CHAPTER
1
High-Acuity Nursing
Objectives: 1. Discuss the various health care environments in which high-acuity patients receive care. 2. Identify the need for resource allocation and staffing strategies for high-acuity patients. 3. Examine the use of technology in high-acuity environments. 4. Identify the components of a healthy work environment. 5. Discuss the importance of patient safety in the high-acuity environment.
I. High-Acuity Environment A. Historical perspective 1. Intensive care units (ICUs) were developed in the 1960s. Medical advances resulted in the initiation of these units. a) The implementation of CPR b) Improved management of patients experiencing hypovolemia and shock c) The implementation of emergency medical services d) Technological advances e) The advancement of renal transplant services B. Determining the level of care needed 1. Systematic triage approach for high-acuity patients aids in giving the most efficient and cost-effective care. a) ICU b) Intermediate-care unit (IMC) (1) Developed to manage those patients who did not require life-saving, critical-care functions (2) Ability to manage the potentially serious health care needs of the patient whose condition is too complex for the traditional medical-surgical floor c) Medical-surgical acute care unit. 2. Nurses should use a prioritization model to triage and determine the level of care needed by acutely ill patients. The model divides patient needs into four categories: a) Priority 1: The patient is acutely ill, requiring intensive treatments not available outside of the intensive care unit. b) Priority 2: The patient is seriously ill and has the potential to require immediate medical interventions to prevent complications.
c) Priority 3: The patient is critically ill but has a limited chance for recovery. There might be limits placed on the amount of life-saving interventions that may be implemented. d) Priority 4: This is a large category of patients. Their inclusion into the ICU will depend on an individualized decision based on the appropriate use of resources and current patient status. C. Levels of intensive care units 1. The American College of Critical Care Medicine has identified three levels of ICUs as determined by resources available to the hospital: a) Level I: Hospitals with ICUs that provide comprehensive care for patients with a wide range of disorders. Sophisticated equipment, specialized nurses and comprehensive support services. b) Level II: Hospitals with ICUs that provide comprehensive care to most critically ill patients. c) Level III: Hospitals with ICUs that provide initial stabilization of critically ill patients. D. Profile of the high-acuity nurse 1. Able to analyze clinical situations. 2. Make decisions based on analysis. 3. Rapidly intervene to ensure optimal patient outcomes. 4. Competent in detecting early signs of an impending complication. 5. Role of the nurse in the management of the high-acuity environment: a) Review the patient’s clinical condition and implement a plan of care. (1) Studies show that constant surveillance of patients by nurses reduces mortality and complications.
PowerPoint Slides 1. Intensive Care Units (ICU) • Developed in 1960 • Why initiated 2. Intermediate Medical Care (IMC) Units • Intended for patients needing close observation but not in need of life-saving, critical interventions • Able to manage those patients too complex for the traditional medical surgical unit 3. Triage Prioritization Model • Priority 1: acutely ill patients requiring life-saving, critical interventions • Priority 2: seriously ill patients possibly in need of immediate medical interventions • Priority 3: critically ill patients who will not likely recover from their disorders • Priority 4: patients who might be terminally ill 4.
The Registered Nurse in High-Acuity Settings • Continual assessment of the patient’s status • Implementation of the plan of care
• Studies link to reduced mortality and complications
II. Resource Allocation A. Nurse staffing 1. Nurse-patient ratios a) Many interrelated factors have led to a shortage of nurses able and willing to work with acutely ill patients. Factors linked to the nursing shortage include: (1) Reduced job satisfaction, resulting in nurses leaving the workforce (2) Aging of the registered nurse workforce (3) Limited number of young adults choosing nursing as a career (4) Increasing number of aging persons, resulting in an increase in persons requiring acute care health services b) The reduction in the number of professional nurses has resulted in an increase in the nurse– patient ratio. c) The Academy of Medical Surgical Nurses (AMSN) does not support the development of exact patient–nurse ratios. 2. Magnet Status: Recruiting and Retaining Nurses a) Magnet designation is a status awarded to hospitals that demonstrate success in recruiting and retaining professional nurses. b) Magnet hospitals promote environments that are attractive to the retention of professional nurses. 3. Unlicensed assistive personnel (UAP) can be used to provide direct care. a) The UAP provides care under the direction of the professional nurse. B. Decreasing resources, increasing care needs 1. Who Belongs in an ICU? a) The health care needs of the patient and the skill mix available must be the deciding factors. b) The assignment of patients to units requires a close review of available resources. c) A goal is to ensure that those patients requiring the greatest level of care will be cared for in the intensive care unit. d) Age and seriousness of illness can be controversial variables in the assignment of intensive care beds. Severity scales are models used to determine which patients will benefit most from intensive care services. e) Additional considerations must be given to ethical, economic, and legal concerns.
PowerPoint Slides 1. Nursing Shortage • The nursing shortage has resulted in a scarcity of nurses available to work with acutely ill patients. Factors linked to the nursing shortage include: • Reduced job satisfaction • Aging of the nursing workforce
• Limited numbers of young adults choosing nursing as a career • The increasing number of aging persons leading to an increase in persons requiring acute care health services 2. Nurse–Patient Ratios • Linked to a reduction of professional nurses • Academy of Medical Surgical Nurses does not support exact ratios 3. Magnet Status • Awarded to hospitals demonstrating success with recruitment and retention of professional nurses • Promotes environments favorable to professional nurses 4. Unlicensed Assistive Personnel • Used to provide direct care • Work under the direct supervision of the professional nurse 5. Allocation of Resources and Patient Bed Assignments • Goals involve ensuring the most favorable use of resources • Resource allocation must include ethical, economic, and legal concerns
III. Use of Technology in High-Acuity Environments A. Benefits 1. The use of technology in the intensive care unit allows for close monitoring of the patient. 2. The technology is a primary incentive for placement in the intensive care unit. 3. The use of computers can provide a programmed approach to guide decision making by providing decision-making trees. 4. Programs are available to diagnose patient conditions. Handheld devices can be used to provide bedside reference guides. B. Patient depersonalization 1. Difficulties arise when machines become the focus of care of the high-acuity patient. 2. Technical devices present mechanical impediments to touching the patient. 3. Little surface area may be available for physical contact, and this may lead to a feeling of depersonalization. 4. Technology may evoke fear in patients and contribute to their anxiety about their recovery process. C. Overload and overreliance issues 1. The potential for increased stress on the nurse as a result of information overload. 2. A potential overreliance on technology by the nurse. D. Finding a Balance 1. The skilled nurse who practices in a high-acuity setting must be able to bridge the gap between complex technology and the art of caring.
PowerPoint Slides 1. Advantages of Technology in the ICU • Allows for close monitoring of the patient • Provides a programmed approach to decision making • Provides programs to diagnose patient disorders • Source of readily available reference information 2. Disadvantages of Technology • Depersonalization of the patient • Overload • Over-reliance
IV. Healthy Work Environment A. Healthy work environment 1. The American Association of Critical Care Nurses (AACN) has identified six standards needed to sustain a healthy work environment. These standards are: a) Skilled communication b) True collaboration c) Effective decision making d) Appropriate staffing e) Meaningful recognition f) Authentic leadership B. Stress and burnout 1. Burnout is a term used to describe feelings of personal and professional frustration, dissatisfaction, job insecurities, and emotional and physical exertion. 2. Causes for burnout: a) Nursing shortages, long work hours, and a loss of concentration b) Stress caused by exposure to patients experiencing pain and suffering c) Feelings of powerlessness d) Repeated exposure to pain and traumatic loss C. Coping with stress and burnout 1. Factors that improve a nurse’s ability to cope with stress are a positive social climate, managerial support, and staff cohesiveness. 2. Debriefings help to promote coping with special situations. 3. A sense of community allows the nurse the ability to share both stresses and joys.
PowerPoint Slides 1. AACN Standards for Healthy Work Environments • Skilled communication
• True collaboration • Effective decision making • Appropriate staffing • Meaningful recognition • Authentic leadership 2. Burnout • Describes feelings of personal and professional frustration, dissatisfaction, job insecurities, and emotional and physical exertion 3. Causes of Nursing Burnout • Nursing shortages • Long work hours • Loss of concentration • Repeated exposure to patients during suffering • Feelings of powerlessness • Exposure to pain and traumatic loss 4. Work-related factors that improve the ability of the nurse to manage stress: • Positive social climate • Managerial support • Staff cohesiveness • Availability of debriefings
V. Ensuring Patient Safety in High-Acuity Environments A. The culture 1. Studies have linked a relationship among work conditions, teamwork, and patient outcomes: a) High levels of teamwork have been associated with a decreased length of stay and decreased mortality. 2. The current culture is supportive of reporting health care errors. B. Patient safety 1. The Joint Commission (TJC) is an accrediting organization that seeks to improve patient safety through an accreditation process. a) TJC developed National Patient Safety Goals for acute care hospitals. b) To receive accreditation, the applying organization must develop and provide evidence that it is meeting the outlined safety goals. C. Technology and patient safety 1. Computerized systems are used to prevent errors
a) The computerized provider order entry (CPOE) systems (1) Used to block incorrect medication orders; warn of drug interactions, allergies, and overdoses; provide current drug information; and alert one to similar drug names b) The barcode point-of-care (BPOC) (1) Allows nurses to scan their badges and then the patient wristbands to access medications c) Personal digital assistants (PDAs) provide helpful reference information D. Other factors contributing to patient safety 1. Patient safety can be promoted with factors other than technology. 2. A strong educational foundation and solid orientation will help the high-acuity nurse provide a safe environment. 3. Strong physician–nurse relationships and responsible management are key.
PowerPoint Slide 1. Error Reporting • Culture in health care is supportive of error reporting. • Error reporting has been accompanied by systems improvement. 2. The Joint Commission (TJC) • Accrediting organization seeking to improve patient safety. • Developed National Patient Safety Goals. • Acute care facilities seeking accreditation must provide evidence of meeting safety goals. 3. Computerized Systems Used to Prevent Errors • Computerized provider order entry (CPOE) systems • Barcode point-of-care (BPOC) • Personal digital assistants (PDAs) 4. Non-Technological Elements That Promote Patient Safety • Strong educational foundation • Solid orientation • Specialty certification • Strong physician–nurse relationships
VI. Chapter Summary VII. Clinical Reasoning Checkpoint VIII. Post-Test IX. References
Suggestions for Classroom Activities • Develop three to four patient scenarios. Lead a class discussion as to whether the patients being referenced are suitable to the ICU, IMC, or general medical–surgical unit. • Determine the students’ interest level. Ask the students if they are considering a nursing career in an ICU, an IMC, or a generalized medical–surgical care unit. What factors do the students cite as the reasons behind their choices? • Contact a local clinical facility. Ask to have a copy of its policies concerning the steps taken when the intensive care units are filled to capacity.
Suggestions for Clinical Activities • During the clinical post conference, ask the students to evaluate whether their assigned patients were appropriate for the ICU, IMC, or general medical–surgical care unit. • Lead a class discussion to determine potential factors that would lead to a patient’s being considered a Priority 4 patient. • Provide the clinical group rotation opportunities to the ICU and the IMC. Ask the students to develop a listing of the noted differences between the units.
CHAPTER
2
Holistic Care of the Patient and Family
Objectives: 1. Discuss the impact of illness on the high-acuity patient and family. 2. Identify way the nurse can help high-acuity patients cope with an illness and/or injury event. 3. Describe the principles of patient and family-centered care in the high-acuity environment as it relates to educational needs of visitation and policies. 4. Discuss the importance of awareness of cultural diversity when caring for high-acuity patients. 5. Examine the role of palliative care in the high-acuity environment and discuss end-of-life issues to be considered in caring for high-acuity patients. 6. Identify environmental stressors, their impact on high-acuity patients and strategies to alleviate those stressors.
I. Impact of Acute Illness on Patient and Family A. Suchman’s stages of illness 1. Illnesses can cause the patients to experience a chronic loss of health, loss of limb, disfigurement, or necessary change in lifestyle. Patients might respond to the losses by passing through a series of phases. These are known as Suchman’s stages of illness. These stages are: a) Shock and disbelief: Diagnoses does not have an emotional meaning. b) Denial: Patient rejects diagnosis. c) Awareness: Attempts to regain control. d) Restitution; Diagnosis is accepted. e) Resolution: Patient’s identity is changed. B. Nursing considerations 1. The family is an important part of the patient’s health outcome. 2. Patients must participate in the care and recovery of their loved one. 3. Patients need information, comfort, support, assurance, and accessibility. 4. Open communication must be maintained.
PowerPoint Slides 1. Suchman’s Stages of Illness • Shock and disbelief
• Denial • Awareness • Restitution • Resolution 2a. Needs of the Family of the Patient with High-Acuity Illness • Information • Comfort • Support • Accessibility • Assurance 2b. Communication Requirements of the Family • Openness • Honesty • Direct • Frequent • Ongoing
II. Coping with Acute Illness A. Complementary and alternative therapies 1. Numerous strategies are used to help patients cope with psychological and physical illness– related stressors. Complementary and alternative therapies can help reduce stress include: a) Aromatherapy (1) Use of oils to reduce stress and anxiety. Oils may be inhaled or used with massage. Commonly used oils include lavender, and jasmine. b) Therapeutic Humor (1) Humor is used to relieve stress. Humor strengthens the bonds among the patient, family, and nurse. The use of humor is tricky during a serious illness. c) Massage Therapy and Therapeutic Touch (1) Massage can help promote relaxation, reduce anxiety, and facilitate sleep. (2) The vascular, muscular, and nervous systems are positively affected by massage. (3) Massage is an acceptable tool to manage pain. Conditions that do not indicate massage therapy include advanced osteoporosis, bone fractures, burns, deep vein thrombosis, eczema, phlebitis, and skin infections. d) Guided Imagery (1) Guided imagery is a technique that encourages relaxation. (2) The patient is asked to focus on positive thoughts and experiences.
PowerPoint Slides 1. Complementary and Alternative Therapies • Aid in stress reduction • May be used in place of or in addition to traditional therapies • Must be an informed decision 2. Aromatherapy • Use of oils to reduce stress and anxiety • May be inhaled or used with massage • Common oils 3. Humor • Relieves stress • Promotes positive communication • Requires skill to use successfully in high-acuity situations 4a. Massage Therapy • Manipulation of soft tissues of the body using the hands • Can reduce anxiety, promote sleep, and reduce pain • Has positive effect on muscular and nervous systems 4b. Massage Therapy and Pain Management • Used to treat all pain domains: • Physical • Spiritual • Emotional 4c. Contraindications to Massage Therapy • Advanced osteoporosis • Bone fractures • Burns • Deep vein thrombosis • Eczema • Phlebitis • Skin infections 5. Guided Imagery • Focuses thinking on positive thoughts and images • Can be used to distract the patient from painful events or treatments
III. Patient- and Family-Centered Care A. Educational needs of patients and families 1. Health literacy a) Patients and families require education with a goal to reduce stress and promote comfort. Establishing a relationship with the patient facilitates trust in the nurse and will promote security and facilitate learning. b) Some factors inhibit learning in the high-acuity patient. Obstacles to education can involve condition-related fatigue, blocks to communication and pain. The nurse must meet the physiological needs of the patient before attempting to promote understanding. c) Palazzo has established educational needs of patients and families. These Include: (1) Information about progress (2) Informed decision making (3) Acknowledgement of the past (4) Optimal learning environment (5) Orientations to routines and care (6) Motivation 2. Transfer anxiety a) Transfer of the patient to a less-acute care unit could cause transfer anxiety in the patient or family. b) The anxiety is the result of a change in environment. c) A plan of care allowing the patient and family to ask questions will promote success of the transfer. d) Moving the patient during daytime hours will help to lessen anxiety. B. Visitation policies 1. Many intensive care units in the United States have restrictive visiting policies: a) Studies indicate that patients prefer open visitation policies. b) Patients demonstrate reduced risks of cardiovascular complications, decreased mortality, and anxiety levels when their visiting hours are unrestricted. 2. The visiting activities of children often are restricted in intensive care units: a) The rationales for these limitations are concerns for the risk of infection and for the emotional well-being of the child. b) In the event a family member is at risk for not recovering, exceptions should be made to allow for “goodbyes” 3. Traditionally, family members have been restricted from their loved ones during invasive procedures and cardiopulmonary resuscitation: a) Studies reveal that many facilities do not have policies restricting family presence during CPR. b) Twibell identified benefits of the presence of the family during CPR. 4. The care delivery model embraces the presence of the family members at the bedside:
a) Nursing staff should provide education to the family members regarding what to expect and actions that should be taken. b) Hospital policies should carefully address the facility’s stance toward visitors exhibiting negative behaviors.
PowerPoint Slides 1. Educating the High-Acuity Patient • Goals • Reduce stress • Promote comfort • Establish a relationship with the patient 2. Barriers to Learning for the High-Acuity Patient • Condition-related fatigue • Communication barriers • Endotracheal tubes • Hourly procedures • Diagnostic tests • Pain • Medications 3. Educational Needs of Patients and Families • Information about patient progress • Informed decision making • Acknowledgement of the past • Optimal learning environment • Orientation to routines and care • Motivation 4. Transfer Anxiety • Can result from movement to a less-acute care unit • Affects patient and family • Tips to reduce: • Provide information to patient and family • Encourage questions from patient and family • Transfer during daytime hours 5. Visitation Policies • Patients prefer open visitation policies
• Benefits of flexible visitation policies: • Reduced incidence of cardiovascular complications • Decreased mortality • Reduced anxiety levels 6. Visitation of Children in Intensive Care Units • Limitations are based on: • Concerns for the risk of infection • Concerns for emotional well-being of the child • Should be allowed if death is imminent 7a. Visitation Limitations • During invasive procedures • During CPR 7b. Twibell’s Summary of Benefits of Family Presence during CPR • The ability of the family to grasp the seriousness of the patient’s illness. • Family members see firsthand that everything was done for the patient. • Families move more positively through the grieving process. • Removal of doubt by families about what is happening to the patient. • Families experience less anxiety and fear. • Provision of a sense of closure for families who lose a loved one. • Facilitation of the grieving process by families who lose a loved one.
IV. Cultural Diversity A. Cultural competence 1. Cultural Assessment a) Cultural competence is defined as an awareness of one’s own thoughts and feelings without letting them influence the care of patients with different backgrounds. b) Nurses who have self-awareness have knowledge, understanding, respect, and acceptance for the patient’s culture. c) Cultural competence includes sensitivity to the culture, race, gender, sexual orientation, social class, and economic status of the patients. 2. Other Sources of Diversity a) Immigrants and refugees may have specific health beliefs and practices. b) Racial and ethnic considerations must be taken into account. c) Socioeconomic status. d) Sexual orientation. B. Developing cultural competence
1. In the quest for developing cultural competence, the nurse must give consideration to individual characteristics. This will prevent stereotyping. The nurse must assess and affirm differences. Educational materials provided must be in the language and at the level needed by the patient. Judgment cannot be made concerning the patient’s choices. The CRASH (culture, respect, assess/affirm, sensitivity/self-awareness, and humility) model is often used: a) Consider culture b) Show respect c) Assess and affirm differences d) Show sensitivity and self-awareness e) Provide care with humility
PowerPoint Slides 1a. Cultural Competence • Self-awareness of one’s own thoughts and feelings about others with different backgrounds • Self-awareness can improve: • Knowledge • Understanding • Respect • Acceptance 1b. Categories Included in Cultural Competence • Culture • Race • Gender • Sexual orientation • Social class • Economic status 2. The CRASH Model • Consider culture • Show respect • Assess and affirm differences • Show sensitivity and self-awareness • Provide care with humility
V. Palliative and End-of-Life Care A. Palliative care 1. Why Palliative Care? a) Palliative care is a multidisciplinary approach to relieving suffering and improving the quality of life.
b) Interventions involve both nursing and medical treatment to manage pain and symptoms. c) The program includes members from other disciplines, including social workers and chaplains. d) Palliative care models allow the needs of patients and families to be met in a cost-effective manner. e) Needs for palliative care are growing. f) Benefits of palliative care include reduced cost, increased bed capacity, and improved quality of care. 2. High-Acuity Patients and Palliative Care: a) Cancer is the most common disorder requiring palliative care. b) Other disorders can include cardiac disease, chronic renal failure, and neurological diseases. 3. Barriers to Providing Palliative Care: a) Barriers to palliative care exist for the high-acuity-care patient. b) It is often difficult to make the transition from a cure perspective to that of a palliative nature. c) The limited collaboration and inconsistent communication between physicians and nurses also plays a role. d) These barriers can be managed with education. 4. A Multidisciplinary Approach a) A palliative care team is needed to facilitate the patient’s progression to a successful palliative care path. b) The team will consist of the high-acuity nurse and personnel from related discipline. 5. Assessment of Sources of Conflict B. End-of-life care 1. Barriers to End-of-Life Care in High-Acuity Settings: a) The Patient Self-Determination Act requires all patients be given information about their right to formulate advanced directives. b) The American Association of Critical-Care Nurses (AACN) recommends nurses base their practice on individual professional accountability; thorough knowledge; recognition and appreciation of a person’s wholeness, uniqueness, and significant social–environmental relationships; and appreciation of the collaborative role of all health team members. c) The Patient Self-Determination Act requires that all patients be provided information about their right to make advanced directives, living wills, and appointment directives: (1) Living wills (2) Power of Attorney for health care 2. Allow Natural Deaths a) Allow Natural Death (AND) (1) Using this term implies that the patient is dying and that everything possible is being done to keep the patient comfortable and allow the dying process to occur naturally. (2) The goal of AND is to prevent unnecessary suffering and allow nature to take its course. 3. Educational Focus
a) Educational programs must be developed and directed toward those individuals already in the workforce as well as those who are completing their basic education requirements.
PowerPoint Slides 1. Palliative Care • Multidisciplinary approach • Geared toward improving quality of life and relieving suffering • Includes all health disciplines 2. Benefits of Palliative Care • Reduced cost • Increased bed capacity • Improved quality of care 3. Disorders Requiring Palliative Care • Cancer (most common) • Cardiac disease • Chronic renal failure • Neurological conditions 4. Barriers to Palliative Care • Difficulty transitioning from a “cure perspective” • Limited collaboration between physicians and nurses • Inconsistent communication • Fragmented care 5. The Palliative Care Team • Goals to meet psychological, social, cultural, and spiritual needs • Includes the high-acuity nurse and other members • Conferences are instrumental • The care plan must be comprehensive 6. The Patient Self-Determination Act • Part of the Omnibus Budget Reconciliation Act • Mandates all patients be given information about the right to formulate advanced directives: • Treatment directives (living wills) • Appointment directives (power of attorney for health care) 7. Allow Natural Death (AND) • Synonymous with DNR • Term acceptable to families
• Goals: • Prevent unnecessary suffering • Allow for nature to take its course
VI. Environmental Stressors A. Sensory perceptual alterations 1. Sensory overload and deprivation a) Environmental characteristics of the high-acuity care unit have a significant impact on the patient. b) The patient is at risk for both sensory overload and deprivation. c) The individual’s normal stimuli are interrupted, and the senses simultaneously are being bombarded with continuous strange stimuli. d) Those who are very old, very young, postoperative, or unresponsive are at the greatest risk for this difficulty, known as sensory perceptual alterations (SPAs). e) The nurse must recognize the stressors presented by the environment and promote adequate sleep and rest periods as well as work to reduce unnecessary noises: (1) The Environmental Protection Agency recommends that hospitals contain noise levels. Daytime levels should not exceed 45 dBA. (2) Nighttime levels should not exceed 35 dBA. Normal conversation is approximately 60 dBA. 2. Delirium a) Delirium can result from sensory perceptual alterations in awareness, impaired ability to attend to environmental stimuli, and disorganized thinking. b) The nurse must assess and identify the cause of the delirium. c) Causes of delirium vary. Once determined, the underlying causes must be treated. 3. Sleep deprivation a) Normal rest and sleep are compromised in the high-acuity unit. b) The changes in the light/dark cycle, pain, and environmental stimuli are related factors. B. Interventions to decrease sensory perceptual alterations 1. Prevent sleep deprivation a) Patients need at least two hours of uninterrupted sleep to promote REM functioning. 2. Facilitate communications a) Communication with mechanically ventilated patients is needed to prevent SPA. b) Stressors are caused by the inability to speak. c) Nonverbal behaviors will vary and must be closely reviewed for messages. d) When caring for the patient who cannot speak, the nurse must act as a patient advocate. (1) The nurse will need to provide support for the decision of the patient or designated surrogate. (2) These choices could conflict with those of the health care provider and family.
PowerPoint Slides 1a. Cause of Environmental Stressors in High-Acuity Care Units • Sensory overload • Sensory deprivation • Pain • Loss of sleep 1b. Patients Most Affected by Environmental Stressors • The aged population • Very young patients • Postoperative patients • Unconsciousness patients 2. Role of the Nurse Caring for the High-Acuity Patient • Assess the patient’s normal environmental stimuli • Provide normal stimuli, if possible • Promote adequate rest and sleep • Reduce unnecessary environmental noise 3. Environmental Protection Agency Recommendations • Daytime levels not to exceed 45 dBA • Nighttime levels not to exceed 35 dBA 4. Environmental Stimuli and the Unconscious Patient • An assessment of the normal stimuli for the unconscious patient must be completed. • The nurse might need to consult a friend or family member about normal stimuli for the patient. 5a. Delirium • Sensory perceptual alterations • Physical disruptions 5b. Manifestations of Delirium • Fluctuating awareness • Impaired ability to attend to environmental stimuli • Disorganized thinking 5c. Potential Causes of Delirium • Hypoxemia • Alcohol or barbiturate withdrawal • Hyponatremia • Drug reactions
• Infections • Liver dysfunction 5d. Role of the Nurse Caring for the Patient Experiencing Delirium • Assess and determine cause • Manage cause 6a. Alterations of the Rest and Sleep Cycles • Associated with changes in the light/dark cycle • Causes: • Pain • Environmental noise • Caregiver interruptions • Stress 6b. Alterations of the Rest and Sleep Cycles (continued) • Management: • Planned rest periods of at least two hours • Nonpharmacologic induction of sleep recommended • Closing doors • Posting signs 6c. Benefits of REM Sleep • Protein anabolism • Improved immune function • Improved healing 7. Communication with Mechanically Ventilated Patients • Necessary to prevent SPA. • The inability to verbally communicate is a stressor. • Assessment of nonverbal behaviors needed. 8. The Patient Who Cannot Speak • Nurses must be patient advocates. • Nurse must represent the patient or patient representative: • Choices may conflict with provider or family desires.
VII. Chapter Summary VIII. Clinical Reasoning Checkpoint IX. Post-Test X. References
Suggestions for Classroom Activities • Ask each student to develop two study questions based on Suchman’s stages. Use these questions as part of an in-class review. • Divide the class into small groups of two to four students. Instruct student groups to develop small care plans addressing the education needs of the acutely ill patient. Allow only a short time for the exercise. Once complete, ask the student groups to share their work with the entire class. • Having the correct learning environment for educating for the acutely ill patient is crucial. Ask students to list their concepts of the optimal learning environment.
Suggestions for Clinical Activities • Discuss the implications of ensuring that patients report all complementary and alternative therapies being used. How and where should they be documented? • During clinical, assign students to patients who are considered to be high acuity. During the clinical post conference, ask the students to determine which Suchman stage the patient they cared for was demonstrating. • Invite a massage therapist to visit with the clinical group. Ask the massage therapist to discuss the use of massage for patients experiencing pain.
CHAPTER
3
The Older Adult High-Acuity Patient
Objectives: 1. Describe the characteristics of the aging population. 2. Apply knowledge of age-related changes in neurologic and neurosensory function. 3. Apply knowledge of the age-related changes in cardiovascular and pulmonary function. 4. Apply knowledge of the age-related changes in integumentary and musculoskeletal function. 5. Apply knowledge of the age-related changes in gastrointestinal and genitourinary function. 6. Apply knowledge of the age-related changes in endocrine and immune function. 7. Differentiate between dementia, delirium, and depression, and describe their impact on older high-acuity patients and their families. 8. Discuss falls, pain, and pharmacology as factors that impact hospitalization in the older patient. 9. Demonstrate the use of common geriatric assessment tools. 10. Demonstrate the nursing management of older patients with high-risk injuries and trauma. 11. Explain special situations including the culture of caring for older adults and end-of-life care.
I. The Older Adult Patient A. The older adult patient 1. Nurses working in high-acuity areas should understand the age-related changes that make older patients vulnerable to complications and that might impact the outcome of their hospitalization. 2. Older adults may present with common problems in uncommon ways: symptoms are less predictable; older patients may have multiple other comorbidities or chronic conditions, multiple medications, and adverse drug reactions; and they are at greater risk for disability and becoming permanently critically ill. 3. The application of early and appropriate interventions and protocols can improve care, promote optimal function, prevent complications, and provide for the best possible outcomes for hospitalized elderly patients. B. Characteristics of the older adult population 1. Demographics a) Demographic characteristics in the U.S. (people are living longer) (1) Population aged 65+ expected to double within next 20 years. (2) By 2030, ~1 in 5 (over 72 million) will be 65+.
(3) More than 70,000 centenarians exist. (4) Fastest-growing group is people 85+. (5) The “age wave” will peak in 2030, when most baby boomers are 65+. 2. General health a) High rates of chronic disease are related to high levels of disability. (1) 82% have at least one chronic condition (many have multiple). (2) Over half have some difficulty with daily activities or self-care. (3) Most common conditions: (a) Hypertension (b) Arthritis or joint problems (c) Heart disease (d) Cancer (e) Diabetes (f) Stroke (g) Asthma (h) Chronic bronchitis 3. Health care a) Increased use of health care services by the older population (1) Older adults will be a majority in general hospital setting. (a) 3 times more hospitalization rates (b) 55% in the intensive care unit 4. Ethnic diversity a) Increasing racial and ethnic diversity in aging population (1) Growing immigrant and minority populations. (2) Older adults; changing percentages. (a) 2008: 6.8% non-Hispanic whites (b) 2050: 20% non-Hispanic whites (3) Nurses will need to strive to provide culturally competent care.
PowerPoint Slides 1. Nurse has to assess each older adult individually. • Multiple medications. • Adverse drug reactions. • Greater risk for disability and becoming permanently critically ill. • Older patients may have multiple other comorbidities or chronic conditions. 2. Aging Demographics Characteristics in the U.S. • Population aged 65+ to double within next 20 years. • By 2030, ~1 in 5 will be 65+.
• More than 70,000 centenarians exist. • Fastest growing group is people 85+. • “Age wave” will peak in 2030. 3a. High rates of chronic disease —> high levels of disability: • 82% have at least one chronic condition. • Over half have difficulty with ADL. 3b. Most common chronic disease conditions: • Hypertension • Arthritis or joint problem • Heart disease • Cancer • Diabetes • Stroke • Asthma • Chronic bronchitis 4. Increased use of health care services by the older population: • Older adults will be a majority in general hospital setting. 5. Increasing racial and ethnic diversity in aging population: • Growing immigrant and minority populations. • Older adults; changing percentages. • Nurses will need to strive to provide culturally competent care.
II. Neurologic and Neurosensory Systems Changes A. Neurologic system 1. Nursing implications of central nervous system changes a) Aging affects many aspects of a person’s life experience: (1) Physical (2) Psychological (3) Social (4) Spiritual (5) Economic b) Aging process: gradual loss of function in all organ systems: (1) Changes associated with the normal aging process (2) Changes occurring due to a pathological process c) The application of early and appropriate interventions: (1) Improves care. (2) Promotes optimal function.
(3) Prevents complications. (4) Provides the best possible outcomes. d) Age-related alterations in the central nervous system (CNS) (1) Loss of nerve cells begins at age 30. (2) Neurotransmitters are not synthesized at the same rate. (3) Declines in nervous system conduction. (4) Memory processes are slower. (5) Learning takes longer. (6) Blood brain barrier is more permeable (medications cross over). (7) Increased cranial dead space. e) Age-related central nervous changes impact the neurologic exam: (1) Mental status (2) Level of consciousness (LOC) (3) Ability to communicate and follow commands (4) Short- and long-term memory (5) Fine and gross motor function f) CNS changes impact ability to perform self-care. (1) Ability to follow instructions (2) Ability to interpret instructions B. Neurosensory systems 1. Changes include: a) As individuals age, there is a decline in all of the sensory receptors: (1) Protein deficiency. (2) Negatively impacts older adults’ ability to interact in their environment. b) Visual: Visual acuity and depth perception decrease. (1) Pupils are smaller; pupillary response to light is decreased. (2) Cornea becomes thicker, flatter, and more irregular in shape. (3) Lens becomes more opaque (cataracts and glaucoma are common). c) Smell: The sensitivity to smells is diminished: (1) More difficulty discriminating between varying intensities of a flavor (2) Taste sensation affected d) Auditory: Auditory function declines and there is decreased sensitivity to sound: (1) Increase in cerumen impactions blocks sound and affects hearing. (2) Difficulty hearing high-pitched sounds and rushed speech. (3) Require more time to process and respond to auditory stimuli. e) Touch: Sensitivity in the fingertips, palms, and lower extremities deteriorates with aging. 2. Nursing implications of neurosensory changes a) Physiologic changes combine to alter ability to adapt to changes in the environment. (1) Decline in proprioception
(2) Decline in balance (3) Decline in postural control
PowerPoint Slides 1. Aging affects many aspects of a person’s life experience • Physical • Psychological • Social • Spiritual • Economic 2. Aging process: gradual loss of function in all organ systems • Changes associated with the normal aging process • Changes occurring due to a pathological process 3. The application of early and appropriate nursing interventions • Improves care. • Promotes optimal function. • Prevents complications. • Provides the best possible outcomes. 4. Age-related alterations in the central nervous system (CNS): • Loss of nerve cells begins at age 30. • Neurotransmitters are not synthesized at the same rate. • Declines in nervous system conduction. • Memory processes are slower. • Learning takes longer. • Blood brain barrier is more permeable (medications cross over). • Increased cranial dead space. 5. Age-related central nervous changes impact the neurologic exam: • Mental status • Level of consciousness (LOC) • Ability to communicate and follow commands • Short- and long-term memory • Fine and gross motor function 6. Age affects self-care: CNS changes impact ability to perform self-care: • Ability to follow instructions • Ability to interpret instructions
7. As individuals age, there is a decline in all of the sensory receptors. • Decline begins in second decade of life; rapid decline after 45–65. • Negatively impacts older adults’ ability to interact in their environment. 8. Visual: Visual acuity and depth perception decrease. • Pupils are smaller; pupillary response to light is decreased. • Cornea becomes thicker, flatter, and more irregular in shape. • Lens becomes more opaque (cataracts and glaucoma are common). 9. Olfactory: The sensitivity to smells is diminished: • More difficulty discriminating between varying intensities of a flavor • Taste sensation affected 10. Auditory: Auditory function declines, and there is decreased sensitivity to sound: • Increase in cerumen impactions blocks sound and affects hearing. • Difficulty hearing high-pitched sounds and rushed speech. • Require more time to process and respond to auditory stimuli. 11. Touch: Sensitivity in the fingertips, palms, and lower extremities deteriorates with aging. 12. Physiologic changes combine to alter ability to adapt to changes in the environment: • Decline in proprioception • Decline in balance • Decline in postural control
III. Cardiovascular and Pulmonary Systems Changes A. Cardiovascular system 1. Coronary heart disease (CHD) statistics: a) CHD is the leading cause of death in America. b) 82% who die of CHD are age 65 or older. 2. Cardiovascular changes alter the function of myocardium and peripheral vasculature. a) Changes: (1) Decreased elasticity (2) Increased stiffness of the arterial walls (3) Heart muscle is replaced with fat (4) Loss of elastic tissue (5) Increase in collagen b) Results: (1) Ventricular hypertrophy (2) Arteriosclerosis (3) Increased systolic blood pressure (4) Decline in ventricular compliance
3. Age-associated physiologic changes combine to impact cardiovascular function: a) Increased prevalence of peripheral vascular disease b) Increased prevalence of coronary heart disease 4. Nursing implications of cardiovascular changes a) Elderly patients with cardiac ischemia and acute myocardial infarction (AMI): (1) Can present atypically. (a) Shortness of breath; abdominal, throat, or back pain (b) Syncope, acute confusion, flu-like syndromes, stroke, and/or falls (2) Can delay or confuse their diagnosis and treatment. 5. Diagnostic tests can be less reliable in the older patient. a) 50% of elderly patients do not have ST-T wave changes in ischemia. b) Creatine kinase levels might be in the normal range. 6. Therapeutic intervention a) Therapeutic treatments are applicable, but modifications may be considered. b) Physiologic age of an individual as well as chronological age should be assessed. c) Vigilant clinical assessment and monitoring to prevent complications. B. Pulmonary system 1. Physiological changes in respiratory system result from changes in compliance of chest wall lung tissue. a) Costal cartilage connecting rib cage calcifies; kyphosis develops. b) Vertebral collapse from osteoporosis. c) Increased anteroposterior (AP) diameter. d) Loss of lung elasticity. e) Decreased rib mobility and decreased strength of respiratory muscles. (1) Decline in maximum inspiratory and expiratory force by as much as 50% 2. Loss of epithelial cells a) Results in decrease in protective mucus, increasing risk for infections. b) Surface area of the lungs is decreased, resulting in less capacity. 3. Nursing implications of pulmonary system changes a) Respiratory disorders are commonly encountered in those: (1) Recovering from surgery. (2) Suffering from rib fractures or chest injuries. (3) Receiving narcotics. (4) With artificial airways. (5) Deconditioned. (6) With altered nutritional or hydration status. b) Nurses need to accurately assess respiratory status to determine: (1) Adequacy of gas exchange. (2) Ventilation and perfusion.
(3) Worsening respiratory function. c) Increased complexity of care of the elderly patient on a mechanical ventilator: (1) Increased risk of ventilator-associated pneumonia (VAP) directly related to ventilation. (2) Implement VAP prevention guidelines. (3) Older patient might experience greater difficulty weaning from a ventilator. (4) Monitor with increased vigilance when weaning from a ventilator.
PowerPoint Slides 1. Coronary heart disease (CHD) statistics: • CHD is the leading cause of death in America. • 82% who die of CHD are age 65 or older. 2. Cardiovascular (CV) changes alter the function of myocardium and peripheral vasculature: • Changes • Results 3. Age-associated physiologic changes combine to impact CV function: • Increased prevalence of peripheral vascular disease • Increased prevalence coronary heart disease 4. Disease presentation in elderly patients with cardiac ischemia and acute myocardial infarction (AMI) • Can present atypically. • Can delay or confuse their diagnosis and treatment. 5. Diagnostic tests can be less reliable in the older patient: • 50% do not have ST-T wave changes in ischemia. • Creatine kinase levels might be in the normal range. 6. Therapeutic interventions in the elderly: • Therapeutic treatments are applicable (consider modifications). • Assess physiologic age as well as chronological age. • Vigilant clinical assessment and monitoring. 7. Respiratory physiological changes result from changes in compliance of chest wall or lung tissue: • Costal cartilage connecting rib cage calcifies; kyphosis develops. • Vertebral collapse from osteoporosis. • Increased anteroposterior (AP) diameter. • Loss of lung elasticity. • Decreased rib mobility; decreased respiratory muscle strength. 8. Epithelial cell changes: • Decrease in protective mucus (increases risk for infections)
• Surface area of the lungs is decreased (less capacity) 9. Respiratory disorders are commonly encountered in those: • Recovering from surgery. • Suffering from rib fractures or chest injuries. • Receiving narcotics. • With artificial airways. • Deconditioned. • With altered nutritional or hydration status. 10. Nurses need to accurately assess respiratory status. Determine: • Adequacy of gas exchange. • Ventilation and perfusion. • Worsening respiratory function. 11. Increased complexity of care on a mechanical ventilator: • Increased risk of VAP directly related to ventilation • Greater difficulty weaning from a ventilator
IV. Integumentary and Musculoskeletal Systems Changes A. Integumentary system 1. Continuous aging process is manifested through changes in the skin: a) Wrinkling and sagging. b) Loss of skin turgor. c) Ecchymosis. d) Skin becomes more transparent (underlying veins more visible). e) Loss of dermal and epidermal thickness. f) Skin becomes thin (more prone to skin breakdown and injury). 2. Number and efficiency of sweat glands decreases with aging, predisposing the patient to: a) Hypothermia. b) Hyperthermia. c) Fluid and electrolyte imbalances. 3. Nursing Implications of Integumentary Changes a) Nurses should complete a thorough skin assessment to monitor for changes in skin integrity. (1) Identify potentially life-threatening rashes, as well as cellulitis. (a) Rashes can be a side effect of a medication. (b) Cellulitis can be due to a contamination of the deep layer of skin. (2) Detect skin break (allows bacteria to enter). (3) Provide information regarding blood supply and venous drainage. (4) Detect skin breakdown. (5) Tissue ischemia.
b) Risk of Skin Breakdown (1) Maintaining skin integrity. (a) A few hours on a backboard can alter skin integrity. (b) A few hours on an operating room table can alter skin integrity. (c) High-risk patients might require specialty beds. (2) Pressure ulcers can delay recovery, prolong hospitalization, and impact quality of life. (a) Use support surfaces. (b) Reposition the patient frequently. (c) Optimize nutritional status. (d) Moisturize sacral skin. c) Thermoregulation Problems. (1) Age-related skin changes can cause difficulty with thermoregulation. (a) Prevent heat loss by monitoring room temperature. (b) Keep the patient covered while bathing. (c) Use warmed blankets when necessary (2) Nursing care to promote skin integrity at IV sites includes: (a) Close monitoring for infiltrations. (b) Use of nonrestrictive dressings and paper tape. B. Musculoskeletal system 1. Common musculoskeletal issues in the older adult: a) Decreased muscle mass b) Bone demineralization c) Increased joint stiffness d) Decreased joint mobility e) Decreased muscle strength f) Fractures more common (pelvis, femur) 2. Age-related changes in other subsystems contribute to muscle mass and strength loss: a) Reductions in neuron-muscular innervation b) Insulin activity c) Estrogen d) Testosterone and growth hormone levels e) Weight loss f) Protein deficiency g) Physical inactivity 3. Osteoporosis a) Primary osteoporosis (1) A common result of aging, independent of disease and medication use b) Secondary osteoporosis (1) Caused by a disease process or medication
4. Osteoarthritis is the most common arthritic condition among older adults: a) Affects 12% of U.S. adults. b) Pathophysiology is not directly related to the aging process. c) Cartilage between joints becomes irregular and eventually is diminished. d) Pain and loss of function are complications. 5. Compression of the spinal column or the spinal nerves is caused by: a) Degenerative stenosis (narrowing of the spinal canal). b) Thinning of the cartilage between the vertebrae. c) Development of bone spurs around the vertebrae. 6. Nursing implications of musculoskeletal changes a) Posture, gait, balance, symmetry, and alignment can be altered. b) Weakness, joint-related pain, and fractures threaten mobility. (1) Might require adaptations in patient care c) Limitations on comfort, recovery, and physical therapy.
PowerPoint Slides 1. Continuous aging process is manifested through skin changes: • Wrinkling and sagging. • Loss of skin turgor. • Ecchymosis. • Skin becomes more transparent. • Loss of dermal and epidermal thickness. 2. Number and efficiency of sweat glands decreases with aging: • Hypothermia • Hyperthermia • Fluid and electrolyte imbalances 3. Nursing Assessment: Monitor for changes in skin integrity: • Identify potentially life-threatening conditions. • Detect skin break. • Provide information (blood supply, venous drainage). • Detect skin breakdown. • Tissue ischemia. 4. Maintaining skin integrity: • A few hours on a backboard can alter skin integrity. • A few hours on an operating room table can alter skin integrity. • High-risk patients may require specialty beds.
5. Pressure ulcers can delay recovery, prolong hospitalization, and impact QOL. • Use support surfaces. • Reposition the patient frequently. • Optimize nutritional status. • Moisturize sacral skin. 6. Age-related skin changes cause thermoregulation difficulty. • Prevent heat loss by monitoring room temperature. • Keep the patient covered while bathing. • Use warmed blankets when necessary. 7. Nursing care to promote skin integrity at IV sites includes: • Close monitoring for infiltrations. • Use of nonrestrictive dressings and paper tape. 8. Common musculoskeletal issues in the older adult: • Decreased muscle mass • Bone demineralization • Increased joint stiffness • Decreased joint mobility • Decreased muscle strength • Fractures more common 9. Other age-related changes contribute to muscle mass and strength loss: • Reductions in neuron-muscular innervation • Insulin activity • Estrogen • Testosterone and growth hormone levels • Weight loss • Protein deficiency • Physical inactivity 10. Osteoporosis • Primary osteoporosis • Secondary osteoporosis 11. Osteoarthritis is the most common arthritic condition: • Affects 12% of U.S. adults • Pathophysiology is not directly related to aging process • Cartilage between joints becomes irregular, diminished • Pain and loss of function
12. Compression of spinal column or spinal nerves is caused by: • Degenerative stenosis. • Thinning of the cartilage between vertebrae. • Development of bone spurs around vertebrae. 13. Important implications for patient care: • Posture, gait, balance, symmetry, and alignment. • Weakness, joint-related pain, and fractures threaten mobility. • Limitations on comfort, recovery, and physical therapy.
V. Gastrointestinal and Genitourinary Systems Changes A. Gastrointestinal (GI) System 1. Oral cavity changes a) Changes affecting the teeth include: (1) Wearing of tooth surfaces. (2) Thinning of enamel. (3) Cracking of teeth. (4) Tooth loss. (5) Periodontal disease. b) Oral tissues become more fragile. c) Salivary production can be altered. d) Osteoporosis or atrophy of the jawbone 2. Esophageal changes a) Changes in motility are not normal age-related changes. (1) Refer patient for further evaluation if: (a) Patient is having difficulty swallowing. (b) Patient is experiencing significant problems with reflux. b) Neurological diseases can contribute to altered motility. 3. Stomach changes a) Secretion of digestive juices is diminished b) Gastric acidity decreases (possibly from chronic infection with Helicobacter pylori) (1) Increases the risk for growth of bacteria in the stomach (2) Increases the risk of aspiration pneumonia 4. Small intestine changes: a) Absorptive capacity of cells is altered. b) Impacts the absorption of vitamins and minerals. 5. Large intestine changes—histological changes contribute to: a) Muscle atrophy. b) Slower transit rate.
c) Diminished sphincter tone. d) Diminished compliance of the rectum. 6. Pancreas change. a) Exocrine function is decreased. 7. Liver changes a) Blood flow to the liver is reduced. b) Hepatocyte count is decreased. c) Hepatic regeneration is reduced. d) Decreased capacity to metabolize drugs 8. Nursing implications of gastrointestinal system changes a) Symptoms of concern that relate to the health of the GI system: (1) Pain (2) Dysphagia (3) Dyspepsia (4) Nausea (5) Vomiting (6) Anorexia (7) Weight loss (8) Changes in stool characteristics (9) Gastrointestinal bleeding b) Many factors contribute to constipation: (1) Sedentary lifestyle (2) Poor diet (3) Dehydration (4) Systemic illness (5) Medications B. Genitourinary (GU) System 1. Kidney changes a) Renal blood flow decreases by 50% due to: (1) Atrophy of the efferent and afferent arterioles. (2) Sclerotic glomeruli. (3) Decrease in number and size of nephrons. b) Decline in glomerular filtration rate. c) Decrease in creatinine clearance. d) Renal tubular function declines. e) Decreased ability to absorb glucose. 2. Ureter changes a) Vulnerable to reflux of the vesicoureteral junction b) Leads to reflux of urine
3. Bladder changes a) Muscles weaken—can lead to incomplete emptying. b) Collagen content increases, limiting distensibility. c) Bladder capacity decreases; frequency of urination increases. 4. Problems in the urination process might be due to: a) Altered sphincter muscles. b) Neural controls. c) Outlet size. d) Muscle strength. e) Obstruction. f) Sensation of the need to void. 5. Contributors to altered genitourinary function in the older adult: a) Increased prevalence of atherosclerosis b) Hypertension c) Heart failure d) Diabetes e) Infection f) Exposure to nephrotoxins 6. Nursing implications for GU changes are numerous: a) Fluid balance b) Renal failure c) UTIs d) Incontinence e) Sexual dysfunction 7. Increased vulnerability to fluid and electrolyte imbalances: a) Decreased urinary concentrating ability b) Limitations in excretion of water, sodium, potassium, and acid c) GU system’s declining ability to compensate 8. Nursing implications of genitourinary changes: a) Urinary tract infections (UTIs) b) Responsible for most community-acquired bacteremia c) Attributed to the presence of indwelling catheters in the hospital d) Often symptoms are not apparent e) Older adult patient might present with atypical manifestations: (1) Mental changes (2) Confusion (3) Nausea and vomiting (4) Abdominal pain f) Atypical manifestations can result in delay in diagnosis
9. Nurses should routinely assess: a) Hemoglobin b) Hematocrit c) BUN d) Serum creatinine e) Urine albumin f) Glucose g) PH h) Microscopic examination of urinary sediment i) Screening for bacteria 10. Nurses should consider urinary symptoms: a) Nocturia b) Dysuria c) Frequency d) Urgency e) Incontinence
PowerPoint Slides 1. Oral cavity changes • Changes affecting the teeth include: • Oral tissues become more fragile. • Salivary production can be altered. • Osteoporosis or atrophy of the jawbone. 2. Esophageal changes • Changes in motility are not normal age-related changes. • Neurological diseases can contribute to altered motility. 3. Stomach changes • Secretion of digestive juices is diminished. • Gastric acidity decreases. 4. Small intestine changes • Absorptive capacity of cells is altered. • Impacts the absorption of vitamins and minerals. 5. Large intestine changes—histological changes contribute to: • Muscle atrophy. • Slower transit rate. • Diminished sphincter tone. • Diminished compliance of the rectum.
6. Pancreas changes • Exocrine function is decreased. 7. Liver changes • Blood flow to the liver is reduced. • Hepatocyte number is decreased. • Hepatic regeneration is reduced. • Decreased capacity to metabolize drugs. 8. GI symptoms of concern: • Pain • Dysphagia • Dyspepsia • Nausea/vomiting • Anorexia • Weight loss • Changes in stool characteristics • Gastrointestinal bleeding 9. Many factors contribute to constipation: • Sedentary lifestyle • Poor diet • Dehydration • Systemic illness • Medications 10. Kidney changes • Renal blood flow decreases. • Decline in glomerular filtration rate. • Decrease in creatinine clearance. • Renal tubular function declines. • Decreased ability to absorb glucose. 11. Ureter changes: • Vulnerable to reflux of the vesicoureteral junction. • Leads to reflux of urine. 12. Bladder changes: • Muscles weaken. • Collagen content increases. • Bladder capacity decreases.
13. Problems in the urination process can be due to: • Altered sphincter muscles. • Neural controls. • Outlet size. • Muscle strength. • Obstruction. • Sensation of the need to void. 14. Other contributors to altered genitourinary function in the older adult: • Increased prevalence of atherosclerosis • Hypertension • Heart failure • Diabetes • Infection • Exposure to nephrotoxins 15. Nursing implications for GU changes are numerous: • Fluid balance • Renal failure • UTIs • Incontinence • Sexual dysfunction 16. Increased vulnerability to fluid and electrolyte imbalances • Decreased urinary concentrating ability • Limitations in excretion of water, sodium, potassium, acid • GU system’s declining ability to compensate 17. Urinary tract infections (UTIs) • Responsible for most community-acquired bacteremia • Attributed to the presence of indwelling catheters • Often symptoms are not apparent • Older adult patient might present atypically • Atypical manifestations can cause delayed diagnosis 18. Nursing assessment should routinely include: • Hemoglobin. • Hematocrit. • BUN. • Serum creatinine.
• Urine albumin. • Glucose. • PH. • Microscopic examination of urinary sediment. • Screening for bacteriuria. 19. Nurses should consider urinary symptoms: • Nocturia • Dysuria • Frequency • Urgency • Incontinence
VI. Endocrine and Immune Systems Changes A. Endocrine system 1. Hormone changes a) Decreased production of estrogen b) Decreased production of progesterone c) Decreased production of testosterone 2. Pancreas changes a) Pancreas secretes less insulin. b) Increase in insulin resistance. c) Decreased ability to metabolize glucose. d) Increase in the prevalence of diabetes mellitus (DM). (1) ~25.8% of the population with diabetes is aged 65+. 3. Nursing Implications of Endocrine System Changes a) Thyroid changes (1) Aging body uses less thyroid hormone. (2) Thyroid gland atrophies. (3) Increased risk for hypothyroidism. (4) TSH values can be elevated. (5) Basal metabolic rates decrease. b) Glucose metabolism changes (1) Influences on glucose metabolism: illness, medications, and nutritional alterations. (2) Assess macro vascular, micro vascular, and retinal complications. (3) Assess foot complications and foot ulcers. c) Thyroid conditions are often undiagnosed. (1) Hypothyroidism is associated with: (a) Slowing of mental and physical function.
(b) Intolerance to cold. (c) Weight gain. (d) Constipation. (e) Alterations in blood pressure. (f) Anemia. d) Hyperthyroidism (1) Irregular heart rhythms (tachycardia and atrial fibrillation) (2) Congestive heart failure (3) Weight loss (4) Fatigue (5) Muscular weakness e) Thyroid storm is a dangerous complication of hyperthyroidism (1) Fever (2) Tachycardia (3) Nausea (4) Vomiting (5) Mental status changes (6) Heart complications B. Immune system 1. The immune system of an older person is more vulnerable. a) Cell-mediated immunity declines with aging. b) T-cell function decreases. c) Humoral-mediated immunity and antibody responses are impaired. 2. Infection can present atypically in an older person. a) Fever might be absent (elderly patients have lower basal temperature). b) Diagnosis might be delayed. c) Nonspecific expressions of infection can include: (1) Changes in mental status. (2) Altered mental status (delirium, somnolence, and coma). (3) Functional decline. (4) Hypothermia. (5) Unexplained hypo- or hyperglycemia. (6) Acidosis. (7) Tachycardia. (8) Falls. (9) Tachypnea. (10) Anorexia. (11) Malaise.
(12) Generalized weakness. (13) Urinary incontinence. 3. Pneumonia and influenza are among the top ten causes of death for older adults. a) It is vital to identify pneumonia early. (1) Breath sound assessment and monitoring of oxygen status. b) Influenza and pneumococcal vaccines decrease the risk for pneumonia. (1) A vaccination history is important to obtain. 4. Nursing implications of immunologic changes a) Nurses must anticipate patients at high risk for infection and assess them appropriately. (1) Consider preexisting illnesses. (2) Consider recent history of diagnostic tests involving invasive or indwelling lines. (3) Carefully monitor clinical signs. 5. Bacteremia —> systemic inflammatory response (SIRS) a) SIRS can further deteriorate to severe sepsis and septic shock. b) Incidence of SIRS in older adults is significant. (1) ~60% of those who develop sepsis in the U.S. are 65+ c) Risk factors: institutionalization, hospitalization, indwelling catheters.
PowerPoint Slides 1. Hormone changes • Decreased production of estrogen • Decreased production of progesterone • Decreased production of testosterone 2. Pancreas changes • Pancreas secretes less insulin. • Increase in insulin resistance. • Decreased ability to metabolize glucose. • Increase in the prevalence of diabetes mellitus. 3. Changes in the thyroid • Aging body uses less thyroid hormone. • Thyroid gland atrophies. • Increased risk for hypothyroidism. • TSH values can be elevated. • Basal metabolic rates decrease. 4. Changes in glucose metabolism • Influences: illness, medications, nutritional alterations • Assess macrovascular, microvascular, retinal complications
• Assess foot complications and foot ulcers 5a. Hypothyroidism is associated with • Slowing of mental and physical function. • Intolerance to cold. • Weight gain. • Constipation. • Alterations in blood pressure. • Anemia. 5b. Hyperthyroidism is associated with • Irregular heart rhythms. • Congestive heart failure. • Weight loss. • Fatigue. • Muscular weakness. 5c. Thyroid storm is associated with • Fever. • Tachycardia. • Nausea. • Vomiting. • Mental status changes. • Heart complications. 6. The immune system of an older person is more vulnerable. • Cell-mediated immunity declines with aging. • T-cell function decreases. • Humoral-mediated immunity and antibody responses are impaired. 7a. Infection can present atypically in an older person. • Fever might be absent. • Diagnosis might be delayed. • Nonspecific expressions of infection can exist. 7b. Nonspecific expressions of infection • Changes in mental status • Altered mental status • Functional decline • Hypothermia • Unexplained hypo- or hyperglycemia
• Acidosis • Tachycardia • Falls • Tachypnea • Anorexia • Malaise • Generalized weakness • Urinary incontinence 8. Pneumonia and influenza are among the top ten causes of death. • It is vital to identify pneumonia early. • Influenza and pneumococcal vaccines decrease risk for pneumonia. 9. Nurses must anticipate patients at high risk for infection. • Consider preexisting illnesses. • Consider recent history of diagnostic tests. • Carefully monitor clinical signs. 10. Systemic inflammatory response Bacteremia —> systemic inflammatory response (SIRS). • SIRS can further deteriorate to severe sepsis, and septic shock. • Incidence of SIRS in older adults is significant. • Risk factors: institutionalization, hospitalization, indwelling catheters.
VII. Cognitive Conditions Impacting Hospitalization A. The “three Ds”-dementia, depression, and delirium 1. Common and often missed by health professionals 2. Mistaken for one another 3. The normal older adult retains memory and thinking abilities throughout life. a) Loss of memory, confusion, and low mood are not a normal part of aging. b) When an older patient exhibits these symptoms, evaluate.
b)
B. Dementia 1. Dementia: cognitive impairment (loss of memory and thinking ability). Causes are: a) Nonreversible dementia (1) Alzheimer’s disease (responsible for the largest percentage) (2) Lewy body disease (3) Vascular dementia (4) Small strokes Reversible dementia (1) Hypothyroidism
(2) B12 deficiency (3) Depression (4) Delirium 2. Alzheimer's disease: description a) 5.2 million affected (could double by 2050) b) Progressive and irreversible brain damage c) Characterized by amyloid plaques and neurofibrillary tangles in the brain d) Course: lose ability to make decisions, care for self, and communicate 3. Alzheimer’s disease: Early diagnosis and treatment is valuable. a) No cure is available. b) Current treatments can improve symptoms. c) Current treatments can slow progression of the disease. C. Depression 1. Depression—causes a) Lifelong problem b) Result of losses (retirement, widowhood, social isolation) c) Chronic stress d) Related to illness 2. Depression—statistics a) Found in10–12% of community-dwelling older adults. b) Rates are higher among those in institutional settings. c) The highest rate of suicide of any age group is among older men. d) Very common in older people with conditions causing pain or disabling conditions. 3. Depression—signs and symptoms a) Difficulty sleeping b) Poor appetite c) Feelings of hopelessness d) Apathy e) Difficulty concentrating f) Low self-esteem g) Low mood (changes in mood) h) Aches and pains 4. Depression—treatment a) Diagnosis based on presence of persistent symptoms not related to loss. b) Depression is very treatable in the older adult. c) Newer medications produce few side effects. d) Long-term treatment should include socialization. e) Counseling is very effective in this age group.
D. Delirium 1. Delirium (acute confusion) is the rapid onset of problems with cognition. a) Characterized by fluctuating symptoms of inattention and confusion b) Caused by an insult to the brain as a result of acute illness c) Often indicates a change in status (can be the first sign of a complication) 2. Delirium statistics a) Develops in up to 62% of older people in the hospital overall b) Develops in up to half of postoperative older patients c) Can be prevented in about one-third of patients d) Many times, delirium is reversible 3. Delirium can have many symptoms: lethargy/inattentiveness to agitation/restlessness. a) Hyperactive delirium is noticeable. b) Hypoactive (“quiet”) delirium might not be noticed.
PowerPoint Slides 1. Overlapping geriatric syndromes • Three Ds—dementia, depression, delirium • Common, often missed and mistaken for one another 2. Three Ds are not normal aging. • Normal adults retain memory and thinking abilities throughout life. • Loss of memory, confusion, and low mood are not normal. • When an older patient exhibits these symptoms, evaluate. 3. Two types of dementia • Dementia: cognitive impairment • Nonreversible dementia • Reversible dementia 4. Alzheimer's disease: description • 5.2 million affected • Progressive and irreversible brain damage • Characterized by amyloid plaques and neurofibrillary tangles • Course: lose ability to decide, care for self, communicate 5. Alzheimer's disease: Early diagnosis and treatment is valuable. • No cure is available. • Current treatments can improve symptoms. • Current treatments slow progression of disease.
6. Causes of depression • Lifelong problem • Result of losses • Chronic stress • Related to illness 7. Statistics about depression • Found in 10–12% of community-dwelling older adults. • Rates are higher in institutional settings. • Highest rate of suicide is among older men. • Very common with pain or disabling conditions. 8. Signs and symptoms of depression • Difficulty sleeping • Poor appetite • Feelings of hopelessness • Apathy • Difficulty concentrating • Low self-esteem • Low mood (changes in mood) • Aches and pains 9. Treatment of depression • Dx based on presence of persistent symptoms. • Depression is treatable in the older adult. • Newer medications produce few side effects. • Long-term treatment should include socialization. • Counseling is effective in this age group. 10. Delirium is the rapid onset of cognition problems. • Characterized by fluctuating symptoms of inattention and confusion • Caused by an insult to the brain as a result of acute illness • Often indicates a change in status 11. Delirium statistics • Develops in up to 62% of older people in the hospital overall. • Develops in up to half of postoperative older patients. • Can be prevented in about one-third of patients. • Many times, delirium is reversible.
12. Two types of delirium • Delirium can have many symptoms. • Hyperactive delirium is noticeable. • Hypoactive (“quiet”) delirium might not be noticed. 13. Management of delirium: Identify causes and remove them. • Infection • Pain • Fever • Sleep disturbance • Immobility • Sensory disturbance • Hypoxia • Dehydration • Medications
VIII. Factors Impacting Hospitalization A. Falls 1. Falls are a common accident in acute care, resulting in injury and increasing length of stay in older patients. 2. Older patients are at higher risk of falls due to: a) Musculoskeletal and sensory changes, combined with chronic conditions. b) Cognitive problems and medications such as antidepressants, benzodiazepines, antipsychotics, and psychotropic drugs. c) A higher RN staffing skill mix was associated with reduced falls. d) Fall prevention for older adults in acute care comprises several levels. (1) First Level (a) A safe environment (b) Use of appropriate beds and side rails (c) No clutter or tripping hazards (d) Safe equipment such as bedside commodes. (2) Second level (a) Adequate surveillance to meet patient needs (b) Frequent nursing rounds to address toileting needs (c) Increased observation of delirious or confused patients (d) Routine ambulation or getting older patients up in the chair as able. (3) Third level (a) Assessment of any additional fall risks and planning interventions to address these risks. Delirium to reduce confusion.
B. Pain 1. Achieving adequate pain control for the older adult in the high-acuity setting can be challenging. a) Variety of types of pain b) Causes of pain c) Physical manifestations of pain 2. Pain affects older adults’ ability to function and their QOL. Pain can be due to: a) An acute condition (fracture). b) Postoperative pain. c) Chronic disease (osteoarthritis, back pain, bone and joint disorders). 3. Pain assessment a) Age-related changes impact the ability to perceive and report pain. b) Ability to discriminate between painful stimuli declines with age. c) Impacts the ability to accurately assess pain: (1) A thorough nursing assessment is required. (2) Pain scales and pain assessment tools exist. (3) Assess nonverbal behavior (facial expressions, body language). 4. Pain medications a) Undertreatment of pain is commonly described among older adults. b) Leads to depression, social isolation, gait problems, sleep disturbances. c) Pain medication should be given routinely to avoid severe pain. (1) Necessitates higher levels of medication. (2) Interferes with recovery from acute conditions. d) Assess pain frequently. e) Create a healing environment to decrease the perception of pain. 5. Pain medications present a challenge in the older patient. a) Nonsteroidal anti-inflammatory drugs have increased risks. b) Meperidine should be avoided (commonly causes neurotoxicity in older patients). c) Evaluating a patient for any untoward reactions to treatments C. Pharmacotherapy 1. Administration of medications to the older adult is complicated because of: a) Drug toxicity. b) Medication errors. c) Adverse drug reactions (ADR). d) Potentially inappropriate medications (PIM). e) Age-related physiologic changes affecting PK and PD. f) Polypharmacy. g) Self-medication. h) Patient–family noncompliance
2. Physiologic Changes a) Consider conditions that potentially could affect ADME. b) Absorption (1) Decreased surface area of the small intestine (2) Decreased splanchnic blood flow (3) Altered gastric pH (4) Decreased gastric motility c) Distribution (1) Decrease in lean body mass (2) Increase in fat content (3) Decrease in total body water content d) Metabolism, Excretion (1) Altered liver and kidney function (2) Decrease in renal filtration 3. Drug dosage and frequency of administration might need to be altered or adjusted frequently. a) Drugs remain present and active for longer period of times. b) Increased opportunity to produce side effects. c) Tolerance for medications might be altered due to a decrease in renal filtration. d) Medications might be active in an older person’s system longer and might be more potent. e) Typical signs of drug toxicity: CNS changes, orthostatic hypotension, and falls. 4. Polypharmacy a) Older adult might have medications that interact/counteract with each other. Evaluate: (1) Prescription medications. (2) Over-the-counter medications. (3) Vitamins and minerals. (4) Alcohol. (5) Caffeine. (6) Tobacco use. (7) Home remedies. 5. Adverse drug reactions a) Inappropriate medications for the elderly—problems, solutions, considerations. b) Identify medications increasing the risk for adverse drug reactions. (1) Beers’ Criteria for Potentially Inappropriate Medication Use in the Elderly b) When an older adult receives a new medication, “start low and go slow.” c) The therapeutic window might be narrow. d) Monitor patient reactions to any new medication. 6. Problems with patient management of medication a) Short-term memory impairment: (1) Incorrect dosages
(2) Multiple doses (3) Skipped doses b) Impaired vision can affect dosage. c) Impaired agility opening containers can lead to missed doses. d) Financial factors and transportation issues can prevent filling prescriptions.
PowerPoint Slides 1. Falls • Falls are a common accident in acute care. • Older patients are at higher risk. • Fall prevention for older adults in acute care comprises several levels. 2. Achieving adequate pain control is challenging. • Variety of types of pain • Causes of pain • Physical manifestations of pain 3. Pain affects ability to function and QOL. Pain can be due to: • Acute condition. • Postoperative pain. • Chronic disease. 4. Age-related changes impact ability to perceive and report pain. • Ability to discriminate between painful stimuli declines. • Impacts the ability to accurately assess pain. 5. Undertreatment of pain is commonly described. • Leads to depression, social isolation, gait problems, sleep disturbances. • Give pain medication routinely to avoid severe pain. • Assess pain frequently. • Create healing environment to decrease perception of pain. 6. Pain medications present a challenge. • NSAIDs have increased risks. • Meperidine should be avoided (neurotoxicity). • Evaluate patient for any bad reactions. 7. Administration of medications is complicated because of • Drug toxicity. • Medication errors. • Adverse drug reactions.
• Potentially inappropriate medications. • Age-related physiologic changes affecting PK and PD. • Polypharmacy. • Self-medication. • Patient–family noncompliance. 8a. Conditions affecting ADME—Absorption: • Decreased surface area of the small intestine • Decreased splanchnic blood flow • Altered gastric pH • Decreased gastric motility 8b. Conditions affecting ADME—Distribution: • Decrease in lean body mass • Increase in fat content • Decrease in total body water content 8c. Conditions affecting ADME—Metabolism and Excretion: • Altered liver and kidney function • Decrease in renal filtration 9. Special elderly complications—Drug dosage/frequency might need to altered/adjusted. • Drugs remain present/active longer. • Increased opportunity to produce side effects. • Tolerance for medications might be altered. • Medications might be active longer and be more potent. • Typical signs of drug toxicity: CNS changes, orthostatic hypotension, falls. 10. Medications can interact/counteract with each other. Evaluate • Prescription medications. • Over-the-counter medications. • Vitamins and minerals. • Alcohol. • Caffeine. • Tobacco use. • Home remedies. 11. Inappropriate medications—problems, solutions, considerations: • Identify medications increasing risk for adverse reactions. • When an older adult receives new medication, “start low and go slow.”
• The therapeutic window might be narrow. • Monitor patient reactions to any new medication. 12. Problems with patient management of medication: • Short-term memory impairment. • Impaired vision can affect dosage. • Impaired agility opening containers. • Financial factors and transportation issues.
