsibilities (a) Monitor blood pressure, pulse, and respirations (b) Note evidence of CNS side effects: Blurred vision, dimmed vision, slurred speech, nystagmus, or confusion (c) Prolonged therapy may require a diet rich in vitamin D (d) Monitor the serum calcium level as ordered; phenytoin can contribute to demineralization of bone (e) When administering anticonvulsants intravenously, monitor closely for respiratory depression and cardiovascular collapse (f) Administer gabapentin 2 hours after antacids (g) Administer tiagabine HCL with food (5) Health education for the patient and family (a) Take exact dosage to avoid convulsions (b) Avoid hazardous tasks until drug has been regulated (c) Maintain good oral hygiene with Dilantin (d) Obtain liver function studies (e) Carry identification indicating the type of seizures (f) Do not take gabapentin 1 hour before or less than 2 hours after an antacid (g) Tell provider if you develop a rash when on lamotrigine (h) Take tiagabine HCL with food d) Surgery (1) Resective surgery: Removal of the epileptogenic focus (2) Responsive Neurostimulator System: Electrodes implanted in the brain suppress seizure; currently in clinical trials e) Vagal nerve stimulation therapy: Sends regular small pulses of electrical energy to the brain via the vagus nerve 2. Nursing care a) Assessment (1) Health history .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(2) Physical assessment b) Diagnosis, outcomes, and interventions (1) Maintain adequate airway clearance (a) Provide interventions to maintain a patent airway (b) Teach interventions to family members (2) Relieve anxiety (a) Provide support by explaining that concerns are normal (b) Help identify safe leisure activities (c) Provide information about sources and support groups (d) Provide accurate information about hiring practices and legal limitations on driving or operating heavy or dangerous machinery (3) Provide special instructions for women (a) Encourage discussion with the woman’s healthcare provider about the increased probability of seizures at the time of menses (b) Discuss the effects of AEDs; effectiveness of oral contraceptives and breakthrough bleeding, and birth defects 3. Transitions of care (1) Seizure management for family members: Care and observations are both necessary before and during seizure (2) The importance of wearing a MedicAlert band or carrying a medical alert card at all times (3) Avoiding alcoholic beverages and limiting coffee intake IV. Stroke A. Pathophysiology 1. Ischemic stroke a) Transient ischemic attack b) Large vessel (thrombotic) stroke c) Small vessel stroke (lacunar infarct) d) Cardiogenic embolic stroke 2. Hemorrhagic stroke B. Risk factors 1. Modifiable a) Hypertension: Treat it b) Cigarette smoking: Quit it c) Heart disease: Manage it d) Diabetes: Control it e) TIAs: Seek help 2. Act fast a) Face: Ask the person to smile. Does one side of the face droop? .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

b) Arm: Ask the person to raise both arms. Does one arm drift downward? c) Speech: Ask the person to repeat a simple sentence. Does the speech sound slurred or strange? d) Time: Call 911 C. Manifestations 1. Manifestations of a stroke by involved cerebral vessel a) Internal carotid artery (1) Contralateral paralysis of the arm, leg, and face (2) Contralateral sensory deficits of the arm, leg, and face (3) If the dominant hemisphere is involved: Aphasia (4) If the nondominant hemisphere is involved: Apraxia, agnosia, unilateral neglect (5) Homonymous hemianopia (see Figure 42.5c) b) Middle cerebral artery (1) Drowsiness, stupor, coma (2) Contralateral hemiplegia of the arm and face (3) Contralateral sensory deficits of the arm and face (4) Global aphasia (if dominant hemisphere is involved) (5) Homonymous hemianopia c) Anterior cerebral artery (1) Contralateral weakness or paralysis of the foot and leg (2) Contralateral sensory loss of the toes, foot, and leg (3) Loss of ability to make decisions or act voluntarily (4) Urinary incontinence d) Vertebral artery (1) Pain in face, nose, or eye (2) Numbness and weakness of the face on involved side (3) Problems with gait (4) Dysphagia 2. Complications a) Sensoriperceptual deficits (1) Hemianopia: The loss of half of the visual field of one or both eyes; when the same half is missing in each eye, the condition is called homonymous hemianopia (refer to Figure 42.5) (2) Agnosia: The inability to recognize one or more subjects that were previously familiar; agnosia may be visual, tactile, or auditory (3) Apraxia: The inability to carry out some motor pattern (e.g., drawing a figure, getting dressed) even when strength and coordination are adequate.

(4) Neglect syndrome b) Cognitive and behavioral changes c) Communication disorders .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Aphasia: The inability to use or understand language; aphasia may be expressive, receptive, or mixed (global) (2) Expressive aphasia: A motor speech problem in which one can understand what is being said but can respond verbally only in short phrases; also called Broca’s aphasia (3) Receptive aphasia: A sensory speech problem in which one cannot understand the spoken (and often written) word. Speech may be fluent but with inappropriate content; also called Wernicke’s aphasia (4) Mixed or global aphasia: Language dysfunction in both understanding and expression (5) Dysarthria: Any disturbance in muscular control of speech d) Motor deficits (1) Hemiplegia: Paralysis of the left or right half of the body (Figure 42.6) (2) Hemiparesis: Weakness of the left or right half of the body (3) Flaccidity: Absence of muscle tone (hypotonia) (4) Spasticity: Increased muscle tone (hypertonia), usually with some degree of weakness e) Elimination disorders D. The Patient with a Stroke 1. Interprofessional care a) Diagnosis (1) Imaging tests (2) Lumbar puncture b) Medications (1) Prevention (a) Antiplatelet agents (2) Acute stroke (a) Fibrinolytic therapy c) Nutrition (1) Healthy diet d) Surgery (1) Carotid endarterectomy (i) Postoperative care (ii) Assess respirations and oxygen saturation e) Rehabilitation (1) Physical therapy (2) Occupational therapy (3) Speech therapy 2. Nursing care a) Assessment .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Health history (2) Physical assessment b) Diagnosis, outcomes, and interventions (1) Maintain adequate cerebral perfusion (a) Monitor respiratory status (b) Suction as necessary (c) Place in a side-lying position (d) Administer oxygen as prescribed (e) (2) Promote physical mobility (a) Encourage ROM exercises and perform passive ROM exercises (b) Turn every 2 hours (3) Promote self-care (a) Screen for executive cognitive function (b) Encourage use of unaffected arm (c) Teach patient to dress (d) Collaborate with the occupational therapist (4) Assist with communication (a) Treat patient as an adult (b) Do not assume they cannot hear if they don’t respond, allow time for patient to respond, face patient and speak slowly, using simple statements and questions, do not use a raised voice; use alternate methods of communication (c) Accept frustration and anger as normal reactions to loss of functions (5) Promote normal urinary and bowel elimination (a) Assess for urinary frequency, urgency, incontinence, nocturia, and patient’s ability to respond to the void (b) Assess for distended bladder, encourage bladder training using schedule, and teach Kegel exercises (c) Discuss prestrike bowl habits, and post-stroke patterns (d) Increase physical activity, fluids, fiber, prescribed stool softeners (6) Prevent aspiration and ensure adequate nutrition (a) Monitor results of swallowing studies prior to providing food and fluids (b) Eating: Upright sitting position, neck slightly flexed, soft foods, teach to eat with unaffected side of mouth (c) Suction equipment in case of choking or aspiration (d) Check affected area of mouth for pocketing of food (e) Monitor lung sounds 3. Transitions of care (1) Self-care .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(2) Physical care, medications, physical therapy, occupational therapy, and speech therapy (3) Home environment modifications (4) Home health services, community resources, and organizational resources V. Intracranial Vascular Disorders A. The Patient with an Intracranial Aneurysm 1. Introduction a) Intracranial aneurysm: Saccular outpouching of a cerebral artery that occurs at the site of a weakness in the vessel wall b) Most common cause of a hemorrhagic stroke c) Most often in adults over the age of 50, a ruptured intracranial aneurysm often results in death or severe disability in those who survive 2. Pathophysiology a) Tend to occur at the bifurcations in the circle of Willis b) Enlarge over time, increasing the probability of rupture 3. Risk factors a) Inherited b) Lifestyle 4. Manifestations a) Rupture causes subarachnoid hemorrhage: Sudden explosive headache, neck pain, nausea, vomiting, photophobia, nerve deficits, and stroke syndrome b) Hypertension and cardiac dysrhythmias may occur c) Fibrin and platelets seal bleeding point, escaped blood forms irritating clot that causes inflammation d) IICP e) Pituitary gland: Diabetes insipidus and hyponatremia 5. Complications a) Rebleeding: 70% of patients with rebleeding will die b) Cerebral vasospasm: Narrows the lumen of one or more cerebral vessels, causing ischemia and infarction of brain tissue supplied by affected vessels c) Hypothalamic dysfunction, hydrocephalus, and seizures 6. Interprofessional care a) Diagnosis (1) CT scan: Detect hemorrhage (2) Spiral computer tomography angiogram (CTA): Identifies the arterial anatomy (3) Angiograms: Visualization of all four major cerebral vessels and their branches .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(4) Lumbar puncture: Blood-tinged spinal fluid b) Medications (1) Calcium channel blockers [e.g., nimodipine (Nimotop)]: Improve neurologic deficits due to vasospasm (2) Anticonvulsants [e.g., phenytoin (Dilantin)]: Prevent seizures in patients with IICP (3) Analgesics: Headache (4) Antacids and H2-receptor antagonist [e.g., ranitidine (Xanax)]: Gastric irritation (5) Stool softeners: Prevent constipation and straining c) Treatment (1) Surgery as soon as possible, depends on patient’s neurologic status (a) Neck of aneurysm may be clipped (b) Balloon embolization (c) Platinum coil electrothrombosis 7. Nursing care a) Rebleeding prevention and needs resulting from neurologic deficits b) Priority interventions in acute stage focus on ineffective cerebral tissue perfusion B. The Patient with an Arteriovenous Malformation 1. Introduction a) Arteriovenous (AV) malformation: Congenital intracranial lesion, formed by a tangled collection of dilated arteries and veins that allows blood to flow directly from the arterial into the venous system, bypassing the normal capillary network b) Rupture in malformations account for 2% of strokes, manifestations develop before age 40, affects men and women equally, 90% are in cerebral hemispheres 2. Pathophysiology a) Transfers higher arterial pressure into lower pressure venous system, causing spontaneous bleeding or rupture b) Blood flow through malformation is diverted from normal cerebral circulation, causing tissue ischemia, sometimes called vascular steal phenomenon 3. Risk factors a) Before 40 years of age b) Affects men and women equally 4. Manifestations a) Large malformations are usually initially manifested by seizure activity b) Small malformations are more often due to a hemorrhage 5. Interprofessional care a) Diagnosis: Same tests used for intracranial aneurysms .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

b) Treatments: Surgical excision, vascular occlusion, and radiosurgery 6. Nursing care a) Depends on condition of malformation b) If hemorrhage has not occurred, teach patient to avoid risky activities c) Medications: Usually given to control blood pressure and prevent seizures d) If ruptured and causes hemorrhage, care is same as stroke VI. Traumatic Brain Injury A. Introduction 1. TBI (also called craniocerebral trauma): Any injury of the scalp, skull, or brain 2. Penetrating or closed head injury; focal or diffuse 3. May cause problems with cognition, movement, sensation, and emotions 4. Mild injuries repeated over time result in cumulative deficits 5. Leading cause of death and disability: Crashes, falls (over 75), violence, sports injury, war; at least half involve alcohol or drug use 6. TBI a) Mechanism, nature, and location of injury determine damage (1) Contact phenomena injury (2) Acceleration–deceleration injury (3) Rotational injury b) Craniocerebral trauma: Skull, brain (concussion, contusion), hematomas, and hemorrhage B. Focal or Diffuse Traumatic Brain Injury 1. Pathophysiology a) Focal brain injuries: Specific brain lesions, including contusions and hemorrhage/hematomas (1) Occur when brain strikes inner skull, coup and contrecoup lesions (Figure 42.8) (2) Contusion: Bruise on brain’s surface, usually accompanied by small, diffuse hemorrhages (a) Edema can follow, resulting in IICP (b) Contusions, hemorrhages, and brain swelling peak 12–24 hours after injury (c) Initial loss of consciousness, LOC may remain altered, behavior changes may persist (d) Intracranial hematomas (Table 42.6) (e) Epidural hematoma: Develops in potential space between the dura and the skull, pulling dura away from skull (i) Usually results from a skull fracture that tears an artery (meningeal), develop rapidly (ii) Headache, vomiting, fixed dilated ipsilateral pupil, contralateral hemiparesis or hemiplegia, and seizures .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(f) Subdural hematoma: Blood collects between dura and arachnoid matter (i) More common, top of head, develops within 48 hours of injury (ii) Drowsiness, confusion, enlargement of ipsilateral pupil, unilateral headache, hemiparesis, and respiratory changes (iii) Chronic type: Occurs spontaneously in older adults or patients with bleeding disorders (g) Intracerebral hematoma: Closed head trauma, contusion or shearing of small blood vessels deep within hemispheres, usually in frontal or temporal lobes (i) More common in older adults whose blood vessels are more fragile (ii) Manifestations vary according to location b) Diffuse cerebral injury: Concussion and diffuse axonal injury (1) Caused by shaking motion with twisting movement (rotational injury) (2) Number of damaged axons increase, astrocytosis (scarring), and demyelation (3) Mild concussion: Temporary axonal disturbances (a) Classic cerebral concussion: Diffuse cerebral disconnection from the brainstem RAS (4) Diffuse axonal injury (DAI): High-speed acceleration–deceleration injury, causing widespread disruption of axons in white matter (many focal lesions) 2. Manifestations a) Short loss of consciousness, amnesia, headache, drowsiness, confusion, dizziness, visual disturbances, and possibly seizure b) Postconcussion syndrome: Persistent headache, dizziness, irritability, insomnia, impaired memory and concentration, and learning problems 3. Interprofessional care a) Concussion (1) Observe patient for 1–2 hours in emergency department (2) Discharge with instructions to observe and detect secondary injury manifestations b) Acute TBI (1) Morbidity and mortality increase with hypotension and hypoxia (hypertonic saline is given) (2) Assessment of airway, breathing, and circulation (ABCs) (3) Intracranial pressure monitor probe (4) Osmotic diuretics, oxygenation (5) ICU: Central venous pressure (CVP) catheter, arterial line, pulmonary catheter, ventriculostomy, ICP monitor, retrograde jugular catheter, endotracheal tube, bilateral sequential pressure boots, and rectal temperature probe c) Diagnosis (1) X-rays: Skull fractures, penetrating objects (2) CT or MRI: Contusions, lacerations (diffuse axonal injury) .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(3) ABGs: Especially oxygen and carbon dioxide levels d) Managing IICP (1) Airway management, hyperventilation, fluid resuscitation, positioning, and temperature regulation (2) Medications (neuroprotectants): Lipid peroxidase inhibitors, free radical scavengers, receptor antagonists, calcium channel blockers, and gangliosides e) Surgery (1) Epidural and large acute subdural hematomas (burr holes) (2) Rebleeding especially in older adults and patients with alcoholism, chronic subdural hematomas (craniotomy) 4. Nursing care a) Assessment (1) Health history (a) Understand the nature of the craniocerebral trauma, knowledge about loss of consciousness (2) Physical examination (a) Neurologic assessment, pupils, LOC, Glasgow Coma Scale, brainstem reflexes, spontaneous movement, response to pain, vital signs, skull and face, and movement of extremities b) Diagnoses, outcomes, and interventions (1) Monitor intracranial pressure (a) Patient should experience fewer than five episodes of disproportionate IICP in 24 hours (b) Monitor for manifestations of IICP, changes in vitals, vomiting, headache, lethargy, restlessness, purposeless movements, and changes in mentation (c) Temperature, hyperthermia may increase ICP, and hypothermia treatment (d) Monitor fluid stats (2) Maintain adequate airway clearance (a) Maintain airway clearance through interventions and suctioning (b) Monitor neurologic manifestations on regular schedule (c) Maintain head and neck in neutral alignment, immobilizing until injury is determined (d) Clear nose and mouth of mucus and blood: Do not suction nose until dural tear has been ruled out (3) Promote effective breathing pattern (a) Ineffective breathing is related to IICP, if ICP increases dramatically tentorial herniation may occur leading to sudden respiratory arrest (b) Patient must utilize techniques to promote adequate ventilation: Deep breathing and slowed respirations 5. Transitions of care .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) Inform patient and family about postconcussion syndrome b) Long-term physical care and rehabilitation c) Realities of possibility of residual deficits in self-care, emotional responses, cognition, communication, and movement VII. Brain Tumors A. The Patient with a Brain Tumor 1. Pathophysiology a) Classification (1) Malignant: Lack of cell differentiation and invasive nature of the tumor (2) Benign (surgically inaccessible = herniation) (3) Primary: Arise from cells and structures found within the brain (4) Metastatic: Originate outside the brain, lungs, breasts, and prostate gland b) Damage: Focal disturbances, vasogenic edema, and altered electrical potential from plasma 2. Manifestations, classifications of primary brain tumors (Table 42.7) a) Changes in cognition or consciousness, headache that is worse in the morning, seizures, vomiting b) Changes seen with cerebral edema and IICP are seen due to compression and invasion of brain tissue by tumor c) Cerebral blood supply diminishes as tumor compresses vessels d) Primary tumors (1) Glioma: Astrocytoma, glioblastoma multiforme, ependymoma, oligodendroglioma, and astroblastoma e) Extracerebral tumor (1) Medulloblastoma, meningioma, and acoustic neuroma (neurofibromatosis) (2) Arise from supporting structures of nervous system, rare f) Congenital tumors (1) Hemangioblastoma and craniopharyngioma g) Pituitary adenomas (1) Chromophobic, eosinophilic, and basophilic 3. Manifestations of brain tumors by location a) Frontal lobe: Inappropriate behavior, recent memory loss, personality changes, headache, inability to concentrate, expressive aphasia, impaired judgment, and motor dysfunctions b) Parietal lobe tumors: Sensory deficits (paresthesia, loss of two-point discrimination, visual field) c) Temporal lobe tumors: Psychomotor seizures d) Occipital lobe tumors: Visual disturbances e) Cerebellum tumors: Disturbances in coordination and equilibrium .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

f) Pituitary tumors: Endocrine dysfunction, visual deficits, and headache 4. Interprofessional care a) Diagnosis (1) History and physical: Fundus of the eye, visual fields, neurologic assessment, and EEG (2) MRI with gadolinium enhancement: Defines size, shape, associated edema, and distortions of anatomy (3) Arteriogram: Stretching or displacement of vessels, presence of tumor vascularity (4) Endocrine studies: Pituitary gland involvement b) Chemotherapy (blood–brain barrier) (1) Intraventricular administration: Ommaya reservoir surgically implanted into lateral ventricle of brain (2) Convection-enhanced delivery (CED): Continuous injection of chemotherapy directly to tumor site through a catheter with positive pressure (3) Biodegradable anhydrous wafer: Impregnated with drug and implanted into tumor at time of surgery c) Surgery: Preferred treatment for primary tumors (1) Burr hole: Removal of clots, series of holes for craniotomy (2) Craniotomy: Bone flap removed and returned (a) Tumors, defects from TBIs, repair cerebral aneurysm (b) Awake craniotomy (3) Craniectomy: Complete removal of bone flap, to remove pressure (4) Cranioplasty: Plastic repair to the skull d) Radiation therapy: Alone or as adjunctive therapy, surgically inaccessible tumors, or to decrease size before surgery e) Specialty procedures: Special instruments, stereotaxic techniques, laser beam, microsurgery, and gamma knife 5. Nursing care a) Diagnoses, outcomes, and interventions (1) Relieve anxiety: (a) Provide emotional and educational support, explain routine procedures, review patient and family strengths and coping skills, etc.

(2) Reduce risk for infection (a) Monitor for leakage of CSF, prevent contamination of leakage areas (b) Nose leakage: Keep bed elevated 20 degrees, do not clean nose or suction, and do not touch (c) Ear: Position patient on side of leakage, do not clean or touch or insert packing (d) Place sterile dressing over area of drainage and change often .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(e) Monitor and report manifestations of infection (f) Implement interventions to prevent infection (3) Reduce risk of ICPP and bleeding (a) Patient with intracranial surgery does not have normal defenses against changes in ICP (b) Internal shunts: Avoid pressure on shunt, reservoir, or tubing (c) External shunts: Avoid kinks in tubing, maintain the drainage collecting device (4) Relieve acute pain (a) Assess location, duration, and intensity of pain (b) Implement interventions: Raise head of bed, reduce noise and lights, loosen head dressing if allowed, use narcotic analgesics with caution (5) Promote acceptance and independence (a) Patient should demonstrate that self-perceptions are accurate given physical capabilities (b) Assess for verbal and nonverbal manifestations of negative self-esteem 6. Transitions of care a) Assess family members for ability to cope with stress of surgery b) Family may assist with ADLs c) Encourage patient to take an active role in care d) Discharge planning: Medication, wound care, wigs, turbans, hats, scarves, follow-up visits, reporting manifestations: Stiff neck, increased headache, elevated temperature, new motor or sensory deficits, vision changes, and seizures VIII. Headache A. Pathophysiology 1. Migraine headache: A recurring primary headache, triggered by an event, and accompanied by a neurologic dysfunction a) Classic migraine with aura (15%): Sensory manifestation occurs prior to manifestations b) Cause not understood, relationships between serotonin and migraines c) Vessels narrow, reducing blood flow, followed by vasodilation, swelling, and pain d) Triggers: Menstruation, rapid changes in glucose levels, stress, emotional excitement, fatigue, alcohol intake, stimuli to bright lights, food high in tyramine, and other vasoactive substances (aged cheese, nuts, chocolate) e) Pain is unilateral and throbbing, may become bilateral; chills, nausea, vomiting, fatigue, sensitivity to light, sound, and odor f) Other manifestations: Blurred vision, anorexia, hunger, diarrhea, abdominal cramping, facial pallor, sweating, and stiffness or tenderness of neck 2. Cluster headache: Severe, unilateral, and burning pain behind or around eyes a) Predominantly experienced by men between 20 and 40 years b) Occur in clusters of one to eight each day for several weeks or months .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

c) Physiologic mechanism is not well understood, involves vascular disorder, a disturbance of serotonin mechanisms, a sympathetic defect, or dysregulation of the hypothalamus d) Triggers: Alcohol, certain foods, smoking, high altitude, and sleep cycle disturbances e) Eye pain is accompanied by shinorrhea, lacrimation, flushing, sweating, facial edema, and possible miosis or ptosis B. The Patient with a Headache 1. Interprofessional care a) Diagnosis (1) History, identifying triggering events, and type of headache (2) Neurodiagnostic testing rules out structural disease (3) Brain scan, MRI, x-ray, EEG, lumbar puncture, serum metabolic screens, and hypersensitivity testing b) Medications (1) Prophylactic therapy: Beta blockers, SSRIs, calcium channel antagonists (2) Once in progress: Narcotic analgesic (3) Inhalation of 100% oxygen at onset of attack (4) Preventive treatment: Calcium channel blockers, lithium carbonate, topiramate, and baclofen (5) Integrative therapies (a) Acupuncture (b) Biofeedback (c) Massage (d) Relaxation (e) Spinal manipulation (f) Herbs: Butterbur while feverfew, magnesium, and riboflavin coenzyme Q10 c) Suggestions to Decrease Incidence of Migraine Headaches (1) Wake up at the same time every morning (2) Eat your meals and exercise on a regular schedule (3) No smoking or caffeine after 3:00 p.m.

(4) No artificial sweeteners or MSG (5) Reduce or eliminate red wine, cheese, alcohol, chocolate, and caffeine.

(6) Practice relaxation techniques, such as yoga, meditation, or biofeedback C. Nursing care 1. Teach for self-care at home 2. Suggest strategies to control pain 3. Suggest diary of duration, onset, location, relation to menstruation or food intake, and any precipitating triggers 4. Methods of stress reduction

.

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter Highlights A. Altered level of consciousness (LOC) is a common response to intracranial disorders and is an early manifestation of deterioration of the function of the cerebral hemispheres. The alteration in cerebral function occurs in a sequential pattern, with characteristic changes in LOC, respiratory patterns, pupillary and oculomotor responses, and motor function.

B. Coma states include persistent vegetative state and locked-in syndrome. Increased intracranial pressure (IICP) is a sustained elevated pressure (greater than 10 mmHg) within the cranial cavity. IICP may result from cerebral edema, hydrocephalus, head trauma, tumors, abscesses, inflammation, hemorrhage, or stroke.

C. The manifestations of IICP include a decreasing LOC, abnormal motor weakness and responses, altered vision, altered vital signs, headache, papilledema, and projectile vomiting. If untreated, IICP causes a displacement (herniation) of cerebral tissue and herniation of the cerebellum through the tentorium, followed by herniation of the brainstem through the foramen magnum. This is a lethal complication of IICP because it puts pressure on the vital centers in the medulla. IICP is primarily managed with osmotic diuretics and monitored with continuous intracranial pressure monitors.

D. A seizure is a single event of abnormal electrical discharge.

E. Epilepsy is a chronic seizure disorder of abnormal, recurring, excessive, and self-terminating electrical discharges from neurons.

F. Seizures are categorized into those that affect only a part of the brain (partial seizures) and those that affect all of the brain (generalized). The most common type of seizure in adults is a tonic–clonic generalized seizure.

G. A stroke is a condition in which neurologic deficits result from a sudden decrease in blood flow to a localized area of the brain. Strokes may be ischemic or hemorrhagic. Ischemic strokes result from a blockage of a cerebral artery by formation of a blood clot or by a clot or foreign substance lodging in a blood vessel; they include transient ischemic attacks, thrombotic strokes, or embolic strokes. Hemorrhagic strokes occur when a cerebral blood vessel ruptures. Depending on the size and location of cerebral tissue damage, strokes may cause cognitive and behavior changes, sensory–perceptual deficits, language disorders, and motor deficits. Treatment of an ischemic stroke with fibrinolytic therapy within 3 hours of the onset of manifestations may reverse damage to cerebral neurons. Nursing care is directed toward both prevention of a stroke through community-based educational programs and interventions to promote recovery and decrease complications.

H. Intracerebral hemorrhage may follow rupture of an intracranial aneurysm or arteriovenous malformation. Intracranial aneurysms occur at the site of a weakness in a cerebral blood vessel. AV malformations are a tangled collection of dilated arteries and veins.

I. An epidural hematoma develops in the potential space between the dura and the skull. A subdural hematoma collects between the dura mater and the arachnoid mater. Diffuse brain injuries include contusions, concussions, and diffuse axonal injury. Patients with an acute TBI must have immediate transport and treatment in an ED, followed by care in an ICU. They will require long-term physical care and rehabilitation.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

J. Arteriovenous malformations are a tangled collection of dilated arteries and veins, increasing the risk for rupture.

K. Traumatic brain injury (TBI) refers to any injury of the scalp, skull, or brain and is a leading cause of death and disability.

L. Traumatic brain injuries can include focal or diffuse brain injury. An acute brain injury affects all body systems and carries the risk of secondary injury to the brain from hypoxia and ischemia.

M. Brain tumors are growths within the cranium, including on or in brain tissue, the meninges, the pituitary gland, or blood vessels.

N. Brain tumors may be benign or malignant, primary or metastatic, and intracerebral or extracerebral.

O. Regardless of the type or location, brain tumors are potentially lethal because they displace or impinge on CNS structures within a closed bony system.

P. Headaches, a common type of intracranial pain, are categorized as tension, migraine, and cluster.

Q. A classic migraine is characterized by an aura; a common migraine does not have an aura.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME ONE Discuss levels of consciousness and increased intracranial pressure. Discuss the pathophysiologic findings and the manifestations as they apply to changes in cerebral tissue perfusion.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME ONE Assign students, if possible, to care for a client with an altered level of consciousness.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME TWO Have students research the diagnosis of persistent vegetative state and brain death. Look for differences between and among states. Look for differences in definition between children and adults.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME TWO Assign students to care for/observe the care of client with increased intracranial pressure.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME THREE Divide the students into small groups. Have the group investigate the pathophysiology, manifestations, complications, and interdisciplinary and nursing care of seizures. Share the group findings. .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME THREE Assign students to care for a client with a seizure disorder.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME FOUR Divide the students into small groups. Have the group investigate the pathophysiology, manifestations, complications, and interdisciplinary and nursing care of a stroke. Share the group findings.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME FOUR Assign students to care for a client recovering from a stroke. This could be in acute care or home care setting.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME FIVE Divide the students into small groups. Have the group investigate the pathophysiology, manifestations, complications, and interdisciplinary and nursing care of intracranial vascular disorders. Share the group findings.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME FIVE Assign students to care for and observe the surgery to correct an intracranial vascular disorder.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME SIX Divide the students into small groups. Have the group investigate the pathophysiology, manifestations, complications, and interdisciplinary and nursing care of traumatic brain injuries.