IX. Geriatric Assessment Tools for the High-Acuity Nurse 1. Geriatric assessment tools are commonly used to screen for problems in older patients. A. Assessment of mental status 1. Mental status assessment—Detects dementia. a) Test patient’s memory, ability to concentrate, and ability to follow directions. b) Simple scoring methods determine if the person has normal cognition. c) Example: Mini-Cog (takes just three minutes): (1) Repeat and recall three items (2) Draw the face of a clock with numbers and hands (3) Then try to repeat the original three items 2. Delirium assessment—Delirium is diagnosed by identifying delirium symptoms. a) Screening instrument walks the nurse through the patient assessment. b) Example: confusion assessment method (CAM): (1) Have an acute onset of symptoms. (2) Have fluctuating course and inattention. (3) Show altered level of consciousness or disorganized thinking. c) Example: ICU CAM (1) Patient completes specific tasks to determine cognitive status (a) Squeezes nurse’s hand when certain letters are recited 3. Geriatric depression scale (GDS) screens for depressive symptoms: a) Nurse asks patient a series of questions about mood over the past two weeks. b) Patient responds yes or no. c) Score is based on the number of answers that indicate depression. B. Skin assessment 1. Skin assessment—Standardized skin assessment will identify those at high risk. a) Assessment of risk for skin breakdown begins at admission. b) Daily assessment and reevaluation of skin integrity. c) Example: Braden scale for predicting pressure sores: (1) Subscales are scored based on descriptive criteria. (a) Sensory, perception, moisture, mobility, nutrition, friction, shear
(2) Lower score indicates a higher risk for pressure sore development. (3) Ulcers are prevented by reducing the risk factors. C. Falls and mobility assessment 1. Falls and mobility assessment—Identify patients at risk for falling. a) Use on admission, after any change (even daily). b) Use to identify what interventions to use, such as: (1) Assisting with transfers. (2) Therapy to increase muscle strength. (3) Frequent toileting. (4) Heavy surveillance (for delirious patients). c) Example: Hendrich II fall risk model: (1) Key risk factors: confusion or disorientation, depression, altered elimination, dizziness, male, antiepileptic drugs or benzodiazepines, difficulty getting up and walking around d) Example: Morse fall scale: (1) Key risk factors: history of falling, multiple conditions, mental status changes, need for a walking aid, walking problems, presence of IV therapy D. Pain assessment 1. Pain Assessment—Lack of objective measures has produced pain intensity scales. a) Most important consideration in pain assessment is patient’s account of the pain. b) Assess pain: impact on the older adult’s ability to function. c) Assess pain: impact on ability to recover from the present health condition. d) Consistent use of any scale brings objectivity to pain assessment. e) The most important consideration in the assessment of the presence and severity of pain is the patient’s account of the pain. f) Nurses work with patients to set goals for pain management. E. Laboratory data assessment 1. Assessment laboratory data a) It is important to be aware of the age-related alterations in laboratory trends
PowerPoint Slides 1. Geriatric assessment tools are commonly used to screen for problems in older patients. 2. Mental status assessment detects dementia. • Tests memory, concentration, direction following. • Simple scoring methods determine normal cognition. • Example: Mini-Cog (takes just three minutes). 3. Delirium diagnosed by identifying symptoms: • Screening instrument walks through patient assessment. • Example: confusion assessment method (CAM).
• Example: ICU CAM. 4. Geriatric depression scale (GDS)—Screens for depressive symptoms. • Series of questions about mood over the past two weeks. • Patient responds yes or no. • Score the number of depressed answers. 5. Standardized skin assessment identifies risk. • Assess skin breakdown at admission • Assessment/evaluation of skin integrity daily. • Example: Braden scale for predicting pressure sores 6. Falls and mobility assessment—Identify patients at risk. • Use on admission, after any change • Use to identify interventions to use • Example: Hendrich II fall risk model • Example: Morse fall scale 7. Lack of objective measures has produced pain intensity scales. • Most important —> patient’s account of pain. • Assess pain: impact on ability to function. • Assess pain: impact on ability to recover. • Patient’s account of the pain. • Nurses work with patients to set goals for pain management. 8. Assessment laboratory data • Age-related alterations in laboratory trends • Table 3-16 data
X. High-Risk Injuries and Complications of Trauma A. Traumatic injury: An overview 1. Traumatic injuries are a leading cause of death in the elderly. Contributing factors: a) Altered sensory function b) Changes in motor strength, postural stability, balance, and coordination c) Exacerbations of medical conditions d) Medication therapies (1) Antihypertensive (2) Oral hypoglycemic agents that might induce syncope (3) Diuretics without potassium supplements (4) β-blocking agents 2. Typical traumatic injuries a) Falls—the most common cause of injury.
b) Motor vehicle crashes account for the most fatalities. c) Burns have a high mortality rate in the elderly. 3. Nursing considerations a) Nursing care is aimed at stabilizing the injuries and preventing complications. (1) More difficulty compensating for injury or trauma (2) Greater risk for complications b) Priorities for care in the high-acuity area include: (1) Monitor oxygenation status. (2) Early hemodynamic monitoring is important; older adults don't tolerate hypo perfusion. (a) Monitor noninvasively: urine output, LOC, pedal pulses (b) Monitor invasively: cardiac output measurements (3) Assessment of hypovolemic shock is challenging. (a) Tachycardia can be obscured, as the heart rate might not respond to blood loss. (b) Volume overload is a concern (particularly with cardiac and renal disease). (c) Thermoregulatory mechanisms might be impaired. 4. Determining the cause a) Perform an in-depth history for information. b) Assess syncopal episodes (cardiovascular disease, hypertension treatment). c) Cardiac dysrhythmias can be a contributing factor. (1) Anemia, hormonal, or electrolyte imbalances d) Other risk factors: diminished senses, diminished reflexes, agility, and coordination. B. Specific types of traumatic injury 1. Head and spine injuries a) Subdural hematomas occur more frequently following a head injury. b) Considerable intracranial bleeding before appearance of symptoms. c) Classic signs of headache and vomiting might be absent. 2. Chest injuries a) Ribs fracture due to osteoporosis. b) Preexisting pulmonary disease and diminished pulmonary reserve: (1) Increase the risk of pulmonary failure. (2) Necessitate intubation and mechanical ventilation. 3. Abdominal injuries a) Fragile ribs and a weakened abdominal wall: (1) Increase the likelihood of abdominal injury with very little force. b) Abdominal trauma has a high mortality rate: (1) Postoperative, pulmonary, infectious complications. c) Typical signs of peritoneal irritation might be absent: (1) Diminished sensation and abdominal wall muscle tone.
4. Pelvic injuries a) Pelvic fractures are associated with great blood loss. b) Early control of hemorrhage is essential. (1) Fewer compensatory responses to combat hypovolemic shock. c) Perform embolization of major pelvic arteries. d) Perform early stabilization with external fixation. 5. Orthopedic trauma a) Loss of bone mass and osteoporosis increase the susceptibility of the older adult to traumatic injuries, which often result in significant fractures such as hip, femur, humerus, wrist, head, or spine injuries. b) Bone fractures result in acute pain and immobility. c) Early stabilization of fractures is important to prevent complications of prolonged immobility. 6. Burn injury a) Mortality of a burn in an older adult is very high. b) Elderly tend to have greater depth and size of burn: (1) Thin skin, slow reactions, reduced mobility, diminished sensations. c) Prolonged healing (particularly in the presence of malnutrition). d) Elderly do not scar as much as younger patients do (pressure garments not essential). e) Common sources of burns: (1) Flame injuries associated with cooking. f) Scald injuries associated with bathing.
PowerPoint Slides 1. Traumatic injuries are a result of • Altered sensory function. • Changes in strength, stability, balance, coordination. • Exacerbations of medical conditions. • Medication therapies. 2. Typical traumatic injuries include: • Falls are the most common. • MVC have the most fatalities. • Burns have high mortality rate. 3. Goals of nursing care: Stabilize the injuries, prevent complications: • Difficulty compensating for injury or trauma • Greater risk for complications 4. Priorities for nursing care in the high-acuity area include: • Monitor oxygenation status.
• Early hemodynamic monitoring is important. • Assessment of hypovolemic shock is challenging. • Thermoregulatory mechanisms might be impaired. 5. Determining the cause of injury: • Perform an in-depth history. • Assess syncopal episodes. • Cardiac dysrhythmias. • Other risk factors. 6. Head and spine injuries • Subdural hematomas occur more frequently following a head injury. • Considerable intracranial bleeding before appearance of symptoms. • Classic signs of headache and vomiting might be absent. • Assess for subtle LOC changes and cranial nerve deficits. 7. Chest injuries • Ribs fracture due to osteoporosis. • Preexisting pulmonary disease, diminished pulmonary reserve. 8. Abdominal injuries • Fragile ribs and a weakened abdominal wall. • Abdominal trauma has a high mortality rate. • Typical signs of peritoneal irritation might be absent. 9. Pelvic injuries • Pelvic fractures are associated with great blood loss. • Early control of hemorrhage is essential. • Perform embolization of major pelvic arteries. • Perform early stabilization with external fixation. 10. Orthopedic Trauma • Loss of bone mass and osteoporosis increase traumatic injuries. • Bone fractures result in acute pain and immobility. • Early stabilization of fractures is important to prevent complications of prolonged immobility. 11. Burns Injury • Mortality is very high. • Elderly have greater depth/size of burn. • Prolonged healing. • Common sources of burns.
XI. Special Considerations: A Culture of Caring and End-of-Life Care 1. Special attention must be given to this patient population to improve outcomes. a) More vulnerable to adverse outcomes b) Greater risk for functional decline or loss of independence when hospitalized A. A culture of caring for older adults 1. Hartford Institute for Geriatric Nursing (HIGN) at New York University’s (NYU) College of Nursing, funded by the John A. Hartford Foundation. a) An exemplary program to help nurses address supportive issues. b) Provides steps the nurse can follow to deliver better care for the older high-acuity patient. c) Physiologic, functional, and psychological needs of older adults.
c)
B. End-of-life care 1. End-of-life care—the problem a) In most acute care settings, the focus of patient care is curative. b) Needs of the elderly person at the end of life are often neglected. c) Nurses are challenged with blending high tech and high-touch care. 2. End-of-life care—the solution a) Palliative care should be integrated into acute/critical care settings. b) Hospitals offer specialists who consult on appropriate palliative care: (1) Increase comfort for patients and families (2) Advise staff on appropriate therapies (such as pain medication) 3. Resuscitation a) Before initiating resuscitation, certain ethical and physiologic issues should be taken into consideration. b) Ethical Issues—numerous ethical issues surround resuscitation efforts at the end of life: (1) Benefits (2) Likelihood of failure or adverse effects (3) Futility (4) Decision making Much debate about an individual’s right to determine medical treatment decisions (1) In the later stages of dementia, intensive treatments might not be appropriate. (2) Decisions about resuscitation and heroic measures for patients who might not benefit. d) Nursing responsibilities at the end of life (1) Nurses provide education and information about patient status. (2) Nurses provide supportive care to families making difficult decisions. (3) Nurses educate patients and families about CPR, DNR, and advanced directives. e) Physiological Issues (1) Consideration of age should be incorporated into standard resuscitation protocols. (2) Physiological issues (a) Heart rate of an older adult has less ability to increase in response to stressors.
(b) Vasopressors or inotropes might be required. (c) Tachycardia might not occur in hypovolemia; nurses must rely on other indicators. (d) Changes in hemodynamic values. (e) Decreased blood pressure. (f) Decreased muscle mass and peripheral vasoconstriction prevents heat conservation. (g) Nurses must monitor for hypothermia (h) Warm environment and warmed IV fluids might be warranted.
PowerPoint Slides 1. Special attention must be given to the elderly patient population: • More vulnerable to adverse outcomes • Greater risk for functional decline when hospitalized 2. Hartford Institute for Geriatric Nursing (HIGN) at New York University’s (NYU) College of Nursing, funded by the John A. Hartford Foundation: • An exemplary program to help nurses address supportive issues • Provides steps the nurse can follow to deliver better care for the older high-acuity patient. • Physiologic, functional, and psychological needs of older adults. 3. End-of-life care—the problem • In most acute care settings, focus of patient care is curative. • Needs of the elderly person are often neglected. • Nurses challenged with blending high tech and high-touch care. 4. End-of-life care—the solution • Palliative care should be integrated. • Hospitals offer specialists who consult on palliative care. 5. Numerous ethical issues surround resuscitation efforts and end-of-life care. • Benefits • Likelihood of failure or adverse effects • Futility • Decision making 6. Individual right to decide • Debate about an individual’s right to determine treatment decisions. • In later dementia, intensive treatments might not be appropriate. • Decisions about resuscitation for patients who might not benefit. 7. Nursing responsibilities at the end of life: • Provide education and information about patient status • Provide supportive care to families making difficult decisions
• Educate about CPR, DNR, and advanced directives 8. Before initiating resuscitation, certain ethical and physiologic issues should be taken into consideration. 9. Physiological issues of resuscitation: • Heart rate of an older adult has less ability to increase. • Tachycardia might not occur in hypovolemia; need other indicators. • Age-related changes prevent heat conservation.
XII. Chapter Summary XIII. Clinical Reasoning Checkpoint XIV. Post-Test XV. References
Suggested Classroom Activities • Table 3-1 summarizes changes in the central nervous system in the older adult. Discuss this, specifically relating these changes to people that you know or have cared for.
Suggestions for Clinical Activities • Visit a local senior center or invite older seniors to the classroom. Specifically, meet with a healthy octogenarian, nonagenarian, and centenarian to appreciate the healthy seniors that are not in health care facilities. Ask them to describe their health through the years, their secrets for longevity, and their attitude about aging. • Visit a health care facility that treats a large elderly population (or invite an administrator to visit the classroom). Ask about the most common health care problems of the elderly that they see. Discuss how this compares with the list of problems in this section.
CHAPTER
4
Acute Pain in the High-Acuity Patient
Objectives: 1. Explain the multidimensional nature of pain. 2. Discuss issues related to the under treatment of pain. 3. Describe potential sources and effects of pain. 4. Assess acute pain in the high-acuity adult patient 5. Demonstrate effective management of pain for the high-acuity adult patient. 6. Perform focused assessments of the patient receiving opioid drug therapy to prevent opioid-induced respiratory depression. 7. Identify considerations associated with pain management in special populations. 8. Discuss the nursing management of patients undergoing procedural sedation populations.
I. The Multifaceted Nature of Pain A. A working definition of acute pain 1. The International Association for the Study of Pain (IASP) defines pain as “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” 2. Differentiating nociception and pain. a) Nociception (1) Physiological response to tissue damage or injury b) Pain (1) Involves psychosocial as well as physiological responses to injury (2) Pain is a subjective experience (3) There is no test to prove its presence. (4) Patient’s report of pain must be believed. (5) Pain is real to that patient 3. Defining acute pain (1) Acute pain continually changing and transient. (2) Rapid onset and relatively brief duration (less than six months)
B. A multifaceted model of pain 1. The multifaceted conceptualization of pain is based on the theoretical model by Loeser and Cousins (1990), which consists of four overlapping spheres: nociception, pain, suffering, and pain behaviors 2. The First Facet: Nociception—refers to the activation of special pain sensory receptors called nociceptors. Noxious (pain causing) stimuli that are mechanical, thermal, or chemical, activate nociceptors in the affected tissue. a) Transduction (1) Transformation of a noxious stimulus to a nociceptive impulse. (2) Begins in the peripheral nervous system and initiates the exchange of sodium and potassium across the neuronal membranes, causing depolarization. b) Transmission (1) Pain transmission refers to conduction of the pain impulse through the nervous system once a noxious stimulus has been transduced. (a) Adelta fibers are small in diameter and are myelinated, conducting pain impulses rapidly along the myelin sheath, causing sharp, pinprick-like pain to be conducted. (b) Are small in diameter but are usually unmyelinated, which results in a slow conduction rate and transmission of deep aching, throbbing sensations (2) Role of the central nervous system in transmission (a) Body has its own analgesia system that influences how each person reacts to pain. (i) Periventricular and periaqueductal gray (PAG) areas (ii) Raphe magnus nucleus (iii) Pain inhibitory complex (3) Sensitization (a) Peripheral sensitization (i) Can decrease the patient’s pain threshold, causing a repeated painful stimulus to be more intense and to prolong the duration of pain. (b) Central sensitization (i) Is the increased excitability of neurons in the CNS and is a complex abnormal response to a barrage of prolonged nociceptive activation. c) Modulation (1) The body’s attempt to modulate (altering) pain transmission in response to specific physiologic events, such as pain and stress. (2) Analgesic substances (endogenous opioid peptides) modulate pain transmission: (a) Enkephalins (b) Beta-endorphins (c) Dynorphin (d) Perception (3) Pain perception refers to the patient’s subjective experience surrounding the pain.
3. The second facet: Pain a) Pain impulses are transmitted to the brain along multiple pathways (dual pathy). b) Neospinothalamic and paleospinothalamic tract (1) Delta pain fibers primarily transmit thermal and mechanical pain. (2) Pain impulses travel along first-order neurons. (3) Upon reaching the lamina marginalis in the dorsal horn, the impulse excites second-order neurons and immediately crosses to the opposite side of the spinal cord. (4) Primarily terminates in a broad area of the brainstem. c) Person perceives pain only when (1) Transmission of the noxious stimulus terminates within the brain. d) Unknown whether the patient’s ability to perceive pain remains intact: (1) When cortical function is compromised; (2) When cortical function has been chemically altered. 4. The third facet: Suffering a) Negative affective response generated in higher nervous centers of the brain. b) Closely connected to the personal meaning of the pain. c) Clinician’s assessment is restricted to observing pain behaviors. d) Suffering is particularly associated with chronic pain. 5. The fourth facet: Pain behaviors a) Pain-expressing behaviors (1) Those that are intended to communicate pain b) Pain-controlling behaviors (1) Those that are intended to lessen or control the pain
PowerPoint Slides 1. The International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” 2. Differentiating nociception and pain • Nociception • Physiological response to tissue damage or injury • Pain • Involves psychosocial as well as physiological responses. • A subjective experience. • No test to prove its presence. • Patient’s report of pain must be believed. • Is real to that patient.
3. The first facet: Nociception • Transduction • Transmission • Modulation • Perception 4. Pain conduction • Impulses are conducted more quickly over large, myelinated nerves. • A delta fibers: Conduct impulses rapidly (sharp, pinprick-like pain) • C fibers: Slow conduction rate (aching, throbbing sensations) 5. Body’s analgesia system influences person’s reaction to pain. • Periventricular and periaqueductal gray areas • Raphe magnus nucleus • Pain inhibitory complex 6. Sensitization to persistent stimulation • Persistent peripheral pain. • Persistent central pain can result in neuroplasticity. 7. Endogenous opioid peptides • Analgesic substances modulate pain transmission: • Enkephalins • Beta-endorphins • Dynorphins 8. The Second Facet: Pain: impulses are transmitted to the brain along multiple pathways • Neospinothalamic tract • Paleospinothalamic tract 9. The Third Facet: Suffering • Negative affective response • Closely connected to the personal meaning of the pain • Clinician’s assessment is restricted • Chronic pain 10. The Fourth Facet: Pain behaviors • Pain-expressing behaviors • Pain-controlling behaviors
II. Acute Pain in the High-Acuity Patient
d)
A. Potential sources of pain 1. Potential sources of pain a) Acute pain of the initial insult. (1) e.g., traumatic injury, organ ischemia, surgical manipulation b) Invasive lines and tubes irritate delicate tissues. (1) E.g., chest tubes, intravenous lines, endotracheal and tracheostomy tubes c) Painful procedures. (1) E.g., lumbar puncture or endoscopic examinations Forced immobility can exacerbate chronic conditions. (1) E.g., back or arthritic pain B. Types of acute pain 1. Somatic pain a) Arises from stimulation of receptors in skin, muscle, joints, and tendons 2. Visceral pain a) Arises from stimulation of receptors in the viscera 3. Neuropathic pain a) Due to abnormal signal processing in the nervous system C. The effects of stress and pain on the body 1. Tissue injury, ischemia, metabolic, or chemical mediators, inflammation, or muscle spasm. 2. The stress response is crucial to self-preservation. It initiates events that increase the body’s chances of survival by minimizing organ damage. When the sympathetic nervous system is activated, blood vessels decrease perfusion in order to limit blood loss while optimizing circulation to vital organs. a) A high-stress response increases vascular shunting resulting in hypoperfusion of vital organs, b) Increases serum levels of endogenous opioid peptides resulting in counter-regulation of hormonal responses, 3. Immobility can cause stasis-related complications. a) Pulmonary complications (atelectasis and stasis pneumonia) (1) Source: thoracic surgery, abdominal surgery, or trauma b) Deep vein thrombosis (DVT) (1) Source: prolonged bed rest
PowerPoint Slides 1. Potential sources of pain • Acute pain of the initial insult • Invasive lines/tubes irritate delicate tissues
• Painful procedures • Forced immobility can exacerbate chronic conditions 2. The three major types of pain • Somatic pain • Visceral pain • Neuropathic pain 3. Factors that can increase pain • Anxiety that can accompany acute pain • Stress associated with the hospital environment 4. A high-stress response • Increases vascular shunting. • Increases serum levels of endogenous opioid peptides. 5. Tissue injury is a strong stress response stimulus. • Initial acute pain • Prolonged pain 6. Immobility can cause stasis-related complications: • Pulmonary complications • Deep vein thrombosis (DVT)
III. Pain Assessment A. Pain history 1. Pain history provides valuable information regarding: a) Preexisting pain experiences. b) Treatment modalities. c) Medication history. d) Usual pain behaviors. e) Usual pain relief methods used at home. B. Unidimensional and multidimensional pain assessment 1. Unidimensional Pain Assessment tools rate a single pain dimension (e.g., intensity), are especially useful in evaluating the effectiveness of interventions, are simple to use, and take little time to administer. a) Visual Analog Scale (VAS) (1) Effective measurement of pain intensity. (2) Line: one end labeled “no pain,” opposite end labeled “worst pain Imaginable.” (3) Patient self-reports the level of pain along this line (usually 10 cm). (4) The point is then converted to a numeric score.
b) Numeric Rating Scale (NRS)) (1) Variation of the VAS. (2) Uses a sequence of numbers from which the patient chooses. (3) Most common and clinically proven NRS is the 0–10 scale. (4) 0 = “no pain” and 10 = “worst pain imaginable.” c) Verbal Descriptor Scales (1) Used to measure levels within any of the pain dimensions (2) Useful for older adults unable to rate their pain using numeric rating scales (3) Using a list, the patient chooses the adjective that best describes the pain: (a) E.g., sensory dimension adjectives—sharp, cutting, lacerating. (4) Potential disadvantages: (a) Careful choice of descriptor words is necessary. (b) Patients have a tendency to choose words from the middle. d) Wong-Baker Faces Scale (Faces) (1) Popular with both children and adults (2) Consists of six facial drawings ranging from smiling to crying (3) Each face is assigned a number from 0 to 5 or 0 to 10 (4) Patient points to the face that represents the current level of pain 2. Adapting the Unidimensional Pain Assessment Tool for the Severely Ill Patient Patients may be able to: a) Nod when a nurse points along a VAS to indicate the “point.” b) Point to the number on an NRS or to the location on the line of a VAS. c) Raise the number of fingers that indicate the level of pain: (1) 0 fingers = “no pain,” 10 fingers = “worst pain imaginable.” 3. Multidimensional Pain Assessment provides the patient with a means to expresses the affective and evaluative aspects of the pain experience. a) Most frequently used measurement of sensory and affective pain. b) Measures four aspects of pain experience: sensory, affective, evaluative, miscellaneous. c) Each pain category is measured using a cluster of descriptive words. d) Patient’s word choice determines from which category the pain is originating C. Assessment of pain in the adult with altered communication status 1. Assessing pain in adults with altered cognitive status: a) Use alternative pain assessment tools for those unable to self-report pain level. b) Patients rely on the nurse to advocate and intervene for them. c) Review of the patient’s medical history provides information. d) Sympathetic nervous system response also should be considered. e) Absence of physiologic indicators does not preclude pain. (1) Patients with chronic pain adapt to the stress response. (2) Pharmacologic interventions can prevent such change.
2. Nurses rely on their observations of behavioral cues, rather than on self-report tools. a) Nurses frequently subjectively interpret the patient’s self-report of pain. b) Nurses’ attitudes frequently alter the assessment of pain. c) This is an inappropriate use of the self-report tools. d) The patient might be using coping skills. e) The patient’s use of distraction and relaxation techniques can be misinterpreted. 3. Behavioral pain scales use patient behaviors (cues) to indicate the presence of pain. a) Vocal: crying, moaning, and grunting b) Facial: grimacing, crying expression (tears might be noted) c) Body posturing: agitation, stiffening, rocking, and tapping 4. Acute pain is associated with stimulation of the sympathetic nervous system response. a) Of value in assessing short-term acute pain b) Loses validity over time
PowerPoint Slides 1. Pain history provides valuable information regarding: • Preexisting pain experiences. • Treatment modalities. • Medication history. • Usual pain behaviors. • Usual pain relief methods used at home. 2. Unidimensional pain assessment tools • Patient rates a single pain dimension (e.g., intensity) • Especially useful in evaluating the effectiveness of interventions • Simple to use, and take little time to administer 3. Multidimensional assessment tools • Patient expresses the affective and evaluative aspects of the pain experience. • Work best for patients with more complex pain (e.g., unknown origin, chronic). 4. Visual analog scale (VAS) • Effective measurement of pain intensity. • Line: one end labeled “no pain,” opposite end “worst pain imaginable.” • Patient self-reports the level of pain along this line. • The point is then converted to a numeric score. 5. Numeric rating scale (NRS) • Variation of the VAS.
• Uses a sequence of numbers from which the patient chooses. • Most common and clinically proven NRS is the 0–10 scale. 6. Verbal descriptor scales • Used to measure levels within any of the pain dimensions. • Useful for older adults unable to rate their pain using numeric rating scales. • Using a list, the patient chooses the adjective that best describes the pain. • Potential disadvantages. 7. Wong–Baker Faces Scale • Popular with both children and adults • Consists of six facial drawings ranging from smiling to crying • Each face is assigned a number from 0 to 5 or 0 to 10 • Patient points to the face that represents the current level of pain 8. Adapt the scale for the severely ill patient. Patients might be able to: • Nod when a nurse points along a VAS to indicate the “point.” • Point to the number on an NRS or to the location on the line of a VAS. • Raise up the number of fingers that indicates the level of pain. 9. McGill Pain Questionnaire (MPQ) • Most frequently used measurement of sensory and affective pain. • Measures four aspects of pain experience. • Each pain category is measured using a cluster of descriptive words. • Patient’s word choice determines from which category the pain is originating. 10. Assessing pain in adults with altered cognitive status • Use alternative pain assessment tools for those unable to self-report pain level. • Patients rely on the nurse to advocate and intervene for them. • Review of the patient’s medical history provides information. • Sympathetic nervous system response also should be considered. • Absence of physiologic indicators does not preclude pain. 11. Behavioral pain scales use patient behaviors (cues) to indicate the presence of pain. • Vocal: crying, moaning, grunting • Facial: grimacing, crying expression • Body posturing: agitation, stiffening, rocking, and tapping 12. Acute pain is associated with stimulation of the sympathetic nervous system response. • It is of value in assessing short-term acute pain. • Use of the sympathetic response criteria loses validity over time.
IV. Management of Acute Pain A. Pharmacologic pain management 1. The World Health Organization (WHO) analgesic ladder a) An organized, systematic approach to effective pain management b) Suggests general pain management choices based on the level of pain: (1) Mild, mild-to-moderate, or moderate-to-severe c) Provides step-by-step approach to adjusting pharmacologic choices 2. Pharmacologic pain management modulates pain transmission at different levels. a) Opioids bind with opioid receptors. b) NSAIDs can relieve pain by working peripherally at the site of injury. 3. Nonopioid therapy a) Pain management can be enhanced by a combination of opioid and nonopioid therapy. (1) Better level of analgesia is often achieved in combination. (2) Nonopioids include acetaminophen, aspirin, NSAIDs. (3) Nonopioids are associated with fewer side effects than are opioids. 4. Adjuvant therapy a) Adjuvant therapy includes drugs that can assist in reducing certain types of pain: (1) Indirect assistance (decrease other symptoms) (2) Direct assistance (as a coanalgesic) (3) Generally used in addition to opioid and nonopioid analgesics (4) Examples of adjuvant drugs include: (a) Corticosteroids for cancer-related pain. (b) Antidepressants or anticonvulsants for treatment of neuropathic pain. 5. Opioid therapy a) First decisions: specific opioid drug, route of administration b) Next decisions: suitable initial dose, frequency, use of nonopioid analgesics c) Note: Dosing needs and analgesic response vary greatly among patients. 6. Multimodal therapy a) Multimodal therapy (balanced analgesia) is a balanced approach to pain treatment. b) Targets multiple pain-signaling pathways, matching treatment to type of pain. c) Preemptive pain treatment is treatment initiated prior to surgery. (1) Goal of reducing postoperative hypersensitivity (sensitization) d) Takes advantage of additive (synergistic) effects of different analgesics. e) Most likely required to reduce opioid-related adverse effects. 7. Routes of administration a) Oral route is most commonly used for opioids (inexpensive, convenient) (1) Might not be available due to nothing-by-mouth status (2) Feeding tubes that act as an alternate medication route
b) IV: When IV access is not possible, use rectal or sublingual routes (AHCPR guidelines). (1) Intravenous patient-controlled analgesia (PCA) (a) Patient can self-dose intravenously (push a button attached to infusion device). (b) Other forms: subcutaneous, intra-muscular, epidural. (2) Repeated use of subcutaneous and intramuscular routes is painful. (3) Avoids lag time between injection and absorption. c) Intraspinal opioids can be administered in a variety of ways: (1) Single-dose epidural or intrathecal (2) Intermittent scheduled-dose epidural or intrathecal (3) Intermittent patient-controlled epidural (PCEA) or intrathecal (4) Continuous infusion of opioid alone or in combination (5) Continuous infusion plus patient-controlled opioid alone or in combination (6) The epidural route (a) Insertion of a small catheter into the space located just before the dura mater. (b) An opioid, or a combination, is delivered using an infusion device. (c) Requires low doses of analgesic, whether administered alone or in combination. (d) Minimizes the potential for side effects. d) Intrathecal route (1) Passage of a small catheter into the cerebrospinal fluid (CSF) space. (2) Opioid flows through the CSF and rapidly binds to opioid receptors. (3) Smaller amounts of drug required to achieve same effects as epidural. (4) Methods: percutaneous catheters, implanted ports, implanted pumps. e) Peripheral Nerve Block (peripheral nerve path transmitting the pain is located) (1) Local anesthetic is injected medial to the point of pain origin. (2) Duration of the analgesia depends on the half-life of the local anesthetic. (3) Example: intercostal nerves medial to the insertion site of chest tubes. (4) Example: femoral nerve prior to total knee arthroplasty. f) Pleural infusion route used primarily when multiple rib fractures are present (1) Small catheter is placed into the pleural space, and a local anesthetic injected. (2) Multiple intercostal nerves can be blocked without repeated needle sticks. B. Nonpharmacologic interventions 1. Nonpharmacologic (complementary) interventions can be used concurrently. a) Identify effective alternative interventions to incorporate into the care plan. b) Patients respond individually to nonpharmacologic interventions to pain.
PowerPoint Slides 1. World Health Organization (WHO) analgesic ladder • An organized, systematic approach
• Choices based on the level of pain • Provides step-by-step approach 2. Modulating pain—pharmacologic pain management • Opioids bind with opioid receptors. • NSAIDs working peripherally. 3. Combination therapy—pain management enhanced by combining opioid and nonopioid • Better level of analgesia in combination. • Nonopioids: acetaminophen, aspirin, NSAIDs. • Nonopioids have fewer side effects than do opioids. 4. Adjuvant therapy drugs assist in reducing pain • Indirect assistance (decrease other symptoms) • Direct assistance (as a coanalgesic) • Used in addition to opioids and nonopioids 5. Opioid therapy • First decisions: specific opioid drug, route of administration • Next decisions: initial dose, frequency, nonopioid analgesics • Note: Dosing needs and analgesic response vary greatly 6. Multimodal therapy (balanced analgesia) • Targets multiple pain-signaling pathways • Preemptive pain treatment initiated prior to surgery • Takes advantage of additive (synergistic) effects • Reduces opioid-related adverse effects 7. Oral route is most commonly used for opioids. • Might not be available due to NPO status. • Feeding tubes act as alternate medication route. 8. Alternative routes of administration • If IV access is not possible —> Use rectal or sublingual routes. • Repeated use of sc and intramuscular routes is painful. • Avoids lag time between injection and absorption. 9. Intravenous patient-controlled analgesia (PCA) • Patient can self-dose intravenously. • Other forms: sc, intra-muscular, epidural. 10. Intraspinal opioids can be administered: • Single-dose epidural or intrathecal • Intermittent scheduled-dose epidural or intrathecal
• Intermittent patient-controlled epidural or intrathecal • Continuous infusion of opioid alone or in combo • Continuous infusion plus patient-controlled opioid alone or in combo 11. Epidural route of administration • Insertion of a small catheter. • An opioid, or a combination, is delivered. • Requires low doses of analgesic. • Minimizes the potential for side effects. 12. Intrathecal route of administration • Small catheter into the CSF space. • Opioid flows through the CSF, binds to opioid receptors. • Smaller amounts of drug to achieve same effects as epidural. • Methods: percutaneous catheters, implanted ports, implanted pumps. 13. Peripheral nerve block • Local anesthetic injected medial to point of pain origin. • Duration depends on the half-life of the local anesthetic. 14. Pleural infusion route of administration used for multiple rib fractures • Small catheter placed in the pleural space. • Local anesthetic injected. • Multiple intercostal nerves can be blocked. 15. Nonpharmacologic (complementary) interventions—used concurrently • Identify effective alternative interventions. • Patients respond individually.
V. Issues in Inadequate Treatment of Acute Pain A. Undertreatment of pain 1. Undertreatment problem is multifactorial (social and health care system issues) a) Inadequate attention to pain education in many medical programs b) Clinical, human, and economic consequences of this shortcoming: (1) Altered immune system functioning (2) Diminished ability to function (3) Increased risk for chronic pain (4) Needless suffering (5) Higher health care costs
B. Definitions 1. Definitions from AHCPR guidelines remain current. a) Tolerance: larger dose of opioid required to maintain same level of analgesia b) Physical dependence: physical adaptation of the body to the presence of opioids c) Psychological dependence (addiction): continued craving for an opioid d) Opioid pseudoaddiction: behaviors that mimic those associated with addiction (1) Results from inadequate pain management, not psychological Dependence. (2) Undertreated pain behaviors frequently are misread as drug seeking. (a) Demands for different or more pain medications that escalates (b) Clock watching (c) Preoccupation with obtaining pain medications (d) Anger (3) Resolution of aberrant behaviors when pain is relieved. C. Reasons for opioid undertreatment of pain 1. Oligoanalgesia—practice of treating pain with minimal drug use a) Physicians underprescribe opioids. (1) Prescribing subtherapeutic doses (2) Prescribing time intervals that are less than the duration of action b) Nurses undertreat pain. (1) Administering less than the physician orders (2) Administering at longer intervals than prescribed c) Patients contribute to their own undertreatment of pain. (1) Not requesting as-needed (PRN) pain medications (2) Taking medication at longer-than-ordered intervals (3) Taking less than the amount prescribed (4) Refusing to take the drug at all 2. Fear of addiction (psychological dependence). a) Probably the major cause of undertreatment of pain. b) Opiophobia: fear of prescribing/consuming adequate amounts of opiates. c) Very few hospitalized patients who receive opioids become addicted. d) Few patients who do develop addiction have a history of prior substance abuse. 3. Fear of physical dependence a) Fear associated with physical dependence. b) Many believe addiction is natural progression of dependence. c) Truth: some degree of withdrawal symptoms if opioid is suddenly stopped. d) These symptoms can be effectively managed. 4. Fear of tolerance a) Patients, physicians, nurses fear that opioids lose their effectiveness over time.
b) Belief in an imaginary dose ceiling. (1) This feared dose ceiling does not seem to exist. c) Tolerance is treated by decreasing dose interval or increasing the dose. 5. Fear of respiratory depression a) Physicians and nurses fear respiratory depression. b) In the majority of hospitalized patients, it is not a significant problem. c) Nursing management: Focus on close observation of the patient’s response. (1) Sedation develops before respiratory depression. D. Nursing approach in acute pain management 1. Preventive approacha) Analgesics are administered before the patient complains of pain. b) Maintain a consistent therapeutic level of analgesic in the bloodstream. c) Diminishes the likelihood of undertreatment of pain. 2. Titration approach a) Adjusting/individualizing therapy based on effects the drug is having (1) Rather than based on the milligrams being administered b) Goal: Gain the desired level of pain relief with minimum side effects c) Consider: dose, interval between doses, route of administration, and choice of drug
PowerPoint Slide 1. Undertreatment of pain—a persistent challenge • Multifactorial (social and health care system issues) • Inadequate attention to pain education • Consequences 2. AHCPR guideline definitions • Tolerance • Physical dependence • Psychological dependence (addiction) • Opioid pseudo addiction 3. Pseudo addiction • Results from inadequate pain management, not psychological dependence. • Undertreated pain behaviors are frequently misread as drug-seeking. • Resolution of aberrant behaviors when pain is relieved. 4. Oligoanalgesia—practice of treating pain with minimal drug use • Physicians underprescribe opioids. • Nurses undertreat pain. • Patients contribute to their own undertreatment of pain.
5. Fear of addiction (psychological dependence) • Major cause of undertreatment of pain. • Opiophobia. • Very few become addicted. 6. Fear of physical dependence • Fear associated with physical dependence. • Many believe dependence leads to addiction. • Truth: some degree of withdrawal symptoms 7. Fear of tolerance • Patients, physicians, nurses fear opioids lose effectiveness. • Belief in an imaginary dose ceiling. • Tolerance treated by decreasing dose interval or increasing dose. 8. Fear of respiratory depression • Physicians and nurses fear respiratory depression. • In the majority, it is not a significant problem. • Nurses should closely observe patient’s response. 9. Effective pain management—preventive approach • Analgesics are administered before pain. • Maintain a consistent therapeutic level. • Diminishes likelihood of undertreatment of pain. 10. Effective pain management—titration approach • Adjusting therapy based on effects the drug is having. • Goal: Gain pain relief with minimum side effects. • Consider: dose, interval, route, and choice of drug.
VI. Monitoring for Opioid-Induced Respiratory Depression A. Assessment 1. Patient variables a) Age and disease or compromise b) History of obstructive sleep apnea (OSA) c) Body mass index (BMI) of greater than 30 kg/m2 d) Neck circumference of greater than 17.5 inches e) Impaired renal or hepatic function f) Neurologic disorder resulting in muscle weakness
2. Iatrogenic (therapy) variables a) Modality and level risk: (1) Lowest risk: Continuous epidural infusion (2) Moderate to high risk: Basal or continuous intravenous infusion b) Hospital environment variables: (1) Night shift patients admitted to units where nurses are unfamiliar with the patients’ needs. (2) A poor environment of care, such as poor nursing/management or nursing/physician communication, poor staffing and less education of nursing staff providing care. 3. Sedation assessment a) The nurse’s recognition of advancing sedation is a sensitive indicator of impending respiratory depression. b) Opioid analgesia depresses both respiratory effort and rate, relaxes pharyngeal tone and depresses the response to hypoxia and hypercarbia. (1) POSS and the RASS are valid and reliable tools for monitoring sedation assessment. 4. Use of technology in assessment a) Pulse oximetry: (1) Measures oxygen saturation in arterial blood and pulse rate. (2) Continuous monitoring of oxygen saturation has been recommended when initiating opioid analgesia for patients at high risk for opioid-induced respiratory depression in order to facilitate the identification of trends. b) Capnography: (1) EtCO2 monitoring has been shown to detect changes in ventilation (the exchange of air between the lungs and the atmosphere) earlier than pulse oximetry, which simply measures the oxygen saturation of hemoglobin. (2) Oximetry only measures oxygenation and EtCO2 only measures ventilation; therefore, to adequately reflect patient status, monitoring of both is necessary. B. Nursing interventions 1. The plan of care for patients at a higher risk for respiratory depression should include a greater frequency and intensity of monitoring. 2. Working collaboratively with the prescribing health care provider to consider the omission of, or dose decreases of other sedating agents may also be effective in reducing the risk of advancing sedation and respiratory depression. 3. Opioid Reversal Agent a) Naloxone (Narcan®), may be required if the patient develops severe respiratory depression. b) The half-life of naloxone is 30–81 minutes, which can result in an extended time during which the patient may be in extreme pain. c) The exact PCA opioid reversal protocol will be specified by the prescribing health care provider or agency policy.
d) Sedatives and analgesics in large doses are frequently administered in the ICU and contribute to delirium, which is subsequently associated with longer hospital stay and decreased quality of life after discharge from the ICU. e) Decreasing the mean doses of opioids and sedative use was accomplished by individualizing the care of each patient.
PowerPoint Slides 1. Assessment • Patient variables • Iatrogenic (therapy) variables • Hospital environment variables 2. Sedation assessment. • Nurse’s recognition • Opioid analgesia • POSS and the RASS 3. Use of technology in assessment • Pulse oximetry. • Capnography. • EtCO2 monitoring. • Oximetry only measures oxygenation, and EtCO2 only measures ventilation. 4. Nursing Interventions • Greater frequency and intensity of monitoring • Working collaboratively with the prescribing health care provider 5.
Opioid reversal Agent • Naloxone (Narcan®) • PCA opioid reversal protocol • Sedatives and analgesics in large doses • Decreasing the mean doses of opioids and sedative use
VII. Pain Management in Special Patient Populations A. Pharmacology and aging 1. Several important patient-focused factors influence acute pain management: a) Age b) Concurrent medical disorders c) History of substance abuse 2. Pharmacology and aging: a) Aging individuals vary greatly in capacity to absorb, metabolize, and excrete drugs.
b) As a group, older adults are at greater risk for drug toxicity than are younger adults. c) Older adults tend to take more drugs—drugs might interact, producing symptoms. d) Older adults tend to have less body water and increased body fat. (1) Less body water causes high blood levels of water-soluble drugs. (2) Increased body fat causes prolonged effects of fat-soluble drugs. 3. Other age-related complicating factors. a) Short-term memory impairment can cause incorrect/missed/multiple doses. b) Impaired vision can lead to overdosage. c) Impaired agility in opening containers can cause missed doses. d) Financial factors and limited transportation can prevent filling prescriptions. 4. Considerations in obtaining a medication history—Ask about: a) Prescription and OTC preparations, OTC supplements. b) Alcohol, caffeine, and tobacco use. c) Home remedies B. Patients with concurrent medical disorders 1. Impaired function of liver and kidneys has serious implications for analgesic therapy. a) Analgesics are metabolized primarily in the liver. b) Kidneys have the major responsibility for opioid excretion. c) If either has decreased functioning, serum drug levels increase. d) Results: severe respiratory depression, deep sedation, and intractable nausea. e) Doses of most opioids must be reduced and the patient monitored closely. C. Management of the tolerant patient with superimposed acute pain 1. Management of the tolerant patient with superimposed acute pain. a) Long-term opioid therapy for chronic pain can result in opioid drug tolerance. b) Consider a patient’s home routine opioid dose as a baseline. c) Additional opioid is titrated to manage the incidence of acute pain. d) The continuous dose and the incremental dose can be slowly titrated upward. 2. Hyperalgesia a) Both the use of high dose opioids over a prolonged time and the effects of chronic pain on the CNS can produce a condition known as hyperalgesia. b) Characterized by increasing pain despite repeated upward titration of opioids. c) Increasing opioids only makes the pain worse. d) Treatment for hyperalgesia requires careful and appropriate detoxification when appropriate. D. The known active or recovering substance abuser as patient 1. An ethical code a) Pain management of an active/recovering substance abuser is a challenge. b) Treating pain in this population poses an ethical dilemma (“do no harm”). c) Should pain be treated using potentially addicting substances? (1) Experts in the fields of pain and addiction answer “Yes”
d) All people, even substances abusers, have the right to pain relief. e) Relief of pain temporarily overrides the problem of addiction. f) Employ recommendations of experts, such as those developed by ASPMN. 2. Assessing opioid misuse or abuse a) Extremely difficult to differentiate drug-seeking from pain relief–seeking behaviors. (1) Pain relief–seeking and drug-seeking behaviors often are interchangeable. (2) Pseudoaddiction behaviors cease when pain relief is achieved. (3) Crucial to observe changes in behavior during pain relief interventions closely. b) Tools exist to determine the level of monitoring required preventing opioid abuse. (1) Opioid Risk Tool (ORT) (2) Screener and Opioid Assessment for Patients with Pain (SOAPP) E. Major considerations in pain management 1. Clinical management considerations a) Involve a multidisciplinary team b) Set realistic goals for therapy c) Evaluate and treat comorbid psychiatric disorders d) Prevent or minimize withdrawal symptoms e) Consider the impact of tolerance f) Apply appropriate pharmacologic principles to treat chronic pain g) Use a multimodal approach to treatment when possible h) Recognize specific drug abuse behaviors i) Use nondrug approaches as appropriate 2. Other clinical suggestions for treating an active/recovering substance abuser: a) Avoid analgesics that have the same pharmacologic basis as the abused drug. b) Choose extended-release and long-acting analgesics rather than short-acting. c) Restrict short-acting opiates for breakthrough pain. d) Avoid naloxone (will precipitate immediate opiate withdrawal). e) Administer analgesics orally rather than intravenously when possible.
PowerPoint Slides 1. Several important patient-focused factors influence acute pain management: • Age • Concurrent medical disorders • History of substance abuse 2. Pharmacology and the effect of aging • Aging individuals vary greatly in capacity to absorb, metabolize, and excrete drugs. • Older adults are at greater risk for drug toxicity.
• Older adults tend to take more drugs—might interact, producing symptoms. • Older adults tend to have less body water and increased body fat. 3. Other age-related complicating factors • Short-term memory impairment. • Impaired vision can lead to overdosage. • Impaired agility in opening containers can cause missed doses. • Unfilled prescriptions. 4. Considerations in obtaining a medication history—Ask about: • Prescription and OTC preparations, OTC supplements • Alcohol, caffeine, and tobacco use • Home remedies 5. Impaired function of liver and kidneys has serious implications for analgesic therapy. • Analgesics are metabolized primarily in the liver. • Kidneys have the major responsibility for opioid excretion. • If either has decreased functioning, serum drug levels increase. • Doses of most opioids must be reduced and the patient monitored closely. 6. The opioid-tolerant patient—management of the tolerant patient with superimposed acute pain. • Long-term opioid therapy for chronic pain can result in drug tolerance. • Consider a patient’s home routine opioid dose as a baseline. • Additional opioid is titrated to manage the incidence of acute pain. • The continuous dose and the incremental dose can be slowly titrated upward. 7. Pain management of an active/recovering substance abuser is a challenge. • Treating pain in this population poses an ethical dilemma. • Should pain be treated using potentially addicting substances? • All people, even substances abusers, have the right to pain relief. • Relief of pain temporarily overrides the problem of addiction. • Employ recommendations of experts. 8. Extremely difficult to differentiate drug-seeking from pain relief–seeking behaviors. • Pain relief–seeking and drug-seeking behaviors often are interchangeable. • Pseudoaddiction behaviors cease when pain relief is achieved. • Crucial to closely observe changes in behavior during pain relief interventions. 9. Tools exist to determine the level of monitoring required to prevent opioid abuse: • Opioid Risk Tool (ORT) • Screener and Opioid Assessment for Patients with Pain (SOAPP)
10. Clinical management considerations for treating active/recovering substance abuser: • Involve a multidisciplinary team • Set realistic goals for therapy • Evaluate and treat comorbid psychiatric disorders • Prevent or minimize withdrawal symptoms • Consider the impact of tolerance • Apply appropriate pharmacologic principles to treat chronic pain • Use a multimodal approach to treatment when possible • Recognize specific drug abuse behaviors • Use nondrug approaches as appropriate 11. Other clinical suggestions for treating an active/recovering substance abuser • Avoid analgesics that have the same pharmacologic basis as the abused drug. • Choose extended-release and long-acting analgesics rather than short-acting. • Restrict short-acting opiates for breakthrough pain. • Avoid naloxone. • Administer analgesics orally rather than intravenously when possible.
VIII. Moderate Sedation/Analgesia A. Conscious sedation 1. Conscious (moderate) sedation is classified as “sedation level 2” (ASA). a) Used to induce relaxation with minimal variation in vital signs. b) Used when patient cooperation is needed for a procedure. c) Produced by administering pharmacological agents (IV). d) Patient has an altered level of consciousness. e) Patient maintains a patent airway and responds to stimuli. 2. Important to have a clear understanding of the different stages of consciousness. a) Clarification of terms leads to increased patient safety. b) Ramsey Sedation Scale assesses sedation in the intensive care unit. c) Sedation definitions have been outlined by JCAHO. B. Purpose of moderate sedation/analgesia 1. Purpose of conscious sedation a) Patient who is moderately sedated can tolerate uncomfortable procedures. b) Patient can breathe spontaneously, maintain airway, cough, swallow, etc. c) More types of procedures are being performed outside the operating room. C. Nursing management of the patient undergoing moderate sedation 1. Institutions providing conscious sedation abide by strict policies, guidelines, and protocols. a) Age-appropriate considerations
b) Necessary equipment and supplies c) Mandatory education requirements d) Process for validating competency e) Interface with risk management and quality improvement f) Required documentation g) Rescue training (rescue patients who become unstable) 2. Before the procedure a) Before the conscious sedation procedure: b) Verify that the patient has given informed consent. c) Verify that the physician has explained the procedure to the patient. (1) E.g., medications, risks, benefits, adverse reactions, alternative treatments d) Do not leave the patient unattended or compromise continuous monitoring. e) Have knowledge of the legal liability of administering conscious sedation. f) Understand the principles of respiratory physiology. g) Have required equipment available. h) Have trained backup personnel readily available. 3. During the procedure. a) Continuously monitor oxygen saturation using pulse oximetry (SpO2). b) Monitor respiratory rate, BP, heart rate, rhythm, and level of consciousness. c) Capnometry is recommended, but is not mandated. 4. Post-procedure a) Post-procedure (after the conscious sedation procedure): b) Monitor the patient’s level of consciousness and vital signs. c) Assess pain, wounds, nausea, vomiting, intake/output, and neurovascular status. d) Patient might report amnesia, headache, hangover, or unpleasant memories. e) No patient should be sent to unsupervised area (e.g., X-ray) until recovered. (1) If it’s necessary for the patient to go, the nurse must accompany. D. Drugs used for moderate sedation 1. A wide variety of drugs is available for use to attain a state of conscious sedation. a) Etomidate b) Propofol c) Ketamine d) Fentanyl e) Midazolam 2. Medications that produce a state of sedation might not control pain. a) Often a combination of analgesics and sedatives is selected. b) These medications should be administered through separate intravenous lines. c) The patient’s level of pain should be assessed using a behavioral pain rating scale. d) Analgesics should be administered as indicated by the patient’s condition.
E. Possible complications of moderate sedation 1. Deep sedation a) Deep sedation is a possible complication of conscious sedation. b) The nurse must be prepared to rescue a patient who progresses to deep sedation: (1) Manage a compromised airway. (2) Provide ventilation. c) Placing a call to the Rapid Response Team does not meet the standard. d) It is not acceptable to continue the procedure if the patient is oversedated. 2. Other possible complications a) Cardiopulmonary arrest b) Airway compromise c) Hypoxemia d) Aspiration e) Significant hypotension f) Significant brady-/tachycardia g) Prolonged sedation h) Death
PowerPoint Slides 1. Conscious sedation is “sedation level 2” (ASA) • Used to induce relaxation. • Used when patient cooperation is needed. • Produced by administering pharmacological agents. • Patient has an altered level of consciousness. • Patient maintains patent airway, responds to stimuli. 2. Different stages of consciousness • Clarification of terms leads to increased patient safety. • Ramsey Sedation Scale assesses sedation in the ICU. • Sedation definitions. 3. Purpose of conscious sedation • Patient can tolerate uncomfortable procedures. • Patient can breathe, cough, swallow, etc. • These types of procedures are increasing. 4. Institutions providing conscious sedation abide by strict policies, guidelines, and protocols. • Age-appropriate considerations • Necessary equipment and supplies • Mandatory education requirements
• Process for validating competency • Interface with Risk Management and Quality Improvement • Required documentation • Rescue training 5. Before the conscious sedation procedure: • Verify the patient has given informed consent. • Verify the physician has explained the procedure. • Do not leave the patient unattended. • Have knowledge of the legal liability. • Understand the principles of respiratory physiology. • Have required equipment available. • Have trained backup personnel available. 6. During the conscious sedation procedure: • Continuously monitor oxygen saturation. • Monitor respiratory rate, BP, heart rate, LOC. • Capnometry is recommended, but not mandated. 7. Post-procedure (after the conscious sedation procedure): • Monitor the patient’s LOC and vital signs. • Assess pain, wounds, nausea/vomiting, intake/output, and neurovascular status. • Patient might report amnesia, headache, hangover, memories. • No patient should be sent to unsupervised area until recovered. 8. A wide variety of drugs are available for conscious sedation • Etomidate • Propofol • Ketamine • Fentanyl • Midazolam 9. Pain medication is also necessary. Medications that produce a state of sedation might not control pain. • Often a combination of analgesics and sedatives needed. • Medications administered through separate IV lines. • Patient’s level of pain should be assessed. • Analgesics should be administered. 10. Deep sedation is a possible complication of conscious sedation. • Rescue a patient who progresses to deep sedation.
• Placing a call to 911 does not meet the standard. • Do not continue procedure if patient is oversedated. 11. Other possible complications of conscious sedation • Cardiopulmonary arrest • Airway compromise • Hypoxemia • Aspiration • Significant hypotension • Significant brady-/tachycardia • Prolonged sedation • Death
IX. Chapter Summary X. Clinical Reasoning Checkpoint XI. Post-Test XII. References
Suggestions for Classroom Activities • Read the original AHCPR guideline definition document. Discuss the AHCPR guideline definitions in detail for tolerance, physical dependence, psychological dependence (addiction), and opioid pseudoaddiction. • Ask students if they have other ideas or thoughts on the undertreatment of pain, other than what was presented in this section. Ask students if any have personally experienced the undertreatment of pain—and who they believed was responsible (physician, nurse, themselves). • Ask each student to take a few moments and write their definition of pain and then of pain management. Ask for student volunteers to discuss their impressions. What similarities and differences are found within the class?
Suggestions for Clinical Activities • Meet with a clinician who regularly treats pain. Ask about the four common misconceptions regarding opioid use that contribute to inadequate treatment: fear of addiction, of physical dependence, of tolerance, and of respiratory depression. Discuss how these fears play out in the actual clinical setting—how they present, how they are handled, how they are avoided, etc. • Obtain the pain management policies for the clinical facility. Discuss the policy with the clinical group. What are the specific nursing responsibilities? Do the students feel they are seeing the guidelines in the policy upheld on a regular basis on the clinical unit?
CHAPTER
5
Nutrition Support
Objectives: 1. Describe the major nutritional alterations and assessment of nutritional deficiencies in the high-acuity patient. 2. Discuss enteral nutrition including the benefits and potential complications, rationale for gastric versus post-pyloric feeding, and barriers to providing optimal enteral nutrition to the high-acuity patient. 3. Discuss the parenteral methods used to provide nutrition for the high-acuity patient, including potential complications.
I. Nutrition Alterations in the High-Acuity Patient A. Nutrition in the high-acuity patient 1. Most high-acuity patients have a greatly increased need for nutrients and calories because of the stress response. a) High levels of stress and starvation alter metabolism (often found in high-acuity patients). b) Older adults, or those with chronic illness, might be in a starvation or semi-starvation state at the time of an injury or acute illness. c) Starvation is a nosocomial problem. d) Provision of nutrition is a nursing priority. B. Undernutrition 1. Malnutrition in hospitalized patients is associated with increased length of stay, complications such as poor wound healing, immunosuppression, and increased morbidity and mortality. a) Definition: an acute, subacute, or chronic state of nutrition, including disorders resulting from a combination of varying degrees of overnutrition, undernutrition with or without inflammatory activity which have led to a change in body composition and diminished function.” b) Incidence in hospitalized patients is up to 40%. c) Associated with: (1) Increased length of stay (2) Complications such as poor wound healing d) Immunosuppression e) Increased morbidity and mortality
2. Starvation a) High-acuity patients are at particular risk for starvation if they do not receive adequate nutrition to meet the body’s increased nutritional demands, which makes provision of sufficient nutrition a priority. (1) Condition that fails to meet minimum body requirement of one or more nutrients. (2) Will continue until resolution or death. (3) Energy expenditure and gluconeogenesis are decreased. (4) Fatty acids are mobilized from adipose tissue. (5) Ketone production is increased. (6) The degree of starvation and physiological stress determines the extent and type of malnutrition. 3. Marasmus a) Insufficient intake of calories and protein with generalized body wasting b) Slow administration and vigilant monitoring of nutrition and fluid volume replacement 4. Kwashiorkor and protein-calorie malnutrition a) Severe malnutrition related to prolonged deficiency or absence of protein. b) Hypoalbuminemia lowers the intravascular colloidal osmotic pressure and allows fluid to shift from the circulating blood volume into the extracellular spaces. c) Edema can mask muscle-wasting process. 5. Overnutrition a) While weight loss is an important long-term goal for overweight and obese patients, implementation of a low-calorie diet during acute illness can accelerate loss of lean body mass, which is inappropriate in an acutely ill patient. (1) Imbalance between energy intake and energy consumption associated with: (a) Hypertension (b) Dyslipidemia (c) Type 2 diabetes (d) Coronary heart disease (e) Stroke (f) Poor wound healing (g) Metabolic syndrome (2) During acute illness, it is crucial to meet the elevated nutrient needs of obese patients to optimize outcomes. C. Assessment of nutritional deficiency 1. Nutritional deficiencies can be identified by physical examination. a) General appearance. b) Weight loss or muscle wasting. c) Subcutaneous tissue loss. d) Edema. e) Ascites are easily assessed and are strong indicators of inadequate nutritional status
2. Objective measurements include a) Physical examination b) Anthropometric measurements c) Body composition d) Laboratory values
PowerPoint Slides 1. High-acuity patients and nutrition • Have increased need for nutrients and calories because of the stress response. • High levels of stress and starvation alter metabolism. • Older adults or those with chronic illness. • Starvation is a nosocomial problem. • Provision of nutrition is a nursing priority. 2. Malnutrition Definition • Incidence in hospitalized patients is up to 40% • Associated with: • Increased length of stay • Complications • Immunosuppression • Increased morbidity and mortality 3. High-acuity patients at risk for starvation • Provision of sufficient nutrition a priority. • Condition that fails to meet minimum body requirement. • Energy expenditure and gluconeogenesis are decreased. • Fatty acids are mobilized. • Ketone production is increased. • The degree of starvation determines the extent and type of malnutrition. 4. Nursing Management and Nutrition • Nursing management includes administration and monitoring of nutrition. • Marasmus. • Kwashiorkor. 5. Overnutrition • Implementing a low-calorie diet is inappropriate for acutely ill patient. • Imbalance between energy intake and energy consumption • During acute illness, it is crucial to meet the elevated nutrient needs of obese patients.
6. Nutritional deficiencies can be identified by physical examination. • General appearance. • Weight loss or muscle wasting. • Edema. • Ascites are easily assessed and are strong indicators of inadequate nutritional status. 7. Objective measurements include • Anthropometric measurement energy • Body composition • Laboratory values. • Physical examination
II. Nutritional Alterations in Specific Disease States A. Hepatic failure 1. Hepatic failure Causes a) Cirrhosis b) Hepatitis c) Acetaminophen toxicity d) Total parenteral nutrition 2. Liver’s role in nutrition a) The liver plays a vital role in nutrition and metabolism. Major metabolic functions of the liver include synthesis and excretion of plasma proteins; synthesis of bile acids; conversion of ammonia to urea; storage of fat-soluble vitamins; maintenance of adequate coagulation; and metabolism of carbohydrates, proteins, and lipids. (1) Metabolism of carbohydrates (2) Plasma proteins produced (3) Primary site for lipid synthesis and degradation 3. Nutritional alterations a) Hyperglycemia b) Hypercatabolism c) Hyponatremia d) Impaired fat metabolism 4. High carbohydrate intake needed 5. Normal-to-moderate protein intake needed a) Depends on other problems b) Usually 8.0–1.0 c) Low fat intake 6. Fluid and electrolyte imbalance and infection: a) Contribute to hepatic encephalopathy.
b) Should be corrected before initiating feeding with significant amounts of branched-chain amino acids. B. Pulmonary failure 1. Pulmonary failure is the inability of the lungs to maintain adequate pulmonary gas exchange, as evidenced by abnormalities in the respiratory components of arterial blood gases. 2. Malnutrition high among patients with pulmonary failure. 3. Nutritional alterations a) Hypoventilation (1) Elevated CO2 levels increase pulmonary failure. (2) Excessive carbohydrates can increase CO2. (3) Increased respiratory rate, bounding pulse, ruddy face, and drowsiness 4. Monitor a) Phosphorus levels 5. Dietary clinical implications a) Normal-to-moderate protein intake needed b) Depends on other problems c) Usually 1.0–1.5 g/kg d) Carbohydrate intake 40–50% e) Protein and lipids 50–60% of total calories C. Kidney failure 1. Acute renal failure a) Azotemia (1) Elevation of nitrogenous wastes that are derived primarily from protein breakdown (2) Results in complex metabolic disturbances 2. Acute kidney failure (AKF) is characterized by a sudden inability to excrete metabolic wastes and is often characterized by oliguria (diminished urinary output of less than 500 mL of urine in 24 hours). a) Metabolic alterations of AKF include hypercatabolism, hypermetabolism, volume overload, and electrolyte imbalances. b) In patients with mild acute renal failure, 30 to 35 kcal/kg/day is usually sufficient to meet nutritional requirements. c) In the absence of dialysis, daily protein intake should be restricted to approximately 0.5 to 0.6 g/kg/day. d) Special renal enteral feedings should contain little or no electrolytes and low protein 3. Chronic kidney failure (CKF) is characterized by a progressive worsening of the kidneys’ ability to excrete waste products, maintain fluid and electrolyte balance, and produce hormones. a) Problems (1) Uremia (2) Anorexia
b) Provide energy needs of hypermetabolic state and individual factors (1) Patient’s general condition (2) Stage of renal disease (3) Dialysis (4) Comorbidities 4. Cardiac failure a) Nutritional needs of all high-acuity patients with cardiac disease should be closely monitored, as the volume associated with nutritional intake can have a negative effect on hemodynamics in some patients. (1) Malnutrition affects the cardiac muscle (cachexia), as well as all other muscles. (2) Decreases cardiac bumping effectiveness. (3) Tissues are also deprived of oxygen. b) For patients with cardiac disease who require enteral or parenteral nutrition support, continuous infusion of the formula might be beneficial to regulate the effects of the nutrients; however, nutrition delivery is generally dictated by individualized tolerance and, in the case of enteral tube feeding, location of the tip of the feeding tube. D. Gut failure 1. GI mucosa depends on nutrient delivery, adequate blood flow, and tissue perfusion to remain healthy and prevent atrophy, there by maintaining the absorptive barrier and immunologic functions of the intestine. a) Nutritional needs should be closely monitored. b) When food is in the gut, the gut needs increased blood supply (pulls from heart and other vital organs). c) Continuous infusion decreases the gut’s extra need. d) Inadequate intestinal perfusion produces increased gut permeability. Facilitates bacterial translocation from the bowel into the peritoneal cavity, lymph, and portal circulation. E. Burns 1. Burns increase energy expenditure and can persist longer in the burn patient than in patients with other types of tissue injuries. 2. Patients with burns are among those with the highest expected energy, protein, and fluid needs. 3. In severe burn injury, caloric intake is increased to 100% above normal levels. 4. Massive fluid losses require fluid resuscitation as prescribed (Parkland and Consensus Formulas). F. Traumatic brain injury 1. Traumatic brain injury (TBI) a) The extent of hypermetabolism in head-injured patients is inversely correlated with the Glasgow Coma Score, and predictive energy requirement formulas, such as the Harris–Benedict formula, have been known to underestimate energy needs in this patient population. b) TBI causes second-most extreme in hypermetabolism responses. (1) Nutrition is usually met with enteral feedings.
PowerPoint Slides 1. Hepatic failure causes • Cirrhosis • Hepatitis • Acetaminophen toxicity • Total parenteral nutrition 2. Liver’s role in nutrition • Metabolism of carbohydrates • Plasma proteins produced • Primary site for lipid synthesis and degradation 3. Nutritional alterations • Hyperglycemia • Hypercatabolism • Hyponatremia • Impaired fat metabolism 4. Fluid and electrolyte imbalance and infection • Contribute to hepatic encephalopathy • Corrected before initiating feeding 5a. Pulmonary failure • Malnutrition high in pulmonary failure • Nutritional alterations • Elevated CO2 levels • Excessive carbohydrates 5b. Pulmonary failure (continued) • Monitor: • Phosphorus levels • Carbohydrate intake • Protein and lipids 6. Acute renal failure • Nutritional alterations • Energy and protein needs determined by: • Hypermetabolic needs • Cause of AKF • Comorbidities
• Restrict protein intake • Renal enteral feedings 7. Chronic renal failure • Problems • Uremia • Anorexia • Provide energy needs of hypermetabolic state 8. Cardiac failure • Malnutrition affects the cardiac muscle. • Decreases cardiac bumping effectiveness. • Tissues are deprived of oxygen. • Closely monitor nutritional needs. • Gut needs increased blood supply for digestion. • Continuous infusion. 9. Gut failure • Inadequate intestinal perfusion produces increased gut permeability. • Facilitates bacterial translocation. 10. Burns • Patients with burns among highest energy, protein, and fluid needs. • In severe burn injury, caloric intake is increased to 100% above normal levels . • Massive fluid losses require fluid resuscitation. • Temperature regulation cause changes in energy expenditure. • Vitamin supplements. 11. Traumatic brain injury • Brain has highest oxygen consumption. • Hypoxemia leads to anaerobic metabolism in brain tissue. • Nutrition is usually met with enteral feedings.
III. Enteral Nutrition A. Criteria for selection of enteral nutrition 1. Gastrointestinal integrity and function a) Will the patient be able to eat in 3–5 days? b) Specific type of feeding tube placed is related to the anticipated time of recovery, the patient’s level of consciousness, the patient’s comfort, and cost effectiveness. 2. Illness severity and possible duration a) Energy expenditure and calorie and protein requirements increase with the severity of illness.
3. Timing of nutrition support a) Early nutritional support is a treatment priority. B. Benefits of enteral nutrition 1. Maintenance of gut barrier function 2. More physiologic than parenteral nutrition 3. Possible decrease in severity of metabolic stress response 4. More cost-effective than parenteral nutrition 5. Decreased risks of infectious complications 6. Enhances wound healing C. Common contraindications for enteral nutrition 1. Inability to place a feeding tube due to mechanical obstruction D. Types of enteral feedings 1. Types of enteral feedings a) Commonly used formulas (1) Lactose-free (2) Nutritionally complete (3) Mixture of carbohydrates, proteins, fats, vitamins, trace elements b) Water Considerations (1) Nutrient requirements (2) The patient’s clinical status (3) Location of the feeding tube tip (4) Gastrointestinal function (5) Cost (6) Duration 2. Free water E. Feeding tube placement 1. Blind placement of small-bore feeding tube 2. Radiologic-assisted placement 3. Percutaneous placement of a gastrostomy and/or jejunostomy 4. Surgical placement of gastrostomy or jejunostomy F. Gastric versus postpyloric feeding 1. Delayed gastric emptying is the primary reason for placement of feeding tube into small bowel over stomach. a) Less interruption of feeding b) Higher nutritional intake c) Lower incidence of pneumonia G. Complications of enteral nutrition 1. Gastrointestinal—nausea, vomiting, diarrhea
2. Nutritional—malnutrition, hypoalbuminemia 3. Mechanical—occlusion 4. Metabolic—hypoglycemia, hyperglycemia, electrolyte imbalance 5. Infectious—aspiration pneumonia H. Supportive drug therapy 1. Malnourished patients generally require supplemental vitamins and minerals to restore essential micronutrients
PowerPoint Slides 1. Criteria for selecting enteral nutrition • Gastrointestinal integrity and function • Illness severity • Timing of nutrition support 2. Benefits of enteral nutrition • Maintenance of gut barrier function • Possible decrease in severity of metabolic stress response • Decreased risks of infectious complications • Enhances wound healing 3. Contraindications to enteral nutrition • Feeding tube because of mechanical obstruction 4. Criteria for selecting nutrition support • GI function • Baseline nutritional status • Present catabolic state and duration 5. Types of enteral feedings • Commonly used formulas • Considerations 6. Feeding tube placement • Blind placement • Radiologic-assisted placement • Percutaneous placement • Surgical placement 7. Gastric versus postpyloric feeding • Delayed gastric emptying • Benefits of postpyloric feeding • Less interruption of feeding
• Higher nutritional intake • Lower incidence of pneumonia 8. Complications of enteral nutrition • Gastrointestinal • Nutritional • Mechanical • Metabolic • Infectious
IV. Total Parenteral Nutrition A. Total parenteral nutrition (TPN) 1. A nutritionally complete, intravenously delivered solution composed of: a) Macronutrients (carbohydrates, proteins, and lipids) b) Micronutrients (electrolytes, vitamins, trace minerals) c) Water d) Used when oral or enteral nutrition is not possible, or when absorption or function of the gastrointestinal tract is not sufficient 2. Contraindications to total parenteral nutrition (TPN) a) Patients with functioning GI tract b) Dependence needed for <5 days c) Aggressive therapy not warranted d) Risks of TPN outweigh benefits B. Delivery of parenteral nutrition 1. Total parenteral nutrition (TPN) with greater than 10% glucose is delivered through a central line to allow higher blood volumes in the larger central veins to rapidly dilute and disperse the solution, which decreases the vessel irritation associated with the increased osmolality of the solution. a) TPN with <10% dextrose can be delivered through a peripheral line (called peripheral parenteral nutrition [PPN]). b) Not to exceed 900mOsm/L. C. Complications of total parenteral nutrition 1. Infectious complications—Catheter-related sepsis (CRS) has a 35% mortality rate, and hospital stays are reportedly longer and more expensive as a result of complications and associated treatment (Bistrian & Driscoll, 2011). Some of the more common reasons for CRS include lack of sterility during placement of central lines and inadequate precautions taken during maintenance of the central line and insertion site (e.g., changing tubings, dressings, bags). a) Clinical manifestations of CRS (1) Fever, rigors, or chills
(2) Erythema, swelling, tenderness, or purulent drainage (3) Leukocytosis (4) Glucose intolerance (5) Bacteremia/septicemia/septic shock b) Prevention and treatment of CRS. (1) One port of multilumen catheters should be dedicated. (2) Sterile gauze dressings. (3) Monitor insertion site. (4) Chlorhexidine solution as local antiseptic. (5) Use impregnated catheters. (6) Chlorhexidine/silver. (7) Sulfadiazine or minocycline/rifampin. 2. Metabolic complications a) Hyperglycemia (1) Reduce neutrophil chemotaxis and phagocytosis (2) Glycemic control needed b) Prerenal azotemia (1) Overaggressive protein administration (2) Signs and symptoms (3) Elevated serum BUN, serum sodium, and signs of dehydration (4) Prevention by monitoring body weight, fluid balance, and adequate protein intake c) Hepatic dysfunction can develop secondary to the macronutrient concentrations in TPN solutions, particularly excessive glucose concentrations. (1) Elevated serum liver function tests 3. Mechanical complications a) Pneumothorax (1) Shortness of breath (2) Restlessness (3) Hypoxia (4) Chest pain radiating to back b) Catheter fracture and occlusion c) Artery puncture d) Air embolism e) Cardiac dysrhythmias
PowerPoint Slides 1. Parenteral defined • Used when oral or enteral nutrition is not possible • A nutritionally complete IV solution:
• Macronutrients • Micronutrients • Water 2. Contraindications to TPN • Functioning GI tract • Needed for <5 days • Aggressive therapy not warranted • Risks outweigh benefits 3. Delivery • Not to exceed 900mOsm/L • TPN with <10% dextrose through a peripheral line 4. Infectious complications—catheter-related sepsis (CRS) • 35% mortality rate • Longer, more expensive hospital stays • Common reasons for CRS • Lack of sterility during placement of central lines • Inadequate precautions taken during maintenance • Signs and symptoms 5. Infectious complications • Prevention • Treatment 6. Metabolic complications of TPN • Hyperglycemia • Prerenal azotemia • Signs and symptoms • Monitoring 7. Hepatic dysfunction • Secondary to the macronutrient concentrations • Elevated serum liver function tests 8. Mechanical complications of TPN • Pneumothorax • Signs and symptoms • Catheter fracture • Artery puncture • Air embolism
• Dysrhythmias
V. Refeeding Considerations A. Refeeding syndrome (RFS) 1. Complication associated with reinitiating nutritional support in a person who is significantly malnourished, particularly with protein-energy malnutrition such as marasmus or kwashiorkor. a) Refeeding should begin slowly; caloric intake should not be greater than 20 kcal/kg of the patient’s actual body weight per day. b) Advancement of nutrition therapy should occur over a period of 3–7 days, with caloric intake increasing by 10–25% per day or 200–250 kcal/day after electrolytes have stabilized.
PowerPoint Slides 1. Refeeding syndrome (RFS) • Refeeding should begin slowly • Advancement of nutrition therapy should occur over a period of 3–7 days
VI. Chapter Summary VII. Clinical Reasoning Checkpoint VIII. Post-Test IX. References
Suggestions for Classroom Activities • Provide samples of tube feeding supplements for students to compare ingredients, taste, and cost. • Provide models or diagrams to illustrate the differences between TPN and PPN catheters. • Ask small student groups to prepare teaching plans for patients receiving TPN, PPN, and fat emulsions, including advantages and rationale for each topic.
Suggestions for Clinical Activities • Have students identify advantages and disadvantages of their experiences with various feeding tubes. • Assign students to care for patients with TPN or PPN to enable them to identify potential complications for each patient and how to prevent the complications. • Ask students to compute calorie and nutritional requirements of patients receiving TPN and PPN with patients on oral feedings.
CHAPTER
6
Mechanical Ventilation
Objectives: 1. Identify criteria used to determine the need for mechanical ventilator support. 2. Select the equipment necessary to initiate mechanical ventilation. 3. Describe the modes of mechanical ventilation. 4. Explain the commonly monitored ventilator settings. 5. Briefly explain noninvasive ventilator support. 6. Discuss the major complications of mechanical ventilation with intubation. 7. Describe artificial airways and implications for practice. 8. Describe the nursing care of the patient requiring ventilatory support. 9. Describe the process of weaning a patient from mechanical ventilation and the nurse’s role in this process.
I. Determining the Need for Ventilatory Support 1. Mechanical ventilators augment and support the ventilation portion of the respiratory process. Mechanical ventilators place a patient at risk for major complications, so the decision to place a patient on a ventilator is a serious one. 2. Criteria used to decide to place a patient on a ventilator: a) Acute ventilator failure (AVF): PaCO2 greater than 50 mm Hg, pH less than 7.30 b) Acute hypoxemia: PaO2 less than 60 mm Hg c) Respiratory rate: greater than 35 breaths/minute d) Vital capacity (VC): less than 15 mL/kg (normal: 65–75) e) Maximum inspiratory pressure (MIP): less than −20 cm H2O (normal: -50–-100 cm H2O) A. Acute ventilator failure 1. Acute ventilator failure (AVF) is the most common indication for ventilator support. It is when the lungs are unable to maintain adequate alveolar ventilation. One exception is patients with COPD. B. Acute oxygenation failure 1. The second major indication for mechanical ventilator support is hypoxemia, which is frequently quantified as a Pao2 of less than 60 mm Hg (the clinical definition of oxygenation failure).
c)
C. Pulmonary mechanics 1. Pulmonary mechanics testing may be used to decide whether mechanical ventilator support is needed. The most common tests are: a) Vital capacity: maximum amount of air expired after maximum inspiration b) Maximum inspiratory pressure: amount of negative pressure that a person can generate from maximum inspiratory effort Respiratory rate D. Special considerations 1. Age-related changes in pulmonary physiology place the elderly at risk for respiratory failure. Common age-related changes are: a) Decreased chest wall compliance b) Decreased oxygenation c) Decreased lung volume and strength
PowerPoint Slides 1. Ventilation criteria • AVF • Acute hypoxemia • Respiratory rate • VC • MIP • VE 2. Common indications for ventilator support • Acute ventilator failure (AVF) • Hypoxemia 3. Most common pulmonary mechanics tests • Vital capacity • Maximum inspiratory pressure • Respiratory rate 4. Age-related changes in pulmonary physiology • Decreased chest wall compliance • Decreased oxygenation • Decreased lung volume and strength
II. Required Equipment for Mechanical Ventilation A. Initial equipment necessary for establishment of a patent airway 1. Endotracheal tubes come in various sizes. The size to use depends mostly on age of patient.
a) Choice of endotracheal tube size and route (1) Endotracheal tubes can take different routes. b) Intubation equipment (1) Other required equipment with an ET: (a) Stylet (b) Topical anesthetic (c) Laryngoscope handle with blade attached (d) Magill forceps (e) Suction machine (f) Suction catheters, Yankauer suction tip (g) Syringe for cuff inflation (h) Water-soluble lubricant (i) Personal protective equipment (j) Sedative medication 2. Tracheostomy tubes: tracheostomy usually used with patients who had head or neck surgery or an upper airway obstruction 3. Securing the artificial airway a) Tube can be secured with adhesive tape; however, commercially available ET tube stabilizers are the preferred method of securing the ET tube commonly are secured with twill tape or a commercially available tracheostomy holder with Velcro fasteners. b) Tube also may be initially sutured in place to prevent accidental dislodgment. 4. Supportive equipment a) In addition to an airway, other equipment is needed for mechanical ventilation: two oxygen sources b) Disposable sterile suction kits or sterile suction catheters, gloves, containers, sterile water. c) Oral pharyngeal airway or a bite block if the oral route is used. d) Cuff manometer to check the ET tube cuff pressure on a regular basis. e) Manual resuscitation bag to provide adequate backup in case of ventilator failure and for suctioning. f) If positive end-expiratory pressure (PEEP) is to be used on the ventilator, a manual resuscitation bag with a PEEP attachment is recommended. g) Secure intravenous access for medication administration. h) Sedation and muscle relaxant agents 5. Post-intubation assessment. a) An immediate method to ensure proper tube placement is to measure carbon dioxide using capnography or a disposable CO detector (Goodrich, 2011).
PowerPoint Slides 1a. Endotracheal tubes (ET) • Various sizes; size to use depends mostly on age of patient
• Different routes • Other required equipment 1b. Tracheostomy tubes: usually used with patients who had head or neck surgery or an upper airway obstruction 2. Securing the artificial airway • Adhesive tape different routes • Tube stabilizers • Sutured in place 3. Postintubation assessment • Measure carbon dioxide using capnography • Disposable CO2 detector
III. Types of Mechanical Ventilators A. Negative pressure ventilators 1. Negative pressure ventilators use negative pressure applied to the thorax by external means. a) Patient’s body is encased in an airtight unit. b) Air pressure in the unit is reduced to below atmospheric pressure, and air moves into the lungs. c) Negative pressure ventilators can help patients who have chronic hypoventilation or who need intermittent ventilator support (such as during sleep). B. Positive pressure ventilators 1. Positive pressure ventilators use an artificial airway to deliver support. Gases are delivered into the lungs. 2. Positive pressure ventilators have four cycling mechanisms: a) Pressure-cycled: Delivers preset pressure into lungs. b) Volume-cycled: Delivers preset volume of gas into lungs. c) Time-cycled: Length of time for inspiration is controlled. d) Flow-cycled: Pre-set pressure augments the patient’s inspiratory effort as long as patient breathes at certain flow rate.
PowerPoint Slides 1. Negative pressure ventilators • Use negative pressure applied to the thorax by external means. • Patient’s body is encased in an airtight unit. • Air pressure reduced to below atmospheric pressure • Air moves into lungs. 2. Positive pressure ventilators 3. Positive pressure ventilators have four cycling mechanisms:
• Pressure-cycled • Volume-cycled • Time-cycled • Flow-cycled
IV. Commonly Monitored Ventilator Settings 1. Positive pressure ventilators offer variables that can be adjusted to meet the individual patient’s needs. The most commonly monitored settings are: a) Tidal volume (VT): amount of air that moves into and out of lungs. b) Fraction of inspired oxygen (FIO2) c) Respiratory rate (f) d) Positive end-expiratory pressure (PEEP) e) Continuous positive airway pressure (CPAP) f) Pressure support (PS) g) Peak pressure (peak) or peak inspiratory pressure (PIP). A. Tidal volume 1. Adverse effects of high tidal volumes a) Barotrauma: A tidal volume of more than 12 mL/kg may overdistend the alveoli, increasing pressure, which may result in injury. b) Volutrauma: increases the permeability of the lungs’ microvasculature, which may result in pulmonary edema. 2. Normal-volume settings: selection of tidal volume may range from 4 to 12 mL/kg of ideal body weight (adult) based on the patient’s lung status 3. Sigh: refers to intermittent hyperinflation of the lungs. B. Fraction of inspired oxygen 1. Fio is commonly set at 0.5 to 1.0 to deliver 50 percent to 100 percent oxygen to the patient. C. Positive end-expiratory pressure 1. PEEP is set to provide pressure at the end of expiration, to prevent alveolar collapse. Theoretically, PEEP supports oxygenation and levels of 5cm H2O. D. Ventilation modes 1. Assist-control mode: sensitive to patient’s inspiratory effort but able to deliver breath at preset rate as a backup. a) Advantages: Every breath is guaranteed, set tidal volume, takes over work of breathing, respiratory muscles rest. b) Disadvantages: risk of hyperventilation, respiratory muscle atrophy. 2. Synchronous intermittent mandatory ventilation mode: Patient breathes spontaneously, with the ventilator circuit doing much of the work of breathing. a) Advantages: Prevents respiratory muscle atrophy, decreased risk of hyperventilation, better ventilation–perfusion distribution b) Disadvantages: tachypnea and fatigue if set rate too low
3. Pressure support ventilation mode pressure support ventilation (PSV) adjunct weaning mode. Applies positive pressure. Triggered by patient’s spontaneous breathing and decreases effort needed to achieve tidal volume. a) Advantages: Improved patient–ventilator synchrony, prevents respiratory muscle atrophy, facilitates weaning b) Disadvantages: Requires spontaneous respiratory effort, tachypnea and fatigue if pressure support is too low 4. Pressure-regulated volume-controlled mode (PRVC) dual control mode: Rate and tidal volume are preset, and breaths can be initiated by patient or the ventilator. a) Advantages: guaranteed VE, improved patient–ventilator synchrony, decreased risk of barotrauma. b) Disadvantages: Respiratory muscle atrophy can result in unequal ventilation–perfusion distribution. 5. High frequency oscillating ventilation (HFV): combines high respiratory rates, with excess rates of 60 and tidal volumes smaller than anatomical dead space. E. Respiratory rate 1. Respiratory rate: Minute ventilation is amount of air that moves in and out of the lungs in one minute. Normal is f:8 t0 12 minute. Tidal volume and rate are the two variables that make up minute ventilation. F. Peak airway pressure or peak inspiratory pressure 1. Amount of pressure needed to deliver tidal volume G. Alarms 1. Low exhaled volume alarm indicates loss of tidal volume or a leak in the system. H. High-pressure alarm 1. Any patient action or problem that increases airway resistance can trigger this alarm; for example, coughing, biting on the tube, or secretions in the airway. I. Initial ventilator settings 1. Initial settings may be determined by the provider or the respiratory therapist.
PowerPoint Slides 1. Positive pressure ventilators variables • Continuous positive airway pressure (CPAP) • Respiratory rate • VT: normal • FIO2 • PEEP • PS • Peak or (PIP)
2. Adverse effects of high tidal volumes • Barotrauma: A tidal volume of more than 12 mL/kg may overdistend the alveoli, increasing pressure, which may result in injury. • Volutrauma. 3. Four ventilation modes • Assist-control mode • Synchronized intermittent mandatory ventilation • Pressure support ventilation • Pressure-regulated volume controlled mode 4. Advantages and disadvantages of modes • Assist-control (AC) • Synchronized intermittent mandatory ventilation (SIMV) • Pressure support ventilation (PSV) • Pressure-regulated volume controlled ventilation (PRVC) 5. Respiratory rate: minute ventilation = air that moves in and out of lungs in 1 minute. Normal = f:8 to 12 minute. 6. PEEP: continuous positive airway pressure (CPAP) or positive end-expiratory pressure. Main indication = oxygen-refractory hypoxemia. 7. Peak airway or peak inspiratory pressure 8. Two most often triggered alarms • Low exhaled volume alarm • High pressure alarm
V. Noninvasive Alternatives to Mechanical Ventilation 1. The use of positive pressure and an artificial airway places a patient at risk for complications and increased morbidity/mortality. Noninvasive ventilation methods have been developed. Two main types of noninvasive methods: a) Noninvasive positive pressure ventilation (NIPPV or NPPV) b) Continuous positive airway pressure (CPAP) A. Noninvasive intermittent positive pressure ventilation is a way to provide ventilation support without intubation. 1. Masks/Interfaces use a ventilator and an interface—usually a noronasal mask, but can also be a nasal pillow, full-face mask, or helmet. 2. Noninvasive Ventilation a) Standard ICU/acute care ventilators b) Portable ventilators c) Bilevel devices
3. Indications and contraindications for use a) At home, NIPPV is used mainly for patients who cannot fully support their own breathing for prolonged periods. In the ICU, it is used for patients in acute respiratory distress (to avoid intubation). (1) Used successfully with patients with hypercapnia (such as those with COPD) and post-surgery patients. (2) Patients with unstable hemodynamic status, cardiac dysrhythmia, or myocardial ischemia, or who are unable to clear their own secretions or maintain airway patency, are contraindicated for use of NIPPV. B. Continuous positive airway pressure (CPAP) 1. CPAP is closely related to NPPV. a) Provides a continuous level of positive airway pressure for a spontaneously breathing person. b) Unlike NPPV, CPAP does not provide assisted ventilation upon inspiration. c) CPAP does not require mechanical vent; it uses a special flow generator (a blower) and a mask. d) CPAP used mostly for obstructive sleep apnea. C. Complications of NIPPV 1. Complications of NIPPV are same as those of regular positive pressure mechanical ventilation (see Learning Objective 6), although not as severe. a) The use of a mask has its own special complications such as skin irritation, aspiration, and conjunctivitis. b) NIPPV requires the nurse to offer the patient a combination of explanations, coaching, and demonstrations. D. Nursing considerations 1. To best assure a patient’s success in using NIPPV, a combination of explanations, patience, and coaching is required. 2. The therapy should be explained and demonstrated at each step, giving the patient an opportunity to ask questions and adapt to the sensations of the masks and air pressures.
PowerPoint Slides 1. Two main types of noninvasive methods • Noninvasive positive pressure ventilation • Continuous positive airway pressure 2. NIPPV provides ventilation support without intubation. 3. Any positive pressure ventilator can be used for NIPPV. 4. NIPV used: • At home • For periods in ICU
5. CPAP • Provides a continuous level of positive airway pressure for a spontaneously breathing person • Does not provide assisted ventilation upon inspiration • CPAP does not require mechanical vent; uses a blower and a mask • Use of a mask 6. With NIPPV, the nurse offers: • Explanations • Coaching • Demonstrations
VI. Major Complications of Mechanical Ventilation And Artificial Airways 1. Positive pressure ventilation can result in complications involving nearly all body systems: cardiovascular, pulmonary, neurovascular, renal, and gastrointestinal. A. Cardiovascular complications 1. Cardiovascular a) Decreased cardiac output b) Decreased preload c) Decreased stroke volume B. Pulmonary complications 1. The distribution of gases to the alveoli normally favors the peripheral and dependent lung areas. C. Altered ventilation and perfusion 1. Barotrauma/volutrauma a) There is increasing evidence that the pulmonary injury associated with PPV results from alveolar distention created by a combination of excessive alveolar pressure (barotrauma) and volume (volutrauma). 2. Oxygen toxicity a) Oxygen toxicity damages the endothelial lining of the lungs and decreases alveolar macrophage activity. It also decreases mucous and surfactant production. 3. Ventilator-associated pneumonia (VAP) a) Nosocomial pulmonary infection is a common major complication of mechanical ventilation that develops in patients intubated for more than 48 hours. D. Neurovascular complications 1. PPV can cause a change in neurovascular status through two major mechanisms: increased intracranial pressure (ICP); and decreased cerebral perfusion pressure (CPP). E. Renal complications 1. Decreased cardiac output 2. Redistribution of renal blood flow 3. Hormonal alterations
F. Gastrointestinal complications 1. Stress ulcers from gastric hyperacidity or a visceral hypoxic episode 2. Gastrointestinal bleeding 3. Hepatic dysfunction
PowerPoint Slides 1. Positive pressure ventilation can result in complications. 2. Cardiovascular complications 3. Pulmonary complications 4. Neurovascular complications 5. Renal complications 6. Gastrointestinal complications
VII. Artificial Airway Complications 1. Artificial airways have their own set of complications that are primarily related to bypassing the normal upper airway defenses that warm and humidify the air. A. Nasal/oral damage 1. Nasal damage a) The airway can traumatize nasal mucous membranes. b) Ischemia and necrosis of the nares can develop from pressure of tube on nasal wall. c) A tube can block Eustachian tubes, which can lead to ear infections. 2. Oral damage a) Pressure can cause ulceration or necrosis of inner cheek or lip. 3. Cuff trauma a) Cuff pressure can cause tracheal and laryngeal injury. b) Decreased blood flow to areas can lead to necrosis, which in turn can lead to fistulas, fibrosis, and ulceration. c) Damage to vocal cords. d) Proper monitoring of cuff pressure and use of correct tube size can significantly decrease risk of cuff complications. 4. Tracheostomy Tubes. a) Tracheomalacia. (1) Acquired tracheomalacia, weakening or erosion of the tracheal cartilage, is a rare complication that can arise when tracheal wall tissue becomes damaged from the presence of the tube, cuff, or suctioning over a prolonged period of time. b) Granulation tissue formation (1) Granulation tissue formation can cause obstruction to airflow. Laryngoscopy can identify the degree of problem,
c) Stoma Erosion (1) Can develop as the stoma size is enlarged in patients with tracheostomies.
PowerPoint Slides 1. Airways have their own specific set of complications. 2. Nasal damage. 3. Oral damage. 4. Cuff trauma. 5. Tracheostomy tubes.
VIII. Care of the Patient Requiring Mechanical Ventilation 1. The goals of nursing management can be divided into physiologic needs and psychosocial needs.
4.
A. Nursing management of physiologic needs 1. Supporting a patient’s physiologic needs involves: a) Promoting optimal oxygenation. b) Treating impaired gas exchange. c) Providing adequate ventilation. d) Clearing the airway: (1) ABCs: airway, breathing, and clearance. (2) Suctioning of secretions. e) Protecting the airway. f) Supporting tissue perfusion. g) Providing adequate nutrition. 2. Ineffective airway clearance a) Excessive secretions are removed by suctioning the artificial airway on an as-necessary basis, which may be every few minutes during initial intubation or several times a shift with ongoing intubation. b) Thick secretions: properly hydrating the patient is an important means of thinning secretions because secretions are composed primarily of water. c) Pooled secretions can cause obstruction of major airways or can plug the tip of the artificial airway. 3. Impaired gas exchange can involve problems of oxygenation, problems of CO2 elimination, or often both. Ineffective breathing pattern a) Alveolar hyperventilation b) Alveolar hypoventilation 5. Protection of the airway must be taken to minimize the possibility of dislodgment, which could precipitate respiratory compromise. 6. Alteration in cardiac output.
7. Alteration in nutrition: collaboration with the dietitian and provider allows for nutritional assessment and formula delivery to meet each individual’s needs. B. Nursing management of psychosocial needs 1. Anxiety and pain a) High-acuity patients, in general, are at high risk for experiencing pain and anxiety related to their underlying illness, procedures, immobility, routine care, and the critical care environment itself. 2. Sleep pattern disturbance a) Airway clearance and other maintenance nursing interventions frequently require disturbing a resting or sleeping high-acuity patient. 3. Communication and sensation a) The presence of an artificial airway prevents the patient from communicating verbally. 4. Family support a) The psychosocial needs of the patient’s family are important, while the patient physical needs being managed on the ventilator.
PowerPoint Slides 1. Goals of nursing management: physiologic needs and psychosocial needs 2. Physiologic needs • Promoting optimal oxygenation • Treating impaired gas exchange • Providing adequate ventilation • Clearing and protecting the airway • Supporting tissue perfusion • Providing adequate nutrition 3. Psychosocial needs • Anxiety • Pain • Communication • Sleep pattern disturbance • Communication and sensation • Family support
IX. Weaning the Patient from the Mechanical Ventilator 1. Patients being evaluated for weaning from a mechanical ventilator fall into three categories: a) Those whose removal is rapid when the reason for ventilation is resolved b) Those whose removal is slow and gradual c) Those who are unweanable and need long-term ventilator support
A. Readiness for weaning 1. Traditional methods to determine readiness to wean a) Initial patient screening b) Comprehensive patient screening 2. Alternative indications of readiness to wean. a) Rapid shallow breathing index less than 60 to 105 breaths/min/L (spontaneous breathing) b) Vital capacity (VC) greater than 15 mL/kg c) Breathing rate (f) less than 35 spontaneous breaths/minute d) Spontaneous tidal volume (VT) greater than 4 to 6 mL/kg (IBW) e) Maximum inspiratory pressure (MIP) less than −20 to −30 cm H2O f) Minute ventilation (VE) less than 10 to 15 L/minute g) Airway occlusion pressure (P0.1 or P100) less than −6 cm H2O B. The weaning process: Duration 1. Rapid weaning (short term): Patient is placed on T-piece for 30–120 minutes and may then be extubated if trial is successful. 2. Slow weaning (long term): difficult and complex process that can require use of many weaning alternatives, such as SIMV, mandatory minute ventilation, PSV, and manual weaning C. The weaning process: Methods 1. Manual Weaning is accomplished by following a schedule of disconnecting the patient from the mechanical ventilator for increasingly longer periods of time. 2. Ventilator Weaning is generally thought to be less traumatic for the patient because it does not involve intermittent removal from the ventilator. D. Special considerations for older adults 1. The elderly are at particular risk for developing complications of mechanical ventilation. a) No best method for weaning elderly patients has been identified. E. Postextubation follow-up 1. Extubation is carried out as soon as it is determined that the patient can sustain spontaneous breathing, usually indicated by maintaining their own airways and coughing adequately to mobilize secretions. 2. Terminal weaning a) Terminal weaning is the intentional removal of the mechanical ventilator when the patient is expected to die without it. b) The nurse closely monitors the patient’s status and provides PRN medications as needed.
PowerPoint Slides 1. Categories of patients to wean • Removal is rapid when the reason for ventilation is resolved. • Removal is slow and gradual. • Unweanable, and need long-term ventilator support.
2. Readiness to wean depends on the physiologic and psychological status of patient. 3. Bedside tests, a.k.a. AKA weaning parameters, can help assess patient’s readiness: • Rapid shallow breathing index < 60 to 105 breaths/min/L (spontaneous breathing) • VC > 15 mL/kg • f < 35 spontaneous breaths/minute • VT > 4–6 mL/kg (IBW) • MIP < −20−30 cm H2O • VE < 10–15 L/minute • Airway occlusion pressure (P0.1 or P100) < −6 cm H2O 4. Weaning process • Rapid/short-term • Slow/long-term 5. Methods of weaning •
Manual Weaning • Ventilator Weaning 6. After extubation, maintain pulmonary hygiene via: • Coughing • Deep breathing • Spirometry
X. Chapter Summary XI. Clinical Reasoning Checkpoint XII. Post-Test XIII. References
Suggestions for Classroom Activities • Ask students to explain the similarities and differences between CPAP and NIPPV. • Ask students to specify which patients might benefit most from noninvasive mechanical ventilation • Ask students to role-play demonstrating to a patient how to use a CPAP ventilator • Ask students to describe the various complications that can arise from use of an artificial airway • Develop a role-play scenario. Select three students to participate. The rest of the class will observe and critique the interaction. The selected student group will demonstrate communication with the patient who is receiving mechanical ventilation. Cast one student as the patient, another the significant other, and the last student will act as the nurse
• Ask students to review the role of the nurse when caring for the patient after extubation. • Review the phenomena of oxygen toxicity. What are the signs and symptoms? What potential causes are associated with the disorder? What actions can the nurse perform in prevention of the disorder?
Suggestions for Clinical Activities • Observe patients on NIPPV and CPAP ventilation. • Ask students to describe the complications that can result from use of an artificial airway. • Assign students to patients who might require secretion suction. Help students to perform the procedure. During the postconference period, discuss the actions taken. What signs did the patient exhibit when suctioning was needed? What monitoring took place after the suction procedures?
CHAPTER
7
Introduction to Hemodynamic Monitoring
Objectives: 1. Describe cardiac output as the major parameter of interest in monitoring a patient’s hemodynamic status. 2. Discuss noninvasive and minimally invasive hemodynamic monitoring technologies, including impedance cardiography and Doppler ultrasound, central venous pressure, direct arterial blood pressure measurement, and arterial pulse contour analysis technology. 3. Explain pulmonary artery catheters, including their purpose, required competencies, interpretation of data, functional components, and care of the catheter. 4. Apply knowledge of PA catheter insertion and management and measurements obtained using the PA catheter. 5. Describe right atrial and right ventricular pressures, including the purposes, measurement, waveform analysis, clinical findings, and treatment of abnormal pressures. 6. Discuss pulmonary artery pressure and pulmonary artery wedge pressure (a measure of left ventricular end diastolic pressure [LVEDP]), including the purposes, measurement, waveform analysis, clinical findings, and related interventions for treating abnormal pressures. 7. Describe vascular resistance (systemic and pulmonary) and its measurements, including treatments for abnormal levels.
I. Introduction to Hemodynamic parameters A. Hemodynamics 1. Physiologic term that refers to the forces involved in the flow of blood as it circulates through the cardiovascular system. 2. Hemodynamics can be measured by obtaining the blood pressure (using a blood pressure cuff and sphygmomanometer), heart rate by auscultating or palpating, and urine output, all basic assessments that are easily acquired. B. Cardiac output and cardiac index 1. Cardiac output is the amount of blood pumped by the heart each minute: CO+HRxSV a) Normal range of CO is 4 to 8 L/min.
2. Cardiac index a) Individualizes patients’ CO by taking body size into account. b) CI provides meaning to CO and determines what is normal for each patient. c) Important parameter in guiding clinical decisions. C. Heart rate 1. Heart rate is the first determinant of cardiac output and is an easily measured parameter. 2. The heart rate is dictated by the heart’s pacemaker sites, with influence from the sympathetic and parasympathetic nervous systems. D. Stroke volume—is the amount of blood ejected by each heartbeat, and it is not readily measurable using simple hemodynamic technologies. 1. Preload a) The pressure or stretch exerted on the walls of the ventricle by the volume of blood filling the ventricle at the end of diastole (ventricular filling). 2. Afterload a) The resistance to ventricular contraction. b) The pressure the ventricle must overcome to open the aortic or pulmonic valve and eject blood out of the ventricle into the systemic or pulmonary circulation, respectively. 3. Contractility a) Is a property of myocardial muscle fibers that slows them to shorten
PowerPoint Slides 1. Hemodynamics • Flow of blood as it circulates through the cardiovascular system • Measured by obtaining the blood pressure heart rate and urine output 2. Cardiac Output and Cardiac Index • Individualizes patients’ CO • CI provides meaning to CO • Important parameter in guiding clinical decisions 3. Heart Rate • First determinant of cardiac output; fluid temperature is cooler than blood temperature • Dictated by the heart’s pacemaker sites 4. Stroke Volume • Reload • Afterload • Contractility
II. Noninvasive and Minimally Invasive Hemodynamic Technologies 1. New, less invasive technologies are emerging for hemodynamic assessment to avoid complications associated with the PA catheter. 2. Ideal cardiac output monitor would be: a) Noninvasive b) Valid c) Reliable under various hemodynamic situations d) Easy to use e) Continuous f) Cost-effective A. Noninvasive technologies 1. Impedance cardiography a) Uses high frequency, low-amplitude current to measure the resistance to electrical current flow. b) Directly measures volume of electrically participating tissue. c) Indirectly measures stroke volume, cardiac output, and contractility indicators. 2. Doppler ultrasound measures blood flow velocity in the vessel. a) Helps to determine: (1) Cardiac output (2) Preload (3) Afterload (4) Contractility status b) Has specific algorithms that determine vessel or valve cross-sectional area. c) Probe is placed on specified area. d) Stroke volume calculated based on blood flow velocity and vessel or valve area. B. Minimally invasive hemodynamic technologies 1. Central venous accesses and measurement a) An indicator of central blood volume and is influenced by a variety of factors, including cardiac output, systemic venous return to the heart, total blood volume an other factors. 2. Arterial access and measurements a) Arterial access line (1) Facilitates monitoring the patient’s blood pressure on a continuous basis, which allows the nurse to monitor the patient’s response to interventions without having to disturb the patient to take a manual blood pressure reading. b) Insertion of the arterial access line (1) The nurse typically is responsible for setting up the equipment for catheter insertion, calibrating the equipment to ensure accurate readings, and assisting the physician with the procedure.
c) Arterial waveform (1) Characteristic morphology is related to the cardiac cycle (Fig. 7-4). d) Arterial pulse contour analysis (1) The use of the pulse contour analysis is based on the principle that the SV may be measured by assessing the beat-to-beat changes in the amplitude of the pulse pressure as displayed on the waveform. e) Mean arterial pressure (MAP) (1) MAP represents the average pressure in the systemic circulation throughout the cardiac cycle. (2) MAP represents the average pressure in the systemic circulation throughout the cardiac cycle. (3) Normal range is 70–90 mmHg. (4) Provided by arterial line or automatic blood pressure equipment. (5) Arterial line is most accurate: measured, not calculated.
PowerPoint Slides 1. New Hemodynamic Monitoring Technologies • New, less invasive technologies are emerging for hemodynamic assessment to avoid complications associated with the PA catheter. 2. Impedance Cardiography • Assesses cardiac function by measuring resistance to high-frequency, low-amplitude electrical current • Directly measures volume of electrically participating tissue • Indirectly measures stroke volume, cardiac output, and contractility indicators 3. Doppler Ultrasound • Measures blood flow velocity in the vessel • Helps to determine: • Cardiac output • Preload • Afterload • Contractility status 4. Minimally Invasive Hemodynamic Technologies • Central venous access and measurement • Arterial access and measurements • Arterial access line • Insertion of the arterial access line • Arterial waveform
• Arterial pulse contour analysis • Mean arterial pressure (MAP).
III. Introduction to Pulmonary Artery Catheters A. Purpose of PA catheters 1. The pulmonary artery (PA) catheter is an invasive diagnostic tool used for the following purposes: a) Determining the pressures within the right heart and PA b) Indirectly measuring left heart pressures c) Determining cardiac output d) Sampling mixed venous blood from the PA e) Infusing fluids B. Required provider competencies 1. Three essential steps required for hemodynamic assessment with the PA catheter: a) Obtain accurate data. (Nurses must ensure proper calibration of hemodynamic monitoring equipment.) b) Perform waveform analysis. c) Integrate data with other assessment parameters. C. Interpretation of data 1. Careful clinical assessment, integrated with the data collected from PA catheter, provides a basis for nursing interventions and the manipulation of potent vasoactive medications or fluids. D. Standard PA catheter construction and components 1. Proximal injectate lumen and hub a) Terminates in the proximal heart chamber, the right atrium. b) Proximal is usually imprinted on the hub or tubing close to it—check for it. c) Tubing is usually blue. e) Monitors and samples RAP when connected to a transducer. f) Injectate used to determine cardiac output placed in this lumen. g) Can also be used to infuse IV fluids. 2. P proximal Infusion Lumen and Hub (Optional) a) Terminates in the right atrium b) White tubing for quick identification c) Used as the “central line” for IV fluid infusions d) Can be used to obtain cardiac output if the proximal injectate is blocked 3. Distal lumen and hub a) Terminates in the PA. b) Distal is usually imprinted on the hub or tubing close to it—check for it. c) Yellow tubing for quick identification.
d) Always connected to transducer for continuous monitoring of the PA pressure (PAP) and waveform. e) Used to obtain PAWP by balloon inflation. f) Used to obtain venous blood oxygen saturation. g) Not used to infuse medications and IV solutions. 4. Thermistor a) A wire that terminates near the catheter tip b) Exposed to blood flowing from the PA c) Detects changes in blood temperature d) Monitors core body temperature e) Proximal end connects to the cardiac output–monitoring device 5. Balloon inflation lumen and valve a) Located near the small balloon at the distal end of the catheter. b) Can be opened or closed with “gate valve” mechanism. c) Balloon inflates to monitor PA waveform. d) Maximum recommended inflation volume should not be exceeded. e) Deflation is always passive—should not be done manually. f) Should not be left in the passive position. E. Hemodynamic monitoring equipment 1. Transducer translates mechanical energy sensed by the catheter into electrical energy, displayed on the monitor screen as a waveform. a) Leveling the Transducer corrects for hydrostatic pressure changes in vessels above and below the heart. b) Zeroing the Transducer corrects for any drift or deviation from baseline that may occur. 2. Pressure bag is used to overcome the pressure within the pulmonary artery and prevent blood from backing up into the pressure tubing. F. Special pulmonary artery catheters. These have the standard design properties of all PA catheters plus additional properties that meet special therapeutic or measurement needs. 1. Pacing port 2. Continuous cardiac output (CCO) 3. Oximetry 4. Volumetrics G. Care of central venous catheters 1. Catheter site dressing regimens 2. Needleless intravascular catheter systems 3. Recommendations for central venous catheters 4. Skin preparation 5. Maximal sterile barrier precautions 6. Replacing administration sets
7. Replacement of peripheral and midline catheters 8. Catheter securement devices
PowerPoint Slides 1. Introduction to Pulmonary Artery Catheters • Purpose of PA catheters • Required provider competencies • Interpretation of data • Standard PA catheter construction and components 2. Standard PA Catheter Construction and Components • Proximal injectate lumen and hub • Proximal infusion lumen and hub (optional) • Distal lumen and hub • Thermistor • Balloon inflation lumen and valve 3. Transducer translates mechanical energy • Leveling • Zeroing 4. Special Pulmonary Artery Catheters • General care focuses on optimizing preload by restoring volume • Pacing port • Oximetry • Continuous cardiac output (CCO) • Volumetric 5.
Care of Central Venous Catheters • Catheter site dressing regimens • Needleless intravascular catheter systems • Recommendations for central venous catheters • Skin preparation • Maximal sterile barrier precautions • Replacing administration sets • Replacement of peripheral and midline catheters • Catheter securement devices
IV. Pulmonary Artery Catheter Insertion and Measurements A. Catheter insertion and management 1. Preprocedure patients and family education a) The patient may be awake when the catheter is inserted, and it can be a frightening experience if he or she does not know what to expect; patient and family education should include information about the procedure. 2. Insertion of the PA catheter a) The ibsertuib if a PA catheter is performed in critical care uits, cardiac catheterization laboratories and operating rooms. b) The insertion of a PA catheter is always a sterile procedure involving maximal bararier precautions. 3. Post-procedure management a) The nurse assumes responsibility for patient safety and comfort and system maintenance. 4. Obtaining accurate hemodynamic measurements a) Repositioning the patient is an important consideration in continuous hemodynamic monitoring. b) Measuring waveforms—evidence suggests that obtaining accurate measurements require reading pressure waveforms at end-expiration, when pleural pressure is at its lowest level. B. PA catheter measurements 1. Measuring cardiac output a) Intermittent Fluid Bolus Thermo dilution Method—the traditional method of thermodilution CO requires the use of injectate, a 10-ml bolus of IV normal saline that is injected through the proximal injectate port of the PA catheter into the right atrium. b) Continuous CO Thermal Filament Thermo dilution Method—uses a thermal (heating) filament about 11 cm in length that is a part of the PA catheter wall. 2. Measuring preload—preload is reflected in two PA catheter measurements, the right atrial pressure (RAP) and the pulmonary artery wedge pressure (PAWP). 3. Measuring afterload a) Systemic vascular resistance (SVR) b) Pulmonary vascular resistance 4. Measuring contractility a) Ventricular stroke work index (VSWI)
PowerPoint Slides 1. Catheter Insertion and Management • Preprocedure patient and family education • Insertion of the PA catheter • Postprocedure management • Obtaining accurate hemodynamic measurements
2. Measuring Cardiac Output • Intermittent Fluid Bolus Thermo Dilution Method • Continuous CO Thermal Filament Thermo Dilution Method 3. Measuring Preload • Pulmonary artery wedge pressure (PAWP) • Right arterial pressure (RAP) 4. Measuring Afterload • Systemic vascular resistance (SVR) • Pulmonary vascular resistance 5. Measuring Contractility • Ventricular stroke work index (VSWI)
V. Right Atrial and Ventricular Pressures A. Right atrial pressure 1. An estimate of right ventricular preload (volume status of the right heart) 2. An estimate of right ventricular end-diastolic pressure (RVEDP) 3. Obtaining Measurements a) Normal right atrial waveform b) Undulating pattern of three positive and two negative excursions c) Positive excursions: a, c, and v waves d) Negative excursions: x and y deflections 4. Waveform analysis 5. Conditions leading to alterations in RAP a) Causes of increased RAP and associated clinical findings b) Causes of decreased RAP and associated clinical findings 6. Interventions for treating abnormal RAP a) Treating increased RAP (1) General care focuses on optimizing preload by reducing volume. (2) Restricting fluid and sodium. (3) Administering diuretics or vasodilation medications. (4) Assessing patient’s response to interventions. (5) Dietary consults—sodium and fluid restrictions. (6) Patient education about medications. b) Treating decreased RAP (1) General care focuses on optimizing preload by restoring volume. (2) Oral replacement of fluids or careful IV hydration. (3) Surgical correction of hemorrhage and volume replacement with IV fluids and blood products.
(4) Hypovolemia and low preload related to sepsis. (5) Regular assessment of patient’s response to interventions. B. Right ventricular pressure is not continuously monitored with a traditional PA catheter but is observed and documented during insertion of the catheter. 1. Waveform recognition consists of a steep upstroke and a sharp downstroke. 2. Clinical implications.
PowerPoint Slides 1. Right Atrial Pressure • An estimate of right ventricular preload • An estimate of right ventricular end-diastolic pressure (RVEDP) • Obtaining measurements 2. Positive a, c, and v waves • A wave produced by the rise in atrial pressure caused by left atrial contraction. • C wave (when it appears) produced by closure of the mitral valve at the initiation of ventricular systole. • V wave forms as the left atrium fills during ventricular systole. 3. Negative x and y descents • X descent reflects decreased volume in the left atrium after atrial systole. • Y descent results from the pressure drop in the left atrium when the mitral valve opens prior to atrial contraction, permitting passive emptying of the left atrium. 4. Conditions Leading to Alterations in RAP • Causes of increased RAP and associated clinical findings • Causes of decreased RAP and associated clinical findings 5. Interventions for Treating Abnormal RAP • Treating increased RAP • Treating decreased RAP 6.
Right Ventricular Pressure • Waveform recognition • Clinical implications
VI. Pulmonary Artery and Pulmonary Artery Wedge Pressures A. Pulmonary artery pressure normally reflects both right and left heart pressures and is read as a systoic and diastolic pressure. 1. Waveform analysis—the PA waveform pattern a) Steep upstroke and down stroke with a dicrotic notch formed by the closure of the pulmonic valve.
b) The dicrotic notch is lost when the catheter tip retreats into the right ventricle. c) Knowing the waveform positions helps nurses identify correct catheter position. 2. Elevated pulmonary artery pressure a) Elevated PAS can result from any condition that increases the afterload of the right ventricle, such as pulmonary hypertension. (1) Right heart failure—distended neck veins, peripheral edema, tender liver, and ascites. (2) Right ventricular lift. (3) S3 and S4 heart sounds. (4) Chronic lung disease patients have chronically elevated PAS pressure. (5) Pulmonary embolus. (6) Can present as a medical emergency—dyspnea, chest pain, hemoptysis, and hemodynamic instability. b) Elevated PAD-associated with conditions of the left heart (1) Angina (2) Myocardial infarction (3) Fluid overload (4) Mitral stenosis (5) Left-to-right intracardiac shunts c) Treatment of elevated PAP (1) General care approach is reducing preload. (2) Administering diuretics. (3) Restricting fluid and sodium intake. (4) Novel therapies aimed at pulmonary vascular vasodilation can also treat pulmonary hypertension. (5) Cardiac contractility—improved by use of inotropic medications, such as digoxin and dopamine. (6) Intra-aortic balloon pump (7) Careful administration of potent medications (8) Intake and output measurements (9) Daily weights 3. Low pulmonary artery diastolic pressure a) Low preload state related to inadequate venous return to the left heart B. Pulmonary artery wedge pressure 1. Measurements are obtained through the distal port of the PA catheter. 2. PAWP Waveform Analysis—the normal range is 4 to 12 mm Hg. 3. Key Points for obtaining PAWP a) Observe the waveform constantly b) Use the smallest inflation volume possible c) Maintain inflation
d) Obtain the PAWP at end expiration e) Allow balloon to deflate passively f) Stop if resistance is felt during balloon inflation 4. Elevated PAWP a) Clinical findings vary according to the degree of elevation. b) Interventions are directed toward optimizing preload by administering diuretics and vasodilators and restricting sodium and fluid. 5. Low PAWP is related to inadequate circulating blood volume.
PowerPoint Slides 1. Pulmonary Artery Pressure (PAP) • Normally reflects both right and left heart pressures and is read as a systoic and diastolic pressure. • PA waveform is monitored continuously. 2. PA Waveform Pattern • A steep upstroke and downstroke with a dicrotic notch. • The dicrotic notch lost when catheter tip retreats into the right ventricle. • Knowing waveform positions helps nurses identify correct catheter position. 3. Elevated pulmonary artery systolic (PAS) pressure • Results from an increase in the afterload of the right ventricle 4. Elevated PAS Pressure—Clinical Findings • Right heart failure • Right ventricular lift • S3 and S4 heart sounds • Chronic lung disease patients have chronically elevated PAS pressure • Pulmonary embolus 5. Elevated Pulmonary Artery Diastolic (PAD) Pressure • Associated with conditions of the left heart • Angina • Myocardial infarction • Fluid overload • Mitral stenosis • Left-to-right intracardiac shunts 6. Elevated PAD Pressure—Clinical Findings • Left heart failure can cause the following signs and symptoms: • Dyspnea
• Tachycardia • S3 or S4 • Bilateral crackles in the lungs 7a. Elevated PAS or PAD pressure • Nursing interventions. • General care approach is reducing preload. • Administering diuretics. • Restricting fluid and sodium intake. • Novel therapies aimed at pulmonary vascular vasodilation. • Cardiac contractility. • Intra-aortic balloon pump. 7b. Elevated PAS or PAD pressure (continued) • Nursing care • Careful administration of potent medications • Intake and output measurements • Daily weights • Planning physical activities followed by rest periods 8. Low Pulmonary Artery Diastolic (PAD) Pressure • Low preload state related to inadequate venous return to the left heart 9. Low PAD Pressure—Clinical Findings • Tachycardia • Flat neck veins • Clear lungs • Dry oral mucosa • Poor skin turgor • Hypotension • Decreased urine output • Severe cases—signs of advanced shock 10. Low PAD Pressure—Nursing Interventions • Focus is on improving left ventricle (LV) preload through volume replacement • Nursing care • Managing fluid replacement 11. Key Points for Obtaining PAWP • Observe the waveform constantly • Use the smallest inflation volume possible
• Maintain inflation • Obtain the PAWP at end expiration • Allow balloon to deflate passively 12. Elevated PAWP Nursing Interventions • Treatment is directed toward optimizing preload. • Diuretics and vasodilators. • Sodium and fluid restrictions. • Intravenous and oral nitrates. • Control of dysrhythmias. 13. Low PAWP Clinical Findings • Flat neck veins • Clear lungs • Low pulse pressure • Decreased urine output • Hypotension • Tachycardia • Thirst 14. Low PAWP Nursing Interventions • Treatment • Careful replacement of fluids or blood products correlated with patient’s response to treatment • Nursing care • Hourly urine output • Intake and output records • Daily weights
VII. Vascular Resistance and Stroke Work 1. Measurements of systemic and pulmonary vascular resistance are the major means of evaluation afterload; stroke volume and ventricular stroke work index are indirect measures of contractility. A. Systemic vascular resistance is an estimate of left ventricular afterload. 1. Elevated SVR or SVRI may be the result of hypothermia, hypovolemia or cardiac failure. a) Collaborative management. 2. Low SVR or SVRI is caused by widespread vasodilation. B. Pulmonary vascular resistance is an estimate of right ventricular afterload. 1. High PVR or PVRI is elevated with hypoxemia, acute lung injury, acute respiratory distress syndrome, pulmonary hypertension and pulmonary congestion.
C. Stroke volume 1. Determining the SV can provide valuable information about contractility, particularly if preload and afterload statuses are already known. D. Ventricular stroke work 1. Left Ventricular Stroke Work Index represents work that is influenced by the pressure the heart beats and the volume the ventricle must pump forward. 2. Right Ventricular Stroke Work Index is the amount of work involved in moving blood in the right ventricle with each beat.
PowerPoint Slides 1. Systemic Vascular Resistance • Elevated SVR or SVRI may be the result of hypothermia, hypovolemia, or cardiac failure. • Low SVR or SVRI is caused by widespread vasodilation. 2. High Pulmonary Vascular Resistance • Hypoxemia • Acute lung injury • Acute respiratory • Distress syndrome • Pulmonary hypertension • Pulmonary congestion 3. C. Stroke Volume • Can provide valuable information about contractility 4. Ventricular Stroke Work • Left Ventricular Stroke Work Index • Right Ventricular Stroke Work Index
VIII. Chapter Summary IX. Clinical Reasoning Checkpoint X. Post-Test XI. References
Suggestions for Classroom Activities • Review Figure 13-5—a right atrial waveform with the a and v wave components identified. Discuss how the waveforms are produced, and compare normal and abnormal waveforms. • Discuss ways to prevent the catheter tip from moving into the RV.
Suggestions for Clinical Activities • Discuss nursing protocols for responding to a catheter tip in the RV with the clinical educator of the acute care nursing unit. • Discuss how nurses can develop the bedside critical-thinking skills that improve patient outcomes for elevated PAWP and other pulmonary conditions.
CHAPTER
8
Basic Cardiac Rhythm Interpretation
Objectives: 1. Explain membrane permeability changes in cardiac cells and the relationship between membrane permeability and serum electrolyte levels. 2. Describe the cardiac conduction system, the normal electrocardiogram (ECG) complex, and nursing responsibilities for the patient who requires cardiac monitoring. 3. Interpret ECG patterns using a systematic approach. 4. Identify factors that place a person at risk for developing dysrhythmias. 5. Differentiate among common dysrhythmias arising from the sinoatrial (SA) node and their treatments. 6. Compare and contrast basic atrial dysrhythmias and their treatments. 7. Distinguish among common functional dysrhythmias and their treatments. 8. Differentiate among common ventricular dysrhythmias and their treatments. 9. Distinguish among the four conduction abnormalities, known as heart blocks, and their treatments. 10. Discuss pharmacologic and counter shock interventions and their nursing implications. 11. Identify indications for pacemaker and implantable cardio version /defibrillation therapy, types of devices, and nursing implications for the patient receiving these therapies.
I. Cellular Membrane Permeability A. Resting cardiac cell 1. Cardiac function is dependent on myocardial cell permeability and is affected by concentrations of electrolytes. 2. During the resting state, the inside of the cell is more electrically negative relative to the outside of the cell due to the differences in ion concentrations. This negatively charged resting state is referred to as its polarized state. B.
Active cardiac cell—action potential 1. Depolarization and repolarization a) The transmission of electrical conduction begins with a change in polarity called action potential, a five-phase cycle that produces changes in the myocardial cell membrane’s electrical charge, stimulating the cardiac cells extending across the myocardial muscle to produce contraction and relaxation.
b) As the cardiac cell receives an electrical stimulus, electrolytes shift, resulting in cardiac depolarization and repolarization of the cardiac muscle. 2. Action potential phases a) Depolarization (Phase 0)—the cell is almost impermeable to sodium unless a stimulus occurs. b) Repolarization (Phases 1–3)—the process of repolarization takes place over phases 1, 2, and 3. c) Resting membrane potential (Phase 4)—during the resting membrane potential phase, repolarization is completed, the original electrochemical gradient is in place, and the cell is ready to be depolarized again. 3. Refractory and supranormal periods a) Absolute refractory period—the cell cannot respond to another stimulus regardless of the strength of the stimulus. b) Relative refractory period—the cell is relatively (but not completely) unresponsive. c) Supernormal period—a time in which a weaker than normal stimulus can produce depolarization.
PowerPoint Slides 1. Cardiac Function • Dependent on myocardial cell permeability. • Cellular permeability is affected by electrolytes. • Sodium and potassium main cations. • Calcium main anion. 2. Resting Cardiac Cell • Negatively charged or polarized. • Potassium concentration is greater inside the cell. • Sodium concentration is greater outside the cell. • Calcium concentration is greater outside the cell. • Produces intracellular electrical negativity. 3. Action Potential • Initiates a change in myocardial cell polarity. • Five-phase cycle 4. Refractory and Supernormal Periods • Absolute refractory period • Relative refractory period • Supranormal period 5. Action Potential of a Cardiac Cell • Produces changes in the cell’s membrane electrical charge.
• Depolarization • Repolarization
II. Cardiac Conduction and the Electrocardiogram 1. The cardiac cycle is maintained by an intrinsic electrical circuit in the myocardium, where specialized areas of myocardial cells influence the electrical conduction pathway. Understanding this cycle is essential for electrocardiographic interpretation. A. Electrical conduction of the heart 1. The primary pacemaker of the heart is the sinoatrial (SA) node, which controls the heart rate normally between 60 and 100 beats per minute (bpm). The impulse from the SA node is transmitted: a) From the atria b) To the ventricles c) Along a cardiac conduction pathway 2. The normal conduction pathway a) The impulse from the SA node is transmitted: (1) From the atria (2) To the ventricles (3) Along a cardiac conduction pathway b) Starting at the SA node, the conduction pathways continues: (1) To the atrial-ventricular (AV) node (2) To the bundle of His (3) Proceeding along the left and right bundle branches (4) Terminating at the Purkinje fibers (5) Leading to ventricular muscle cells B. The electrocardiogram 1. The Normal ECG Pattern. a) P wave and PR interval. b) QRS complex c) ST segment and T wave d) QT interval. C. Cardiac monitoring systems 1. Proper lead placement is essential for accurate cardiac monitoring, and lead placement is verified by the nurse at the beginning of each shift. Figure 8-7 shows placement of a five electrode lead system. D. Nursing care of a patient who requires cardiac monitoring 1. Electrode management. 2. Monitor alarms. 3. ECG strip analysis.
E. Patient electrical safety 1. Always check for frayed wires or components before performing an ECG. F. Patient and family education 1. Patients need to know why they require ECG monitoring.
PowerPoint Slides 1. Electrical Conduction of the Heart • Intrinsic electrical circuit 2. Primary Pacemaker—Sinoatrial node (SA) 3. Cardiac Conduction Pathway 4. The Electrocardiogram (ECG) • Represents electrical activity 5. Nursing Care of a Patient Who Requires Cardiac Monitoring • Components of ECG monitoring • Electrode placement
III. Basic Interpretation Guidelines 1. The ECG is printed on graph paper, with each small block of the graph paper being equal to 1 mm or 0.04 seconds on the horizontal axis. The horizontal axis also represents time. The vertical axis of the graph paper represents voltage; each small block is equivalent to 1 mm (0.1 mV) on the vertical axis. For basic ECG interpretation, time is the most important factor to consider. Each small block equals 0.04 seconds; a large block, composed of five small blocks, equals 0.20 seconds. Five large blocks represent 1 second. 2. There are eight steps to follow when interpreting an ECG: get heart rate, observe R–R interval, examine the P wave, measure the PR interval, determine if each P wave is followed by a QRS complex, examine and measure the QRS complex, examine and measure the QT interval, and diagnose/interpret the rhythm. A. ECG graph paper B. Measure the heart rate C. Examine the R–R intervals D. Examine the P waves E. Measure the PR interval F. P waves precede each QRS G. Examine and measure the QRS complex H. Measure the QT interval I. Diagnose the rhythm J. Clinical significance
PowerPoint Slides 1. ECG • ECG paper 2. Eight steps for ECG Interpretation • Measure heart rate
IV. Risk Factors for Development of Dysrhythmias A. Electrolyte abnormalities 1. Dysrhythmias are abnormal heart rhythms that result from a variety of causes. They occur in both healthy hearts and diseased hearts. 2. A major complication associated with dysrhythmias is their negative impact on myocardial contractility. 3. Dysrhythmias are abnormal heart rhythms that result from a variety of causes. They occur in both healthy hearts and diseased hearts. 4. A major complication associated with dysrhythmias is their negative impact on myocardial contractility. 5. Potassium abnormalities. a) Hypokalemia b) Hyperkalemia 6. Calcium abnormalities a) Hypocalcemia. b) Hypercalcemia. 7. Magnesium abnormalities. a) Hypomagnesemia b) Hypermagnesemia B. Fluid volume abnormalities 1. Fluid volume deficit 2. Tachydysrhythmias 3. Fluid volume overload 4. Ventricular enlargement 5. Decreased contractility 6. Premature beats 7. Cardiac conduction blocks 8. Alteration in heart rate C. Hypoxemia 1. Decreased myocardial tissue perfusion 2. Affects action potentials 3. Increases cell excitability
D. Altered body temperature 1. Hypothermia 2. Decreased electrical heart activity 3. Prolonged PR, QT intervals 4. Widened QRS complex 5. Increases electrical heart activity 6. Increases heart rate
PowerPoint Slides 1. Dysrhythmias • Abnormal heart rhythms • Normal and abnormal cardiac events 2. Major Complication Associated with Dysrhythmias 3. High-Acuity patients with Electrolyte Abnormalities are Prone to the Development of Dysrhythmias. • Fluid volume abnormalities • Hypoxemia • Altered body temperature • Hyperthermia • Increases electrical heart activity • Increases heart rate
V. Sinus Dysrhythmias A. Sinus bradycardia 1. Sinus bradycardia is defined as a heart rate less than 60 bpm; it originates in the SA node. It is evidenced by a regular P wave preceding each QRS complex. It is recognized as a normal rhythm in athletes as a result of stronger myocardial muscle contractions. 2. Symptomatic sinus bradycardia can result in lethal ventricular dysrhythmias and can be treated with medication that blocks the parasympathetic innervations to the SA node. B. Sinus tachycardia 1. Sinus tachycardia has a rapid rate, from 100 to 150, and is not associated with any abnormal characteristics in rhythm. Sinus tachycardia can produce angina if the cardiac output decreases to the point of reducing coronary circulation. Treatment for sinus tachycardia is aimed at relieving the cause of increased sympathetic stimulation and can include imagery, distraction, and drug therapy. 2. In cases of sinus node dysfunction, impulses originating in atria cells will result in a variety of atrial dysfunction, and can even require a pacemaker.
PowerPoint Slides 1. Sinus Bradycardia Defined 2. Sinus Bradycardia Treatment: Atropine 3. Sinus Tachycardia • Heart rate 100–150 • Complications: angina • Nursing measures • Drug therapy 4. Sinus Node Dysfunction • Impulses originate elsewhere in atria • Decrease cardiac output • Nursing assessment
VI. Atrial Dysrhythmias 1. Atrial dysrhythmias originate from ectopic impulses within the atria. They may develop when the SA node is not working properly or when an irritable focus (or multiple foci) develops in the atria. A. Premature atrial contractions 1. Premature atrial contractions (PACs) are a common type of premature beat that originates from one or more (multifocal) ectopic pacemakers located in the atria B. Supraventricular tachycardia 1. Supraventricular tachycardia (SVT) has a rate between 150 and 250. The rhythm is regular; however, the P waves are not distinguishable, because they are buried in the preceding T wave. Normal QRS complex indicates that the ectopic pacemaker is located above the ventricles. 2. Treatment for SVT varies, from Valsalva’s maneuver to the use of calcium channel blocking agent’s antidysrhythmic agents such as adenosine, calcium channel blocking agents, beta adrenergic blocking agents, or digoxin. C. Atrial flutter 1. Atrial flutter has a faster rate than SVT has, with a rate greater than 250 bpm. The ventricular rate depends on the number of impulses that pass through the AV node. D. Atrial fibrillation 1. Atrial fibrillation (A Fib) is a condition in which the atria are contracting so fast—greater than 350 bpm—that they are unable to have adequate filling or contraction.
PowerPoint Slides 1a. Atrial Dysrhythmias • Characterized by a rapid atrial rate • Rapid ventricular response results in symptoms.
1b. Atrial Fibrillation (AF) • Most common sustained arrhythmia • Atria contracting very rapidly, unable to empty, discharging greater than 400 bpm • Unable to refill atrial chambers before contraction • Inadequate ventricular filling • Decreases stroke volume (SV) 25% • Blood remaining in atria prone to form clots • Increases risk of thrombotic stroke • QRS complex normal, irregular • Absent P waves • Treatment 2. Superventricular Tachycardia 3. Supraventricular Tachycardia (SVT) • Rate between 150 and 250 • Regular rhythm • Undistinguishable P wave • QRS complex normal 4. Treatment • Valsalva’s maneuver • Calcium channel blocking agents 5. Atrial Flutter • Atrial rate greater than 250 • Ventricular rate regular or irregular • Atrial oscillations appear as sawtooth or flutter waves • Described by the number of atrial oscillations • f waves 5a. Atrial Flutter 5b. Atrial Oscillations/Treatment • Cardioversion • Calcium channel blockers
VII. Junctional Dysrhythmias 1. Junctional dysrhythmias occur because the SA node fails to fire, so the AV node initiates the impulses. The junctional area is located around the AV node. 2. Pacemaker cells around the AV node have an intrinsic rate of 40–60 bpm.
3. Once the pacemaker cell discharges, the impulse spreads upward to depolarize the atria and downward to depolarize the ventricles. 4. The QRS complex appears normal, the atria are depolarized in an abnormal manner; therefore, the P wave might be inverted. The timing of the P wave is abnormal; it precedes the QRS complex, and the PR interval is shorter than 0.12 seconds. The P wave also might be buried in the QRS complex, and might not be distinguishable, or might follow the QRS complex. 5. Junctional tachycardia refers to a junctional rhythm with a rate greater than 100 bpm. If the rate is between 60 and 100, it is called accelerated junctional rhythm. 6. Treatment is dependent on patient symptomology and can consist of drug therapy and/or the insertion of a pacemaker.
PowerPoint Slides 1. Junctional Dysrhythmias • SA node fails to fire 2. AV Node Becomes Pacemaker • Junctional area around AV node • Intrinsic rate 40–60 bpm 3. P Wave Timing 4. Junctional Tachycardia • Junctional rhythm • Possible precipitant • Rate <100 bpm 5. Treatment
VIII. Ventricular Dysrhythmias 1. Ventricular dysrhythmias are ectopic impulses that originate in the ventricle and can be life-threatening. 2. Ectopic impulses of ventricular origin alter hemodynamics. This results in a decrease in cardiac output from loss of the atrial kick from backwards depolarization and from pushing ventricular blood. A. Premature ventricular contractions 1. Premature ventricular contractions (PVCs) are ectopic impulses that originate in the ventricle and discharge before the next normal sinus beat is due. 2. During ECG interpretation, the nurse assesses and describes the patient’s underlying cardiac rhythm and the type of PVCs (unifocal versus multifocal). 3. A major responsibility of the nurse is to assess the patient for factors that contribute to the development of PVCs and the presence of specific PVC patterns (see Table 8-6) warrant high vigilance because they are associated with development of two life-threatening dysrhythmias, ventricular tachycardia (VT) and ventricular fibrillation (VF). Occasional PVCs do not require treatment.
B. Ventricular tachycardia 1. Ventricular tachycardia (VT) is classified as three or more consecutive PVCs occurring at a rapid rate, usually greater than 100 bpm. 2. A danger of ventricular tachycardia is that it may deteriorate into ventricular fibrillation. 3. Support (ACLS) by trained interdisciplinary team members such as nurses, respiratory therapists, pharmacists, and physicians. C. Ventricular fibrillation 1. Ventricular fibrillation, a fatal rhythm, is the most common cause of sudden cardiac arrest. 2. Defibrillation is the treatment of choice (AHA, 2011). 3. Pharmacotherapy includes a bolus of epinephrine or vasopressin. If the patient remains pulseless, CPR and attempts at defibrillation continue per ACLS guidelines (AHA, 2011). D. Asystole 1. Asystole represents complete cessation of electrical impulses. The patient is unconscious and pulseless. 2. It is imperative that the nurse check that the rhythm is verified in two separate leads, as fine ventricular fibrillation can mimic asystole but requires different interventions. 3. Often, despite rigorous efforts, asystole is a terminal rhythm.
PowerPoint Slides 1. Ventricular Dysrhythmias • Life-threatening • Inadequate ventricular ejection • Insufficient stroke volume • Decrease oxygen tissue perfusion. 2. Ventricular Contractions 3. Ventricular Tachycardia • Classified as three or more consecutive PVCs occurring at a rapid rate, usually greater than 100 bpm • Support (ACLS) by trained interdisciplinary team members • May deteriorate into ventricular fibrillation. 4. Ventricular Contractions 5. Ventricular Fibrillation • The most common cause of sudden cardiac arrest. • Defibrillation is the treatment of choice (AHA, 2011). • Pharmacotherapy includes a bolus of epinephrine or vasopressin. 6. Asystole • Represents complete cessation of electrical impulses.
• Ventricular fibrillation can mimic asystole. • Asytole is a terminal rhythm.
IX. Conduction abnormalities 1. Cardiac impulse conduction can be inhibited anywhere along the conduction pathway. Factors that can slow conduction include cardiac ischemia, digitalis, antiarrhythmic agents, and increased parasympathetic activity. 2. When the delay occurs at the antrioventricular (AV) node area, it is called an AV block. Acute AV blocks are associated with myocardial infarction. Chronic AV blocks develop from coronary artery disease. AV blocks have three classifications, and are based on the relationship of the P wave to the QRS complex. A. First-degree atrioventricular block 1. First-degree atrioventricular block is denoted by a prolonged PR interval; there is a delay in conduction through the AV node; the remainder of the ECG is normal. Patients are usually asymptomatic; however, in the presence of acute MI or coronary artery disease, conduction delay can increase and can lead to second- or third-degree block. B. Second-degree atrioventricular block 1. Second-degree atrioventricular block indicates that an SA node impulse is conducted with a delay or a completely blocked AV nodal area. A P wave is present, but the PR interval is irregular or is not measurable, due to a missing QRS complex. There are two patterns of AV block, Mobitz I and Mobitz II. a) Mobitz Type I (Wenckebach) is a second-degree AV block (Wenckebach). b) Mobitz Type II second-degree AV block PR intervals are constant before dropping the QRS complex. Nursing management depends on the degree of block and symptoms indicative of hypoxia that are exhibited by the patient. c) Management of Second-Degree AV Block. C. Third-degree (complete) atrioventricular block 1. Third-degree (complete) atrioventricular block requires emergency treatment, because the atria and ventricles are contracting independently, resulting in inadequate filling of the ventricles. No impulses are conducted through the AV node. The atria and ventricles fire at a regular interval, but they do not function as a single unit. This form of block is usually associated with myocardial infarction. 2. P–P wave interval is regular, as is the R–R wave interval, but the PR intervals vary. There is no relationship between the P wave and the QRS complex, because the atria and the ventricles are paced by a separate pacemaker. The QRS complex is usually wide because of the ventricular origin of the stimulus. In rare cases, the ventricular rate is fast enough to maintain cardiac output; however, complete block can progress to ventricular fibrillation. Treatment for complete heart block is the same as for type II second-degree block. D. Bundle branch block 1. Bundle branch block (BBB) results from an impairment in conduction through the bundle of His branches.
PowerPoint Slides 1. Conduction Abnormalities • Inhibition of cardiac impulses along conduction pathway • Factors • Classification 2. First-Degree Atrioventricular Block • PR interval >0.20 seconds • Delayed conduction through AV node • Rest of ECG normal • Patient usually asymptomatic • No treatment necessary • Acute MI • Coronary artery disease 3. Second-degree Atrioventricular Block • SA node impulse conduction is delayed or completely blocked. • Occurs in the AV nodal area. • P wave is present. • PR interval is irregular or not measurable. • Two patterns of AV block. • Associated with third-degree AV block and asystole. • Management 4. Third-Degree (Complete) Atrioventricular Block • Requires emergency treatment. • Atria and ventricles are contracting independently. • Cardiac output greatly diminished. • Impulses are not conducted through the AV node. • Atria and ventricles fire at regular rate, but not as a single unit. • P–P and R–R wave interval are regular. • PR interval varies. • No relationship between the P wave and QRS complex. • Wide QRS complex. • Associated with myocardial infarction. • Can progress to ventricular fibrillation. • Treatment.
5. Bundle Branch Block (BBB) • Impairment in conduction through the bundle of His branches. • Conduction through right and left bundle branches can be impaired. • Impulse travels slowly through the blocked side. • 12-lead ECG necessary to determine type of block. • Treatment not necessary.