Share the group findings.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME SIX Assign students to observe/participate in the care of a client recovering from a traumatic brain injury.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME SEVEN Divide the students into small groups. Have the group investigate the pathophysiology, manifestations, complications, and interdisciplinary and nursing care of brain tumors. Share the group findings.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME SEVEN Assign students to observe/participate in the care of a client with a brain tumor.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME EIGHT Divide the students into small groups. Have the group investigate the pathophysiology, manifestations, complications, and interdisciplinary and nursing care of headaches. Share the group findings.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME EIGHT Assign students to assess a client with a headache. Have the students create a teaching tool to share with the client to assist with reducing the frequency of headaches.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter 43 Nursing Care of Patients with Spinal Cord Disorders and CNS Infections

Learning Outcomes 1. Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders.

2. Describe the pathophysiology and manifestations of central nervous system infections, and outline the interprofessional care and nursing care of patients with these disorders.

Key Concepts I.

Spinal Cord Disorders A. The Patient with a Spinal Cord Injury 1. Pathophysiology a) Spinal cord (1) Outer region, white matter, tracts, or pathways that convey information (a) Ascending (sensory) pathways: Information about proprioception, discrimination, pain, temperature, deep pressure, and touch (b) Descending (motor) pathways: Information about movement (i) Pyramidal tract: Skilled voluntary movements (ii) Extrapyramidal tract: All other body movements (2) Inner region, gray matter, compromises central canal, posterior horns, anterior horns, and lateral horns (a) Sensory half (dorsal) (b) Motor half (ventral) b) Injury: Damage to vertebrae, ligaments, and spinal cord itself (1) Microscopic hemorrhages in gray matter and edema of white matter lead to necrosis of neural tissue and increase in area of injury (2) Loss of reflexes below level of neuronal injury (3) Microcirculation to cord is impaired: Causes ischemia and necrosis in neurons (4) Norepinephrine, serotonin, dopamine, and histamine released (5) Tissue repair occurs in 3–4 weeks (a) Tissue replaced by acellular collagenous tissue c) Forces resulting in SCI (1) Acceleration: External force applied in rear-end collision (2) Deceleration: Head-on collision (3) Other forces: Hyperflexion, hyperextension, axial loading, excessive rotation, and penetrating objects d) Sites of pathology are identified by vertebral level

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

e) Classification of SCI (1) Quadriplegia: Damage in cervical area (a) Impairment of arms, trunk, legs, and pelvic organs (2) Paraplegia: Damage thoracic, lumbar, and sacral area (a) Impairment of trunk, legs, and pelvic organs (3) Complete SCIs: Complete interruption of motor and sensory function below level of injury (4) Incomplete: Partial interruption with variable loss below level of injury 2. Risk factors a) Motor vehicle crashes b) Falls c) Acts of violence 3. Manifestations a) Affect movement, perception, sensation, sexual function, and elimination b) Spinal shock: Response of cord itself (1) Flaccid paralysis, loss of reflexes and sensations below the level of injury (2) Loss of urinary bladder tone, intestinal peristalsis, perspiration, and vasomotor tone (3) Results in hypotension, bradycardia, and warm skin (4) Recovery gradual, lasts 4–6 weeks c) Neurogenic shock: Cardiovascular changes from inability of brainstem to modulate reflexes (1) Hypotension and bradycardia occur (2) Respiratory insufficiency, hypothermia, paralytic ileus, urinary retention, and oliguria d) Incomplete spinal cord injury syndromes (1) Central cord syndrome, anterior syndrome, posterior syndrome, Brown-Séquard syndrome, and Homer’s syndrome 4. Complications a) Upper and lower motor neuron deficits (1) Upper motor neurons: Responsible for voluntary movement (a) Manifestations: Spastic paralysis and hyperreflexia (2) Lower motor lesions: Responsible for innervation and contraction of skeletal muscles (a) Manifestations: Muscle flaccidity and atrophy, loss of voluntary and involuntary movement, partial or complete paralysis b) Paraplegia and quadriplegia c) Autonomic dysreflexia: Exaggerated sympathetic response at or above T6 .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Occurs only after recovery from spinal shock (a) Triggered by: Full bladder (most common) resulting from a blocked urinary catheter, fecal impaction, bladder infections or stones, sexual intercourse, intrauterine contractions, pressure ulcers, and surgical procedures (2) Vasoconstriction below injury and vasodilation above injury occur (3) Manifestations: Headache, bradycardia, flushing, blurred vision, nausea, diaphoresis above the lesion, and hypertension (a) Potentially fatal if untreated 5. Interdisciplinary care a) Emergency care (1) Respiratory paralysis common for injuries from C1 to C4 or lower with ascending edema (2) All patients with trauma to head or spine, or unconscious, treated as SCI patients b) Prehospital management (1) Rapid assessment of ABCs (2) Immobilizing and stabilizing head and neck (3) Removing from site of injury, stabilizing injuries, transporting to trauma center or other facility c) In ED (1) Assess and implement interventions for respiratory distress, paralytic ileus, atonic bladder, and cardiovascular alterations (2) Steroid protocols instituted if within 8 hours of injury to reduce compression d) Diagnosis (1) To identify location: X-ray, CT or MRI, somatosensory-evoked potential studies (2) ABGs: For baseline, respiratory assessment (3) Trauma screen: Blood type, blood alcohol level, urine drug screen, and pregnancy test e) Fluid management (1) Crystalloids (2) Potassium and multivitamins (3) IV fluids for hypotension f) Medications (1) Corticosteroids: For inflammation and edema (2) Vasopressors: For acute bradycardia or hypotension (3) Antispasmodics: For spasticity (4) Antiemetics: For pain (5) Proton pump inhibitors: To prevent stress-related gastric ulcers (6) Anticoagulants: To prevent thrombophlebitis (7) Stool softeners: May be part of bowel-training program g) Nutrition .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Regular diet (2) High fiber (3) Generous fluids h) Treatments (1) Surgery (a) For evidence of compression by bone fragments of hematoma (b) Decompression laminectomy, a spinal fusion, and insertion of metal rods (2) Stabilization and immobilization (a) External fixation device to stabilize and prevent further injury (b) Cervical traction device (c) Halo external fixation device (d) Physician applies device, nurse maintains and assesses i) Research to improve SCI management (1) Current research conducted on neurons of the spinal cord, stimulators to improve muscle function, and equipment to aid activities of daily living (2) Research to improve rehabilitation 6. Nursing care a) Assessment (1) Health history (a) Information about injury event conditions (2) Physical examination (a) Motor strength, movement, spinal reflexes, bladder distention, mental status b) Priorities of care (1) Acute: Preserve life, prevent complications (2) As acuity resolves: Restoring functional capabilities c) Diagnoses, outcomes, and interventions (1) Promote physical mobility (a) Perform passive ROM exercises, identify stimuli that cause spastic movements (b) Maintain skin integrity by turning patient (c) Assess lower extremities for deep vein thrombosis (2) Promote oxygenation (a) Monitor vital capacity and respiratory effectiveness (b) Monitor for signs of ascending edema of spinal cord (c) Reduce risk of and monitor for ventilator-associated pneumonia (3) Monitor breathing pattern (a) Assess respiratory quality (b) Administer supplemental oxygen and monitor oxygen saturation (c) Assist patient to turn, cough, and deep breathe (d) Increase fluids by mouth .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(4) Prevent autonomic dysreflexia (a) Elevate head of bed, remove compression stockings (b) Assess blood pressure every 2–3 minutes and administer IV diazoxide if prescribed for dangerously high blood pressure (5) Promote normal urinary and bowel elimination (a) Monitor for manifestations of a full bladder, residual urine (b) Teach how to use trigger voiding techniques (c) Teach self-catheterization methods (d) Monitor for stool quality, frequency (e) Institute bowel retraining program (6) Promote optimal sexual function (a) Include data about sexuality during assessment (b) Provide information about sexual dysfunction (c) Initiate discussion with patient and partner on alternative means of gaining sexual satisfaction (d) Refer for sexual counseling, if appropriate (7) Promote optimal self-esteem (a) Encourage talking about function and care and include family and important others in conversations (b) Help identify strategies to increase independence; encourage self-care (c) Refer to counseling and support groups 7. Transitions of care a) Teach about self-care, mobility, preparation of the home environment, and psychological support b) Provide resources to read and information about home health agencies B. The Patient with a Herniated Intervertebral Disk 1. Pathophysiology a) Intervertebral discs (1) Located between vertebral bodies (2) Absorb compression b) Herniated disk: Rupture of cartilage surrounding disk, protrusion of the nucleus pulposus (1) May occur anywhere, but most common in lumbar region (2) From trauma, degenerative disorders, and aging (3) Can be abrupt or gradual 2. Risk factors a) Normal wear and tear b) Trauma .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

c) Repeated lifting d) Weight-bearing sports 3. Manifestations a) Lumbar disk manifestations (1) Sciatica: Lumbar back pain radiating down posterior leg from pressure on sciatic nerve (2) Postural deformity, motor deficits, sensory deficits, and changes in reflexes b) Cervical disk manifestations (1) Lateral herniation: Radicular pain in shoulder, neck, and arm (a) Paresthesias along dermatome of compressed nerve root (b) Muscle spasms, stiff neck, and decreased arm reflexes (2) Central herniation: Dull, intermittent pain, lower extremity weakness, unsteady gait, and muscle spasms (a) Severe: Paralysis of extremity 4. Complications a) Cauda equina syndrome 5. Interdisciplinary care a) Diagnosis (1) Assess pain, muscle strength, and reflexes (2) Tests: X-ray, CT scans, Electromyography (EMG), and myelogram with contrast medium b) Medications (1) Non-steroidal anti-inflammatory drugs (NSAIDs) for pain (2) Relaxants for muscle spasms c) Treatments (1) Conservative treatment (a) Patient advised to continue with normal activities as much as possible, take medications (2) Surgery (a) For patients with unrelenting pain, who do not respond to conservative management, who have serious neurological deficits (b) Laminectomy: Removal of part of the vertebral lamina to relieve pressure on nerves (i) Often done with nucleotomy (removal of protruding nucleus pulposus) (ii) Disketomy: Removal of nucleus pulposus and intervertebral disk (iii) Microdiskectomy: Through very small incision (c) Spinal fusion: Insertion of wedge-shaped piece of bone or titanic device between vertebrae to stabilize them .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(d) Foraminotomy: Removal of bone or tissue from obstructing passage where spinal nerve exits spinal canal (e) Intradiscal electrothermal therapy (IDET): Spinal needle inserted into disk and heated to thicken and seal disc wall, decrease bulging 6. Nursing care a) Assessment (1) Health history (a) Risk factors, manifestations (2) Physical assessment (a) Muscle strength, coordination, sensation, reflexes b) Diagnosis, outcomes, and interventions (1) Relieve acute pain (a) Assess pain from 1 to 10, identify contributing factors (b) Teach positions that decrease stress (c) Provide analgesic medications (2) Manage chronic pain (a) Treat complaints with respect and do not infer that patient is addicted to medications (b) Monitor for changes in condition (c) Teach alternative methods of pain management, methods for improving sleep (d) Refer patient to physical therapist or exercise program, assess need for referrals (3) Promote normal bowel elimination (a) Assess patient’s bowel routine (b) Encourage increased fluid intake, fiber, and bulk 7. Transitions of care a) Goal to control pain and perform ADLs C. The Patient with a Spinal Cord Tumor 1. Classification a) Primary: Have unknown cause, arise at any level b) Metastatic: Commonly a result of other malignancy c) Intramedullary: Arise from within neural tissues d) Extramedullary: Arise from tissues outside spinal cord (1) Intradural: Arise from nerve roots or meninges within subarachnoid space (2) Extradural: Arise from epidural tissue of vertebrae outside dura e) Leptomeningeal disease (LMD): Involve cerebrospinal fluid

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

2. Pathophysiology a) Tumors obstruct arteries and veins and cause compression, invasion, or ischemia b) Compression: Minor sensory disturbance to severe pain, irreversible paralysis, edema which can ascend the cord c) Most common site in bony skeleton for cancer metastasis 3. Risk factors a) Environmental exposure b) Previous diagnosis of cancer 4. Manifestations a) Depend on location, level of occurrence, type of tumor, spinal nerves involved b) General manifestations: Pain, motor and sensory deficits, changes in bowel and bladder elimination, changes in sexual function c) Syringomyelia: Formation of fluid-filled cystic cavity in central intramedullary gray matter (1) Causes pain, motor weakness, and spasticity 5. Complications a) Spinal cord compression b) Infarction c) Paralysis 6. Interdisciplinary care a) Diagnosis (1) Tests: X-ray, CT scan, MRI, and myelogram (2) Lumbar puncture (a) Froin’s syndrome: CSF with xanthochromic appearance, elevated protein, few to no cells, and immediate clotting (3) Biopsy to identify type b) Medications (1) Opioid analgesics: For pain and edema (2) Epidural catheter and narcotic analgesia for severe pain from metastatic tumor (3) Steroids: To control cord edema c) Immobilization (1) Assess biomechanics, anatomy, and flexibility of spine (2) External spinal support used if needed d) Surgery (1) Laminectomy: To remove intramedullary and intradural tumors (2) Surgical decompression of cord and/or partial removal sometimes necessary to restore motor, bowel, or bladder function .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

e) Other treatments f) Stereotactic radiosurgery (1) Cyberknife: High doses of precisely targeted radiation controlled by robotic arm g) Radiation therapy (1) Uses: Emergency basis, to reduce pain, and following surgery (2) May induce radiation-induced myelopathy (a) Manifestations: Brown-Séquard syndrome, paraplegia, sensory loss, and loss of bowel and bladder control 7. Nursing care a) Depends on type of tumor and type of treatment b) Regardless of type (1) Monitor for neurologic changes (2) Provide pain management (3) Manage motor and sensory deficits c) Assessment (1) Similar to those for SCI or surgery from herniated intervertebral disk 8. Transitions of care a) Referrals for home care, occupational or physical therapy b) Teach patient and family members care techniques II.

Infectious Disorders of the Central Nervous System A. The Patient with a Central Nervous System Infection 1. Pathophysiology a) Infectious inflammatory process leads to edema, increased intracranial pressure b) May result in brain damage and life-threatening complications c) Meningitis (1) Pyogenic purulent infection that involves the pia matter, arachnoid, and subarachnoid space (2) Circulates rapidly through cerebrospinal fluid circulation (3) Can be acute, chronic, bacterial, viral, fungal, or parasitic (4) Infection path (a) Usually invades through nasopharyngeal mucosa (b) Travels to vascular system (c) Penetrates CNS if blood–brain barrier is damaged (5) Infection and inflammatory response in brain, spinal cord, and optic nerves (6) Bacterial meningitis (a) Caused by several organisms (b) Risk factors: (i) Otitis media, mastoiditis, sinusitis, neurosurgery, systemic sepsis, immunocompromise, basal skull fractures, and crowded living conditions

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(c) Disease process (i) Inflammatory response in meninges, CSF, and ventricles (ii) Meningeal vessels engorged, increased permeability (iii) Phagocytic white blood cells migrate to subarachnoid space, impair CSF flow (iv) Edema of meningeal cells and IICP (7) Viral meningitis/aseptic meningitis (a) Less severe than bacterial, caused by numerous viruses (8) Arbovirus encephalitis (a) Arthropod-borne (mosquito and tick) agents that infect humans d) Encephalitis (1) Generalized infection of parenchyma of brain or spinal cord (2) Viral encephalitis (a) Enter CNS through bloodstream or meningitis case (b) Degeneration of neurons, local necrotizing hemorrhage, generalized hemorrhage, edema, and progressive degeneration of nerve cell bodies (c) No exudate formation (d) Manifestations (i) Depend on organism and area of brain (ii) Similar to those of meningitis (e) Arbovirus encephalitis (i) Different types of arthropod-borne agents (e.g., West Nile) e) Brain abscess (1) Infection with collection of purulent material within brain tissue (2) Causes: Open trauma, neurosurgery; infections of ear, nose, sinuses; metastatic spread (3) Most commonly caused by bacteria, also from yeast and fungi (4) If encapsulated, may enlarge, cause systemic inflammatory response, IICP 2. Risk factors a) Meningitis (1) Otitis media, mastoiditis, sinusitis, neurosurgery, systemic sepsis, immunocompromise, diabetes, intravenous drug use, basal skull fractures, or crowded living conditions b) Encephalitis (1) Age and immunocompromise c) Brain abscess (1) Immunocompromised or intravenous drug users 3. Manifestations a) Bacterial meningitis .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Fever and chills, severe headache, and nausea and vomiting (2) Confusion (3) Nuchal rigidity, a positive Brudzinski sign, and positive Kernig sign (4) Photophobia and possibly diplopia b) Viral meningitis (1) Mild flu-like symptoms, intense headache and malaise, nausea, and vomiting (2) Photophobia may occur, but patient remains oriented (3) Neck stiffness, positive Brudzinski sign, and positive Kernig’s sign usually present c) Viral encephalitis (1) Fever, headache, seizures, stiff neck, and altered LOC (2) Disoriented, agitated, restless, lethargic, or drowsy d) Arbovirus encephalitis (1) Fever, malaise, sore throat, nausea and vomiting, stiff neck, tremors, paralysis, exaggerated deep tendon reflexes, seizures, and altered LOC e) Brain abscess (1) Fever, severe headache, back and abdominal pain, nausea and vomiting, photophobia, diplopia meningeal irritation: Nuchal rigidity, positive Brudzinski sign, and positive Kernig’s sign 4. Complications a) Bacterial meningitis (1) Arachnoid layer may have fibrotic changes and formation of scar tissue from the infection.

(2) Adhesions and effusions can develop (3) Cranial nerve damage and hydrocephalus b) Encephalitis (1) Decreased level of consciousness (LOC), confusion, and slurred speech c) Brain abscesses (1) Seizures and hydrocephaly 5. Interprofessional care a) Diagnosis (1) Gram stain and culture: To determine bacterial agent (2) Counterimmunoelectrophoresis (CIE): To determine presence of virus or protozoa (3) Polymerase chain reaction (PCR:) to detect viral DNA or RNA in spinal fluid (4) CR scan: For brain abscess (5) Lumbar puncture: To differentiate bacterial meningitis from encephalitis from brain abscess b) Medications

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Bacterial meningitis: Immediate IV broad spectrum antibiotic that crosses bloodbrain barrier (a) More specific antibiotic after culture results for 2 weeks (b) Steroids to suppress inflammation from released toxins as bacteria die (2) Encephalitis: Medications to prevent complications (3) Fungal meningitis: Antifungal agents (4) Brain abscess: Antibiotic therapy (a) Anticonvulsants to prevent seizures (b) Antipyretic and analgesics for symptomatic relief (i) Analgesics with opiate effect avoided c) Surgery: To drain encapsulated abscess (1) Depends on patient’s condition, stage of abscess development, site of abscess 6. Nursing care a) Assessment (1) Health history: Risk factor and history of manifestations (2) Physical examination (a) Glasgow coma scale, LOC, motor function, pupillary check, cranial nerves, neck ROM, Brudzinski sign, Kernig’s sign, skin status, and muscle movement and strength b) Diagnoses, outcomes, and interventions (1) Reduce risk for infection (a) Monitor neurologic stats, vital signs, level of consciousness on a regular basis (b) Monitor for manifestations of seizure, cranial nerve damage, and manifestations of IICP (c) Administer prescribed medications and fluids (2) Maintain hydration (a) Monitor intake and output, daily body weight, skin turgor and mucous membrane conditions, BUN: Creatinine ratio (b) Consider concurrent illness when administering fluids 7. Transitions of care a) Vaccinations b) Hand hygiene c) Avoid exposure to insect vectors B. The Patient with Tetanus 1. Pathophysiology a) Tetanus (lockjaw) b) Neurotoxin Clostidrium tetani spores enter body through contaminated wounds c) Spores germinate, produce tetanospasmin .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Incubation ranges from 5 days to 15 weeks d) Toxins impair transmission of neuromuscular impulses resulting in muscle spasms 2. Risk factors a) Lack of immunization b) Manifestations (1) Pain at infection site followed by neck and jaw stiffness and dysphagia (2) Perspiration, salivation, and drooling can occur (3) Hyperreflexia and spasms of face muscles followed by spasms of neck and torso (4) Generalized tonic seizures (5) Urinary retention, airway obstruction, cardiac and respiratory failure may occur (6) Normal mental status throughout symptoms 3. Complications a) Laryngospasms, fractures, hypertension, pneumonia, and death 4. Interprofessional care (1) Diagnosis (a) Based on manifestations (b) Preventable with active immunization (c) Passive immunization administered with antibiotics if wound is contaminated and immunization status is uncertain (2) Medications (a) Penicillin administered (b) Choropromazine or diazepam for spasms and seizures (c) Anticoagulants for venous thrombosis (d) Severe cases: Curare-like medication and mechanical ventilation 5. Nursing care a) Tetanus (1) Decrease stimuli as much as possible (2) Maintain oxygenation, IV access (3) Administer medications and nutritional support (4) Monitor respiratory, cardiovascular, fluid and electrolyte status, and urinary output (5) Monitor for hazards of immobility 6. Transitions of care a) Promote immunizations and booster doses b) Teach proper wound care

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

C. The Patient with Creutzfeldt–Jakob Disease 1. Classic Cruetzfeldt–Jakob disease/spongiform encephalopathy a) Rapidly progressive disease, causes fatal brain degeneration without inflammation b) Causative agent: (Believed to be) Prion protein (cellular glycoprotein) c) Transmission by direct contamination with infected neural tissue 2. New variant CJD (“mad-cow disease”) a) Causative agent: Consumption of cattle products contaminated with bovine spongiform encephalopathy 3. Pathophysiology a) Brain degeneration, tiny holes form 4. Manifestations a) Onset: Memory changes, exaggerated startle reflex, sleep disturbances, nervousness b) Progresses to: Deterioration in motor, sensory, and language functions (1) Tremors, hyperreflexia, rigidity, and positive Babinski reflex c) Progresses to dementia d) Terminal state: Comatose, decorticate, and decerebrate posturing 5. Diagnosis a) Neurologic exam, specific EEG changes, and CT scan b) Final diagnosis only possible in postmortem examination 6. Treatment a) None to stop or slow progression b) Focus on manifestations 7. Nursing care a) Health history (1) Cultural and geographic risk (2) High risk occupations or procedures b) Physical assessment (1) Mental function, reflexes, and cranial nerve function c) Interventions (1) Provide quiet environment, administer analgesics, and provide skin care (2) Communicate with patient and family, even if patient does not respond (3) Institute seizure precautions (4) Precautions to avoid transmission (5) Allow family time to grieve, give them information on care and support systems

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

D. The Patient with Postpoliomyelitis Syndrome 1. Complication from previous poliomyelitis virus 2. Polio widely spread in 1940s and 1950s, now largely eradicated through immunization 3. 25–50% those who contracted disease experience acute manifestations later 4. Manifestations a) Muscle weakness, fatigue, and pain can progress to muscle atrophy and scoliosis 5. Cause unknown 6. Diagnosis a) Previous history of polio and manifestations for at least 1 year 7. Treatment: Addresses manifestations a) Physical therapy and pulmonary rehabilitation b) Oxygen may be prescribed 8. Nursing care a) Health history (1) Not all patients know they had polio as children b) Health promotion (1) Teaching to meet physical and psychosocial needs of patient and family (2) Fatigue prevention, promote respiratory function, perform self-care, maintain safety (3) Referral to support group E. The Patient with Rabies 1. Viral infection most often transmitted through bite of infected animal 2. Virus travels from wound to muscle cells to peripheral nerves to CNS 3. Manifestations a) Infection causes anxiety, irritability, and depression b) General manifestations of infection occur c) Increased sensitivity to light, sounds, and changes in temperature d) Prodromal stage followed by excitement stage (1) Hydrophobia occurs; thick, tenacious mucus present (2) Convulsions, muscle spasms, periods of apnea e) Fatal if untreated, usually from respiratory failure 4. Diagnosis a) Animals that bite kept under observation b) Blood of infected person tested for rabies antibodies .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

5. Nursing care a) Interventions (1) Decrease stimulation in room (2) Maintain airway and oxygenation (3) Control seizures (4) Caution with patient’s saliva b) Patient and family teaching (1) Importance of immunizing pets and seeking immediate care for animal bites c) Treatment (1) Rabies immune globulin (RIG) administered following exposure for passive immunization (2) Inactivated human diploid cell vaccine administered at the same time F. The Patient with Botulism 1. Clostridium botulinum: Anaerobic spore-forming bacillus found in soil, causes food poisoning when ingested 2. Infection from eating improperly canned or cooked food 3. Toxins absorbed by GI tract, bind to nerve tissue, cause skeletal muscle paralysis and respiratory paralysis 4. Manifestations a) Visual disturbances, loss of accommodation, and ptosis b) GI: Nausea and vomiting, diarrhea, dysphagia, and dry mouth c) Paralysis of all muscle groups 5. Diagnosis a) Laboratory analysis of serum, stool, and suspected food 6. Treatment a) Botulism antitoxin administered (1) Must be procured from state health department and CDC b) Total parenteral nutrition and IV fluids administered c) With maintained ventilation, patient may recover without neurologic deficits (1) Fatigue and weakness can last a year 7. Nursing care a) Monitor for respiratory failure, paralytic ileus, urinary retention b) Continuity of care (1) Methods of precaution for preparing and consuming home-canned foods (2) Do not eat canned foods with defective seals, or that are damaged, bulging, or leaking

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter Highlights A. Spinal cord injuries are typically related to trauma, with the major risk factors being age (young adults), gender (male), and alcohol or drug abuse. The causes of SCI’s include direct trauma, fractures, torn ligaments, circulatory impairment, contusions, lacerations, or transections of the cord. Complete or incomplete SCIs are determined by the degree of interruption in motor and sensory pathways. Movement, perception, sensation, sexual function, and elimination are potentially affected by these injuries.

B. Complications of SCIs include spinal shock, which is the temporary loss of all reflexes (areflexia) below the level of injury. Manifestations of spinal shock include bradycardia, hypotension, and flaccid paralysis. Autonomic dysreflexia (AD) is an exaggerated sympathetic response when SCI injuries are at or above T6. AD is triggered by noxious stimuli and results in severe and life-threatening hypertension.

C. Community education and use of protective equipment (such as car seats, seat belts, and bicycle helmets) are essential for prevention of SCI. D. Rehabilitation of the SCI patient is an ongoing process from intensive care to home care.

Nursing interventions are necessary in all settings to promote independence in self-care.

E. A herniated intervertebral disk is a rupture of the cartilage surrounding the intervertebral disk with protrusion of the nucleus pulposus. The major manifestation of lumbar disks is lower back and sciatic pain on the affected side.

F. Spinal cord tumors may be benign or malignant, primary, or metastatic. Depending on tumor size and location, pathologic changes in function can result from compression, invasion, or ischemia.

G. CNS infections are caused by bacteria, bacterial toxins, viruses, fungi, protozoans, and rickettsiae. Organisms enter the CNS through the bloodstream or by direct invasion. The major CNS infections are meningitis and encephalitis. Treatments include broad-spectrum antibiotics or antifungal agents. Community-based health education can provide important preventive information.

SUGGESTIONS FOR CLASSROOM ACTIVITY—LEARNING OUTCOME ONE Arrange for a paramedic and an Emergency Department RN to come to the class to discuss the management of the client who has suffered a spinal cord injury.

Using anatomic models, identify the primary areas of spinal cord injury. Have students identify the deficits that occur at each level. Discuss the care of patients with these deficits.

Using anatomic models, demonstrate the techniques used to immobilize a spinal cord injury.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME ONE If possible, assign students to care for clients recovering from a spinal cord injury or intervertebral disk disorder. Have the students discuss the care of their clients during postclinical conference.

SUGGESTION FOR CLASSROOM ACTIVITY- LEARNING OUTCOME TWO Have students group the common medications used for cerebrovascular and spinal cord disorders according to pharmacodynamics. Have students identify the commonalities and differences among these medications.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME TWO If possible assign students to care for clients recovering from a central nervous system infection.

Have the students discuss the types of medications used to treat these infections during postclinical conference.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter 44 Nursing Care of Patients with Neurologic Disorders Learning Outcomes 1. Describe the pathophysiology and manifestations of degenerative neurologic disorders, and outline the interprofessional care and nursing care of patients with these disorders.