X. Pharmacologic and Countershock Interventions and Nursing Implications A. Antidysrhythmic agents 1. Antiarrhythmic agents are used in treating cardiac conduction disturbances. Antiarrhythmics have several subcategories, class I through class IV, and are classified according to their effects during the slow and fast action potentials. Each of these drugs is capable of producing new dysrhythmias or worsening current dysrhythmias (proarrhythmics). Therefore, constant ECG monitoring is required as these medications are initiated. Antiarrhythmic agents are summarized in the box called “Related Pharmacotherapy: Antiarrhythmic Agents.” 2. Class I agents a) Class I drugs are fast sodium channel blockers. By blocking these channels, these drugs slow impulse conduction through the atria, ventricles, and the bundle of His. There are three categories of class I drugs. (1) Class IA drugs suppress dysrhythmias by reducing automaticity and prolonging the refractory period of the heart. They are indicated in the treatment of supraventricular and ventricular dysrhythmias. (2) Class IB drugs decrease refractory periods but do not affect automaticity to a great extent, and are used chiefly in the treatment of ventricular dysrhythmias. (3) Class IC agents delay ventricular repolarization, and are used as a maintenance therapy for supraventricular dysrhythmias. 3. Class II agents a) Class II agents block the effects of catecholamines (e.g., epinephrine). They decrease SA node automaticity and slow AV conduction velocity and myocardial contractility. Their exact effects depend on which catecholamine receptor they block. (1) Most of the class II agents used to treat dysrhythmias in this category are beta-blocking agents, and decrease cardiac stimulation, and can produce vasodilation and bronchoconstriction. Drugs in this category are used in treating tachydysrhythmias. (2) Class II drugs are not to be used in patients with severe congestive heart failure, significant bradycardia, and second-degree or higher heart blocks, because of decreased cardiac stimulation. They are contraindicated in asthma because of bronchoconstriction. Because class II drugs decrease the heart rate, the heart rate might be unable to increase to maintain CO in some situations, such as exercise.
4. Class III agents a) Class III agents block potassium channels, thereby delaying repolarization and prolonging the refractory period. They increase the fibrillation threshold (making the cell more resistant) and are indicated in the treatment of atrial and ventricular dysrhythmias. 5. Class IV agents a) Class IV agents are calcium channel blockers. These drugs block the entry of calcium through the cell membranes, thereby decreasing depolarization. Automaticity in the SA node is reduced, AV node conduction is slowed, and overall decrease in myocardial contractility is produced with class IV agents. Verapamil and Diltiazem are calcium channel blockers commonly used for treating supraventricular tachydysrhythmias. 6. Other agents a) Adenosine and digoxin do not fit within the four major classes. Adenosine is classified as an antiarrhythmic and is first-line therapy to convert supraventricular tachycardia to normal sinus rhythm. It is administered rapidly IV push over a 1–3 second period (Diepenbrock, 2012). Digoxin is classified as a cardiac glycoside and inotropic agent. It can be used to treat supraventricular tachycardia, atrial fibrillation, and atrial flutter. 7. Nursing management of patients receiving antidysrhythmic agents a) Prior to administration of any antiarrhythmic agent, the nurse assesses the following baseline data: (1) Vital signs (2) ECG interpretation using the seven-step process b) Physical assessment of the cardiac, respiratory, and neurologic systems B. Countershock 1. Elective Cardioversion. Delivers electrical current that is synchronized with the patient’s heart rhythm. It is used to treat SVT that is resistant to medication, atrial fibrillation or atrial flutter, and ventricular tachycardia in an unstable patient. a) Nursing considerations. In preparation for the procedure, the nurse obtains informed consent and educates the patient as to the purpose of the cardioversion and what to expect during it. C. Defibrillation 1. Defibrillation is an emergency procedure used to treat ventricular tachycardia in an unresponsive patient and ventricular fibrillation. Defibrillation is an unsynchronized electric shock that usually administers a larger number of joules (up to 360 J) than cardioversion does, once again depending on the type of defibrillator used.
PowerPoint Slides 1. Antiarrhythmic Agents • Used in treating cardiac conduction disturbances • Classifications
2. Class I Agents • Fast sodium channel blockers • Three categories 3. Class II Agents • Block the effects of catecholamines. • Decrease SA node automaticity. • Slow AV conduction, velocity, and myocardial contractility. • Four catecholamine receptors 4. Class III • Block potassium channels. • Delay repolarization. • Prolong refractory period. • Prolong QRS interval. • Treat atrial and ventricular dysrhythmias. 5. Class IV Agents • Calcium channel blockers • Decrease depolarization • Reduce automaticity in SA node • AV node conduction delayed • Decrease myocardial contractility • Treatment for SVTs • Nursing assessment • Drug administration 6. Nurse Assessment of Baseline Data • Vital signs • ECG interpretation • Physical assessment 7. Countershock • Cardioversion • Nurse’s responsibilities 8. Defibrillation • An unsynchronized electric shock that usually administers a larger number of joules than cardioversion does
XI. Electrical Therapy A. Pacemakers 1. A pacemaker is a pulse generator used to provide an electrical stimulus to the heart when the heart fails to conduct or generate impulses on its own at a rate that maintains cardiac output. a) The pulse generator is connected to leads (wires) that provide an electrical stimulus to the heart when necessary. b) Pacemakers are used in addition to drug therapy when one of three conditions exists: failure of the conduction system, failure to initiate an impulse spontaneously, or failure to maintain primary pacing control. (Spontaneous impulses might occur, but they are not synchronized.) c) There are three commonly used pacing mechanisms: external, epicardial, and endocardial. 2. External pacemakers a) External pacing is a temporary measure. It delivers electric impulses to the myocardium transthoracically through two electrode pads placed anteriorly and posteriorly on the chest. b) This type of pacing can be a painful experience for the patient, who should be medicated accordingly. c) The presence of an adequate pulse and blood pressure demonstrates mechanical capture. 3. Epicardial pacemakers a) Epicardial pacers are inserted during open heart surgery; electrodes are placed directly on the surface of the heart. b) Affixed to the epicardium, the pacing wires are brought through the skin (below the sternum) for access. 4. Transvenous pacemakers a) Temporary transvenous pacing is achieved through electrical stimulation of the right ventricular or right atrial endocardium by an electrode-tipped catheter. b) There are two approaches available for placing a pacing wire: by direct insertion of the pacing wire or by insertion of a special pulmonary artery catheter that has an embedded pacing port c) When the procedure is complete, a chest X-ray is required to assure proper placement of the lead wire in addition to assuring the patient did not experience complications from the central line placement (i.e., pneumothorax). d) Caring for the transvenous pacing wire and site is done with sterile technique as this line poses risks for blood stream infection. 5. Permanent Implanted Pacemakers. a) Permanent pacemakers use an internal pulse generator. This generator is typically located in a subcutaneous tissue pocket (above the muscles and ribs, below the clavicle) in the chest wall. b) The leads are passed transvenously into the heart and rest on the endocardium. c) The generator is a small, thin, sealed device that contains a battery and is programmed according to the needs of the patient (Fig. 8-38). B. Chambers paced 1. Ventricle— Pacemakers have the ability to pace the atrium, the ventricle, or both (called “dual” or “AV sequential”) chamber.
2. Atrium—The atria can also be paced and can be noted on the ECG rhythm strip as a spike that appears just before the wave. This method of pacing is used with sinus node disease. 3. Dual Chamber—Atrial-ventricular (AV) sequential or dual pacing is used to synchronize heart depolarization in order to maintain cardiac output. In this type of pacing, both the atria and the ventricles are paced (dual chamber). Spikes appear before the wave and the QRS complex on the ECG. C. Pacemaker sensing 1. Pacemakers have the capability of sensing intrinsic (heart generated) electrical activity and may be either set on demand or fixed pacing. a) In demand pacing b) Fixed pacing D. Pacemaker settings 1. As with many types of technology-based devices, desired settings need to be set into the device. Pacemakers have three major settings: sensitivity, output, and rate. E. Pacemaker modes 1. Pacemakers vary in how they respond to electrical events in the heart. There are three major modes: triggered, inhibited, and double. F. Pacing problems 1. The number of times the pacemaker fires is determined by the sensitivity setting of the pacemaker. If the sensitivity is too low, the pacemaker may not sense the patient’s own cardiac electrical activity and will pace more frequently. If the sensitivity is too high, the pacemaker is better able to sense the patient’s own cardiac electrical activity and is inhibited from firing. a) Failure to sense term b) Failure to capture c) Failure to fire. G. Pacemaker classification 1. Pacemakers are classified according to a uniform system that is universally used to describe how the device functions according to where the pacing leads are and the mode of pacing. H. Implantable cardioverter/defibrillator 1. An implantable cardioverter/defibrillator (ICD) is placed in patients who have had prior aborted sudden cardiac death or proven sustained ventricular tachycardia. a) It also may be placed prophylactically in high-risk groups, such as those with various forms of cardiomyopathy. b) The device is a fully implantable, battery-operated system designed to recognize and terminate ventricular tachyarrhythmias that can cause sudden death. c) Patients who need an ICD require extensive training. d) Patients must understand the difference between heart attack and cardiac arrest. e) The ICD does not prevent a myocardial infarction, but it does prevent cardiac arrest.
2. Patient education a) The patient is taught that the ICD can “reorganize” his heart rhythm as well as stimulate the heart. (Pacemaker action is available on most recent models.) b) Patients are encouraged to keep a diary of shocks received, activities before and after treatment, symptoms, and response after shock. c) They should contact their cardiologist when they receive a shock. I. Electrical Therapy Nursing Considerations 1. Caring for a patient with a pacemaker or ICD requires specialized nursing care, including preparing the patient for insertion of an endocardial pacemaker or applying and using an external pacing device correctly.
PowerPoint Slides 1. Pacemakers • A pulse generator to provide an electrical stimulus to the heart • Used when myocardial conduction cannot maintain adequate cardiac output • Pulse generator connected to wires that carry electrical stimulus to the myocardial cells • Used in addition to drug therapy • Pacing mechanism 2. External Pacing • Temporary measure • Electrical impulses to myocardium transthoracically • Nursing intervention 3. Permanent Implanted Pacemakers • Use internal pulse generator • Location • Epicardial pacing • Endocardial pacing 4. Types of Pacing • Programmed to pace different areas of the heart. • Most common are designed to pace ventricles. • Will produce a spike before QRS complex. • Used when transmission of atrial impulses is blocked. • Can be programmed to pace when an intrinsic beat is not sensed. • Triggered mode. • Initiates impulse on sensing electrical activity. • Double function pacemaker.
5. Pacing Problems • Low sensitivity • High sensitivity • Failure to sense • Failure to capture 6. Pacemaker Classification • Classified according to uniform, universal system • Pacemaker code written using five-letter format • DDD pacemaker • DDDR pacemaker 7. Implantable cardioverter/defibrillator (ICD) • Implanted for those who aborted sudden cardiac death • Aborted proven sustained VT. • Prophylactically in high cardiac risk groups • Designed to recognize and terminate ventricular tachyarrhythmias • Distinguish between VT and VF • Provide backup bradycardia pacing. • Storing cardiac events • Implantation of ICD 8. Automatic External Defibrillator (AED) • Used by both medical and non-medical personnel • Taught to general public • ECG pattern detected through large chest pads
XII. Chapter Summary XIII. Clinical Reasoning Checkpoint XIV. Post-Test XV. References
Suggestions for Classroom Activities • Have the students practice identifying ECG wave forms, and identifying and measuring intervals and complexes associated with premature ventricular contractions using the seven steps in rhythm interpretation. • Have students discuss patients they have cared for, past or present, who have had dysrhythmias. Ask if there were predisposing factors for the development of premature contractions. • Discuss nursing diagnoses for patients experiencing cardiac dysrhythmias.
Suggestions for Clinical Activities • Have the students obtain ECG strips from several patients and practice wave form identification and interval and complex measurements. • Discuss individual students’ strips specific to their assigned patients. • Have students discuss patients they have cared for, past or present, who have had dysrhythmias. Ask if predisposing factors for the development of ventricular dysrhythmias were evident.
CHAPTER
9
Complex Wound Management
Objectives: 1. Describe the anatomic structures and functions of the skin and the effects of wounds on skin integrity. 2. Explain wound physiology, including the physiologic events that occur in each phase of wound repair and the methods of wound closure. 3. Discuss physiologic and environmental factors that affect wound healing. 4. Identify the common clinical assessments used to evaluate wound healing. 5. Discuss treatment modalities used in wound management and their rationale. 6. Explain wound infections, including conditions that predispose a patient to developing an infection, diagnostic criteria, and treatment interventions. 7. Describe necrotizing soft-tissue infections, including pathophysiology, signs and symptoms, risk factors, and treatment strategies for necrotizing fasciitis and Fournier’s gangrene. 8. Discuss enterocutaneous fistula, including pathophysiology, risk factors, clinical presentation, and collaborative management. 9. Review pressure ulcers, including etiology, risk factors, assessment tools, and collaborative management.
I. Anatomy and Physiology of the Skin and Effects of Wounds A. Normal Skin anatomy 1. Epidermis, the vascular outermost layer, is composed of stratified squamous epitherial cells and is divided into five sub-layers called stratum. 2. Dermis is the innermost layer of skin, the thickest tissue layer of the skin. It provides support to the epidermis and is made up of two major proteins (elastin and collagen) that provide elasticity and strength to the skin. 3. Hypodermis is a subcutaneous layer below the dermis that consists of adipose tissue and blood vessels. B. Wounds—A disruption of skin functions 1. A wound creates an alteration and disruption of the anatomic and physiologic functions of the skin. A wound can be created intentionally, as with a surgeon’s knife; by accidental trauma, such as occurs in a motor vehicle crash; or by mechanical forces, such as occurs in pressure ulcer formation. a) Partial thickness or full thickness
PowerPoint Slides 1. Normal Skin Anatomy • Epidermis • Dermis • Hypodermis 2. Wounds—A Disruption of Skin Functions • Partial thickness or full thickness
II. Wound Physiology 1. Acute wounds occur suddenly and progress rapidly through a predictable series of repair events that result in wound closure. Acute wounds are usually a consequence of a traumatic injury or surgery. In contrast, chronic wounds fail to proceed through an orderly and timely repair process, resulting in lengthy closure or failure to close. Chronic wounds are often caused by vascular compromise, chronic inflammation, or repetitive injury to an existing wound or ulcer. A. Phases of wound repair 1. Inflammation Phase—This occurs immediately after injury and lasts 3 days. This is a critical phase because the wound environment is being prepared for subsequent tissue development. The major events that occur in this phase are hemostasis (i.e., control of bleeding). 2. Proliferation Phase—begins several days after injury and continues for several weeks. The major processes that occur during this phase are focused on building new tissue to fill the wound space and restoring a functional barrier. a) Angiogenesis—is the formation of new blood vessels to reestablish perfusion to the wound bed. b) Epithelialization. Epithelialization involves the migration of epithelial cells across a wound’s surface. c) Collagen Formation —Fibroblasts produce the major component of new connective tissue. d) Granulation Tissue Formation is a provisional matrix characterized by unstructured collagen and high amounts of fibronectin. e) Contraction—As new granulation tissue is formed, the wound margins begin to contract or pull together toward the center of the wound, and the surface area of the wound decreases. 3. Remodeling/Maturation Phase Usually by the third week after a disruption in skin integrity, the wound has closed and the remodeling phase begins. Remodeling/maturationis the final repair process. This phase can last from months to years. B. Classifications of wound closure–Wound closure is classified as primary, secondary, or tertiary intention (Fig. 9–4). The rate of wound healing depends on the method used to close the wound, which in turn depends on the amount of tissue damage or loss and the potential for wound infection. 1. Primary Intention refers to closing the wound by mechanical means. This method is used when there is minimal tissue loss and skin edges are well approximated.
2. Secondary Intention are usually large wounds characterized by significant tissue loss, damage, or bacterial contamination. These wound cavities close gradually through the normal phases of wound healing. 3. Tertiary Intention is a method of delayed wound closure that uses a combination of primary and secondary intention.
PowerPoint Slides 1. Phases of Wound Repair • Inflammation phase • Proliferation phase • Remodeling/maturation phase 2. Proliferation Phase • Angiogenesis • Epithelialization • Collagen formation • Granulation tissue formation • Contraction 3. Classifications of Wound Closure • Primary intention • Secondary intention • Tertiary intention
III. Factors That Affect Wound Healing A. Oxygenation/tissue perfusion 1. Adequate oxygen supply to wounds is required by immune and inflammatory cells to produce proteins, reestablish vascular structure and epithelium, and provide resistance to bacterial invasion. Adequate oxygenation promotes neovascularization and optimizes collagen deposition, which increases the tensile strength of wound beds. 2. The availability of oxygen to tissue and wound beds depends on vascular supply, vasomotor tone, arterial oxygen tension, and the diffusion distance for oxygen to cross the capillary membrane. 3. Many conditions interfere with the delivery of oxygen to the wound (e.g., thrombosis, radiation, obesity, diabetes, cardiovascular disease, cigarette smoking, hypotension, hypothermia, hypovolemia, and the administration of vasoactive drugs). 4. Nursing care for the patient with a wound must include supportive measures to enhance tissue perfusion. B. Nutrition—Wound healing is an anabolic metabolic process; that is, it requires energy to build new tissue. Therefore, adequate nutrition is a critical factor in wound repair.
1. Proteins are the building blocks of collagen, a cellular matrix that forms the basis of tissue granulation. 2. Fats serve as building blocks for prostaglandins, which regulate cell metabolism, inflammation, and circulation. 3. Vitamins and minerals are needed to build new tissues and aid in normal immune function. C. Age 1. Aging affects almost every stage of wound healing; the wound healing process is markedly slower as patients age. D. Diabetes mellitus 1. Wound healing in the patient with diabetes is compromised as a result of macrovascular and microvascular changes, poor glycemic control, and loss of sensation. E. Medications 1. Steroid therapy, used to block the inflammatory component of many diseases, has a well-known inhibitory effect on wound healing. 2. Corticosteroids suppress inflammation and reduce proliferation of keratinocytes and fibroblasts, impairing both granulation and epithelial resurfacing. F. Obesity 1. The obese patient (body mass index of 30 or greater) experiences an increased incidence of dehiscence, herniation, and infection (Rolstad, Bryant, & Nix, 2012). G. Topical therapy 1. Implement best practice dressing strategies to eliminate necrotic tissue and heavy bacterial loads. Use topical therapies that keep the wound surface clean and moist.
PowerPoint Slides 1. Oxygenation/Tissue Perfusion • Adequate oxygenation promotes neovascularization and optimizes collagen deposition. • Availability of oxygen to tissue. • Many conditions interfere with the delivery of oxygen to the wound. • Nursing care for the patient with a wound. 2. Nutrition • Wound healing is an anabolic metabolic process. • Proteins. • Fats. • Vitamins and minerals. 3. Age • Aging affects almost every stage of wound healing; the wound healing process is markedly slower as patients age.
4. Diabetes Mellitus • Wound healing in the patient with diabetes is compromised as a result of macrovascular and microvascular changes, poor glycemic control, and loss of sensation. 5. Medications • Steroid therapy, used to block the inflammatory component of many diseases, has a well-known inhibitory effect on wound healing. • Corticosteroids suppress inflammation and reduce proliferation of keratinocytes and fibroblasts, impairing both granulation and epithelial resurfacing. 6. Obesity • The obese patient (body mass index of 30 or greater) experiences an increased incidence of dehiscence, herniation, and infection (Rolstad, Bryant, & Nix, 2012). 7. Topical Therapy • Implement best-practice dressing strategies to eliminate necrotic tissue and heavy bacterial loads. Use topical therapies that keep the wound surface clean and moist.
IV. Clinical Assessment of Wound Healing A. Wound assessment 1. Assessment entails the inspection and collection of data that lead to a comprehensive individualized plan of care. Physical assessment parameters address wound etiology, wound duration, and intrinsic and extrinsic factors impairing wound healing. B. Inspection 1. Wound measurement a) Changes in wound dimensions may indicate improvement or decline in wound status. b) Measure and record the length, width, and depth of the wound. 2. Presence of exudate or drainage a) The fluid produced by wounds is called exudate. Assess wound exudate for volume (none, light, moderate, or heavy), type (clear, serosanguineous, sanguineous, purulent), and odor (absent, faint, moderate, or strong). The amount of exudate generally varies with the type of wound. 3. Appearance of wound tissue a) Wound tissue characteristics are an indication of the state of healing. Normal progression from the inflammatory phase to proliferation in a full-thickness wound results in a vascular granulating wound surface. b) Bioburden refers to the degree of foreign material and debris resulting from bacteria and tissue injury that cause a delay in the wound healing process. c) Nonviable tissue known as eschar is a black, gray, or yellow-tan necrotic tissue, thick and leathery, that appears even with the skin margin but extends more deeply. d) Nonviable tissue known as slough is a moist, slimy, gray, tan, or yellow necrotic tissue attached to the wound base.
4. Inspection of wound edges a) The wound edges should be attached (approximated) to each other without undermining. b) Edges should be moist and flush with the wound base, allowing epithelial cells to migrate from the edges across the surface once granulation and wound contraction are complete. 5. Inspection of periwound skin a) Periwound assessment provides information about the effectiveness of the treatment plan and topical therapy (Nix, 2012). b) Impaired periwound skin integrity compromises and complicates wound healing. c) Periwound skin integrity can also be altered by frequent tape removal. 6. Palpation of Periwound Area a) Palpation of the wound and surrounding areas assists in recognizing changes in size, consistency, moisture, and texture. C. Assessment of tissue perfusion/oxygenation status 1. Adequate tissue perfusion/oxygenation is the most important factor to assess for in wound healing. 2. To assess circulation into and from a wound, assess the proximal and distal pulses by palpation or by Doppler ultrasound. D. Assessment of immunologic status 1. An intact immunologic response to injury, regardless of the cause of injury, is a key factor in proper wound healing. 2. The patient is assessed for the three predisposing elements for wound infection: susceptible host, compromised wound, and infectious organism. E. Assessment of nutritional status 1. A complete and thorough nutritional assessment for all patients with altered skin and tissue integrity is imperative. 2. The assessment must include baseline height and weight, serial weight monitoring, and regular assessment of intake and output.
PowerPoint Slides 1. Wound Assessment • Wound etiology • Wound duration • Intrinsic and extrinsic factors impairing wound healing 2. Inspection • Wound measurement • Presence of exudate or drainage • Appearance of wound tissue • Inspection of wound edges
• Inspection of periwound skin • Palpation of periwound area 3. Assessment of Tissue Perfusion/Oxygenation Status • Adequate tissue perfusion/oxygenation • Assess the proximal and distal pulses 4. Assessment of Immunologic Status • Intact immunologic response to injury • Three predisposing elements for wound infection: susceptible host, compromised wound, and infectious organism 5. Assessment of Nutritional Status • Complete and thorough nutritional assessment for all patients. • Assessment must include baseline height and weight, serial weight monitoring, and regular assessment of intake and output.
V. Principles of Wound Management 1. There are three important principles of wound management: controlling or eliminating the etiology or causative factors, providing systemic support to reduce existing and potential cofactors, and maintaining an optimal physiologic local wound environment. A. Wound cleansing 1. Wound cleansing involves removing debris, microorganisms, contaminants, exudate, and devitalized tissue, usually by flushing the surface of the wound with a nontoxic irrigating solution such as normal saline. 2. The effective and safe range for wound cleansing is 4 to 15 psi. A large wound with a significant amount of necrosis requires high-pressure (8 to 15 pounds per square inch [psi]) irrigation with enough solution to adequately remove the debris. 3. The goal of cleansing proliferative, granulating wounds is to remove inorganic debris from the wound using a gentle flushing technique. B. Debridement 1. The removal of nonviable tissue, foreign matter, and debris from the wound bed is a naturally occurring event in the wound repair process. 2. The five methods of debridement are: a) Sharp debridement is the removal of necrotic areas using a scalpel or scissors. b) Mechanical debridement is accomplished with wet-to-dry gauze dressings, irrigation, or hydrotherapy. c) Chemical debridement involves the removal of necrotic tissue using enzymes or sodium hypochlorite. d) Autolytic debridement is a selective, painless form whereby usual body processes effectively remove nonviable necrotic tissue. e) Biosurgical (maggot) debridement was first used to remove necrotic tissue in the wounds of soldiers on the battlefield.
C. Dressings 1. Dressings are placed over wounds for multiple purposes: debridement; protection from the external environment; provision of a physiological environment conducive to wound healing; and provision of immobilization, support, and comfort. 2. Dressings assist in the assessment of quality and quantity of drainage, pressure reduction, and absorption. D. Negative pressure wound therapy 1. Negative pressure wound therapy (NPWT) is the application of subatmospheric pressure to the wound bed using suction to enhance granulation and contraction and collect wound fluid. 2. NPWT has been effective in treating Stage III and IV pressure ulcers, leg ulcers, diabetic foot ulcers, and dehisced incisions. 3. The wound filler dressing may be changed every 12 hours for infected wounds or every 72 hours in the absence of infection. a) Patients may experience pain from the interaction of the wound filler. b) Pain etiology should be assessed and interventions employed to alleviate the pain. (1) Changing the type of dressing (2) Adding a no adherent contact layer prior to the wound filler dressing (3) Using lower pressure (75–80 mmHg) (4) Switching from intermittent to constant suction (5) Instilling normal saline to moisten the dressing prior to removal (6) Instilling with topical Xylocaine (without epinephrine) (7) Changing the type of NPWT system
PowerPoint Slides 1. There are three important principles of wound management: • Controlling or eliminating the etiology or causative factors • Providing systemic support to reduce existing and potential cofactors • Maintaining an optimal physiologic local wound environment 2. Wound cleansing involves: • Removing debris • Microorganisms • Contaminants • Exudate • Devitalized tissue 3. The five methods of debridement are: • Sharp debridement • Mechanical debridement • Chemical debridement
• Autolytic debridement • Biosurgical (maggot) debridement 4. Dressings are placed over wounds for multiple purposes: • Protection from the external environment • Provision of a physiological environment conducive to wound healing • Provision of immobilization, support, and comfort 5. Negative Pressure Wound Therapy • Pain etiology should be assessed and interventions employed to alleviate the pain. • Changing the type of dressing • Adding a nonadherent contact layer prior to the wound filler dressing • Using lower pressure (75–80 mmHg) • Switching from intermittent to constant suction • Instilling normal saline to moisten the dressing prior to removal • Instilling with topical Xylocaine (without epinephrine) • Changing the type of NPWT system.
VI. Wound Infection: Etiology, Diagnosis, and Treatment 1. Intact skin provides a barrier to microorganism invasion and infection. Once epidermal integrity is disrupted, the wound quickly becomes contaminated by body fluids and normal skin flora (Acinetobacter, Streptococcus, and Staphylococcus). a) Bioburden, on the wound is vast and complicated. All wounds have some level of microorganism burden; most do not become infected. b) The presence of nonreplicating microbes is called contamination. c) Critical colonization describes a level of microorganism burden that affects skin cell proliferation and tissue repair, altering wound healing but not invading the wound tissue. d) Biofilm—As microorganisms adhere to the wound, they develop a biofilm. e) Wound infection occurs when the microorganisms multiply and invade body tissues A. Predisposing factors for wound infection 1. Susceptible Host—the patient who is a has some degree of local or systemic impairment of resistance to bacterial invasion a) The causes of systemic impairment may include diabetes, immune deficiency, acute or chronic use of steroids, renal disease, malnutrition, cardiovascular disease, pulmonary disease, extremes of age, obesity, cancer, and the use of immunosuppressive therapies. 2. Compromised Wound—One that contains devitalized tissue, which is tissue that has been separated from the circulation and the body’s antimicrobial defenses. 3. Infectious Organism —Many different organisms are capable of initiating a wound infection. Organisms come from endogenous or exogenous sources. a) Endogenous sources arise within the patient. b) Exogenous organisms enter the body from the external environment.
B. Diagnosis and treatment of wound infection 1. In diagnosing wound infection, it is important to consider the patient’s physical assessment and individual risk factors for wound infection along with the clinical presentation of the wound. 2. Local wound management for infection refers back to the three principles of wound management discussed in the prior section. 3. Systemic signs of wound infection require treatment with systemic antibiotics that are sensitive to the causative microorganism. 4. Wound assessment, diligent management of wound bioburden, providing individual patient system support, administering antibiotics, and monitoring therapeutic drug levels when indicated are important in supporting wound healing and avoiding sepsis in this population. C. Prevention of wound infections 1. Prevention begins with recognizing the three elements that predispose the patient to a wound infection, as described above: susceptible host, compromised wound, and infectious organism. 2. For elective surgical procedures, prevention begins preoperatively with skin preparation, mechanical and antibiotic bowel preparations, timely prophylactic administration of antibiotics, and sterile operative site draping. 3. For patients with traumatic injury, resuscitation and lifesaving measures often take priority over the immediate treatment of wounds. 4. Hand washing is still considered one of the most important methods of preventing wound infections.
PowerPoint Slides 1. Wound Infections: Etiology, Diagnosis, and Treatment • Bioburden • Contamination • Critical colonization • Biofilm • Wound infection 2. Predisposing Factors for Wound Infection • Susceptible host • Causes of systemic impairment • Compromised wound • Infectious organism 3. Diagnoses and Treatment of Wound Infection • Diagnosing wound infection • Local wound management • Systemic signs of wound infection • Wound assessment
4. Prevention of Wound Infections • Prevention begins with recognizing the three elements that predispose the patient to a wound: • Susceptible host • Compromised wound • Infectious organism • Elective surgical procedures • Patients with traumatic injury • Hand washing
VII. Necrotizing Soft-Tissue Infections 1. Necrotic tissue is dead, devitalized tissue. It is an impediment to wound healing and provides an environment for microorganism growth and infection. A. Necrotizing fasciitis (NF) is a severe deep soft tissue infection that leads to necrosis of the subcutaneous tissue and fascia without involvement of the underlying muscle. 1. Signs and symptoms a) NF is difficult to diagnose in the beginning stage because symptoms mimic nonsevere soft-tissue infections. Early signs include those associated with the inflammatory process: erythema, edema, and pain in the affected area. b) In later stages, crepitus may be palpated in the affected area or may be seen radiographically. Crepitus results from gas-forming organisms and anaerobic infection (Morgan, 2010). c) The underlying disease process is common to all types of NF, but the speed of development and associated clinical features differ greatly depending on the causative microorganism(s). d) Depending on the causative organism, NF is categorized as: (1) Type I is caused by a synergistic mixture of aerobic and anaerobic bacteria and is the most common form (Morgan, 2010). (2) Type II is a monomicrobial infection caused by GAS, either alone or with Staphylococcus aureus. (3) Type III is caused by marine organisms, mainly Vibrio. (4) Type IV is a fungal infection related to Candida and is rare, mainly affecting immunocompromised patients (Morgan, 2010). 2. Pathogenesis of NF a) The pathogens causing NF invade the subcutaneous tissue and proliferate rapidly. 3. Treatment includes: a) Antibiotics b) Intravenous administration of broad-spectrum antibiotics c) Wound management d) Aggressive surgical debridement e) Dressing changes
4. NF antibiotic therapy typically consists of: a) Intravenous administration of penicillin for gram-positive cocci b) Aminoglycoside for gram-negative aerobes c) Metronidazole for anaerobes 5. Surgical debridement is only effective treatment (lack of antibiotic penetration). a) All nonviable tissue, including fascia, must be surgically debrided. b) Patient might require debridement in operating room every couple of days. c) NPWT may be used. d) Amputation might be required (not healing, septic shock). 6. Given the high rate of systemic toxicity, decrease mortality by: a) Intensive monitoring b) Hemodynamic resuscitation c) Nutritional support B. Fournier’s gangrene 1. Fournier’s gangrene (FG) is a form of necrotizing fasciitis that develops in the perineal, genital, and perianal regions. It is more common in males than females (Czymek et al., 2010). 2. Treatment is similar to that for patients with NF: administration of broad-spectrum antibiotics for polymicrobial infections, aggressive surgical debridement, and wound management. C. Nursing care 1. Nursing care for NSTIs: Patients require complex, specific wound management. a) Dressing changes usually done several times a day. (1) Often complex and time consuming. (2) Dressing changes can be extremely painful. b) Administration of antibiotics in a timely fashion is imperative. (1) Peak and trough levels should be drawn accurately. (2) Antibiotic doses adjusted for maximal effect.
PowerPoint Slides 1. Signs and Symptoms • NF is difficult to diagnose in the beginning stage. • In later stages, crepitus may be palpated in the affected area or may be seen radiographically. • The underlying disease process is common to all types of NF. • Depending on the causative organism. 2. NF is categorized as: • Type I • Type II • Type III • Type IV
3. NF Surgical Debridement—Only Effective Treatment • All nonviable tissue must be surgically debrided. • Patient might require debridement every couple of days. • NPWT may be used. • Amputation might be required. 4. Ways to Decrease Mortality • Given high rate of systemic toxicity, decrease mortality by: • Intensive monitoring • Hemodynamic resuscitation • Nutritional support 5. NF Possible Adjunct Therapies • Hyperbaric oxygen therapy • Intravenous immunoglobulins 6. NF Healing Process • Systemic manifestations of infection disappear. • Organisms reduced or eradicated. • Transudate decreases in volume. • Healthy granulation tissue appears. 7. Nursing Care for NSTIs • Dressing changes several times a day • Administration of antibiotics • Aggressive pain management • Monitor for septic shock and multisystem organ dysfunction • Psychological support
VIII. Enterocutaneous Fistulas A. Risk factors 1. Enterocutaneous fistula (ECF): passageway between GI tract and the skin a) Abdominal surgery b) Bowel anastomosis c) Repair of an enterotomy d) Unrecognized bowel injury 2. Management of ECFs is complex, challenging. Requires multidisciplinary team: a) Surgeons b) Enterostomal therapy nurses c) Nutritionists
d) Physical therapists e) Occupational therapists 3. Conditions that increase the risk of enterocutaneous fistulas a) Hypoalbuminemia (albumin less than 3 mg/dL) b) Malnutrition at the time of surgery c) History of steroid use d) History of chemotherapy or radiation therapy to the abdomen e) Inflammatory bowel disease f) Trauma to the abdomen, abdominal compartment syndrome 4. Risk: malnutrition at the time of surgery a) Tissue repair and regeneration are compromised b) Bowel anastomoses are more likely to fail c) Allows GI contents to leak into the peritoneum 5. Risk: history of steroid use a) Long-term and/or high-dose steroids b) Poor wound healing 6. Risk: history of chemotherapy or radiation therapy to the abdomen a) Decreased tissue integrity b) Interferes with wound healing 7. Risk: trauma to the abdomen; abdominal compartment syndrome a) Bowel injury missed at the initial operation. b) Patient developed abdominal compartment syndrome. c) Abdomen was left open to heal by secondary intention. (1) Exposed bowel receives mechanical debridement from dressing changes. (2) Epithelial cells removed with the dressing changes. (3) Thinning of bowel wall; eventually breaks open. (4) Protect bowel with Vaseline gauze until sufficient epithelialization. B. Clinical presentation 1. First sign of an ECF is a local wound infection. 2. Abdominal incision healing by primary intention. a) Skin around the sutures or staples can become erythematous. b) Skin becomes shiny and tight. c) Appearance and odor of GI contents noted. d) Small amount of drainage might seep out of the sutures. 3. Open abdomen healing by secondary intention. a) Drainage might not be visible in the wound bed. b) Drainage apparent on the dressings as they are removed. c) Drainage changes from serosanguinous to green/brown. d) Drainage can have a fecal odor.
e) Nurse must notify health care provider immediately. f) Early recognition crucial to prevent life-threatening complications. 4. Determine exact anatomic location of ECF—an important prognostic factor. a) Upper GI contrast study b) CT scan 5. Small bowel ECF vs. colon ECF a) Small bowel ECFs (proximal GI tract) (1) Associated with worse outcomes (2) Take longer to heal (3) Require longer courses of treatment and hospitalization (4) Higher output of GI drainage b) Colon ECFs (distal GI tract) (1) Do not have as much drainage (2) Stool from ECF more formed C. Collaborative management 1. Treatment includes: a) Correction of fluid and electrolyte imbalances. b) Nutritional support. c) Complex wound management. 2. Monitor and measure: a) Accurately measure ECF drainage for replacement. b) Monitor the patient for signs of hypovolemia. c) Monitor for the development of hypokalemia, hypocholoremia, and acidosis. 3. Nutritional support may include enteral or parenteral nutrition. a) Enteral nutrition b) Maintenance of GI mucosal integrity c) Improved immunologic host response d) Parenteral nutrition e) Allow administration of full nutritional requirements f) Aid in wound healing by decreasing ECF drainage 4. Nutritional support decisions are individualized based on: a) Location of the ECF b) Output from the ECF c) Patient’s overall metabolic and nutritional requirements 5. Management of skin integrity is extremely complex and challenging. a) Wound ostomy nurse can help manage these complex wounds. b) Developing the plan of care for these patients. c) Skin protection.
d) Drainage quantification. e) Drainage containment. 6. Skin care: application of ostomy appliances (protect skin and contain drainage) a) Alteration in skin integrity around the fistula b) Enzyme content of the ECF drainage c) Prolonged exposure of the perifistula skin to moisture d) Prevents spontaneous closure of the ECF e) Predisposes the patient to infection 7. Decrease ECF output a) Reducing fluid and electrolyte imbalances. b) Promotes wound healing. c) Reduces GI secretions. d) H2 receptor antagonists. e) Proton pump inhibitors. f) Bowel transit may be slowed with anti-motility agents. 8. Anti-secretory agents are controversial (somatostatin, octreotide). a) Reduce secretion of GI hormones (gastrin and cholecystokinin). b) Decrease gastric and pancreatic secretions. c) Reduce fistula drainage. d) Decrease time to closure of ECFs.
PowerPoint Slides 1. Enterocutaneous Fistula (ECF) • Abdominal surgery • Bowel anastomosis • Repair of an enterotomy • Unrecognized bowel injury 2. Multidisciplinary Team to Manage ECFs • Surgeons • Enterostomal therapy nurses • Nutritionists • Physical therapists • Occupational therapists 3. Conditions That Increase Risk of ECFs • Hypoalbuminemia • Malnutrition at the time of surgery • History of steroid use
• History of chemotherapy/radiation • Inflammatory bowel disease • Trauma to the abdomen 4. Risk: Malnutrition at Time of Surgery • Tissue repair/regeneration compromised. • Bowel anastamoses are more likely to fail. • Allows GI contents to leak into peritoneum. 5. Risk: History of Steroid Use • Long-term and/or high-dose steroids • Poor wound healing 6. Risk: Chemotherapy/Radiation Therapy to Abdomen • Decreased tissue integrity • Interferes with wound healing 7. Other Risks • Bowel injury missed at initial operation. • Patient develops abdominal compartment syndrome. • Abdomen left open to heal by secondary intention. 8. First sign of an ECF is a local wound infection. 9. Abdominal incision healing by primary intention • Skin around the sutures or staples can become erythematous. • Skin becomes shiny and tight. • Appearance and odor of GI contents noted. • Small amount of drainage might seep out of the sutures. 10. Open abdomen healing by secondary intention • Drainage might not be visible in the wound bed. • Drainage apparent on the dressings as they are removed. • Drainage changes from serosanguinous to green/brown. • Drainage can have a fecal odor. • Nurse must notify health care provider immediately. • Early recognition crucial to prevent life-threatening complications. 11. Determine exact anatomic location of ECF—an important prognostic factor. • Upper GI contrast study • CT scan
12. Small bowel ECF vs. colon ECF • Small bowel ECFs (proximal GI tract) • Associated with worse outcomes • Take longer to heal • Require longer courses of treatment and hospitalization • Higher output of GI drainage • Colon ECFs (distal GI tract) • Do not have as much drainage. • Stool from ECF more formed. 13. ECF Treatment • Correction of imbalances • Nutritional support • Complex wound management 14. Monitor and Measure • Accurately measure ECF drainage • Monitor patient for: • Hypovolemia • Hypokalemia • Hypocholoremia • Acidosis 15. Nutritional Support • Enteral nutrition • Maintenance of GI mucosal integrity • Improved immunologic host response • Parenteral nutrition • Full nutritional requirements • Aid wound healing by decreasing drainage 16. Nutritional Support Decisions Are Individualized • Location of the ECF • Output from the ECF • Patient’s overall metabolic/nutritional requirements 17. Management of Skin Integrity • Wound ostomy • Developing the plan of care • Skin protection
• Drainage quantification • Drainage containment 18. Skin Care: Application of Ostomy Appliances • Alteration in skin integrity around fistula • Prevents spontaneous closure of the ECF • Predisposes the patient to infection 19. Decrease ECF Output • Reducing fluid and electrolyte imbalances • Promotes wound healing • Reduces GI secretions • Bowel transit slowed with anti-motility agents 20. Anti-Secretory Agents • Controversial • Reduce secretion of GI hormones • Decrease gastric and pancreatic secretions • Reduce fistula drainage • Decrease time to closure of ECF
IX. Pressure ulcers 1. A pressure ulcer is a localized injury to the skin and/or underlying tissue, usually over a bony prominence that occurs when blood circulation to an area is decreased due to compression of the skin between the bone and another surface. A. Etiology of pressure ulcers 1. Intrinsic factors that contribute to the development of pressure ulcers are those internal conditions that relate to the patient’s physical or mental health, such as nutritional status, mobility, incontinence, age, and skin condition. 2. Extrinsic factors are those that derive from the immediate environment, such as skin hygiene, medications, shear, and friction, and place the patient at increased risk. B. Risk factors for pressure ulcer development 1. Patients whose activity is restricted 2. Malnourished patients 3. Patients who are incontinent or whose skin is exposed to moisture C. Predicting risk for pressure ulcers 1. A widely used, clinically validated tool that allows nurses to score a high-acuity patient’s risk for development of pressure ulcers is the Braden Scale for Predicting Pressure Sore Risk (Table 9-5) D. Pressure ulcer staging 1. Pressure ulcers are staged according to the depth of injury using a staging classification system developed to ensure consistency in the assessment and documentation of these wounds.
E. Collaborative management of pressure 1. Preventive measures are the best strategy to prevent or reduce the development of pressure ulcers 2. Treatment Decision Are Guided By the Stage of the Ulcer a) In Stage I, frequent turning and removal of pressure can prevent progression of the ulcer. b) Stage II and III ulcers need a moist healing environment. c) Stage IV wounds may require debridement, which can be accomplished surgically or by using specialized dressings or enzymes as well as packing to fill dead space and/or absorb exudate. F. Nursing management 1. Once a pressure ulcer develops, the nurse is responsible for assessing the wound at periodic intervals for improvement and response to treatment. G. Evaluation of pressure ulcer healing 1. The National Pressure Ulcer Advisory Panel (NPUAP) developed a tool to document the healing of ulcers known as the Pressure Ulcer Scale for Healing (PUSH).
PowerPoint Slides 1. Pressure ulcer • Skin and/or underlying tissue • Usually over a bony prominence 2. Etiology of Pressure Ulcers • Intrinsic factors • Extrinsic factors 3. Risk Factors for Pressure Ulcer Development • Patients whose activity is restricted • Malnourished patients • Patients who are incontinent or whose skin is exposed to moisture 4. Treatment Decision Are Guided by the Stage of the Ulcer • Stage I • Stage II and III • Stage IV
X. Chapter Summary XI. Clinical Reasoning Checkpoint XII. Post-Test XIII. References
Suggestions for Classroom Activities • Using the Internet and an image search engine (e.g., Google images), search for images of “necrotic wounds.” Study the various examples. Discuss in class. • Using the Internet, visit the websites of the two commercial negative-pressure wound therapy systems mentioned in this section. Read the manufacturer’s website to see pictures of the equipment and see how their devices work:Vacuum-assisted closure® (VAC) by Kinetic Concepts, Inc., at www.kci1.com/82.asp. Blue Sky Medical Verstaile-1 Wound Management System at www.whatisbluesky.com.
Suggestions for Clinical Activities • Take the clinical group to tour a wound care clinic. • Invite a guest speaker to meet with the class. The speaker could be one who has had a history of a longstanding wound. Ask the speaker to discuss the impact of the wound on his or her daily life. • Review the health history of patients on the nursing unit who have wounds. What characteristics do they have in common? Are their treatment plans similar? What trends are noted?
CHAPTER
10
Determinants and Assessment of Pulmonary Function
Objectives 1. Explain the conducting airways and the concept of ventilation. 2. Discuss external respiration and pulmonary gas diffusion. 3. Describe pulmonary perfusion and its components. 4. Differentiate between respiratory and metabolic acid-base imbalances and levels of compensation. 5. Interpret arterial blood gases, including compensatory status. 6. Conduct a focused respiratory nursing history and assessment. 7. Describe tests used to evaluate pulmonary function. 8. Discuss noninvasive and invasive methods of monitoring gas exchange and applications.
I. Mechanics of Breathing—Ventilation 1. Ventilation: respiratory process has three vital components: ventilation, diffusion, and perfusion. A. The conducting airways 1. Respiratory tract can be divided into conducting and respiratory airways. 2. Conducting airways include: a) Nasal passages b) Mouth c) Pharynx d) Larynx e) Trachea f) Bronchi g) Bronchioles 3. These airways serve as an air conduit to move air to and from the atmosphere and alveoli. a) Protective functions: (1) Humidifying (2) Filtering (3) Warming air
4. Conducting airway contains a mucociliary system that removes pathogens and foreign materials. a) It captures them on the mucus layer and removes them through ciliary movement, transporting foreign particles toward the pharynx, where they can be swallowed and destroyed in the stomach. b) In high-acuity patients who require an artificial airway, the initial conducting airway is bypassed, reducing the protective functions and placing patients at increased risk of aspiration and ventilator associated pneumonia (VAP). 5. The tracheobronchial tree consists of the trachea, with right and left bronchi. a) The junction of the “Y” formed by the two primary bronchial branches is the carina, which is heavily enervated and very sensitive to stimulation. (1) When the carina is touched by a suction catheter, it can trigger bronchospasm or severe coughing. b) The right bronchus is shorter and larger in diameter and at almost a straight angle with the trachea. c) The left bronchus is longer and smaller in diameter and at a more acute angle. d) Size and positioning of the right bronchus makes it more vulnerable to pathogens and foreign particles and misplacement of endotracheal tube. 6. The trachea and bronchial walls contain a C-shaped cartilage structure present down to the bronchiole level that gives structure and protection to larger airways. 7. Toward the terminal end of the bronchial tree are the bronchioles, surrounded by smooth muscle but lacking cartilage. a) Bronchioles have the ability to regulate resistance to flow by causing constriction or dilation, controlling airflow distribution. b) Bronchioles control airflow through bronchoconstriction and bronchodilation. B. Ventilation 1. Ventilation is the first of the three components of the respiratory process. a) It is defined as the mechanical movement of airflow to and from the atmosphere and the alveoli. b) Ventilation involves the actual work of breathing, requiring nervous system control and adequate functioning of the lungs and conducting airways, thorax, and ventilatory muscles. 2. Air is able to move in and out of the lungs as a result of the changing size of the thorax caused by ventilatory muscle activity. a) When the thorax enlarges, the intrapulmonary pressure drops to below atmospheric pressure. b) Air then moves from the area of higher pressure to the area of lower pressure. c) The result is air flowing into the lungs (inspiration) until the pressure in the lungs becomes slightly higher than atmospheric pressure. d) Air then flows back out of the lungs (expiration) until pressures are again equalized.
3. Lung tissue has a constant tendency to collapse. a) The fluid lining of the alveoli has a naturally high surface tension, causing them to tend to collapse. (1) Type II cells in the alveoli secrete a lipoprotein called surfactant. (a) Surfactant has a detergent-like action that reduces the surface tension of the fluid lining the alveolar sacs, decreasing the tendency to collapse. b) Lungs are composed of elastic fibers. (1) The elastic force of these fibers seeks to return to a resting state. To maintain the lungs in an inflated state, the elastic forces must constantly be overcome by opposing forces. 4. The thorax is the primary opposing force that keeps the lungs expanded. 5. The thoracic bony structure provides a framework that maintains the lungs in a baseline inflated state, even at rest, because of the attraction between the visceral and parietal pleurae. 6. The pleura is a slick-surfaced, moist membrane. 7. The parietal pleura adheres to the thoracic walls, diaphragm, and mediastinum. 8. The visceral pleura adheres to the lung parenchyma. a) Normally, the parietal and visceral pleurae act as one membrane. 9. As the thorax increases and decreases in size, so will the lungs increase and decrease in volume.
Lung Compliance 1. The ease with which the lungs can be expanded is measured in terms of lung compliance. 2. Compliance (CL) is defined in terms of lung volume (mL) and pressure (cm H2O) as CL = deltaV/deltaP, where CL is lung compliance, deltaV is change in volume (mL), and deltaP is change in pressure (cm H20). 3. Each size of alveolus has a filling capacity beyond which it becomes overexpanded and can burst. a) As the alveoli approach their filling capacity, they become less compliant. 4. Many pulmonary and extrapulmonary problems influence compliance. 5. Compliance is very sensitive to conditions that affect the lung’s tissues, particularly if the disorder causes a reduction in pulmonary surfactant, critical for maintenance of functional alveoli. a) When there is a deficiency of surfactant, compliance is decreased. b) Decreased compliance is sometimes called “stiff lungs”; it takes more force (pressure) to increase lung volume. c) Decreased compliance increases the work of breathing and causes a decreased tidal volume. d) The breathing rate increases to compensate for the decreased tidal volume. e) Pulmonary problems causing decreased compliance are called restrictive pulmonary disorders. Examples: (1) Pneumonia (2) Pulmonary edema (3) Pulmonary fibrosis (4) Pneumothorax
Effects of Aging on Ventilation 1. Aging has certain effects on ventilation. 2. As a person ages, the diaphragm flattens, the chest wall becomes more rigid, the respiratory muscles weaken, and the anterior–posterior diameter of the chest increases. a) These factors contribute to decreased lung compliance, altered pulmonary mechanics, and air trapping. 3. The lung’s functional ability reduces roughly 5–20% per decade of life. 4. A person who has never smoked and has maintained normal lungs might show little, if any, clinically significant changes in ventilation through aging. 5. The aging person with a history of smoking and some degree of lung damage tends to become increasingly symptomatic with aging and is at increased risk for developing respiratory complications.
PowerPoint Slides Slide 1 Mechanics of Breathing—Ventilation Slide 2 The Conducting Airways Slide 3 Ventilation Lung Compliance Effects of Aging on Ventilation
II. Pulmonary Gas Exchange—Respiration and Diffusion A. Respiration is the process by which the body’s cells are supplied with oxygen and carbon dioxide is eliminated. 1. Internal and external respiration a) Internal respiration refers to movement of gases across systemic capillary-cell membrane in tissues. b) External respiration refers to movement of gases across alveolar-capillary membrane. c) Both use diffusion to exchange gases.
Diffusion 1. Diffusion is the second of the three components of the respiratory process. 2. Oxygenation of tissues depends on diffusion for both external and internal respiration. 3. Diffusion: the movement of gases down a pressure gradient from an area of high pressure to an area of low pressure. 4. Alveolar-capillary membrane is very thin and offers little resistance to diffusion. a) The membrane can thicken with pulmonary disease, reducing diffusion. (1) When diffusion is reduced, the carbon dioxide tension can remain normal initially because carbon dioxide diffuses 20 times faster than oxygen, but the oxygen tension decreases rapidly.
5. Factors that affect diffusion: a) Partial pressures and gradient b) Surface area c) Thickness d) Length of exposure 6. Oxyhemoglobin dissociation curve important in determining affinity of oxygen to hemoglobin, affecting diffusion.
Partial Pressures of Gases 1. Atmospheric air is composed of molecules of nitrogen, oxygen, carbon dioxide, and water vapor. a) These gases combined exert about 760 mmHg of pressure at sea level. 2. The respiratory process only involves exchange of oxygen and carbon dioxide, which both exert a certain percentage of the total air pressure. a) Oxygen in alveoli exerts an average of 100 mmHg pressure; this partial pressure is called PO2 or oxygen tension. (1) When the PO2 refers to oxygen in alveoli, it is called PAO2. (2) When it refers to arterial blood, it is called PaO2. (3) When it refers to venous blood, it is called PVO2. b) Carbon dioxide in alveoli exerts an average of 40 mmHg of pressure; this partial pressure is called PCO2. c) The other abbreviations used for oxygen are also used for carbon dioxide. 3. Venous blood returning to the lungs from the tissues is oxygen-poor because the blood has dropped off its load of oxygen for the tissues’ use. 4. Venous blood is rich in carbon dioxide because of transport of carbon dioxide for removal from the lungs. 5. The differences in gas partial pressures between the alveoli and pulmonary capillary blood and the systemic capillary blood and tissues dictate which direction each gas will flow based on the law of diffusion. 6. Henry’s law: When a gas is exposed to liquid, some of it will dissolve in the liquid. The partial pressure of the gas and its solubility determine the amount that dissolves. a) Oxygen is not very soluble in plasma, and only 3% of total oxygen content dissolves in blood. 7. Difference between partial pressures is called the pressure gradient. a) In external respiration, a pressure gradient exists between the atmosphere and the alveoli and between the alveoli and the pulmonary capillaries. b) The greater the pressure difference, the more rapid the flow of gases. c) Multiple factors can increase the gradient—for example, exercise, positive pressure mechanical ventilation, and intermittent positive pressure breathing (IPPB). d) Air enters the alveoli from the atmosphere because the atmospheric air pressure is slightly higher than alveolar pressure, creating a pressure gradient.
e) In external respiration, a pressure gradient exists between the alveoli and the pulmonary capillaries, causing flow of gases across the alveolar-capillary membrane. f) In internal respiration, the process is reversed. The arterial blood is rich in oxygen and poor in carbon dioxide, whereas the cells are poor in oxygen and rich in carbon dioxide. (1) The pressure differences between the PO2 and PCO2 in the blood and cells cause oxygen to move from the circulating hemoglobin into the cells. (2) The cells release carbon dioxide into the bloodstream.
Lung Surface Area 1. Total surface area of the lung is very large. 2. The greater the available alveolar-capillary membrane surface area, the greater the amount of oxygen and carbon dioxide that can diffuse across it in a specific time period. 3. Emphysema is a major pulmonary disorder that destroys the alveolar-capillary membrane. a) This greatly reduces the functional surface area and consequently impairs gas exchange. 4. Many pulmonary conditions—including severe pneumonia, lung tumors, pneumothorax, and pneumonectomy—can significantly reduce functioning surface area.
Alveolar-Capillary Membrane Thickness 1. Thickness of the alveolar-capillary membrane is important. 2. The thinner the membrane, the more rapid the rate of diffusion of gases. 3. Several conditions can increase membrane thickness: a) Fluid in the alveoli or interstitial spaces, or both b) An inflammatory process involving the alveoli c) Lung conditions that cause fibrosis
Length of Gas Exposure 1. During rest, blood flows through the alveolar-capillary system in approximately 0.75 seconds. 2. Diffusion of oxygen and carbon dioxide requires about 0.25 seconds to reach equilibrium. 3. During periods of high cardiac output, blood flow is faster through the alveolar-capillary system. 4. Diffusion takes place during a shortened exposure time. 5. In healthy lungs, oxygen exchange is usually not impaired with high–cardiac output states. 6. Hypoxemia can result if diffusion abnormalities are present, such as pulmonary edema, alveolar consolidation, or alveolar fibrosis.
Oxyhemoglobin Dissociation Curve 1. Hemoglobin is the primary carrier of oxygen in the blood. a) It has an affinity for oxygen molecules. 2. In the pulmonary capillaries, oxygen binds loosely and reversibly to hemoglobin, forming oxyhemoglobin for transport to the tissues.
a) Amount of oxygen that loads onto hemoglobin is expressed as a percentage of hemoglobin saturation by oxygen (percent SaO2). 3. The affinity of hemoglobin for oxygen varies, depending on certain physiologic factors. 4. The oxyhemoglobin dissociation curve represents the relationship of the partial pressure of arterial oxygen and hemoglobin saturation. 5. The percentage saturation of hemoglobin does not maintain a direct relationship with the PaO2. 6. The top portion of the curve is flattened into a horizontal position. a) In this portion of the curve, a large alteration in PaO2 produces only small alterations in percentage of hemoglobin saturation. (1) Clinically, this means that, although administering supplemental oxygen might significantly increase the patient’s PaO2, the resulting SaO2 increase will be proportionally small. 7. The bottom portion of the curve is steep. In this portion, any alteration in PaO2 yields a large change in percentage of hemoglobin saturation. a) Clinically, this means that administration of supplemental oxygen sufficient to increase the PaO2 should yield large increases in SaO2. 8. Low PaO2 at the tissue level stimulates oxygen release from hemoglobin to tissue. 9. High PaO2 at the pulmonary capillary level stimulates hemoglobin to bind with more oxygen. 10. Slight shifts are adaptive, but severe or rapid shifts can produce life-threatening tissue hypoxia.
The Effects of Aging on Diffusion 1. As a person ages, total lung surface area decreases, the alveolar-capillary membrane thickness increases, and alveoli are destroyed because of aging processes. a) These changes result in decreased diffusion across the alveolar-capillary membrane, altering the ventilation–perfusion relationship. 2. Gas exchange becomes less efficient, placing the high-acuity older patient at risk for hypoxemia and/or hypercapnia problems. 3. Over time, the airways become larger, increasing dead space ventilation, and terminal airways lose supportive structures, which can result in air trapping. a) Both the gas exchange and airway changes can lead to carbon dioxide retention.
PowerPoint Slides Slide 1 Pulmonary Gas Exchange—Respiration and Diffusion Slide 2 Respiration Slide 3 Diffusion Partial pressures of gases Pressure gradient Lung surface area Alveolar-capillary membrane thickness
Length of gas exposure Slide 4 Oxyhemoglobin Dissociation Curve Slide 5 The Effects of Aging on Diffusion
III. Pulmonary Gas Exchange—Perfusion A. Perfusion is the third component of the respiratory process. 1. Perfusion refers to the pumping or flow of blood into tissues and organs. 2. Perfusion can be divided into two circulatory systems: a) Systemic system (1) Vast, running from aorta through right atrium of heart b) Pulmonary system (1) Much smaller than systemic system, beginning with pulmonary artery in right ventricle, running through the lungs and back into left ventricle (2) Depends on adequate perfusion in the systemic system (3) Adequate perfusion in both systems needed for oxygenation of tissues in entire body (4) Both perfusion systems composed of a complex network of blood vessels of varying sizes and functions (5) Pulmonary perfusion depends on three factors: (a) Cardiac output (CO) (b) Gravity (c) Pulmonary vascular resistance (PVR)
Cardiac Output 1. A function of stroke volume (SV) and heart rate (HR): CO = SV × HR. 2. Normal cardiac output is between 4 and 8 liters per minute. 3. Stroke volume is a function of ventricular preload, afterload, and contractility. 4. Common measurement is mean arterial pressure (MAP). a) Can be approximated using the equation MAP = [2(Pdias) + Psys]/3. b) A MAP of <60 mmHg is inadequate for perfusing major organs, such as the brain, heart, and kidneys. c) Clinical goal is to maintain MAP at 70 or above to prevent hypoperfusion, which can lead to organ ischemia and multiple organ dysfunction syndrome (MODS).
Gravity 1. Effects of gravity on blood are important for pulmonary gas exchange. 2. Blood has weight and, therefore, is gravity dependent. a) It naturally flows toward dependent areas of the body. 3. Gravity has a major influence on the relationship between ventilation and pulmonary perfusion.
Ventilation–Perfusion Relationship 1. Normal diffusion of gases requires a certain balance of alveolar ventilation and pulmonary perfusion. 2. Should a significant imbalance in this relationship develop, normal gas exchange cannot take place in affected areas. 3. Relationship of ventilation (V) to perfusion (Q) is expressed as a ratio of alveolar ventilation to pulmonary capillary perfusion (V/Q ratio). 4. For approximately every 4 liters of air flowing into alveoli, about 5 liters of blood flows past, for an average of 4:5, or 0.8. 5. Balance of ventilation to perfusion is greatly affected by the PAO2 and PACO2. 6. This balance depends on adequate diffusion of oxygen and carbon dioxide across the alveolarcapillary membrane and movement of oxygen into and carbon dioxide out of the alveoli. 7. When breathing spontaneously, airflow naturally moves toward the diaphragm, which results in more air movement into the bases and peripheral lung during inspiration. 8. Pulmonary capillary perfusion is gravity dependent, making perfusion greatest in the dependent areas of the lungs. 9. Because ventilation and perfusion are both greatest in the bases of the lungs, the greatest amount of gas exchange occurs in this portion of the lung fields. 10. In upper lungs, moderate alveolar ventilation and significantly reduced perfusion result in a “high” V/Q ratio. 11. In lower lungs, there is a moderate increase in ventilation with a significant increase in perfusion, resulting in a “low” V/Q ratio. 12. The clinical significance of ventilation–perfusion balance becomes apparent when considering high-acuity patients needing prolonged bed rest. 13. Because blood is gravity dependent, it will shift from the lung bases to whichever lung area is in the dependent position while air continues to be drawn toward the diaphragm.
Pulmonary Shunt 1. Pulmonary shunt refers to the percentage of cardiac output that flows from the right heart and back into the left heart without undergoing pulmonary gas exchange (true shunt or physiologic shunt). 2. Pulmonary shunting is a major cause of hypoxemia in high-acuity patients. 3. Helps explain how problems in ventilation and perfusion originate. 4. Two types of true shunts: anatomic and capillary
Anatomic Shunt 1. Anatomic shunt: not all blood that flows through the lungs participates in gas exchange. 2. Anatomic shunt refers to blood that moves from right heart and back into left heart without contact with alveoli, approximately 2–5% of blood flow.
3. Normal anatomic shunting occurs as a result of emptying of the bronchial and several other veins into the lung’s own venous system. 4. Abnormal anatomic shunting can occur because of heart or lung problems.
Capillary Shunt 1. Capillary shunt is the normal flow of blood past completely unventilated alveoli. 2. Blood flowing by the affected units will not take part in diffusion. 3. Capillary shunt results from consolidation or collapse of alveoli, atelectasis, or fluid in the alveoli.
Absolute Shunt 1. The combined amount of anatomic shunt and capillary shunt is called absolute shunt. a) The total percentage of cardiac output involved in absolute shunt has important clinical implications. b) Lung tissue affected by absolute shunt is unaffected by oxygen therapy because it involves nonfunctioning alveoli. c) Shunting of >15% of cardiac output can result in severe respiratory failure. d) Patients with acute respiratory distress syndrome (ARDS) generally have an absolute shunt of >20% of cardiac output. e) A hallmark of ARDS is refractory hypoxemia consistent with absolute shunt.
Shuntlike Effect 1. Shuntlike effect is not a true shunt because the shunting is not complete. 2. Shuntlike effect exists when there is an excess of perfusion in relation to alveolar ventilation; that is, alveolar ventilation is reduced but not totally absent. 3. Common causes: a) Bronchospasm b) Hyperventilation c) Pooling of secretions 4. Hypoxemia secondary to shuntlike effect is very responsive to oxygen therapy.
Venous Admixture 1. Venous admixture refers to the effect that pulmonary shunt has on the contents of the blood as it drains into the left heart and out into the system as arterial blood. 2. Beyond the shunted areas, the fully reoxygenated blood mixes with the completely or relatively unoxygenated blood. 3. The oxygen molecules remix in the combined blood to establish a new balance, resulting in a PaO2 that is higher than that which existed in blood affected by shunt but lower than it would be with normal alveoli.
Estimating Intrapulmonary Shunt 1. The simplest way to estimate intrapulmonary shunt is by calculating the P/F ratio (PaO2/FIO2). 2. It is best used when the patient’s PaCO2 is stable, because it is not sensitive to changes in that value.
Pulmonary Vascular Resistance (PVR) 1. PVR measures the resistance to blood flow in the pulmonary vascular system, a low-resistance system. 2. Three main factors determine the amount of pulmonary resistance: a) The length of the vessels b) The radius of the vessels c) The viscosity of the blood (1) Of these factors, the major determinant of pulmonary vascular resistance is vessel radius (caliber), which is altered by: (a) The volume of blood in the pulmonary vascular system (b) The amount of vasoconstriction (c) The degree of lung inflation 3. Factors related to the volume of blood in the pulmonary vascular system include capillary recruitment and distention. a) Recruitment is most influential. (1) The small pulmonary capillaries open up (are recruited) in response to an increase in blood flow. (2) When pulmonary blood flow is low (e.g., shock), the smaller capillaries can receive so little blood that they collapse. b) Distention occurs in response to increased cardiac output or increased intravascular fluid volume. (1) By distending, the capillaries can accommodate the increased flow. (2) Distention of capillaries decreases PVR. 4. Pulmonary vasoconstriction occurs in response to hypoxia, hypercapnia, and acidosis. a) Vasoconstriction is a major cause of increased PVR in the high-acuity patient. b) Hypoxia is the strongest stimulant for pulmonary vasoconstriction. c) When an area of the lung becomes hypoxic, vasoconstriction is triggered. This response diverts blood flow to more functional areas of the lungs and results in reduction in impact of shunt. 5. Degree of lung inflation has impact on diameter of pulmonary capillaries; as lung inflates, capillaries become stretched. a) In states of high lung inflation, capillaries become compressed, which decreases their diameter and increases PVR. b) Lower lung volumes are associated with decreased PVR.
6. Calculating pulmonary vascular resistance requires a flow-directed pulmonary artery catheter. a) The calculation measures resistance, which is a function of pressure and flow. b) Pressure is determined by mean pulmonary artery pressure and pulmonary capillary wedge pressure. c) Flow is measured as cardiac output.
Cor Pulmonale 1. Refers to right ventricular hypertrophy and dilation secondary to pulmonary disease. 2. A complication of both restrictive and obstructive pulmonary diseases. 3. It can cause right heart failure and is a major cause of death in chronic obstructive pulmonary disease (COPD). 4. Cor pulmonale results from a sequence of events precipitated by pulmonary hypertension.
PowerPoint Slides Slide 1 Pulmonary Gas Exchange—Perfusion Perfusion Cardiac output Slide 2 Gravity Ventilation–perfusion relationship Slide 3 Pulmonary Shunt Anatomic shunt Capillary shunt Absolute shunt Shuntlike effect Venous admixture Slide 4 Estimating Intrapulmonary Shunt Slide 5 Pulmonary Vascular Resistance (PVR) Cor Pulmonale
IV. Acid–Base Physiology and Disturbances 1. Acid-base status is another determinant of gas exchange because lungs play critical role in homeostasis 2. Also source of severe acid-base imbalances in presence of certain pulmonary disease states A. Acid-base physiology 1. Acid–base balance is crucial to the effective functioning of body systems. 2. Severe imbalances can be lethal. 3. Acids are substances that dissociate or lose ions. 4. Bases are substances capable of accepting ions.
5. A buffer is a substance that reacts with acids and bases to maintain a neutral environment of stable pH. 6. pH represents free hydrogen ion (H+) concentration. a) An increase in H+ concentration lowers pH and increases acidity. b) A decrease in H+ concentration increases pH and increases alkalinity. 7. Body’s acids include volatile acids and nonvolatile acids. a) Volatile acids can convert to a gas for excretion. (1) Carbonic acid rapidly converts to carbon dioxide for excretion from the lungs. b) Nonvolatile (metabolic) acids cannot be converted to gas, so they must be excreted through the kidneys. (1) The kidneys are capable of excreting only a small amount of acid each day, and they respond slowly to changes. (2) Hydrogen ions are excreted in the proximal and distal tubules of the kidneys in exchange for sodium.
Maintaining Acid–Base Balance: Buffer Systems and Compensation
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1. Buffer systems a) Buffering mechanisms represent chemical reactions between acids and bases to maintain a neutral environment. b) Bases react with excess hydrogen ions (H+), and acids react with excess HCO3 to prevent shifts in pH. c) The buffering mechanisms are triggered quickly in response to any change in pH. 2. Compensation a) The process whereby an abnormal pH is returned to within normal limits through counterbalancing acid–base activities. b) Compensation occurs over time; it is referred to in terms of the degree or level to which the body has achieved compensation. Four levels of compensation (1) Uncompensated (acute) (a) The pH is abnormal because other buffer and regulatory mechanisms have not begun to correct the balance. (2) Partially compensated (a) The pH is abnormal, but body buffers and regulatory mechanisms have begun to respond. (3) Compensated (chronic) (a) The pH has returned to within normal limits. (4) Corrected (a) All acid–base parameters have returned to normal ranges.
Metabolic (Renal) Compensation Mechanism 1. Bicarbonate buffer system is the major buffering system in the body. 2. Its components are regulated by the lungs (CO2) and kidneys (HCO3). 3. Additional nonbicarbonate buffers include hemoglobin, serum proteins, and the phosphate system. 4. The bicarbonate system is a relatively slowly responding system, taking hours to days. 5. The metabolic compensation mechanism controls the rate of elimination or reabsorption of hydrogen and bicarbonate ions in the kidney. 6. With increased acid loads, H+ elimination and bicarbonate reabsorption are increased. 7. In alkalosis, H+ is reabsorbed, and HCO3 is excreted. 8. Metabolic compensation is slow, beginning in hours but taking days to reach maximum compensation. a) This delayed compensatory mechanism helps explain why so many respiratory problems initially cause acute (uncompensated) acid–base disturbances.
Respiratory (Pulmonary) Compensation Mechanism 1. The respiratory buffer system is a rapid-response compensatory mechanism for metabolic acid–base disturbances; it responds within minutes. 2. The lungs have two ways to compensate: a) Alveolar hypoventilation in response to metabolic alkalosis (1) Hypoventilation retains CO2. b) Alveolar hyperventilation in response to metabolic acidosis (1) Hyperventilation blows off CO2.