2. Describe the pathophysiology and manifestations of peripheral nervous system disorders, and outline the interprofessional care and nursing care of patients with these disorders.

3. Describe the pathophysiology and manifestations of cranial nerve disorders, and outline the interprofessional care and nursing care of patients with these disorders.

Key Concepts I.

Degenerative Neurologic Disorders A. Dementia: Cognitive decline caused by any disorder that permanently damages areas of the brain necessary for memory and learning 1. Results from the death of neurons and/or the loss of communication among the cells 2. Diagnosis depends on the presence of two or more deficits in the following cognitive abilities: a) Memory loss b) Ability to generate coherent speech or understand spoken or written language c) Ability to recognize or identify objects, assuming intact sensory function d) Ability to execute motor activities, assuming intact motor abilities, sensory function, and comprehension of the required task e) Ability to focus and pay attention f) Ability reason and problem solve 3. The decline in cognitive abilities must be severe enough to interfere with daily life.

4. Causes: Alzheimer disease, vascular dementia, Parkinson disease, normal pressure hydrocephalus, Creutzfeldt-Jakob disease, metabolic disorders, medications, poisoning, chronic traumatic encephalopathy (CTE), and anoxia 5. Risk factors: Aging, a family history of dementia, smoking and alcohol use, atherosclerosis, high cholesterol, elevated plasma homocysteine levels, diabetes mellitus, and Down syndrome B. The patient with Alzheimer disease 1. Form of dementia characterized by progressive, irreversible deterioration of general intellectual functioning 2. 80% of dementia due to AD 3. Cause unknown, develops from interaction of multiple factors 4. Early onset: Under 65; late onset: Over 65

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) Rare genetic variation causes some cases of early onset.

5. Pathophysiology a) Atrophy of the cortical area of the brain and loss of neurons, especially in the parietal and temporal lobes b) Theories about cause and development: Amyloid hypothesis, tau hypothesis, and vascular hypothesis c) Neuritic plaques: Groups of nerve cells that degenerate and clump around an amyloid core and disrupt nerve impulses (1) Consist primarily of insoluble deposits of beta-amyloid d) Neurofibrillary tangles: Found in the cytoplasm of abnormal neurons, composed of fibrous proteins wound around each other; disrupt communication between neurons (1) Contain the protein tau 6. Risk factors a) Age, head trauma, inflammatory factors, oxidative stress, low educational level, lack of mental stimulation, migraines, and heavy smoking and alcohol consumption b) Gene mutation 7. Stages and manifestations a) Stage 1: No cognitive impairment b) Stage 2: Very mild decline c) Stage 3: Mild cognitive decline d) Stage 4: Moderate cognitive decline e) Stage 5: Moderately severe cognitive decline (1) Some assistance with ADLs is essential.

(2) Usually retain essential knowledge about themselves and family (3) Confusion about date, day of the week, etc. f) Stage 6: Severe cognitive decline (1) Emergence of personality changes (2) Extensive help with ADLs needed (3) May forget most personal history g) Stage 7: Very severe cognitive decline (1) Loss of ability to respond to environment, speak, and control movement 8. Interprofessional care a) Diagnosis: No specific test (1) Ruling out causes for manifestations: Medications, depression, infection, hypothyroidism, dehydration, heart disease, stroke, and chronic obstructive respiratory disease (2) Mental status tests: Folstein Mini Mental State Examination, Alzheimer Disease Assessment Scale, draw a clock .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(3) Only completely confirmed in postmortem examination b) Medications (1) Acetylcholinesterase inhibitors (AChEls) and N-methyl-D-aspartate (NMDA): May slow progression of cognitive decline (2) Medications for manifestations: Sleep disturbances, depression, agitation, delusions, and aggression c) Nutrition (1) Mediterranean diet has neuroprotective benefits. d) Integrative therapies (1) Huperzine A, a traditional Chinese medicine (2) Coenzyme Q10, an antioxidant (3) Supplements: Zinc, ginkgo biloba, B vitamins, vitamin E (4) Therapies: Massage, art, music, sound, dance, and pet therapy 9. Nursing care a) Assessment (1) Health history (2) Physical assessment b) Priorities of care (1) Falls prevention (2) Memory loss (3) General safety considerations c) Diagnoses, outcomes, and interventions (1) Reduce risk for harm (a) Recommend a medication box labeled with days and times (b) Provide continuity in nursing staff (c) Repeat explanations simply and as needed (2) Relieve anxiety (a) Monitor for early behaviors of fatigue and agitation (b) Remove from situations that increase anxiety (c) Keep daily routine as consistent as possible (d) Schedule rest periods or quiet times throughout the day and provide quite activities (e) Assess for decreased oxygen, infections, fatigue, constipation, and electrolyte imbalance if unyielding anxiety (f) Use therapeutic touch or gentle hand massage (3) Instill hope (a) Assess the patient’s and family’s response to the diagnosis and understanding of AD (b) Teach about the disorder (c) Support positive family bonds (d) Encourage the patient to make as many decisions as possible .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(e) Encourage the family and patient to use coping mechanisms that previously helped (4) Reduce caregiver stress (a) Teach the caregivers self-care techniques (b) Have the caregivers list and regularly take part in physical activities they enjoy (c) Refer the caregivers to local AD support groups, Meals on Wheels, home health, respite care, and other community services (d) Ensure the family knows of availability of hospice care for end stages 10. Transitions of care a) Discuss: Support groups; care that matches the patient’s coping; regular rest periods; and plan care for the caregiver b) Refer to resources C. The patient with multiple sclerosis 1. Chronic demyelinating disease of the CNS 2. Pathophysiology a) Believed to occur as a result of an autoimmune response in a genetically susceptible person b) Plaques destroy myelin sheaths around nerves, disrupt nerve impulses c) Plaques usually in white matter and may extend to gray matter d) First stage: Development of small inflammatory lesions e) Second stage: Lesions extend and consolidate as gliosis and demyelination occurs. f) Courses: Relapsing–remitting, primary progression, secondary progression, and progressive-relapsing 3. Risk factors a) Genetics, geographic location, diagnosis of other autoimmune disorders (type 1 diabetes), low levels of vitamin D, obesity, smoking, and high salt intake 4. Manifestations a) Fatigue b) Pain c) Visual deficits d) Cognitive dysfunctions e) Mood alterations f) Weakness and/or numbness in one or both extremities g) Upper motor neuron involvement h) Bladder dysfunctions i) Bowel dysfunction j) Sexual dysfunction .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

5. Complications a) Increased risk for falls 6. Interprofessional care a) Diagnosis (1) Based on manifestations and patterns of exacerbation and remission (2) MRI and CT scans: Can detect lesions (3) CSF: Indicates immune response, shows elevated levels of immunoglobulin G (IgG) b) Medications (1) During acute exacerbations (a) Combination of adrenal corticosteroid hormone (ACTH) and glucocorticoids (b) Immunosuppressive agents (2) To reduce exacerbations in relapsing courses (a) Interferon and glatiramer acetate (b) Fingolimod (Gilenya) (3) For manifestations (a) Anticholinergics: For bladder spasticity (b) Cholinergics: For bladder flaccidity (c) Amantadine (Symmetrel): For fatigue c) Nutrition and fluids (1) Inability to ambulate and depression can lead to overweight condition (2) Inability to prepare and eat food may occur with progression, dysphagia may occur, diet must be accommodated d) Rehabilitation (1) Stretching exercises, gait training, braces, splints: For spasticity (2) Collaborators: Speech therapists, occupational therapy and occupational counseling, urologist, and respiratory therapist e) Surgery (1) Tendon release procedures : For foot drop from severe plantar flexion 7. Nursing care a) Assessment (1) Health history (2) Physical assessment b) Diagnoses, outcomes, and interventions (1) Prevent fatigue (a) Assess degree of fatigue, identify contributing factors (b) Set priorities for activities and include rest periods (c) Advise to avoid temperature extremes (d) Provide interventions to relieve pain (e) Refer to appropriate specialists to manage fatigue .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(2) Encourage self-care (a) Assist with bathing, toileting, dressing, grooming, and feeding from minimal guidance to complete dependence 8. Transitions of care a) Discuss: Treatment and side effects; ongoing care from interprofessional team b) Refer to helpful resources D. The patient with Parkinson disease 1. Progressive, degenerative disorder of basal ganglia function characterized by tremor, muscle rigidity, bradykinesia, and postural instability 2. Cause is unknown; there is a genetic link; environmental factors play a role 3. Pathophysiology a) Decrease in production of dopamine b) Relative excess of acetylcholine 4. Manifestations a) Early: Patients complain of being tired and moving more slowly, may experience impaired sense of smell and pain b) Tremor (1) Begins unilateral, progresses to bilateral, progressive impairment hinders activities that require dexterity and fine muscle control c) Rigidity and bradykinesia (1) Rigidity can cause muscle cramps in toes or hands, stiffness, heaviness, or aching in muscles, may cause flexion contractures (2) Bradykinesia: Difficulty in starting, continuing, or coordinating movements (a) Patients have staring gaze with minimal change in expression, or remain still for long periods of time d) Abnormal posture (1) Postural fixation: Stooped, leaning forward position (2) Equilibrium: Increased risk of injury from falls e) Autonomic and neuroendocrine effects (1) Elimination problems (2) Orthostatic hypotension (3) Eczematous skin changes and seborrhea f) Mood and cognition (1) Depression: Occurs in 50% (2) Dementia: Occurs in 20%, similar manifestations to AD (3) Bradyphrenia: Slow thinking and decreased ability to form thoughts or plan g) Sleep disturbances (1) From excess acetylcholine and muscle rigidity h) Interrelated effects .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Constipation 5. Complications a) Paranoia, hallucinations, impaired communications, falls, infections, malnutrition, altered sleep patterns, skin breakdown and pressure ulcers, depression and social isolation 6. Interprofessional care a) Diagnosis: Based on manifestations b) Medications (1) Dopamine precursors (a) Carbidopa, levodopa, levodopa-carbidopa (Parcopa, Sinemet) (b) Help balance dopamine/acetylcholine imbalance (2) Monoamine oxidase B inhibitors (a) Selegiline (Eldepryl, Zelapar) and rasagiline (Azilect) (b) Selectively inhibits the enzyme that inactivates dopamine in the brain (3) Dopamine agonists (a) Bromocriptine (Parlodel) and pramipexole (Mirapex) (b) Mimic role of dopamine in the brain (4) Catechol-O-methyltransferase (COMT) inhibitors (a) Tolcapone (Tasmar) and entacapone (Comtan) (b) Inhibit dopamine metabolism (5) Anticholinergics (a) Trihexyphenidyl (Artane) and benzotropine (Cogentin) (b) Block the excitatory action of the neurotransmitter acetylcholine c) Nutrition (1) Fluids (2) Avoid high-protein diets d) Surgery (1) Deep brain stimulation (DBS): For those with advanced tremors (a) Pacemaker-like neurostimulator is implanted in brain, connected to pulse generator, pulses interfere with brain’s electrical signals that cause manifestations (2) Gene therapy, cell replacement therapy, and vaccines (a) Investigational treatment e) Integrative therapies (1) Exercise 7. Nursing care a) Assessment (1) Health history (2) Physical examination .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

b) Diagnoses, outcomes, and interventions (1) Promote physical mobility (a) Suggest referral to physical therapist, request that caregivers learn how to assist with ROM exercises (b) Ask caregivers to ambulate patient at least four times a day if possible (c) Recommend assistive devices (d) Modify environment for safety and reduction of fall risks (2) Promote verbal communication (a) Assess current communication abilities in speech, hearing, and writing (b) Develop methods of communication appropriate to coordination abilities (c) Suggest referral to a speech pathologist (d) Remind patient to speak more loudly, if possible (3) Promote adequate nutrition (a) Assess nutritional status (b) Teach caregivers how to prepare foods of appropriate consistency (c) Weight weekly (d) Teach eating methods to decrease tremors (e) Encourage diet that is high in bulk and fluids (4) Manage sleep pattern (a) Assess sleep pattern and existing conditions that may affect sleep (b) Explain the disease process and the effects on sleep (c) Review patient’s medication (d) Teach how to modify lifestyle activities that affect sleep and mobility 8. Transitions of care a) Discuss: Realistic expectations, equipment suppliers, home environment, gait training and exercises, increased fluid intake, stool softeners, swallowing during eating and taking medications, and foods that can easily swallow b) Refer to specialists and helpful resources E. The patient with Huntington disease 1. Progressive, degenerative, inherited neurologic disease characterized by increasing dementia and chorea a) Autosomal-dominant inherited 2. Pathophysiology a) Destruction of cells in the upper and lower motor neurons b) Other areas of the brain may selectively atrophy c) Several neurotransmitters are decreased, including acetylcholine d) Excess of dopamine relative to acetylcholine causes excessive, uncontrolled movement 3. Manifestations .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) Motor effects (1) Early: Restlessness, fidgety feeling, minor gait changes, posture and positioning disturbances, inability to keep the tongue from protruding, and slurred speech (2) Later: Chorea, facial grimacing, dysphagia, unintelligible speech, and impaired diaphragmatic movement b) Psychosocial effects (1) Early: Irritability, outbursts of rage alternating with euphoria, and depression (2) Late: Decreasing memory, loss of cognitive skills, and eventual dementia 4. Interprofessional care a) Diagnosis b) Prognosis is poor c) Nursing care (1) Teaching about the disease (2) Psychologic support (3) Genetic counseling (4) Immobility (5) Altered nutrition (6) Self-care deficits F. The patient with amyotrophic lateral sclerosis 1. Rapidly progressive and fatal degenerative neurologic disease characterized by weakness and wasting of muscles under voluntary control, without any accompanying sensory changes 2. 90–95% of cases occur randomly with no associated risk factors; 5–10% are inherited.

3. Pathophysiology a) Death of the motor neurons results in axonal degeneration, demyelination, glial proliferation, and scarring along the corticospinal tract b) Pathogenesis is being researched.

4. Manifestations a) Early: Spastic, weak muscles, increased deep tendon reflexes, muscle flaccidity, and slurred speech b) Atrophy ensues, paralysis results c) Eventually requires ventilatory support to breathe 5. Interprofessional care a) Diagnosis (1) Based on manifestations and tests to rule out other diseases b) Medications

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Riluzole (Rilutek), an antiglutamate: Inhibits the presynaptic release of glutamic acid in the CNS and protects neurons against the excitotoxicity of glutamic acid 6. Nursing care a) Diagnoses, outcomes, and interventions (1) Promote physical mobility (a) Assess current condition for baseline parameters (b) Assess skin, provide skin care, and obtain alternating-pressure mattress (c) Institute active ROM exercises and/or perform passive ROM exercises (d) Maintain positive nitrogen balance and hydration status (e) Monitor for manifestations of infection (2) Promote effective breathing (a) Obtain a baseline assessment of breathing pattern, air movement, and oxygen saturation (b) Turn at least every 2 hours (c) Elevate the head of the bed at least 30° (d) Monitor temperature and lung sounds routinely, obtain sputum culture as indicated 7. Transitions of care a) Explain disease process, expected course, and prognosis b) Referral to social worker, home health agency, dietician, physical, speech, and occupational therapists c) As disease progresses, focus on preventing complications, and teach family measures d) Much consideration to psychosocial concerns II.

Peripheral Nervous System Disorders A. The patient with myasthenia gravis 1. Chronic autoimmune neuromuscular disorder characterized by fatigue and severe weakness of skeletal muscles 2. Pathophysiology a) Antibodies destroy or block neuromuscular junction receptor sites, resulting in a decreased number of acetylcholine receptors b) Decrease in the muscle’s ability to contract despite a sufficient amount of acetylcholine c) Thymus believed to be a source of an autoantigen that triggers autoimmune response d) Sometimes associated with thyrotoxicosis, rheumatoid arthritis, and lupus erythematosus 3. Manifestations a) Ocular and facial: Ptosis, diplopia, facial weakness, dysphagia, and dysarthria b) Musculoskeletal: Weakness, fatigue, decreased function of hands, arms, legs, and neck

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

c) Respiratory: Weakening of intercostal muscles, decrease in diaphragm movement, breathlessness and dyspnea, poor gas exchange d) Nutritional: Inability to chew and swallow, decreased ability to move tongue, and impairment of fine motor movements 4. Complications a) Aspiration and pneumonia b) Myasthenic crisis: Sudden exacerbation of motor weakness putting the patient at risk of respiratory failure and aspiration (1) Due to undermedication, missed doses of medication, or a developing infection (2) Manifestations: Tachycardia, tachypnea, severe respiratory distress, dysphagia, restlessness, impaired speech, and anxiety c) Cholinergic crisis: Result of overdosage with the anticholinesterase (cholinergic) medications (1) Manifestations: GI manifestations, severe muscle weakness, vertigo, and respiratory distress are signs of cholinergic crisis.

5. Interprofessional care a) Diagnosis (1) Tensilon test: Injection of edrophonium chloride (Tensilon), results in significant improvement of muscle strength that lasts a few minutes (2) Single-fiber electromyography (3) Serum assay of circulating acetylcholine receptor antibodies: Increases b) Medications (1) Anticholinesterases (a) Neostigmine (Prostigmin), , pyridostigmine (Mestinon, Regonol) (b) Enhance the effects of acetylcholine at the remaining skeletal muscle receptors (2) Immunosuppression with glucocorticoids: To improve muscle strength c) Surgery (1) Thymectomy: For patients younger than 60 (a) Transcervical approach versus transsternal approach (b) Tapered with steroid therapy (c) Nursing care: Preventing complications, controlling pain d) Plasmapheresis (1) Goal to remove antiacetylcholine receptor antibodies 6. Nursing care a) Diagnoses, outcomes, and interventions (1) Maintain effective airway clearance (a) Assist with turning, deep breathing, and coughing every 2 hours (b) Place in semi-Fowler position .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(c) Maintain hydration status and monitor for dehydration (d) Monitor lung sounds, respiration status (2) Reduce risk of aspiration (a) Assess ability to manage various consistencies of foods (b) Speech therapy consultation (c) Plan meals to promote medication effectiveness (d) Have the patient eat slowly, using small bites of food (e) Give cues while eating (f) Teach caregivers the Heimlich maneuver and suctioning (g) Monitor lung sounds, respirations, and pulse oximetry 7. Transitions of care a) Discuss: Treatment, realistic expectations, methods to avoid fatigue and undue stress, and birth control measures b) Refer to support groups and helpful resources B. The patient with Guillain-Barré syndrome 1. Acute inflammatory demyelinating disorder of the PNS characterized by an acute onset of motor paralysis (usually ascending) 2. Precipitating events: Respiratory or gastrointestinal viral or bacterial infection 1–3 weeks prior to the onset of manifestations, surgery, viral immunizations, and other viral illnesses a) Sometimes no precipitating event 3. Pathophysiology a) Destruction of myelin sheaths results in poor conduction of nerve impulses 4. Manifestations a) Acute stage: Severe and rapid weakness, progresses to quadriplegia and respiratory failure; decreased deep tendon reflexes; decreased vital capacity; paresthesias, numbness; and pain b) Stabilizing/plateau stage: “Leveling off” of symptoms; 2–3 weeks after onset c) Recovery stage: May take several months to 2 years; improvement of symptoms; muscle strength and function return 5. Interprofessional care a) Diagnosis: Based on manifestations, history of recent viral infection, elevated CSF proteins, EMG studies (1) CT scan, lumbar punctures, and nerve conduction study b) Medications (1) Antibiotics for prophylaxis (2) Morphine for muscle pain (3) Anticoagulation therapy to prevent thromboembolic complications .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(4) Vasopressors for hypotension c) Nutrition and fluids (1) Maintaining positive nitrogen balance, ensuring sufficient fluid intake and electrolyte balance, and ensuring recommended caloric intake (2) Total parenteral nutrition in case of swallowing problems d) Plasmapheresis (1) Can be beneficial within first two weeks of syndrome development e) Physical and occupational therapy (1) Long term and crucial to recovery (2) Have to relearn walking (3) Controlling pain important 6. Nursing care a) Diagnoses, outcomes, and interventions b) Control acute pain (a) Listen to description of pain; determine triggers and/or pattern (b) Use complementary therapies to relieve pain (c) Provide analgesics as indicated (d) Monitor for side effects of analgesics (2) Promote good skin integrity (a) Inspect and provide skin care every 2 hours (b) Pad bony prominences (c) Use an alternating-pressure mattress (d) Monitor for incontinence 7. Transitions of care a) Teach disease process, include patient and family in treatment decisions b) Teach to avoid complications c) Refer to appropriate specialists for rehabilitation III.

Cranial Nerve Disorders A. The patient with trigeminal neuralgia 1. Severe, brief, repetitive attacks of lightening-like or throbbing pain, occurring along the distribution of a spinal or cranial nerve 2. Pathophysiology a) Follows vascular compression and demyelination of the trigeminal nerve b) Contributing factors include trauma, dental or jaw infections, flulike illnesses, aneurysm, tumor, and MS c) Pain episodes triggered by stimulation of trigger zones on face 3. Manifestations

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) Brief (lasting a few seconds to a few minutes), repetitive episodes of sudden severe facial pain (1) May occur as often as hundreds of times a day to as infrequently as a few times a year 4. Interprofessional care a) Diagnosis: Based on manifestations b) Medications (1) Tricyclic anticonvulsant carbamazepine (Tegretol) (2) Anticonvulsants carbamazepine (Tegretol ) or gabapentin (Neurontin) or the skeletal muscle relaxant baclofen (Lioresal) c) Surgery (1) Rhizotomy: Surgical severing of a nerve root (a) Open and closed procedures 5. Nursing care a) Diagnoses, outcomes, and interventions (1) Control acute pain (a) Identify factors that trigger an attack (b) Determine usual response to pain (c) Assess factors that affect pain tolerance (d) Monitor effects of medications prescribed (2) Promote balanced diet (a) Monitor dietary intake and weight at each visit (b) Discuss temperature and consistency of foods (c) Suggest chewing on unaffected side of mouth (d) Tube feedings may be necessary 6. Transitions of care a) Teach disease process, medications, and ways to reduce incidents of pain B. The patient with Bell Palsy 1. Disorder of the seventh cranial (facial) nerve, characterized by unilateral weakness of the facial muscles 2. May occur as a distinct classic disease or may accompany other diseases such as GuillainBarré syndrome, tumor, Lyme disease, or stroke 3. Pathophysiology a) Believed to be caused by herpes simplex virus type 1 and herpes zoster virus 4. Manifestations a) Onset is sudden. b) Pain behind ear or along jaw may accompany symptoms. c) Face becomes distorted. .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

d) Paralysis varies.

5. Interprofessional care a) No specific diagnostic test or treatments b) Medications: Antiviral drugs combined with anti-inflammatory drug c) Physical therapy d) Moist heat to decrease pain 6. Nursing care a) Interventions (1) Use artificial tears (2) Massage with warm, moist heat (3) Soft diet (4) Facial exercises 7. Transitions of care a) Healthy diet b) Daily exercise

Chapter Highlights A. Dementia involves impairment in short- and long-term memory; impairment in language, motor activity, recognition, and/or abstract thinking; and a clinical course characterized by gradual onset and continuing cognitive decline.

B. Alzheimer Disease (AD) is progressive and relentless and is characterized by cognitive and functional decline. The disease is characterized by atrophy of brain tissue, loss of neurons, neurofibrillary tangles, and amyloid plaques. There are no effective treatments for preventing AD, although pharmacologic and nonpharmacologic therapies may slow its course. Education of caregivers addresses burdens and expectations and provides instruction regarding community resources. The goal is to maximize the environment to the patient’s functional abilities and safety needs.

C. Multiple sclerosis (MS) is an autoimmune, demyelinating disease of the central nervous system. MS is multifactorial, with genetic and environmental factors linked to its incidence.

Exposure to UVB light and exposure to the Epstein-Barr virus have both been implicated as environmental factors that interact with genes to lead to the onset of MS. The loss of myelin leads to axon dysfunction, which slows and distorts nerve impulses. Medications are used to slow the progression of the disease, decrease the number of exacerbations, and treat manifestations.

D. Parkinson disease (PD) is a progressive degenerative neurologic disease characterized by tremor, muscle rigidity, and bradykinesia. The loss of voluntary motor control is the result of pathologic processes resulting in a decrease of dopamine (an inhibitory neurotransmitter) so that it can no longer inhibit acetylcholine (an excitatory neurotransmitter). Medications

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

to treat manifestations include MAO inhibitors, dopaminergics, dopamine agonists, and anticholinergics.

E. Huntington disease (chorea) is a progressive, degenerative inherited neurologic disease characterized by increasing dementia and chorea.

F. Amyotrophic lateral sclerosis (ALS) is a rapidly progressive and fatal degenerative motor neuron disease characterized by weakness and wasting of voluntary control muscles, but without sensory or cognitive changes. The patient eventually loses the ability to communicate and breathe.

G. Myasthenia gravis (MG) is a chronic autoimmune PNS disorder characterized by fatigue and severe skeletal muscle weakness. It results from a decreased number of acetylcholine receptors at the neuromuscular junction, so muscles are unable to contract. Lifethreatening emergencies include myasthenic crisis (sudden increase in motor weakness) and cholinergic crisis (from an overdose of the anticholinesterase medications used to treat MG).

H. Guillain-Barré syndrome (GBS) is an acute inflammatory demyelinating disease of the PNS characterized by an acute onset of flaccid motor paralysis that begins in the lower extremities and ascends to involve the upper extremities, torso, and cranial nerves.

Paralysis of intercostal and diaphragmatic muscles often necessitates ventilatory assistance.

The progressive phase lasts up to 4 weeks, followed by recovery, which takes from 6 months to 2 years.

I. Cranial nerve disorders include trigeminal neuralgia (TN) and Bell palsy. TN is a chronic disorder of cranial nerve V and causes severe facial pain. Bell palsy is an acute disorder of cranial nerve VII, characterized by unilateral paralysis of the facial muscles.

SUGGESTIONS FOR CLASSROOM ACTIVITY—LEARNING OUTCOME ONE Have a family member of a patient with Alzheimer disease address the class regarding the experience of caring for a patient with Alzheimer disease in the home.

In class, have students share what they have learned about stages of Alzheimer disease and nursing care strategies pertinent to each stage.

Have the class access the internet for information regarding support groups for each of the disorders discussed.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME ONE Assign students to care for clients with AD, MS, or PD. Have the students discuss the care required during postclinical conference.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTIONS FOR CLASSROOM ACTIVITY—LEARNING OUTCOME TWO Have students review the medical records of clinical patients for medications that are commonly administered to people with chronic neurologic disorders. Require students to develop medication administration information sheets on the medications. Include information regarding dose, side effects, administration implications, and teaching required.

Have the class access the internet for information regarding support groups for each of the disorders discussed.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME TWO Assign students to care for clients with MG if possible. If not available, assign students to observe the plasmapheresis procedure.

SUGGESTIONS FOR CLASSROOM ACTIVITY—LEARNING OUTCOME THREE Using anatomic models, discuss the procedures to treat trigeminal neuralgia. Discuss the nursing implications of care of the postoperative patient.

Have the class access the internet for information regarding support groups for each of the disorders discussed.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME THREE Assign students to care for a client with trigeminal neuralgia or Bell palsy. If not available, have the students creating a teaching tool that supports self-care needs of the client with these disorders.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter 45 Assessing the Eye and Ear Learning Outcomes 1. Describe the anatomy, physiology, and functions of the eye, and identify abnormal findings that may indicate visual impairment.

2. Outline the components of the assessment of the eye and vision, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.

3. Describe the anatomy, physiology, and functions of the ear, and identify abnormal findings that may indicate hearing impairment.

4. Outline the components of the assessment of the ear and hearing, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.

5. Differentiate considerations for assessing vision and hearing of older adults, veterans, and adults with sequelae of childhood/congenital conditions.

6. Summarize topics that nurses teach to promote healthy vision and hearing across the lifespan.

Key Concepts I.

Anatomy, Physiology, and Functions of the Eyes A. Introduction 1.

Eyes contain 70% of the sensory receptors of the body 2.

The primary function of the eye is to encode patterns of light and carry them to the brain.

B.

Accessory structures of the eye 1.

Eyebrows: Shade 2.

Eyelashes: Protect, regulate entry of light, and distribute tears 3.

Conjunctiva: Thin, transparent mucous membrane that lubricates the eyes a) Palpebral conjunctiva: Lines upper and lower eyelids (1) Bulbar conjunctiva: Loosely covers the anterior sclera 4.

Lacrimal apparatus: Lacrimal gland, the puncta, the lacrimal sac, and the nasolacrimal duct; these secrete, distribute, drain tears.

5.

Six extrinsic eye muscles: Control movement and maintain eye shape

C.

The eye 1.

Sclera and cornea a) Sclera: Outer fibrous layer of eyeball; protects and gives shape

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

b) Cornea: Over iris and pupil, transparent, avascular, and sensitive to touch (corneal reflex) 2.

Iris a) Part of vascular layer, a disc of muscle surrounding the pupil, regulates light entry b) Pupil: Light enters through pupil, constricts with bright light (pupillary light reflex) or near vision 3.

Aqueous fluid a) Called humor, a clear fluid circulating through the anterior chamber (space between cornea and iris) and the posterior chamber (space between iris and lens) b) Canal of Schlemm 4.

Internal chamber structures: a) Posterior cavity b) Lens: Biconvex, avascular, transparent structure, directly behind pupil, and changes shape to focus and reflect light onto retina c) Uvea: Vascular layer and middle layer of the eyeball (iris, ciliary body, and choroid) d) Retina: Innermost layer of the eye, absorbs light, contains light receptor structures (1) Rods: Enable vision in dim light and peripheral vision (2) Cones: Used for bright light and the perception of color; located in the macula e) Vitreous humor f) Optic disc g) Physiologic cup h) Macula i) Fovea centralis D.

The visual pathway 1.

The visual fields of the eye and the visual pathways to the brain 2.

Stimulation of photoreceptors → bipolar cells → ganglion cells 3.

Optic nerves are cranial nerves formed of the axons of ganglion cells.

4.

Two optic nerves meet at the optic chiasma, in the anterior of the pituitary gland a) Here, axons from each retina cross to the opposite side to form pairs of axons from each eye: The left and right optic tracts b) Each optic tract carries information from both eyes 5.

Axons in optic tracts travel to the thalamus and synapse with neurons, forming pathways called optic radiations 6.

Optic radiations terminate in the visual cortex of the occipital lobe, where information is fused into one image.

7.

Depth perception depends on visual input from two eyes that both focus well

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

8.

E.

II.

Refraction

Refraction 1.

Refraction: The bending of light rays as they pass from one medium to another medium of different density 2.

Light refracts as it passes through the cornea → aqueous humor → lens → vitreous humor a) At lens, light is bent into one single point on the retina; process is called accommodation. b) The convex lens causes the image to project upside down, reversed from left to right.

3.

The brain decodes the image.

4.

Emmetropic vision: Far point of vision (20 ft), near the point of vision (8–10 in.)

5.

Convergence: Medial rotation of the eyeballs so that each is directed toward the viewed object; allows focusing of the image on the retinal fovea of each eye

Assessing the Eyes A. Health assessment interview 1.

Analyze onset, characteristics and course, severity, precipitating and relieving factors, and associated symptoms, noting timing and circumstance 2.

Be alert to nonverbal behaviors that suggest problem with eye function 3.

Ask about family history or personal history of eye issues 4.

Collect information about environmental exposure to irritating chemicals and activities that pose the risk of eye injury B.

Genetic considerations 1.

Glaucoma: Diseases associated with increased intraocular pressure (IOP) causing damage to nerves and blindness 2.

Leber hereditary optic neuropathy: Usually affecting young men, causes loss of central vision 3.

Retinitis pigmentosa: Progressive night blindness

C.

Physical assessment of the eyes 1.

Vision assessment a) Snellen chart, E chart: Distant vision b) Rosenbaum chart: Near vision c) Confrontation test: Peripheral vision 2.

Visual field testing 3.

Eye movement assessment a) Assess cardinal fields of gaze, follow pen test b) Test corneal light reflex c) Assess convergence

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

4.

Pupillary assessment a) Assess size, shape, and equality with light b) Test for accommodation by moving object’s distance from patient 5.

External eye assessment a) Inspect eyelids, puncta, bulbar and palpebral conjunctiva, sclera, and cornea b) Assess corneal sensitivity 6.

Internal eye assessment a) Assess internal structures using ophthalmoscope b) Inspect for the red reflex c) Inspect the lens and vitreous body, retina, optic disc, blood vessels of retina, and retinal background d) Palpate over the lacrimal glands, the puncta, and the nasolacrimal duct 7.

Using an ophthalmoscope a) Guidelines for using the ophthalmoscope D.

III.

Diagnostic tests and nursing interventions 1.

Computed tomography (CT), MRI: Identify foreign objects, tumors a) Remove hair pins, jewelry, assess for allergies to iodine 2.

Fluorescein angiography: Used to evaluate blood vessels for conditions such as diabetes, macular degeneration, or retinal vessel occlusion a) Informed consent, pregnancy, hot flush, and nausea b) Monitor for anaphylactic hypersensitivity responses 3.

Refraction, retinoscopy, refractometry: Measure refractive error 4.

Tonometry: Used to diagnose increased intraocular pressure in glaucoma 5.

Ultrasonography: Assess retinal tumors or detachments, and vitreous hemorrhage to locate foreign bodies

Anatomy, Physiology, and Functions of the Ears A. The external ear 1.

Auricle (pinna): Sebaceous and sweat glands, helix, and lobe; directs sound waves into ear 2.

External auditory canal: Extends from auricle to tympanic membrane, lined with skin and hair, sebaceous glands, and ceruminous glands a) Serves as a resonator for the range of sound waves typical of human speech b) Cerumen: Yellow to brown waxy substance with bacteriostatic properties that traps foreign bodies 3.

Tympanic membrane: Between external and middle ear a) Thin, semitransparent, fibrous structure covered with skin on external side and mucous on internal b) As sound waves strike, vibrations are transferred as sound waves to middle ear.

B.

The middle ear

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

1.

Air-filled cavity in temporal bone 2.

Three auditory ossicles: Conduct vibrations from tympanic membrane to oval window a) Malleus: Attaches to tympanic membrane and articulates with the incus b) Incus: Articulates with stapes c) Stapes: Fits into oval window 3.

Vibrations set the fluids of the inner ear in motion, which stimulates hearing receptors 4.

Bony wall on medial side with two membrane-covered openings: The oval window and the round window 5.

Mastoid antrum: At posterior wall of middle ear, communicated with mastoid sinuses 6.

Mastoid sinuses: Help middle ear adjust to changes in pressure 7.

Auditory tube: Helps to equalize air pressure in middle ear by opening in response to atmospheric pressure C.

The inner ear 1.

A maze of bony chambers located deep within the temporal lobe, behind eye socket 2.

The membranous labyrinth lies within maze 3.

Perilymph and endolymph 4.

The regions: a) Vestibule: Central portion of inner ear, contains saccule and utricle, which contain receptors for equilibrium b) Semicircular canals: Three canals of which each project into a different plane (anterior, posterior, and lateral) c) Cochlea: Bony chamber that houses the organ of Corti, the receptor organ for hearing 5.

Sound conduction a) Sound is produced when the molecules of a medium are compressed; the pressure disturbance is evidenced as a sound wave. b) Sound waves enter external auditory canal, causing tympanic membrane to vibrate at same frequency. c) Ossicles transmit and amplify energy. d) Stapes moves against oval window, and the perilymph in the vestibule is set in motion. e) Increased pressure of perilymph is transmitted to fibers of basilar membrane, and then to the organ of Corti f) Pull on the hair cells of the organ of Corti generates action potentials that are transmitted to cranial nerve VIII, then to the brain for interpretation 6.

Equilibrium

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) Static balance: Affected by changes in head position; detected by maculae receptors b) Dynamic balance: Affected by movement of the head; detected by crista receptors IV.

Assessing the Ears A. Health assessment interview 1.

Ask about family history 2.

Analyze problem 3.

Ask about difficulty hearing high- or low-pitched sounds, ringing in ears, and if workplace is noisy 4.

Be alert to nonverbal behaviors (inappropriate answers, requests to repeat statements, or tilting the head toward you) 5.

Ask about medical history of the ear, medical history of infectious diseases, medications B.

Genetic considerations 1.

Ear disorders a) Hereditary hearing impairment (HHI): Believed to account for more than 50% of childhood hearing loss b) Heredity as a contributor to presbycusis c) Pendred syndrome: Usually accompanied by a thyroid goiter d) Neurofibromatosis: Rare inherited disorder, acoustic neuromas, and malignant central nervous system tumors

C.

Physical assessment 1.

Using an otoscope 2.

Assess for any manifestations that might indicate a genetic syndrome such as symptoms of thyroid, kidney, or vision disorders 3.

Hearing assessment a) Whisper test b) Tuning fork (1) Weber test (2) Rinne test 4.

Ear assessment a) Inspect external ears for symmetry, proportion, color, and integrity b) Palpate the auricles and over each mastoid process c) Inspect the external auditory canal with otoscope d) Inspect the tympanic membrane (1) Tympanometry: Evaluate the response of the tympanic membrane

D.

Diagnostic tests and nursing interventions

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

1.

Audiometry: Evaluate conductive and sensorineural hearing loss 2.

Auditory brainstem response (ABR) and auditory evoked potential (AEP): Used to identify the site of sensorineural hearing loss or to diagnose brainstem pathology, stroke, and acoustic neuroma 3.

Electronystagmography (ENG) or videonystagmography (VNG): Used to evaluate vertigo or help diagnose Ménière’s disease 4.

Avoid consuming caffeine or alcohol 24 hours prior to test; food intake restricted 6 hours prior to testing 5.

Vestibular evoked myogenic potentials (VEMP): Diagnose inner ear disorders such as Ménière’s disease V.

Assessment of Special Populations 1.

Age-related changes in the eye a) Decreased musculature of eyelids, atrophy of lacrimal glands, loss of orbital fat, and xanthelasma on lids b) Lipid deposits around periphery of cornea, decrease in corneal sensitivity. c) Decrease in pupil responsiveness to light d) Lens loses elasticity, with reduced ability to change shape and focus light e) Lens becomes thicker and loses clarity, increasingly opaque. f) Vitreous humor shrinks and pulls away from retina. g) Visual field narrows. h) Photoreceptor cells atrophy and are lost. i) Light scatter in the retina increases. j) Retinal blood vessels thin and sclerose. k) Transmission and interpretation of stimuli slows.

2.

Age-related changes in the ear a) Loss of hair cells, decrease in blood supply, etc.: Presbycusis b) Loss of high-frequency sounds c) Vestibular structures degenerate, organ of Corti and cochlea atrophy d) Muscles and ligaments of middle ear weaken and stiffen e) External ear: Cerumen is dryer and harder, decreased apocrine gland activity contributes to cerumen accumulation

VI. Health Promotion A. Regular examinations 1. Eye exam: Every 2 years until the age of 60, then yearly after that 2. Ear examination: Yearly with the physical examination

Chapter Highlights A. Abnormalities in the structure or function of the eyes and their accessory structures can threaten or impair vision and the patient’s safety, independence, and social interactions.

B. Careful examination of the eyes are an important part of the comprehensive assessment. .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

C. Careful history taking is imperative to evaluate for hereditary eye conditions.

D. For hearing to occur, sound waves must travel from the external auditory meatus, through the ear canal, to vibrate the tympanic membrane and bony structures of the middle ear, which in turn activate the receptors of the cochlea.

E. Careful examination of the ears are an important part of the comprehensive assessment.

F. Careful history taking related to personal and environmental exposure to loud sounds provides information for the primary risk factors for hearing loss.

G. Changes of normal gaining lead to changes in both the eyes and ears. Environmental exposures can also trigger changes (cataracts, hearing loss).

H. Veterans have a higher risk for traumatic eye injury and hearing injury while deployed.

I. Regular examinations are the most important health-promoting practice for eye and ear health.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME ONE Provide students with unlabeled diagrams of the eye. Give the students 5 minutes to label the diagrams.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME TWO Assign each student a disorder of the eye to investigate. Divide the students into pairs and have them complete a health history interview pertinent to the assessment of the eyes. Have the “patient” of each group provide answers according to the assigned disorder.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME TWO Assign the students to assess the eyes of an assigned client.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME THREE Provide students with unlabeled diagrams of the ear. Give the students 5 minutes to label the diagrams.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME FOUR Assign each student a disorder of the ear to investigate. Divide the students into pairs and have them complete a health history interview pertinent to the assessment of the ears. Have the “patient” of each group provide answers according to the assigned disorder.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME FOUR Assign the students to assess the ears of an assigned client.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME FIVE Provide the students with a list of assessment findings. Ask the students to identify whether these findings are normal or abnormal in the older adult.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME FIVE Assess the students to assess the eyes and ears of an older client. Have the students discuss findings from this assessment during postclinical conference.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME SIX Have the students research information to create a teaching tool that focuses on eye and ear health promotion activities.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter 46 Nursing Care of Patients with Eye and Ear Disorders

Learning Outcomes 1. Describe the pathophysiology and manifestations of eye disorders, and outline the interprofessional care and nursing care of patients with these disorders.

2. Describe the pathophysiology and manifestations of ear disorders, and outline the interprofessional care and nursing care of patients with these disorders.

Key Concepts I.

Eye Disorders A. The patient with conjunctivitis 1. Conjunctivitis a) Inflammation of the conjunctiva b) Most common eye disease c) Cause is bacterial or viral infection. d) Transmitted by direct contact e) Allergens, chemical irritants, and exposure to radiant energy 2. Pathophysiology a) Acute conjunctivitis: Bacterial, viral, or fungal in origin (1) Often caused by Staphylococcus or Haemophilus b) Trachoma: A chronic conjunctivitis caused by Chlamydia trachomatis (1) Significant preventable cause of blindness worldwide (2) Transmitted primarily by close personal contact (3) Scarring of cornea 3. Manifestations: a) Conjunctivitis (1) Redness, itching, scratchy, burning, gritty sensation, and tearing and discharge b) Trachoma (1) Redness, eyelid edema, tearing, and photophobia (2) Small conjunctival follicles develop on the upper lids causing superficial corneal vascularization and infiltration with granulation tissue.

(3) Scarring of the conjunctival lining of the lid causes entropion.

(4) Lashes abrade the cornea, causing ulceration and scarring.

(5) Scarred cornea is opaque, resulting in loss of vision.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

4. Interprofessional care a) Diagnosis (1) Culture and sensitivity of exudates (2) Fluorescein stain with slit-lamp examination (3) Conjunctival scrapings b) Medications (1) Antibiotic, antiviral, or anti-inflammatory drugs (2) Anti-infectives: Erythromycin, gentamicin, penicillin, bacitracin, sulfacetamide sodium, amphotericin B, or idoxuridine (3) Antihistamines when an allergic response underlies the inflammatory process 5. Integrative therapies: Eye irrigations, soaking lid with saline compress 6. Nursing care a) Assessment (1) Health history (2) Physical assessment: Visual acuity; inspect eyelids, conjunctiva, sclera, and cornea; vital signs including temperature b) Diagnoses, outcomes, and interventions (1) Reduce risk for infection (a) Risk for scarring and cornea damage (b) Wash hands before administering eye medication (c) Teach to avoid contact lens until after infection (2) Reduce risk for impaired vision (a) Assess vision with and without corrective lenses (b) Avoid activities requiring high visual acuity (c) Dark sunglasses with appropriate UV protection 7. Transitions of care a) Teaching of home-care especially important, conjunctivitis is typically managed in the community. b) Avoidance of activities such as excessive reading while eye is inflamed 8. Nursing care of the patient who is blind a) Visual impairment: 20/40 vision in better eye, even with corrective lenses b) Blindness: No better than 20/200 in better eye with optimal correction, or a visual field of less than 20° in diameter c) Total blindness: No light whatsoever d) Nursing care (1) Orient to the environment (2) Use verbal communication freely (3) Provide other sensory stimuli .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(4) Orient to food trays by using the face of a clock (5) Allow the patient to hold your arm as you walk slightly ahead (6) Ask what assistance the client desires e) Rehabilitation: Counseling, mobility training, self-care, education in Braille, etc.

B. The patient with a corneal disorder 1. Pathophysiology a) Refractive errors (1) Myopia: Excessive curvature of cornea or elongation of eyeball (2) Hyperopia: Flattening of the cornea or an eyeball that is too short (3) Astigmatism: Irregular or abnormal curvature of the cornea b) Keratitis: Inflammation of the cornea (1) Nonulcerative keratitis (2) Ulcerative keratitis c) Corneal ulcer: Local necrosis of the cornea, with destruction of epithelium and/or stroma d) Corneal dystrophies: Accumulation of cloudy material 2. Interprofessional care a) Diagnosis: (1) Fluorescein stain (2) Conjunctival or ulcer scrapings (3) Additional lab testing (i.e., blood counts, antibody titers): Underlying infections to identify infections of autoimmune processes b) Medications (1) Antibiotic or antiviral therapy (2) Topical anti-infectives: Erythromycin, gentamicin, penicillin, bacitracin, sulfacetamide sodium, amphotericin B, or idoxuridine (3) Corticosteroids: Keratitis related to systemic inflammatory disorders or trauma c) Corrective lenses (1) Eye glasses, or contacts: Refractive errors (2) Contact lenses that reduce vision distortion for patients with keratoconus d) Surgery (1) Laser eye surgery (a) Corrects refractive errors (b) Procedures: (i) Laser in situ keratomileusis (LASIK) (ii) Photorefractive keratectomy (PRK) (iii)Laser epithelial keratomileusis (LASEK) (iv) Laser thermokeratoplasty (LTK) (2) Phototherapeutic keratectomy (PTK): Diseased corneal tissue is vaporized, and surface irregularities are corrected. .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(3) Corneal transplant (a) Lamellar keratoplasty: The superficial layer of cornea is removed and replaced with a graft. (b) Penetrating keratoplasty: A button or full thickness of the cornea is removed and replaced by donor tissue (Figure 46.3). (c) Medications: Narcotic analgesia, corticosteroid eye drops, and antibiotic drops (d) Risk of rejection very low 3. Nursing care a) Assessment (1) Health history: Risk factors; presence of redness, discomfort, tearing, photophobia, edema, and drainage; symptom onset; and presence of pain, effect on vision (2) Physical assessment: Visual acuity; inspect external eye, including conjunctiva, sclera, and cornea; and extraocular movements b) Diagnoses, outcomes, and interventions (1) Reduce risk for impaired vision (a) Assess vision, proper eye care, and protection (b) If corneal perforation is suspected, apply supine position, close eye, cover with dry, sterile dressing, and notify physician.

(2) Manage acute pain (a) Assess pain using verbal and nonverbal cues (b) Administer prescribed analgesia (c) Patch both eyes if necessary (d) Teach to apply warm compresses to reduce inflammation and pain (3) Reduce risk for injury (a) Instruct to call for help before getting up or ambulating after surgery (b) Teach how to apply an eye shield at night after the eye patch is removed (c) Instruct not to rub or scratch the eye 4. Transitions of care a) Eye cleaning, eye patch, excessive reading b) Signs of graft rejection c) Avoid increasing intraocular pressure: Straining, coughing, sneezing, bending over, and lifting heavy objects d) Resources: National Eye Institute and Lighthouse National Center for Vision and Aging C. The patient with a disorder affecting the eyelids 1. Pathophysiology a) Marginal blepharitis: Inflammation of the glands and lash follicles (1) Caused by a staphylococcal infection; or could be seborrheic in origin (or both) .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

b) Seborrheic blepharitis: Associated with seborrhea (dandruff) of the scalp or eyebrows (1) Red rimmed with mucous discharge, crusting or scaling of lid margins (2) Loss of eyelashes c) Hordeolum: A staphylococcal abscess (1) External hordeola: Acute pain at the lid margin, small tender raised area, photophobia, tearing, and the sensation of a foreign body in the affected eye (2) Internal hordeola: Seen on the conjunctival side of the lid and may have more severe manifestations d) Chalazion: A granulomatous cyst or nodule of the lid (1) Hard swelling on the lid and red surrounding tissue (2) Painless e) Entropion: Inversion of the lid margin (Figure 46.2) (1) Due to normal aging process (senile entropion) or results from an infectious process such as trachoma (2) Corneal irritation and scarring as the lashes rub on the conjunctiva f) Ectropion: Eversion of the lid margin, occurs with aging (Figure 46.6) 2. Manifestations a) Blepharitis (1) Irritation, burning, and itching of eyelid margins (2) Eye is red rimmed with mucous discharge.

(3) Crusting/scaling of lid margins (4) Loss of eyelashes b) External hordeolum (1) Acute pain at the lid margin, redness, and small tender raised area (2) Photophobia, tearing, and the sensation of a foreign body c) Internal hordeola (1) Occur on the conjunctival side of the lid d) Chalazions (1) Hard swelling on the lid, surrounding conjunctival tissue is reddened (2) Painless, increase in size, may need removed, but can resolve within several months 3. Interprofessional care a) Diagnosis (1) Typically managed in the community b) Medications (1) Topical antibiotics: Hordeolum, or infection from irritation by a deformed lid c) Treatment (1) Cleansing lid margins using a “no-tears” baby shampoo for marginal blepharitis (2) Warm saline compresses, local heat applications (3) Surgery to drain .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

4. Nursing care a) Education and comfort measures b) Eye care, risks of using old makeup c) New cotton swab or ball for each eye D. The patient with eye trauma 1. Pathophysiology a) Corneal abrasion (1) Objects causing abrasions: Contact lenses, eyelashes, small foreign bodies such as dust and dirt, and fingernails b) Burns (1) Chemical burns: Acid versus alkaline substances (2) Thermal burns: Explosions, ultraviolet rays (snowblindness, welder’s arc burn, or flash burn) c) Penetrating trauma (1) Metal flakes, arrows, knives, and gunshots (2) Sometimes not readily apparent, inspect underlying eye tissue d) Blunt trauma (1) Sports injuries (2) Lid ecchymosis (black eye) or subconjunctival hemorrhage (3) Orbital blowout fracture, ethmoid bone most likely, contents may herniate (4) Hyphema: Bleeding into the anterior chamber of the eye (a) Occurs when uveal tract of the eye is disrupted by blunt force (b) Eye pain, decreased visual acuity, and seeing a reddish tint 2. Manifestations a) Superficial abrasions of the cornea (1) Painful, heal without scarring; photophobia, and tearing b) Burns (1) Eye pain, decrease vision, swollen eyelids, red conjunctiva, edematous conjunctiva, sloughing, and cloudy/hazy cornea with ulcerations c) Eye perforations (1) Pain, partial/complete loss of vision, and bleeding or extrusion of eye contents d) Lid ecchymosis and subconjunctival hemorrhage (1) Well-defined area of erythema, no pain (2) No treatment, blood reabsorbs within 2 to 3 weeks e) Hyphema (1) Eye pain, decreased visual acuity, and seeing a reddish tint (2) Blood is visible in the anterior chamber. f) Orbital blowout fractures

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Diplopia, pain with upward movement of the affected eye, and decreased sensation on the affected cheek.

(2) Eye appears sunken (enophthalmos) and has limited movement on examination 3. Interprofessional care a) Diagnosis (1) Fluorescein, ophthalmoscopic examination (2) Conjunctival or anterior chamber hemorrhage: Presence or absence of the red reflex (3) Facial x-rays and CT scans (4) Ultrasonography: Detached retina or vitreous hemorrhage b) Treatment: Depends upon the injury (1) Removal of foreign body (2) Irrigation (3) Topical antibiotics (4) Eye patch (5) Surgical intervention (6) Bed rest in semi-Fowler position, protect injured eye with eye shield, and patch uninjured eye (7) Carbonic anhydrase inhibitor such as acetazolamide (Diamox) or dichlorphenamide (Daranide): Prescribed to reduce intraocular pressure c) Medications (1) Pain management (2) Sedations and antiemetic medications to prevent vomiting (3) Antibiotics 4. Nursing care a) Diagnoses, outcomes, and interventions (1) Reduce risk of vision loss (a) Assess vision in each eye and both eyes, with and without corrective lenses, on entry into the emergency department or primary care setting (b) Inspect eye(s) carefully for evidence of foreign bodies, burns, penetrating injury, or blunt trauma (i) Eye trauma may be hidden by other injuries. (c) If a burn or foreign body is present, anesthetic drops may be instilled and the eye irrigated either before or after the physician evaluates the patient. (d) Loose foreign bodies may be removed using a moist, sterile, cotton-tipped applicator. (e) For a severe or penetrating injury, promote rest and stabilize eye. (i) Apply eye pad or gauze dressing loosely over both the affected and unaffected eye (ii) Stabilize any penetrating object if possible .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(f) Apply eyedrops or ointment as prescribed and apply an eye pad or shield if ordered 5. Transitions of care a) Strategies to prevent further trauma b) Avoidance of activities that increase intraocular pressure E. The patient with uveitis 1. Uveitis a) Inflammation of middle vascular layer b) Can be linked to a systemic disease (arthritic or autoimmune disorder such as ankylosing spondylitis, Reiter’s syndrome, rheumatoid arthritis, or sarcoidosis), tuberculosis, and syphilis c) Manifestations: Pupillary constriction and erythema around the limbus d) Severe eye pain, photophobia, and blurred vision e) Medications: Immunosuppressive therapy, atropine, and analgesics F. The patient with cataracts 1. Cataract a) Opacification (clouding) of the lens of the eye, interferes with light transmission to retina b) Risk factors (1) CATARACt: (a) Congenital (b) Aging (c) Toxicity (steroids, etc.) (d) Accidents (e) Radiation (sunlight) (f) Altered metabolism (diabetes mellitus) (g) Cigarette smoking 2. Pathophysiology a) Senile cataracts: Fibers and proteins change and degenerate with age.

3. Risk factors a) Age b) Genetics c) Environment/lifestyle factors d) Eye trauma e) Diabetes mellitus f) Specific drugs

.

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

4. Manifestations a) Occur bilaterally unless related to eye trauma b) Visual acuity decreases, affecting both close and distance vision c) Glare, color discrimination impaired, particularly in blue to purple range d) Cloudy pupil 5. Interprofessional care a) Diagnosis (1) History, eye exam, and ophthalmoscopic exam b) Surgery (1) Extracapsular extraction (2) Intraocular lens implant (a) Often correct refractive disorders (3) Opacification of the remaining posterior capsule (a) Laser capsulotomy or surgical incision into the posterior capsule 6. Nursing care a) Assessment: Health history and physical exam b) Diagnoses, outcomes, and interventions (1) Promote knowledge and reduce anxiety (a) Explain the nonemergent nature of the condition and help the patient determine the extent to which the cataract is affecting daily life (b) Attend to verbalized concerns about surgery and its outcome (2) Promote self-care following cataract surgery (a) Assess for factors that may interfere with the patient’s ability to provide selfcare postoperatively (b) Assess for other care needs that may be impacted by vision changes in the early postoperative period 7. Transitions of care a) Initial limitations, avoid rubbing eye, prescribed medications and follow-ups b) Manifestations of postoperative complications c) Anticipated vision changes as appropriate G. The patient with glaucoma 1. Incidence and risk factors a) Affects about 3 million people over the age of 40 in the United States; remains undetected in approximately 50% b) Leading cause of blindness 2. Pathophysiology

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) Intraocular pressure of 10 to 20 mmHg is maintained by a balance between the production of aqueous humor, its flow from the posterior to the anterior chamber of the eye, and its outflow canal of Schlemm (Figure 45.3) b) Increased intraocular pressure injures the optic nerve c) Rim of the optic disc shrinks, and the optic cup becomes larger and deeper (optic “cupping”); visible before changes in visual field d) Open-angle glaucoma (also known as, chronic simple glaucoma): Anterior chamber angle between the iris and cornea is normal (1) Approximately 90% of all glaucoma (2) Cause unknown (3) Pathophysiology: Impaired aqueous outflow through the scleral venous sinus (a) Damage to axons of retinal ganglion cells with optic nerve atrophy (b) Gradual, consistent increase in intraocular pressure, and usually bilateral e) Angle-closure glaucoma (also known as, narrow-angle or closed-angle) (1) Affects people with a shallow anterior chamber caused by an inherited defect, uncommon (2) Pathophysiology: Pupil dilation or lens accommodation causes already narrowed angle to close, and blocking aqueous outflow (3) Rapid rise in intraocular pressure and permanent loss of vision if not treated promptly 3. Risk factors a) Primary condition without an identified cause b) Primary glaucoma most common in adults over the age of 60 c) May be a congenital condition in infants and children d) Secondary glaucoma: Infection or inflammation of the eye, cataract, tumor, hemorrhage, or eye trauma.

4. Manifestations a) Open-angle (1) Painless, gradual loss of visual fields, and elevated intraocular pressure b) Angle-closure (1) Severe eye and face pain, general malaise, nausea and vomiting, seeing colored halos around lights, abrupt decrease in visual acuity, and pupil may be fixed; some patients may experience periodic mild attacks.