Respiratory Acid-Base Disturbances 1. Primary respiratory disturbances are reflected in changes in the PaCO2. a) Normal as in respiratory acidosis b) Below normal as in respiratory alkalosis
Respiratory Acidosis 1. Occurs when the PaCO2 moves above 45 mmHg and the pH drops below 7.35. 2. Hypercapnia, elevated CO2, indicates alveolar hypoventilation. a) The lungs are not blowing off enough carbon dioxide, causing a carbonic acid excess. b) Carbon dioxide is considered an acid because it combines with water to form carbonic acid. c) Essential to determine cause of hypoventilation and correct it when possible. 3. A “chronic” abnormal acid–base state means that a state of compensation exists. 4. Chronic respiratory acidosis usually is associated with a chronic obstructive pulmonary disease.
5. Elevation of carbon dioxide occurs gradually over many years; the body can compensate to maintain a normal pH by elevating the bicarbonate. 6. Additional stressors can cause decompensation, producing respiratory failure.
Respiratory Alkalosis 1. This occurs when PaCO2 falls below 35 mmHg, with a corresponding rise in pH to greater than 7.45. 2. Decreased carbon dioxide indicates alveolar hyperventilation. a) Lungs are eliminating too much carbon dioxide, creating a carbonic acid deficit. 3. In respiratory alkalosis, there is insufficient carbon dioxide available to combine with water to form carbonic acid. 4. Effective treatment involves determining the cause of the hyperventilation and providing the necessary intervention. 5. Chronic respiratory alkalosis is uncommon. The same factors causing acute respiratory alkalosis could cause a chronic state if the problem remained uncorrected.
Base Excess Deficit (BE)
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1. A measure of the amount of buffer required to return the blood to a normal pH state. 2. A base excess is present if the BE is greater than +2 mEq/L. a) Signals the presence of a metabolic alkalosis state A base deficit is present if BE is less than –2 mEq/L. a) Signals the presence of a metabolic acidosis state
Metabolic Acidosis 1. Defined clinically as HCO3 < 22 mEq/L, pH < 7.35, with a base deficit (less than –2). 2. Metabolic acidosis can be caused by an increase in metabolic acids or excessive loss of base. 3. Examples of conditions that can cause an increase in H+ concentration. 4. Examples of conditions that precipitate a decrease in bicarbonate (HCO3) levels.
Lactic Acidosis 1. Acid metabolites, such as lactic acid (lactate), result from cellular breakdown and anaerobic metabolism. 2. The normal range for serum lactate is 0.5–2.0 mEq/L. 3. High-acuity patients are at risk for developing elevated levels of lactate because lactic acidosis is closely associated with shock and other severe physiologic insults. 4. During shock, cellular hypoxia drives serum lactate up rapidly, usually >5 mEq/L. a) This rise often precedes decompensatory signs and can be an indicator of impending shock. 5. Other conditions that can cause lactic acidosis include severe dehydration, severe infection, severe trauma, diabetic ketoacidosis, and hepatic failure.
Metabolic Alkalosis 1. Clinically defined as bicarbonate (HCO3) level > 26 mEq/L, pH > 7.45, and a base excess (greater than +2). 2. Metabolic alkalosis occurs when amount of alkali increases or excessive loss of acid occurs. a) A common cause of increased alkali is ingestion of alkaline drugs due to overuse of antacids or over-administration of sodium bicarbonate during a cardiac arrest emergency. b) Decreased acid conditions: (1) Loss of gastric fluids (2) Treatment with steroids (3) Diuretic therapy causing loss of potassium (4) Binge–purge syndrome
PowerPoint Slides Slide 1 Acid–Base Physiology and Disturbances Acid-base physiology Slide 2 Maintaining Acid–Base Balance: Buffer Systems and Compensation Metabolic (Renal) Compensation Mechanism Respiratory (Pulmonary) Compensation Mechanism Slide 3 Respiratory Acid–Base Disturbances Slide 4 Respiratory Acidosis Respiratory Alkalosis Base Excess Deficit (BE) Slide 5 Metabolic Acidosis Lactic Acidosis Metabolic Alkalosis
V. Arterial Blood Gases (ABGs) 1. Interpretation of ABGs provides valuable information on patient’s acid-base and oxygenation status. 2. The following section focuses on the determinants of oxygenation status and interpretation of the entire ABG. A. Determinants of oxygenation status 1. There are three major determinants of oxygenation status: a) PaO2 b) SaO2 or (SpO2) c) hemoglobin
PaO2 1. This represents the partial pressure of the oxygen dissolved in arterial blood (3% of total oxygen) (normal value 80–100 mmHg), not the total amount of oxygen available. 2. It is an important indicator of oxygenation because PaO2 and oxygen saturation (SaO2) maintain a relationship. a) This relationship is reflected in the oxyhemoglobin dissociation curve.
SaO2 and SpO2 1. Oxygen saturation (SaO2) is the measure of the percentage of oxygen combined with hemoglobin compared with the total amount it could carry (normal value > 95%). 2. The degree of saturation is important in determining the amount of oxygen available for delivery to the tissues.
Hemoglobin 1. Hgb or Hb is the major component of red blood cells (normal values 12–15 g/dL in women, 13.5–17 g/dL in men). 2. It is composed of protein and heme, which contains iron. 3. Oxygen binds to the iron atoms on the four heme groups of each hemoglobin molecule. 4. Hemoglobin is the major carrier of oxygen in the blood and is an important factor in tissue oxygenation.
Arterial Blood Gas 1. ABG normal values typically are reported as normal-at-sea-level (760 mmHg) partial pressures, room air (21% oxygen), and a blood temperature of 37°C (98.6°F). 2. Age also affects normal ABG values. 3. Newborns have a lower PaO2, as do elderly people, whose PaO2 decreases approximately 25–30% (in the 30- to 80-year range). 4. Normal ABG values are ranges for normal, healthy adults.
Arterial Blood Gas Interpretation 1. A single ABG measurement represents only a single point in time. 2. Arterial blood gases are most valuable when trends are evaluated over time, correlated with other values, and incorporated into the overall clinical picture. 3. Interpretation of ABGs includes determination of acid–base state, level of compensation, and oxygenation status. 4. The severity of hypoxemia is frequently referred to in terms of being mild, moderate, or severe, but the exact associated PaO2 levels are somewhat arbitrary. a) Mild hypoxemia: PaO2 60–75 mmHg b) Moderate hypoxemia: PaO2 45–59 mmHg c) Severe hypoxemia: PaO2 < 45 mmHg
5. Although acid-base balance determination is presented first, oxygenation status is often analyzed first, based on patient’s need and person performing analysis
PowerPoint Slides Slide 1 Arterial Blood Gases (ABGs) Slide 2 Determinants of Oxygenation Status PaO2 SaO2 and SpO2 Slide 3 Hemoglobin Slide 4 Arterial Blood Gas Arterial Blood Gas Interpretation
VI. Focused Respiratory Nursing History and Assessment 1. Many high-acuity patients are at increased risk for being admitted with pulmonary diseases or developing respiratory complications
Nursing History 1. When a patient is admitted to the hospital in acute distress, the nurse initially assesses airway, breathing, and circulation, and the nurse immediately takes appropriate action based on those assessments. 2. As soon as feasible, information regarding the immediate events leading to admission should be obtained. a) A recent history gives important clues as to etiology and chain of events related to the current problem. 3. The presence of severe respiratory distress limits the amount of health history information a patient can relate. a) Minimize questions directed to the patient to reduce stress on breathing. b) State inquiries in a way that requires very brief answers.
Social History 1. Assess tobacco and alcohol use. a) Assess number of cigarettes smoked per day and number of years patient has smoked. b) Alcohol use in association with prescribed drug therapy can adversely affect patient’s respiratory condition. c) Problems with alcohol withdrawal can complicate cardiopulmonary status should delirium tremens develop.
Nutritional History 1. Nutritional state is crucial to assess because malnutrition can contribute to developing respiratory failure. 2. Many patients with chronic pulmonary disorders are admitted to hospital in a malnourished state, which negatively affects patient outcomes. a) Protein–calorie deficit weakens muscles, including respiratory muscles. b) Malnutrition is associated with weakened immune system, increasing susceptibility to infection, making it harder to fight against existing infections. c) Increased stress associated with acute infection can precipitate acute respiratory failure. d) High-carbohydrate diet increases carbon dioxide load in body, which can lead to ventilatory complications.
Cardiopulmonary History 1. Often difficult to differentiate between problems of pulmonary and cardiovascular etiology. 2. Of particular importance are data concerning pre-existing cardiovascular conditions such as history of hypertension, coronary artery disease, or previous myocardial infarction. 3. Previous pulmonary problems, as well as prehospital activity tolerance, can also help differentiate pulmonary from cardiac problems.
Sleep–Rest History 1. Pulmonary problems frequently interfere with sleep and rest. 2. If the respiratory problem is severe enough to cause hypoxia, the patient often exhibits restlessness associated with inadequate oxygenation of the brain. 3. Pulmonary disorders can increase the work of breathing, which can interfere with sleep and rest. 4. Patients in respiratory distress might sleep poorly because they fear they will cease to breathe when they are unaware. 5. Others cannot sleep because of their level of general discomfort. 6. Dyspnea and air hunger are anxiety-producing and threatening experiences for pulmonary patients.
Common Complaints Associated with Pulmonary Disorders 1. If a respiratory problem is suspected, nurse should obtain information about the most common respiratory complaints: dyspnea, chest pain, cough, sputum, and hemoptysis. 2. Interview the patient or family (subjective data), and perform a nursing assessment (objective data). 3. Regular assessment of common respiratory symptoms is also important.
Dyspnea 1. A subjective symptom 2. Two major categories: a) Orthopnea b) Paroxysmal nocturnal dyspnea
Subjective Data 1. Dyspnea is the feeling of having difficulty breathing or shortness of breath. 2. It is associated with increased work of breathing and supply-and-demand imbalance. a) The body’s ability to respond. 3. Progressive dyspnea is noted in both restrictive and obstructive pulmonary disorders.
Orthopnea 1. A type of dyspnea associated with cardiac problems or severe pulmonary disease. 2. It refers to a state in which the patient assumes a head-up position to relieve dyspnea. 3. Orthopnea can be mild or severe. 4. Ask how many pillows are needed for breathing comfortably while at rest. 5. A state where additional pillows are needed for breathing comfortably while lying down is sometimes called “pillow orthopnea.” 6. Paroxysmal nocturnal dyspnea (PND) is associated with left heart failure. 7. Patient reports waking at night after being asleep several hours with a sudden onset of severe orthopnea. 8. Upon sitting up or getting out of bed, the dyspnea is relieved, and the patient can resume sleep. 9. It is a form of transient mild pulmonary edema. 10. Fluids that have been congested in the lower extremities during the day shift to the heart and lungs, causing a fluid volume overload when the person becomes horizontal for several hours.
Objective Data 1. Nurse may note tachypnea, nasal flaring, use of accessory muscles, or abnormal arterial blood gases. 2. Patient may voluntarily assume a high-Fowler sitting position secondary to orthopnea. 3. Severe tachypnea, a respiratory rate of >30 breaths per minute, significantly increases the work of breathing. 4. If allowed to continue, respiratory muscle fatigue can occur, which could cause acute respiratory failure.
Chest Pain 1. Critical to differentiate pain caused by pulmonary disease or pain caused by cardiac disease.
Subjective Data 1. When assessing chest pain, note how long the pain has been present, whether it radiates, and the triggering and alleviating factors. 2. Can be helpful in differentiating cardiogenic pain from pleuritic pain. a) Cardiogenic pain (1) Generally described as dull, pressure-like discomfort often radiating to jaw, back, or left arm (2) Unaffected by breathing b) Pleuritic pain (1) Described as sharp and knifelike (2) When patient is between breaths or the breath is held, pain decreases or stops (3) Pain increases with deep breathing but doesn’t radiate (4) Pleural friction rub sometimes can be auscultated at the focal pain point 3. Most pulmonary disorders affect only lung parenchyma, which is insensitive to pain. 4. The attached visceral pleurais insensitive as well. 5. The parietal pleura is well innervated, and when inflammation occurs, it can trigger sharp pain.
Objective Data 1. Note splinting, shallow respirations, tachypnea, facial changes associated with pain, and increased blood pressure and pulse.
Cough Subjective data 1. Assess frequency, character (dry, productive, congested), duration, triggers and pattern of occurrence, and alleviating factors. Objective data 1. Observe strength, character, and frequency of cough.
Sputum 1. Characteristics of, or changes in, provide important information about a pulmonary disease. Subjective data 1. Obtain description of sputum production. 2. If patient has a disease associated with chronic production of sputum, ask for description of usual quantity, characteristics, and color, as well as any changes in sputum associated with current problem.
Objective data 1. Monitor sputum regularly for quantity and characteristics. 2. Sputum changes should be noted and documented. 3. Normal secretions are thin and clear.
Hemoptysis 1. Refers to expectoration of bloody secretions. 2. Determine source of bleeding: upper or lower airway. Subjective Data 1. Can be of cardiovascular or pulmonary origin. 2. Common causes: pulmonary embolism and cardiogenic pulmonary edema secondary to left heart failure. 3. Most common source is lung disease. 4. Information to obtain includes color, consistency and quantity, and frequency and duration. Objective data 1. Assess for color, consistency, quantity, frequency, and duration.
Focused Respiratory Assessment 1. The onset of acute respiratory distress can be rapid and severe. 2. The nurse should be alert to changes from previously assessed baseline data and data trends. 3. When such changes are noted, a rapid focused respiratory assessment should be immediately conducted, focusing on key data that strongly suggest an acute alteration in respiratory function.
Inspection 1. Inspect skin color for cyanosis: observe lips, earlobes, and beneath tongue for central cyanosis. 2. In patients with dark skin color, cyanosis can be observed on lips and tongue. 3. Cyanosis is not a reliable indicator of hypoxia, because it depends on amount of reduced hemoglobin present. 4. When present, cyanosis is a late sign of respiratory distress. 5. Inspect shape of chest, and observe chest movement for symmetry and rate, depth, and pattern of breathing. 6. Chest may be palpated for tactile fremitus and chest expansion. 7. Chest percussion can help detect presence of air, fluid, or consolidation.
Auscultation 1. Auscultation is important. 2. Diaphragm of stethoscope is best for hearing most breath sounds and comparing one lung with the other.
Normal Breath Sounds 1. There are three types of normal breath sounds: a) Vesicular, bronchial (tubular), and bronchovesicular.
Abnormal Breath Sounds 1. Auscultate chest for diminished or absent sounds; presence of abnormal breath sounds associated with change in lung status. 2. Adventitious breath sounds are heard on top of other breath sounds and are never normal. 3. When abnormal breath sounds are present, nurse should assess and document location and when in respiratory cycle they are heard. 4. Adventitious sounds are classified as: a) Crackles b) Rhonchi c) Wheeze d) Plural rub e) Diminished or absent lung sounds
Crackles 1. Relatively discrete, delicate popping sounds of short duration associated with either fluid or secretions in small airways or alveoli, or opening of alveoli from a collapsed state. a) Most commonly heard during inspiration b) Described as either fine or coarse (1) Fine crackles (a) Delicate, high-pitched, short duration (b) Sound of rubbing hair between one’s fingers (c) Conditions include: atelectasis and pneumonia (2) Coarse or loud crackles (a) Louder, high-pitched, longer duration (b) Sound of Velcro separating (c) Conditions include: bronchitis and pulmonary edema
Rhonchi 1. Heard as coarse, “bubbly” sounds a) Most common during expiration and are auscultated over larger airways b) Associated with accumulation of fluid or secretions in larger airways
Wheeze 1. Caused by air passing through constricted airways. a) Wheeze has a musical quality: can be high- or low-pitched. b) Heard on inspiration or expiration and is of long duration.
Stridor 1. A type of wheeze caused by upper airway obstruction from inflamed tissue or foreign body. a) Described as a high-pitched, inspiratory wheeze heard louder over neck than over chest wall b) Can develop from airway edema, resulting from problems such as thermal burn inhalation injury or airway trauma during extubation
Pleural Rub 1. Caused by inflammation of pleural linings. a) When inflammation occurs, linings become resistant to free movement. b) Characteristic sound is heard during breathing and ceases between breaths or with breath holding. c) Also referred to as pleural friction rub
Decreased or Absent Breath Sounds 1. Caused by diminished or absent air flow to an area of the lungs. a) When assessed, nurse should document the location. b) In patients with lung hyperinflation disorders such as chronic obstructive pulmonary disease (COPD) and acute asthma, generalized loss of breath sounds can indicate a potentially lifethreatening hypoventilation situation.
Vital Signs and Hemodynamic Values 1. These give crucial baseline data and are important indicators of changing patient status over time. 2. Vital signs include arterial blood pressure, pulse rate and rhythm, respiratory rate and rhythm, and temperature. 3. Pulse oximeter reading should be obtained. 4. If a pulmonary artery catheter is in place, important monitoring assessments include central venous pressure (CVP), pulmonary artery pressure, pulmonary artery wedge pressure, mean arterial pressure, and cardiac output. 5. Hemodynamic monitoring generally is initiated when cardiac involvement is suspected or fluid status is questioned. 6. The presence of pulmonary hypertension can alter hemodynamic measurements.
PowerPoint Slides Slide 1 Focused Respiratory Nursing History and Assessment Slide 2 Nursing History Social History Nutritional History Cardiopulmonary History Sleep–Rest History Slide 3 Common Complaints Associated with Pulmonary Disorders Dyspnea Subjective data Slide 4 Orthopnea Objective data Slide 5 Chest Pain Subjective Data Objective Data Slide 6 Cough Subjective data Objective data Slide 7 Sputum Subjective data Objective data Slide 8 Hemoptysis Subjective data Objective data Slide 9 Focused Respiratory Assessment Inspection Auscultation Slide 10 Normal Breath Sounds Slide 11 Abnormal Breath Sounds Crackles Rhonchi Wheeze Stridor
Pleural rub Decreased or absent breath sounds Slide 12 Vital Signs and Hemodynamic Values
VII. Pulmonary Function Evaluation 1. Provider or medical team initiates orders for pulmonary function testing a) Assists to diagnose or update or evaluate pulmonary status 2. Implementation and interpretation of tests becomes interdisciplinary approach
Pulmonary Function Tests (PFTs) 1. Ventilation is measured using pulmonary function tests. 2. These tests provide baseline data and a means to monitor progress of functional impairments. 3. They help differentiate a restrictive pulmonary problem from an obstructive problem. 4. PFTs are useful for monitoring effectiveness of therapeutic interventions. 5. Diagnostic PFT is usually conducted in a pulmonary laboratory using special computerized equipment that accurately measures pulmonary volumes, capacities, and air flow. 6. Simpler measures of pulmonary function can be taken at bedside easily, using a spirometer.
Bedside Pulmonary Function Measurements 1. High-acuity patients are at risk of developing pulmonary complications associated with immobility and respiratory muscle fatigue. 2. Pulmonary function may be monitored in patients at particular risk for ventilatory decompensation. 3. Of interest are tidal volume, vital capacity, and minute ventilation. a) Tidal volume and vital capacity help monitor respiratory muscle strength. (1) Both of these PFTs can be easily measured using a respiratory spirometer and frequently are part of weaning criteria during mechanical ventilation.
Tidal Volume (VT or TV) 1. Amount of air that moves in and out of lungs with each normal breath. 2. When TV drops below 4 mL/kg, a state of alveolar hypoventilation develops. 3. Acute respiratory failure results when hypoventilation becomes severe and results in hypercapnia.
Vital Capacity (VC) 1. VC is the maximum amount of air expired after a maximal inspiration. 2. Normal vital capacity differs with gender, height, weight, and age. 3. It decreases with age and in the presence of acute or chronic restrictive pulmonary diseases.
Minute Ventilation (VE) 1. The total amount of expired air in 1 minute. 2. Used as a rapid method of measuring total lung ventilation changes. 3. Not considered an accurate measure of alveolar ventilation. 4. Normal minute ventilation is 5–10 L/minute. 5. When it increases to >10 L/minute, the work of breathing is significantly increased. 6. Minute ventilation <5 L/minute indicates patient at risk for problems associated with hypoventilation.
Forced Expiratory Volumes (FEVs) 1. FEVs are important diagnostic measurements that help differentiate restrictive pulmonary problems from obstructive problems and measure airway resistance. 2. They are also important in determining severity of obstructive diseases. 3. FEVs measure how rapidly a person can forcefully exhale air after a maximal inhalation, measuring volume (in liters) over time (in seconds). 4. Patients with a restrictive airway problem are able to push air forcefully out of their lungs at a normal rate. 5. Persons with an obstructive disorder have a delayed emptying rate. 6. FEV testing generally is not conducted at the bedside.
PowerPoint Slides Slide 1 Pulmonary Function Evaluation Slide 2 Pulmonary Function Tests (PFTs) Bedside Pulmonary Function Measurements Tidal Volume (VT or TV) Vital Capacity (VC) Minute Ventilation (VE) Forced Expiratory Volumes (FEVs)
VIII. Noninvasive and Invasive Monitoring of Gas Exchange 1. High-acuity patients frequently require monitoring of their oxygenation or ventilation status. When possible, noninvasive technologies such as pulse oximetry and capnography are used. 2. When hemodynamic monitoring is also needed, an invasive arterial line is inserted because it can continuously monitor hemodynamics, measure arterial oxygen saturation, and provide ready access to arterial blood for ABG sampling.
Pulse Oximetry 1. A noninvasive technique for monitoring arterial capillary hemoglobin saturation (SpO2) and pulse rate. 2. It uses light wavelengths to determine oxyhemoglobin saturation. 3. It also detects pulsatile flow to differentiate between venous and arterial blood. 4. A sensor is placed on a finger, nose, or ear, and an oximeter provides a constant assessment of arterial oxygen saturation. 5. Fingers are most commonly used for sensor placement, but adequacy of peripheral circulation must be considered when choosing the best sensor location. 6. Pulse oximetry is best used as an adjunct to other assessment modalities in providing continuous information for evaluation of oxygenation status. 7. Ideally, the continuous arterial oxygen readings reflect the patient’s oxygenation status and alert the clinician to subtle or sudden changes. 8. In some patients, use of oximetry can decrease frequency of invasive ABG measurements if acid–base and ventilation are not problems.
Causes of Inaccurate Readings 1. Many factors can alter the accuracy of pulse oximetry in high-acuity patients. 2. Technical problems a) Motion artifact: a major cause of false alarms and inaccurate readings b) External light sources: can compete with the pulse light source c) Improper sensor placement: might not be able to register arterial pulsations because of lack of sufficient arterial flow 3. Physiologic factors a) Hemoglobin level affects oxygen content of blood. b) Acid–base imbalance: Acidosis can cause a lower saturation reading, and alkalosis can cause a higher reading because of shifts in the oxyhemoglobin dissociation curve. c) Vasoconstrictive situations: Sensor might read more accurately if removed from distal sites and attached to a more central location. d) Cardiac dysrhythmias.
Capnography 1. Capnometry is the numeric measurement of CO2 2. Capnography is the noninvasive measurement of carbon dioxide concentration in expired gas. 3. It results in a single value measurement called the PETCO2 (partial pressure of end-tidal CO2). 4. Continuous bedside monitoring of CO2 is accomplished using infrared light absorption or mass spectrometry. 5. Infrared analyzers measure carbon dioxide based on its strong absorption band at a distinctive wavelength.
6. A capnogram displays the capnometry measurements as a continuous waveform that can be read, breath by breath, throughout the breathing cycle. 7. CO2 can be sampled using either sidestream or mainstream techniques.
Capnography Applications 1. Capnography is commonly used to monitor the adequacy of ventilation in surgical and procedural anesthesia, postoperative recovery, critical care units, and emergency departments (EDs). 2. New ACLS guidelines for CPR and emergency care call for the use of capnography to confirm endotracheal tube placement and monitor the adequacy of ventilation 3. The Agency for Healthcare Research and Quality (AHRQ) recommends monitoring oxygenation (using pulse oximetry and respiratory rate) and ventilation (using capnography) for postoperative patients receiving patient-controlled analgesia (PCA) to reduce the risk of potentially life-threatening respiratory depression. 4. Other applications include the detection of mechanical ventilator problems and confirmation of enteric feeding tube placement. 5. End-tidal carbon dioxide monitoring may be used to assess ventilatory status and provide an early warning of changes in ventilation. a) An abnormally low ETCO2 (less than 30 mm Hg) is most commonly associated with hyperventilation, hypothermia, pulmonary embolism, or decreased cardiac output. b) Increased ETCO2 (greater than 44 mm Hg) is associated with increased production of carbon dioxide (e.g., fever or increased cardiac output) or hypoventilation (e.g., respiratory center depression or neuromuscular diseases). 6. The usefulness of bedside capnography is not without limitations. a) In patients with morbid obesity, severe pulmonary edema, or ventilation–perfusion abnormalities, the ETCO2 may not accurately reflect PaCO2 . b) May still be helpful if a correlation between PaCO2 and ETCO2 can be established and used for trending. c) Unfortunately, many high-acuity patients develop ventilation–perfusion abnormalities, which may limit the usefulness of ETCO2 monitoring.
Types of Capnography 1. CO2 is sampled for capnography in three ways. a) Infrared analyzers are applied either sidestream or mainstream b) Colorimetric capnography uses pH-sensitive paper to estimate ETCO2 ranges.
Sidestream 1. When a sidestream analyzer is used, a small volume of exhaled gas is diverted from the main airway circuit through a small tube and is analyzed in a special chamber apart from the airway circuit. a) Major disadvantage: values are indirect estimated measurements b) Major disadvantage: can be used with patients that are not intubated.
Mainstream 1. Mainstream analyzers are placed in-line as part of the airway circuit, and continuous ETCO2 directly in real time. a) Major disadvantage: requires the patient to be intubated.
Colorimetric Capnography 1. Uses pH-sensitive paper that changes color based on the patient’s exhaled pH to represent a range of ETCO2 2. Most commonly used in the ED to assess for proper endotracheal tube (ETT) placement a) Also used in the field by emergency squads and in ICU settings. 3. A CO2 detector device is attached to the ET tube following tube insertion, the patient is given six breaths, and the device is read at full-end expiration. 4. The device rapidly responds to the patient’s exhaled CO2 with three color ranges: a) For example, with a Nellcor EASYCAP II (Nellcor, Boulder, CO), the detector device has a color range of purple to yellow with interpretation as follows: (1) Color range A (purple): 0.03% to less than 0.5% ETCO2 (less than 4 mmHg CO2); interpretation: ET tube is not in the trachea (2) Color range B (brown): 0.5% to less than 2% ETCO2 (4 to less than 15 mmHg CO2); interpretation: ET tube may be in the esophagus, and patient may have hypocarbia or low pulmonary blood flow (3) Color range C (yellow): 2% to 5% ETCO2 (15 to 38 mmHg CO2); interpretation: ET tube is properly located in the trachea 5. While colorimetric capnography is adequate for assessing proper ETT placement, it does not provide precise ETCO2 data and therefore has limited applications
The Capnogram 1. The pattern that is visible on the capnography screen. 2. A normal capnogram shows an ETCO2 within several mm Hg of arterial PaCO2 at the end of the plateau phase (the end-tidal CO2). 3. In a normal capnogram, the carbon dioxide concentration is zero at the beginning of expiration, gradually rising until it reaches a plateau. 4. The end-tidal carbon dioxide is the highest concentration at the end of exhalation. 5. ETCO2 monitoring is used in the clinical setting as a noninvasive indirect method of measuring PaCO2. 6. In a normal person, ETCO2 is 30–43 mm Hg, typically 4 to 6 mm Hg below PaCO2.
Invasive Blood Gas Monitoring 1. The arterial catheter is an invasive means to monitor hemodynamic status as well as pulmonary gas exchange status. 2. Arterial catheters are most commonly inserted into a radial artery but also can be inserted into a femoral or other artery. 3. A major advantage of drawing blood, including arterial blood gases from the arterial line, is that frequent samples can be obtained without causing additional trauma and pain to the patient from repeated needle sticks.
PowerPoint Slides Slide 1 Pulse Oximetry Slide 2 Causes of Inaccurate Readings Slide 3 Capnography Capnography Applications Slide 4 Types of Capnography Sidestream Mainstream Colorimetric Capnography Slide 5 The Capnogram Slide 6 Invasive Blood Gas Monitoring
IX. Chapter Summary X. Clinical Reasoning Checkpoint XI. Post-Test XII. References
Suggestions for Classroom Activities • Discuss the different mechanisms the body uses to compensate for acid–base imbalances. • Discuss the impact on the respiratory system when patients are placed on extended bedrest. What nursing interventions can be implemented to reduce the risk factors for pulmonary complications?
Suggestions for Clinical Activities • Discuss clinical conditions that can arise from acid–base imbalances. • Compare and contrast the oxygenation levels of a young adult of 25, a middle-aged adult of 40, and an older adult of 75. Are there any gender differences? What factors will change the findings between the generations?
CHAPTER
11
Alterations in Pulmonary Function
Objectives 1. Explain the basic differences between restrictive and obstructive pulmonary diseases. 2. Discuss the pathophysiologic basis of respiratory failure. 3. Describe acute respiratory distress syndrome (ARDS). 4. Explain the types, pathophysiology, and management of acute pulmonary embolism. 5. Discuss the types, pathophysiology, and management of acute bacterial and viral pneumonias. 6. Describe the principles and management of patients undergoing thoracic surgery and chest drainage. 7. Implement a general plan of care for a patient with an acute alteration in respiratory function.
I. Review of Restrictive and Obstructive Pulmonary Disorders 1. Pulmonary diseases may be divided into acute and chronic problems. a) Acute problems have a rapid onset, are episodic, and frequently are confined to the lungs. b) Chronic problems usually have a slow, often insidious onset, and the pulmonary impairment either does not change or slowly worsens over an extended period. (1) Chronic pulmonary problems generally involve other organs as part of the disease process. (2) Patients with chronic pulmonary problems, such as emphysema, may develop an acute problem (e.g., pneumonia) that may further stress their pulmonary status. 2. Pulmonary disease may also be divided into problems of a) Restrictive: problem with inflow of air. b) Obstructive: problem with outflow of air. A. Restrictive pulmonary disorders 1. Associated with decreased lung compliance, stiffness of lungs, and decreased lung expansion 2. May be caused by internal problems: a) Atelectasis or pneumonia b) Loss of lung tissue (pneumonectomy or lung tumors) 3. May be caused by external problems: a) Chest burns b) Morbid obesity
4. Problems of volume (the amount of air, measured in mL or L, that flows in and out of the lungs) rather than airflow (the rate or speed at which air moves into or out of the lungs). In other words, the volume of air that is inhaled can be exhaled at a normal rate of flow. 5. The patient with a restrictive disorder will have a reduced tidal volume (VT) total lung capacity (TLC). Air cannot move into the alveoli as readily as it should because of limited expansion (decreased lung compliance), which can lead to alveolar hypoventilation. 6. Hypoxemia will result if alveolar oxygen diffuses into the blood at a faster rate than it is replaced by ventilation. When this occurs, the PaO2 falls at approximately the same rate as the PaCO2 rises, assuming that diffusion is normal. 7. Restrictive pulmonary problems often disturb the relationship of ventilation to perfusion ( ratio). a) In mild-to-moderate restrictive disease, the ratio may stay normal because both ventilation and perfusion may be fairly equally disturbed. b) In many acute restrictive diseases, perfusion becomes diminished because of edema that results from an inflammatory process. Perfusion can also become reduced by compression or blockage of the pulmonary vasculature. c) In severe disease, a low ratio may develop because ventilation is greatly diminished, whereas perfusion may be fairly normal or moderately disturbed. ratio is associated with hypoxemia with a decreasing pH and increasing PaCO2.They 8. A low differ in their effects on lung volume, airflow, pathophysiology, blood gas disturbance, and physical assessment. B. Obstructive Pulmonary Disorders 1. Chronic obstructive pulmonary disease (COPD) is the term commonly applied in the clinical setting to pulmonary disorders that hinder expiratory airflow. The more accurate and preferred term for these disorders, however, is chronic airflow limitation. Currently, these two terms are often used interchangeably. 2. Some of the major obstructive disorders include: a) Emphysema b) Chronic bronchitis c) Asthma d) Cystic fibrosis 3. In obstructive pulmonary disorders, air is able to flow into the lungs but then becomes trapped. If expiratory time becomes significantly prolonged, the alveoli are unable to empty before the person inhales again, trapping CO2 within them. a) Expiratory times are measured by forced expiratory volume (FEV) testing, which is a measure of dynamic lung function. b) FEV testing determines how rapidly a person can forcefully exhale air after a maximal inhalation. 4. Obstructive problems may be caused by airway narrowing, such as bronchospasm, bronchoconstriction, edema, or by airway obstruction
5. Obstructive disorders are associated with increased lung compliance (hyperinflated lungs) accompanied by a loss of elastic recoil. The ratio may be disturbed with this group of disorders. 6. In disease processes that do not destroy alveoli, such as chronic bronchitis, the ratio may be low. 7. If lung tissue is actually destroyed, such as occurs with emphysema, the ratio may remain normal because both ventilation and perfusion are equally impaired. a) A normal ratio does not necessarily indicate healthy lungs. It indicates only that a balance exists between ventilation and blood flow. 8. Restrictive and obstructive diseases differ in their effect on lung volume, air flow, pathophysiology, blood gas disturbances, and physical assessment. C. Status Asthmaticus 1. Asthma differs from the other obstructive pulmonary diseases in that the airflow obstruction is episodic. 2. For many years, asthma was considered a reversible disease in that lung function and gas exchange were thought to return to normal with treatment. Today, however, experts know that the process is not always completely reversible with some continuing problems: a) Physiologic changes that characterize acute asthma exacerbations include: inflammation, which causes airway edema with narrowing of airway passages b) Hyperresponsiveness of airways to irritants, which results in bronchospasm and mucus plugging 3. The classic triad of asthma symptoms includes paroxysmal episodes of dyspnea, wheeze, and cough triggered by a stimulus. 4. Some of the more common triggering stimuli include allergens, exercise, stress, and infections. 5. Commonly, asthma is managed with combinations of inhaled corticosteroids and bronchodilators. 6. Status asthmaticus also referred to as acute severe asthma, is a severe exacerbation of asthma signs and symptoms that does not respond to the usual drug therapy. 7. Status asthmaticus can become a life-threatening emergency from airway obstruction. 8. The ability to rapidly recognize a life-threatening episode of status asthmaticus is crucial for health care professionals who work in emergency settings. 9. A particularly ominous clinical finding is a sudden decrease in wheezing or loss of breath sounds, which may indicate complete airway obstruction from mucus plugs and impending cardiopulmonary arrest. 10. Recommendations for treatment of status asthmaticus include oxygen, intravenous corticosteroids, and possibly inhalation of heliox and repeated doses of a short-acting sympathomimetic inhalation agent such as albuterol. Corticosteroids are the mainstay of treatment of this inflammatory disease and must be given early, as they take several hours to become effective. 11. Fatigue and decreasing level of consciousness may signal the need for mechanical ventilation. 12. Mechanical ventilation in acute asthma presents particular risks during intubation and challenges in ventilator management due to the bronchospasm and air trapping. a) Ventilator management goals are to achieve adequate gas exchange and avoid complications.
b) Ventilator strategies include lower tidal volumes and slower respiratory rates to avoid high inspiratory pressures, minimize air trapping, and allow for extended expiratory time. c) Complications of mechanical ventilation in status asthmaticus include barotrauma and hypotension.
PowerPoint Slides Slide 1 Review of Restrictive and Obstructive Pulmonary Disorders Slide 2 Restrictive Pulmonary Disorders Slide 3 Obstructive Pulmonary Disorders Slide 4 Status Asthmaticus
II. Acute Respiratory Failure 1. Heart and lungs are a complex integrated system: Problems of cardiac origin can cause pulmonary problems and vice versa. 2. The cardiopulmonary system is very sensitive to pressure changes within it, requiring compensatory adjustments to maintain homeostasis. 3. If a pulmonary disorder decreases the ability of the lungs to maintain adequate acid–base balance and oxygenation, the heart must work harder to make more blood available for diffusion, causing a compensatory increase in vital signs (increased blood pressure and pulse). The patient’s lungs work harder by increasing the respiratory rate (tachypnea) and depth (hyperventilation). A. Respiratory insufficiency and failure 1. Respiratory disorders affect lungs in various ways. The amount of diffusion surface area that becomes damaged affects gas exchange. The degree of damage plus rate of disease onset determine the body’s ability to cope via compensatory mechanisms. 2. The levels of this compensation are called: a) Chronic respiratory insufficiency b) Acute respiratory failure B. Chronic respiratory insufficiency 1. Respiratory insufficiency: state where acceptable level of gas exchange is maintained via compensatory emphasis. 2. Chronic pulmonary problems have a slow onset, so the body has time to compensate for pulmonary deficits and can maintain oxygenation level and acid–base balance. 3. Arterial blood gases (ABGs) noted when chronic respiratory insufficiency exists include normal pH, elevated PaCO2 and HCO3, normal to low PaO2. 4. Stressors can push patients beyond their ability to compensate and into respiratory failure. 5. Nurse has key role in recognizing impending respiratory failure. 6. Clinical signs of impending respiratory failure: a) Tachypnea, tachycardia, increased use of accessory respiratory muscles (e.g., trapezius, abdominals), nasal flaring, abnormal chest wall movement, labored breathing, and decreasing SpO2
b) Also: diaphoresis, orthopnea, air hunger, and anxiety 7. An arterial blood gas test (ABG) should be done if there are clinical signs of impending respiratory failure. C. Acute respiratory failure 1. Life-threatening state that can result from many pulmonary diseases 2. Caused by imbalance in supply and demand; develops when cardiopulmonary system is unable to maintain adequate gas exchange of oxygen and CO2. D. Components of acute respiratory failure 1. Acute respiratory failure pertains to both oxygen and CO2, but it is useful to break it down into two component parts: a) Failure of oxygenation b) Failure of ventilation 2. Important to differentiate the two failure components E. Failure of oxygenation 1. Primary problem is hypoxemia. 2. CO2 can diffuse across alveolar-capillary membrane 20 times more quickly than oxygen. 3. CO2 levels might remain normal when diffusion is disrupted, even if patient is hypoxemic. 4. Oxygenation failure is caused by restrictive pulmonary disorders, such as ARDS and pneumonia. 5. Compensation mechanisms will work to regain an adequate oxygen state. a) Important to maintain PaO2 at 60 mmHg or above because of oxygen’s affinity for hemoglobin at PaO2 level less than 60 mmHg. 6. The clinical manifestations of oxygen failure include dyspnea, tachypnea, increased blood pressure and heart rate, cyanosis, confusion, and restlessness. F. Failure of ventilation 1. Ventilatory failure (acute respiratory acidosis) is caused by alveolar hypoventilation—when air cannot move adequately out of the alveoli, which causes buildup of CO2. 2. Can be caused by any problems that interfere with airflow (e.g., COPD or respiratory muscle fatigue). Clinical manifestations reflect hypercapnia (elevated CO2). 3. CO2 narcosis is the term used to describe anesthetic effects of ventilatory failure. 4. The clinical manifestations of ventilation failure include tachypnea, headache, flushed/wet skin, bounding pulse, increased heart rate and blood pressure, and anesthetic effects: lethargy, drowsiness, and coma. G. Complications of respiratory failure 1. Can affect almost all body’s systems by causing organ hypoxia. 2. If respiratory failure is combined with decreased cardiac output, patient is at risk for hypoperfusion/hypoxic shock. 3. Hypercapnia and acidosis impair cellular function. 4. Vasodilatory effects can increase intracranial pressure and decrease cardiac output and vascular resistance. 5. Ventilation failure is considered more serious than oxygenation failure.
H. Pathogenesis of respiratory failure 1. Sequence of events leading to respiratory failure is complicated. 2. Initiated by disease process interferes directly or indirectly with normal lung function. 3. As pulmonary function deteriorates, patient develops V/Q ratio abnormalities and decreasing PaO2. 4. Body compensates for increase in O2 demands by increasing rate and depth of respirations. 5. PaO2 increases, and PaCO2 decreases to regain adequate level of oxygen and acid–base balance. 6. More energy is required, so metabolic rate increases. 7. More oxygen is required by tissues, and more CO2 is produced. 8. Effect is an increase in arterial CO2 and decease in arterial O2. 9. Acute respiratory failure occurs when patient meets clinical criteria: a) PaCO2 greater than 50 mmHg with pH less than 7.30; and/or b) PaO2 of less than 60 mmHg 10. If the events leading to acute respiratory failure are not corrected, the level of failure worsens and can be fatal. I. Management of the Patient with Acute Respiratory Failure 1. Treat underlying cause(s). 2. Support patient. 3. Prevent or treat complications.
PowerPoint Slides Slide 1 Acute Respiratory Failure Respiratory insufficiency and failure Chronic respiratory insufficiency Acute respiratory failure Slide 2 Components of Acute Respiratory Failure Failure of oxygenation Failure of ventilation Complications of respiratory failure Pathogenesis of respiratory failure Management of the patient with acute respiratory failure
III. Acute Lung Injury/Acute Respiratory Distress Syndrome 1. Acute respiratory distress syndrome (ARDS) is a severe expression of acute lung injury (ALI); referred to as ALI/ARDS. 2. Acute lung injury ranges from mild (subclinical) to severe (ARDS). 3. ALI is described as a disorder of acute inflammation that causes disruption of the lung endothelial and epithelial barriers
4. ARDS is a severe, often fatal, inflammatory disease of the lung characterized by the sudden onset of pulmonary edema and respiratory failure, usually in the setting of other acute medical conditions resulting from local (e.g., pneumonia) or distant (e.g., multiple trauma) injury. 5. New proposed definition of ARDS called the Berlin Definition. A. Etiologic factors 1. ARDS is predominantly a complication of systemic disease processes. 2. All are known to trigger a systemic inflammatory response that, if sufficiently strong, may involve the lungs, leading to diffuse lung injury. 3. Currently there is no explanation as to why, in similar pathologic conditions, a few people develop ARDS but most do not. 4. Gastric aspiration and septic shock (sepsis with refractory hypotension) are associated with a greater than 25% risk of ARDS, whereas the administration of multiple blood transfusions carries a risk of ARDS of less than 5%. 5. The risk of ARDS appears to be additive when multiple risk factors are present). 6. Further, genetic factors that produce a more extreme inflammatory response may also play a role in the severity of this syndrome (Maloney, 2009). B. Diagnosis 1. Defining ARDS and differentiating it from other acute pulmonary disorders has been a difficult task since it was first described. 2. ALI is differentiated from ARDS based on the ratio of PaO2 to FiO2 (P/F ratio). These criteria are still commonly used in clinically defining and diagnosing ALI/ARDS. 3. Differentiating the pulmonary edema of ARDS from that of congestive heart failure (CHF) can be difficult, but it is important to make this differentiation because therapy differs between the two distinct disease states. Several criteria assist in making a differential diagnosis: a) Pulmonary artery wedge pressure (PAWP). A PAWP of 18 or greater is suggestive of heart failure (HF), whereas a PAWP of less than 18 is suggestive of ARDS. b) Bronchoalveolar lavage (BAL) fluid. Bronchoalveolar fluid is obtained during a bronchoscopic examination into a lung lobe. BAL fluid present in HF (hydrostatic pulmonary edema) is protein poor and lacks inflammatory cells, whereas BAL fluid present in ARDS pulmonary edema is protein rich and contains inflammatory cells (Crouser & Fahy, 2009). c) Brain natriuretic peptide (BNP). This marker of heart strain is suggested as a helpful test to distinguish ALI/ARDS from HF if the BNP level is <100 pg/mL. Low BNP levels imply that HF is not present (Hansen-Flaschen & Siegel, 2011). d) Chest radiography. Heart enlargement is typically noted in HF but not in ARDS. Pulmonary infiltrates noted in heart failure are usually greatest in the dependent lung fields; pulmonary infiltrates noted in ARDS are more diffuse (throughout the lung fields). Pulmonary effusions may be noted in HF, whereas they are not common in ARDS. 4. The new Berlin Definition of ARDS was published in 2012 as an attempt to simplify diagnosis and improve the predictive ability of the criteria. The new criteria define three levels of ARDS severity, dropping the concept of ALI in favor of calling it mild ARDS. This definition also removes the heart failure exclusion criteria (PAWP over 18 and/or left atrial hypertension) to allow patients with heart failure to meet the ARDS criteria.
C. Pathogenesis 1. ALI/ARDS: not a disease but a syndrome, a pattern of physiological lung changes and corresponding clinical manifestations. 2. ALI/ARDS is caused by diffuse inflammatory injury to the alveolar-capillary membrane, which results in disruption of pulmonary capillary endothelium and the alveolar epithelium. Lung tissue is invaded by neutrophils, which activate a variety of inflammatory byproducts, central to the inflammatory response. 3. Disruption of the pulmonary capillary endothelium allows plasma proteins and fluid to escape into the pulmonary interstitial spaces, and injury to the alveolar epithelial linings allows fluid and plasma proteins to flood into the alveoli, resulting in nonhydrostatic pulmonary edema. 4. The edema of ARDS can worsen through increased hydrostatic pressure, resulting from fluid overload. 5. ARDS can be triggered by either a local pulmonary inflammatory problem or a distant systemic problem (e.g., sepsis or SIRS). 6. Regardless of the initial direct or indirect injury that triggers the onset of ALI/ARDS, the subsequent sequence of events remains more or less the same. 7. ARDS has two phases: a) Exudative phase lasts 1–3 days and involves microvascular injury, alveolar damage, and infiltration of inflammatory cells into interstitium. Hyaline membranes (made of plasma proteins and cell debris) develop in alveolar spaces. b) Fibroproliferative phase lasts 3–7 days and involves lung repair. The degree of repair depends on severity of injury and presence of secondary forms of injury (such as infection). D. Clinical presentation 1. Because ARDS is the result of another underlying illness or injury, the patient’s clinical presentation will reflect both processes. 2. Respiratory symptoms due to ARDS typically develop within 48 to 72 hours of the precipitating event (e.g., sepsis) and progress rapidly 3. The respiratory rate increases, accompanied by hypoxemia and dyspnea. The increased ventilation, a compensation for hypoxemia, results in respiratory alkalosis in arterial blood gases. Early chest radiography may demonstrate only mild bilateral infiltrates. 4. As ARDS progresses, cyanosis and accessory muscle use may be noted. A cough develops, frequently producing sputum that is typical of pulmonary edema. The heart rate increases and diffuse crackles may be auscultated. 5. Arterial blood gas findings show a pattern of increasing hypoxemia that is refractory to increasing concentrations of oxygen. 6. Pulmonary function tests will be consistent with lung restriction, including decreased lung compliance (CL) and decreased functional residual capacity (FRC). E. Collaborative management of the ALI/ARDS patient 1. Management is a collaborative effort between medicine and nursing and requires multidisciplinary planning and interventions.
2. Medical therapy concentrates on promoting oxygenation, maintaining adequate hemodynamics, and promoting healing. 3. Nursing plays a crucial role: a) Focusing on implementing supportive measures to maintain the patient until the alveolar– capillary membrane regains its integrity and the syndrome resolves b) Monitoring the patient’s status, the therapeutic and nontherapeutic effects of medical therapy c) Monitoring for possible multisystem complications. 4. No specific therapies have been found that directly heal the lungs; thus, historically, treatment of ALI/ARDS has been primarily supportive and anticipatory. 5. The patient’s needs must all be met for adequate lung healing, and complications must be anticipated and either prevented or aggressively treated. 6. The management of ALI/ARDS is similar and includes mechanical ventilation with PEEP, patient positioning strategies, drug therapy, and other interventions based on the complex nature of the disease and its detrimental effect on other body systems. 7. Rapid identification and treatment of the underlying cause of the ARDS episode is essential to successful ARDS management. 8. Prevention of secondary lung injury (e.g., aspiration, oxygen toxicity, ventilator-induced lung injury [baro- or volutrauma], and pneumonia) is a major priority. 9. The management of ARDS can be divided into two major strategies: mechanical ventilation and pharmacologic therapy. F. Positive pressure mechanical ventilators 1. Two mainstays of ALI/ARDS therapy have been positive pressure mechanical ventilators and positive end expiratory pressure (PEEP) to adequately overcome low lung compliance and refractory hypoxemia. 2. Positive pressure mechanical ventilators apply positive force through an artificial airway to deliver ventilatory support. 3. The results of the ARDS Network study suggest that using a low tidal volume (6 mL/kg body weight), called protective ventilation, with a plateau pressure of 30 cm H2O or less significantly reduces mortality as well as ventilator days in ALI/ARDS patients regardless of the precipitating cause. 4. A major complicating factor in ALI/ARDS is the massive collapse of alveoli, which causes a significant shunt, decreased lung compliance, and severe hypoxemia. 5. PEEP applies positive pressure into the patient’s airway at the end of expiration and prevents the alveoli from closing. 6. PEEP maintains the alveoli in an open state throughout the breathing cycle, which increases gas diffusion time, thereby increasing gas exchange. 7. PEEP also reduces shunt by recruiting collapsed alveoli (popping them open). 8. The goal in using PEEP is to achieve an adequate PaO2 (usually at least 60 mm Hg) while reducing the inspired oxygen concentration (FiO2) to less than 0.6 (60%) because high concentrations of oxygen eventually cause oxygen toxicity.
9. The level of desired PEEP is individually evaluated. Current recommendations are to use the least amount of PEEP to achieve oxygenation goals and avoid toxic oxygen levels. 10. Although PEEP has been invaluable for treatment of ALI/ARDS, it is not without hazards, including decreased cardiac output, overdistention of alveoli, and pneumothorax (abnormal presence of air in the intrapleural space), among others. 11. The use of smaller tidal volumes, while reducing the risk of alveolar injury from overdistention, creates another concern for microatelectasis despite the use of PEEP. This microatelectasis is also termed “derecruitment.” 12. Alveolar collapse can occur when the ventilator is disconnected or during suctioning. “Recruitment maneuvers,” strategies to reopen these closed alveoli by momentarily using higher pressures/volumes, are under investigation. They can improve oxygenation but to date have not changed outcomes in ARDS. 13. Alternative mechanical ventilation options may be initiated when conventional therapy has not been effective in attaining adequate gas exchange. Some of the more common alternatives include: a) Pressure control ventilation b) Reverse I:E ratio ventilation c) Airway pressure release ventilation d) High-frequency ventilation e) Bilevel ventilation G. Patient-Positioning Strategies 1. There has been increasing interest in the effects of various types of patient positioning in improving patient outcomes. 2. Two major types of therapy include: a) Continuous lateral rotation therapy b) Prone positioning, H. Continuous lateral rotation therapy (CLRT) 1. Beds that provide CLRT (also called Kinetic Therapy™ or oscillation therapy) continuously rotate the patient’s body from side to side (with brief pauses), thus shifting pressure and fluid. 2. CLRT is commonly employed in critical care units as an alternative to manual turning for the purpose of reducing stasis of fluid and gas-related complications. 3. Decreases atelectasis and the incidence of ventilator-associated pneumonia (VAP). 4. Most effective when initiated early in the course of critical illness and when used for more than 18 hours per day I. Prone Position Therapy 1. Periodic placement of patient in prone position to increase oxygenation and reduce oxygen therapy concentration. 2. Understanding the effects of the supine position on the injured lung helps explain why the prone position might be therapeutic.
J. Physiology of prone positioning 1. The prone position may improve oxygenation by recruiting alveoli. 2. A major advantage of prone positioning is that improved oxygenation can be achieved using a noninvasive, relatively simple procedure. 3. Evidence suggests that there is a window of opportunity in which prone positioning is therapeutic in ALI/ARDS patients, namely the early phase of the disease, with up to 70%–80% of patients benefiting. 4. No clear evidence that use of the prone position improves survival overall, but there may be improved survival in the most severely ill patients, e.g., those with a PaO2/FiO2 <100 mm Hg. K. Appropriate application of prone positioning a) Prone position should be reserved for patients with severe hypoxemia, with careful assessment of clinical response. b) Not all patients can tolerate being placed in the prone position and may develop worsening oxygenation or hemodynamic instability, and uncontrolled intracranial pressure has been identified as a contraindication. c) Careful preparation prior to the turn is essential to minimize positioning-related complications such as accidental ET tube dislodgement, pressure ulcers, loss of venous access, intolerance of enteral feeding, or eye injury. L. Fluid management 1. Current thinking supports conservative fluid management in hemodynamically stable patients after initial resuscitation. 2. Avoiding fluid gain improves oxygenation and results in less time on mechanical ventilators. M. Pharmacologic therapy 1. Pharmacologic treatment has failed to significantly improve ALI/ARDS patient outcomes. 2. Several therapies warrant description. N. Corticosteroids 1. Corticosteroids as a treatment for ALI/ARDS remain controversial and are based on the inflammatory nature of the disease pathology. 2. High-dose steroids have not been shown to be effective and may be harmful. 3. Using different doses and timing of steroids, found that early, prolonged steroid administration improved survival rates. O. Inhaled nitric oxide (iNO) a) Nitric oxide, a potent vasodilator, is normally produced by the body and plays an important role in pulmonary blood flow regulation. b) Inhalation of nitric oxide increases PaO2 by selectively redistributing pulmonary blood flow to working alveoli, thereby reducing shunt. c) iNO has been shown to improve oxygenation in the first days of use, but not to improve survival from ARDS. P. Surfactant replacement therapy 1. Surfactant therapy may improve oxygenation, but not mortality.
Q. Partial liquid ventilation 1. This is the introduction of perfluorocarbon liquid into the lungs. 2. Studies have shown no benefit to partial or total liquid ventilation and a higher risk of complications such as barotrauma. R. Neuromuscular blocking agents 1. Neuromuscular blockade has been used less frequently in the past decade due to concerns of prolonged muscle weakness and patient management strategies aimed at reducing sedation. 2. This therapy carries the risk of profound muscle weakness and requires frequent reassessment of need and train-of-four monitoring. S. Nutrition 1. Low carbohydrate formulas to limit CO2 production are recommended. T. Other emerging drug therapy 1. There remains high interest in finding new therapies that can effectively reduce mortality in patients with ARDS. 2. Possibilities for the future include statins, stem cells, and aerosolized albuterol. U. Prognosis 1. Patients who show improvement within the first week of treatment have more successful outcomes. 2. Two relatively new interventions, however, have reduced mortality rates: a) Low (protective) tidal volumes using mechanical ventilation b) Conservative fluid management following initial resuscitation 3. Work is under way to validate biological markers such as IL-8 as well as lung injury scoring. 4. Quality of life for ARDS survivors is an issue receiving a great deal of attention. 5. Nursing can play a pivotal role in these prevention strategies.
PowerPoint Slides Slide 1 Acute Lung Injury/Acute Respiratory Distress Syndrome Etiologic Factors Diagnosis Pathogenesis Clinical Presentation Slide 2 Collaborative Management of the ALI/ARDS Patient Slide 3 Positive Pressure Mechanical Ventilators Slide 4 Patient-Positioning Strategies Continuous Lateral Rotation Therapy (CLRT) Prone Position Therapy Physiology of Prone Positioning Appropriate Application of Prone Positioning
Slide 5 Fluid Management Slide 6 Pharmacologic Therapy Corticosteroids Inhaled Nitric Oxide (iNO) Surfactant Replacement Therapy Partial Liquid Ventilation Neuromuscular Blocking Agents Slide 7 Nutrition Slide 8 Other Emerging Drug Therapy Slide 9 Prognosis
IV. Pulmonary Embolism (PE) 1. Accounts for about 250,000 hospitalizations annually in U.S. 2. Has a high mortality rate if untreated A. Pulmonary embolism 1. Embolism is a blockage of primary blood vessel caused by lodging of a thromboembolism or other blood material. B. Types and causes of emboli 1. There are four types of pulmonary emboli: a) Thromboembolism: accounts for almost all pulmonary emboli. Major source is deep vein thrombosis (DVT) in lower extremities. b) Fat embolism: common but not life threatening. Usually is the result of long bone trauma or orthopedic surgery. c) Amniotic: amniotic fluid mixes with maternal blood. Can be result of mechanical obstruction, cytokine release, or anaphylactic shock-like syndrome. d) Venous air embolism: result of air introduced into venous circulation. Can be the result of catheterization or processes that involve air, such as laparoscopy. C. Predisposing factors of venous thromboembolism (VTE) 1. Venous thromboembolism (VTE) is the term applied to both pulmonary embolism and deepvein thrombosis (DVT). 2. VTE is a common, potentially preventable hospital complication and is the focus of national prevention strategies. 3. More than 80% of pulmonary emboli (PE) originate as deep-vein thrombosis (DVT) in lowerextremity deep veins. Many high-acuity patients are at increased risk for development of venous thromboembolism. 4. Three major factors, called Virchow’s triad, place a person at risk for development of VTE: a) Venous stasis: slowing of blood flow, as from illness, surgery, paralysis b) Hypercoagulability: from cancer, oral contraceptives, sepsis c) Venous endothelial injury: as from surgery, trauma, infection
D. Pathophysiology of pulmonary embolism 1. Severity of embolism depends on degree and location of obstruction. More than half lodge in main or lobar pulmonary arteries. 2. Pulmonary embolism creates changes in both pulmonary and cardiovascular function. 3. A clot in the pulmonary vasculature creates dead space, may cause bronchoconstriction, and leads to hypoxemia by complex mechanisms. E. Signs and symptoms of pulmonary embolism 1. Pulmonary embolism often is not easy to recognize or diagnose, particularly when the patient’s health status is deteriorating rapidly. a) Dyspnea b) Tachypnea c) Pleuritic pain d) Cough e) Unilateral leg pain and swelling f) Wheezing g) Crackles (rales) F. Diagnosis 1. Diagnosis of pulmonary embolism is frequently not made until autopsy. 2. Diagnostic testing generally is initiated based on clinical suspicion, such as a positive history and presenting signs and symptoms. 3. A variety of tests are recommended to aid in diagnosis: a) Clinical probability assessment: Wells Score and Geneva Score give probabilities based on past medical history of DVT or PE and other factors. b) D-dimer: fibrin degradation product found in blood following a thrombotic event. c) Contrast enhanced CT Angiogram: CT scan that can reveal pulmonary pathologies. d) Ventilation–Perfusion (v/q) Scan: gives information on ventilation and perfusion relationships in lungs. e) MRI f) Compression Ultrasound: performed if CT scan or V/Q is non-diagnostic. If the vein cannot be fully compressed, a positive result is suspected. g) Chest Radiography: helpful when used with other tests. h) Echocardiogram: can be used to support diagnosis of PE. i) Pulmonary Angiogram: considered the definitive diagnostic test for PE, but it is invasive and expensive. j) Arterial Blood Gases: helpful in assessing level of hypoxia present. G. Management of pulmonary embolism 1. Treatment options for PE include: a) Anticoagulant therapy b) Vena cava filter
c) Thrombolytic therapy d) Embolectomy H. Nursing considerations 1. Because DVT is the major cause of PE, management should center on interventions to prevent DVT. 2. Preventive measures include: early ambulation, anticoagulant therapy, antiembolism stockings, compression boots, elevation of the injured leg above heart level, and frequent assessment of the leg for signs of DVT. There may be no signs or symptoms; however, when present, they may include unilateral leg swelling, pain or tenderness, or cramping. 3. PE is a potential complication, not a nursing diagnosis. The following interventions are recommended: a) Monitor for signs and symptoms of pulmonary embolism. b) Initiate shock protocols if manifestations of PE develop. c) Initiate O2 therapy, and monitor SpO2 or SaO2. d) Monitor labs: ABG, CBC, electrolytes, BUN. e) Initiate thrombolytic therapy as ordered. f) Initiate and monitor heparin therapy as ordered following thrombolytic therapy. g) Monitor clotting times. h) Monitor closely for abnormal bleeding when patient is receiving thrombolytics or anticoagulant therapy. 4. The major nursing diagnoses typically appropriate in the care of the patient with PE include: a) Activity intolerance b) Impaired gas exchange c) Risk for ineffective peripheral tissue perfusion d) Risk for ineffective respiratory function e) Ineffective breathing pattern f) Acute pain g) Fear/anxiety h) Knowledge deficit
PowerPoint Slides Slide 1 Pulmonary Embolism (PE) Types and Causes of Emboli Predisposing Factors of Venous Thromboembolism (VTE) Slide 2 Pathophysiology of Pulmonary Embolism Signs and Symptoms of Pulmonary Embolism Diagnosis Management of Pulmonary Embolism Slide 3 Nursing Considerations
V. Acute respiratory infections 1. When the lung is exposed to pathogens, immune defenses are typically sufficient to resist infection. When host defenses are overwhelmed, microorganisms that gain access to the lung may cause infection, such as bronchitis or pneumonia. A. Pneumonia 1. Most serious respiratory infection and the leading cause of death from infection. B. Classification 1. Pneumonia traditionally classified as community-acquired or nosocomial according to where patient acquired the infection. Today, these categories are broken down further to reflect the complex dynamics of exposure: a) Hospital-acquired (nosocomial) pneumonia (HAP) b) Ventilator-associated pneumonia (VAP) c) Health care–associated pneumonia (HCAP) d) Community-acquired pneumonia (CAP) C. Microbiology and pathogenesis 1. The type of pathogen varies according to location of exposure: a) CAP: Streptococcus pneumoniae is most common b) VAP: usually P. aeruginosa, acinetobacter, or enterobacter c) Both CAP and HAP: methicillin-resistant S. auerus (MRSA) D. Clinical presentation 1. Classic signs and symptoms: acute onset of cough, fever, chills, purulent sputum, chest pain, and shortness of breath. Atypical pneumonia can have gradual onset with fever, headache, and gastrointestinal symptoms. 2. Severity varies greatly and determines where to treat patient. Criteria to be considered are: a) Confusion, altered level of consciousness b) BUN (greater than 19.6 mg/dL) c) Respiratory rate (30 or more breaths/minute) d) Blood pressure (SBP less than 90; DBP less than 60) e) Patient age is 65 or older (1) Each of these criteria is assigned 1 point. A score of 3 or higher is associated with increased mortality, and hospitalization should be considered. f) A P/F ratio of less than 250, low albumin, and the need for vasopressor therapy are also sometimes included E. Prevention of pneumonia 1. Prevention strategies aimed at decreasing the incidence of community-acquired pneumonia include influenza and pneumococcal vaccines and smoking cessation. 2. Centers for Disease Control (CDC) guidelines now require assessment of vaccination status and administration of vaccine to appropriate patients while in the hospital.
F. Diagnosis 1. Diagnostic testing is done to determine whether a patient has pneumonia and to identify the causative organism. 2. Diagnosis of pneumonia presents several challenges depending on the organism involved. In many cases, the pathogen is never identified. 3. The following diagnostic and laboratory tests are used in this setting to help identify the pathogen involved and the severity of disease: a) X-ray b) Sputum culture c) Blood culture d) Complete blood count e) Blood chemistries f) ABG, pulse oximetry g) Special tests include bronchoscopy, thoracentesis, and lung biopsy G. Treatment 1. Includes blood cultures, oxygenation, screening for pneumococcal infection, and antibiotic regimens. 2. Some patients with pneumonia develop pleural effusions, which can become infected and pose a risk of sepsis and pleural thickening. H. Aspiration pneumonia 1. Aspiration, the entry of oral secretions or gastric contents into the lower respiratory tract, is the cause of CAP in 10% of all patients and up to 30% of patients admitted from long-term care. 2. There are two different aspiration syndromes: a) Aspiration pneumonitis: aspiration of acidic gastric contents into the lower respiratory tract. b) Aspiration pneumonia: oral secretions or colonized gastric secretions reach the lung. I. Aspiration pneumonia 1. Aspiration of acidic gastric contents results in aspiration pneumonitis, an acute chemical lung injury. 2. This injury is seen in states of decreased level of consciousness such as stroke, seizures, and drug overdose. 3. Inflammation, not infection, results from aspiration as the acidic gastric juices trigger an inflammatory response that damages exposed airway tissues. J. Aspiration pneumonia 1. Aspiration pneumonia may result when oral secretions or colonized gastric secretions reach the lung. 2. Gastric contents can become colonized with bacteria when the gastric pH is alkalinized (e.g., by acid-reducing medications or enteral feedings). 3. Proton pump inhibitors are increasingly identified as a risk factor for aspiration. 4. Pneumonia results when the volume of aspirate is greater, the aspirate contains pathogens, or the natural defenses are impaired.
5. Major risk factors for aspiration include: decreased level of consciousness, an incompetent lower esophageal sphincter (e.g., GERD), elevated pressure or volume in the stomach, and neuromuscular diseases that alter glottic closure. 6. Two additional risk factors are poor oral hygiene, which increases the bacterial load in oral secretions, and dysphagia. K. Clinical manifestations of aspiration 1. Clinical manifestations of aspiration pneumonitis are the acute onset of: a) Tachypnea. b) Dyspnea. c) Bronchospasm. d) Cyanosis. e) Chest X-ray with diffuse opacities. f) For aspiration pneumonia, presentation is same as that of bacterial pneumonia. L. Prevention of aspiration syndromes 1. Reducing the incidence of aspiration requires a multidisciplinary approach. 2. Nurses must recognize signs of aspiration such as coughing, drooling, development of a hoarse voice, or gurgling sounds associated with eating. 3. Nurses must also be aware that some patients show no overt signs of aspiration; the only indication of an event may be oxygen desaturation if the patient is monitored. 4. Oral care in all at-risk patients reduces the incidence of aspiration pneumonia, as does elevation of the head of the bed at least 30 degrees. 5. Medications that can contribute to aspiration by impairing swallowing, such as sedatives, antipsychotics, and anticholinergics, should be avoided when possible. M. Viral pneumonias 1. Viral pneumonia is now more frequently recognized as a common etiology of communityacquired pneumonia. 2. There are emerging viral infections that have the potential to become the world’s next viral pandemics. N. Influenza viral pneumonia 1. Viral pneumonia is a serious-to-severe complication of influenza, more commonly referred to as “the flu.” 2. There are three types of influenza-related pneumonias: a) Primary viral pneumonia—caused by the influenza virus b) Secondary bacterial pneumonia—develops directly following influenza c) Mixed viral and bacterial pneumonia—concurrent infections 3. Primary viral pneumonia is a complication of influenza, usually type A. While it is the least common influenza-related pneumonia, it is the most severe and deadly of the three types.
O. Clinical presentation and diagnosis 1. Primary viral pneumonia presents as flu that, rather than resolving after a few days, becomes progressively worse. The patient develops progressive dyspnea that begins several days after the onset of flu symptoms; a persistent fever; and eventual onset of cyanosis. 2. Blood may be present due to sloughing of necrosed airway tissue. As the pneumonia progresses, the chest X-ray usually shows diffuse infiltrates that have a similar pattern to acute respiratory distress syndrome (ARDS). 3. Diagnosis can be made on the basis of a confirmed influenza virus culture, the presence of antigens or elevated serum antibody titre, or by nucleic acid testing, especially the polymerase chain reaction (PCR) test. 4. Mixed viral and bacterial pneumonia is the most common complication of influenza. People with chronic respiratory or cardiac disease are at highest risk for developing the mixed type. The clinical presentation is more typical of bacterial pneumonia. P. H1N1 influenza pneumonia 1. As with many other seasonal influenza viruses, transmission is airborne, via large-particle droplets dispersed through coughing and sneezing. 2. The incubation is short, 1 to 7 days or less, and patients frequently report gastrointestinal symptoms of vomiting and diarrhea as well as respiratory symptoms. 3. Risk factors for severe H1N1 pneumonia differ from those for seasonal influenza in that many patients are younger and previously healthy. Obesity and pregnancy have also emerged as risk factors. 4. While most cases of H1N1 influenza are mild, severe respiratory failure can develop. 5. In severe cases, chest radiographic changes resemble ARDS and patients require mechanical ventilation and aggressive oxygenation strategies. Q. Prevention and treatment 1. Given the potential for serious illness, widespread vaccination for influenza is recommended as a public health policy. 2. Vaccination of healthcare workers is increasingly promoted to protect hospitalized patients (Johnson & Talbot, 2011). 3. Although the prognosis for influenza pneumonia is poor, it has shown improvement with the advancement of antiviral drug therapy. Ideally, treatment with neuraminidase inhibitors, such as zanamivir or oseltamivir, is initiated within 96 hours of symptom onset. 4. Other potential supportive therapies include high-frequency oscillatory ventilator, extracorporeal membrane oxygenation (ECMO), and high-dose corticosteroids in specific patient populations. R. Emerging viral infections 1. Of particular concern is the development of viruses able to cross species and not only infect humans but also become transmissible via human-to-human contact. 2. Two such viruses, H5N1 and SARS CoV, have caused outbreaks in recent years. There is no vaccine or treatment for either virus.