5. Interprofessional care a) Early diagnosis and vision preservation b) Routine eye exams for early detection c) Diagnosis: (1) Tonometry (2) Fundoscopy .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(3) Gonioscopy (4) Visual field testing d) Medications (1) Open-angle glaucoma (a) Beta-blockers, adrenergics, and prostaglandin analogs (b) Carbonic anhydrase inhibitors (2) Angle-closure glaucoma (a) Topical miotics or beta-blockers (b) Systemic osmotic agents and carbonic anhydrase inhibitors e) Surgery (1) Open angle: Laser trabeculoplasty and trabeculectomy (2) Angle-closure: Gonioplasty, laser iridotomy, or peripheral iridectomy 6. Nursing care a) Assessment (1) Health history (2) Physical exam b) Diagnoses, outcomes, and interventions (1) Provide orientation to environment (a) Identify yourself, orient, and state the purpose of your visit (b) Make visual aids accessible (c) Other tools: Bright, nonglare lighting, large print, books on tape, etc. (d) Assist with meals (read menu selections, describing the position of foods, etc.) (e) Assist with mobility and ambulation (f) Unilateral and recent loss: Change in depth perception, etc.

(2) Reduce risk for injury (a) Assess ability to perform ADLs (b) Do not change arrangement of room (c) Discuss adaptations in the home for independence and safety (3) Reduce anxiety (a) Verbal and nonverbal indications of anxiety (b) Repeated expressions of concern or denial that the vision change will affect the patient’s life indicate anxiety. (c) Encourage to verbalize feelings (d) Identify how patient’s historical coping strategies can be applied 7. Transitions of care a) Prescribed medications, prescription mixing with over-the-counter medications b) Periodic eye examinations with intraocular pressure measurement c) Risks, warning signs, and management of acute angle-closure glaucoma d) Possible surgical options .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

e) Community resources, such as Visually Impaired Society, local library, and transportation services H. The patient with age-related macular degeneration 1. Pathophysiology a) Nonexudative (dry) form (1) More common (2) Accumulation of drusen causes pigment epithelium of the retina to detach in places and atrophy (3) Vision loss typically not significant, progresses slowly, can progress to exudative b) Exudative (wet) form (1) Formation of new, weak blood vessels in the potential space between the choroid and retina (2) Vessels leak, retina elevates from choroid.

(3) Scar tissue causes central vision loss.

2. Risk factors a) Aging b) Smoking c) Race d) Genetics 3. Manifestations: Central vision becomes blurred and distorted.

4. Interprofessional care a) Diagnosis (1) Amsler grid (2) Fluorescein angiogram: Detection of leaks b) Medications (1) Inhibit the growth of new blood vessels: Bevacizumab (Avastin) and ranibizumab (Lucentis) c) Nutrition (1) Vitamins C and E, beta-carotene (vitamin A), and zinc: Slow progression d) Treatment (1) Wet AMD: Laser surgery or photodynamic therapy slows vision loss 5. Nursing care a) Early intervention b) Help patient and family cope I. The patient with diabetic retinopathy 1. Diabetic retinopathy .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) 4.1 million people in the United States b) Leading cause of new blindness in people ages 20 to 74 c) Hispanics disproportionately affected 2. Pathophysiology a) Nonproliferative or background retinopathy (1) Initial form, about 10 years after diabetes is diagnosed (2) Microaneurysms that cause retinal edema or small hemorrhages (3) Yellow exudates, cotton-wool patches indicative of retinal ischemia, and red-dot hemorrhages b) Proliferative retinopathy (1) Large areas of retinal ischemia, neovascularization spreading over the inner surface of the retina and into the vitreous body (2) Vessels are fragile and easily ruptured (3) Increased risk of retinal detachment with progression 3. Risk factors a) Type 1 and type 2 diabetes mellitus b) Hypertension 4. Interprofessional care a) Yearly ophthalmologist exams b) Strict control of blood glucose levels and blood pressure c) Laser photocoagulation: Seals microaneurysms, destroys proliferating vessels d) Ranibizumab (Lucentis) improves laser treatment for patients with macular edema 5. Nursing care a) Diagnoses, outcomes, and interventions (1) Education (a) Regular eye exams: 5 years after onset of type 1, at the time of diagnosis of type 2 6. Transitions of care a) Patient should report promptly any new visual manifestation b) Cannot be cured, slowed with aggressive self-management J. The patient with a retinal detachment 1. Pathophysiology a) Separation of the retina or sensory portion of the eye from the choroid b) Area of the visual field affected is directly related to the area of detachment 2. Risk factors a) Aging, myopia, and aphakia .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

3. Manifestations a) Floaters, “spots,” lines, flashes of light, and curtain drawn over vision 4. Interprofessional care a) Diagnosis (1) Prompt treatment is necessary to preserve vision.

(2) Ophthalmoscopy established diagnosis (3) Detached portion will become necrotic, lost contact with vascular supply of the choroid, permanent blindness results. b) Treatment (1) Goal is to bring retina and choroid back into contact and reestablish the blood and nutrient supply to the retina.

(2) Inflammation treatments: Cryotherapy, supercooled probe, or laser photocoagulation (3) Other treatments: Scleral buckling, pneumatic retinopexy, and silicone oil 5. Nursing care a) Diagnoses, outcomes, and interventions (1) Promote effective retinal tissue perfusion (a) Assess for other manifestations of eye disease (b) Position so the area of detachment is inferior (2) Reduce anxiety (a) Maintain a calm, confident attitude while carrying out priority interventions (b) Reassure that most retinal detachments are successfully treated, usually on an outpatient basis (c) For spontaneous detachments, assure the patient that he or she did not cause the detachment to occur (d) Explain all procedures fully, including the reason for positioning (e) Allow supportive family members or friends to remain with the patient as much as possible 6. Transitions of care a) Limitations on positioning the head before or following repair b) Activity restrictions, eye shield c) Early manifestations K. The patient with retinitis pigmentosa 1. Hereditary degenerative disease a) Retinal atrophy and loss of retinal function progressing from the periphery to center b) Rhodopsin → degeneration of rod cells 2. Manifestations .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) Difficulty with night vision, loss of visual fields, photophobia, and disrupted color vision, and blindness by 40 3. No effective treatment L.

II.

The patient with an enucleation 1. Surgical removal of the eye a) Conjunctiva and eye muscles are sutured to a round implant inserted into the orbit. b) Permanent prosthesis fitted c) Postoperative nursing care: Teaching, psychologic support, and observation for potential complications

Ear Disorders A. The patient with otitis externa 1. Pathology a) Inflammation of the ear canal, swimmer’s ear, caused by environmental disruption b) Retained moisture and cleaning may remove cerumen, leaving canal open to infection c) Exostoses predisposes 2. Manifestations: Fullness in ear, ear pain, drainage, ear canal inflamed and edematous 3. Complications a) Cellulitis 4. Interprofessional care a) Medications (1) Relieve pain and itching: Topical corticosteroid (2) Local or systemic antibiotics, depending: Polymyxin B-neomycin-hydrocortisone (Cortisporin Otic) b) Treatment (1) Cleansing of the ear canal, particularly if drainage or debris is present (2) Teach prevention 5. Nursing care a) Diagnoses, outcomes, and interventions (1) Provide teaching to restore tissue integrity (a) Do not clean ear canals with any implement (b) Teach patient how to instill prescribed eardrops (c) Teach to avoid water in the affected ear until it is fully healed 6. Transitions of care a) Teach prevention: Dry ear after swimming, keep ear dry while swimming, and disinfect pools

.

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

B. The patient with impacted cerumen or a foreign body 1. Pathology a) Cerum accumulation: Aging is risk factor, aggravated by attempt to remove with implement 2. Risk factors a) Age 3. Manifestations: Conductive hearing loss, sensation of fullness, tinnitus, and coughing (vagal nerve) 4. Interprofessional care a) Treatment b) Removal of impacted objects: Irrigation, ear curet, forceps, and right-angle hook c) Medications (1) Mineral oil or topical lidocaine drops are used to immobilize insects 5. Nursing care a) Removal of obstructions b) Determine if tympanic membrane is intact before irrigating 6. Transitions of care a) Teach external ear care C. The patient with otitis media 1. Pathophysiology a) Inflammation or infection of the middle ear, primarily affecting the young b) Caused by upper respiratory infection and auditory tube dysfunction c) Serous: Obstruction of auditory tube for prolonged time, impairing air pressure equalization (1) Resulting negative pressure in the middle ear causes sterile serous fluid to move from the capillaries into the space (2) Sterile effusion of the middle ear (3) Barotrauma (4) Pressure differences may cause pain, hemorrhage, rupture of tympanic membrane, or of round window, and vertigo. d) Acute: Edema of the auditory tube impairs drainage, causing mucus and serous fluid to accumulate, where bacteria grows.

(1) Streptococcus pneumoniae, Haemophilus influenzae, and Streptococcus pyogenes account for most cases in adults (2) Pus can rupture tympanic membrane, bacteria may migrate causing mastoiditis or meningitis. .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(3) Fever, nausea, vomiting, lethargy, or persistent headache may indicate a complication such as meningitis.

2. Risk factors a) Upper respiratory infections, hay fever, barotrauma 3. Manifestations a) Serous (1) Decreased hearing; “snapping” or “popping”; tympanic membrane has decreased mobility; fluid or air bubbles behind the drum b) Acute (1) Pain, elevated temperature, diminished hearing, dizziness, vertigo, tinnitus, pus, tympanic membrane appears red and inflamed or dull and bulging 4. Complications a) Ruptured tympanic membrane b) Mastoiditis c) Brain abscess d) Bacterial meningitis 5. Interprofessional care a) Diagnosis (1) Impedance audiometry: Otitis media with effusion (2) A complete blood count (CBC): Bacterial infection b) Medications (1) Anti-inflammatory drug: Auditory tube dysfunction and serous otitis media do not spontaneously resolve.

(2) Antibiotic therapy, especially amoxicillin, cefdinir (Omnicef), cefuroxime, or azithromycin: Acute otitis media c) Surgery (1) Myringotomy: Relieve excess pressure in the middle ear 6. Nursing care a) Assessment (1) Health history (2) Physical exam b) Diagnosis, outcomes, and interventions (1) Manage acute pain (a) Assess pain for severity, quality, and location (b) Mild analgesics such as aspirin or acetaminophen (c) Advise to apply heat to the affected side unless contraindicated (d) Avoid air travel, rapid changes in elevation, or diving

.

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(e) Instruct to report promptly an abrupt relief of pain to the primary care provider (i) Spontaneous perforation of the tympanic membrane 7. Transitions of care a) Antibiotic therapy, its indications, use, and potential side effects b) Completing doses, keeping follow-ups c) Avoidance of swimming, diving, submerging the head while bathing (ventilation tubes) d) Postoperative care D. The patient with acute mastoiditis 1. Pathophysiology a) Infection of the mastoid air cells; pressure created by pus destroys bony septa between the cells b) Occurs when acute otitis media is not treated effectively c) Abscess, bony sclerosis of the mastoid, or meningitis may develop. d) Rare; antibiotics 2. Manifestations: a) Beginning 2 to 3 weeks after acute otitis media, earache and hearing loss, tenderness behind ear, swelling, fever, tinnitus, headache, and drainage 3. Interprofessional care a) Radiologic exam: Loss of septa b) IV antibiotic therapy c) Mastoidectomy: Partial or radical, tympanoplasty 4. Nursing care a) Prevention through treatment of acute otitis media b) Develop means to communicate with patient if surgery will impair total hearing c) Vertigo, assist with ambulation d) Recover from ear surgery (1) Importance of prescribed antibiotic therapy and follow-ups (2) Teach aseptic technique for changing the surgical dressing E. The patient with chronic otitis media 1. Permanent perforation of the tympanic membrane, with or without recurrent pus formation a) Marginal (results in cholesteatoma) (1) Infected desquamating epithelium accumulates (2) Collagenases destroy adjacent bone.

(3) Inflammation prevents blood flow to stapes, causing conductive hearing loss. .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(4) Cholesteatomas can enlarge to fill entire middle ear, causing hearing loss. b) Central perforations 2. Treatment a) Systemic antibiotics b) Tympanoplasty c) Surgical removal of cholesteatoma 3. Nursing care a) Long-term risk of not treating a perforated tympanic membrane b) Do not irrigate ear when the tympanic membrane is suspected to be perforated c) Hearing loss after surgery and communication techniques for patient and family F. The patient with otosclerosis 1. Pathophysiology and manifestations a) Abnormal bone formation in the osseous labyrinth b) Footplate of the stapes to become fixed or immobile in the oval window c) Hereditary disorder resulting in conductive hearing loss, affecting white females commonly d) Manifestations: Asymmetric hearing loss and tinnitus 2. Treatment a) Diagnoses: (1) Reddish or pinkish-orange tympanic membrane (2) Rinne test: Bone conduction of sound is retained. b) Hearing aid, sodium fluoride, stapedectomy, stapedotomy 3. Nursing care a) Education and referrals b) Nursing diagnoses: Risk for injury (hearing loss and vertigo), impaired hearing, impaired verbal communication, anxiety (transmission to children) G. The patient with inner ear disorder 1. Pathophysiology a) Vertigo: Sensation of movement when there is none, whirling, rotation (1) May be disabling, resulting in falls, injury, and difficulty walking (2) Accompanied by nausea, vomiting, nystagmus, pallor, sweating, hypotension, and salivation (3) Caused by disorders of the labyrinth, vestibular nerve or nuclei, eyes, cerebellum, brainstem, or cerebral cortex b) Labyrinthitis (also known as, otitis interna): Inflammation of the inner ear

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Uncommon, occurs when organisms enter through the oval window, the cochlear aqueduct, or through blood c) Ménière disease (also known as, endolymphatic hydrops) (1) Excess of endolymph, mechanism is unclear 2. Risk factors a) Ménière disease (1) Men and women equally, adults between the ages of 35 and 60 at highest risk (2) Cause unclear (3) Most common form thought to result from viral injury to the fluid transport system of the inner ear.

(4) Trauma, bacterial infection, autoimmune processes, and selected drugs and toxins (5) A family history 3. Manifestations a) Vertigo (1) Subjective: Sensation of movement when there is none (2) Objective: Sensation of stability while moving b) Labyrinthitis (1) Manifestations: Vertigo, sensorineural hearing deficit, nystagmus, permanent or temporary hearing loss c) Ménière disease (1) Attacks of vertigo with tinnitus and progressive unilateral hearing loss (2) Feeling of fullness in the ears, roaring or ringing sensation (3) Attacks of severe rotary vertigo 4. Interprofessional care a) Diagnosis (1) Electronystagmography: Evaluate vestibulo-ocular reflex (2) Rinne and Weber tests (3) X-rays and CT scans (4) Glycerol test: Decrease fluid pressure in the inner ear, test for Ménière disease b) Medications (1) Acetazolamide (Diamox) or hydrochlorothiazide: Reduce endolymphatic pressure (2) Diazepam (Valium) or lorazepam (Ativan): Halt an attack of vertigo (3) Parenteral droperidol (Inapsine): Sedative and antiemetic effect (4) Meclizine (Antivert), prochlorperazine (Compazine), or hydroxyzine hydrochloride (Vistaril): Antivertigo/antiemetic medications (5) Intratympanic gentamicin: Reduces vertigo of Ménière disease c) Treatments (1) Vertigo: Minimal sensory stimuli and minimal movement .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(2) Ménière disease: Prevent future attacks and preserve hearing (a) Low-sodium diet, avoid tobacco, alcohol, and caffeine d) Surgery (1) Endolymphatic decompression: Relieve excess pressure (2) Vestibular neurectomy: Destruction of a portion of the acoustic nerve (3) Labyrinthectomy: Last resort for Ménière disease 5. Nursing care a) Assessment: Health history (symptoms), physical exam (nystagmus, balance) b) Diagnoses, outcomes, and interventions (1) Reduce risk for injury (a) Attacks of vertigo are unpredictable. (b) Monitor for vertigo, nystagmus, nausea, vomiting, and hearing loss (c) Teach to avoid sudden head movements or position changes (d) Teach safety techniques during attacks (2) Promote adequate sleep (a) Masking tinnitus: Ambient noise, white-noise machine, hearing aid techniques (b) Risks and benefits of medications, oral antidepressants at bedtime 6. Transitions of care a) Discuss techniques to increase safety and deal with symptoms b) Medications, other treatment options c) Medical alert jewelry d) Community resources H. The patient with a vestibular schwannoma 1. Pathophysiology and manifestations a) Vestibular schwannoma (also known as, acoustic neuroma): A benign tumor of the vestibular portion of cranial nerve VIII b) Eventually destroys the labyrinth, impinges on brainstem, cerebellum, cranial nerves VII (facial) and V (trigeminal), and wraps around the facial nerve c) Early manifestations: Those associated with disorders of the inner ear, then neurologic signs related to area of brain affected d) Surgery, stereotactic radiotherapy, and bevacizumab (Avastin) e) Postoperative care: Gag reflex affected, speech therapy, education, and support I. The patient with hearing loss 1. Pathophysiology a) 15% of adults in the United States; 50% of those over 75 b) Conductive hearing loss

.

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Disruption in the transmission of sound from external auditory meatus to inner ear (2) Common causes: Obstruction of canal, perforated tympanic membrane, disruption or fixation of the ossicles of the middle ear, fluid, scarring, or tumors of the middle ear (3) Equal loss of hearing at all frequencies (4) Hearing aid c) Sensorineural hearing loss (1) Disorders affecting inner ear, auditory nerve, or auditory pathways of the brain (2) Inner ear damage or abnormalities decrease or distort the ability to receive and interpret stimuli (3) Common causes: Damage to the hair cells of the organ of Corti (noise exposure) especially when combined with ototoxic drugs, prenatal exposure to rubella, viral infections, meningitis, trauma, Ménière disease, and aging (4) Tumors, vascular disorders, demyelinating or degenerative diseases, infections damage central auditory pathways (5) Affects ability to hear high-frequency more than low-frequency tones (6) Speech discrimination difficult, hearing aids may not work. d) Presbycusis (1) Degeneration of hair cells of cochlea, producing a progressive sensorineural hearing loss e) Tinnitus (1) Hearing a steady, intermittent, or pulsatile, buzzing, roaring, or ringing sound without stimulus from the environment (2) Often an early symptom, most tinnitus has no pathologic importance.

2. Manifestations a) Conductive hearing loss (1) Equal loss of hearing at all sound frequencies b) Sensorineural hearing loss c) Affect the ability to hear high-frequency tones more than low-frequency tones. d) Presbycusis (1) Hearing acuity begins to decrease in early adulthood and continuously progresses (2) Associated with hearing loss: (a) Depression, confusion, inattentiveness, tension, and negativism (b) Poor general health, reduced mobility, and impaired interpersonal communication 3. Interprofessional care a) Diagnosis (1) Gross tests of hearing (such as the whisper test) .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(2) Rinne and Weber tests: Compare air and bone sound conduction (3) Audiometry: Sound frequencies are presented to each ear by either air or bone conduction (4) Speech audiometry (5) Tympanometry: External auditory meatus is subjected to varying air pressure while the sound energy flow is monitored; indirect measurement of the middle ear (6) Acoustic reflex testing: Assess movement of the structures of the middle ear b) Amplification (1) Does nothing to prevent, minimize, or treat the hearing loss (2) Bring level of sound above the hearing threshold (3) Less helpful when sound perception is distorted (4) Low usage of aids: Denial of the deficit, other health problems, poor visual acuity, decreased manual dexterity, and cost (5) Types of hearing aids (a) Completely in canal (b) In the canal (c) In the ear (d) Behind the ear with earmold (e) Behind the ear open-fit (f) Assistive listening device c) Surgery (1) Stapedectomy (2) Tympanoplasty (3) Cochlear implant 4. Nursing care a) Assessment: Health history and physical exam b) Diagnoses, outcomes, and interventions (1) Promote understanding of the hearing loss (a) Maximize hearing and prevent deterioration (b) Provide support and encourage the patient to develop coping strategies (c) Support patient’s understanding of deficit (2) Promote effective verbal communication (a) Techniques to improve communication: Signal before speaking, encourage clean corrective lenses (b) Face patient with hands away from face, keep face in full light, use facial expressions and gestures (c) Use a low pitch voice with normal loudness, normal rate; do not overarticulate (d) Do not place IVs in dominant hand; supply a magic slate (3) Promote socialization .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(a) Isolation comes about gradually and without intention. (b) Help to differentiate the reality of the isolation and its cause from the patient’s perception of isolation (c) Encourage one-to-one social interaction in quiet settings (d) Remind friends and family that a hearing deficit does not indicate loss of mental faculties 5. Transitions of care a) Teaching for home and community-based care b) Focuses on managing the deficit and developing coping strategies

Chapter Highlights A. Structures of the external eye are vulnerable to trauma and infection. Although usually minor, these problems can cause significant pain, scarring and clouding of the cornea, and loss or impairment of vision.

B. Cataracts, glaucoma, age-related macular degeneration, and diabetic retinopathy are leading causes of visual impairment in the United States. Although these conditions cannot, in most cases, be prevented, they often can be treated or their progress slowed, preserving vision.

C. Age, smoking, diabetes, radiation (sun exposure), and long-term use of certain drugs are risk factors for cataract development. Removal of the clouded lens with insertion of an intraocular lens is the treatment of choice for cataracts. Surgery is elective, performed only when the cataract significantly impairs the ability to maintain ADLs and recreational activities.

D. Glaucoma is progressive loss of visual fields associated with increased intraocular pressure and impaired aqueous humor drainage. Open-angle or chronic glaucoma, the predominant form of the disorder, has few symptoms, making regular vision exams an important factor to preserve vision. It can be controlled using medications and, as needed, laser surgery to promote aqueous humor drainage.

E. Angle-closure glaucoma is a medical emergency requiring immediate treatment to lower intraocular pressure to preserve vision. Angle-closure glaucoma usually affects only one eye; however, the patient is at risk for future attacks affecting the other eye.

F. Age-related macular degeneration, a leading cause of blindness, cannot be effectively treated, although its progress may be slowed or halted through use of high-dose antioxidant vitamins and zinc if it is identified early. Macular degeneration affects the macula, the area of high-acuity central vision.

G. Diabetic retinopathy eventually affects nearly all people with diabetes. It is a disease of the small blood vessels of the retina, leading to formation of aneurysms, retinal ischemia, and growth of fragile new vessels (neovascularization) that easily rupture leading to hemorrhage. It is treated with laser surgery to seal fragile vessels.

H. Disruption of the integrity of any portion of the auditory pathway from the external ear through neural transmission to auditory centers of the brain can impact an individual’s .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

ability to hear and interpret sounds. Health promotion activities and prompt treatment of disorders are important measures to preserve hearing.

I. Otitis media is related to auditory tube dysfunction, with impaired pressure equalization of the middle ear. Otitis media may be either serous (sterile) or infectious. Both cause acute discomfort with diminished hearing, snapping, popping, and possible vertigo and systemic symptoms. The risk of complications, including rupture of the tympanic membrane, damage to structures of the middle ear, and spread of infection to surrounding tissues, is greater with acute otitis media.

J. Potential complications of acute otitis media include mastoiditis, chronic otitis media with tympanic membrane perforation, and cholesteatoma formation. Hearing loss in the affected ear is a possibility with these disorders. The primary treatment is prevention through adequate treatment of acute otitis media.

K. Inner ear disorders can affect the perception of sound as well as equilibrium. When balance is affected, the patient is at significant risk for injury, making safety a nursing care priority.

L. The primary manifestations of disorders of the inner ear are vertigo and possible hearing loss. Severe vertigo can interfere with safety, nutrition, and the patient’s ability to maintain ADLs and life roles.

M. Hearing loss affects people of all ages, although older adults are disproportionately affected. Impaired hearing significantly affects the ability to communicate, making it a major public health problem. Despite its prevalence, impaired hearing is often undiagnosed and untreated.

N. The two major types of hearing loss are conductive and sensorineural. Presbycusis, hearing loss associated with aging, is a type of sensorineural hearing loss. Hearing loss may be accompanied by tinnitus, the perception of sound without an environmental stimulus.

Amplification devices (hearing aids) are the primary treatment for hearing loss.

SUGGESTIONS FOR CLASSROOM ACTIVITY—LEARNING OUTCOME ONE Divide the class into small groups. Assign each group a type of eye disorder covered in this chapter.

Have the group create a visual presentation of the disorder’s pathophysiology. Share the work in class.

Have students develop a teaching plan for the prevention of vision loss.

Using anatomic models, explain the proper technique for instillation of eye drops.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME ONE Assign students to care for clients with visual disorders. Prepare to discuss the clients’ care needs during postclinical conferred.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTIONS FOR CLASSROOM ACTIVITY—LEARNING OUTCOME TWO Divide the class into small groups. Assign each group a type of ear disorder covered in this chapter.

Have the group create a visual presentation of the disorder’s pathophysiology. Share the work in class.

Have students develop a teaching plan for the prevention of hearing loss.

Using anatomic models, explain the proper technique for instillation of ear drops.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME TWO Assign students to care for clients with hearing disorders. Prepare to discuss the clients’ care needs during postclinical conferred.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter 47 Assessing the Male and Female Reproductive Systems

Learning Outcomes 1. Describe the anatomy, physiology, and functions of the male reproductive system, and identify abnormal findings that may indicate impairment of the reproductive system.

2. Outline the components of the assessment of the male reproductive system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.

3. Describe the anatomy, physiology, and functions of the female reproductive system, and identify abnormal findings that may indicate impairment of the reproductive system.

4. Outline the components of the assessment of the female reproductive system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.

5. Differentiate considerations for assessing the reproductive systems of older adults and of individuals in the LGBTQI population.

6. Summarize topics that nurses teach to promote healthy sexuality and reproduction across the lifespan.

Key Concepts I.

Anatomy, Physiology, and Functions of the Male Reproductive System A. The breasts 1.

Areola and small nipple 2.

Undeveloped breast tissue 3.

Gynecomastia B.

The penis 1.

Genital organ enclosing urethra 2.

Homologous to the clitoris 3.

Shaft and tip called the glans, which is covered by the foreskin (or prepuce) 4.

Erection: Erectile tissue is filled with blood in response to a reflex that triggers the parasympathetic nervous system to stimulate arteriolar vasodilation

C.

The scrotum 1.

Regulates the temperature of the testes 2.

Contracts and relaxes to regulate temperature 3.

Optimum temperature for sperm production is about 2 to 3 degrees below body temperature

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

II.

D.

The testes 1.

Develop in abdominal cavity of the fetus, then descend through the inguinal canal into the scrotum just before birth 2.

Homologous to the female’s ovaries 3.

Each testis contains 250 to 300 lobules, each lobule contains one to four seminiferous tubules (responsible for sperm production)

E.

The ducts and semen 1.

Sperm production a) Seminiferous tubules lead into the efferent ducts and become the rete testis b) From the rete testis, 10,000 to 20,000 efferent ducts join the epididymis c) Epididymis contracts to propel the sperm 2.

Seminal fluid a) Nourishes the sperm, provides bulk, and increases its alkalinity b) Produced mainly by seminal vesicles c) Also contains secretions from accessory sex organs, epididymis, prostate gland, Cowper’s glands 3.

Semen: Sperm mixed with seminal fluid 4.

Ejaculation a) Seminal fluid mixes with sperm at ejaculatory duct b) Semen enters urethra through ejaculatory duct for expulsion

F.

The prostate gland 1.

Encircles the urethra just below the urinary bladder, is surrounded by smooth muscle 2.

Secretions of prostate enter urethra through ducts during ejaculation, 1/3 total semen

G.

Male sex hormones (androgens) 1.

Mostly produced in testes, also adrenal cortex 2.

Testosterone: Development and maintenance of sexual organs, secondary sex characteristics, spermatogenesis, metabolism, growth of muscles and bone, libido

Assessing the Male Reproductive System A. Health assessment interview 1.

Family history of testicular or prostate cancer 2.

Chronic diseases 3.

Medication use 4.

Mother’s pregnancy 5.

Did patient have mumps as a child?

6.

Lifestyle

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

7.

Questions about sexuality

B.

Genetic considerations 1.

Family history is a major risk factor for prostate and testicular cancers 2.

XX chromosomes instead of XY

C.

Male reproductive system assessments 1.

Breast and lymph node assessment a) Gynecomastia b) Hard, irregular nodule in nipple area c) Enlarged axillary nodes d) Enlarged supraclavicular nodes 2.

External genitalia assessment a) Inguinal and femoral area (Figure 47.2) b) Inspect the penis (1) Phimosis (2) Paraphimosis (3) Balanitis (4) Ulcers, vesicles, or warts c) Inspect the external urinary meatus (Figure 47.3) (1) Erythema or discharge d) Inspect the skin on the shaft of the penis for inflammation e) Palpate the shaft of the penis f) Inspect the scrotum (1) Unilateral/bilateral poorly developed scrotum (2) Swelling of the scrotum (3) Tender, painful scrotal swelling (4) A painless testicular nodule g) Palpate each testis and epididymis 3.