S. Avian influenza pneumonia 1. Potential pandemic virus. 2. Currently few humans have contracted the virus, and the flu has developed only in humans with close direct contact with infected birds. 3. Avian influenza can lead to viral pneumonia and has a poor prognosis and a high mortality rate. 4. As with SARS CoV, there is no vaccine or definitive treatment for avian influenza. T. Severe acute respiratory syndrome (SARS) 1. The virus that causes SARS (SARS-CoV) is actually a novel form of coronavirus (CoV), which is a major cause of the common cold worldwide and usually affects the upper respiratory tract. a) The unique SARS-CoV is suspected to have originated as a nonhuman virus, possibly in bats, that jumped to humans (McIntosh, 2011). b) Lessons learned from SARS have application for other infectious diseases. These include the importance of public health preparation and response systems, strict implementation of infection control measures, and training of personnel.
PowerPoint Slides Slide 1 Acute Respiratory Infections Slide 2 Pneumonia Classification Microbiology and Pathogenesis Clinical Presentation Prevention of Pneumonia Slide 3 Diagnosis Treatment Aspiration Pneumonia Clinical Manifestations of Aspiration Slide 4 Prevention of Aspiration Syndromes Slide 5 Viral Pneumonias Influenza Viral Pneumonia Clinical Presentation and Diagnosis Slide 6 H1N1 Influenza Pneumonia Prevention and Treatment Slide 7 Emerging Viral Infections Slide 8 Avian Influenza Pneumonia
VI. Thoracic Surgery and Chest Tubes 1. Thoracic surgery applies to procedures on the structures within the chest: heart, lungs, esophagus, and great vessels. 2. Disorders commonly treated with thoracic surgery include lung cancer, emphysema, localized infection of the lung and pleura (e.g., abscess, empyema), injuries, lung transplantation, and chest wall deformities. 3. The surgical entry into the thorax is called a thoracotomy. Thoracic surgery for lung resection is categorized by the amount of lung tissue removed, as follows: a) Pneumonectomy–removal of one entire lung and creation of a “stump” (the sutured end of a main bronchus) b) Removal of smaller portions of the lung: (1) Lobectomy–removal of one or more lobes of the lung (2) Segmentectomy–removal of one or more portions (segments) of a lobe (3) Wedge resection–removal of a small wedge-shaped section of the peripheral portion of the lung A. Pneumectomy 1. The lung and vessels are removed. 2. Used primarily in the treatment of lung cancer. 3. Despite surgical improvements, pneumonectomy remains a high-risk procedure, with mortality estimates of 2% to 12% for elective surgery but significantly higher rates when performed in an emergent situation such as trauma. 4. Potential complications associated with pneumonectomy include vocal cord dysfunction (nerve injury during the procedure), atrial arrhythmias, pulmonary edema, bronchopleural fistula and empyema resulting from the breakdown of the stump suture line, and postpneumonectomy syndrome. 5. Pulmonary edema may result from the dramatic change in hemodynamics as the entire blood volume is directed through the pulmonary vessels of the remaining lung. 6. Postpneumonectomy syndrome is a tracheal obstruction caused by abnormal shifting of the intrathoracic structures. B. Thoracic incisions 1. Thoracotomy incisions used in thoracic procedures vary, depending on the size and area to be resected. 2. Posterolateral incisions extend from the scapula/spine to the anterior axillary line. 3. A smaller incision, axillary thoracotomy, also called “muscle sparing,” is used for smaller procedures. 4. Other approaches include anterior, median sternotomy (used in cardiac surgery) and the “clamshell” incision, used primarily in bilateral lung transplantation C. Video-assisted thoracoscopic surgery (VATS) 1. Uses a scope and small incisions. 2. Used for both diagnostic and therapeutic procedure. Less invasive than thoracostomy with less pain and fewer complications.
D. Postthoracic surgery management 1. Important considerations for postsurgery management are the common issues of pain management, postoperative pulmonary hygiene, and early mobilization to prevent complications. E. Pain management 1. Postthoracic surgical pain is significant due to retraction of the ribs and in some cases rib dissection, muscle dissection, possible nerve injury, and chest tubes. 2. Postoperative pain is controlled with PCA or epidural catheters. Pain control is especially important to prevent postoperative hypoventilation and impaired cough, which may result in atelectasis and respiratory failure. F. Pulmonary hygiene 1. An even greater priority following thoracic surgery. 2. Effective cough is essential for adequate airway clearance but causes pain. 3. Pharmacologic control of pain must be balanced to avoid oversedation and respiratory depression. 4. After surgery, patients must be able to cough strongly enough to clear secretions: a) Cascade cough: 3 to 4 coughs on one exhalation b) Huff cough: cough with glottis open G. Chest drainage 1. The active or passive removal of air or fluid from the intrapleural space of the lungs or from the mediastinal compartment. 2. Chest drainage may be a short-term or intermittent therapy (e.g., aspiration of intrapleural air or fluid using a needle and syringe), or it may be relatively long-term therapy (e.g., treatment of pneumothorax or hemothorax [the abnormal presence of blood in the intrapleural space] resulting from chest trauma). H. Who requires chest drainage? 1. Chest drainage is used to treat thoracic problems that may be external or internal in origin. 2. External origins include blunt chest trauma and traumatic or surgical entry into the intrapleural or mediastinal spaces that results in pneumothorax or hemothorax. 3. Frequently both pneumothorax and hemothorax occur simultaneously (hemopneumothorax). 4. Internal origins of pneumothorax include spontaneous rupture of a pulmonar bleb (a cyst that develops in the visceral pleura), procedural rupture of the visceral pleura, or barotrauma. Bleb rupture is most commonly found in patients with chronic lung diseases. 5. Chest tubes may be inserted to drain severe pleural effusion or empyema if either condition is causing significant compression of lung tissue. I. Pathogenesis of a collapsed lung 1. The thorax and lungs exist as opposing forces—the thorax’s natural state is expansion, whereas the lungs’ natural state is collapsed. 2. Loss of negative intrapleural pressure, either of external or internal origin, results in the rapid collapse (atelectasis) of the affected lung tissue because the two pleura separate, allowing the opposing forces to come into play.
3. The size of lung collapse depends on how much of the intrapleural space loses negative pressure. 4. The size of the pneumothorax and the patient’s symptoms are important considerations when determining whether chest drainage is required. J. Common clinical findings 1. Many of the typical clinical findings are those noted with an acute hypoxia episode and reflect normal compensatory mechanisms, including tachypnea, tachycardia, agitation, and confusion. 2. If chest pain is present, shallow respirations with splinting may be noted. In addition, the presence of tachypnea is frequently associated with initial respiratory alkalosis. K. Chest tube insertion 1. The nurse frequently assists with insertion of chest tubes. Equipment includes: a) Chest tube thoracotomy tray and drainage system b) Antiseptic solution c) Protective eyewear d) Local anesthetic (1% lidocaine) e) Sterile gowns, gloves, masks, caps, and drapes f) Chest tube (size dependent on indication) g) Suction source and tubing 2. Depending on the size of the pneumothorax and other circumstances, preparation for insertion may need to be rapid. 3. It is important to prepare the patient for the procedure as thoroughly as possible based on the patient’s condition and the need for speed. 4. The nurse’s role often centers on obtaining (and possibly preparing) the necessary equipment, supporting the patient, and maintaining the patient in the appropriate position during the procedure. L. The procedure 1. If a pneumothorax is present, the chest tube typically is inserted anteriorly at the level of the second intercostal space, which approximates the lung apex. 2. If a hemothorax (or fluid) is present, the chest tube is typically inserted midaxillary at the fifth or sixth intercostal space to drain the base of the lung field. 3. After the chest tube has been inserted, it is quickly connected to special extension tubing that joins with the collection chamber of the chest drainage system. 4. The chest tube is then sutured to the patient to prevent unintentional removal. 5. An occlusive dressing is applied. All connections are properly taped or banded (plastic strips tightly wrapped around connections) to prevent unintentional disconnection. 6. The chest drainage system is placed and maintained below heart level at all times to assure proper drainage. 7. A chest X-ray is ordered immediately following the procedure to assure correct tube placement. M. Chest drainage system 1. The most common is the disposable self-contained system sometimes referred to as a “threechamber system.” It includes the collection, water-seal, and suction chambers.
N. Collection chamber 1. The collection chamber accepts air or fluid coming into the system through extension tubing directly attached to the patient’s chest tube. 2. The collection chamber is composed of several interconnected vertical towers that are marked in mL for ease of fluid volume measurement. O. Water-seal chamber 1. The water-seal (or air-leak) chamber is located in the center of the three-chamber system. 2. Its purpose is to act as a one-way valve to prevent airflow back into the patient. Prior to initial use, the water-seal chamber is filled with sterile water to the 2 cm mark. 3. The design of the water-seal chamber is simple but effective, based on the one-bottle chest tube drainage system. 4. The bottle is placed on the floor, and the proximal end of the tube is kept at bed height. Air is drawn into the bottle through the tube because of negative gravity pull. 5. As the air is pulled through the distal end of the tube, it bubbles through the water and escapes through the second hole in the lid. 6. Bubbling in the water-seal chamber indicates one of two things: a) Intermittent bubbling noted with pneumothorax suggests that air continues to be present in the intrapleural space. b) Constant or vigorous bubbling may indicate an air leak in the system. If the chest tube drainage system is not attached to external suction, the water level in the water-seal chamber should move up and down with breathing. This is a normal phenomenon called “tidling.” Tidling ceases when the lung has reinflated. P. Suction Chamber 1. The suction chamber regulates the amount of negative suction pressure being exerted on the intrapleural space. 2. The suction chamber does not require attachment to external suction (e.g., wall suction) to work, but it is commonly added to make the system more effective. Q. Dry chest drainage systems 1. Some chest drainage systems are “dry” in that they may not require water in the suction chamber. The amount of suction is regulated by a dial on the system and the wall suction. 2. Dry systems offer the advantage of easily adjusted levels of suction and are quiet. R. Assessment of the patient with a chest tube in place 1. Assessing the patient with a chest tube includes assessing the patient as well as the chest tube and drainage system. 2. The patient’s status, vital signs and respiratory status are closely monitored, including chest auscultation and oxygenation status (e.g., level of consciousness, ABG, pulse oximetry [SpO2], skin/mucous membrane coloring, and respiratory effort). 3. Chest radiographs may be ordered to monitor the status of the pneumothorax. Chest tube–related pain is common and should be assessed frequently, with appropriate administration of analgesia.
4. Assessment of the chest tube and drainage system includes the dressing and site, position and patency of the extension tubing, type and amount of output draining into the collection chamber, and fluid levels and activities in the water-seal and suction chambers. S. Chest tube removal 1. Nurses may assist with the procedure to remove chest tubes. Determining when a chest tube can be safely removed depends on the patient’s requirement for chest drainage (e.g., pneumothorax, thoracic surgery). 2. Chest tube removal is a painful procedure. Premedication for anticipated pain is important and may be accomplished with systemic narcotic or nonsteroidal medication 3. An occlusive dressing with Vaseline gauze is applied as the chest tube is removed to prevent air entry into the pleural space. T. Related nursing diagnoses 1. Multiple nursing diagnoses and potential complications (PC) may be applicable to the patient who requires a chest tube, including: a) Anxiety b) Impaired gas exchange c) Ineffective breathing pattern d) Knowledge deficit e) Chest pain f) Risk for infection g) PC: hemorrhage h) PC: pneumothorax
PowerPoint Slides Slide 1 Thoracic Surgery and Chest Tubes Pneumectomy Thoracic Incisions Slide 2 Video-Assisted Thoracoscopic Surgery (VATS) Postthoracic Surgery Management Pain Management Slide 3 Pulmonary Hygiene Chest Drainage Who Requires Chest Drainage? Slide 4 Pathogenesis of a Collapsed Lung Common Clinical Findings Slide 5 Chest Tube Insertion The Procedure
Slide 6 Chest Drainage System Collection Chamber Water-Seal Chamber Suction Chamber Dry Chest Drainage Sytems Slide 7 Assessment of the Patient with a Chest Tube in Place Chest Tube Removal Slide 8 Related Nursing Diagnoses
VII. Chapter Summary VIII. Clinical Reasoning Checkpoint IX. Post-Test X. References
Suggestions for Classroom Activities • Discuss lifestyle changes that the patient with asthma can make to reduce the chances of having repeated attacks. • Ask students to describe the lung volume, airflow, and blood gas composition characteristic of a restrictive disorder vs. those of an obstructive disorder. • Discuss the CO2 levels of a patient with hypoxemia.
Suggestions for Clinical Activities • Listen to lung sounds of a variety of patients. Differentiate among wheezes, crackles, and rhonchi. In what types of patients are the different lung sounds heard? • Rotate students to the respiratory therapy department. During postconference, discuss the experience. • Assign the students to patients diagnosed with acute respiratory failure. What types of nursing interventions are being performed? What characteristics do the patients have in common?
CHAPTER
12
Determinants and Assessment of Cardiac Function
Objectives: 1. Describe the normal anatomy of the cardiopulmonary vascular system. 2. Explain the anatomy and physiology specific to the heart. 3. Discuss cardiac output and its determinants, including preload, contractility, and afterload and how they relate to stroke volume. 4. Describe the basis of arterial and venous blood pressure and the regulation of arterial blood pressure. 5. Apply knowledge of the assessment of cardiac function to provide safe, quality patient care. 6. Describe common cardiovascular diagnostic procedures used to evaluate cardiac function.
I. Review of the Cardiopulmonary System 1. Composed of the heart, lungs, a vast network of blood vessels and blood. 2. Its purpose is to take in and deliver oxygen and nutrients to the organs and tissues and remove metabolic waste products for elimination from the body. A. Cardiopulmonary circuits 1. The cardiopulmonary vascular system consists of two interdependent major circuits: a) Pulmonary circuit b) Systemic circuits B. Pulmonary circuit 1. The pulmonary circuit includes: a) The right side of the heart b) The pulmonary arteries c) The lungs d) Pulmonary capillaries e) Ends with the pulmonary veins where they join the left atrium. 2. Its purpose is to facilitate pulmonary (external) gas exchange. a) The pulmonary veins have no valves; if pressures in the left heart increase (e.g., heart failure), blood can back up through the pulmonary veins and into the lungs, causing increased pulmonary vascular pressures and pulmonary edema.
C. Systemic circuit 1. Begins with the left side of the heart (left atrium) and ends with the superior and inferior vena cava where they join the right atrium. a) Transports oxygen-enriched blood to the capillary beds of the organs and tissues for gas exchange at the tissue level b) Delivers nutrients and transports metabolic waste products away from the organs and tissues for removal from the body c) Returns oxygen-depleted blood to the pulmonary circuit 2. The systemic circuit is a high-pressure system; the heart must pump using sufficient pressure to perfuse the organs and tissues. D. Blood Vessels 1. A vast network of conduits through which oxygen and nutrients are delivered to the tissues. 2. Blood vessel walls are composed of one to three layers, called tunica. 3. Vessels that move blood away from the heart are arteries, and those that move blood toward the heart are veins. E. Blood vessel layers 1. Blood vessels are composed of three layers: a) The tunica intima (interna): (1) Lines the inside of the vessel and is the only layer that directly interfaces with the blood rushing through the vessels. (2) It consists of endothelium. (3) The smooth surface of the endothelium reduces friction and prevents clotting and damage to blood cells as blood flows by. 2. The tunica media (middle layer): a) Composed of smooth muscle with loose connective tissue and elastic fibers. b) This layer is thicker in arteries than in veins. 3. Tunica externa (adventitia) (outermost layer surrounding the vessel): a) Composed of connective tissue. b) Protects and stabilizes the vessels. c) This layer is thicker in veins than in arteries. F. Types of blood vessels 1. The cardiovascular system consists of an intricate network of arteries, veins, and capillaries. 2. Each has some unique properties and functions. G. Arteries 1. Arteries are blood vessels that transport blood away from the heart. 2. Classified by diameter as large, medium, and small. Each size has a slightly different wall layer structure.
3. The large arteries are also known as elastic arteries. a) They comprise the major arteries, such as the aorta and its major branches and the trunk of the pulmonary artery. b) These arteries have a large tunica media that contains more elastic fibers than smooth muscle, well suited for the constantly changing pulsatile pressures and blood volume coming from the heart, readily expanding and relaxing in response to the cardiac cycle. 4. The medium arteries are also known as muscular arteries a) Have a tunica media that contains more smooth muscle than elastic fibers. b) They deliver blood to the muscles and organs and are sometimes referred to as distribution arteries. 5. The arterioles are the smallest arteries. a) Consist of only two layers, a tunica media and a tunica intima. b) The tunica media is thin, and depending on the size of the arteriole, it may have one or two smooth muscle layers c) The arterioles are referred to as resistance vessels because they play a critical role in the regulation of blood flow and blood pressure. H. Veins 1. Veins are exposed only to low pressures. 2. Thin, smooth-muscle tunica media. 3. Limited ability to constrict and dilate; however, this ability influences the venous return of blood to the heart. 4. In the limbs, veins rely on a valve system, referred to as the venous muscle pump, to move blood in a forward direction toward the heart against gravity. As a person moves, the skeletal muscles in the limbs contract, exerting force against the veins and moving the blood toward the heart. Blood is prevented from flowing backward by the closing of the valves. 5. Veins can be classified by diameter as large, medium, and small: a) The large veins include the superior and inferior venae cavae and their immediate tributaries. b) The medium veins are of equivalent size to the medium arteries and, in the limbs, contain valves. c) The small veins, or venules, are transition vessels located between the capillaries and the medium veins. Medium veins and venules are referred to as capacitance vessels because they hold large volumes of blood. I. Capillaries 1. The capillaries are the smallest structures of the vascular system. a) Composed of a single layer, the tunica intima, which consists of endothelium with a basement membrane. b) Form a complex interconnected network known as a capillary bed that links the arterioles with the venules. c) Interact with their adjacent (interstitial) environment by way of the selectively permeable endothelial membrane.
d) Begin with a precapillary sphincter that expands and constricts the entryway into the capillary to control the rate and volume of blood flow. e) Flow through the capillaries is not continuous; rather, the precapillary sphincters open and close in a cyclic fashion, resulting in intermittent blood flow and increasing the time available for the exchange of gases, fluids, and other molecules.
PowerPoint Slides Slide 1 Review of the Cardiopulmonary System Slide 2 Cardiopulmonary Circuits Pulmonary Circuit Systemic Circuit Slide 3 Blood Vessels Blood Vessel Layers Types of Blood Vessels Slide 4 Arteries Veins Capillaries
II. Review of Heart Anatomy 1. The heart is nestled within the mediastinum directly behind the sternum between the right and left lungs, with the majority of the heart apex lying in the left chest. 2. It is protected by the anterior and posterior bony structures of the thorax. A. Heart chambers 1. The heart is a four-chambered, two-pump system (right and left heart) that drives fluid (blood) through a complex network of pipes (blood vessels) for the purposes of facilitating gas exchange and cellular nutrition and transporting metabolic waste products. 2. The right and left sides of the heart each have two chambers: a) Atrium. b) Ventricle. 3. The upper chambers are called: a) Atria (singular, atrium): act as a temporary holding tank for blood coming into the heart. b) Right atrium accepts venous (oxygen-poor) blood coming into the heart from the superior and inferior venae cavae and the coronary sinus. c) The left atrium accepts arterial (oxygen-rich) blood from the lungs via the pulmonary veins. 4. The lower chambers are called ventricles. a) Ventricles eject blood forward out of the heart. b) The right ventricle accepts the blood from the right atrium and ejects it into the pulmonary artery and into the lungs.
c) The left ventricle accepts blood from the left atrium and ejects it from the heart through the aorta to the organs and tissues. B. Heart wall layers 1. The heart is essentially a muscle that is lined on the inside and outside by thin sheaths. It is composed of three distinct layers: a) Endocardium (innermost layer of the heart). b) Myocardium (thick middle layer; forms the bulk of the heart wall). c) Epicardium (outer layer of heart tissue ) C. Endocardium 1. It is composed of squamous-cell epithelium. 2. Only heart surface that directly interfaces with blood flowing through the chambers. 3. The direct contact with the blood, however, also makes the endocardium more susceptible to injury, such as colonization by bloodborne pathogens (e.g., endocarditis). D. Myocardium 1. Composed of contractile muscle fibers, called myofibrils, that are unique in the way they conduct electrical impulses. 2. The thickness of the myocardium in each of the four heart chambers varies based on its workload. 3. The thickness of the right and left ventricular walls differs relative to the amount of work required to pump blood forward. 4. The right ventricle pumps blood only into the lungs, which are a low-pressure system (about 15–28 mm Hg). 5. The left ventricle, which pumps blood to all the organs and tissues in the systemic circuit. 6. The left ventricle is often referred to as the workhorse of the heart because it must provide adequate pumping power to perfuse organs and tissues. Such pumping power requires a high-pressure system (about 100–120 mm Hg). 7. The left ventricle wall is thick to accommodate the additional stress. E. Cardiac muscle structure 1. Cardiac muscle has many similarities with skeletal muscle but also has unique characteristics (Hall, 2011). 2. It is striated and contains identical myofibrils (basic muscle units), and muscle contraction involves shortening of the sarcomeres (segments of myofibrils). 3. Cardiac muscle, however, has more mitochondria (to make energy via aerobic metabolism) and more myoglobin (to store oxygen) than does skeletal muscle. 4. Cardiac muscle cells have a unique latticework structure whereby fibers divide, combine, and redivide, making them highly interconnected (Hall, 2011). 5. Cardiac muscle cells are separated by an intercalated disk, which is a special type of cell membrane that facilitates fast travel of action potentials from one cell to the next.
6. The interconnectedness and rapid electrical impulse transport system of the cardiac muscle result in a strong, well-organized, and relatively long muscular contraction in response to a sufficiently strong electrical stimulus. F. Epicardium 1. A tough fibrous covering surrounding the outside of the heart that helps maintain the heart in position and contributes to its structure. 2. It consists of two overlapping layers: a) The visceral pericardium, which is attached to the heart b) The parietal pericardium, which overlaps the visceral pericardium, forming the pericardial sac that surrounds the heart (1) The two layers create a potential space called the pericardial cavity, which contains approximately 30 mL of serous fluid. (a) The pericardial fluid provides lubrication to reduce friction associated with the rhythmic contraction and relaxation of the heart. G. Structure and function of heart valves 1. Heart valves play a critical role in maintaining normal blood flow through the heart. 2. Sole function is to promote blood flow in a forward direction, thereby preventing backflow (known as regurgitation). 3. The heart valves are thin, paperlike, fibrous structures that open and close in response to changes in pressure gradients within the heart. There are two sets of valves: a) The atrioventricular (AV) valves: (1) Two AV valves separate the atria from the ventricles and prevent the backflow of blood from the ventricles back into the atria. (2) The right heart has the tricuspid valve, consisting of three flaps, or cusps, that open and close. It separates the right atrium from the right ventricle. (3) The left heart has the mitral valve, which has two cusps (bicuspid) and separates the left atrium from the left ventricle. b) The semilunar valves: (1) Two semilunar valves separate the ventricles from adjacent great vessel trunks. (2) The right heart contains the pulmonic (or pulmonary) valve, which is located at the junction of the right ventricle and the pulmonary artery. It prevents the backflow of blood from the pulmonary artery into the right ventricle. (3) The left heart has the aortic valve, at the junction of the left ventricle and the aorta, which prevents the backflow of blood from the aorta into the left ventricle. (4) In contrast to AV valves, semilunar valves have no supportive structures and are dependent on pressure gradients on either side of the valves for opening and closing. H. Cardiac cycle 1. Refers to the heart muscle activities associated with one complete heartbeat. There are two phases to the cardiac cycle: a) Systole
(1) The contraction of a heart chamber, whereby blood is ejected into either an adjacent ventricle (atrial systole) or into the pulmonary artery or aorta (ventricular systole). (2) Chamber pressure increases during systole. (3) The atrial contraction during systole, also called “atrial kick,” contributes about 20% of total ventricular blood volume. b) Diastole (1) The relaxation of a heart chamber, when blood fills the chamber in preparation for the next cardiac cycle and the coronary arteries fill with blood. (2) Chamber pressure decreases during diastole. (3) As soon as systole ends, blood passively flows back into the chambers from the adjoining vessels (vena cava on right and pulmonary veins on left), refilling the atria. In the ventricles, diastole occurs in three phases: early, middle, and late c) Each of the four heart chambers experiences both phases. I. Myocardial tissue perfusion 1. The coronary arteries begin in the ascending aorta, close to the aortic valve. This location provides the heart with arterial blood that contains the richest oxygen concentration. J. Anatomy of the coronary arteries 1. The main coronary arteries lie along the epicardial surface of the heart. 2. There are four primary coronary arteries: a) The left main coronary artery (LMCA) b) Left anterior descending artery (LAD) (1) The LAD supplies the anterior aspect of the left ventricle and septum. c) Left circumflex artery (LCX) (1) LCX supplies the lateral walls of the left ventricle d) Right coronary artery (RCA) (1) The RCA predominantly supplies the right ventricle and atrium and gives rise to the posterior descending artery (PDA). e) The LAD and the LCX are branches of the LMCA after its bifurcation. 3. As the arteries cross the epicardial surface, small feeder arterioles penetrate the chamber walls, giving rise to a dense network of thousands of capillaries per square millimeter called arteriosinusoidal channels. 4. This network of capillaries ensures that each cardiac muscle cell is in contact with a bordering capillary. 5. There are no connections between the large coronary arteries, but there are collateral channels between the smaller arterioles. 6. These channels become important when the large arteries occlude. The collateral channels, if present, can enlarge to provide an alternate route for blood and oxygen to myocardial tissues, which can diminish or eliminate myocardial tissue damage from poor perfusion, as seen in myocardial infarction.
K. Regulation of Coronary perfusion 1. Blood flow through the coronary arteries and perfusion of the myocardium are regulated primarily by aortic pressure. 2. The coronary arteries fill with blood after the aortic valve closes during diastole (resting phase). 3. Coronary blood flow is greatest just after closure of the aortic valve and gradually slows during diastole. One way to evaluate the effectiveness of coronary perfusion is to calculate the coronary perfusion pressure (CPP).
PowerPoint Slides Slide 1 Heart Chambers Slide 2 Heart Wall Layers Endocardium Myocardium Cardiac Muscle Structure Epicardium Slide 3 Structure and Function of Heart Valves Slide 4 Cardiac Cycle Myocardial Tissue Perfusion Slide 5 Anatomy of the Coronary Arteries Regulation of Coronary Perfusion
III. Determinants of cardiac output 1. Cardiac output (CO) is the amount of blood pumped by the heart each minute. 2. It is a critical aspect of cardiovascular function in both health and illness. 3. Normal CO varies significantly for individuals depending on body size (body surface area, BSA); therefore, when CO is measured, it is corrected to account for BSA. 4. The correction is called the cardiac index (CI) and is calculated by dividing CO by BSA. A. Determinants of cardiac output 1. There are four determinants of cardiac output (CO): a) Heart rate (HR) b) Preload c) Afterload d) Contractility 2. Any condition or disease that affects one determinant will alter one or more other determinants in an effort to maintain a stable CO. B. Heart rate 1. Heart rate is controlled by the heart’s pacemaker sites, which are influenced by the interplay of the sympathetic and parasympathetic nervous systems.
a) The sympathetic nervous system (SNS) causes the fight-or-flight reaction, in which the body’s resources are mobilized to counteract a real or perceived threat. The cardiovascular effects of SNS stimulation include increased heart rate, increased contractility, and vasoconstriction. b) Stimulation of the parasympathetic nervous system causes the opposite effects—decreased heart rate, decreased contractility, and vasodilation. 2. Increasing the heart rate is the most effective mechanism for increasing cardiac output; however, this mechanism has limitations. a) A severe tachycardia causes stroke volume to decrease because the heart spends too little time in diastole (relaxation) and the ventricles do not have time to fill with blood. b) The faster the heart rate, the shorter the time spent in diastole. c) Reduced ventricular filling results in decreased preload and decreased stroke volume. C. Stroke volume 1. The volume of blood pumped with each heartbeat is called the stroke volume (SV) a) It is calculated as cardiac output (CO) divided by heart rate (HR), a simple calculation once CO is known; there is a limit to the capacity of the body to use these compensatory efforts to maintain cardiac output. D. Preload 1. Preload is the amount of stretch in the myocardial fibers at the end of diastole and represents the volume of blood in the ventricle at the end of diastole. 2. Preload is greatly affected by the volume of blood delivered to the heart from the venous system. a) If a large volume of blood returns from the venous system to the ventricle, the myocardial fibers are stretched so that they are far apart. This represents a high preload. b) If a small volume of blood returns from the venous system to the ventricle, there is less stretch and, therefore, less preload. High preload corresponds to high volume; low preload corresponds to low volume. 3. Within limits, the heart pumps the amount of blood it receives with each beat. This is known as the Frank–Starling law of the heart. E. Afterload 1. Afterload is the resistance against which the ventricles pump blood. 2. An optimal amount of resistance is necessary for the system to work properly. 3. If afterload increases, stroke volume decreases because the ventricle is meeting increased resistance and cannot effectively pump out its volume. 4. Most of the resistance the heart meets is related to the “size” of the arterioles—that is, whether they are vasoconstricted or vasodilated. a) If they are vasoconstricted, afterload to the ventricle increases, and stroke volume decreases. b) If the vessels are vasodilated, afterload to the ventricle decreases, and stroke volume increases. 5. Other variables include the functionality of the semilunar (pulmonic and aortic) valves, which, if stenotic, are unable to fully open during systole, increasing afterload in the ventricles. 6. This relationship among flow, resistance, and pressure is expressed in Ohm’s law: Pressure = Flow × Resistance
F. Contractility 1. Contractility is the ability of a muscle cell to become shorter, given a suitable stimulus: i.e., the heart’s ability to function as a pump. a) If the heart contracts forcefully, it pumps out most of the blood in the ventricles. b) If the heart pumps weakly, it pumps out less blood. 2. The functioning of cardiac muscle is dependent on the coordinated interaction of multiple factors: a) Including heart rate b) Velocity of cardiac muscle shortening c) Calcium (1) Increased calcium release allows for greater interaction between actin and myosin filaments, resulting in greater contraction. (2) Cardiac muscle contraction depends on an influx of calcium; however, cardiac muscle does not store calcium, so serum calcium levels are important to monitor. (3) It is important for the nurse to recognize that when a patient’s serum calcium is low, contractility may be reduced. Intravenous replacement of calcium may be required to regain normal levels and increase contractility. d) force e) muscle length 3. Factors that influence contractility are known as inotropes. 4. Factors that increase myocardial contractility have a positive inotropic effect; examples of positive inotropes include: a) Sympathetic nervous system stimulation b) Increased calcium release c) Administration of inotropic drugs 5. Factors that decrease contractility have a negative inotropic effect. Because hypoxemia decreases contractility, it is an example of a negative inotrope. 6. Ejection fraction is a measure of the percent of blood ejected with each stroke volume and is used as an index of myocardial function. a) The ejection fraction is the stroke volume divided by end diastolic volume. b) A normal ejection fraction is 60%.
PowerPoint Slides Slide 1 Determinants of Cardiac Output Heart Rate Stroke Volume Slide 2 Preload Afterload Contractility
IV. Review of Blood Pressure 1. Blood pressure is the amount of pressure exerted against blood vessel walls by circulating blood as it is pumped throughout the body. 2. Arterial blood pressure is a major factor in tissue oxygenation and perfusion, and is closely tied to cardiac output. 3. The purpose of blood pressure is to circulate blood throughout the pulmonary and systemic circuits. 4. There are two types of measurable blood pressure a) arterial pressure (AP) b) venous pressure (VP) A. Arterial blood pressure 1. Arterial pressure is a function of peripheral resistance (PR) and cardiac output (CO) and is expressed as: arterial BP = PR × CO 2. This formula shows that anything that alters peripheral resistance or cardiac output must alter arterial blood pressure. B. Venous blood pressure 1. The venous blood pressure is influenced by four factors: a) Systemic filling pressure b) Adequacy of the venous (muscle) pump c) Venous peripheral resistance d) Right atrial pressure C. Systemic filling pressure 1. Systemic filling pressure refers to the amount of force that is available to return blood to the right side of the heart. 2. The filling pressure is influenced by venous tone (how dilated or constricted the veins are) and blood volume; thus, venous vasoconstriction or increased blood volume increases filling pressure and increases venous blood return to the heart. 3. The opposite is true as well: venous vasodilation or decreased blood volume decreases filling pressure and therefore decreases venous blood return to the heart. D. Venous muscle pump 1. The adequacy of the venous muscle pump is an important factor in determining venous blood pressure because if the venous valves are not working correctly blood pools in the extremities rather than moving forward to the heart. 2. Less blood coming back into the right heart reduces the amount of blood available for gas exchange and decreases cardiac output. E. Venous peripheral resistance 1. When the lumen size of veins becomes reduced for any reason, the result is increased resistance to blood flow. 2. Veins have a thin muscular wall layer, limiting their ability to change size; however, their lumen size is heavily influenced by external factors such as pressure from muscles and organs, which
can partially collapse adjacent veins. Moreover, any condition that increases intra-abdominal pressure (e.g., morbid obesity, ascites, or abdominal compartment syndrome) can result in complete or partial collapse of abdominal veins if the intraabdominal pressure exceeds venous pressures. F. Right atrial pressure 1. The pressure in the right atrium (RA) is the final influencing factor. 2. At rest, the right atrial pressure is near zero; however, when the atrium contracts (systole), it causes a slightly negative pressure, which has a mild sucking or vacuum effect, pulling blood into the atrium from the vena cava. 3. This action contributes to venous blood pressure as well as cardiac output. G. Regulation of arterial blood pressure 1. Recall that arterial blood pressure is determined by peripheral resistance and cardiac output. 2. It is important, then, to briefly consider the ways in which these factors are normally regulated by the body. 3. There are three major regulatory systems: a) The renin-angiotensin-aldosterone system (RAAS) (1) Influences arterial blood pressure through two mechanisms, vasoconstriction and water retention b) The kidneys (1) The kidneys alter blood pressure through the RAAS mechanism and through retention of water. (2) Blood flow through the kidneys diminishes as arterial blood pressure drops, resulting in a reduced glomerular filtration rate (GFR) (3) As GFR decreases, so does urine output, with resultant water retention, increased circulating blood volume, and increasing blood pressure. (4) The close relationship between arterial blood pressure and urine output is clinically important because the nurse can monitor urine output trends as one indicator of adequate arterial blood pressure. c) The autonomic nervous system (ANS): (1) Both branches of the ANS (sympathetic and parasympathetic) play active roles in regulating blood pressure through adjusting peripheral resistance and cardiac output (Lehne, 2010). The sympathetic nervous system (SNS) increases CO by causing vasoconstriction, speeding up the heart rate, and increasing cardiac contractility, while the parasympathetic NS decreases cardiac output by slowing the heart rate and decreasing cardiac contractility and vasodilation. (a) The autonomic nervous system is also responsible for the baroreceptor reflex, which is largely responsible for maintaining a steady-state blood pressure (BP) at the individual’s “preset” level (Lehne, 2010). Baroreceptors are special nerve endings located in the walls of certain large vessels (e.g., aortic arch, aorta, vena cava, and carotid sinus) and the atria. These receptors are sensitive to changes in pressure at their locations. When pressure changes at a baroreceptor, it sends a signal to the medulla to trigger one of two
actions: (1) If BP has fallen below the preset value, the medulla stimulates the heart rate to increase and the arterioles (and veins to a lesser extent) to constrict; or (2) if BP has risen above the preset level, it will slow down the heart rate and trigger vessel dilation. Reflecting back on the two formulae presented at the beginning of this section, these actions alter cardiac output in two ways: i. BP = PR × CO – any change in vessel tone (peripheral resistance, or PR) or BP changes CO ii. CO = HR × SV – any change in heart rate (HR) or stroke volume (SV) components (contractility, preload, and afterload) changes CO
PowerPoint Slides Slide 1 Review of Blood Pressure Arterial Blood Pressure Venous Blood Pressure Systemic Filling Pressure Slide 2 Venous Muscle Pump Venous Peripheral Resistance Right Atrial Pressure Regulation of Arterial Blood Pressure
V. Assessment of cardiac function 1. In high-acuity patients with potentially severe hemodynamic issues, invasive or noninvasive means of monitoring hemodynamic status, including cardiac output, may be warranted. 2. The key to accurately evaluating cardiac function lies in the assessment skills of the nurse. 3. Assessment begins on admission. 4. The nurse must obtain: a) Subjective data b) Conduct a complete physical assessment c) Interpret lab results d) Use bedside monitoring equipment effectively e) Apply the data gained via various diagnostic procedures A. Patient history 1. On admission, airway, breathing, and circulation are assessed prior to obtaining a nursing history to assure that the patient is sufficiently stable to be interviewed. 2. This initial assessment is generally a rapid, limited one that may take no more than a minute. 3. Appropriate priority interventions are then performed based on the assessed priority needs. 4. Once the patient is stabilized, the nurse obtains a nursing history, including present illness and medical history. 5. It is important to assess perfusion regardless of whether the patient has a previous history of perfusion abnormalities.
B. Present illness and medical history 1. At the time of admission, the nurse may be interviewing the patient, a family member, or other person or persons. 2. Eliciting a recent history of the present illness 3. A detailed patient history at the time of admission helps determine the plan of care. 4. Knowledge about the patient’s functional status prior to onset of illness allows for setting realistic goals of therapy and patient/family education. 5. Obtaining a complete list of prescribed and over-the-counter drugs the patient is taking provides important clues regarding comorbidities and possible drug adverse effects or interactions and is a crucial first step in medication reconciliation. 6. The mnemonic PQRST is helpful in organizing assessment data related to pain. Eliciting information about precipitating factors (P), quality (Q), radiation and region (R), associated symptoms (S), and timing and treatment strategies (T) helps the nurse determine the origin of the pain. 7. A patient with a perfusion disorder may complain of palpitations, often described as a “skipping” or “thumping” of the heart. 8. A patient with a perfusion disorder may experience a change in level of consciousness related to a decreased cardiac output or blockage of cerebral circulation. C. Nursing physical assessment 1. Techniques of physical assessment of cardiac function include: a) Inspection (1) Inspection of the precordium may demonstrate rhythmic movement. Abnormal movement may be visualized in the aortic, pulmonic, or tricuspid areas. Normal movement is found in the area of the mitral valve. This is the apical impulse. It is usually seen in the area of the left fifth intercostal space along the midclavicular line. b) Palpation c) Auscultation. 2. The nurse rapidly ascertains changes in hemodynamic status. 3. Data obtained by technological means must be corroborated with physical assessments. D. Peripheral assessment 1. Inspection and palpation of the periphery can also indicate variations in the patient’s cardiac output. a) Changes in skin color are a late sign of hemodynamic compromise, as is clubbing of the fingers. b) A cooling of the skin is brought about by the vasoconstriction of the arterioles as blood is shunted to the internal organs. A decrease in CO may be the cause. Cool distal extremities may be a useful marker of decreased CO. E. Urine output 1. Urine output is frequently used to assess the adequacy of cardiac output. 2. The elderly may have chronic diseases and use medications that affect urine output.
F. Edema 1. The presence of peripheral edema may indicate too much preload to the right side of the heart. 2. Edema associated with heart failure is generally located in the gravity-dependent areas of the body, such as the feet and lower legs and sacrum. G. Jugular vein distention 1. Jugular venous distention (JVD) may indicate a fluid distribution problem and too much preload to the right side of the heart. 2. In assessing for venous distention, the head of the bed is elevated to approximately 45 degrees. H. Palpation 1. Palpation gives the nurse a tactile indication of cardiac function. 2. Precordial palpation may produce a vibration, also known as a thrill. This may correspond to a murmur, valvular stenosis, or increased afterload. 3. Pulses should be of regular rate, strength, and rhythm. A hyperkinetic (bounding) pulse may indicate increased CO because of thyrotoxicosis, fever, pain, or anxiety. a) A hypokinetic pulse may be the result of decreased CO, with causes such as dysrhythmias, damaged myocardium, or cardiomyopathy. b) Severely depressed cardiac function may cause pulsus alternans alternating weak and strong pulses in a regular rhythm. I. Auscultation 1. Auscultation is another technique for assessing cardiac output. Knowledge of the heart sounds associated with valvular dysfunction is essential. J. Recall that the function of heart valves is to provide a unidirectional flow of blood through the heart. With valve dysfunction, blood flow is turbulent or reduced, resulting in a decrease in CO. 1. Auscultation of the precordium must be systematic and performed using both the bell and the diaphragm of the stethoscope. The pattern of auscultation begins at the base of the heart, using the diaphragm in the area of the aortic valve, and proceeds to the pulmonic, tricuspid, and mitral valves in order. 2. Diastolic filling sounds may help determine why cardiac output is reduced. The S3 sound, heard early in diastole, is a ventricular filling sound caused by decreased ventricular compliance and is a sign of early heart failure. It is also known as ventricular gallop. S4 is also a ventricular filling sound but occurs late in diastole. It is heard during atrial contraction and is known as atrial gallop. It is a result of myocardial infarction, ventricular hypertrophy, and increased afterload. A summation gallop, when both S3 and S4 sounds are heard, is often indicative of severe heart failure. The presence of wet-sounding crackles (rales) on auscultation of the lungs indicates pulmonary edema. Severe pulmonary edema is associated with frothy, pink sputum production. Ausculatory techniques can also be used on the peripheral vasculature system. Bruits along the carotid arteries may indicate areas of occlusion. These partial blockages represent potential compromise to the cerebral vasculature and account for some signs and symptoms also attributable to decreased cardiac output. Renal artery bruits may indicate renal artery stenosis, which leads to systemic hypertension. The resulting increase in afterload may compromise cardiac output.
K. Diagnostic laboratory tests 1. Numerous diagnostic lab parameters are used to assess cardiac function, which is adversely affected by myocardial damage. L. Cardiac markers 1. When the myocardium is damaged as a result of ischemia, myocardial cells die and release their intracellular contents, including enzymes, into the general circulation. M. Creatine kinase-myocardial band (CK-MB) 1. CK-MB is a cardiac-specific myocardial isoenzyme that is released 4 to 12 hours after the onset of myocardial necrosis and is very specific for myocardial damage. 2. Serial CK-MB measurement resulting in an elevation or upward trend is a cardiac marker for acute myocardial infarction or “heart attack.” 3. The major limitation of CK-MB is that levels do not start to rise until 4 hours after the onset of myocardial damage; this can delay diagnosis and treatment of myocardial infarction. N. Troponin 1. Troponin is a protein found in cardiac and skeletal muscle. 2. It is part of a protein complex that binds myosin and actin, the myofilaments that regulate contraction. O. Other laboratory tests 1. Other laboratory tests may be ordered to provide additional supportive data, including: a) C-reactive protein (1) A peptide released by the liver in response to systemic inflammation, infection, and tissue damage. It is a normal part of the inflammatory response, playing an important role in fighting infection or injury. b) B-type natriuretic peptide (1) (BNP) is a neurohormone released from the ventricular myocardium in response to increased preload (increased ventricular wall tension and pressure within the myocardium). (2) When released, it causes urinary excretion of sodium and diuresis and counteracts the water-retaining effects of the RAAS; this results in a reduction of preload. (3) Certain factors shift normal BNP levels upward, including age (increases with age), progressive renal injury, and gender (higher in women); therefore, results in these patients should be interpreted cautiously. c) Lipid profile (1) Hyperlipidemia high levels of lipids in the blood, is associated with a high risk for coronary heart disease. (a) High-risk lipids include: elevated total cholesterol, increased LDL, HDL, and elevated triglycerides. P. Assessment of specific components of cardiac output 1. Without special monitoring devices, the nurse must use indirect measures to estimate preload, contractility, and afterload. 2. The following assessments are needed:
a) Assessing Heart Rate b) Assessing Preload (1) Right ventricular preload (2) Left ventricular preload c) Assessing contractility d) Assessing afterload
PowerPoint Slides Slide 1 Assessment of Cardiac Function Patient History Present Illness and Medical History Nursing Physical Assessment Slide 2 Peripheral Assessment Urine Output Edema Jugular Vein Distention Slide 3 Palpation Auscultation Slide 4 Diagnostic Laboratory Tests Cardiac Markers Creatine Kinase-Myocardial Band (CK-MB) Troponin Other Laboratory Tests Slide 5 Assessment of Specific Components of Cardiac Output
VI. Cardiovascular Diagnostic Procedures 1. A thorough investigation of cardiac status often requires a combination of diagnostic procedures. A. Noninvasive procedures 1. Common noninvasive procedures include: a) Imaging techniques b) Exercise electrocardiogram c) Transthoracic echocardiogram (1) A variety of imaging techniques are available for evaluating cardiac function: (a) Chest radiography (b) Magnetic resonance imaging (MRI) (c) Radionuclide testing
(d) Exercise electrocardiogram (e) Echocardiogram: transthoracic echocardiogram and transesophageal echocardiogram (TEE). B. Invasive Diagnostic Procedures 1. Common invasive procedures to evaluate cardiac function include: a) Transesophageal echocardiogram (TEE) b) Cardiac catheterization c) Electrophysiology study (EPS)
PowerPoint Slides Slide 1 Cardiovascular Diagnostic Procedures Noninvasive Procedures Invasive Diagnostic Procedures
VII. Chapter Summary VIII. Clinical Reasoning Checkpoint IX. Post-Test X. References
CHAPTER
13
Alterations in Cardiac Function
Objectives: 1. Describe the pathophysiology and treatment of patients with valvular heart diseases. 2. Apply knowledge of heart failure to the assessment and management of the high-acuity patient. 3. Demonstrate the ability to assess and manage care of patients with hypertension. 4. Apply knowledge of hypertensive crises to the assessment and management of the high-acuity patient. 5. Demonstrate the ability to assess and manage the patient with aortic aneurysm.
I. Valvular Heart Disease 1. There are four heart valves, which allow forward blood flow, prevent regurgitation (backward flow of blood), and open and close in response to changes in pressure gradients. 2. The opening and closing of the valves during the cardiac cycle allows for forward unidirectional movement of blood through the four chambers of the heart. 3. When valve dysfunction occurs, this forward unidirectional movement of blood flow through the heart is affected. 4. The three major categories for valvular dysfunction are: a) Stenosis b) Regurgitation c) Prolapse A. Valve stenosis 1. Stenosis occurs when valve leaflets fuse together. 2. Valve components become thickened; valve orifice narrows. 3. Blood from chamber before the valve “backs up” to preceding chamber. 4. Stenosis can be caused by: a) Calcification b) Congenital factors c) Rheumatic fever 5. Risk factors B. Mitral valve stenosis 1. MS is a narrowing of the mitral valve orifice that obstructs blood flow from the left atrium into the left ventricle during diastole.
2. Predominantly caused by rheumatic fever. 3. Occurs more frequently in women. 4. Left atrial (LA) pressure increases and causes increase in pulmonary artery (PA) pressure and pulmonary vascular resistance (PVR). 5. As MS becomes more severe, CO decreases. 6. LV diastolic pressure increases. 7. HR important factor. 8. Elevated LA pressures lead to LA dilatation and changes in the LA electrical refractory period, which can precipitate atrial fibrillation. C. Aortic valve stenosis 1. AS: a condition in which aortic valve is narrowed and blood flow obstructed from LV into aorta during systole. 2. Congenital or acquired. 3. Valvular orifice narrows, increases pressure gradient between LV and aorta. 4. “Back-up phenomenon.” 5. LV end-diastolic pressure increases and LV hypertrophies. 6. LA contractility increases to eject volume against higher LV pressures. 7. If loss of effective atrial contraction occurs, immediate decompensation can occur. D. Valvular regurgitation 1. Regurgitant valves: insufficient or incompetent valves that do not close completely. 2. This allows regurgitation of blood through valve and back into the chamber the blood just left. 3. Risk factors. E. Mitral valve regurgitation (MR) 1. MR occurs when the mitral valve does not completely close, allowing blood to flow back into the LA during systole. 2. Causes regurgitation. 3. Causes of MR: a) Abnormalities of the leaflets b) Abnormalities of the annulus c) Abnormalities of the chordae tendineae or papillary muscle F. Aortic valve regurgitation (AR) 1. AR is caused by an incompetent aortic valve that allows blood to flow back into the left ventricle from the aorta during diastole. 2. Cause: rheumatic heart disease. 3. Leaflets’ structures are altered. 4. Regurgitation of part of the ventricular stroke volume back into left ventricle leads to ventricular hypertrophy. 5. Hypertrophy associated with AR is more severe than with aortic stenosis.
G. Valvular prolapse 1. Valvular prolapse is an abnormal condition in which a heart valve (almost always the mitral) cusps balloon (bulge) up into the atrium during ventricular systole, making a “floppy” valve. 2. Mitral valve prolapse is a type of mitral valve insufficiency that occurs when one or both of the mitral valve cusps bulge back into the LA during ventricular systole. a) Excess tissue in the valve leaflets and elongated chordae tendineae impair mitral valve closure during systole. 3. Prolapse is usually asymptomatic; may not be diagnosed except by chance during a routine physical exam. 4. MVR is present in a small percentage of patients with severe mitral valve prolapse. H. Infective endocarditis (IE) 1. When valves have structural abnormalities, it increases their susceptibility to infection. 2. IE is caused by a microbial infection of the endothelial lining of the heart. 3. Process starts with damage to endothelium of a valve. 4. Can be congenital or iatrogenic. 5. Disrupted surface of endothelium attracts platelets. 6. Next phase of IE is introduction of bacteria in blood. 7. After bacteria enter, they settle on the thrombi on the heart valve. 8. Infected thrombi enlarge and increase valve dysfunction. 9. Group of patients more susceptible to this possible infection: patients with weakened local and systemic defense mechanisms that are unable to destroy the bacteria and stop the infectious process. 10. Subacute or acute. 11. Several species of bacteria. 12. Aortic stenosis and mitral regurgitation most commonly occur as a result of IE. 13. Appropriate and aggressive administration of antibiotics. 14. Timely administration of antibiotics imperative. 15. Valve replacement might be required. 16. Antibiotic prophylaxis suggested, though little evidence to support this intervention. I. Assessment and diagnosis of valvular disorders 1. Thorough physical assessment. 2. Auscultation of heart. 3. Valve position in relation to ventricular systole or diastole. a) Mitral valve is open during ventricular diastole, so murmur of mitral stenosis occurs during diastole. b) Aortic valve is open during ventricular systole, so murmur of aortic stenosis occurs during systole. 4. Opposite timing applies for regurgitation. 5. With aortic stenosis, angina can occur. a) Syncope on exertion
6. If valvular dysfunction is critical, patient can experience heart failure or pulmonary edema. 7. Other symptoms. J. Collaborative management 1. Asymptomatic patients: no intervention. 2. As dysfunction becomes more severe, heart rate is controlled with drugs. 3. Major therapeutic goal: to maintain normal sinus rhythm and avoid atrial fibrillation. 4. If atrial fibrillation occurs, immediate treatment with cardioversion. 5. If HF occurs, diuretics and sodium and fluid restriction. 6. With regurgitation, afterload reduction very important: improves symptoms. 7. ACE inhibitors. 8. If severe dysfunction: surgical intervention to replace valve. a) Anticoagulation b) Anticoagulation also required if chronic atrial fibrillation 9. New intervention for aortic stenosis: percutaneous aortic valve replacement. 10. Artificial valve patients require anticoagulation. K. Nursing management 1. Nursing diagnoses. 2. Nursing priorities. 3. Vital signs monitored. 4. Hypotension and tachycardia indicate decreased cardiac output. 5. If pulmonary artery catheter is present, hemodynamic findings can include decreased cardiac output and elevated pulmonary artery wedge pressure and right atrial pressure associated with pulmonary congestion. 6. Auscultation of heart sounds. 7. Aggressive repletion of potassium and magnesium, antiarrhythmics. 8. Decreased oxygen delivery to tissues and impaired tissue perfusion. 9. Dyspnea with exertion. 10. Activity intolerance. 11. Asymptomatic patients counseled. 12. Discharge planning. 13. Vigilant assessment of serum coagulation studies. 14. Patients receiving anticoagulant therapy monitored for signs of bleeding. 15. Patient education. 16. Possible antibiotic prophylaxis.
PowerPoint Slides Slide 1 Valvular Heart Disease Slide 2 Valve Stenosis
Mitral Valve Stenosis Aortic Valve Stenosis Slide 3 Valvular Regurgitation Aortic Valve Regurgitation (AR) Slide 4 Valvular Prolapse Slide 5 Infective Endocarditis (IE) Slide 6 Assessment and Diagnosis of Valvular Disorders Collaborative Management Nursing Management
II. Heart Failure 1. Heart failure is a major health problem. 2. It is a clinical syndrome resulting from any structural or functional cardiac disorder that decreases the ability of the ventricle to fill or eject. A. Clinical manifestations and classification 1. Dyspnea 2. Fatigue that limits exercise tolerance 3. Fluid retention 4. Term heart failure preferred over congestive heart failure 5. Symptoms result of impairment of left ventricular function 6. NYHA classification a) Class I: cardiac disease but without resulting limitations of physical activity b) Class II: cardiac disease resulting in slight limitations of physical activity c) Class III: cardiac disease resulting in marked limitations of physical activity d) Class IV: cardiac disease resulting in inability to carry on any physical activity without discomfort 7. There are two categories of heart failure: a) Systolic dysfunction: an ejection fraction (EF) less than 40% b) Diastolic dysfunction: impairment of ventricular relaxation B. Pathophysiology 1. A progressive disease. 2. Causes cardiac remodeling. 3. Left ventricle dilates, hypertrophies, and becomes more spherical. 4. Some cardiomyocytes are destroyed. 5. Other cells try to adapt by increasing their size and elongating. 6. Compensatory neurohormonal mechanisms help achieve this adaptive response. 7. Sodium and water retention occur. 8. Renin–angiotensin system stimulates aldosterone release and increases sodium retention. 9. Sympathetic nervous system releases norepinephrine and vasopressin.
10. Short-term adaptation but negative long-term effects. 11. Decrease in cardiac output. 12. Leads to pulmonary congestion and peripheral edema. 13. Prolonged increases in adrenergic activity lead to dysrhythmias increased cardiac cellular activity, increased energy utilization, and cell death. 14. ANP and BNP released, causing vasodilation and inducing natriuresis. C. Cardiomyopathy 1. Cardiomyopathy is a severe myocardial disease that can produce heart failure. 2. In advanced cardiomyopathy, symptoms of heart failure occur at rest, and the patient cannot perform activities of daily living. 3. Causes of cardiomyopathy may be genetic or acquired; sometimes the origins of the disorder are unknown. 4. The most common cause of heart failure is a specific type of dilation cardiomyopathy called “ischemic cardiomyopathy,” a type of failure that occurs secondary to coronary artery disease and hypertension. 5. The disease progression is diffuse and can affect all heart chambers, although it may be more extensive in one chamber than others. 6. Cardiomyopathies are classified into three major functional categories: according to clinical and structural findings: a) Dilated cardiomyopathy: associated with right and or left ventricular dilation and decreased ejection fraction (EF). Ischemic cardiomyopathy typically presents as this type of heart disease. b) Hypertrophic cardiomyopathy: associated with left ventricular hypertrophy that decreases the ability of the chamber to relax (diastolic dysfunction), and there may also be a reduction in ventricular outflow. c) Restrictive cardiomyopathy: associated with a stiff non-compliant left ventricle that fills inadequately during diastole. Poor ventricular filling results in a low stroke volume and heart failure D. Assessment and diagnosis 1. Careful history and physical examination. 2. Classic respiratory symptoms. a) Dyspnea b) Orthopnea c) Paroxysmal nocturnal dyspnea (PND) 3. Other symptoms and signs. a) Fatigue b) Jugular vein distention c) Peripheral edema d) Crackles: unreliable sign e) Third heart sound (S3)
4. Two-dimensional echocardiogram with Doppler flow studies. 5. Chest X-ray. 6. 15-lead electrocardiogram (ECG). 7. Cardiac catheterization might be needed. 8. B-type natriuretic peptide (BNP) can be useful. E. Collaborative management 1. American College of Cardiologists and the American Heart Association established evidencebased guidelines for management of HF. 2. Therapy is divided into four categories: a) Stage A: patients at great risk for developing heart failure without structural heart disease or heart failure symptoms b) Stage B: patients with structural heart disease who have not developed heart failure symptoms c) Stage C: patients with structural heart disease with prior or current heart failure symptoms d) Stage D: patients with refractory heart failure requiring specialized interventions 3. Focus of treatment for patients at high risk for heart failure is to control risk factors F. Pharmacologic therapy 1. First-line drug management includes an ACE inhibitor and a beta-blocker. 2. Once patients display symptoms of HF, a combination of four types of drugs is used: a) Diuretics b) ACE inhibitors c) Beta-blockers d) Ionotropic agents 3. ARBs may be used for patients who cannot tolerate an ACE inhibitor. 4. Drug classes that should be avoided in HF include antiarrhythmics. 5. NSAIDs should be avoided. G. Invasive treatments 1. Other procedural and surgical interventions have demonstrated some improvement in symptoms and are being used to prevent life-threatening dysrhythmias or improve cardiac output: a) Implantable cardioverter/defibrillator (ICD) b) Biventricular pacing or cardiac resynchronization therapy (CRT) 2. Surgical interventions may include: a) Mitral valve replacement to decrease LV dysfunction b) Coronary artery bypass surgery or percutaneous coronary intervention to improve cardiac muscle perfusion and contractility c) Placement of ventricular assist devices (VAD) and cardiac transplantation H. Nursing management 1. Nursing diagnoses: decreased cardiac output, activity intolerance, excess fluid volume, knowledge deficit.
2. Major nursing goal is to decrease patient’s oxygen demands. 3. Many of the nursing interventions listed for the patient with valve disease are pertinent for the patient with heart failure. 4. Nursing assessments focus on patient observation for signs of decompensation. 5. Vital signs are monitored for signs of decreased cardiac output. 6. Palpation of the apical pulse. 7. Heart sounds auscultated. 8. Lung sounds monitored. 9. Cardiac rhythm, exercise tolerance, and renal function assessed. 10. Continuous telemetry monitoring recommended for patients in the high-acuity setting. 11. Patients are instructed on how to correctly take their pulse and when to contact health care provider. 12. Taking vital signs before, during, and after an activity. 13. Obtain brief sleep history: Rule out other causes of sleep disturbance. 14. Family-focused care. 15. Monitoring of fluid status important. 16. Obtaining daily weights is vital. I. Cardiogenic shock 1. Patients with acute heart failure may experience cardiogenic shock when pumping failure is severe. 2. Approximately 8% of patients with acute left ventricular myocardial infarction and consequent heart failure experience shock. 3. The mean arterial pressure (MAP) is less than 65 mm Hg, and the pulse will be weak and thready in this shock state. 4. Acute cardiogenic pulmonary edema occurs secondary to left ventricular failure. 5. Treatment includes: a) Continuous monitoring b) Endotracheal intubation with mechanical ventilation c) Vasopressors d) Positive inotropes e) Diuretics f) IV fluids (1) Fluid resuscitation is contraindicated in pulmonary edema with shock. J. Hospital discharge 1. For discharge planning, patient is given tools for recording daily weights and advised when to call a health care provider. 2. Nursing interventions focus on patient education to improve compliance with prescribed drug regimen. 3. Drug allergy versus drug side effect.
4. Understand financial constraints.
PowerPoint Slides Slide 1 Heart Failure Clinical Manifestations and Classification Pathophysiology Cardiomyopathy Slide 2 Assessment and Diagnosis Collaborative Management Pharmacologic Therapy Slide 3 Invasive Treatments Slide 4 Nursing Management Slide 5 Cardiogenic Shock Slide 6 Hospital Discharge
III. Hypertension A. Hypertension 1. Top priority in health care. 2. Frequently asymptomatic. 3. Risk factors. 4. Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure. 5. Normal blood pressure: a) Systolic blood pressure (SBP) less than 120 mm Hg b) Diastolic blood pressure (DBP) less than 80 mm Hg (1) Prehypertension: SBP of 120–139 mm Hg and DBP of 80–89 mm Hg 6. Neurohormonal mechanisms key to development of hypertension. 7. SNS releases catecholamines, resulting in increased heart rate and vasoconstriction. 8. Renin–angiotensin system influences development of hypertension by secreting aldosterone. 9. Hyperinsulinemia and insulin resistance can contribute. 10. Insulin can act as a vasopressor. 11. Nitric oxide release is inhibited. 12. Endothelin-1 appears to contribute. 13. Accumulation of advanced glycation end-products. B. Assessment and diagnosis 1. Measurement of blood pressure 2. Obtained at least two different times before diagnosis is made 3. Target organ damage: dysfunction in organs affected by high blood pressure
4. Cardiovascular consequences 5. Patient assessment focused on detection or limitation of target organ involvement 6. Ophthalmoscopic visualization of optic fundi 7. Auscultation of arteries 8. Assessment of lower extremities 9. Exam of heart, lungs, and abdomen 10. Neurologic assessment 11. Electrocardiogram 12. Urinalysis 13. Serum evaluations C. Collaborative Management 1. Lower SBP. 2. Management centers on pharmacologic agents and lifestyle changes. 3. DASH eating plan.
PowerPoint Slides Slide 1 Hypertension Assessment and Diagnosis Collaborative Management Pharmacologic Therapies Slide 2 Nursing Management Patient Education
IV. Pharmacologic Therapies A. Pharmacologic treatment is evidence-based and includes the use of several classes of drugs, including ACE inhibitors, ARBs, BBs, CCBs, and thiazide-type diuretics. B. Thiazide diuretics are the basis of antihypertensive therapy. C. Stage 1: thiazide diuretics. D. Stage 2: two-drug combination. E. Direct renin inhibitors are a new class of drugs to treat hypertension. F. Statins also can decrease blood pressure. G. In patients with ischemic heart disease, beta blockers, and ACE inhibitors. H. Patients with heart failure: beta blockers and ACE inhibitors. 1. If symptomatic, aldosterone blockers and loop diuretics I.
Diabetic hypertension responds to ACE inhibitors or ARBs. J. ACE inhibitors should not be used as first line therapy for African-Americans. K. Chronic kidney disease treated aggressively and can require three or more types of drugs.
V. Nursing Management A. Nursing diagnoses 1. Altered peripheral tissue perfusion 2. Excess fluid volume 3. Ineffective health maintenance 4. Risk for noncompliance B. Nursing management 1. Starts with accurate blood pressure measurement. 2. Patient education. a) Develop a patient medication administration schedule. b) Instruct in medications, their actions, and side effects. C. Regular monitoring of serum electrolytes
VI. Patient Education A. Patient education is a major component. B. The goal is to increase adherence to the treatment plan. C. Patients and families need significant training to manage this chronic condition. D. The nurse assists the patient with developing a medication administration schedule to promote adherence. E. It is essential that the patient and/or caregivers learn about medications, their actions, and side effects. F. The nurse instructs the patient to rise slowly from a supine position to avoid hypotension. G. Understand use of taking diuretics and their effects. H. Patients must know how to correctly take their pulse to self-monitor for bradycardias that can occur with beta-blocker therapy. I. Instructions on dietary sodium restrictions are part of routine patient education. J. Exercise programs may be introduced.
VII. Hypertensive crises A. Hypertensive crises 1. Hypertension is a usually chronic disease process associated with a slowly rising baseline blood pressure over a relatively long period of time. 2. A small percentage (less than 1%) of hypertensive patients develop an acute onset of severe hypertension that is significantly beyond their baseline levels—a hypertensive crisis. B. Risk factors for development of crises 1. There are no known specific risk factors to predict who will develop a hypertensive crisis. 2. Common factors are found in the patient history of those who develop crises: a) History of hypertension that has not been well controlled b) Inadequate adherence to the prescribed drug regimen or inadequate treatment
C. Pathophysiology 1. The pathophysiology underlying hypertensive crises is not well understood. 2. It is believed that an acute increase in blood pressure causes additional stress on blood vessels, damaging the vessel endothelium. a) A cascade of physiologic events are triggered. 3. Autoregulation is another important factor in explaining organ damage associated with hypertensive crises, particularly in the brain, heart, and kidneys. 4. People who develop hypertensive crises usually have chronic hypertension, which resets their “normal” autoregulation range to a higher baseline normal. D. Types of hypertensive crises 1. Hypertensive crises are divided into two levels of severity: a) Hypertensive urgencies b) Hypertensive emergencies (1) These designations are based on blood pressure and whether there is evidence of target organ (end-organ) damage. 2. When a patient presents in a hypertensive crisis, it is crucial to rapidly establish whether it is an urgent or emergency situation. a) Interventions are based on the severity of crisis. E. Hypertensive urgency 1. Hypertensive urgency is defined as an arterial blood pressure greater than 180/110–120 mm Hg without evidence of acute target organ damage. 2. The recommended therapy is to administer oral antihypertensive agents to decrease the blood pressure gradually over a 12- to 24-hour period to a lower target blood pressure. 3. The patient may present with minimal or no manifestations associated with the hypertension; however, severe headache and anxiety, epistaxis, or dyspnea may be present. 4. Unless the patient has some underlying health issue that triggered the acute hypertension exacerbation, it is managed on an outpatient basis. F. Hypertensive emergency 1. Hypertensive emergency is defined as an arterial blood pressure greater than 180/110–120 mm Hg with evidence of acute target organ. 2. This is a medical emergency, and rapid reduction of blood pressure to lessen the degree of target organ damage is the highest priority. 3. The patient is admitted to intensive care, and titratable intravenous antihypertensive agents are initiated. 4. The choice of drug therapy will differ based on which organ is being targeted.
PowerPoint Slides Slide 1 Hypertensive Crises Risk Factors for Development of Crises Pathophysiology
Slide 2 Types of Hypertensive Crises Hypertensive Urgency Hypertensive Emergency
VIII. Aortic Aneurysm 1. The incidence of aortic aneurysm and its complications have been on a steady rise as lifespan has increased. 2. It is a silent disease that often only becomes symptomatic when the aneurysm ruptures or dissects. A. Aneurysms 1. An aneurysm is an abnormal localized dilation of an artery that results from a weakened arterial wall. 2. Aneurysms can occur throughout the body, but those of the aorta are relatively common and can be life-threatening. B. Classification 1. Aortic aneurysms are classified by vessel wall involvement, shape, and location. C. By vessel wall involvement 1. When classified by the amount of vessel wall involvement, there are two types: a) True aneurysms: all layers of the arterial wall (tunica intima, media, and externa) are involved, b) Pseudoaneurysms (false aneurysms): at least one layer of the wall is not involved (1) Usually a complication of an invasive intervention such as artery catheterization or artery anastomosis D. By aneurysm shape 1. There are two shapes characteristic of aortic aneurysm: a) Saccular aneurysm: one that involves only part of the vessel circumference. b) Fusiform aneurysm involves the entire artery circumference; this is much more common than the saccula . E. By aneurysm location 1. Aortic aneurysms can be located all along the aorta, from the ascending thoracic aorta through the trunk of the abdominal aorta. 2. They are often referred to by their location, such as thoracic and abdominal aneurysms: a) Thoracic aneurysms are generally subcategorized by their specific location as ascending (most common thoracic location), transverse, or descending thoracic aneurysm. 3. If the aneurysm involves both the lower thoracic aorta and the upper abdominal aorta, it is a thoracoabdominal aneurysm. 4. The most common location for aortic aneurysm development is in the abdomen (abdominal aortic aneurysm [AAA]); a) The most common location is in the distal abdominal aorta beginning just below the junction of the renal arteries to the junction of the aorta and iliac arteries.
F. Etiology and risk factors 1. Aneurysms are usually a complication of longstanding atherosclerosis; however, other etiologies include: a) A genetic predisposition (positive family history of aneurysm) b) Certain connective tissue disorders (e.g., Marfan syndrome) c) Traumatic injury d) Infection 2. Major risk factors are similar to those of atherosclerosis and include: a) Hypertension b) Smoking (a particular concern) c) Age d) Male gender e) Hyperlipidemia f) History of peripheral arterial disease G. Pathophysiology 1. Aneurysms are the result of degenerative atherosclerotic changes in the aorta. 2. The middle layer of the arterial wall, the tunica media (thick middle muscle layer), slowly degenerates, which weakens the wall. 3. LaPlace’s Law (applied to blood vessels) helps explain why aneurysms grow. a) The law states that wall tension (T) is equal to the pressure (P) being exerted against the wall, multiplied by the wall radius (R), or T = P × R; therefore, as an artery dilates, it increases the force on the arterial wall, which then causes more dilation. 4. Once an aneurysm begins to grow, it will continue to do so, potentially leading to aortic rupture. H. Clinical manifestations 1. Aortic aneurysms are often asymptomatic or cause only minimal symptoms. a) They are often inadvertently discovered when the individual is undergoing diagnostic exams for other health problems. 2. The patient may not be diagnosed with an aneurysm until it is large and impinging on some adjacent structure or a complication arises such as rupture or dissection. I. Diagnosis 1. Diagnostic imaging is the primary tool for diagnosing aortic aneurysms. 2. Common tests include: a) Chest or abdominal radiograph b) Computed tomography (CT) scanageal or transthoracic echocardiography c) Magnetic resonance imaging (MRI) 3. Physical assessment is not considered a strong tool for diagnosing aneurysm. J. Management 1. Once discovered, aneurysms are monitored closely through regular diagnostic imaging to track changes in diameter.
2. To qualify as an aneurysm, the affected artery must be at least 1.5 times the normal diameter; and the larger the aneurysm is, the faster it tends to grow (LaPlace’s Law) K. Medical management 1. The goal of medical management is to keep the aneurysm small in size. a) This is primarily accomplished by aggressive blood pressure control. 2. The management plan may also include treatment of hyperlipidemia and smoking cessation. 3. Pressure needs to be reduced to a level that provides maximum pressure relief to the aneurysm while maintaining adequate organ perfusion. 4. The patient’s vital signs and organ function status must be monitored closely as antihypertensive therapy is initiated. L. Interventional management 1. Procedural intervention is considered once the aneurysm has grown to a diameter of greater than 5 to 5.5 cm because of the high risk of rupture. 2. There are two major repair interventions: a) Open surgical repair (1) This is a relatively high risk procedure; therefore, surgery is reserved for when the risk of rupture outweighs the risk of the surgery b) Endovascular aneurysm repair (EVAR) (1) A less invasive procedure that is performed under fluoroscopic guidance. (2) The EVAR option can be used in individuals who meet specific vascular anatomic criteria and prefer to have a less invasive intervention with reduced recovery time. (3) It is also used when the patient’s general condition is poor, making OSR an undesirable option. (4) Research suggests that mortality and complication rates are lower with this procedure when compared to OSR. (5) Two major advantages of EVAR over OSR are a short postprocedure recovery time and an earlier discharge from the hospital, often within 24 hours of the procedure. M. Nursing considerations 1. Regardless of the situation, the patient’s aneurysm must be taken into consideration during the admission. 2. Blood pressure must be carefully monitored. 3. The nurse should also be aware of the common manifestations of aneurysm rupture and dissection. N. Patient education 1. The patient needs to have a strong understanding of the disease and therapeutic plan. 2. Blood pressure control and smoking cessation. 3. Healthy lifestyle changes. 4. The medication regimen, including therapeutic and nontherapeutic effects; and signs and symptoms of complications of aneurysm are critical for the patient and family to understand.
5. The patient should also have a clear understanding of when to seek medical or emergency assistance. O. Aortic aneurysm emergencies 1. As aneurysms progress, they become more prone to two complications: a) Aneurysm rupture b) Aortic dissection 2. Aneurysm dissection is most common in thoracic aneurysm. 3. Rupture is more common in abdominal aneurysm. 4. Both of these situations are life-threatening emergencies. P. Aortic rupture 1. Aneurysm rupture occurs when the pressure being exerted on the artery wall goes beyond the wall’s tensile strength. 2. The risk for rupture becomes significant as the circumference approaches 5.5 cm or greater. 3. It is estimated that AAA that is 7.0 cm or greater in size has an 80% risk of rupture. 4. Aortic rupture is associated with extremely high mortality. Q. Clinical manifestations of rupture 1. The patient is often asymptomatic prior to rupture. 2. The most common symptom of rupture is rapid onset of severe pain located in the chest, back, abdomen, or flank; however, the patient may present with atypical pain anywhere in the trunk, even the hips. 3. With AAA there is a triad of classic signs and symptoms that strongly suggest aneurysm rupture when they present in rapid sequence, including syncope, acute onset of severe abdominal pain, and hypotension. 4. Rapid onset of shock develops as the patient hemorrhages into the extravascular spaces adjacent to the rupture site, and death is inevitable unless the patient has immediate emergency repair. R. Collaborative management 1. Aneurysm rupture is a surgical emergency, and time is critical, making OSR the procedure of choice. 2. Fluid resuscitation and blood replacement therapy is initiated. 3. Narcotics may be administered for pain. 4. Postoperatively, the patient is admitted to the critical care unit, where blood pressure is tightly controlled to reduce pressure on the anastomosis sites and hemodynamic status is continuously monitored. 5. Mechanical ventilation may be continued to optimize oxygenation status until the patient is fully stabilized. 6. Renal function is closely monitored. 7. The patient will be placed on anticoagulant therapy to prevent clot formation from the presence of the prosthetic graft.
S. Aortic dissection 1. Aortic dissection refers to a potentially catastrophic event in which arterial blood enters the aorta tunica media, causing separation of the tunica media from the tunica intima. 2. It is more common than aortic rupture and usually develops in the thoracic aorta and has an extremely high early mortality rate. T. Pathophysiology 1. There are two proposed causes of aortic dissection: a) First, it may result from a tear in the tunica intima. b) Second, it may result from rupture of the vasa vasorum, which results in hemorrhage from within the aorta wall. U. Classification 1. Aortic dissection is classified by location using one of two major classification systems: a) DeBakey system: (1) Divides aortic dissection into types I, II, and III (with two subclassifications of IIIa and IIIb) based on point of origin and extension. b) Stanford system (1) Divides dissection into types A and B based solely on whether the ascending thoracic aorta is involved.
IX. Clinical Manifestations 1. The most common presenting symptom of aortic dissection is acute onset of severe pain that does not change in severity; however, the location may migrate along the extension path. 2. Additional pain descriptors that may be given by the patient include ripping, stabbing, tearing, or burning; however, in a small percentage of cases, no pain is present. 3. The effect of dissection on blood pressure often depends on its location with the most common finding being hypertension. 4. In type A (ascending) dissection, the patient may be hypotensive on presentation related to aortic regurgitation, cardiac tamponade, or heart failure. 5. Hypotension is considered an ominous finding and is associated with a high death rate.
X. Diagnosis 1. Rapid detection of aortic dissection is necessary to improve patient outcomes, yet the signs and symptoms of dissection are similar to those of multiple acute diseases, which makes a differential diagnosis more difficult. 2. The same diagnostic imaging tests that are used for diagnosing aneurysms are used for dissection; however, CT scan is a common test with echocardiogram as the back-up tool when CT scan cannot be used. 3. To improve the speed and accuracy with which dissection is diagnosed, risk score tools are available: a) Acute Aortic Dissection Diagnostic (ADD) Risk Score (1) Combines a diagnostic algorithm and risk score based on three high-risk categories: predisposing conditions, pain features, and examination features
XI. Management 1. Treatment of aortic dissection requires rapid stabilization of the patient. 2. Goals of therapy include: a) Rapid control of blood pressure b) Fluid management c) Anticoagulation d) Decreasing shear stress on the aorta e) Pain control 3. Immediate surgical treatment is recommended for patients who present with type A dissection because it significantly improves patient outcomes. 4. Patients with type B dissection are often treated medically; if invasive interventions are warranted, an endovascular procedure may be a viable option.
XII. Nursing Considerations A. Nursing care includes the prevention and management of complications and pain control; postoperative pain can be a challenge. B. The patient is returned to the critical care unit for frequent assessments and continuous cardiac and hemodynamic monitoring. C. The patient will most likely remain on the mechanical ventilator to optimize oxygenation during the immediate postoperative period. D. Blood pressure is tightly controlled to reduce stress on the operative site. E. Peripheral sensation and pulses are monitored to assure that adequate circulation is getting to the extremities following the procedure. 1. This is a critical assessment because vascular occlusion is a major complication associated with aortic procedures. F. Kidney function and neurological status are assessed to evaluate adequacy of circulation to the kidneys, brain, and spinal cord. G. The nurse will also closely monitor the patient for the development of complications.
PowerPoint Slides Slide 1 Aneurysms Slide 2 Classification By Vessel Wall Involvement By Aneurysm Shape By Aneurysm Location Slide 3 Etiology and Risk Factors Pathophysiology Clinical Manifestations Diagnosis
Management Slide 4 Medical Management Slide 5 Interventional Management Slide 6 Nursing Considerations Patient Education Slide 7 Aortic Aneurysm Emergencies Aortic Rupture Clinical Manifestations of Rupture Collaborative Management Slide 8 Aortic Dissection Pathophysiology Classification Clinical Manifestations Diagnosis Management
XIII. Chapter Summary XIV. Clinical Reasoning Checkpoint XV. Post-Test XVI. References
Suggestions for Classroom Activities • Discuss pathophysiologic mechanisms of cardiac valve dysfunction. • Discuss the progress of heart failure from stage A through stage D. What are the assessment, diagnostic, treatment, and management components at each stage?
Suggestions for Clinical Activities • Assign the students patients who are experiencing cardiac disorders. What types of cardiac sounds are noted? • Review the medications ordered for the assigned cardiac patients. What medications do they have in common? Review the medications and their anticipated actions during postconference.
CHAPTER
14
Alterations in Myocardial Tissue Perfusion
Objectives 1. Describe the pathophysiology of atherosclerosis and coronary artery disease. 2. Identify risk factors for coronary artery disease and discuss collaborative interventions to reduce or manage the risk factors. 3. Differentiate types of angina and their assessment including stable angina, unstable angina, and variant angina. 4. Describe the diagnostic work-up for alterations in myocardial tissue perfusion. 5. Describe the initial collaborative management of acute coronary syndromes, unstable angina, and myocardial infarction. 6. Explain the collaborative interventions commonly used to restore myocardial tissue perfusion.
I. Pathophysiology of Atherosclerosis/Coronary Artery Disease 1. Atherosclerosis is commonly referred to as “hardening of the arteries” and accounts for a high percentage of deaths as a result of cardiovascular disease (CVD) in the United States. It is the primary underlying cause of: a) Peripheral artery disease (PVD). b) Coronary artery disease (CAD). c) Cerebrovascular disease. d) Atherosclerosis and its associated disorders are pervasive, and affect both men and women. e) Approximately one of every three deaths in the U.S. is attributed to cardiovascular disease. 2. A normal artery consists of three concentric layers: a) The innermost layer is the tunica intima. b) The middle layer is the tunica media. c) The outermost layer is the tunica adventitia. d) Atherosclerosis is a chronic inflammatory disorder associated with injury to the intimal lining. e) It is a progressive disease characterized by formation of plaque in the intimal lining of medium and large arteries. 3. Atherosclerosis appears to begin with chronic injury or inflammation to the endothelial cells that line blood vessels. These endothelial cells are called the endothelium.
a) These factors damage the endothelium, causing endothelial cells to separate. b) This allows monocytes from the bloodstream to enter into the intimal lining and become macrophages, which oxidize low-density lipoproteins (LDL). c) This causes the evolution of “foam cells” that become “fatty streaks” along the vessel wall. d) Over time, the fatty streaks develop in fibrous atheromatous plaque, which is the basic lesion associated with atherosclerosis. e) These lesions become thicker and more complex as they grow, eventually narrowing the vessel lumen and reducing blood flow. 4. Some atherosclerotic plaques advance to a more complicated lesion called an atheroma. Atheromas are calcified lesions that contain areas of hemorrhage, surface ulcerations, and scar tissue deposits. a) Decreased or sluggish blood flow past an atherosclerotic lesion combined with ideal blood clotting conditions such as increased platelet aggregation can produce a thrombus on the lesion. b) The formation of this thrombus is dangerous because not only does it further reduce blood flow, but it can occlude the artery or break off to become an embolus. A. Atherosclerosis and coronary artery disease 1. Coronary artery disease (CAD) is a narrowing of the internal space or lumen of a coronary artery. a) Most typically caused by atherosclerotic plaque formations. 2. Two types of atherosclerotic plaque directly contribute to disruptions in myocardial blood flow in patients with CAD: a) Stable plaque (impedes blood flow to myocardial tissues and is associated with the development of stable angina, a predictable and less threatening type of cardiac ischemia). b) Unstable plaque (more ominous with a greater tendency toward rupture, platelet aggregation, fibrin attraction, and thrombus formation in the coronary arteries). (1) Unstable plaque activity can precipitate an acute coronary syndrome (ACS) such as unstable angina, non-ST-segment elevation myocardial infarction, or ST-segment elevation myocardial infarction in the patient with CAD.
PowerPoint Slides Slide 1 Pathophysiology of Atherosclerosis/Coronary Artery Disease Slide 2 Atherosclerosis and Coronary Artery Disease
II. Etiologic Factors for Coronary Artery Disease 1. Risk factors are categorized as either modifiable or non-modifiable. a) Modifiable risk factors include those risk factors that can be altered through either lifestyle modification or medication. b) Nonmodifiable risk factors include those risk factors that, regardless of therapy, cannot be altered. A. Nonmodifiable risk factors
1. Increasing age is a nonmodifiable risk factor. 2. In 2007, almost 33% of deaths from all cardiovascular diseases occurred before the age of 75 years in the U.S. 3. Men are at greater risk for developing atherosclerosis and coronary artery disease than premenopausal women. 4. After menopause, the risk of atherosclerosis-related diseases increases in women. 5. Coronary heart disease in a first-degree relative increases the risk for disease development because of genetic and environmental influences. 6. Diabetes mellitus increases coronary artery/atherosclerotic disease risk by two- to fourfold. B. Modifiable risk factors 1. Hypercholesterolemia 2. Cholesterol is carried in the bloodstream bound to proteins; this combination forms a molecule called a lipoprotein. 3. Low-density lipoprotein (LDL) 4. High-density lipoprotein (HDL) a) These lipoproteins cause vessel inflammation. 5. Type II diabetes 6. Metabolic syndrome 7. Hypertension 8. Obesity 9. C-reactive protein (CRP), which is an indicator for cardiovascular diseases related to atherosclerosis 10. Several of these modifiable risk factors can be altered with lifestyle changes C. Collaborative management of risk factor reduction 1. Management of these risk factors is a collaborative effort with patient care providers such as physicians, nurses, and dietitians. 2. Nursing diagnoses may include imbalanced nutrition: more than body requirements, and altered health maintenance. 3. Obtaining a thorough health history. 4. Laboratory testing. 5. Smoking cessation. 6. Control of hypertension. 7. Low sodium diet, regular exercise, stress management, and compliance with medication regimens. 8. Drug therapy must be used in combination with a diet that is low in fat and cholesterol.
PowerPoint Slides Slide 1 Etiologic Factors for Coronary Artery Disease Nonmodifiable Risk Factors Modifiable Risk Factors
Slide 2 Collaborative Management of Risk Factor Reduction
III. Clinical Presentation of Impaired Myocardial Tissue Perfusion A. Subjective data 1. The classic presenting symptom of CAD is angina pectoris. a) Angina is chest pain that usually is precipitated by exercise and relieved by rest. b) Angina is caused by an increase in myocardial oxygen demand and a decrease in myocardial oxygen supply as a result of partially occluded coronary arteries. c) The by-product of anaerobic metabolism is lactate. d) Lactate, an acid, irritates nerve endings and causes pain. e) Patients might describe their angina as tightness, heaviness, or a vise-like sensation in the chest. 2. It can be accompanied by diaphoresis, shortness of breath, and lightheadedness. 3. Patients often will report that the pain radiates to the left arm and hand, jaw, and shoulder. 4. They also might report symptoms of nausea, shortness of breath, or fatigue. 5. Symptoms that are suggestive of cardiac ischemia but do not include angina are called anginal equivalents. 6. Time is an important variable to consider when assessing a patient complaining of angina symptoms. Typically, angina begins gradually and peaks over a period of minutes as the precipitating activity continues. 7. Chest pain that lasts several seconds or constant pain over a period of hours is not typical pain associated with altered myocardial tissue perfusion. 8. When assessing a patient presenting with angina symptoms, it is helpful to employ the mnemonic PQRST as an assessment tool: a) Precipitating factors (P) b) Quality (Q) c) Radiation and region (R) d) Associated symptoms (S) e) Timing and treatment strategies (T) 9. This is a systematic way to remember to ask appropriate questions to a patient experiencing chest pain 10. Three types of angina: a) Stable angina: chest pain that is predictable. It occurs with increased physical activity. Often, patients know they will get chest pain if they participate in a certain amount of activity. b) Prinzmetal’s or variant angina: not common; occurs at rest and not related to physical activity or heart rate. c) Unstable angina: chest pain that is not predictable; requires immediate medical attention. 11. Diabetics, women, and elderly patients are more likely to experience anginal equivalents or silent ischemia. B. Objective data: Physical assessment
1. A focused physical assessment (objective data) of the cardiovascular and pulmonary systems is completed. 2. Patients with CAD might not exhibit any outward signs of the disease. 3. They might be of normal weight and have normal vital signs. 4. An attempt should be made to correlate subjective data with physical signs. 5. Vital signs are reviewed for evidence of hypertension. 6. Skin is examinated for evidence of cyanosis and xanthomas. 7. Color and temperature of extremities. 8. Alterations in the heart and respiratory rates. 9. Chest and abdomen are inspected. 10. Heart sounds are auscultated. 11. The abdomen is auscultated for bowel sounds and the presence of abdominal bruits, which can be an indication of renal artery stenosis or abdominal aortic aneurysm.
PowerPoint Slides Slide 1 Clinical Presentation of Impaired Myocardial Tissue Perfusion Subjective Data Objective Data: Physical Assessment
IV. Diagnostic Tests for Alterations in Myocardial Tissue Perfusion A. Electrocardiogram 1. The easiest and most cost-effective to perform is the 12-lead electrocardiogram (ECG). Thousands of ECGs are performed each year. All patients being evaluated for chest pain have a 12lead ECG performed to document baseline cardiac rhythm. The ECG aids in the identification of QRS or ST segment abnormalities indicating ischemia or injury to the myocardium. 2. The standard ECG includes 12 leads. ECG leads are categorized as limb leads (leads I, II, III), augmented limb leads (aVR, aVL, aVF), and the precordial leads (V1 through V6). Each lead overlies a specific area of the myocardium and provides an electrographic snapshot of electrochemical activity taking place at the level of the cell membrane (Pyne, 2004). 3. Review the basic components of an ECG, including depolarization and repolarization; identify and measure the various intervals and wave forms. Review ECG ischemia and injury patterns such as horizontal ST depression, hyperacute T waves, ST segment deviation, and T wave inversions. a) Continuous ST segment monitoring provides valuable information for the management of patients at risk for a myocardial infarction (MI) and for those who have experienced an MI, undergone revascularization procedures, or who require ECG monitoring after noncardiac surgery. b) Current monitoring technology includes the ability to monitor ST segments continuously, and by doing so, ST segment changes can be identified early and appropriate therapy implemented.
4. Proteins released by necrotic myocytes into the bloodstream are referred to as serum cardiac markers. When present in the blood, these markers signify myocardial muscle damage. These markers include the troponins (cTn), creatine phosphokinase (CK), and creatine phosphokinase– myocardial bands (CK-MB). These different markers appear in the blood at different times and, often, the higher the marker the worse the amount of necrotic cardiac muscle damage. B. Exercise stress test (EST) 1. One of the most commonly used diagnostic tests available for the assessment of a patient suspected of having CAD. 2. Patients who cannot exercise might include those with arthritis, amputation, severe peripheral vascular disease, or chronic obstructive pulmonary disease. 3. These patients undergo a pharmacologic stress test. An inotropic drug, such as dobutamine, is given to increase myocardial contractility and workload similar to that which would occur with exercise. 4. Patient instructed not to eat, smoke, or drink before test; certain drugs may also be withheld. 5. Echocardiography is an imaging technique used to assess the functional structures of the heart using ultrasound waves. a) Ultrasound waves are applied to the chest wall through a transducer and transect the heart at different planes, providing pictures of various cardiac structures. b) In conjunction, a stress test also may be done with an echocardiogram. c) During a stress echocardiogram, the patient’s ECG is monitored for abnormalities, and the myocardial walls are evaluated for ischemia-induced motion abnormalities. d) Myocardial wall motion abnormalities noted can include hypokinesis (decrease in movement), akinesis (lack of movement), and dyskinesis (movement in the opposite direction). C. Myocardial perfusion imaging (MPI) 1. Performed by injecting an intravenous nucleotide during peak exercise. 2. This procedure is very helpful in identifying specific areas of myocardial ischemia and damage. 3. The perfusion images help differentiate between exertional and resting myocardial perfusion abnormalities. 4. Perfusion is reported as being without defect (normal), with a fixed defect, or with a reversible defect. D. Diagnosis of acute coronary syndromes 1. Coronary heart disease is commonly divided into two types of disorders: a) Chronic ischemic heart disease: stable angina and variant angina. b) Acute coronary syndromes (ACS): represents a continuum of the atherosclerotic disease processes, and includes unstable angina and myocardial infarction. c) ACS is characterized by an imbalance between myocardial oxygen supply and demand. d) As blood flow is reduced, the affected myocardium becomes ischemic, leading to symptoms of angina. e) Thrombi that partially occlude arteries produce symptoms of unstable angina (UA). f) Total occlusion of the artery results in cell necrosis, release of cardiac markers, and MI distal to the occlusion.
g) Classification of ACS has changed based on a clearer understanding of plaque disruption and thrombus development. f) Current guidelines establish the following diagnostic criteria: (1) Patients with ECG changes suggestive of ischemia, but without the presence of serum biomarkers, are diagnosed as UA. (2) Patients with ischemic ST segment changes and the presence of serum cardiac markers are diagnosed as having non-ST elevation myocardial infarction (NSTEMI). (3) Patients with ST segment elevation and the presence of serum cardiac markers are diagnosed with ST elevation MI (STEMI) (Alpert et al., 2000). i. T wave inversion and ST segment depression in two or more contiguous leads are hallmarks of myocardial ischemia. In patients suspected of having ACS, symmetrical T wave inversion 2 mm (0.2 mv) or greater strongly suggests acute ischemia. ii. ST segments that are depressed from the baseline by 0.5 mm (0.05 mV) or greater and are horizontal or downsloping in two contiguous leads are also suggestive of ischemia. iii. Nonspecific ST segment changes can complicate the picture of a patient presenting with symptoms suggestive of ACS. iv. Nonspecific changes are usually defined as T wave inversion less than 2 mm or ST segment variations of less than 0.05 mV (0.5 mm). 2. Patients presenting with symptoms suggestive of ACS require a rapid assessment and ECG. 3. Chest pain that is suggestive of acute MI typically lasts longer than 20 minutes, but less than 12 hours. a) Patients might describe the pain as crushing or gripping, or they might report chest heaviness and a sense of impending doom. b) UA is described as having three possible presentations: symptoms of angina at rest (usually prolonged, greater than 20 minutes), new-onset angina of ordinary physical activity (such as walking one or two blocks), and increasing angina that has become more frequent and longer in duration. c) Other diagnostic and prognostic tools have been developed, and are in use for risk stratification. d) The Thrombolysis in Myocardial Infarction (TIMI) score is a well-validated, easy-to-use calculation that predicts risk of death and ischemic events for unstable angina and NSTEMI. E. Initial collaborative management 1. Nursing care priorities include relieving chest pain and reducing myocardial oxygen demand. Psychosocial support for the patient and family is important at this time because they are faced with potential mortality. 2. Initial management of all patients with chest pain includes rapid triage to immediate care and placement in a treatment area established to manage such emergencies. 3. After a 12-lead ECG is obtained, acetylsalicylic acid (ASA [aspirin]) is administered. Oxygen by nasal cannula is applied and intravenous (IV) access is obtained. 4. Administration of ASA has been shown to significantly reduce mortality and nonfatal MI by 50% in patients with ACS and begins to decrease platelet aggregation and clot formation by
blocking thromboxane A2 as soon as 10 minutes after oral administration (Van Horn and Maniu, 2007). 5. If the preliminary ECG is normal or nondiagnostic, the patient may be monitored in a chest pain unit, and serial serum cardiac markers and ECGs are obtained every six hours. 6. The patient is “ruled out” for an MI if subsequent ECGs and serum cardiac markers remain unchanged for 12–24 hours. 7. Most patients will undergo some form of noninvasive testing (stress test or noninvasive cardiac imaging) prior to discharge. F. Pharmaceutical management 1. Early pharmaceutical management should include beta blockers unless contraindicated. 2. Beta blockers are administered to block catecholamine stimulation and decrease myocardial oxygen demand (with goal heart rate to 50–60 bpm), which increases the time of diastole (rest) and allows more time for coronary artery and myocardial perfusion. 3. Beta blockers have been shown to have significant reduction in mortality and morbidity. 4. Pharmaceutical management may include an anticoagulation regimen. 5. LMWH (enoxaparin) has also demonstrated excellent efficacy when used in conjunction with ASA in patients with UA and NSTEMI. 6. Advantages to the use of LMWH include its subcutaneous delivery, safety, and administration without a PTT monitoring. 7. In addition to ASA, thienopyridines, such as clopidogrel (Plavix), may be administered to patients with ACS. Clopidogrel blocks ADP-induced platelet aggregation and is recommended for patients with UA and NSTEMI. 8. Other antiplatelet medications, such as glycoprotein (GP) IIb/IIIa inhibitors, bind to IIb/IIIa platelet receptors inhibiting platelet aggregation and new clot formation. GP IIb/IIIa inhibitors can be used with patients experiencing UA or NSTEMI.
PowerPoint Slides Slide 1 Diagnostic Tests for Alterations in Myocardial Tissue Perfusion Electrocardiogram Exercise Stress Test (EST) Myocardial Perfusion Imaging (MPI) Slide 2 Diagnosis of Acute Coronary Syndromes Initial Collaborative Management Pharmaceutical Management
V. Collaborative Interventions to Restore Myocardial Tissue Perfusion A. Reperfusion 1. Patients with STEMI have a high likelihood that a thrombus is the cause of the infarct. 2. The goal of these interventions is to promote reperfusion of the affected artery within 30 minutes.
3. Interventions to restore myocardial tissue perfusion include administration of thrombolytic therapy, percutaneous coronary intervention, and coronary artery bypass surgery. 4. Rapid reperfusion of the affected artery reduces the amount of damage to the myocardium, and preserves ventricular function. 5. Maximum damage occurs approximately six hours after the initial occlusion. 6. The amount of damage depends on the artery occluded and the location of the thrombus. 7. Survival and quality of life are significantly improved if the function of the left ventricle is preserved. B. Thrombolytic therapy 1. Includes the use of drugs that break up blood clots. a) These drugs activate the fibrinolytic system to dissolve the blood clot and restore blood flow to the obstructed artery. b) This actually changes the course of an MI by reducing the area of infarction, decreasing mortality and the likelihood that the patient will develop Q waves on an ECG and increasing the likelihood that LV function will be preserved. 2. Nursing responsibilities for the patient receiving thrombolytics include monitoring for evidence of bleeding, hemodynamic instability, reperfusion, and reocclusion. 3. The risk for intracranial hemorrhage (ICH) is relatively low, but increases in patients older than 65 years of age, in those with low body weight or hypertension, and in females. 4. The first 24 hours after fibrinolytic administration holds the greatest risk for intracranial hemorrhage. 5. Thrombolysis and reperfusion of the affected myocardium are indicated by resolution of ST segment elevation, pain resolution, and the occurrence of reperfusion arrhythmias, such as premature ventricular complexes or ventricular tachycardia. 6. Continuous ST segment monitoring is useful in this setting to identify evidence of reperfusion. 7. Patients not eligible for revascularization will typically be admitted to a high-acuity cardiac unit for observation and continued medical management. a) Patients who are not eligible for revascularization include those of advanced age with significant comorbidities such as end-stage renal failure, severe chronic obstructive pulmonary disease, advanced cancer, or significant LV dysfunction. b) In these patients, the risks of the procedures outweigh the potential benefits. c) Vital signs and fluid balance are closely monitored in these patients, and continuous ECG monitoring allows for prompt treatment of dysrhythmias. C. Percutaneous coronary intervention 1. The procedure of choice for patients with STEMI. PCI is especially useful for patients who are elderly, those who are not candidates for thrombolytics, or those who have experienced reocclusion after receiving thrombolytic therapy. 2. Patients considered for PCI receive all the appropriate therapies used in the management of STEMI, with the exception of thrombolytics. 3. Thrombolytics are not necessary in the setting of acute PCI, because their intended purpose is to lyse the thrombus.
D. Preparing the patient for PCI 1. Prior to the procedure, nursing responsibilities include continued monitoring of the patient’s vital signs, timely medication administration, and patient and family education. 2. Renal function is assessed (blood urea nitrogen and serum creatinine). 3. Renal function can be altered by contrast dye used during the procedure. 4. Patients with renal insufficiency may receive N-acetylcysteine (mucomyst) prior to and after the procedure to decrease the renal toxic effects of contrast dye. 5. Patients who are not eligible for revascularization include those who are of advanced age and are accompanied by significant comorbidities (e.g., end-stage renal failure, severe chronic obstructive pulmonary disease, advanced cancer, and significant LV dysfunction). 6. In these patients, the risks of the procedure outweigh the potential benefit. 7. Patients admitted to the high-acuity unit might require short-term support with an intra-aortic balloon counterpulsation device or inotropic support for cardiogenic shock. 8. Vital signs and fluid balance are closely monitored. 9. Continuous ECG monitoring allows for prompt treatment of dysrhythmias. E. PCI procedure 1. The PCI procedure typically involves the insertion of an introducer catheter into the femoral or radial artery. 2. Guiding catheters, similar to those shown in Figure 16-6, are inserted through the introducer, and the target vessel is engaged. 3. The coronary anatomy is assessed using fluoroscopy, and the offending thrombus is located. 4. A key decision at this point is whether the occlusion can be removed and a balloon angioplasty performed safely, or whether the patient needs to be transported to the operating room for emergent bypass surgery. 5. Indications for surgery include severe LMCA disease, LMCA equivalent disease, and three or more proximal coronary artery obstructions. a) After the decision has been made to proceed with the intervention, the cardiologist crosses the occlusion with a guidewire and removes the thrombus. 6. A thrombectomy device such as the Angiojet™ may be used to remove the thrombus. 7. The Angiojet™ uses a catheter and high-pressure saline jets to create a vacuum effect that removes the thrombus. 8. The lesion is then predilated with an angioplasty balloon. 9. Bare metal stents are commonly used for PCI procedures, and have significantly reduced the potential for acute closure and restenosis of the dilated coronary artery. 10. Restenosis rates averaging 30–50 percent with plain balloon angioplasty have now been reduced to 5–15 percent with the use of stents F. Care of the patient post-PCI 1. Post-procedure management of the PCI patient includes monitoring frequent vital signs; the ECG; and assessing the access site for pain, swelling, or bleeding. 2. Routine blood work typically includes complete blood count, chemistry panel, and coagulation studies.
3. IV infusions may include a GP IIb/IIIa inhibitor and crystalloid solutions. 4. GP IIb/IIIa inhibitors are continued for a minimum of 18 hours post-PCI unless contraindicated. 5. Clopidogrel and ASA may be ordered. 6. IV hydration continues until just prior to discharge, if the patient is to go home the same day. If the patient is admitted to a high-acuity unit, IV hydration may continue for another 10–12 hours. 7. The most common post-procedure complications include chest pain, hypotension, and bleeding at the access site. 8. Chest pain shortly after PCI can indicate acute closure. If the patient complains of chest pain, the nurse obtains vital signs and an ECG, and notifies the cardiologist. 9. Patient and family education are important prior to discharge and will include activity limitations, such as when to shower, drive, lift, and exercise, and taking care of the access site. 10. Medication instruction is paramount so that the patient/family understands the importance of taking medications as prescribed. G. Coronary artery bypass surgery 1. Coronary artery bypass graft (CABG) has been performed in the United States since the late 1960s. 2. Advances in surgical technique, cardiopulmonary bypass (CPB), conduit selection, and cardioplegic solutions have improved patient outcomes and made the procedure available to a broader selection of patients. 3. Indications for CABG include severe LMCA disease, LMCA equivalent disease, and three or more proximal artery obstructions. 4. CABG may be performed as a rescue procedure for acute restenosis or rupture of a coronary artery. a) CPB is a technique used during surgery whereby blood is directed from the vascular system and circulated through a system of reservoirs and pumps. 5. The system that performs this function is referred to as extracorporeal circulation. 6. Blood that filters through the bypass system undergoes oxygenation, filtration, and cooling, and is returned to the systemic circulation. 7. The grafts are harvested from either the anterior chest wall (in the case of IMA grafts) or the saphenous veins of the legs. 8. Many surgeons prefer the use of IMA grafts (depending on lesion location) because of the higher patency rates and increased longevity (10–15 years) of the IMA grafts. H. Care of the patient post-CABG surgery 1. While mortality from this surgery has decreased, length of stay has increased due to the increased survivability of those with multisystem complications who would have previously died. Because of this, it is important for the nurse to be knowledgeable of potential complications. 2. The patient post-CABG is at an increased risk for infections, such as ventilator-associated pneumonia (VAP) and central line or incisional infections. 3. The risk of infection is significantly increased if patients have poor glucose control or diabetes. Increased risk for pressure ulcers exists from decreased mobility; other risks include postoperative delirium or confusion.
4. Nursing responsibilities include frequent and ongoing physical assessments of cardiopulmonary status, vital signs, strict intake and output, ECG rhythms, and level of consciousness. 5. Ongoing physical assessments also include the gastrointestinal and renal systems. 6. The nurse must be vigilant in detecting problems in the postoperative period: hypovolemia, hypotension, hypertension, sinus bradycardia. I. Complications 1. Additional problems that can occur include low CO, hypotension or hypertension, electrolyte imbalances, and postoperative arrhythmias (Katz, 2007). 2. Hypovolemia and vasodilatation lead to inadequate preload and low CO. 3. Diuresis (greater than 2–3 liters/hour) can be significant during the initial postoperative period. 4. Cardiac tamponade is a life-threatening postoperative complication. Cardiac tamponade is caused by bleeding into the nonflexible sac around the heart. The accumulating pressure around the heart increases intracardiac pressures, impairs ventricular filling, and decreases CO. Pulsus paradoxus is one of the classic signs of cardiac tamponade. J. Discharge Planning 1. Multidisciplinary approach and includes health care team members from Physical Therapy, Occupational Therapy, and Nutritional Support. 2. Patient recovery, discharge planning, and patient and family education continue until the patient is discharged, usually 5–7 days after surgery. 3. Cardiac rehabilitation is coordinated for after discharge. 4. Psychological support and individualized patient and family education remain priorities.
PowerPoint Slides Slide 1 Collaborative Interventions to Restore Myocardial Tissue Perfusion Reperfusion Thrombolytic Therapy Percutaneous Coronary Intervention Slide 2 Preparing the Patient for PCI PCI Procedure Care of the patient post-PCI Slide 3 Coronary Artery Bypass Surgery Care of the Patient Post-CABG Surgery Complications Discharge Planning
VI. Chapter Summary VII. Clinical Reasoning Checkpoint
VIII. Post-Test IX. References
Suggestions for Classroom Activities • Review and draw the five phases of plaque development. • Show a video of the various stages of atherosclerotic development.
Suggestions for Clinical Activities • Assign the student to a patient diagnosed with a myocardial disease process with some form of hemodynamic monitoring. • Have the student review rhythm strips from a patient suffering chest pain diagnosed as angina. The rhythm strip may be from the admission chart of the student’s assigned patient or from another patient with rhythm strips obtained during chest pain. Identify the various wave forms and measure the intervals and complexes. • Develop a nursing process for the care of the patient suffering from chest pain and, in post conference, discuss the objective and subjective assessment data presented in the patient’s chart.
CHAPTER
15
Determinants and Assessment of Cerebral Tissue Perfusion
Objectives: 1. Explain selected anatomy and physiology of the brain, including cerebral tissue perfusion. 2. Describe the components of intracranial pressure (ICP), including the Monro-Kellie hypothesis, and cerebral perfusion pressure. 3. Assess cerebral tissue perfusion. 4. Describe procedures used in diagnosing brain injury.
I. Selective Neurological Anatomy and Physiology A. The central nervous system (CNS) consists of the brain and spinal cord, which act to accept, interconnect, interpret, and generate responses to nerve impulses originating in other parts of the body. 1. Cerebrum—The two hemispheres of the cerebrum, the right and left hemispheres, accounts for 60% of the brain weight. a) Each cerebral hemisphere is divided into lobes (frontal, parietal, temporal, and occipital) and communicates with the other via nerve fibers called the corpus callosum. b) The diencephalon, located deep within the cerebrum and superior to the brainstem, consists of the thalamus, hypothalamus, pituitary gland, and the epithalamus, which contains the pineal gland (Patton, Thibodeau, & Douglas, 2012; Martini, Bartholomew, & Bledsoe, 2008). 2. Cerebellum—The cerebellum is the second largest brain structure. a) Cerebellar functions include coordination of skeletal muscles, balance and postural stability, and fine motor movement (Patton et al., 2012). 3. Brainstem—contains the midbrain, pons, and medulla oblongata. 4. Meninges—are the protective connective tissue that covers the brain and spinal cord, forms the divisions that separate the lobes and structures of the brain, and contains venous sinuses. 5. Ventricles and Cerebral Spinal Fluid—The brain contains four ventricles, which are chambers that contain cerebral spinal fluid (CSF). 6. Spinal Cord—The spinal cord is centrally located within the spinal cavity of the vertebral column. B. The peripheral nervous system—The peripheral nervous system (PNS) links the CNS with the rest of the body, from which it receives information and to which it sends information. The PNS consists of nerves (cranial and spinal) and sensory receptors peripherally located (outside of the brain and
spinal cord). Spinal nerves originate from the spinal cord and contain both sensory and motor fibers, which branch out and innervate the rest of the body. 1. The autonomic nervous system (ANS) is a component of the peripheral nervous system and regulates the internal environment of the body. a) The sympathetic nervous system (SNS) mediates stress by preparing the body to respond to stimuli that are perceived as harmful or stressful, known as the fight or flight response. b) Table 15-3 and Table 3 lists effects of both the SNS and the parasympathetic nervous system on target organ systems and tissues. C. Arterial circulation—Cerebral arteries are structurally different from other arteries. 1. Circle of Willis, a connecting junction that provides collateral blood flow to either side of the brain. 2. The vertebrobasilar system supplies the posterior portion of the cerebrum, cerebellum, and brainstem. 3. The network of cells and membranes in the brain capillaries, called the blood–brain barrier, allows lipids, glucose, amino acids, water, carbon dioxide, and oxygen to pass through it, thus maintaining a controlled environment. Substances that can irritate the brain—such as urea, creatinine, proteins, some toxins, and most antibiotics—cannot pass through this barrier into the brain. D. Cerebral venous circulation—from the brain is a low-pressure system, as compared with the arterial circulation, which is a high-pressure, high-resistance system. Craniospinal veins are valveless and drain by gravity, an important characteristic to remember when positioning patients with increased intracranial pressure. E. Cerebral oxygenation—The brain requires a continuous supply of glucose, oxygen, and substrates for energy because it cannot store oxygen, and its glucose reserves last for only a few minutes. 1. Cerebral blood flow (CBF), or blood flow to the brain, varies regionally as well. 2. Autoregulation enables cerebral arterioles to alter their blood flow within a mean arterial pressure (MAP) limit (60 to 130 mm Hg in adults), to promote a constant blood supply to the brain regardless of systemic blood pressure fluctuations. 3. Hyperemia exists when CBF is higher than the metabolic needs of the brain.
PowerPoint Slides 1. The Central Nervous System (CNS) 2. Cerebellum 3. Brainstem 4. Meninges 5. Ventricles and Cerebral Spinal Fluid 6. Spinal Cord 7. The Peripheral Nervous System 8. Arterial Circulation—Cerebral arteries are structurally different from other arteries
9. Cerebral Venous Circulation Contents of the intracranial vault 10. Cerebral Oxygenation
II. Intracranial and Cerebral Perfusion Pressures A. Intracranial pressure—The intracranial vault is a rigid container within a limited space. 1. The contents of the intracranial vault include: a) The brain (80%) b) Cerebral blood volume (12%) c) Cerebrospinal fluid (CSF) (8%) 2. Monro-Kellie Hypothesis—The Monro-Kellie hypothesis: a change in volume of any one of the above components must be accompanied by a reciprocal change in one or both of the other components. If the reciprocal change is not accomplished, the result is an increase in ICP. a) Brain Volume (1) Mainly water; the majority of the water is intracellular. (a) Kept constant through the blood-brain barrier, a network of cells and membranes in the brain capillaries i. Blood-brain barrier controls volume by regulating the solutes and water that attempt to cross it and enter the cerebral circulation. ii. Permeable to water, oxygen, lipid-soluble compounds, carbon dioxide; slightly permeable to electrolytes. Most drugs do not cross the blood-brain barrier. iii. Barrier can be physically disrupted by trauma or functionally impaired by metabolic abnormalities (such as drug overdoses). b) Cerebral Blood Volume (1) Amount of blood in the cranial vault at any point in time (2) Maintained at a constant level by cerebral blood flow (CBF) (3) Conditions that affect CBF and cerebral blood volume (a) Systemic hypo-/hypertension (b) Body metabolic rate (c) Systemic acidosis/alkalosis (d) Cerebral vasodilation/constriction (e) Cardiac output c) Cerebrospinal Fluid (1) Circulates in the subarachnoid spaces and spinal cord, and reabsorbed into the venous system. (2) Functions: (a) Cushions and supports the spinal cord (b) Maintains a stable chemical milieu for the nervous system (c) Excretes toxic wastes (carbon dioxide, lactate, and hydrogen ions) (3) Of the three components in the cranial vault, is displaced most easily and rapidly into the external jugular veins.
B. Cerebral perfusion pressure 1. ICP is measured in the CSF, and is defined as the pressure exerted by the CSF within the ventricles of the brain. 2. Normal ICP ranges from 0 to 15 mm Hg (0–10 mm Hg in children). 3. ICP fluctuates (in response to changes in respiratory rate, body position, coughing, or sneezing), and is considered abnormal if increase is sustained for more than five minutes. 4. When ICP approaches 30 mm Hg, autoregulation fails. 5. Causes of increased ICP include: a) Cranial surgery (blood clot, pneumocephalus (air), cerebral edema) b) Increased CBF (increased BP, PaCO2; decreased PaO2, vasodilators) c) Increased intrathoracic pressure (coughing, straining, suctioning, PEEP) d) Decreased cerebral venous draining (supine position with head of bed flat, neck flexion/rotation).
PowerPoint Slides 1. The Intracranial Vault: Rigid Container 1a. Monro-Kellie Hypothesis 2. Brain Volume 2a. Slightly Permeable to Electrolytes 3. Cerebral Blood Volume 4. Cerebrospinal Fluid (CSF) 5. Intracranial Pressure (ICP) 5a. Abnormal if increase sustained > 5 minutes
III. Assessment of Cerebral Tissue Perfusion—Decreased cerebral perfusion pressure (CPP), requires prompt recognition. A. Level of consciousness 1. The most important component of the neurologic assessment in the high acuity patient. a) Several terms are used to describe LOCs. 2. Components of Consciousness a) Arousal (1) Assessment involves the reticular activating system. (a) Glasgow Coma Scale (GCS) (3–15) i. Score < 7 = coma ii. Certain patient conditions, such as motor deficits or inability to open eyes for other reasons, prevent use. iii. Determine what stimulus arouses the patient. (a) Central stimulation: (b) Trapezius pinch
(c) Sternal rub (d) Supraorbital pressure (iv) Peripheral stimulation: (a) Decorticate posturing (abnormal flexion) indicates cerebral hemisphere dysfunction. (b) Decerebrate posturing (abnormal extension) indicates brainstem dysfunction (more ominous). b) Content (1) Content (awareness; orientation to time, place, and person) (a) Assessment evaluates the cerebral hemispheres. i. Alterations in content are manifested by cognitive deficits: (a) Memory impairment (b) Disorientation (c) Impaired problem-solving abilities (d) Attention deficits ii. Degree of cognitive deficit is related to the location (and whether localized or diffuse) and the size of the lesion. (a) Assess by noting behavior: 1. Orientation (assuming patient can respond verbally) 2. Patient should know name, date, location 3. Ability to follow commands 4. Behavioral changes (restlessness, irritability) 5. Verbal response (speech pattern) a) Receptive aphasia (inability to understand written or spoken words) b) Expressive aphasia (inability to write or use language appropriately) c) Global aphasia (inability to use or understand language) B. In-depth clinical assessment 1. Pupillary Reactions a) Pupillary reactions provide information about the location of lesions. b) Pupils assessed for size, symmetry, shape, reaction to light. 2. Oculomotor Responses—determine brainstem integrity, test cranial nerves a) Awake patient: Ask patient to do extraocular eye movements. b) Unresponsive patient: (1) Oculocephalic (doll’s eyes) reflex (do this one first). (2) Oculovestibular (cold caloric) reflex: cold water into ear canal. (3) Intact brainstem causes nystagmus (lateral tonic deviation of eyes). (4) Don’t use with ear drainage or perforated tympanic membrane. 3. Vital Signs a) Respirations
(1) Respiratory rate and pattern: (a) Are controlled by the medulla. (b) Useful information: correlates with the anatomic level of dysfunction. i. Cheyne-Stokes pattern indicates bilateral lesion. ii. Central neurogenic hyperventilation. iii. Apneustic breathing. iv. Cluster breathing. v. Ataxic breathing. (2) Remember that abnormal respiratory patterns can have a variety of other causes (anxiety, pulmonary disease, drugs, etc.). b) Pulse—Increased heart rate could indicate poor cerebral oxygenation. (1) Heart rate and rhythm: (a) Increased heart rate could indicate poor cerebral oxygenation. (b) Decreased heart rate is present in late stages of increased ICP. (c) Pulse oximetry. c) Blood Pressure d) Temperature (1) Hypothalamus is the center of temperature regulation, so alterations indicate injury or dysfunction there. (a) Hypothermia is a result of spinal shock, metabolic coma, drug overdose, and destructive lesions of the hypothalamus. (b) Hyperthermia occurs as a result of CNS infection, subarachnoid hemorrhage, hypothalamic lesions, or hemorrhage. 4. Cranial Nerve Reflexes—indicate brainstem functioning. They are protective reflexes, and if any of the following are absent, measures must be taken to protect the patient from injury: a) Corneal reflex (blink) b) Gag reflex c) Swallow reflex d) Cough reflex C. Intracranial pressure monitoring 1. Continuous monitoring a) Allows titration of therapies to prevent ischemia. b) Enables identification of impending brain herniation. c) Determines the need for and impact of therapies. d) Predicts outcome. 2. Not all patients with altered cerebral tissue perfusion are appropriate candidates for ICP monitoring. It is appropriate with either: a) Patients with a GSC < 8 who also have abnormal findings on a head CT scan. b) Patients with evidence of altered cerebral tissue perfusion, but who have a normal head CT scan and have two or more of the following characteristics:
(1) Age > 40 years (2) Unilateral or bilateral motor posturing (3) Systolic blood pressure < 90 mm Hg 3. Types of ICP Monitoring Devices a) Intraventricular catheter (IVC) (the gold standard) (1) Provides precise and consistent waveforms (2) Also used therapeutically to drain CSF from the intraventricular cavity (3) Most invasive method (introduced directly into brain tissue), so there is a risk of infection, of bleeding, and of neuron destruction (4) Contraindicated for patients with coagulopathies, small or collapsed ventricles, or severe generalized cerebral edema b) Subarachnoid screw or bolt (1) Used in patients with small, collapsed, or shifted ventricles. (2) Placed into the subdural or subarachnoid space. (3) Also measures ICP and provides waveform monitoring, but bits of bone and brain tissue can obstruct the tip of the bolt. (4) Unlike using IVC, drainage of CSF is not possible. c) Intraparenchymal catheters (1) Placed directly into brain tissue via a bolt device (2) Easy to place, provide sharp and distinct waveforms, transmit accurate ICP measurement, and carry a low risk of infection (3) More costly, require a separate monitoring system, and do not have CSF drainage capabilities d) Epidural probes (1) A small fiber optic sensor placed through a burr hole and into the epidural space (2) Easy to place and carry low risk of infection, but CSF cannot be drained 4. ICP Waveforms a) From pulsations transmitted in the brain from intracranial arteries and veins. b) There are three peaks within each ICP waveform (P1, P2, P3). c) There are three types of ICP pressure waveform patterns (A (plateau) waves, which indicate neurologic deterioration; B waves, which indicate intracranial compliance; and C waves, which vary with respiration and blood pressure). D. Cerebral oxygenation monitoring 1. Jugular bulb oximetry a) Measures cerebral oxygen saturation to assess the relationship between cerebral oxygen supply and demand. b) Cerebral oxygen extraction is the difference between the percentage of oxygen delivered to cerebral tissue or the percentage returning from cerebral tissues. (1) The nurse monitors for changes in SjO2 measurements using an established set of parameters, such as noted below (Slazinski, 2011a):
(a) 55 to 70%: Indicates normal range (b) Less than 45 to 50% (or Ceo2 greater than 40%): Reflects brain ischemia (c) Greater than 70% (or Ceo2 less than 24%): Reflects brain hyperemia (elevated brain blood volume) or death of brain cells (dead tissue does not extract oxygen). If either cerebral ischemia or hyperemia persists for more than 15 minutes, the nurse should notify the provider (Chow & deMoya, 2010; Slazinski, 2011a). 2. Brain tissue oxygen monitoring a) Provides continuous measurement of local brain tissue oxygen partial pressure (PbtO2). b) Normal PbtO2 is > 20 mmHg. c) Brain tissue extracts oxygen from the hemoglobin into the brain tissue, and is measured as partial pressure. d) The catheter is placed in the frontal white matter. A CT scan is recommended to verify correct placement.
PowerPoint Slides 1. Physical Assessments 1a. Physical Assessments (continued) 2. In-Depth Clinical Assessment 2a. Cranial nerve reflexes 2b. ICP waveforms
IV. Diagnostic Procedures A. Computed tomography scanning 1. Initial procedure of choice for head injury because it is non-invasive, produces rapid results, is safe and painless, and reduces the need for more invasive procedures, such as angiograms. 2. Useful for detecting primary injuries (skull fractures, hematomas, contusions) and secondary injuries (herniation, edema, and shifting of brain tissue secondary to swelling; and abscesses and tumors). 3. May be done with IV contrast to enhance visualization of vascular structures. 4. Xenon-enhanced CT can measure CBF. B. Magnetic resonance imaging 1. MRI image is superior to CT scanning. 2. As with CT scanning, can determine the anatomic location of a lesion, but with more anatomic detail than a CT scan can. Can detect pathologic processes at an earlier stage than with CT, so MRI is the procedure of choice for early diagnosis of cerebral infarction and brain tumors. 3. MRI is the preferred diagnostic study for cervical spine imaging and evaluation of spinal cord injury. 4. MRI limitations (compared to CT): a) Must remove all metal from the patient’s body (MRI is a powerful magnet). b) Obtaining an MRI takes longer than obtaining CT.
c) MRI provides a poor image of bone tissue. C. Tomography 1. Involves IV injection and tracking of radionucleotides to evaluate cerebral blood flow. a) Positron emission topography (PET) (costs more than SPECT) b) Single photon emission computed tomography (SPECT) D. Transcranial doppler 1. A non-invasive tool for measuring cerebral blood velocity in branches of the circle of Willis a) Velocity depends on the pressure gradient between the two ends of a vessel, the radius of the vessel, and blood viscosity. b) Ideal for use in the high-acuity environments because it’s non-invasive and uses portable equipment. c) Often used to monitor for cerebral vasospasm and intracranial lesions poststroke, and to detect cerebral blood flow changes associated with elevated ICP. E. Evoked potentials 1. Recordings of cerebral electrical impulses generated in response to visual, auditory, or somatosensory stimuli. a) Electrophysiologic response extracted from continuous EEG monitoring. b) So sensitive that it detects lesions that cannot be detected with other clinical or laboratory tests. c) Testing for evoked potentials does not require an alert, cooperative patient, and is not affected by anesthesia or sedation. F. Electroencephalography 1. Allows recording of the electrical activity of the brain using electrodes attached to the scalp. 2. Abnormal voltage fluctuations indicate seizures or space-occupying lesions, cerebral infarct, altered consciousness, and brain death. 3. Significant pathology can be present even in the face of a normal EEG. 4. Continuous EEG may be used in some high acuity units to monitor ICP, seizure activity, and cerebral ischemia. G. Cerebral angiography 1. Involves the injection of contrast material into arteries to visualize intra- and extracranial circulation. 2. Results can diagnose arteriovenous malformations, aneurysms, carotid artery disease, vasospasm, and venous thrombosis. 3. A major complication of the procedure is stroke, caused from the dislodgement of an atherosclerotic plaque. H. Magnetic resonance angiography 1. Combines MRI with angiography for noninvasive visualization of cerebral vasculature. 2. Useful in the evaluation of carotid artery disease and in the identification of intracranial aneurysms
I. Lumbar puncture 1. Procedure uses needle placed in subarachnoid space. 2. CSF is removed for laboratory analysis for the presence of blood or infection. 3. Medications may be administered by this route. 4. Contraindicated in patients with increased ICP.
PowerPoint Slides 1. Computer Tomography Scanning (CT) 2. Magnetic Resonance Scanning (MRI) 2a. MRI Limitations 3. Tomography 4. Transcranial Doppler (TCD) 5. Evoked Potentials 6. Electroencephalography (EEG) 7. Continuous EEG Used in High Acuity Units 8. Cerebral Angiography 9. Magnetic Resonance Angiography (MRA) 10. Lumbar Puncture (LP)
V. Chapter Summary VI. Clinical Reasoning Checkpoint VII. Post-Test VIII. References
Suggestions for Classroom Activities • Discuss and demonstrate the use of the Glasgow Coma Scale. Provide a series of scenarios, and allow the students to determine the patient’s ratings. Review the implications of each of the results. • Instruct students to measure each other’s blood pressure in different postures and, assuming ICP is 10 mm Hg, calculate their relative CPPs.
Suggestions for Clinical Activities • Assign students to care for patients who are experiencing neurological disorders. Observe the students performing comprehensive neurological assessments. • Review the Kardexes for patients diagnosed with neurological disorders. What types of interventions are seen? What treatments do the patients have in common?
CHAPTER
16
Mentation and Sensory Motor Complications of Acute Illness
Objectives: 1. Explain disorders of mentation and consciousness common to acute and critical illness. 2. Describe characteristics and management of delirium and coma. 3. Explain disorders of movement that occur with acute and critical illness, including polyneuropathy, myopathy, neuromuscular blockade, and related muscle weakness. 4. Describe characteristics and management of common seizure complications associated with acute and critical illness.
I. Decreased Level of Consciousness, Abnormal Mentation, and Anxiety A. Alterations in mentation 1. Alterations in LOC a) Disorders of mentation are classified as alterations in the level of consciousness and alterations in cognitive ability. (1) Impaired mentation is often unrecognized and not treated. b) Altered consciousness (wakefulness and responsiveness) and delirium are two disorders of mentation that are common in critically ill patients. (1) Delirium is associated with an aroused and unaware state. c) Mentation disorders are associated with: (1) Increased mortality. (2) Increased number of days requiring mechanical ventilation. (3) Longer hospital and ICU stays. d) Coma is characterized by the absence of arousal and awareness and can be reversible. e) Dementia is associated with an aroused and aware state of consciousness. 2. Alterations in cognitive function a) There are many causes of cognitive dysfunction or impaired mentation in patients who have not sustained a head injury: (1) Infection (2) Ischemia
(a) Ischemic stroke is the most frequent cause of impaired mentation on admission to an ICU. B. Anxiety and insomnia 1. Anxiety and insomnia are contributing factors to the development of cognitive dysfunction (the inability to reason) and altered mentation. 2. Treatment for insomnia, anxiety, or both includes the administration of benzodiazepines. a) Therapy should be started at the lowest recommended dosage. b) Toxicity can occur in the presence of malnutrition, advanced age, hepatic disease, and concomitant use of alcohol, other CNS depressants, isoniazid, or cimetidine. c) Certain benzodiazepines with longer half-life can contribute to an accumulation of active metabolites in the elderly or in those with liver disease. (1) This accumulation can contribute to the development of prolonged sedation, delirium, psychomotor impairment, and respiratory depression.
PowerPoint Slides 1. Disorders of mentation 2. Altered consciousness and delirium are two disorders of mentation common in critically ill patients. 3. Mentation disorders are associated with: 4. Coma 5. Dementia 6. Causes of cognitive dysfunction or impaired mentation in patients who have not sustained a head injury include: 7. Anxiety and insomnia are contributing factors to the development of cognitive dysfunction and altered mentation. 8. Treatment for insomnia, anxiety, or both includes the administration of benzodiazepines.
II. Delirium and Coma A. Delirium—Delirium is the most common cognitive disorder in acute and critically ill patients. 1. One of the six leading causes of preventable injury in those older than 65 years old. 2. Develops in 20–50% of ICU patients not receiving mechanical ventilation. 3. Develops in 60–80% of patients receiving mechanical ventilation. 4. It can add as many as 10 additional days to a patient’s hospital stay. 5. Delirium in ICU is associated with higher in-hospital mortality. 6. Delirium risks are cumulative, in that for each additional day spent in delirium, there is a 20% increase in the risk of prolonged hospitalization and a 10% increase in risk of death. 7. Between 10 and 24% of patients experience persistent delirium that might be related to longterm cognitive impairment. 8. Defining Delirium—an acute confusional cognitive disorder.
a) Delirium is characterized by attention deficits, fluctuating mental status, and either disordered thinking or an altered level of consciousness that develops over a short period of time (hours to days) and fluctuates over time. b) The hallmark of delirium is its acute onset and/or fluctuating clinical course. c) Delirium is a dynamic state that is characterized by both hypo- and hyperactive behaviors (1) Hyperactive Delirium—(also known as encephalopathy) is characterized by lethargy, withdrawal, flat affect, apathy, and decreased responsiveness. (a) It is the most common form of delirium in the elderly. (2) Hypoactive and Mixed Delirium—Hyperactive delirium (a.k.a. ICU psychosis) is less common and associated with better overall prognosis. (a) It is characterized by agitation and restlessness, and it is common for these patients to “pick” at their monitoring, feeding, or intravenous devices. (3) Septic Encephalopathy—Septic encephalopathy is a type of delirium that results from a non–central nervous system infection or sepsis in 50–70% of ICU patients. (a) The encephalopathy can be an early sign of a septicemia. 9. Differentiating Delirium from Dementia a) Delirium and dementia are distinct mental disorders that are easily confused because of two overlapping clinical characteristics: attention deficits and abnormal thinking. (1) Dementia is characterized by slow, insidious onset of memory impairment that follows a long-term, progressive course over a period of months to years. It is irreversible, chronic in nature, and progressive. 10. Etiology—Risk factors for developing delirium a) Sleep deprivation b) Dementia, advanced age, comorbidity, and depression c) Precipitating factors: Preexisting hypertension, smoking, alcoholism, increased severity of illness scores, hypoxia, metabolic disturbances, electrolyte imbalances, withdrawal syndromes, acute infection, seizures, dehydration, hyperthermia, head trauma, vascular disorders, impaired vision or hearing, and immobilization 11. Assessments and management a) The management and prevention of delirium should focus on identifying and treating the underlying cause. b) Assessment for delirium should occur early in a patient’s hospitalization or critical care course. c) Early monitoring for delirium, along with daily goals for sedation and analgesia, are essential in creating a treatment plan that effectively manages pain and includes sedation while avoiding overuse of agents that are known to cause delirium. d) Prevention should be the major goal of care. e) Interventions for delirium are classified as physiologic, environmental, patient safety, and pharmacologic. (1) Physiologic measures include correction of dehydration, metabolic, and oxygenation imbalances.
(2) Environmental interventions include early mobilization, adequate sleep/rest, and providing patients with eyeglasses and hearing aids when appropriate. (a) Encouraging family/significant other visitation, placing patients near a window, providing for TV or radio stimulation, and maintaining normal day/night light variations help the patient to remain oriented, rested, and free of delirium. (3) Pharmacologic interventions for delirium include using neuroleptics or benzodiazepines to manage symptoms. B. Coma is persistent unarousability lasting for more than six hours and implies extensive brain injury. 1. Assessments and management a) Common causes of coma are cardiac arrest, stroke, and intracerebral hemorrhage. b) For ICU patients with persistent coma, the outcome is poor. c) Outcomes of coma include full recovery with no long-term residual effects, recovery with residual damage that can include learning deficits, emotional instability, or impaired cognition/judgment. More severe outcomes include persistent vegetative state or brain death.
PowerPoint Slides 1. Delirium is the most common cognitive disorder in acute and critically ill patients. 2. Delirium is an acute confusional cognitive disorder. 3. Risk factors for developing delirium 4. Management of delirium 5. Coma is persistent unarousability lasting for more than six hours and implies extensive brain injury.
III. Disorders of Movement A. Critical illness polyneuropathy and myopathy 1. Risk factors for development—Neuromuscular weakness disorders can produce severe and lifethreatening complications that can impair function and quality of life following acute or critical care illness. a) Critical illness polyneuropathy (CIP) and critical illness myopathy (CIM) are complications of acute and critical illness. (1) They are associated with progressive and uncontrolled systemic inflammation, such as that which occurs with systemic inflammatory response syndrome (SIRS), severe sepsis, and multiorgan failure. (2) These neuromuscular weakness disorders are relatively common and often go undetected because they are overshadowed by the more prominent clinical manifestations of the inciting conditions. (3) The onset of CIP can occur as early as three days after the diagnosis of sepsis or SIRS. (4) CIP and CIM also have been associated with prolonged mechanical ventilation, malnutrition, coagulopathies, high-dose corticosteroids, the use of certain antibiotics (aminoglycosides such as gentamicin), use of neuromuscular blocking agents (most notably pancuronium bromide), electrolyte disturbances, and elevated glucose levels.
(5) Both CIP and CIM are present in 52–57% of patients in the ICU for seven days or more, and in 68–100% of patients with sepsis or SIRS. 2. Critical illness polyneuropathy—CIP is an acute axonal sensory-motor polyneuropathy that mainly affects the lower limb nerves. a) CIP is often preceded by septic encephalopathy and is followed by difficulty in weaning from the ventilator. b) Symptoms include reduced or absent movement of the affected limbs and distal loss of pain, temperature, and vibration sensory abilities. c) Deep tendon reflexes and autonomic function are preserved in CIP. d) Onset of CIP is variable, occurring from two days to a few weeks after the onset of the inciting illness. e) Electrodiagnostic testing (with nerve conduction studies and electromyograms) are necessary to diagnose this disorder. f) There is no specific treatment for CIP. g) Prevention by anticipation of this complication and prompt treatment of the predisposing condition comprise the plan of care. h) Tight glucose control with intensive insulin therapy can reduce the incidence of critical illness polyneuropathy by 44%. i) Complete recovery is expected in 50% of cases. 3. Critical illness myopathy—CIM is a spectrum of muscle disorders that present with diffuse weakness, depressed deep tendon reflexes, and mildly elevated creatine kinase levels. a) Electrodiagnostic testing reveals a myopathy, and muscle biopsy reveals atrophy with loss of the thick myosin filaments. b) Neuromuscular blocking agent use is associated with CIM. c) There is no specific treatment for CIM, and most patients with this disorder make a full recovery within a few months. d) Pulmonary complications are particularly problematic for patients with CIP and CIM. (1) Pulmonary consequences of progressive neuromuscular weakness include decreased respiratory muscle strength, impaired cough and ability to clear secretions, increased risk of infection and airway obstruction, atelectasis, progressive hypoxemia, alveolar hypoventilation, and hypercapnia. (2) Management of these complications includes careful observation of oxygenation and ventilator status, chest physiotherapy, tracheal intubation, supplemental oxygen, mechanical ventilation, and PEEP. B. Neuromuscular blockade and paralysis 1. Action a) Common to induce paralysis in mechanically ventilated patients whose agitation interferes with ventilation. b) The goal is to maximize oxygenation and ventilation by control of ineffective breathing patterns. 2. Nondepolarizing agents
a) Neuromuscular blocking (NMB) agents are used only when analgesia and sedation have not been effective or when needed to facilitate treatment. b) They might be indicated for patients who are mechanically ventilated, for those with tetanus, or for patients with increased intracranial pressure (ICP). 3. Potential complications a) NMB agents used in the critical care settings are pancuronium (Pavulon), cisatracurium (Nimbex), vecuronium (Norcuron), and rocuronium (Zemuron). b) Aminoglycosides, antibiotics, hypothermia, hyperkalemia, and hypercalcemia potentiate the effects of neuromuscular blocking agents. c) The use of neuromuscular blockage is associated with: (1) Prolonged muscle weakness after the drug is discontinued. (2) Elevated serum creatine kinase levels, muscle fiber atrophy, and muscle fiber necrosis. (3) Immobility complications, including deep vein thrombosis, pulmonary embolism, atelectasis, and pneumonia. d) It is important to establish effective levels of sedation and analgesia before initiating paralysis to avoid fearful and painful reactions. 4. Nursing considerations a) When administering neuromuscular blocking agents, the nurse should monitor the level of paralysis or neuromuscular blockade by applying a “train of four” series of low-frequency (2Hz) electrical impulses (current strength 50–90 milliamps) to the ulnar nerve at the forearm and observing for adduction of the thumb. b) Nursing management during prolonged neuromuscular blockade also consists of protecting the airway, maintaining adequate ventilation, monitoring cardiac rhythm and blood pressure, treating pain and anxiety, protecting the patient’s eyes, and maintaining skin integrity.
PowerPoint Slides 1. Neuromuscular weakness disorders complications 2. CIP is an acute axonal sensory-motor polyneuropathy mainly affecting the lower limb nerves. 3. CIM is a spectrum of muscle disorders that present with diffuse weakness, depressed deep tendon reflexes, and mildly elevated creatine kinase levels. 4. Neuromuscular blockade and paralysis 5. Potential Complications 6. Nursing Considerations
IV. Seizure Complications in High-Acuity: Patients A. Causes 1. Seizures are a sensory motor complication that can occur in critically ill patients. a) The incidence of new onset seizures in ICU patients is 0.8–3.5%. b) Seizures are manifested by muscle contractions characterized as tonic, atonic, clonic, or myoclonic.
c) The tonic phase of a seizure is characterized by a sudden loss of consciousness and sharp tonic muscle contractions. d) The clonic phase is characterized by alternating contraction and relaxation of the muscles in all of the extremities, along with hyperventilation. e) Atonic seizures cause a brief loss of motor tone that can cause the patient to fall. f) Absence seizures (petit mal) are brief, last less than 10 seconds, and are associated with less prominent changes in muscle tone. g) Generalized tonic-clonic seizures (formerly grand mal) have an initial tonic phase that is associated with apnea and cyanosis. h) Status epilepticus refers to seizures that are continuous for more than 30 minutes or seizures that recur without a recovery of consciousness. (1) Mortality is highest in this type of seizure activity. 2. Causes of new-onset seizures a) New onset seizures can be the result of drug intoxication, drug withdrawal (alcohol, sedative, or opioid), infections, head trauma, ischemic injury of the brain, space-occupying lesions of the brain, or systemic metabolic derangements that can occur with hepatic or renal failure, sepsis, hypoglycemia, hyponatremia, or hypocalcemia. b) Toxic levels of certain drugs. c) Withdrawal from some drugs can precipitate seizure activity. B. Classification 1. Generalized tonic–Clonic a) Adverse effects of generalized seizures include hypertension, lactic acidosis, hyperthermia, respiratory compromise, pulmonary aspiration or edema, rhabdomyolysis, self-injury, and irreversible neurological damage, especially if the seizure lasts for more than 30 minutes. C. Management of acute onset seizures 1. Pharmacotherapy—Identify any correctible etiology of the seizure and treat appropriately. If the seizure lasts for longer than 5–10 minutes, drug management will be needed. a) Benzodiazepines (1) Intravenous benzodiazepines (lorazepam, diazepam) are effective in stopping the seizure 65–80% of the time (Marino, 2007). b) Phenytoins (1) Intravenous phenytoins, including fosphenytoin (Cerebryx) and phenytoin (Dilantin), should be administered with diazepam, or if the seizure is persistent despite lorazepam administration c) Other Drug Options (1) If seizures continue to persist despite administration of benzodiazepines, fosphenytoin, or phenytoin, other drugs are needed, including phenobarbital, propofol, midazolam, or pentobarbital. D. Status epilepticus 1. Some of these therapies require intubation and mechanical ventilation.
E. Nursing considerations 1. Observe the injection site frequently during administration of phenytoin to prevent infiltration. 2. Watch for respiratory depression, hypotension, arrhythmias, or further neurologic compromise, such as decreased level of consciousness during IV administration of medications. 3. Observe for signs and symptoms of an allergic reaction, such as rash or itching, burning or tingling, or glucose intolerance in diabetics.
PowerPoint Slides 1. Seizures are a sensory motor complication. 2. New-onset seizures 3. Management of acute-onset seizures 4. Nursing care for acute-onset seizures
V. Chapter Summary VI. Clinical Reasoning Checkpoint VII. Post-Test VIII. References
Suggestions for Classroom Activities • Visit a health care facility that treats a large elderly population (or invite an administrator to visit the classroom). Ask about the most common disorders of mentation and consciousness that they see. Discuss how frequently these problems are seen in this population and contributing causes. • Using the internet, go to the U.S. Census Web site: www.census.gov. Under “Subjects A-Z,” research: disorders of mentation, dementia, elderly, etc. • Table 24-6 discusses the interventions for management of acute-onset seizures. Special Table-1 discusses the nursing care for patients experiencing seizures. Discuss these in small groups, citing examples of patients that you have cared for, and list ways to improve your patient care.
Suggestions for Clinical Activities • Review the standards of care for patients with seizures. Determine what procedures/methods can be implemented with the patients you care for. • Assign students to patients having a history of seizure disorders. Review the care plan in the postconference period.
CHAPTER
17
Acute Stroke Injury
Objectives: 1. Define stroke and discuss the major classifications of stroke. 2. Explain the pathophysiology of stroke. 3. Identify the modifiable and nonmodifiable risk factors for stroke. 4. Analyze the manifestations of stroke and explain the rationale of various diagnostic tests used in the evaluation of stroke. 5. Apply the collaborative management of acute stroke. 6. Apply priority-nursing interventions for the patient with acute stroke.
I. Definition and Classifications of Strokes A. Major classifications of stroke 1. Stroke, or acute brain attack, is an acute neurologic deficit that occurs when impaired blood flow to a localized area of the brain results in injury to brain tissue. a) Sometimes called “brain attack” to raise awareness of the need for rapid emergency treatment, similar to that with heart attack. b) It is the third-leading cause of death in the United States, and a leading cause of serious longterm disability. c) There are two major classifications of stroke: ischemic and hemorrhagic. (1) Ischemic: Occurs when blood supply to a part of the brain is suddenly interrupted by a thrombus or embolus. (2) Hemorrhagic: Occurs when there is bleeding into brain tissue, e.g., with head injury, aneurysms, arteriovenous malformations, or hypertension. 2. Ischemic Strokes—the most common cause of ischemic stroke is atherosclerosis of cerebral arteries. a) Deposits of atherosclerotic plaque narrow vessel lumens and decrease cerebral blood flow. b) Plaque deposits cause thinning, weakening, and holes in the vessel lining. c) Platelet plugs adhere and aggregate in the hole, leading to clot formation. (1) Thrombotic stroke: Clot remains at the site, eventually getting large enough to occlude the vessel completely. (2) Embolic stroke: Clot breaks off and become an embolus.
(2)
d) Thrombotic stroke is frequently accompanied by evidence of atherosclerotic plaque deposits in the coronary or peripheral vasculature. (1) They are more common in older persons, can occur at rest, and are not associated with activity. Lacunar infarcts are thrombotic strokes involving smaller vessels. (a) Infarcted areas leave behind small cavities (lacunae, or lakes). (b) Lacunar infarcts occur in deep-penetrating arteries in a single region of the brain. e) Embolic stroke is caused by a blood clot that travels from its original site and eventually becomes lodged in a vessel. (1) Most emboli originate from a thrombus in the heart that develops with certain cardiac conditions: (a) Atrial fibrillation (b) Rheumatic heart disease (c) Recent myocardial infarction (d) Endocarditis (2) Emboli also can originate from rupture of atherosclerotic plaque. (3) Embolic strokes, common in younger individuals, occur suddenly when the person is awake and active. f) Transient ischemic strokes are preceded by episodes of focal neurologic deficits called transient ischemic attacks (TIAs). (1) Interruption of cerebral blood flow can result in TIA. (2) TIAs can resolve in a few minutes and are always completely resolved within 24 hours. (3) They manifest with sudden unilateral dimness or partial loss of vision in one eye, weakness, numbness, tingling, severe headache, speechlessness, or unexplained dizziness. (4) The symptoms are produced by inadequate perfusion to the brain caused by carotid or microemboli TIAs, are warnings of an impending stroke, and require immediate referral for treatment. (a) The highest incidence for stroke occurs within the first few weeks after the TIA. (b) The more frequently the TIAs occur, the higher the probability of stroke. 3. Hemorrhagic strokes a) Intracerebral hemorrhage occurs when a cerebral blood vessel ruptures and blood accumulates in brain tissue, causing compression of intracerebral contents, edema, and spasm of adjacent blood vessels. (1) Hypertension is a common cause; other causes include arteriovenous malformations, anticoagulant therapy, aneurysms, trauma, and erosions of blood vessels by tumors. (2) Appears suddenly without warning, unlike ischemic strokes, which are preceded by TIAs. (3) Spontaneous intracranial hemorrhage is the most common cause of a fatal stroke. (4) Several conditions can cause a cerebral blood vessel to rupture, including degenerative changes, developmental defects, high–blood flow areas, and hypertension. b) Subarachnoid hemorrhage (SAH) is bleeding in the subarachnoid space, frequently caused by leakage of blood from aneurysms.
(1) Develops suddenly without warning. (2) Signs include sudden, severe unilateral headache; nuchal rigidity; photophobia, and vomiting. (3) The cerebrospinal fluid (CSF) is usually bloody because the aneurysm commonly ruptures in the subarachnoid space. (4) Following a SAH, a decrease in cerebral blood flow and transient loss of consciousness secondary to increased intracranial pressure (ICP) can occur.
PowerPoint Slides 1. Definition of stroke 2. Atherosclerosis of cerebral arteries 3. Thrombotic strokes 4. Embolic stroke 5. Transient ischemic attack (TIAs) 6. Intracranial hemorrhage 7. Subarachnoid hemorrhage (SAH)
II. Pathophysiology of Stroke A. A stroke is characterized by neurologic deficits that occur when cerebral blood flow is diminished as a result of ischemic or hemorrhagic cerebral vascular events. 1. The majority of strokes result from ischemic infarction and inadequate blood flow. 2. The process of atherosclerosis results in plaque formation, which enhances platelet aggregation and results in narrowing or occlusion of arteries. a) Atherosclerosis of cerebral arteries is similar to that found in cardiovascular arteries. b) Formation of a blood clot on atherosclerotic plaque causes significant stenosis of cerebral arteries. c) The most common site of atherosclerosis is at the bifurcation of the common carotid artery. 3. An embolism results in a stroke when a clot, plaque, or platelet plug breaks off an atherosclerotic lesion, enters the circulation, and blocks an artery. B. Diminished blood flow impairs oxygen delivery to neurons, resulting in impaired cellular function because the cells do not have enough oxygen to generate energy. 1. Without oxygen, cellular sodium–potassium pumps fail. 2. Intracellular concentrations of sodium, chloride, and calcium increase. 3. Electrolyte accumulation is toxic to intracellular structures, particularly mitochondria. 4. Severe or prolonged ischemia leads to cellular death. C. Cerebral ischemia can be focal or global. 1. Global ischemia a) Lack of collateral blood flow b) Irreversible brain damage (within minutes)
2. Focal ischemia a) Some degree of collateral circulation remains. b) Survival of neurons and reversal of neuronal damage are possible. c) Focal ischemia is treatable because of the potential for recovery. D. In the evolution of a stroke, there are usually two zones of affected neurons 1. In the central zone are neurons that are infarcted and dead. a) They do not function, and do not regain function. 2. The penumbra is a zone of neurons surrounding the infarcted zone that are minimally perfused but not totally ischemic. a) Although these neurons still function, they are somewhat impaired. b) They remain viable and are capable of responding to therapy within a certain period. c) If perfusion to neurons in the penumbra is reestablished, the cells recover function. d) If not, neurons in the penumbra die, and the central (nonfunctional) zone enlarges. E. The fundamental goal of medical management of stroke is to restore cerebral blood flow and limit the size and extension of the infarcted zone.
PowerPoint Slides 1. Stroke is neurologic deficit. 2. Diminished circulation impairs oxygenation, cell function. 3. Focal and global ischemia 4. Neurons in central zone 5. Penumbra surrounds infarcted zone. 6. Goals of medical management of stroke
III. Risk Factors for Stroke A. Modifiable risk factors 1. Blood pressure a) Hypertension (1) An important modifiable risk factor for stroke. (a) It is implicated in both ischemic and hemorrhagic strokes. (b) Both systolic and diastolic hypertensions (greater than 140/95) are risk factors. (c) Reduction of both systolic and diastolic pressures in hypertensive individuals reduces stroke risk by 30–40 percent. b) Hypotension (1) A sudden and profound hypotensive episode could be a significant risk factor. (a) Causes can include antihypertensive agents, myocardial infarction, and bleeding. (b) Elderly are especially at risk. c) Dehydration
(1) Dehydration can lower blood pressure dangerously and decrease perfusion in the elderly. (a) These patients already have an age-related decline in cerebral blood flow. 2. Cardiac disease a) Individuals with cardiac disease have more than twice the stroke risk compared with those without cardiac disease. (1) Coronary heart disease, congestive heart failure (2) Congestive heart failure (3) Left ventricular hypertrophy (4) Arrhythmias (specifically atrial fibrillation) b) To prevent stroke, implement cardiovascular risk reduction. c) Treat hyperlipidemia with statins, etc., to reduce risk of atherosclerosis. 3. Diabetes mellitus and dyslipidemia a) Diabetes mellitus is a risk factor for ischemic stroke involving large and small vessels. b) History: An individual with a previous stroke has a great risk of developing a recurrent stroke. c) Hypercholesterolemia (elevated total or low-density lipoprotein [LDL] cholesterol) (1) Dyslipidemia is a risk factor for atherosclerosis in both the coronary and cerebral vascular beds. (2) Lipid-lowering drugs (statins) reduce risk of stroke in patients with coronary artery disease and elevated total or LDL cholesterol. 4. Smoking a) Cigarette smoking causes increased fibrinogen and platelet aggregation. (1) Smoking reduces high-density lipoproteins. (2) Cessation of smoking rapidly reduces stroke risk. B. Nonmodifiable risk factors 1. Age a) Age is the single most important nonmodifiable risk factor for stroke. b) For each successive decade after 55 years, the stroke rate more than doubles. 2. Gender a) Men have a greater stroke risk than do women. 3. Race/ethnicity a) A higher percentage of African-Americans, particularly males, have hypertensive disease and strokes than do other races. b) Prevalence of certain modifiable risk factors among African-Americans might be the reason: (1) Obesity (2) Smoking (3) Diabetes mellitus 4. Genetic Factors a) There appears to be a genetic predisposition to stroke in women.
b) Aging women sustain a large burden for stroke. c) The specific gene has not been identified. d) Clinical trials do not support use of estrogen replacement therapy for prevention of vascular disease. 5. Reasons why control of these factors is still inadequate a) Poor patient compliance and adherence to behavior modifications. b) Decreased detection and treatment by health care providers. c) Further reducing the risk of stroke requires improving ability to identify, modify, and manage cerebral vascular risk factors.
PowerPoint Slides 1. Modifiable risk factors 2. Sudden and profound hypotensive episode 3. Dehydration 4. Cardiac disease more than doubles risk 5. Other modifiable risk factors: 6. Nonmodifiable risk factors 7. Race 8. Genetic factors 9. Why control of these factors is still inadequate
IV. Assessment and Diagnosis of Stroke A. Assessment 1. Manifestations of stroke a) The most common manifestation is numbness and weakness of the face and arm. b) Others are difficulties with balance or speech and loss of vision in one eye. c) Symptoms are usually sudden at onset and one-sided. d) The specific stroke signs depend on the specific vascular territory compromised. 2. Manifestations by type of stroke a) Thrombotic stroke: Manifestations typically occur rapidly but progress slowly. b) Embolic stroke: Manifestations typically appear suddenly and cause immediate neurologic deficits. c) Hemorrhagic stroke: Manifestations appear suddenly and depend on the location of the hemorrhage. d) Can include headache, nausea/vomiting, seizures, hemiplegia, and loss of consciousness. B. Determining Diagnosis and Recovery 1. Diagnosis a) A patient thought to be having a stroke requires prompt triage and determination of whether stroke is ischemic or hemorrhagic.
(1) Complete history of medical and neurological events and medication history are needed. (2) Perform a thorough physical assessment and focused neurological exam. (a) Irregular heart rhythm can indicate atrial fibrillation. (b) Hypertension increases the likelihood of intracranial hemorrhage. (c) Neurologic exam tests for signs of focal injury. 2. Diagnostic tests and procedures a) Rapid diagnosis of a stroke is essential so that patients who meet the inclusion criteria (and do not meet the exclusion criteria) can receive thrombolytic therapy, the goal of which is to save damaged brain tissue and minimize permanent deficits. b) The time of symptom onset to administration of thrombolytic therapy (or “time to needle”) should be within a 3-hour window (Goyal & Axelrod, 2011). c) A variety of tests and procedures are performed as soon as possible after arrival of the patient to the ED to determine the exact nature of the stroke. d) Table 17-4 lists some of the more common scans, ultrasonography, and angiography tests used for diagnosing strokes: (1) Lumbar puncture to detect blood in CSF if SAH is suspected but CT scan is negative (2) Transesophageal echocardiography to detect cardiac and aortic causes of embolism (3) A 12-lead ECG to detect cardiac abnormalities, prevalent among patients with stroke (4) A complete blood count (CBC) to detect coagulopathies and establish baselines for therapy (5) Serum electrolytes and blood glucose levels to rule out conditions that mimic stroke, e.g., hypoglycemia (6) Arterial blood gases (ABGs), drug screen, and serum alcohol level to detect possible causes of stroke (7) Doppler ultrasonography and duplex imaging—if carotid artery disease is suspected 3. Determining degree of recovery a) Internet resources for stroke assessment (1) The National Institutes of Health Stroke Scale is widely used in the United States to assess neurologic outcome and degree of recovery.
PowerPoint Slides 1. Stroke manifestations depend on territory compromised. 2. Prompt triage and determination of stroke type 3. Clinical assessment of suspected stroke patient 4. Internet resources for stroke assessment 5. Diagnostic tests and procedures 6. Other diagnostic tests and procedures
V. Medical, Surgical, and Nursing Management A. Medical management of strokes
1. Most strokes are caused by an occlusion of a cerebral vessel. Improvement and restoration of perfusion to the ischemic area are imperative. 2. Patients with acute ischemic stroke presenting to the Emergency Department within 48 hours of the onset of symptoms are given aspirin (50–325 mg/day). a) Reduces stroke mortality and decreases morbidity. b) Allergy and gastrointestinal bleeding must be absent. c) Only give if patient has not or will not be treated with tissue plasminogen activator. 3. Thrombolytic therapy a) Intravenous tissue plasminogen activator (tPA or rtPA) is strongly recommended for patients with acute ischemic stroke who meet specific criteria and who can be treated within three hours of onset of ischemic stroke (Summers, et al 2009; Lansberg et al., 2012). b) Recently, the window for which the patient may receive tPA has been extended to 4.5 hours from symptom onset (Lansberg et al., 2012; Summers et al., 2009). In patients with acute ischemic stroke in whom treatment cannot be administered within 4.5 hours of symptom onset, intravenous tPA is not routinely recommended. c) An exception to the 4.5 hour time limit rule is the patient with acute ischemic stroke due to occlusion of the proximal cerebral artery. d) In this situation tPA can be administered within 6 hours of symptom onset, by injecting it directly into the proximal cerebral artery (intra-arterial) at the clot site. e) Intravenous tissue plasminogen activator (rtPA) is strongly recommended for patients who can be treated within three hours of onset of ischemic stroke. (1) A small dose is given as a bolus and is followed by an IV infusion of the drug over an hour. (2) During and after infusion, perform frequent neurological assessments and evaluate blood pressure. (3) Discontinue infusion and notify physician immediately if patient develops nausea, vomiting, severe headache, or acute hypertension. (4) Give antihypertensive medications as required. (5) Delay placement of nasogastric tubes, bladder catheters, or intra-arterial catheters. 4. Other priority interventions a) In addition to thrombolytic therapy to reperfuse brain tissue, priority interventions in the first 24 hours of stroke care are management of oxygenation, blood pressure, serum glucose, dysrhythmias, and fever since alterations in these parameters are associated with worse outcomes. b) Oxygenation (1) It is important to maintain oxygen saturation at greater than 92%. c) Serum Glucose (1) Stress hyperglycemia is common and should be managed with rapid-acting insulin to decrease serum glucose if levels exceed 140 mg/dL (Summers et al, 2009). (2) Hyperglycemia of 155 mg/dL or greater has been associated with higher mortality and worse outcomes
d) Blood pressure (1) Many patients who experience an ischemic stroke are hypertensive. (2) Permissive hypertension is an evidence-based treatment strategy in which higher than normal blood pressures are allowed for maintaining optimal cerebral blood flow. (3) Hypotension following ischemic stroke should be avoided to prevent inadequate cerebral blood flow, which increases ischemia in the penumbra. e) Fever (1) Fever increases cerebral oxygenation consumption, which can increase ischemia and injury to the penumbra (Smith et al., 2012). (2) Fevers must be monitored frequently and managed aggressively in the acute stroke patient. f) Dysrhythmias (1) All patients admitted with acute stroke should have an admission ECG and continuous cardiac rhythm monitoring. B. Invasive procedure and surgical management of strokes 1. Angioplasty and stent placement a) Cerebral angioplasty can reverse neurological deficits caused by atherosclerotic lesions in the cerebral arteries. (1) Angioplasty uses a microballoon catheter to dilate vessels. (2) Catheter is introduced via the femoral artery and directed to the major arteries at the base of the brain. (3) Cerebral angiography carries risks of intracerebral hemorrhage, injury to the vessel wall, and distal embolization. (4) Vascular stenting is an alternative to angioplasty. (5) Following angioplasty or stenting, assess for neurologic and vital sign changes frequently until patient is neurologically stable. 2. Craniotomy a) Emergency surgery is indicated for cerebellar infarction or hemorrhage with clinical evidence of brainstem compression and increased ICP. (1) Cerebellar lesions are critical because a hemorrhage or infarction can rapidly become lifethreatening by compromising the brainstem. (2) Patients with large hemorrhages or infarctions are more likely to have brainstem compression and an urgent need for surgery. 3. Aneurysm clipping a) Bleeding into the subarachnoid space, such as that which occurs with a ruptured aneurysm, requires immediate medical attention. (1) Treatment depends on the severity of neurological symptoms. (2) People with no neurological deficits might require cerebral arteriography and early surgery. (3) Aneurysm clipping is performed within 72 hours of the bleed.
(a) Involves opening cranium, inserting metal clip around aneurysm to prevent rebleeding (4) Postoperative complications: cerebral vasospasm (decreases perfusion to brain tissue). (a) Prevent and treat with “triple H therapy” for the first 2–3 days postoperatively. (b) Stands for hypervolemia, hypertension, hemodilution. 4. Carotid endarterectomy a) A carotid endarterectomy removes exposed occlusive atherosclerotic plaque from the carotid artery. (1) For ischemic cerebrovascular disease, may be performed to prevent recurring cerebral infarcts and TIAs. (2) Removes the source of the occlusion and increases cerebral blood flow to the ischemic area. C. Nursing management 1. Initial Priorities a) When a stroke is suspected, the ABCs (airway, breathing, and circulation) are assessed. (1) Impaired airway clearance may result from hemiplegia, dysphagia, a weak cough reflex, and immobility. (2) Continuous monitoring of breath sounds, breathing patterns, oxygen saturation, skin color, and arterial blood gases (ABGs) is important. 2. Activity a) As the patient’s condition stabilizes, the activity level should increase, and physical therapy should be started for strengthening, range of motion, and early mobilization to prevent joint contractures and muscle atrophy of limbs. 3. Nutritional support and adequate fluid balance are important to offset malnutrition and dehydration, which can delay recovery, decrease cerebral perfusion, and increase the risk for venous thromboembolism (VTE). 4. Preventing infection a) Pneumonia and urinary tract infection are some of the most common infections that complicate stroke recovery. b) Interventions aimed at preventing aspiration pneumonia as well as urinary tract infections are necessary. c) Patients should be monitored for the presence of infection and antibiotics started promptly if identified. 5. Preventing complications a) In patients with acute ischemic stroke or TIA, the use of aspirin therapy at a dose of 160–325 mg is recommended (Lansberg et al., 2012). b) In patients with acute ischemic stroke and restricted mobility, prophylactic use of anticoagulant medications such as low molecular weight heparin (Lovenox) or heparin is recommended between days 2 and 4 following administration of thrombolytic agents c) Seizures may develop in a small percentage of patients with ischemic stroke and are most likely to occur within 24 hours of stroke onset; however, there is no evidence to support the
use of prophylactic administration of anticonvulsants after stroke (Summers et al., 2009). Seizures are managed with benzodiazepines and anticonvulsant medications. 6. Related nursing diagnoses a) Priority nursing diagnoses in the acute care phase include: (1) Ineffective breathing patterns related to decreased LOC, aspiration, loss of protective reflexes, or decreased in respiratory muscle tone (2) Ineffective airway clearance related to from hemiplegia, dysphagia, a weak cough reflex, and immobility (3) Altered cerebral tissue perfusion related to interruption of arterial blood flow resulting from obstruction or rupture of vessels in an area of the brain causing possible increase in ICP and neurologic deficits (4) Pain related to biological and physical factors of pressure or irritation to pain-sensitive areas resulting from hemorrhagic stroke, cerebral infarction, or carotid artery occlusive stroke
PowerPoint Slides 1. Rationale for interventions 2. Aspirin 3. Intravenous tissue plasminogen activator (rtPA) 4. Anticoagulants (heparin, low–molecular weight heparin, heparinoid) 5. Anticonvulsants 6. Cerebral angioplasty 7. Cerebral angioplasty risks 8. Emergency surgery for cerebellar lesion 9. Aneurysm clipping 10. Carotid endarterectomy
VI. Hospital Management and Secondary Prevention in the Acute Phase A. Risk for ineffective peripheral tissue perfusion 1. In the high-acuity unit, care of the patient with a stroke focuses on prevention and treatment of complications. a) Neurological complications include secondary hemorrhage, space-occupying edema, and seizures. b) Medical complications include infections, decubitus ulcers, deep vein thrombosis (VTE), and pulmonary embolism. 2. Prevent and treat deep venous thrombosis (VTE). a) Altered tissue perfusion related to interruption of flow and venous stasis from inactivity is a priority nursing diagnosis for patients in the acute phase after a stroke. b) Hemiplegic stroke patients are at great risk for VTE, which can lead to pulmonary embolus because of hemiplegia, loss of vasomotor tone, venous stasis, edema, and immobility.
c) Dehydration also places the patient at high risk for VTE. d) Pharmacologic interventions: VTE prophylaxis using subcutaneous unfractionated heparin, low–molecular weight heparin, and heparinoids is given to at-risk patients with ischemic stroke. e) Nonpharmacologic interventions include sequential compression devices and correct positioning. (1) Poor positioning (one extremity lying on another) or sitting for long periods can precipitate or exacerbate VTE formation. B. Impaired physical mobility 1. Rehabilitation is key to restoring independence to patients with impaired physical mobility. a) Impaired physical mobility is related to motor and sensory deficits, particularly hemiplegia and impaired balance, changes in postural tone, and disinhibition of primitive reflex activity. b) A multidisciplinary effort beginning soon after stroke is required for maximum rehabilitation potential. c) The goal of the main intervention, rehabilitation, is to increase independence. (1) Physical therapists assess motor function, plan exercise programs, and provide splints to prevent contractures. (2) Occupational therapists assess the patient, provide a plan of therapy, and evaluate sensory and cognitive problems that interfere with functional independence. (3) The physiatrist is a physician responsible for diagnosing and treating rehabilitative problems, such as spasticity and subluxation. 2. Maintaining functional abilities in the acute phase after stroke is an important component of patient care. a) Perform active and/or passive range of motion (ROM) exercises three or four times daily in acute phase. b) Proper body alignment while reclining, sitting, and eating prevents contractures and pain, and maintains functional positioning. c) Tennis shoes help to prevent contractures in the flaccid stage but tend to stimulate more spasticity in the hyperreflexic stages. 3. The patient is ready to ambulate when there is evidence of leg strength, some balance, and proprioception. a) Assess muscle tone regularly. b) Do not ask the patient to do an activity with the disabled limb until muscle tone is restored. c) Avoid traditional arm slings because they reinforce abnormal arm posture and adduction and promote shoulder contractures. d) Support the affected arm with pillows and handle it gently to avoid subluxation of the shoulder joint. C. Imbalanced nutrition: Less than body requirements 1. Prevent undernutrition following stroke.
a) Factors: Dysphagia, absent or diminished gag reflexes, facial paralysis, perceptual and cognitive deficits, hemiplegia (particularly affecting the dominant hand), an inability to perform bilateral hand tasks, and immobility all contribute to undernutrition. b) In well-nourished patients, start nutritional support if no oral intake is anticipated for more than five days. c) If the patient is malnourished on admission, initiate nutritional support promptly. d) Assess ability to bring food to the mouth, handle utensils, see all the food on the tray, and successfully chew and swallow food and liquids, with no pocketing in the affected cheek. e) Evaluate swallowing as soon as possible. (1) Dysphagia is usually caused by lesions involving trigeminal, facial, glossopharyngeal, vagus, accessory, or hypoglossal cranial nerves. 2. Also assess: a) Cognitive ability to feed self b) Drooling (a clue to swallowing problems) or difficulty swallowing liquids or foods c) Continuous clearing of the throat or coughing while eating d) Appropriate positioning during eating D. Impaired urinary elimination 1. After stroke, elimination problems might appear. a) Alteration in elimination could be related to impaired mobility, cognitive impairment, aphasia, or preexisting elimination problems. b) Establish daily assessment and outcome criteria. c) Maintain elimination, prevent complications. 2. Interventions for common urinary elimination problems. a) Problems include detrusor muscle hyporeflexia (flaccid bladder), detrusor muscle hyperreflexia (spastic bladder), and detrusor muscle–sphincter dyssynergy (causes urinary retention). (1) Hyporeflexia: Insert indwelling urinary catheter as soon as possible after stroke; monitor intake and output. Following acute phase, remove indwelling catheter; catheterize every four hours to ensure that the urine volume does not exceed 400 mL. (2) Hyperreflexia: Establish a voiding schedule with the patient and family based on previous patterns of voiding. (3) When possible, avoid diapers and long-term indwelling urinary catheter use. 3. Interventions for common gastronintestinal elimination problems a) Constipation is common after stroke. b) Possible reasons include age-related hypotonicity of the bowel, decreased roughage and fluid intake, immobility, inability to communicate the need to defecate, and medications such as diuretics. c) Constipation-related straining can elevate blood pressure. (1) To promote adequate elimination, establish a convenient pattern after assessing former and current bowel patterns.
(2) Determine fluids and foods that normally elicit bowel movements and patient preferences in roughage foods. (3) Use stool softeners and suppositories to establish a regular pattern, as well as gastrointestinal reflexes. E. Risk for impaired skin integrity 1. Interventions related to sensory alterations a) Prevent injury to patients with impaired sensation and skin integrity related to loss of touch, pressure, temperature, sensation, motor or vascular tone loss, or vision and hearing impairment. (1) Protect cornea with tape or eye patch; prevent drying and laceration with artificial tears or lubricants. (2) For the diplopic patient, alternating eye patch permits a clear image. (3) Avoid exposing desensitized areas to extremes of heat or cold. (4) Handle patients gently when transferring from bed to wheelchair. (5) Teach patient and family to avoid environmental hazards in the home. (6) Teach patient and family to move patient gently from bed to wheelchair, supporting and protecting neglected or hemiplegic part. 2. Treat and prevent pressure ulcers. a) Pressure ulcers are a risk in the acute stages of stroke because of sensory, motor, or vascular tone loss as well as incontinence, parietal neglect, and spasticity. b) With hemiplegics or those who are experiencing neglect or denial, alert patient and family to the deficit and related hazards. c) Self-care: Inspect the skin with mirrors; observe for adequate capillary refill, pallor, and hyperemia; avoid pressure on the area should any of these appear. d) Reposition and inspect skin at least every two hours. e) Revise turning schedule based on patient tolerance and skin integrity. F. Unilateral neglect 1. Alleviate effects of perceptual hemineglect. a) Disorder of attention causes inability to integrate and use perceptions in the side contralateral to the brain lesion. 2. Increase patient’s awareness of surroundings and alleviate apprehension as to source of problem. a) Initially, approach patient from unaffected side, position so that intact visual field is toward the action, arrange personal items within field of vision, and teach to scan environment by turning head vertically and horizontally. b) As apprehension decreases, stimulate patient by placing personal items toward affected side; position so that eyes are facing the affected side; teach patient to handle the affected extremities with the unaffected arm. c) Denial of illness usually resolves as patient recovers.
G. Impaired verbal communication 1. Wernicke’s aphasia a) Aphasia/dysphasia is a disorder of linguistic processing in which there is a disruption of translating thought to language. (1) Literally, aphasia means a total inability to understand or formulate language. (2) Language comprehension, speech expression, or writing ability might be lost. b) Dysphasia refers to difficulty comprehending, speaking, or writing. c) Wernicke’s aphasia: Patient receives auditory impulses but is unable to comprehend them. (1) The goal of therapy is to develop an awareness of the language problem and to increase comprehension. (2) Remove extraneous sounds and distractions to assist in getting the person’s attention. (3) Use nonverbal behavior to enhance communication. (4) Keep the conversation on one defined subject with one question at a time and avoid multiple choices when communicating. 2. Broca’s aphasia a) Broca’s aphasia: expressive aphasia characterized by nonfluent, telegraphic speech with outbursts of profanity, uninhibited speech, and word-finding difficulty, which reflects impaired memory for language (1) The goal of therapy is to establish reliable language output to express needs. (2) This can be accomplished initially by asking the patient “yes–no” questions. 3. Global aphasia is a combination of Broca’s and Wernicke’s aphasia with an almost complete loss of comprehension and expression of speech. a) The goal of therapy is to improve the ability to communicate. b) Teach the patient to enhance communication with nonverbal gestures and facial expressions. c) The measures cited for both Wernicke’s and Broca’s aphasias are applicable with these patients as well. 4. Dysarthria is an impairment of the muscles that control speech. a) The goal of therapy is to strengthen the speech muscles in order to speak more clearly and fluently. b) Encourage the patient to enunciate one word at a time, particularly consonants, and increase voice volume when it is low. H. Ineffective coping 1. Interventions for ineffective patient and family coping a) Coping issues arise from abrupt change in lifestyle, loss of roles, dependency, and economic insecurity, as well as the emotional and cognitive impairments following a stroke. (1) Provide appropriate information to alleviate fears. (2) Prevent unrealistic expectations for recovery; inform the patient that most recovery takes up to six months (sometimes longer). b) Strengthen support systems. (1) Clergy, friends, and family support groups can help both the patient and the family.
c) Emotional liability and inappropriate or impulsive behavior can be additional sources of stress. (1) If inappropriate crying or laughter occurs, divert the patient’s attention from the behavior to stop it. (2) Provide feedback in a matter-of-fact way when behavior is inappropriate. (3) Avoid nagging, angry, or punitive responses. (4) Be patient and gently slow down impulsive behavior. d) Reinforce a positive body image by focusing on the function that is left and not on that which is lost. (1) Speak positively about the remainder of body functions. (2) Use terms such as “affected” and “unaffected” rather than “good” and “bad.” e) Reinforce independence early by involving the patient in decisions about care. (1) Teach the family to do the same related to family roles and care. f) Make multidisciplinary referrals as needed. (1) Social workers, home health nurses, dieticians, occupational therapists, physiatrists, support groups, and voluntary and governmental agencies (e.g., Medicare) provide assistance. (2) The American Heart Association and the National Stroke Association provide free and low-cost literature on stroke care developed by experts. (3) These referral groups and services are essential for the functional recovery and provide invaluable assistance in restoring the patient to a functional or complete recovery. I. Other sensory and motor deficits 1. Agnosia is a cortical impairment that results in the inability to recognize or interpret familiar sensory information although there is no impairment of sensory input or dementia. a) Visual agnosia is the inability to recognize or name familiar objects or faces although visual acuity is intact (i.e., the patient is unable to recognize utensils, toothbrush, clothes, or photographs). b) Auditory agnosia is the inability to recognize familiar sounds, such as a doorbell, telephone, horn, gun, or siren. 2. Apraxia is the inability to carry out a purposeful movement although movement, coordination, and sensation are intact. a) Ideational apraxia is assessed by observing the patient’s ability to perform spontaneous acts or acts on command, such as writing. b) For ideomotor and ideational apraxia, the components of a motor sequence leading up to the entire activity need to be broken down and taught in simple terms, speaking slowly with clear directions. c) The patient with dressing apraxia is assisted by the use of labels to distinguish right and left, back from front, right and wrong side, or by color-coding garments.
PowerPoint Slides 1. Care focus: Prevent/treat complications. 2. Prevent/treat deep venous thrombosis (DVT)
3. Impaired physical mobility: Rehabilitation increases independence 4. Maintain functional abilities in acute phase 5. Ambulation requires strength, balance, proprioception 6. Prevent undernutrition following stroke 7. After stroke, elimination problems might appear. 8. Interventions for common urinary elimination problems 9. Interventions for common gastronintestinal elimination problems 10. Interventions related to sensory alterations 11. Interventions for impaired communication 12. Interventions for ineffective patient/family coping 13. Interventions for ineffective patient/family coping 14. Other Sensory and Motor Deficits
VII. Chapter Summary VIII. Clinical Reasoning Checkpoint IX. Post-Test X. References
Suggestions for Classroom Activities • Obtain a large-scale, detailed image of the brain, including blood vessels (possibly an enlarged illustration from an anatomy textbook). Have students create visual aids to map the location and, if relevant, the progress of each type of stroke. They can use colored pens, pencils, or pushpins; each stroke should have its own color. • Facilitate discussion of parallels between atherosclerosis of cerebral and coronary arteries. Based on these similarities, compare/contrast ischemic stroke and heart attack. • Ask students to “profile” their own stroke risk based on modifiable and nonmodifiable risk factors. If they are not comfortable with personal disclosure, they can choose a friend, relative, or celebrity. Then ask them what lifestyle changes (if any) they or their “subject” would be willing and able to adopt to lower their risk.
Suggestions for Clinical Activities • Research (through interviews or literature) how rapidly perfusion needs to be reestablished to cells in the penumbra if they are to recover function. What factors narrow/broaden this time window? • Using interviews or literature, research and compare how frequently TIAs are diagnosed in an outpatient setting, in a hospital Emergency Department, and in patients hospitalized for other reasons. • Invite a recovered stroke patient to speak to the clinical group. Ask the speaker to discuss his or her road to recovery.
CHAPTER
18
Traumatic Brain Injury
Objectives: 1. Describe mechanisms of injury and skull fractures associated with brain trauma. 2. Explain implications of decreased intracranial adaptive capacity. 3. Compare and contrast focal and diffuse brain injuries. 4. Discuss the assessment and diagnosis of traumatic brain injury. 5. Apply evidence-based principles to the collaborative management of traumatic brain injury. 6. Apply evidence-based principles to the nursing management of the patient with traumatic brain injury. 7. Discuss complications associated with increased intracranial pressure.
I. Mechanisms of Brain Injury and Skull Fractures A. Mechanisms of injury 1. Acceleration and deceleration injury a) Acceleration injury occurs when the stationary brain is suddenly and rapidly moved in one direction along a linear path. (1) This type of injury is seen in victims of assault who have been hit in the head with a bat or have hit the steering wheel or front windshield in a vehicle crash. (2) The sudden acceleration causes brain injury at the site of impact. b) Deceleration injury occurs when the brain stops rapidly in the cranial vault. (1) As the skull ceases movement, the brain continues to move until it hits the skull. The force of deceleration causes injury at the site of impact with the skull. (2) The rapid deceleration of the person’s head hitting the ground results in a deceleration injury of the brain as it hits the bony wall of the cranium. 2. Rotational Injury occurs when the force impacting the head transfers energy to the brain in a nonlinear fashion, whereby the head rotates on its axis (the neck), resulting in shearing forces being exerted throughout the brain and its axons (Fig. 18-1b). a) An example of this type of mechanism is in boxing. When a boxer is punched in the side of the head, the force causes a rapid spinning (rotational) motion of the head and its contents, which causes tearing of the axons in the brain. 3. Penetrating injury occurs when a foreign object invades the brain. a) The penetrating object may be a bullet, knife, or a falling object (Fig. 18–1c).
b) The penetrating object may pass completely through the brain and exit on the opposite side, or it may bounce around the cranium causing multiple areas of injury. 4. Primary and secondary brain injured a) Primary injury occurs when neurons sustain direct injury from the offending event. (1) Example: diffuse axonal injury (DAI) sustained during a motor vehicle crash (a) Primary injury: shearing of axons (2) Primary injury is immediate and often irreversible damage b) Secondary injury occurs in response to the primary injury. (1) Four causes of secondary injury: ischemia, neuronal death, cerebral swelling, and inflammation B. Skull fractures 1. Linear skull fractures are simple fissures in the skull with no bony fragmentation, and they are associated with minor traumatic injury. a) They are not typically obvious to the naked eye and are usually discovered during a head computerized tomography (CT) scan. b) Linear skull fractures are not life threatening and are allowed to heal naturally without surgical intervention. 2. Depressed skull fracture is one in which there is fragmentation of bone that depresses down into the cranial vault. a) It occurs with higher forces of impact. b) Depressed skull fractures may be visible and palpable as an indentation of the skull and may be open or closed fractures. c) Medical interventions include surgical repair of the fracture and meninges and the evacuation of any hematomas beneath the fracture. 3. Open skull fracture are skull fractures accompanied by a scalp laceration. a) These fractures are of particular concern because of the risk of infection associated with exposure of the dura to a contaminated environment. b) Medical interventions include surgical repair and debridement of the contaminated wound. c) Antibiotics are administered to prevent infection. 4. Basilar skull fractures are fractures of one of the bones that make up the base of the skull. a) Careful physical assessment of drainage from the nares and ear canals must be performed to detect the presence of cerebral spinal fluid (CSF) drainage. b) Medical management of basilar skull fracture includes allowing the CSF to drain and the dura to close on its own. If the injury does not heal within the first one to two weeks post-injury, surgical repair may be necessary. c) Sterile cotton gauzes are placed in the ear or under the nose and require changing when wet because moisture facilitates the movement of microorganisms and predisposes the patient to infection. 5. Nursing considerations in caring for patients with skull fractures focus on neurological assessments and pain management.
a) The nurse must be cautious when administering pain medications to patients with brain injuries. b) The presence of narcotics may obscure the neurological exam and make it difficult during an assessment to differentiate changes in mental status as a result of the actual injury from changes caused by the narcotic. c) Patients with an open skull fracture, particularly an open depressed fracture, or basilar fracture should be monitored for signs and symptoms of infection associated with a disrupted meningeal layer. d) All dressings should be changed with aseptic technique in an effort to reduce the possibility of an infection.
PowerPoint Slides 1. Mechanisms of Injury
II. Decreased Intracranial Adaptive Capacity A. Increase in brain volume 1. Space-occupying lesions and cerebral edema are the primary processes that increase brain volume. a) Space-occupying lesions may develop due to tumors, abscesses, hemorrhages, and hematomas. b) Cerebral edema is caused by an abnormal accumulation of fluid that increases brain tissue volume. (1) May occur after any type of insult to the head, including trauma, surgery, brain anoxia, or ischemia. (2) Does not impair brain function until the edema increases ICP. (3) Slower-growing lesions, such as a chronic hematoma or slow-growing tumor, may be tolerated for a longer time period than an acute subdural hematoma, which develops at a faster rate. (4) A mass or edema that progresses and is uncompensated eventually results in a shifting of brain tissue, and carries a grave prognosis. B. Cerebral blood volume 1. Hypoxemia or hypercapnia a) Any systemic process that affects blood levels of oxygen and carbon dioxide affects cerebral blood flow (CBF), cerebral perfusion pressure (CPP), and cerebral blood volume. b) Conditions may include chronic respiratory insufficiency, hypoventilation, respiratory depression from oversedation, and insufficient oxygenation. 2. Impeded venous outflow from head a) Cerebral blood volume increases with any process that impedes venous outflow. (1) This includes anything that impedes jugular vein drainage from the head, such as head/neck rotation or flexion, or endotracheal tube ties that are too tight or circumferential around the head and neck
3. Loss of autoregulation is a compensatory mechanism by which cerebral blood flow remains relatively constant despite changes in cerebral perfusion pressure (CPP) (Boss & Huether, 2012). a) Autoregulation works by altering cerebral vascular tone—as CPP increases, compensatory cerebral vasoconstriction occurs, and as it decreases, cerebral vasodilation occurs (Cipolla, 2009). (1) Has limits and only works within certain hemodynamic parameters sustained states (2) When autoregulation is lost, the cerebral blood vessels passively dilate and produce further increases in cerebral blood volume and ICP. C. Cerebrospinal fluid 1. Cerebrospinal fluid (CSF) volume increases when production of it increases, its circulation is obstructed, or its absorption decreases, producing a condition termed “hydrocephalus.” 2. Obstruction to CSF can be caused by mass lesions or infection. Decreased absorption can result from a subarachnoid hemorrhage or meningitis.
PowerPoint Slides 1. Increase in Brain Volume 2. Cerebral Blood Volume 3. Cerebrospinal Fluid
III. Focal and Diffuse Brain Injuries Diffuse injuries A. Focal brain injuries occur in a well-defined area of the brain and include cerebral hematomas and contusion. 1. Cerebral hematomas are focal cerebral injuries associated with the accumulation of blood in the cranial vault. a) Occur as result of injury to cerebral vein or artery. b) A high-impact injury can cause two or more different types of cerebral hematomas. c) The types of cerebral hematomas are named according to location in the cranium: (1) Subdural hematoma (2) Epidural hematoma (3) Intracerebral hematoma d) Subdural hematoma is the accumulation of blood between the dura and the arachnoid layers of the meninges. (1) It is usually secondary to venous injury. (2) It develops more slowly. (3) It is categorized according to the time between injury and onset of manifestations: (a) Acute (less than 48 hours from injury) (b) Subacute (48 hours to 2 weeks) (c) Chronic (more than 2 weeks from injury) (4) Assessment findings are determined by the rate of blood accumulation in the subdural space.
(5) Clinical manifestations vary by category: (a) Acute SDH acute cases: drowsiness, headache, confusion, slowed thinking, or agitation. (b) Subacute SDH neurological deterioration might not occur for days or weeks. (c) Chronic SDH Manifestations are vague and often attributed to other conditions: (i) Typical symptoms are headache, lethargy, absent-mindedness, and vomiting. (ii) More serious symptoms are seizures, stiff neck, pupil changes, and hemiparesis. (6) Medical management (a) Surgical evacuation of the hematoma (b) Possible placement of a subdural drain (7) Nursing priorities (a) Monitoring level of consciousness (b) Performing regular and frequent focused neurological assessments e) Epidural Hematoma occurs in the space between the dura mater and the skull. (1) High impact to the temporal areas of the brain can induce an epidural hematoma. (2) When the force of the impact is transferred to the brain, small arteries are sheared, causing a rapid accumulation of blood between the skull and the dura mater. (3) Clinical manifestations: (a) Brief loss of consciousness immediately following the injury, followed by an episode of being alert and oriented, and then a loss of consciousness again (b) Fixed and dilated pupil on the same side as the impact area (4) Medical management: Identify and treat these injuries quickly before intracranial pressure reaches a critical point. Regimen typically includes: (a) Surgical evacuation of the hematoma (b) Placement of an intracranial pressure (ICP) monitor (c) Admission to the ICU for frequent neurological checks and ICP monitoring (5) Nursing care: diligent neurological assessment to determine if bleeding has recurred, causing an emergent medical situation (a) Sudden changes in level of consciousness (b) Fixed and dilated pupil on the side of injury f) Intracerebral hematoma is the accumulation of blood in the parenchyma of brain tissue (rather than between the meninges). (1) Can result from uncontrolled hypertension, ruptured aneurysm, or trauma (high-impact blow to the head) (2) Manifestations: (a) Vary according to the location of the hematoma. (b) Can include headache, decreasing level of consciousness, dilation of one pupil, and hemiplegia. (3) Medical management (a) Management of intracranial pressure and cerebral perfusion pressure (CPP).
(b) Surgical evacuation is usually not possible because the hematoma is deep within brain tissue. 2. Contusion is a bruising of soft tissue and is considered a moderate-to-severe injury. a) It is commonly seen in traumatic brain injury. b) It might begin local but become more diffuse over time. c) It causes macroscopic tissue and vessel damage detectable through CT or MRI scanning. d) Associated with longer periods of unconsciousness than concussions, and a more guarded prognosis, depending on the severity of injury B. Diffuse brain injuries occur in a well-defined area of the brain and include cerebral hematomas and contusion. 1. Concussion is a mild traumatic brain injury (MTBI) caused by blunt trauma to the head. a) Effects: (1) Cerebral damage occurs at the microscopic level. (2) Damage is not detectable through radiographic or other testing. (3) Possible effects include inability to function at preinjury levels. b) Signs: (1) Transient unconsciousness (lasting up to 20 minutes) (2) Order CT scan of head if patient presents at Emergency Department with amnesia, headache, dizziness, vertigo, nausea, vomiting, slurred speech, or confusion c) Postconcussive syndrome occurs in almost half of patients with concussion. (1) Symptoms are similar to those seen on presentation. (2) Can continue for three months or more after injury. 2. Diffuse axonal injury occurs when rotational movement of the brain within the skull causes widespread shearing of axons in the white matter. a) It typically results from high-speed acceleration/deceleration (e.g., motor vehicle crashes). b) The severity of injury can range from mild to severe. c) Signs: (1) Can be present without bleeding, making it difficult to visualize on CT or MRI. (2) The presence of multiple small hemorrhages on CT scan strongly suggestive of DAI. (3) Magnetic resonance imaging (MRI) might provide a more conclusive diagnosis. d) Outcomes (1) In mild cases, coma (hours to days long) can be followed by recovery with minimal residual neurological damage. (2) Can contribute to postconcussive syndrome experienced by many patients following a brain concussion. (3) In more severe DAI, the prognosis is poor: prolonged coma, death, or persistent vegetative state. 3. Subarachnoid hemorrhage is the accumulation of blood/hematoma between the arachnoid layer of the meninges and the brain. a) Additional accumulation of blood results in blood leaking into the cerebrospinal fluid.
b) Bleeding can be focal or massive and diffuse with subsequent intracranial hypotension. c) Signs include nuchal rigidity (neck stiffness) and severe headache. 4. Management of diffuse brain injuries a) Because injuries are not limited to a localized area, they can be more difficult to detect and treat than are focal injuries. b) The patient’s recovery can be unpredictable. c) Acute care phase: (1) Diligent and frequent neurological assessments (2) Pain management d) Moderate-to-severe injury (e.g., contusion or DAI): Management focuses on improving outcome by: (1) Lowering intracranial pressure (ICP) (2) Increasing cerebral perfusion pressure (3) Stabilizing vital signs e) Discharge planning must begin early because many patients require rehabilitation services.
PowerPoint Slides 1a. Focal injuries 2. Diffuse injuries 3. Cerebral hematoma 4. Subdural hematoma 5. Subdural hematoma—clinical manifestations 6. Subdural hematoma—medical management 7. Epidural hematoma 8. Epidural hematoma—management: 9. Intracerebral hematoma 10. Intracerebral hematoma—management 11. Contusion 12. Concussion 13. Signs include amnesia, headache, vertigo, vomiting, and slurred speech: 14. Diffuse axonal injury (DAI) rotational movement of brain within skull 15. Diffuse axonal injury (DIA) 16. Subarachnoid hemorrhage 17. Management of diffuse head injuries
IV. Assessment and Diagnosis A. Assessment 1. Initial assessments
a) Initial neurological assessment that occurs in the emergency department becomes the baseline against which subsequent serial neurologic examinations are compared in order to detect changes in the patient’s condition. (1) Any unfavorable change in the patient’s neurological condition, even the most subtle, may indicate neurological deterioration and should be reported to the medical team immediately. b) The secondary assessment will include gathering a detailed history of how the injury occurred, the prehospital care, and the past medical history, including medications, allergies, surgeries, and comorbid conditions that may impact management of the patient’s condition. 2. Determining Severity of Injury is an objective neurological assessment tool that was originally developed to standardize measurement of the ability of the patient with a TBI to interact with the environment (Wright & Merck, 2011). a) Mild Injury involves a GCS score of 13–15, with a loss of consciousness that lasts up to 15 minutes. b) Moderate Injury involves a GCS score of 9–12, accompanied by a loss of consciousness for up to 6 hours. c) Severe Injury; patient has a severe injury if the GCS score is 8 or less on initial assessment or if the patient’s status deteriorates to that level within 48 hours of admission. 3. Bedside neurological assessment a) Level of consciousness, motor movements, pupillary response, respiratory function, and vital signs are all part of the serial assessments. 4. Advanced assessment modalities a) The advent of cerebral tissue oxygen monitoring is reshaping current thoughts on management of brain injury. (1) Clinicians now have the ability to measure local brain tissue oxygen content (PbtO2). The measurement of this new parameter is achieved using a fiber optic monitoring device, which is inserted into the white matter of the brain (Leal-Noval et al., 2010; MaloneyWilensky, Bloom & Stiefel, 2011). (a) A normal PbtO2 is greater than 20 mm Hg, and PbtO2 levels less than 15 mm Hg have been associated with poor outcomes, including death. (b) The normal range of SjO2 is 55–70%, and a value of less than 45–50% suggests brain ischemia (Slazinski, 2011 B. Initial diagnostic tests and procedures 1. Laboratory tests’ values are monitored for changes to ensure early detection of cerebral hypoxia and impending ischemia to prevent secondary brain injury. a) Arterial blood gases are analyzed, with particular attention to oxygen and carbon dioxide levels. b) Laboratory monitoring includes complete blood count with emphasis on hemoglobin; hematocrit, and platelets; coagulation profile (prothrombin time, international normalized ration, partial thromboplastin time); electrolytes, BUN and creatinine, liver function, and serum osmolality; urinalysis and urine osmolality. 2. Imaging studies
a) CT scan is typically the first-line imaging study performed because it can visualize skull fractures as well as many soft tissue injuries (e.g., lacerations or contusions), hemorrhages or masses (Henry, Little, Jagoda, Pellegrino, & Quint, 2010). b) An MRI may be performed if the CT scan is unable to adequately visualize an area of concern in the brain. If DAI is suspected and requires immediate diagnosis, MRI is better able to detect that type of injury (Henry et al., 2010; Wright & Merck, 2011). 3. Other diagnostic testing a) There are a variety of other diagnostic tests that may be performed during the acute phase of TBI treatment to further evaluate some aspect of the patient’s neurologic deficits. (1) These may include tomography or transcranial Doppler, which can detect changes in CBF; evoked potentials, which can detect lesions in the CNS; and electroencephalography (EEG), which can detect abnormalities in brain electrical impulses such as seizures or brain death.
PowerPoint Slides 1. Initial Assessments 2. Determining Severity of Injury 3. Bedside Neurological Assessment 4. Advanced Assessment Modalities 5. Initial Diagnostic Tests and Procedures
V. Collaborative Management of Traumatic Brain Injury A. Approach to cerebral tissue perfusion management 1. Optimizing cerebral perfusion pressure (CPP) and cerebral blood flow (CBF) are directly related. a) CPP is optimized by controlling blood pressure, temperature, and promoting venous return and normalizing ICP. (1) Ideally, mean arterial pressure (MAP) is maintained at levels greater than 90 mm Hg to keep CPP greater than 70 mm Hg (Chou & de Moya, 2010; Wind et al., 2011). (2) Ideally, CPP is maintained between 70 and 80 mm Hg to facilitate the delivery of oxygen to cerebral tissue. (3) IV fluids and vasopressors are given to maintain optimal CPP and cerebral blood flow, preventing ischemic etiologies of increased intracranial pressure (Chou & de Moya, 2010; Wind et al., 2011). 2. Optimizing oxygenation a) Controlling body temperature (1) The injured brain is sensitive to changes in body temperature because hyperthermia raises cerebral metabolism. (2) Under conditions of increased cerebral metabolic rate, CBF increases to meet high tissue metabolic demands. (a) Antipyretics and cooling blankets help to control body temperature.
(3) Induced or therapeutic hypothermia (TH) is a neuroprotective therapy whereby the patient’s body temperature is cooled down to protect the injured brain tissue from secondary injury. (a) Induction of TH typically requires a multimodal approach, including the use of both pharmacological agents and physical cooling techniques. (b) The practical application of therapeutic hypothermia treatment carries risks and requires a clinical management protocol that focuses on detection and control of complications, which may include atrial fibrillation, acidosis, shivering, and coagulopathies. b) Promoting venous return (1) Nursing care can promote venous return by using body positioning. Unless the patient has a cervical spine injury, the head of the bed is elevated at least 30 degrees. (a) It is important to assess the patient’s response to head of bed elevation and to avoid hypotension as this would place the patient at risk for cerebral ischemia and cause a decrease in CPP. (b) The nurse must assess the patient’s response to position changes and determine which position maximizes CPP and minimizes ICP. (c) Neck flexion, lateral head rotation, and hip flexion of greater than 90 degrees should be avoided because these positions cause venous congestion in the intracranial and abdominal compartments, which can increase ICP. c) Maintaining oxygenation and ventilation (1) Any patient with a Glasgow Coma Scale (GCS) score of 8 or less will be intubated with an adequate airway for optimal ventilation and oxygenation (Chou & de Moya, 2010). (a) Mechanical ventilator settings are adjusted to maintain Pao2 greater than 60 mm Hg and Paco2 between 35 and 40 mm Hg. (2) Therapeutic hyperventilation (increasing tidal volume and/or respiratory rate) has been used to produce vasoconstriction of cerebral blood vessels to decrease CBV and ICP. (a) Current guidelines recommend keeping the Paco2 above 35 mm Hg for the first 24 hours of injury because reduced blood flow compromises cerebral perfusion. (b) Overall, patients with acute TBI are best maintained within a normal Paco2 range (35 to 45 mm Hg). B. Leveled approach to intracranial pressure management 1. Level one interventions a) First-level interventions to reduce elevated ICP include patient positioning strategies to prevent constriction of venous outflow from the brain. 2. Level two interventions a) Level two interventions aim to reduce ICP, optimize CPP, and prevent secondary injury; they include cerebrospinal fluid (CSF) drainage, hyperosmolar therapy, and maintenance of normal Paco2 levels with mechanical ventilation. b) Hyperosmolar and diuretic therapy
(1) Hyperosmolar therapy consists of intermittent administration of an osmotic diuretic such as mannitol (Osmitrol). (a) Mannitol draws fluid from the intracellular and interstitial spaces into the vascular compartment, reducing blood viscosity and resulting in improved cerebral blood flow c) Fluid volume maintenance (1) The goal for fluid volume maintenance is to keep the patient in a euvolemic state to optimize cerebral perfusion. (2) Volume replacement strategies should include fluid boluses, fluid replacements, and albumin administration. d) Hypertonic saline therapy has been shown to prevent secondary injury and has several effects on injured brain tissue. (1) It reduces cerebral edema by creating an osmotic gradient that promotes passage of intracellular fluid from swollen neuronal cells into the blood vessels. (2) Hypertonic saline also possesses hemodynamic, vasoregulatory, and anti-inflammatory properties that help reduce secondary injury. (3) Nurses caring for patients receiving hypertonic saline must pay careful attention to the patient’s serum sodium levels and serum osmolality because extreme elevations in these values may result in neurological injury and renal failure. 3. Level three interventions to reduce ICP include neuromuscular blockade and mild hyperventilation and mild hypothermia. a) Skeletal muscle paralysis using a neuromuscular blocking agent may be necessary to facilitate mechanical ventilation and prevent coughing, posturing, and severe agitation that increases ICP. 4. Level four interventions to reduce intracranial hypertension include medical interventions for the treatment of severe, refractory intracranial hypertension that does not respond to conventional therapeutic measures. a) Treatment of increased ICP that is refractory to all other medical interventions may include the use of high-dose barbiturates.
PowerPoint Slides 1. Approach to Cerebral Tissue Perfusion Management 2. Optimizing Cerebral Perfusion Pressure (CPP) and cerebral blood flow (CBF) are directly related. 3. Leveled Approach to Intracranial Pressure Management
VI. Nursing Management A. Interventions to Reduce Secondary Injury 1. Optimizing cerebral perfusion pressure and oxygenation a) Important collaborative interventions to manage CPP and oxygenation to reduce secondary injury.
b) Promote venous return by correctly positioning the patient; maintaining normal body temperature by using antipyretics or cooling blankets; and maintaining ventilation through mechanical ventilation and controlling PaCO2 level. c) Maintain adequate oxygenation when suctioning patients. d) Stabilize the patient’s ICP. B. Interventions to Manage ICP 1. A major advantage of placement of an intraventricular ICP device is that CSF can be removed to reduce ICP. a) The determination of when to drain CSF is important. b) Clinical assessment and overall hemodynamic status are considered when the physician selects the appropriate ICP level at which to initiate treatment. c) Current guidelines recommend that ICP treatment be initiated at upper thresholds of 20 to 25 mm Hg. 2. Maintenance of system integrity and troubleshooting a) One of the most important nursing interventions is to gather, document, and report accurate data. b) It is the nurse’s responsibility to ensure that ICP monitoring systems are intact and that data are accurate. c) When caring for patients with ICP monitoring technology, the nurse must have a clear understanding of the benefits and limitations of the system used, troubleshooting scenarios that might arise, and support from the manufacturer when needed (Wiegand, 2011). 3. Prevention of complications a) Risk of bleeding (1) Patients with coagulopathies are at higher risk for hemorrhage or hematoma formation. (2) Because a hemorrhage or hematoma is a space-occupying lesion, the patient’s neurologic status must be carefully monitored before, during, and after insertion of the ICP monitoring device to detect neurologic deterioration. b) Risk for CSF overdrainage is a major complication of an intraventricular device, particularly an open system. (1) To prevent overdrainage, the nurse observes unit standards for CSF drainage; accurately measures and positions the CSF drainage bag using the correct landmarks; and securely fastens the drainage bag at the prescribed level. (2) Systems that are closed and periodically opened for therapeutic drainage require nursing interventions that are sound and clinically based. For this type of system, drainage is instituted when the ICP is consistently elevated. 4. Risk of infection is the greatest concern, with the duration of ICP monitoring and the type of device and system used associated with infection. a) Sterile techniques must be absolutely observed during insertion of the ICP monitoring device. (1) For fluid-filled systems, system integrity must be maintained. All connection points are checked to ensure that they are tight.
(2) The insertion site is inspected for signs of infection. The appearance of the insertion site and duration (in days) of the monitoring device placement is documented (Wiegand, 2011). C. Interventions to Provide a Safe and Protective Environment 1. Patients with cognitive deficits become easily confused with external stimuli. a) Astute nursing assessments are required, especially during routine care, such as bathing and suctioning, to evaluate the patient’s response to interventions. b) Noise is kept to a minimum, information is presented simply and calmly, and the number of visitors at one time is limited c) Patients with cognitive deficits often attempt to get out of bed and may pull out IV lines and catheters. Interventions, such as keeping the bed in a low position, using side rails, and frequent checks, keep the patient safe from harm.
PowerPoint Slides 1. Interventions to Reduce Secondary Injury 2. Interventions to Manage ICP 3. Interventions to Provide a Safe and Protective Environment
VII. Complications Associated with Increased Intracranial Pressure A. Neurogenic (central) diabetes insipidus 1. Diabetes insipidus (DI) is a condition associated with improper water balance. a) Occurs when TBI causes pressure on the pituitary gland and loss of antidiuretic hormone (ADH) secretion, leading to diuresis. (1) Classic profile: production of large amounts of dilute urine and increase in serum sodium. (2) Any patient with traumatic brain injury and increased ICP is at risk of developing DI. (3) Time of onset is 5–10 days following the initial injury. (4) Earliest signs: large amounts of pale, clear, waterlike urine; hypotension (5) Treatment: (a) Aggressive replacement of intravascular volume with IV fluids (b) Administration of synthetic DH B. Syndrome of inappropriate antidiuresis hormone (SIADH) increases total body water because excess ADH secretion results in retention of water. 1. Classic profile: production of small amounts of concentrated) urine with an associated decrease in serum sodium (dilutional hyponatremia) a) This hypoosmolar state results in cellular swelling, systemically and intracerebrally. b) Cerebral swelling increases intracranial pressure and leads to secondary injury. 2. Treatment involves restricting fluid intake to prevent further dilution of the serum. 3. Nursing interventions: a) Monitoring intake and output and neurologic status b) Enforcement of fluid restriction
C. Cerebral salt wasting (CSW) is a state of hypovolemia in which patients present with low serum sodium and a low serum and urine osmolarity. 1. The mechanism of CSW is not well understood, but the end result is the loss of sodium into the urine, causing water to follow. 2. It is important to differentiate CSW from SIADH (a state of volume overload) because restricting fluid in the CSW patient, who is already volume-depleted, can have disastrous results. 3. Cerebral salt wasting tends to correct itself over the course of 3–4 weeks. Treatment: a) Replace salt via IV saline and oral salt tablets. b) In more severe cases, administer hypertonic saline and fludrocortisones (Florinef). D. Seizure activity is a complication of traumatic brain injury with an incidence of 22 percent and as high as 50 percent in penetrating injuries. 1. Classified as either early (within seven days of injury) or late (more than seven days after injury) 2. Early seizures can cause increased intracranial pressure, hypoxia, and increased metabolic demands and secondary injury. a) Management of early seizures via intravenous lorazepam (Ativan), which can be followed by loading dose of phenytoin (Dilantin) or fosphenytoin (Cerebyx) 3. Goals of treatment a) Keep the patient safe b) Timely administration of anticonvulsant drugs c) Attention to airway, breathing, and circulation E. Brain herniation 1. Brain herniation is a catastrophic complication of TBI caused by increased ICP when the space occupying the skull fills with edematous brain tissue and/or blood, causing the brain tissue to shift from its normal position in the cranial vault to an area of less pressure. a) It increases pressure on the medulla, where basic functions needed to sustain life are located. b) The direction in which the brain herniates depends on the type and location of injury. (1) Cingulate: One hemisphere is forced into the space occupied by the opposite hemisphere. (2) Central: Both hemispheres are displaced downward. c) Drastic deterioration of neurologic status and vital signs. (1) Cushing’s triad: bradycardia, severe hypertension with widened pulse pressure, and irregular breathing (2) Pupillary alteration: unequal pupils with sluggish or no reaction to light followed by bilaterally fixed, fully dilated pupils d) Management requires emergent interventions to relieve ICP, which might include emergency craniotomy. e) Prevention through close monitoring and control of ICP is key to improving outcomes. F. Brain death 1. Brain death is an irreversible cessation of all brain function, including brainstem function.
a) It is suspected when there is no evidence of brainstem function for up to 24 hours in a patient with a normal temperature who is not under any influence of depressant drugs, paralytics, or alcohol. b) Signs of impending death: (1) Loss of the body’s ability to maintain adequate blood pressure (2) Profound bradycardia (3) Loss of basic neurological functioning c) Diagnosis requires physician to document coma, absence of brainstem reflexes, and apnea. d) Electroencephalogram demonstrates absence of brain activity with flat (isoelectric) waves. e) An angiogram reveals no cerebral blood flow. f) Motor and reflex movements are absent, although spinal reflexes can cause the body to move after brain death has been established. g) Nursing care includes providing emotional reassurance to family and providing a spiritual advisor on request.
PowerPoint Slides 1. Diabetes insipidus (DI) 2. Diabetes insipidus (DI) 3. Syndrome of inappropriate antidiuretic hormone (SIADH) 4. SIADH 5. Cerebral salt wasting (CSW) 6. Seizure activity—common complication 7. Brain herniation—catastrophic complication 8. Brain death—irreversible complication 9. Brain death
VIII. Chapter Summary IX. Clinical Reasoning Checkpoint X. Post-Test XI. References
Suggestions for Classroom Activities • Break out into small groups and discuss the best way to inform family members that a physician has diagnosed brain death. Give each group a scenario (patient is very elderly, a child, pregnant, etc.; family members speak limited English, are very religious, were injured in the same motor vehicle accident as the patient, etc.). Reconvene the group to compare and evaluate communication strategies.
• Lead a group discussion comparing contusion and concussion. Make a two-column chart on whiteboard or screen and fill in with student answers. Encourage students to discuss lay understanding of what these terms mean. • Break students into small groups and assign each group a life stage: infants, toddlers, schoolchildren, adolescents, working adults, and seniors. Have groups identify which traumatic brain injuries pose the greatest risk to individuals in that life stage, and why.
Suggestions for Clinical Activities • Take the clinical group to tour the acute care unit and view equipment and medications used to induce mild hypothermia. In what sequence are they used, and how long does it take to achieve results? • Research (using either interviews or literature) which techniques for reducing intracranial pressure would be appropriate for an emergent situation, such as a patient with apparent brain herniation. How rapidly do they work, and what are the risks?
CHAPTER
19
Acute Spinal Cord Injury
Objectives: 1. Explain anatomic features of the spinal cord and vertebrae, including unstable spinal cord injury. 2. Discuss spinal cord injury, including types of injury and primary and secondary injury. 3. Describe physical assessment techniques and diagnostic tests frequently used to identify the type and severity of spinal cord injury. 4. Discuss stabilization techniques used for spinal cord injuries. 5. Identify priority nursing assessments and interventions for the patient with a spinal cord injury in the acute care phase of recovery..
I. Spinal Cord Anatomy and Physiology A. Vertebral column 1. The spinal cord is composed of 33 individual and fused vertebrae. a) There are 7 cervical (C), 12 thoracic (T), and 5 lumbar (L) vertebrae. b) In the cervical region, the cord receives afferent impulses from the upper and lower extremities. c) The end of the cord contains reflex centers for bowel, bladder, and sexual function. d) Each vertebra consists of a body (anterior) and an arch (posterior). (1) The arch section is composed of two pedicles that attach the arch to the body and two laminae that form the roof of the arch. (2) The spinous process is located at the rear of the vertebrae. In order to bear additional weight, vertebral bodies increase in size as they descend. 2. The spine is conceptualized as having three columns. a) The anterior column includes the anterior part of the vertebral body. b) The middle column houses the posterior wall of the vertebral body. c) The posterior column includes the vertebral arch. 3. The spinal cord runs through the center of the vertebral column through the spinal canal. a) It starts at the foramen magnum of the brain and ends at the first or second lumbar vertebra. 4. Unstable spinal injury exists when the vertebral and ligamentous structures are unable to support and protect an injured area. a) If two or more columns of the spine are damaged, the injury is considered to be unstable.
B. Spinal cord 1. The spinal nerves join complex networks after leaving the cord to innervate parts of the body. a) The main blood supply to the spinal cord is provided by the anterior spinal artery and the posterior spinal arteries. (1) Any disruption in this vascular supply can damage the cord without direct physical trauma. C. Spinal cord neuronal function 1. The spinal cord consists of an outer region of white matter and an inner region of gray matter. a) The gray matter helps transmit motor activity and sensory messages between the brain and body. b) In the first thoracic through the second lumbar sections of the cord, the gray matter gives rise to the sympathetic nervous system. Activation of the thoracic section gray matter stimulates the sympathetic nervous system to increase perfusion and ventilation, and decrease elimination and digestion. 2. The white matter consists of three major tracts of insulated nerve fibers. a) The three major tracts are the corticospinal, spinothalamic, and posterior column tracts for touch, vibration, and position sense, respectively. b) The parasympathetic nervous system originates in a group of neurons located in the brainstem and in a group located between the second and fourth sacral segments of the cord. 3. Parasympathetic stimulation assists elimination and digestion, among other functions.
PowerPoint Slides 1. Spinal cord anatomy 2. Unstable spinal injury 3. Neuronal function
II. Spinal Cord Injury A. Spinal cord injury etiologies 1. Trauma-related injuries a) Motor vehicle crashes account for 39.2% of SCI cases. b) The next most common cause is falls, followed by acts of violence (primarily gunshot wounds) and recreational sporting activities. (1) Between 1990 and 1999, the percentage of injuries caused by violence peaked at 24.8%, and has declined to only 14.6% since 2005 (NSCISC, 2012). c) Death following SCI: (1) Primarily caused by pneumonia, pulmonary emboli, and septicemia d) Prognosis following SCI: (1) Poorest for individuals over the age of 50 with complete lesions at the time of injury. (2) For severely injured persons, mortality rates are significantly higher during the first year after injury than in following years.
2. Nontrauma-related injuries
d)
B. Spinal cord injury classification 1. Complete spinal cord injury a) Loss of all voluntary motor and sensory function below the level of injury b) It results in one of two conditions: (1) Paraplegia—the result of injury to the thoracolumbar region (T2 to L1) causing loss of motor and sensory function of the lower extremities. (a) Upper extremity function remains intact. (2) Tetraplegia (also referred to as quadriplegia)—the result of injury to cervical or thoracic regions (C1 to T1). (a) Muscle function depends on the specific segments involved, but impaired function of the arms, trunk, legs, and pelvic organs can occur. 2. Incomplete spinal cord injury a) Preservation of some voluntary motor and sensory function below the level of injury. b) About 60 percent of patients admitted to high-acuity units have incomplete SCI, and 59 percent of these develop significant recovery of function. c) The alterations in function that occur vary greatly, depending on the amount and location of tissue damage, and the level of injury. American Spinal Injury Association (ASIA) classification (1) Injuries are defined by location of affected vertebrae. 3. Spinal cord injury level a) Cervical injuries (1) The cervical region is the most vulnerable region of the spine because of its poor stability. (2) Complete cord injuries at the C1 or C2 level are often fatal because the patient is unable to breathe spontaneously