Prostate assessment a) Digital rectal examination (DRE) b) Enlargement/obliteration of median sulcus c) Enlargement with asymmetry/tenderness d) Hard irregular nodule

D.

Diagnostic tests 1.

Biopsy of the prostate 2.

Gonorrhea culture 3.

Prostate specific antigen (PSA) 4.

Prostate ultrasound 5.

Semen analysis 6.

Syphilis screening tests

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) Venereal Disease Research Laboratory (VDRL) b) Rapid plasma reagin (RPR) c) Fluorescent treponemal antibody absorption (FTA-ABS) III.

Anatomy, Physiology, and Functions of the Female Reproductive System A. The breasts 1.

Mammary glands; supported by pectoral muscles and richly supplied with nerves, blood, and lymph 2.

The areola is located slightly below the center of the breast; contains sebaceous glands and a nipple 3.

Made of adipose tissue, fibrous connective tissue, glandular tissue 4.

Cooper’s ligaments: Support breast and extend from the outer breast tissue to the nipple, dividing the breast into 15 to 25 lobes 5.

Each lobe is made of alveolar glands connected by ducts that open to nipple B.

The external genitalia 1.

Collectively called the vulva a) Mons pubis: Pad of adipose (fat) tissue covered with skin and hair that lies anterior to the symphysis pubis b) Labia: Majora and minora c) Vestibule: Contains the openings for the vagina and the urethra as well as the Bartholin’s and Skene’s glands d) Clitoris: Erectile organ analogous to the penis, highly sensitive and distends during sexual arousal e) Introitus: Prior to the first intercourse or trauma, the introitus is surrounded by a connective tissue membrane called the hymen

C.

The internal organs 1.

The vagina and cervix a) Vagina is a fibromuscular tube b) Uterine cervix is at the vagina’s upper end in an area called the fornix c) Route for secretions, organ of sexual response, passageway for birth d) pH is bacteriostatic, maintained by estrogen and vaginal flora (1) Estrogen stimulates the growth of vaginal mucosal cells (2) They thicken and have increased glycogen content (3) Glycogen is fermented to lactic acid by lactobacilli e) Cervix is a firm structure, protected by mucus that changes consistency and quantity during the menstrual cycle and during pregnancy 2.

The uterus a) Hollow muscular organ located between bladder and rectum b) Comprised of the fundus, the body, and the cervix

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

c) Supported by the broad ligaments, the round ligaments, the uterosacral ligaments, the transverse cervical ligaments d) Three layers: (1) Perimetrium (2) Myometrium (a) Muscle fibers that run in various directions, allowing contractions during menstruation (3) Endometrium (a) Outermost layer is shed 3.

The fallopian tubes a) Attached to the uterus on one end and supported by the broad ligaments b) Lateral ends of the fallopian tubes are open and made of fimbriae c) Fimbriae pick up the ovum d) Cilia and contractions of muscle move ovum through tubes toward uterus e) Fertilization usually occurs in outer portion of a fallopian tube

4.

The ovaries a) Primary reproductive organs in women b) Flat, almond-shaped structures located on either side of the uterus below the ends of the fallopian tubes c) Homologous to the male’s testes d) Ovaries store ova and produce estrogen and progesterone

D.

Female sex hormones 1.

Estrogens: Essential for development and maintenance of secondary sex characteristics a) Three forms estrone (E1), estradiol (E2), estriol (E3) b) Responsible for the normal structure of skin and blood vessels c) Decrease rate of bone resorption, promote increased high-density lipoproteins, reduce cholesterol levels, enhance blood clotting, promote retention of sodium and water 2.

Progesterone: Development of breast glandular tissue and the endometrium a) Relaxes smooth muscle to decrease uterine contractions during pregnancy 3.

Androgens: Responsible for normal hair growth patterns at puberty; may also have metabolic effects

E.

The menstrual cycle 1.

Menstrual phase: Inner endometrial (functionalis) is expelled as menstrual fluid 2.

Proliferative phase: Functionalis layer thickens, spiral arteries increase, tubular glands form, cervical mucus forms channels to help sperm move

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

3.

Secretory phase: If fertilization does not occur, hormone levels fall, endometrial cells degenerate and slough off IV.

Assessing the Female Reproductive System A. Health assessment interview 1.

Family history of ovarian or breast cancer 2.

Menstrual history 3.

Obstetric history 4.

Sexual history 5.

Medication use 6.

Reproductive system examination history 7.

Chronic illnesses 8.

History of diethylstilbestrol exposure in utero 9.

Exposure to asbestos 10.

Exposure to cigarette smoke 11.

History of fibrocystic disease 12.

History of vaginal bleeding and vaginal discharge 13.

Questions about sexuality B.

Genetic considerations 1.

Ovarian and breast cancer a) BRCA1 and BRCA2 2.

Family history of endometrial, colon, or breast cancer increases a woman’s risk for endometrial cancer 3.

Turner’s syndrome

C.

Physical assessment 1.

Breast assessment a) Palpate both breasts, axillae, and supraclavicular areas (Figure 47.7) b) Palpate the nipple, and then compress it c) Abnormal findings: (1) Retractions, dimpling, abnormal contours (2) Peau d’orange/unilateral venous patterns (3) Redness (4) Recent unilateral inversion of nipple (5) Asymmetry in nipple direction (6) Tenderness upon breast palpation (7) Nodules in tail of breast (8) Hard, irregular, poorly delineated, fixed unilateral masses (9) Bilateral, single or multiple, round, mobile, well-delineated masses (10) Swelling, tenderness, erythema, and heat (11) Loss of nipple elasticity

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(12) Blood or serous discharge (13) Bilateral milky discharge not due to prior pregnancy (14) Unilateral discharge from one or two ducts 2.

Axillary assessment a) Inspect and palpate the axillae (Figure 47.8) (1) Rash (2) Signs of inflammation and infections (3) Enlarged axillary nodes (4) Enlarge supraclavicular nodes

3.

External genitalia assessment a) Inspect and palpate the labia majora b) Inspect the labia minora c) Palpate the inside of the labia minora between thumb and forefinger d) Inspect the clitoris e) Inspect the vaginal opening f) Palpate Skene’s glands (Figure 47.9) g) Palpate Bartholin’s glands (Figure 47.10) h) Inspect the vaginal orifice for bulging and urinary incontinence i) Inspect and palpate the perineum j) Abnormal findings (1) Excoriation, rashes or lesions of labia (2) Bulging of labia (3) Varicosities (4) Ulcers or vesicles on labia (5) Small, firm, round cystic nodules in labia (6) Wartlike lesions (7) Firm, painless ulcers (8) Shallow, painful ulcers (9) Ulcerated or red raised lesions in older women (10) Enlargement of the clitoris (11) Swelling, discoloration, or lacerations of vaginal opening (12) Discharge from or lesions on vaginal opening (13) Fissures or fistulas associated with vaginal opening (14) Discharge/tenderness of Skene’s glands (15) A nontender mass in posteriolateral labia majora

4.

Vaginal and cervical assessment a) Use a vaginal speculum to inspect the vaginal walls and cervix (Box 47.1) b) Palpate the cervix, uterus, and ovaries (Box 47.2) c) Abnormal findings

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Bluish color of cervix/vaginal mucosa (2) Pale cervix (3) Cervix to the right or left of midline (4) Projection of cervix more than 3 cm into vaginal canal (5) Transverse or star-shaped cervical lacerations (6) Enlarged cervix (7) Small, white, or yellow raised round areas on cervix (8) Cervical polyps (9) Retroverted uterus (10) Retroflexed uterus (11) Pain on movement of the cervix (12) Objective signs of pregnancy (13) Myomas (14) Ovarian tumors (15) Profuse menstrual bleeding (16) Irregular bleeding (17) Postmenopausal bleeding D.

Diagnostic tests 1.

Breast biopsy (fine-needle aspiration, core needle biopsy, vacuum-assisted mammotome, large core surgical biopsy, open surgical biopsy) 2.

Breast cancer genetic testing (BRAC-1, BRAC-2) 3.

Breast ultrasound 4.

Chlamydia screening 5.

Colposcopy 6.

Conization of cervix a) LEEP (loop electrosurgical excision procedure) b) LETZ (loop electrosurgical excision of transformation zone) 7.

Cultures for bacteria, Candida (yeast), or Trichomonas 8.

Endometrial biopsy 9.

Gonorrhea culture 10.

HPV test (HPV DNA test, genital human papilloma test) 11.

Hysterosalpingogram 12.

Laparoscopy 13.

Mammogram 14.

Papanicolaou smear 15.

Syphilis (dark-field examination) 16.

Syphilis screening tests a) Venereal Disease Research Laboratory (VDRL) b) Rapid plasma reagin (RPR) c) Fluorescent treponemal antibody absorption (FTA-ABS) 17.

Ultrasound (abdominal, vaginal)

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

V.

Assessment of Special Populations A. Assessing older adults 1.

Age-related changes in the male reproductive system a) Prostate gland: Benign prostatic hyperplasia b) Penis, testes, and scrotum (1) Reduced capacity of the epithelial tissue and mucosa of seminal vesicles (2) Sclerosis of penile arteries and veins (3) Impotence 2.

Age-related changes in the female reproductive system a) Breasts (1) Atrophy, with sagging of breast tissue (2) Linear strands may appear from shrinkage and fibrotic changes b) External genitalia (1) Labia flatten, and vulvar adipose tissue and hair decrease (2) Decrease in collagen and adipose tissues in the vaginal canal, resulting in loss of rugae, and shortening and narrowing of vaginal canal (3) Decrease in vaginal lubrication; epithelium becomes thinner and avascular (4) More alkaline pH of vagina (5) Cervix becomes smaller c) Internal organs (1) Uterus shrinks (2) Fallopian tubes shrink and shorten (3) Ovaries are smaller and thicker (4) With menopause, hormone production of estrogen decreases (5) Loss of estrogen may cause pelvic floor muscles to weaken (6) Loss of estrogen causes changes throughout the body, including loss of skin tone (wrinkling) and growth of facial hair B. Assessing the LGBTQI community 1. Routine health screenings for breast, ovarian, cervical, testicular, and prostate cancer should be offered for anyone who has an organ at risk

VI. Health Promotion A. Prevention 1. Nutrition, weight management, regular exercise, and not using any tobacco products B. Routine Examinations 1. Anticipated changes with aging

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter Highlights A. The male reproductive system contains both internal and external organs. There is an overlap between the reproductive system and the urinary system in male patients.

B. Psychosocial factors including stress, anxiety, and grief influence sexual functioning.

Sensitivity to cultural differences in discussions of reproductive function is important.

C. Physical assessment of the male reproductive system includes inspection and palpation of external genitalia, palpation of internal reproductive organs, transillumination of the testes, assessment of inguinal areas, and assessment of the perianal area and rectum.

D. Abnormal findings in the male reproductive system include lesions, disorders of the penis or scrotum, and inguinal hernias.

E. The female reproductive system undergoes cyclic changes in response to estrogen and progesterone levels. The female reproductive system manufactures ova for fertilization, transports fertilized ova for implantation, regulates production and secretion of hormones, and provides sexual stimulation and pleasure. Abnormal findings in the female reproductive system include inflammatory processes and problems with the external genitalia, the cervix, and the vagina.

F. Psychosocial factors including stress, anxiety, and grief influence sexual functioning.

Sensitivity to cultural differences in discussions of reproductive function is important.

G. The external portion of the female reproductive system can be assessed by the registered nurse. The internal organs, however, are usually assessed by healthcare providers or specially trained nurses.

H. The nurse should be familiar with the techniques of proper draping and assistance so the examination can be provided in comfort for the patient.

I. Most older men require more stimulation to achieve an erection and orgasm, and they have shorter orgasms with less forceful ejaculation. A man’s overall health, chronic health conditions, and prescription medications can all affect his sexuality.

J. Loss of sexual function in older women is not an inevitable result of aging, although physical changes related to aging do affect the female sexual response.

K. The LGBTQI community presents unique concerns for care of the reproductive system.

Sensitivity and acceptance are important in the care of these patients. The specific assessments and findings depend on the patients themselves.

L. All patients should be educated to specific reproductive system health promotion. Nurses need to be current on the most up-to-date guidelines for screening based on gender, age, and risk factors for the patient.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME ONE Use anatomic models to outline the reproductive systems of both sexes.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME TWO Discuss therapeutic communication techniques that are useful when interviewing patients in regard to sexual disorders or history.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME TWO Have students review the medical records of clinical patients for indications of sexual disorders.

Help students identify pertinent assessment questions, techniques, and findings.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME THREE Use anatomic models to outline the reproductive systems of both sexes.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME FOUR Discuss therapeutic communication techniques that are useful when interviewing patients in regard to sexual disorders or history.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME FOUR Have students review the medical records of clinical patients for indications of sexual disorders.

Help students identify pertinent assessment questions, techniques, and findings.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME FIVE Provide the students with a list of various assessment findings for the male and female reproductive system. Have the students identify which findings are normal and which are abnormal in the older adult.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME SIX Have the students create a tool to instruct clients to prevent reproductive system health problems.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter 48 Nursing Care of Men with Reproductive System and Breast Disorders

Learning Outcomes 1. Describe the pathophysiology and manifestations of male sexual dysfunction, and outline the interprofessional care and nursing care of patients with erectile dysfunction.

2. Describe the pathophysiology and manifestations of disorders of the penis, and outline the interprofessional care and nursing care of patients with these disorders.

3. Describe the pathophysiology and manifestations of disorders of the testis and scrotum, and outline the interprofessional care and nursing care of patients with these disorders.

4. Describe the pathophysiology and manifestations of disorders of the prostate gland, and outline the interprofessional care and nursing care of patients with these disorders.

5. Describe the pathophysiology and manifestations of disorders of the breast, and outline the interprofessional care and nursing care of patients with these disorders.

Key Concepts I. Disorders of Male Sexual Function A. The Patient with Erectile Dysfunction 1. Treatments and disorders of the male reproductive system often affect erection and ejaculation a) Erectile dysfunction: Inability to attain and maintain an erection sufficient to permit satisfactory sexual intercourse, impotence: Total or inconsistent ability 2. Pathophysiology a) Age-related (1) Cellular and tissue changes in the penis, decreased sensory activity, hypogonadism, effects of chronic illness (2) Penis: (a) Elastic collagen to more rigid collagen: Decreased distensibility, interferes with veno-occlusive mechanism (b) Vibrotactile sensation decreases (3) Hypogonadism 3. Common causes a) Vascular b) Neurologic c) Urologic d) Endocrine e) Respiratory .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

f) Inflammatory g) Mechanical h) Iatrogenic i) Lifestyle related 4. Risk factors: a) Most common: Damage to arteries, smooth muscles, and fibrous tissues b) Diseases: Diabetes, kidney disease, chronic alcoholism, atherosclerosis, and vascular disease, Parkinson disease, prostate surgery 5. Manifestations a) Inability to achieve an erect penis to complete sexual intercourse 6. Interdisciplinary care a) Diagnosis (1) Penile monitoring, penile blood flow (2) Blood chemistry, complete blood count, lipid profile (3) Urinalysis, testosterone, prolactin, thyroxin, and prostate specific antigen (PSA) (4) Nocturnal penile tumescence and rigidity (NPTR) monitoring (psychogenic vs. organic causes) (5) Cavernosometry and cavernosography b) Medications (1) Oral medications: Sildenafil citrate (Viagra), vardenafil hydrochloride (Levitra), or tadalafil (Cialis) (2) Injectable medications (hormone replacement): Papaverine and prostaglandin E injections, alprostadil (Caverject) c) Mechanical devices: Vacuum constriction device (VCD) and O-ring d) Surgery (1) Revascularization procedures do not treat underlying causes (2) Implantation of prosthetic devices e) Lifestyle changes: Quitting smoking, eating healthy, exercise, reduced alcohol use, and stress reduction 7. Nursing care a) Diagnoses, outcomes, and interventions (1) Promote sexual function (a) Assess for risk factors for ED (medications and surgery) (b) Assess for sexual dysfunction (c) Assessment of current sexual practices (d) Discuss previous methods of coping with ED (e) Provide information about treatment options (f) Encourage discussion with partner .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(2) Situational low self-esteem (a) Health history: Physiologic function, other chronic illnesses, and feelings about sexual inadequacy (b) If the man has had a penile implant, teach use to him and his partner 8. Transitions of care a) Give information about ED in order to relieve shame b) Referral sources B. The Patient with Ejaculatory Dysfunction 1. Retrograde ejaculation a) Seminal fluid discharged into the bladder b) Usually related to surgery 2. Premature ejaculation a) Most common b) Most responsive to management (1) SSRIs, tricyclic antidepressants, and topical anesthetics (2) Techniques (condoms, relaxation, guided imagery, and constrictive rings) c) Psychogenic, serotonin regulation, and diabetes 3. Delayed ejaculation a) Age-related decreased vibrotactile sensation b) Medications II. Disorders of the Penis A. The Patient with Phimosis or Priapism 1. Pathophysiology a) Phimosis: Constriction of the foreskin in uncircumcised men so it cannot be retracted over the glans penis (1) Congenital or from chronic infection (2) Prevents adequate hygiene, which may increase risk of cancer (3) May interfere with urinary elimination and intercourse b) Paraphimosis: Foreskin is tight and constricted, and not able to cover the glans penis (1) Glans becomes engorged and edematous, ischemia (2) Caused by long-term retraction of the foreskin, catheter in the uncircumcised male c) Priapism: Involuntary, sustained, painful erection that is not associated with sexual arousal (1) Results in ischemia and fibrosis of the erectile tissue (2) Caused by impaired blood flow in the corpora cavernosa (3) Primary (tumors and trauma) or secondary (blood or neurologic disorders, medications, and renal failure)

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

2. Interdisciplinary care a) Surgical circumcision b) Priapism (1) Iced saline enemas, IV ketamine (Ketalar), and spinal anesthesia (2) Blood aspirated from corpus through dorsal glans, catheterization and pressure dressings (3) Vascular shunts to maintain blood flow 3. Nursing care a) Assessing the penis: Degree of erection, ischemia, and palpation b) Monitoring urinary output: Oliguria, urinary retention c) Providing pain control B. The Patient with Cancer of the Penis 1. Pathophysiology a) Rare; squamous cell carcinoma accounts for 95% of all penile cancers b) Nodular or wartlike growth or a red velvety lesion on glans or foreskin, drainage c) If treated before inguinal node involvement, chances for cure are good 2. Interdisciplinary care a) Biopsy of lesion and suspected inguinal lymph nodes b) Early stage treatment: Fluorouracil cream, external-beam radiation, laser therapy, surgical excision c) Larger lesions may require partial or total penectomy d) Distant metastasis requires chemotherapy 3. Nursing care a) Teaching about hygiene, safer sex, protection from UV light b) Body-image issues associated with penectomy c) Urine dribbling III. Disorders of the Testis and Scrotum A. The Patient with a Benign Scrotal Mass 1. Pathophysiology a) Hydrocele (1) Collection of fluid within the tunica vaginalis (2) Occurs secondary to trauma, infection, or a tumor (3) Chronic hydrocele: Over 40, production and reabsorption imbalance (4) Treatment: Aspirate, agent is injected into scrotal sac to sclerose tunica vaginalis b) Spermatocele (1) Efferent ducts in the epididymis dilate and form a cyst (2) Result from sperm leakage after trauma or infection .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

c) Varicocele (1) Caused by valve issue, allowing blood to pool in spermatic cord veins (2) Soft mass forms, decreasing blood flow through testis, can cause infertility (3) Occurring mostly on left side 2. Nursing care a) Information and reassurance about pain management regarding surgical treatment b) Hematomas occasionally develop, manifested by edema and purple discoloration B. The Patient with Epididymitis 1. Infection of the epididymis a) Sexually active men less than 35 years (most often) (1) Precipitated by urethritis caused by Chlamydia trachomatis or Neisseria gonorrhoeae (2) Sexually transmitted from Escherichia coli, Haemophilus influenzae, Cryptococcus, or tuberculosis b) Men over 35: Associated with urinary tract infection or prostatitis c) Infectious epididymis manifests pain and local edema, progresses to erythema and edema of entire scrotum 2. Inflammation of the epididymis: Response to the reflux of urine into the ejaculatory ducts 3. Interdisciplinary care a) Diagnosis: Culture from urethral swab or epididymal aspiration b) Treatment: IV antibiotics, outpatient antibiotics c) Patient’s partner if transmitted sexually 4. Nursing care a) Symptomatic relief and teaching b) Information on possibility of infertility c) STI prevention C. The Patient with Orchitis 1. Acute infection of the testes a) Most common: An extension of a genitourinary infection or complication of systemic illness (mumps, scarlet fever, and pneumonia) b) Manifestations: Sudden, high fever, increased WBCs, scrotal redness, swelling, and pain 2. Acute inflammation of the testes: Trauma and surgery 3. Interdisciplinary care: Urine culture, antibiotic therapy, scrotal support and elevation, hot or cold compresses, and analgesics .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

D. The Patient with Testicular Torsion 1. Twisting of spermatic cord, sudden onset of scrotal swelling, pain, nausea, vomiting 2. Vascular engorgement and ischemia 3. Medical emergency requiring immediate diagnosis (scanning, ultrasound) and surgery 4. Spontaneous or following trauma or physical exertion, usually occurring between 0 and 20 years E. The Patient with Testicular Cancer 1. Pathophysiology a) 95% 5-year survival rate b) 90% are germ cell tumors (1) Seminomas: Seminiferous epithelium of the testes (2) Nonseminomas: Include embryonal carcinoma, teratoma, choriocarcinoma, and yolk cell carcinoma (3) Gonadal stroma cells tumors: Leydig cell, Sertoli cell, granulosa cell, and theca cell tumors c) Spreads by lymphatic and vascular channels, causing distant disease d) Metastatic symptoms: Lower extremity edema, back pain, cough, hemoptysis, and dizziness 2. Risk factors a) Most common: White males, years 13 to 35 b) Age, cryptorchidism, family history, cancer of the other testicle, occupational risks, presence of multiple atypical nevi 3. Manifestations a) Slight, painless enlargement of one testicle, abdominal ache, feeling of heaviness in scrotum 4. Complications a) Rare unless metastasized 5. Interdisciplinary care a) Diagnosis: Serum studies (1) Germ cell: Chorionic gonadotropin (hCG) and alpha-fetoprotein (AFP) (2) Serum lactate dehydrogenase (LDH) b) Medications: Platinum-based combination chemotherapy c) Surgery: Radical orchiectomy, modified retroperitoneal lymph node dissection d) Radiation therapy: Distant metastasis stage I seminoma in retroperitoneal lymph nodes 6. Nursing care a) Diagnosis, outcomes, and interventions .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) Educate patient about postoperative care (a) Explain pain control methods (b) Teach the manifestations of complications (2) Promote sexual function (a) Ejaculation and fertility issues resulting from treatments (b) Assess prediagnosis sexual function (c) Preserving sperm in a bank (d) Coping with altered sexual function and appearance 7. Transitions of care a) Include family in teaching to facilitate support of patient b) Teach for risk of recurrence c) Long-term health effects of chemotherapy and radiation IV. Disorders of the Prostate Gland A. The Patient with Prostatitis 1. Pathophysiology a) Acute bacterial prostatitis: Infection from urethra or reflux of infected urine b) Chronic bacterial prostatitis: Urinary tract infections c) Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) (1) Most common, least understood; dysfunction of the pelvic floor musculature, not prostate issue (2) Inflammatory prostatitis; autoimmune disorder, cause unknown (a) Abnormal inflammatory cells present (3) Noninflammatory prostatitis: Similar manifestations, no evidence of prostatic infection or inflammation 2. Risk factors a) Urinary tract infection or catheterization, transrectal biopsy, sexually transmitted infection, HIV, dehydration, urethral stricture, and prostate calculi 3. Manifestations a) Acute bacterial (1) Fever, malaise, muscle and joint pain, painful ejaculation, urinary frequency and urgency, dysuria, and urethral discharge (2) Pain in perineum, prostate gland, rectum, and lower back b) Chronic bacterial (1) Urinary frequency and urgency, dysuria, low back pain, and perineal discomfort c) Chronic prostatitis/chronic pelvic pain syndrome (1) Pelvic wall pain d) Inflammatory

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(a) Low back pain, urinary manifestations; pain in the penis, testicles, scrotum, lower back, and rectum; decreased libido, painful ejaculations 4. Complications a) Epididymitis, prostatic abscess, bacteremia, and sepsis 5. Interdisciplinary care a) Diagnosis: Urine and prostatic secretion determine type of blood cells and bacteria b) Medications: Antibiotics, nonsteroidal anti-inflammatories, and anticholinergics 6.

Nursing care: Symptom management teaching (increase fiber, fluids, and local heat)

B. The patient with benign prostatic hyperplasia 1. Age-related, nonmalignant prostate enlargement; over ½ of men over 60 2. Pathophysiology a) Increased sensitivity to DHT with age, plus estrogen sensitizes prostate to DHT b) Increased estrogen and/or decreased testosterone c) Begins as small nodules in periurethral glands, hypertrophy occurs d) Enlargement presses on urethra (main issue of BPH) (Figure 48.3) 3. Risk factors a) Age b) Testosterone 4. Manifestations a) Partial or complete obstruction of outflow of urine, bladder instability occurs b) Overflow incontinence with any increase in intra-abdominal pressure 5. Complications: Bladder distention → diverticula = infection → ascend to kidneys = hydroureter, hydronephrosis, renal insufficiency 6. Interdisciplinary care a) Diagnosis: (1) DRE (asymmetrical and enlarged prostate) (2) Blood: Creatinine levels (3) Urine: WBCs, RBCs, bacteria (4) Residual urine and urine flow rate measured (5) PSA levels b) Medications (1) Antiandrogens: Shrink prostate by inhibiting conversion of testosterone to DHT (2) Alpha-adrenergic antagonists: Block contractions that exacerbate urinary blockage .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

c) Surgery (1) Minimally invasive surgery: Transurethral microwave thermotherapy, transurethral needle ablation (TUNA) system (2) Transurethral surgery (a) Transurethral resection of the prostate (TURP) (b) Transurethral incision of the prostate (TUIP) (3) Open surgery: Prostatectomy (4) Laser surgery d) Balloon urethroplasty e) Integrative therapies (1) Phytotherapy: Saw palmetto berry, Pygeum africanum bark, Echinacea purpurea root, Hypoxis rooperi, trembling poplar leaves 7. Nursing care a) Diagnoses, outcomes, and interventions (1) Educate patients about BPH (a) Explain the anatomy and physiology of the prostate gland, as well as normal changes that occur with aging (b) Discuss treatment options, including information about effects on erectile function, ejaculation, and fertility (c) Discuss effects of prostate surgery (d) Explain the use and after-effects of the catheter to patients having a TURP (2) Reduce risk of urinary retention (a) Teach manifestations: Dysuria, overflow incontinence, bladder pain and distention, no urine output (b) Risk increases with OTC decongestant medications, or prescription medications such as antidepressants, anticholinergics, calcium channel blockers, antipsychotics, and medications to treat Parkinson’s (c) Teach how to use the double-voiding technique (3) Reduce risk for infection (a) Monitor WBC and vital signs (b) Sterile procedures when changing irrigation fluids and emptying Foley catheter draining bag (4) Promote balanced fluid volume (a) Monitor pulse and blood pressure (b) Monitor color of drainage in urinary drainage bag 8. Transitions of care: Teach how to care for the catheter and drainage bag C. The Patient with Prostate Cancer 1. Incidence a) Second-leading cause of death in North America .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

b) 85% of men are diagnosed after the age of 65 c) Disproportionately affects Black men, who also experience higher mortality rates d) Usually curable if detected early 2. Pathophysiology a) Etiology is unknown, androgens are believed to have a role in development b) Primary prostate cancers are usually adenocarcinomas c) May obstruct urinary flow, metastasize to involved seminal vesicles or bladder, or by lymph and venous channels 3. Risk factors a) Genetic and hereditary factors, family history b) Vasectomy c) Diet high in animal fat and excessive supplemental vitamin A 4. Manifestations a) Early-stage prostate cancer is often asymptomatic b) Urinary manifestations like those in BPH, hematuria or blood in the ejaculate c) Musculoskeletal d) Neurologic: Muscle spasms, nerve pain, and bilateral lower extremity weakness e) Systemic: Weight loss and fatigue 5. Complications: Compression of spinal cord, severe anemias once reaching bone marrow 6. Interdisciplinary care a) Diagnosis: Increasing number now diagnosed with asymptomatic prostate cancer (1) DRE (2) Prostate-specific antigen (PSA) levels (3) Transrectal ultrasonography (TRUS) (4) Urinalysis, cystoscopy (5) Bone scan, MRI, or CT (metastasis) b) Research for treatment: Immunological response drugs (sipuleucel-T approved 2010) c) Prostate cancer staging and treatment (1) Treatment depends on general health of patient and preference (2) Surgery, radiation therapy, hormone manipulation, and chemotherapeutic agents (3) Medications: Androgen deprivation therapy: Advanced stage (4) Surgery (a) Radical prostatectomy (i) Retropubic prostatectomy (ii) Perineal prostatectomy (iii)Suprapubic prostatectomy .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(b) Artificial urinary sphincter implant (5) Radiation therapy (a) External beam (b) Interstitial implants of radioactive seeds of iodine, gold, palladium, or iridium (brachytherapy): Lower risk of impotence and rectal damage 7. Nursing care a) Assessment: Health history, physical assessment (DRE) b) Diagnoses, outcomes, and interventions (1) Promote urinary continence (a) Assess the degree of incontinence and its effects on lifestyle (b) Teach Kegel exercises (c) Teach methods to control dampness and odor from stress incontinence (don’t restrict intake, thereby concentrating odor of urine, and use pads) (d) Explore options (external collection device), encourage talk of feelings, revert to PT (2) Promote sexual function (a) Assess pretreatment sexual function (b) Teach actual or potential effects of therapy on sexual function (c) Provide an opportunity for patient and their partner to discuss impact on sexual function (d) Discuss medical and surgical treatments for ED, and refer to counseling (3) Manage acute and chronic pain (a) Metastasis to spinal column, usually the thoracic spine (b) Fractures, lymphedema of the lower extremities, and muscle spasms (c) Provide optimal pain relief with prescribed analgesics (d) Teach patient and family noninvasive methods of pain control 8. Transitions of care a) Surgery: Manifestations of infection and excessive bleeding, catheter care, wound care, and pain management b) Radiation therapy: Danger of radiation damage to others, condom use (discolored ejaculate) c) Follow-ups, information resources, and community resources V. Disorders of the Male Breast A. The Patient with Gynecomastia 1. High ratio of estradiol to testosterone 2. Common during puberty, resolves in months 3. Conditions that increase estrogen: Obesity, testicular tumors, liver disease, adrenal carcinoma

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

4. Conditions that decrease testosterone: Tuberculosis, Hodgkin’s disease, injury, and orchitis 5. Drugs: Digitalis, opiates, and chemotherapeutic agents 6. Treatment: Surgery, treatment if underlying disorder is present B. The Patient with Breast Cancer 1. Most tumors are estrogen-receptor positive 2. Thought to only affect women, delayed medical attention 3. Treatment similar as with women 4. Anti-androgen therapy

Chapter Highlights A. Many different illnesses, medications, and surgical procedures may affect male sexual function. It is important for nurses to initiate a conversation regarding sexual concerns with male patients.

B. Psychological issues can result from alterations in a man’s sexual function at any age.

Nurses must recognize patient values and preferences, and demonstrate a sensitivity to the patient’s concerns.

C. Disorders of male sexual function include erectile dysfunction (ED) and ejaculatory dysfunction. Many different illnesses, medications, and surgical procedures may affect male sexual function. Treatments include medications, mechanical devices, and surgical procedures. It is important for nurses to initiate a discussion of sexual concerns during assessments and to recognize that many male reproductive treatments and surgeries may result in sexual dysfunction.

D. Disorders of the male reproductive system including scrotal masses, testicular infections and cancer, prostate enlargement and cancer, phimosis and priapism may interfere with normal urination and sexual function.

E. Phimosis and priapism are disorders of the penis that can cause problems with urination and sexual activity and may in some cases be considered medical emergencies. The risk of cancer of the penis, although rare, is increased by phimosis, poor genital hygiene, and viral HPV and HIV infections.

F. Benign scrotal masses include hydrocele, spermatocele, and varicocele. Epididymitis may be associated with a urinary tract infection, prostatitis, urethral strictures, or an STI. G. The testes may be infected (orchitis), twisted (testicular torsion), or develop cancer.

Testicular cancer is the most common cancer in men between the ages of 15 and 40.

Monthly testicular self-examination is critical to early detection and treatment of cancer.

H. The prostate gland may be inflamed or infected (prostatitis), enlarged (benign prostatic hyperplasia [BPH]), or may develop cancer. BPH is a common disorder of the aging male that causes problems with urination as the enlarging prostate gland constricts the

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

urethra. Treatments include medications and various types of surgery, depending on the size of the prostate and the age and health status of the man.

I. Cancer of the prostate is the most common type of cancer and the second leading cause of death in American men. When diagnosed early, prostate cancer is curable. Diagnosis is often based on an increasing level of PSA and an abnormal DRE. The cancer is treated with surgery, radiation, or hormonal manipulation.

J. The male breast may become enlarged (gynecomastia) or develop cancer.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME ONE Have students discuss why a man who takes nitrates or alpha blockers might be tempted to be dishonest about taking a medication for erectile dysfunction.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME TWO Have the students create a teaching tool to address disorders of the penis.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME THREE Have the students create a tool to instruct clients having surgery on the testes.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME FOUR Using anatomic models, describe the surgical procedures presented in the chapter. Have students discuss the nursing implications of caring for the patient preoperatively and postoperatively.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME FOUR Assign students to care for clients with disorders of the prostate gland. Have the students discuss the clients’ issues with this type of surgery during post-clinical conference.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME FIVE Have the students compare and contrast the care of a male client with breast cancer with that of a female having the same disorder.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter 49 Nursing Care of Women with Reproductive System and Breast Disorders Learning Outcomes 1. Describe the pathophysiology and manifestations of disorders of female sexual function, and outline the interprofessional care and nursing care of patients with these disorders.

2. Describe the pathophysiology and manifestations of menstrual disorders, and outline the interprofessional care and nursing care of patients with these disorders.

3. Describe the pathophysiology and manifestations of perimenopause, and outline the interprofessional care and nursing care of patients with this condition.

4. Describe the pathophysiology and manifestations of structural disorders of the female reproductive system, and outline the interprofessional care and nursing care of patients with these disorders.

5. Describe the pathophysiology and manifestations of disorders of female reproductive tissue, and outline the interprofessional care and nursing care of patients with these disorders.

6. Describe the pathophysiology and manifestations of disorders of the breast, and outline the interprofessional care and nursing care of patients with these disorders.

Key Concepts I.

Disorders of Female Sexual Function A. The patient with sexual dysfunction 1.

Pathophysiology a) Dyspareunia (1) Decreased desire or inhibited orgasm (2) Causes: Imperforate hymen, vaginal scarring, and vaginismus b) Inhibited sexual desire (1) Pathophysiologic processes or psychogenic (2) Rooted deeply in childhood teaching, experience, cultural, and religious values c) Orgasmic dysfunction (1) Primary or secondary anorgasmia (2) Causes: Disease resulting in general debilitation or affecting sexual response cycle and use of drugs that depress the central nervous system 2.

Interprofessional care a) Tibolone (approved for use in Europe), Yohimbine (a natural extract), and topical estrogens and testosterone creams

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

3.

II.

Nursing care a) Identifying type of sexual dysfunction b) Medications c) Teach to increase self-awareness, differences in sexual stimulation in men and women

Menstrual Disorders A. The patient with premenstrual syndrome 1.

Pathophysiology a) Contributors to PMS: Altered estrogen–progesterone ratios, increased prolactin levels, and rising aldosterone levels during the luteal phase b) Increased production of aldosterone results in sodium retention and edema c) Decreased levels of monoamine oxidase in the brain are associated with depression d) Reduced serotonin can lead to mood swings 2.

Risk factors a) Obesity, smoking, and early sexual abuse/trauma

3.

Manifestations a) Occur during luteal phase, 7 to 10 days prior to onset of menstrual flow b) Physiologic and psychologic manifestations and intensity vary by woman and may differ month to month

4.

Complications a) Miss time from work or school b) Affect quality of life

5.

Interprofessional care a) Goal: Relieve manifestations and help develop self-care patterns b) Diagnosis (1) No specific tests (2) Symptoms that occur for 3 months c) Medications (1) SSRIs to manage mood and some physical manifestations (2) Oral contraceptives (3) If severe manifestations, ovulation may be suppressed by use of GnRH (4) Progesterone and antiprostaglandin agents such as nonsteroidal antiinflammatory drugs may help relieve cramping

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(5) Diuretics for bloating d) Nutrition (1) Diet high in complex carbohydrates during the late luteal phase (2) A healthy diet e) Integrative therapies (1) Diet, exercise, rest, relaxation, and stress management (a) Calcium and vitamin B6 (b) Cognitive-behavioral therapy (c) Ginkgo biloba and St. John’s wort (d) deep abdominal breathing, meditation, muscle relaxation, and guided imagery 6.

Nursing care a) Diagnoses, outcomes, and interventions (1) Manage acute pain (a) Teach pharmacologic and nonpharmacologic self-care measures to relieve pain: Application of heat, relaxation techniques (such as breathing exercises, imagery techniques, meditation), and exercise (b) Suggest ways to balance rest periods and activity (c) Correlate manifestations with dietary patterns and activity levels (2) Promote effective coping (a) Cognitive-behavior therapy (b) Alter schedule (c) Self-care measures B.

The Woman with dysmenorrhea 1.

Pathophysiology a) Primary dysmenorrhea: Uterine ischemia and pain, contributors include psychologic factors of anxiety and tension b) Secondary dysmenorrhea related to pathologic conditions, scarring, or injury c) Endometriosis, fibroid tumors, chronic pelvic inflammatory disease, endometrial polyps, and IUD may result in painful menses 2.

3.

Manifestations a) Primary dysmenorrhea manifestations: Abdominal pain, radiating pain to lower back and thighs, headache, nausea, vomiting, diarrhea, fatigue, and breast tenderness Interprofessional care

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) Diagnosis: Identify structural abnormalities, hormonal imbalances, pathologic conditions based on pelvic examination and diagnostic procedures b) Medications: Analgesics, prostaglandin inhibitors NSAIDs, or oral contraceptives 4.

C.

Nursing care a) Primary dysmenorrhea: Focus on controlling manifestations and self-care b) Secondary dysmenorrhea: Varies according to underlying cause

The Woman with Dysfunctional Uterine Bleeding 1.

Pathophysiology a) Classified by the PALM-COEIN system for the underlying cause (1) Polyp (2) Adenomyosis (3) Leimyoma (4) Malignancy and hyperplasia (5) Coagulopathy (6) Ovarian dysfunction (7) Endometrial (8) Iatrogenic (9) Not otherwise classified b) Classifications (1) Heavy menstrual bleeding (2) Intermenstrual bleeding (3) Irregular uterine bleeding c) Previous classifications: (1) Polymenorrhea: Menstrual bleeding every 21 days or less (2) Menorrhagia: May result from thyroid disorders, endometriosis, pelvic inflammatory disease, functional ovarian cysts, or uterine fibroids or polyps (3) Metrorrhagia: Postmenopausal bleeding may be caused by cervical polyps, endometrial polyps, endometrial hyperplasia, or uterine cancer (4) Menometrorrhagia: Frequent menstrual bleeding that is excessive and irregular in amount and duration 2.

Interprofessional care a) Diagnosis: Variety of diagnostic tests and laboratory studies b) Medications: Oral contraceptives, IUD, progesterone or medroxyprogesterone, progestins during the luteal phase, and oral iron supplement to replace lost iron c) Surgery (1) Therapeutic D&C (2) Endometrial ablation

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(3) Hysterectomy

III.

3.

Nursing care a) Diagnoses, outcomes, and interventions (1) Relieve anxiety (a) Discuss results of test and examinations (b) Provide information (c) Evaluate coping strategies and psychosocial support systems (2) Promote sexual function (a) Offer information about sexual activity and alternative methods of sexual expression (b) Provide an opportunity for the expression of concerns related to alterations in lifestyle and sexual functioning (c) Encourage frequent rest periods

4.

Transitions of care a) Provide support, reassurance, and information b) Administration and side effects of prescribed medication c) Balanced diet of iron-rich food, maintain fluid intake of 2000 to 3000 mL a day d) Immediately report recurring episodes of DUB

Perimenopause A. The patient with perimenopause 1.

Physiology a) Natural biologic end of reproductive ability, surgical menopause, and chemical menopause b) Estradiol decreases and is replaced by estrone, and progesterone is markedly reduced 2.

Manifestations a) Decrease in breast tissue, body hair, skin elasticity, and subcutaneous fat b) Reduced size of ovaries, uterus, cervix, and vagina c) Vaginal dryness, dyspareunia, incontinence, UTIs, and vaginitis d) Vasomotor instability may cause hot flashes, palpitations, dizziness, headaches, insomnia, frequent awakening, perspiration, mood, and memory problems e) Imbalance in bone remodeling, osteoporosis, fractures, and kyphosis f) Cardiovascular diseases from atherosclerosis

3.

Interprofessional care a) Diagnosis: Estrogen secretion diminishes, FSH and LH rise and remain elevated

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

b) Medications (1) HRT for limited periods of time (2) SERMs (3) Antidepressants and SSRIs c) Nutrition (1) Maintain a healthy weight, exercise daily, and limit alcohol consumption d) Integrative therapies (1) Phytoestrogens in cereals, vegetables, and legumes, including soy (2) Herbs: Cimicifuga racemosa (black cohosh), Vitex agnus castus (chaste tree), Rehmannia, ginseng, Kava, dong quai, golden seal, flaxseed, valerian, and evening primrose (3) Acupuncture, biofeedback, massage, meditation, and yoga 4.

Nursing care a) Assessment (1) Health history: Urinary, menstrual, dyspareunia, alcohol, nicotine, drugs, medications, sleep patterns, hot flashes, night sweats, and emotions (2) Physical assessment: Vital signs, breast and pelvic examination, abdominal assessment b) Diagnoses, outcomes, and interventions (1) Provide education (a) Discuss physiologic manifestations, such as hot flashes and night sweats (b) Dietary recommendations; daily intake of calcium for women over 50 is 1200 mg (c) Emphasize the importance of weight-bearing exercise (d) Provide information about the benefits and risks of HRT (e) Encourage yearly mammograms, clinical breast examinations, Pap tests, familiarity with tissues and consistency of their breasts (2) Promote sexual function (a) Encourage expression of feelings and concerns (b) Explain that as women age, it may take longer for vaginal lubrication and orgasm to occur (3) Support acceptance of the aging process (a) Encourage expression of fears and concerns related to changes in interpersonal and family functions

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(b) Discuss the importance of a healthy lifestyle in maintaining physical attractiveness (c) Encourage the woman to describe her perceptions of her own body (d) Encourage verbalization of feelings of concern, anger, anxiety, loss, and fear over body changes (e) Stress that certain physical characteristics of a person cannot be changed; emphasize the importance of learning to recognize and appreciate one’s own special strengths 5.

IV.

Transitions of carte a) Periodic cancer-related checkups b) Health counseling: Tobacco, alcohol, sun exposure, diet and nutrition, exercise, and risk factors

Structural Disorders A. The patient with uterine displacement 1.

Pathophysiology a) Displacement or prolapse of the uterus, bladder, or rectum can be congenital or an acquired condition b) Causes of uterine displacement within the pelvic cavity: Related to the scarring and inflammation of pelvic inflammatory disease, endometriosis, pregnancy, and tumors c) Causes of pelvic organs’ displacement into vagina: Weakened pelvic musculature, unrepaired lacerations from childbirth, rapid deliveries, multiple pregnancies, congenital weakness, and loss of elasticity and muscle tone with aging 2.

Manifestations a) Uterine displacement within the pelvic cavity (1) Dysmenorrhea, backache, dyspareunia, and infertility b) Uterine prolapse (1) Backache, bearing-down sensation, constipation, urinary incontinence, hemorrhoids, and dyspareunia c) Cytocele/rectocele (1) Bearing-down sensation, constipation, fecal incontinence, hemorrhoids, and urinary incontinence

3.

Interprofessional care a) Diagnosis (1) Herniated uterus or rectum (2) Kegel exercises

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

b) Nutrition (1) Maintain a healthy weight c) Surgery (1) Anterior colporrhaphy is the most common procedure (2) Marshall–Marchetti–Krantz procedure (3) Posterior colporrhaphy (4) Surgically reposition the uterus (5) Hysterectomy d) Pessary (1) Used when surgery is contraindicated

B.

4.

Nursing care a) Priorities of care (1) Promote urinary continence (a) Teach Kegel exercises (b) Permeal pads and care (c) Eliminate caffeine (2) Reduce anxiety (a) Encourage questions from woman and partner (b) Reassure that the capacity for orgasm will not be affected

5.

Transitions of care a) Surgery: Preoperative and postoperative period expectations b) Relieving manifestations: Kegel exercises, incontinence pads, pessary use and care c) Dietary counseling

The patient with a vaginal fistula 1.

Pathophysiology a) Fistula (1) Vesicovaginal fistula is an abnormal opening between the urinary bladder and the vagina, leading to incontinent leakage of urine through the vagina (2) Rectovaginal fistula (less common) is an abnormal opening between the rectum and vagina, causing incontinent leakage of stool or flatus through the vagina (3) Fistulas may develop as a complication of childbirth, gynecologic or urologic surgery, or radiation therapy for gynecologic cancer 2.

Interprofessional care a) Fistulas are diagnosed by pelvic examinations

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

b) Fistulas may resolve spontaneously, otherwise surgery is performed 3.

Nursing care a) Vaginal fistula: Teaching perineal care, irrigation, and sitz baths; perineal pads b) Rectovaginal fistula: Teach to avoid gas-forming foods V.

Disorders of Female Reproductive Tissue A. The patient with cysts or polyps 1.

Pathophysiology a) Bartholin’s gland cysts: Most common cystic disorder of the vulva, caused by infection or obstruction of Bartholin’s gland b) Cervical polyps tend to occur in women over age 40, who have borne several children, with a history of oral contraceptives; polyp develops at vaginal end of cervix, has stem, is highly vascular; possibly develops from endocervical hyperplasia c) Endometrial polyps usually have a stalk d) Endometrial cysts caused by endometrial overgrowth and are often filled with old blood e) Ovarian cysts are classified as follicular cysts and corpus luteum cysts f) Polycystic ovarian syndrome is an endocrine disorder characterized by an excess of androgens and a long-term lack of ovulation 2.

Manifestations and complications a) Ovary, functional cysts; origin ovulation; includes follicular cysts and corpus luteum cysts; manifestations are pain, menstrual irregularities, amenorrhea, and may resolve spontaneously b) Polycystic ovarian syndrome; origin unknown, possible hypothalamic–pituitary dysfunction; manifestations include hirsutism, obesity, amenorrhea, irregular menses, hyperinsulinemia, and infertility c) Chocolate cysts: Endometrial overgrowth; filled with old blood d) Vulva, Bartholin’s cysts; origin obstruction or infection of Bartholin’s gland; manifestations include pain, redness, perineal mass, and dyspareunia e) Endometrial polyps; origin unknown; manifestations bleeding between periods f) Cervix, cervical polyps; origin unknown; manifestations are bleeding after intercourse or after activities involving heavy lifting

3.

Interprofessional care a) Diagnosis: Diagnostic tests, laboratory analysis b) Medications: Antibiotics, oral contraceptives, clomiphene, and dexamethasone c) Surgery: Clamp removal, transcervical, incision and drainage, laser surgery, wedge resection of the ovary, and rarely oophorectomy

4.

Nursing care

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) Relieve pain, prevent recurrence and complications, follow up appointments, postsurgical care, and long-term follow up B.

The patient with leiomyoma 1.

Pathophysiology: Fibroids benign tumors, usually develop in the uterine corpus, may be intramural, subserous, or submucuous 2.

Manifestations: Small tumors may be asymptomatic; large tumors may lead to pelvic pressure pain, dysmenorrhea, menorrhagia, fatigue, constipation, and urinary urgency 3.

Interprofessional care a) Diagnosis: Ultrasound and laparoscopy b) Medications: None which permanently shrink fibroids c) Surgery: Myomectomy, laparoscopic laser technique, and hysterectomy 4.

Nursing care a) If surgery is deferred, then regular follow-up assessments to monitor tumor growth b) If hysterectomy is performed, teach preoperative and postoperative care, and iron intake

C.

The woman with endometriosis 1.

Pathophysiology a) Theories: Metaplasia theory, theory of retrograde menstruation, and transplantation theory b) Slowly progressive disease, responsive to ovarian hormone stimulation, bleeding at time of menstruation occurs at sites of abnormally located endometrial implanted tissue 2.

Manifestations and complications: a) Heavy throbbing pain of lower abdomen and pelvis, feeling of rectal pressure and discomfort during bowel movement, dyspareunia, dysfunctional uterine bleeding, and infertility

3.

Interprofessional care a) Diagnosis: Pelvic ultrasound, laparoscopy, and CBC b) Medications: Hormone therapy, oral contraceptives, GnRG-a, oral or injectable progestin, danazol, aromatase inhibitors, and hormone therapy c) Surgery: Laparoscopy with laser ablation

4.

Nursing care a) Diagnoses, outcomes, and interventions (1) Reduce anxiety

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(a) Encourage expression of fears and anxiety about infertility (b) Provide information on fertility awareness methods 5.

Transitions of care: Explain cause of disorder, various treatment options, fertility awareness methods, exercise, smoking cessation, weight control, and preoperative and postoperative teaching D.

The patient with cervical cancer 1.

Pathophysiology: a) Second most common cancer worldwide, 14th most common in the United States b) Most are squamous cell carcinomas that begin as neoplasia in the cervical epithelium, spreads by direct invasion of accessory structures, including the vaginal wall, pelvic wall, bladder, and rectum 2.

Risk factors: Infection with HPV is most important risk factor, intercourse before 16 years of age, woman or partner having multiple sex partners, history of STIs, and HIV 3.

Manifestations a) Preinvasive cancer, limited to cervix, rarely causes manifestations b) Invasive cancer causes vaginal bleeding after intercourse, between menstrual periods, and a bloody or brown vaginal discharge that increases as the cancer progresses c) Advanced disease: Referred pain in the back or thighs, hematuria, bloody stools, anemia, and weight loss

4.

Interprofessional care a) Diagnosis: Pap smear, colposcopy, cervical biopsy, loop diathermy technique; MRI or CT of the pelvis, abdomen, or bones is used to evaluate spread of the tumor b) Medications: Chemotherapy c) Surgery: Combination of colposcopy with laser surgery, cryosurgery, conization, hysterectomy or radical hysterectomy, pelvic exenteration, anterior exenteration, and posterior exenteration d) Radiation and chemoradiation therapy: External radiation beam therapy and intracavitary cesium irradiation e) Targeted therapies (1) Bevacizumab: Targeted therapy for cervical cancer that prevents blood vessel formation

5.

Nursing care

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) Assessment: Health history and physical assessment b) Diagnoses, outcomes, and interventions (1) Reduce anxiety (a) explain early diagnosis, survival rate, cancer counselor, and support group (2) Promote tissue integrity (a) Bacteria due to surgery, inflammatory skin and mucous membrane response to radiation, risks; teach wound and skin care, stoma care, non-oil-based lotions, and fistula formation monitoring 6.

Transitions of care: Teach, provide resources and info concerning radiation, chemotherapy, surgery, preoperative, and postoperative E.

The patient with endometrial cancer 1.

Pathophysiology: a) Adenocarcinomas that are slow to grow and metastasize b) Tumor growth usually begins in the fundus, invades the vascular myometrium, spreads throughout the female reproductive tract c) Metastasis occurs via the lymphatic system, through the fallopian tubes to the peritoneal cavity, and to the rest of the body via the bloodstream d) Target areas for metastasis include the lungs, liver, and bone 2.

Risk factors: Prolonged estrogen stimulation, obesity, anovulatory menstrual cycles, high fat diet, prior breast or ovary cancer, prior radiation in pelvic region, atypical endometrial hyperplasia, decreasing ovarian function (as from menopause), estrogen-secreting tumors, and unopposed estrogen 3.

Manifestations: Abnormal painless vaginal bleeding, in menstruating women manifested as menorrhagia or metrorrhagia 4.

Complications a) Lymph node enlargement, pleural effusion, abdominal masses, and ascites

5.

Interprofessional care a) Diagnosis: Transvaginal ultrasound, endometrial biopsy, a D&C, chest x-ray, cystoscopy and intravenous pyelogram, proctoscopy, CT scan, PET, MRI, bone scans, CBC, and CA 125 blood test b) Surgery: If stage I, total abdominal hysterectomy and bilateral salpingooophorectomy; if stage II or beyond, radical hysterectomy with node dissection c) Radiation therapy: External and internal radiation

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

d) Hormone therapy: Progestins, tamoxifen, gonadotropin-releasing hormone agonists, and aromatase inhibitors e) Chemotherapy: Combination of drugs including doxorubicin (Adriamycin), cisplatin, carboplatin, and paclitaxel (Taxol) (ACS, 2012c) 6.

Nursing care a) Assessment: Health history, physical assessment of pelvic exam, abdomen, and lymph glands b) Diagnoses, interventions, and outcomes (1) Mange pain: Analgesics, encourage ambulation, and apply heat to abdomen (2) Promote healthy body image: Review side effects and develop plan (3) Promote sexual function: Communication, explore alternative sexual positions 7.

Transitions of care: Regular screening, treatment and prognosis info, and side effects F.

The patient with ovarian cancer 1.

Pathophysiology a) Types of ovarian cancers: Epithelial tumors, germ cell tumors, and gonadal stromal tumors; most are epithelial tumors b) Spreads by local shedding of cancer cells into the peritoneal cavity, by direct invasion of the bowel and bladder, then implanting in intestines, bladder, and mesentery 2.

Risk factors: Two or more first or second-degree relatives who have had the disease, BRCAI and BRCAII, Lynch syndrome, increasing age, no children or giving birth after 35, early menarche, late menopause, infertility drugs, obesity, high-fat diet, and personal history of breast cancer 3.

Manifestations and complications: a) Generally no early warning signs; prior to menopause signs include fatigue, back pain, intercourse pain, constipation, and menstrual changes; enlarged abdomen with ascites signals later stage disease b) Complications: Ascites, intestinal obstruction, deep venous thrombosis, and lymphedema

4.

Interprofessional care a) Diagnosis: Transvaginal or abdominal ultrasound, CT scan of the abdomen and pelvis, MRI of the abdomen, PET scan, laparoscopy, colonoscopy, ovarian biopsy, blood test CA-125 antigen level, and CA-125

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

b) Surgery: Young women removal of 1 ovary, normally total hysterectomy with bilateral salpingo-oophorectomy, sometimes combined with chemotherapy and radiation c) Chemotherapy: Primarily combination chemotherapy d) Radiation therapy: External-beam or intracavitary implants for palliative purposes only, shrink the tumor at selected sites e) 5.

Nursing care: Education of manifestations, risk factors, treatment, side effects 6.

Transitions of care: If family history of breast, ovarian, colon cancer stress regular pelvic exams; discuss treatment options, side effects, and hospice services G.

VI.

The patient with cancer of the vulva 1.

Relatively rare, occurs in women over 60 years, most are epidermoid or squamous cell carcinomas 2.

Risk factors: Cause unknown, evidence it is associated with STIs, particularly HPV, HSV2, leukoplakia, vulvar cancer, smoking, HIV, VIN, other genital cancers, melanoma, and other atypical moles 3.

Metastasis by direct extension into the vagina, perineal skin, anus, urethra, and spreads through lymphatic system 4.

Manifestations: Pruritus, wart-like growths, patchy changes in color or vulva density, vaginal bleeding, dysuria, and inguinal lymph nodes enlarged 5.

Interprofessional care: Surgical resection is usual treatment, postoperative lymph node radiation therapy, and chemotherapy for distant metastases 6.

Nursing care: Fear of death, surgery, and treatment’s pain and suffering

Disorders of the Female Breast A. The patient with a benign breast disorder 1.

Pathophysiology a) Fibrocystic changes (FCC): Physiologic nodularity and breast tenderness that increases and decreases with the menstrual cycle (1) Nonproliferative form, more common, does not increase breast cancer risk (2) Proliferative form: Giant cysts, proliferative epithelial lesions, and increases breast cancer risk b) Intraductal disorders: Intraductal papilloma and mammary duct ectasia 2.

Manifestations a) Fibrocystic changes (1) Bilateral or unilateral pain or tenderness in the upper, outer quadrants; breasts feel thick and lumpy the week prior to menses; nipple discharge may be present, pain from edema of the connective tissue of

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

the breast, dilation of the ducts, and inflammatory response; an increase in breast size, multiple, mobile cysts may form, usually in both breasts (2) Fluid aspirated from these cysts ranges in color from milky white to yellow, brown, or green.

(3) If the fluid is tinged with blood, malignancy should be suspected b) Mammary duct ectasia (1) Sticky, thick nipple discharge with burning and itching around the nipple and inflammation (2) Discharge may be green, greenish-brown, or bloody (3) Nipple retraction in postmenopausal women 3.

Interprofessional care: History, physical exam, imaging studies, biopsy, analysis of nipple discharge, mammography, and ductography 4.

Nursing care: Health history, follow-up care, education, self-care, and resources B.

The patient with breast cancer 1.

Pathophysiology a) Environmental, hormonal, reproductive, and hereditary factors b) Two genes: BRCA1 on chromosome 17 and BRCA2 on chromosome 13 c) Classified as noninvasive (in situ) or invasive d) Categorized as carcinoma of the mammary ducts, carcinoma of mammary lobules, or sarcoma of the breast e) Two atypical types of breast cancer: Inflammatory carcinoma and Paget’s disease f) Metastasize: Through the bloodstream or lymphatic system; common sites are bone, brain, lung, liver, skin, and lymph nodes 2.

Risk factors a) Age and gender b) Genetic risk factors c) Family history of breast cancer d) Dense breast tissue e) Personal history of breast cancer f) Previous chest irradiation g) Menstrual history

3.

Manifestations : Nontender lump in breast, abnormal nipple discharge, nipple area rash, nipple retraction, skin dimpling, nipple position change, nipple pain, scaliness, ulceration, skin irritation, and discharge .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

4.

Interprofessional care a) Diagnosis: Detection of asymptomatic or symptomatic lesions, CBE, mammogram, MRI, and PET scan b) Medications: Biphosphonates strengthens bones c) Surgery: Axillary node dissection, mastectomy, and breast reconstruction; lumpectomy and partial mastectomy d) Radiation therapy: External-beam or tissue implants, intraoperative radiotherapy, brachytherapy, and intracavity brachytherapy e) Chemotherapy: Neoadjuvant chemotherapy and adjuvant systemic therapy f) Hormone therapy: Tamoxifen citrate (Nolvadex) and toremifene (Fareston); immunotherapy, using trastuzumab (Herceptin) g) Integrative therapies (1) Music therapy, stress management, and yoga (2) Herbal supplements are not used because of adverse interactions with chemotherapy

5.

Nursing care a) Assessment: Health history and physical exams (1) Diagnoses, outcomes, and interventions (a) Reduce anxiety: Provide opportunities to name her fears, listen educate, dispel, and explain surgical procedure (b) Support thoughtful decision making: Simple and direct answers, focus on immediate concerns, nonjudgmental manner, opportunities to meet others, team approach with surgeon, anesthesiologist, oncologist, plastic surgeon, and other health professionals (c) Facilitate the grieving process: Listen attentively, no rushed reactions, explain depression, anger, denial are normal, and involve partners (d) Reduce risk for infection: Assess surgical dressings, encourage protein-rich diet, encourage self-care, and teach signs of infection (e) Promote good tissue integrity: Explain risk for lymphedema (LE), monitor for LE manifestations, elevate affected arm, teach woman to report manifestations of infections (f) Promote healthy body image: Assess how woman views her body, explain redness and scarring will fade, include partner and family, offer pamphlets, suggest books, videos, encourage woman to look at her incision, provide breast reconstruction written material, and prosthesis option

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

6.

Transitions of care a) Reporting infections, importance of ADLs, postmastectomy exercises, lymphedema care, adequate rest, emotional support; support groups, online info services, and prosthesis management (Reach to Recover, the ACS, National Breast Cancer Coalition, National Lymphedema Network)

Chapter Highlights A. Many different illnesses, medications, and surgical procedures may affect female sexual function. It is important for nurses to initiate a conversation regarding sexual concerns with female patients and respond in a caring nonjudgmental manner.

B. Disorders of sexual function include dyspareunia (pain during intercourse), inhibited sexual desire, and orgasmic dysfunction.

C. Premenstrual syndrome (PMS) is a complex of manifestations (e.g., mood swings, breast tenderness, fatigue, irritability, food cravings, and depression) that are limited to 3 to 14 days before menstruation and relieved by the onset of menses.

D. Dysmenorrhea (pain or discomfort associated with menstruation), which is estimated to occur in 40 to 95% of menstruating women, may be primary or secondary.

E. Abnormal uterine bleeding (AUB) refers to vaginal bleeding that is usually painless but is abnormal in amount, duration, or time of occurrence.

F. Menopause is the permanent cessation of menses, a normal physiologic process as a woman ages. Menopause is a normal physiologic life event but may result in many changes in the woman’s body including osteoporosis, fractures, and cardiovascular disease.

G. The perimenopausal period, which usually lasts for several years, denotes the time during which reproductive function gradually ceases. It begins with a decline in the production of the hormone estrogen, includes the permanent cessation of menstruation due to loss of ovarian function, and extends for 1 year after the final menstrual period, at which time a woman is said to be postmenopausal.

H. Disorders of the female reproductive system can include benign as well as malignant diagnoses. It is important to understand the emotional concerns of anxiety and fear of the diagnoses as well as the treatments.

I. Uterine displacement occurs when the uterus prolapses into the pelvic cavity of the vagina. Treatments include Kegel exercises, use of a pessary, or surgical repair.

J. A vaginal fistula is an abnormal opening between the vagina and bladder (vesicovaginal) or the vagina and rectum (rectovaginal). Minor fistulas may resolve on their own; most require surgical repair.

K. Cysts are fluid-filled sacs, while polyps are vascularized solid tumors that can develop on many of the structures of the female reproductive system. They can develop at any age. Treatment focuses on surgical removal and prevention of recurrence.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

L. Leiomyomas, commonly called fibroids, are benign tumors that arise from the smooth muscle wall of the uterus. Treatment depends on size, location, and impact on comfort or fertility.

M. Endometriosis is a chronic inflammatory disease where functional endometrial tissue is found outside the uterus. Depending on the severity of the condition, fertility can be impacted. Treatment ranges from medical management to surgical intervention and is dependent on severity of the condition.

N. Cancer of the cervix is common in women. Cervical cancer is linked to HPV infection and can be prevented or diagnosed early with cervical exams and Pap smears. Treatment includes surgery, chemotherapy, and radiation therapy.

O. Endometrial cancer is the most common cancer of the female reproductive system.

Treatment depends on stage of disease, ranging from chemotherapy to surgical intervention including hysterectomy.

P. Ovarian cancer does not have clear-cut symptoms or early warning signs.

Unfortunately, this results in late diagnosis, reducing curative treatment options. Treatment includes surgery, chemotherapy, and radiation therapy.

Q. Cancer of the vulva is rare. Treatment often requires surgical excision of the involved external genitalia, a loss for the patient.

R. Benign breast disorders often correspond to hormonal changes of the menstrual cycle.

S. Breast cancer is one of the most common forms of cancer in women.

T. Breast cancer treatment is based on stage and can range from nonsurgical treatment to radical mastectomy.

U. Mammograms can detect breast cancer at an early stage. Education is necessary to encourage early diagnosis and prevention.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME ONE Split the class into several small groups. Have each group research and present information to the class on a disorder of female sexual function.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME ONE Have the students prepare a teaching plan for a patient with a disorder of female sexual function.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME TWO Split the class into several small groups. Have each group research and present information to the class on a menstrual disorder.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME TWO Have the students prepare a teaching plan for a patient with a menstrual disorder

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME THREE Split the class into several small groups. Have each group research and present information to the class on perimenopause.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME THREE Have the students prepare a teaching plan for a patient with perimenopause.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME FOUR Split the class into several small groups. Have each group research and present information to the class on a structural disorder of the female reproductive system.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME FOUR Have the students prepare a teaching plan for a patient with a structural disorder of the female reproductive system.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME FIVE Split the class into several small groups. Have each group research and present information to the class on a disorder of female reproductive tissue.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME FIVE Have the students prepare a teaching plan for a patient with a disorder of female reproductive tissue.

SUGGESTIONS FOR CLASSROOM ACTIVITY—LEARNING OUTCOME SIX Split the class into several small groups. Have each group research and present information to the class on a breast disorder.

Have the students prepare a teaching plan for a patient receiving treatment for breast cancer

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME SIX Assign the students, if possible, to care for a patient with breast cancer. Have the students observe radiation treatments, chemotherapy sessions, and physical therapy sessions. Have the students discuss the patient’s physical and psychosocial care needs during post-clinical conference.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

Chapter 50 Nursing Care of Patients with Sexually Transmitted Infections Learning Outcomes 1. Describe the characteristics of sexually transmitted infections, as well as key factors in their prevention and control.

2. Describe the pathophysiology and manifestations of viral sexually transmitted diseases, including genital herpes and human papillomavirus, and outline the interprofessional care and nursing care of patients with these disorders 3. Describe the pathophysiology and manifestations of bacterial sexually transmitted diseases, including vaginal infection, chlamydia, gonorrhea, syphilis, and pelvic inflammatory disease, and outline the interprofessional care and nursing care of patients with these disorders.

Key Concepts I.

Overview of Sexually Transmitted Infections A. Incidence and prevalence 1. Women and infants are disproportionately affected a) Transmission is often easier from man to woman 2. Psychological, behavioral, and social factors are associated 3. Healthcare disparities increase incidence for adolescents, young adults, and ethnic minorities 4. Epidemiologic synergy (i.e., greater risk of acquiring HIV if infected with an STI) 5. African Americans are disproportionately affected B. Characteristics 1. Most can be prevented by condom 2. Oral, vaginal, and anal intercourse; HPV through skin-to-skin contact 3. Sexual partners of the infected person must also be treated 4. Two or more STIs frequently coexist in same patient C. Prevention and control 1. Education, detection, diagnosis, treatment, and evaluation of partners 2. Health history is essential a) Number and gender of sexual partners, birth control, and protection use b) Sexual practices, history, or recent exposure c) 5 Ps: Partners, Prevention, Protection, Practice, and Past history

II.

Virally Sexually Transmitted Infections A. The patient with genital herpes

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

1. Pathophysiology and risk factors a) HSV-1 is associated with cold sores, may be transmitted to genital area, HSV-2 more common b) Transmission: Sexually or during child birth, exposure by contact to lesion or secretions c) Infects the neurons (neurotropic) that innervate the stratified squamous epithelium d) Dormancy: Virus ascends to dorsal root ganglia e) Reactivates, returning to nerve root of skin, and causing lesions 2. Risk factors: a) Sexual intercourse without the use of a condom, oral sexual activities without the use of a barrier device, and multiple sexual partners 3. Manifestations a) First episode infection (1) 2 to 10 days after exposure (2) Painful red papules appear → blisters with virus fluid → ulcers (3) On glans, penis, labia, vagina, cervix, and anus b) Autoinoculation c) Other manifestations: Herpetic lesions, regional lymphadenopathy, headache, fever, general malaise, dysuria, urinary retention, and vaginal or urethral discharge d) Recurrent infections, latency, and cycle several times a year e) Sexual contact should be avoided during outbreak 4. Complications a) Increased risk for other STIs and HIV, the inability to void, meningitis and proctitis b) Most severe complication: Babies born to mothers with active HSV infections 5. Interprofessional care a) Diagnosis (1) Lesions, patterns of recurrence, and health history (2) Tissue culture b) Medications (1) No cure, treat symptoms, prevent spread (2) Acyclovir (Zovirax); resistance is developing (3) Other antivirals: Foscarnet (Foscavir), valacyclovir (Valtrex), and famciclovir (Famvir) (4) Suppressive therapy (acyclovir, valacyclovir, or famciclovir): Reduce outbreaks and risk of transmission 6. Nursing care a) Assessment: Health history, physical assessment (popular lesions) .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

b) Diagnoses, outcomes, and interventions (1) Relieve acute pain (a) Teach how to keep herpes blisters clean and dry (b) For dysuria, pour water over genitals while urinating (c) Warm baths: Soothing and facilitate wound healing (2) Promote healthy self-esteem (a) Encourage patient to discuss feelings and ask questions (b) Provide information about suppressive therapy (c) Resources and community support 7. Transitions of care a) Recognizing prodromal symptoms and triggering factors (emotional stress, acidic food, and sun exposure) b) Abstinence from sexual contact from the time prodromal symptoms appear until 10 days after lesions heal c) Topical acyclovir for infected lesion d) Latex condoms due to viral shedding at any time and careful hygiene practices B. The patient with human papillomavirus 1. Pathophysiology a) 100 Human papillomaviruses (HPV), 40 affect genital area b) HPV infections often asymptomatic, resolve without treatment c) Most asymptomatic or unrecognized d) Transmission: Most often through vaginal and anal sex, also oral and genital-to-genital contact e) Infects squamous epithelium f) Most infections have no clinical manifestations, resolve within 1–2 years g) Some linger, causing oncogenic complications or genital warts 2. Risk factors for cervical cancer: Long-term contraceptive use, high parity, smoking, coinfection with other STI 3. Manifestations a) Genital warts: Single or multiple painless, soft, moist, pink or flesh-colored swellings in vulvovaginal area, vagina, cervix, perineum, penis, urethra, anus, groin, or thigh (1) Condyloma acuminate (2) Keratotic warts (3) Papular warts (4) Flat warts 4. Complications a) Cancer of the cervix, vagina, vulva, penis, anus, oropharynx, tonsils .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

5. Interprofessional care a) Treatment: Removal of warts, relief of symptoms, teaching risk reduction b) Diagnosis: Papanicolaou (Pap) test identifies cervical cell changes, HPV DNA test c) Medications (1) Cervarix vaccine against types 16 and 18 (2) Gardasil vaccine against the four types of HPV that cause most cervical cancers and genital warts (3) Topical for warts: Podophyllin (Condylox, Podofin), imiquimod d) Other treatments: Cryotherapy, electrocautery, laser vaporization, surgical excision, carbon dioxide laser surgery 6. Nursing care a) Diagnoses, outcomes, and interventions (1) Provide patient teaching (a) Provide vaccine information, especially to recommended age range, mothers of young girls (b) Prompt treatment and sexual abstinence until lesions heal, or condom use with lesions (c) Importance of Pap smear: Increased risk of cervical cancer associated with HPV (d) Hand hygiene is essential to prevent the spread 7. Transitions of care: Regular treatment of lesions, condom use, annual Pap smears III.

Bacterially Sexually Transmitted Infections 1. The Patient with a Vaginal Infection 2. Pathophysiology a) Bacterial vaginosis (1) Most common cause in women of reproductive age (2) Caused by Gardnerella vaginalis and other organisms (3) Treatments: Oral or intravaginal antibacterial agents b) Candidiasis: Moniliasis or yeast infection (1) Caused by Candida albicans (2) Normal part of vagina in 50% of women (3) Organism proliferates when normal vaginal flora is altered (a) Estrogen levels, antibiotics, diabetes mellitus, and fecal contamination (4) Treatment: Oral or intravaginal antifungal agents c) Trichomoniasis (1) Caused by Trichomonas vaginalis, protozoan parasite

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(2) Most common, curable STI in young women (3) Treatment: Metronidazole or tinidazole 3. Manifestations a) Bacterial vaginosis (1) Vaginal discharge that is thin and grayish-white and has a foul, fishy odor b) Candidiasis (1) Odorless, thick, cheesy vaginal discharge, by itching and irritation of the vulva and vagina, with dysuria and dyspareunia c) Trichomoniasis (1) Men are asymptomatic; when symptomatic, complain of dysuria and urethral discomfort (2) Women have a frothy, green-yellow vaginal discharge with a strong fishy odor, itching and irritation of the genitalia 4. Complications a) Bacterial vaginosis (1) PID, preterm labor, premature rupture of the membranes, and postpartum endometritis b) Candidiasis (1) Uncircumcised males may develop a yeast infection over the glans penis, itching and dysuria c) Trichomoniasis (1) Increases a woman’s risk of developing HIV and increased risk of transmitting HIV to sexual partners 5. Interprofessional care a) Diagnosis: Cervical cultures, vaginal discharge (trichomas), 10% potassium hydroxide (candida) b) Medications: Varies with organism, self-medication with over-the-counter treatments may be incorrect 6. Nursing care a) Diagnoses, outcomes, and interventions (1) Provide patient teaching (a) Explain the transmission of the infection, need to complete treatment (b) Warn against douching or use of feminine hygiene sprays (2) Manage acute pain (a) Cool compresses, sitz baths, and cotton underwear (b) Avoid sex until treatment of trichomas completes to prevent reinfection

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

7. Transitions of care: Teaching prevention, eradication, comfort, safer sex, and genital hygiene B. The patient with chlamydia 1. Pathophysiology a) Chlamydia trachomatis: Intracellular bacterial pathogen resembling both virus and bacteria b) Organism enters cells and changes into a reticulate body, dividing and bursting cell c) Asymptomatic until uterus and fallopian tubes have been invaded, and in 1/3 of men 2. Manifestations a) Dysuria, urinary frequency, and vaginal discharge in women or urethral discharge in men b) Infectious even when asymptomatic 3. Complications a) Women: (1) Ascends into upper reproductive tract: PID (endometritis, salpingitis) (2) Infertility and ectopic pregnancy b) Men: Epididymitis, prostatitis, sterility, and Reiter’s syndrome 4. Interprofessional care a) Diagnosis (1) Urine specimen or swab of vagina or endocervix, urethra, or rectum (2) NAAT performed on specimen b) Medications (1) Azithromycin (Zithromax) single dose, doxycycline (Adoxa, Apo-Doxy) 7 days 5. Nursing care a) Eradication of infection, prevention of future infection, and management of chronic complications b) Nursing priorities similar to gonorrhea and genital herpes 6. Transitions of care a) Preventions b) Comply with prescribed treatment regimen C. The patient with gonorrhea 1. Pathophysiology and risk factors a) Caused by Neisseria gonorrhea, a pyogenic bacteria causing inflammation and purulent exudate .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

b) Transmitted via intercourse and during birth c) Portal of entry: Genitourinary tract, eyes, oropharynx, anorectum, and skin d) Incubation period is 2 to 7 days e) Men: Acute, painful inflammation of prostate, epididymis, periurethral glands, can lead to sterility f) Women: PID, endometritis, salpingitis, and pelvic peritonitis 2. Manifestations a) Men: Dysuria and serous, milky, purulent discharge from penis, and regional lymphadenopathy b) Women: Dysuria, urinary frequency, abnormal menses (increased flow or dysmenorrhea), increased vaginal discharge, and dyspareunia c) 20% of men and 80% of women remain asymptomatic until disease advancement d) Anorectal gonorrhea: Most commonly experienced by gay men; pruritus, mucopurulent rectal discharge, rectal bleeding and pain, and constipation e) Gonococcal pharyngitis: Occurs primarily in men who have sex with men, or women after oral sexual contact with an infected male partner; fever, sore throat, and enlarged lymph glands 3. Complications a) Women: PID, leading to internal abscesses, chronic pain, ectopic pregnancy, and infertility b) Newborns: Blindness, infection of joints, and potentially lethal infections of the blood c) Men: Epididymitis and prostatitis, resulting in infertility and dysuria d) Spread of the infection to blood and joints e) Increased susceptibility and transmission of HIV 4. Interprofessional care a) Diagnosis: NAAT of specimens, culture and sensitivity testing to resistant infection b) Medications (1) Single intramuscular dose of Ceftriaxone and a concurrent oral course of azithromycin or doxycycline (2) N. gonorrhoeae strains are increasingly resistant to the quinolone antibiotics 5. Nursing care a) Assessment (1) Health history: Urination, discharge, menses, intercourse, sore throat, swollen glands, and sexual practices, etc.

(2) Physical assessment: Discharge and regional lymphadenopathy b) Diagnoses, outcomes, and interventions c) Promote adherence to therapeutic regimen .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

(1) May leave any coexisting chlamydial infection unresolved, failure to refer partners leads to reinfection (2) Importance of abstinence until cured, referral of partners; consistent condom use to prevent reinfection regardless of birth control d) Promote social interaction (1) Provide privacy, confidentiality, and a safe, nonjudgmental environment for expression of concerns (2) Gonorrhea is a consequence, not a punishment 6. Transitions of care a) Prescribed medication, referring sexual partners, abstaining from contact until patient and partners are cured, condom use to avoid transmission, and follow-up visit D. The patient with syphilis 1. Pathophysiology a) Caused by the spirochete Treponema pallidum b) Transmitted from open lesions during any sexual contact c) Spreads through blood and lymphatic system; congenital syphilis transfers due to placental circulation d) Can lead to blindness, paralysis, mental illness, cardiovascular damage, and death e) Primary syphilis (1) Chancre at site of inoculation 3–4 weeks after; may go unnoticed (Figure 50.4) (2) Regional enlargement of lymph nodes (3) Little or no pain (4) Highly infectious f) Secondary syphilis (1) 2 weeks to 6 months after initial chancre (2) Skin rash on palms and soles, mucous patches of oral cavity; sore throat; generalized lymphadenopathy; condyloma lata on labia, anus, corner of the mouth; flulike symptoms; alopecia g) Latent and tertiary syphilis (1) 2 or more years after initial infection, can last up to 50 years (2) No symptoms, not sexually transmissible (infected blood, yes) (3) Most stay latent, 1/3 progress to late-stage or tertiary syphilis; sped up in presence of HIV (a) Benign late syphilis: Localized development of gummas in skin, bones, and liver, generally responding promptly to treatment (b) Diffuse inflammatory response onset involves central nervous system and cardiovascular system; treatable but more damage is irreversible 2. Risk Factors .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) Highest in people 20 to 29 years of age b) Most prevalent in men who have sex with men 3. Manifestations a) Primary syphilis (1) Genital chancre (2) Lymphadenopathy b) Secondary syphilis (1) Condyloma lata (2) Rash on palms of hands and soles of feet (3) Anorexia (4) Oral mucous patches (5) Meningitis (6) Headache (7) Cranial neuropathies (8) Arthralgias (9) Myalgia (10) Bone and joint arthritis (11) Periostitis (12) Glomerulonephritis (13) Nephrotic syndrome (14) Fever (15) Malaise (16) Hepatitis (17) Alopecia c) Latent and tertiary syphilis (1) Granulomatous lesions involving mucous membranes and skin (2) Tabes dorsalis (3) Neurosyphilis (4) Seizures, hemiparesis, and hemiplegia (5) Personality changes, hyperactive reflexes (6) Argyll Robertson pupil (7) Decreased memory (8) Slurred speech (9) Optic atrophy (10) Gummas (11) Aortic insufficiency (12) Aortic aneurysm (13) Stenosis of openings to coronary arteries 4. Interprofessional care .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

a) Diagnosis; complex because syphilis mimics other diseases (1) VDRL (Venereal Disease Research Laboratory) and RPR (rapid plasma reagin) blood tests measure antibody production; other diseases may cause positive results (2) FTA-ABS (fluorescent treponemal antibody absorption) test is specific for T. pallidum (3) Immunofluorescent staining of a specimen obtained from early lesions or aspiration of lymph nodes (4) Dark-field microscopy involves examining a specimen from the chancre b) Medications (1) Penicillin G, given intramuscularly (IM) in a single dose (2) Oral doxycycline or tetracycline for 28 days, if allergic to penicillin (3) Jarisch–Herxheimer reaction to treatment: Fever, musculoskeletal pain, tachycardia, and sometimes hypotension 5. Nursing care a) Assessment: Health history for symptoms, sexual practices; physical exam b) Diagnoses, outcomes, and interventions (1) Reduce risk for injury: Take medications, refer partners, abstain until cured, follow-ups to ensure eradication, and manifestations of reinfection (2) Reduce anxiety: Well-being of self and partners, and of fetus (3) Promote healthy self-esteem: Private and confidential environment where patient is free to express feelings, express that healthcare providers care about them 6. Transitions of care a) Taking medications, referring partners, sexual contact during treatment, and follow-ups E. The Patient with Pelvic Inflammatory Disease 1. Pathophysiology a) Infection of the pelvic organs b) Polymicrobial in origin; gonorrhea and chlamydia common causative organisms c) Ascend from vagina via endocervical canal to fallopian tubes and ovaries d) Infection can extend beyond reproductive tract to involve the peritoneum or other abdominal organs e) Risk: Women ages 16 to 24, history of STIs, BV, multiple sex partners, douching 2. Manifestations and complications a) Fever, purulent vaginal discharge, abnormal bleeding, lower abdominal or back pain, dyspareunia, and painful cervical movement b) Manifestations may be so mild that infection is not recognized

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

c) Pelvic abscess, infertility, ectopic pregnancy, chronic pelvic pain, pelvic adhesions, and chronic pelvic pain 3. Interprofessional care a) Diagnosis (1) CBC with differential (2) Laparoscopy or laparotomy: Inflammation, edema, or hyperemia of the fallopian tubes, or tubal discharge, generalized pelvic involvement, abscesses, and scarring b) Medications: Two broad-spectrum antibiotics c) Surgery: Drain abscess or treat a life-threatening complication (rupture of fallopian tube or abscess) 4. Nursing care a) Diagnosis, outcomes, and intervention (1) Reduce risk for complications (a) Administer antibiotics as ordered, monitor closely for adverse effects (b) Practice hand hygiene and precautions when handling perineal pads and linens (2) Provide patient teaching (a) Explain infection transmission and prevention (b) Teach proper perineal care, especially wiping from front to back (c) Caution the patient about using tampons; change every 4 hours (d) Provide information about safer sex practices and family planning 5. Transitions of care: Provide information, teach eradication and prevention, help with physical and psychological implications of treatment (infertility)

Chapter Highlights A. Sexually transmitted infections (STIs) are infections transmitted by sexual contact, including vaginal, oral, and anal intercourse. STIs affect women more than men, and are more common in people who have multiple sex partners, abuse drugs, and are of lower socioeconomic status.

B. STIs can coexist in the same person and can be transmitted by either heterosexual or homosexual sexual contact. Effective treatment mandates that both sex partners be treated. Most STIs can be prevented using latex condoms.

C. Genital herpes, caused by an infection with an HSV virus, is a commonly occurring STI in teens and young adults.

D. There is no cure for genital herpes and treatment is primarily symptomatic. Nursing care is directed toward relieving the pain of the lesions, mitigating sexual dysfunction, and relieving anxiety. .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

E. Human papillomavirus (HPV) is the most commonly occurring STI in the United States. Some strains cause genital warts, a chronic, incurable STI manifested by warts of various forms.

Other strains cause no initial symptoms but are associated with cancers of the cervix, vulva, and penis, as well as oropharyngeal cancer.

F. Infection with HPV poses a major risk for cervical cancer. A vaccine against the virus is recommended for adolescent boys and girls and young women.

G. Urogenital infections include vaginal infections (bacterial vaginosis, candidiasis, and trichomoniasis), chlamydia, gonorrhea, syphilis, and pelvic inflammatory disease (PID).

H. Chlamydia, occurring most in young adults under age 25, is a bacterial infection that can spread to the uterus and fallopian tubes in women, causing PID, infertility, and ectopic pregnancy. Untreated chlamydia in men may result in epididymitis, prostatitis, sterility, and Reiter’s syndrome.

I. Gonorrhea (caused by a bacteria) and syphilis (caused by a spirochete) affect both men and women, and may infect the newborn as it moves through the birth canal in an untreated woman.

J. Syphilis, if untreated, exists in the body in three stages, with the third stage lasting up to 50 years.

K. Nursing care of gonorrhea and syphilis focuses on education, preventing injury from complications, relieving anxiety, and supporting self-esteem.

L. PID is an infection of the female pelvic organs, and may be caused by one or more infectious agents.

M. Sexually active young women between the ages of 16 and 24 are most at risk for PID. The prognosis depends on the number of episodes, promptness of treatment, and modification of risk-taking behaviors. The goals of nursing care are to treat the infection and prevent complications.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME ONE Have the students research the prevalence of sexually transmitted infections on a global, national, state, and county level.

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME ONE Have the students review the medical records of patients in the clinical are for the risk of developing an STI.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME TWO Have students group the medications commonly given for viral STIs according to the mechanism of action. Discuss the nursing implications of giving these medications. .

Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME TWO Have the students create a teaching tool to reduce the risk of contracting a viral STI.

SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME THREE Have students group the medications commonly given for bacterial STIs according to the mechanism of action. Discuss the nursing implications of giving these medications

SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME THREE Have the students create a teaching tool to reduce the risk of contracting a bacterial STI.

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Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition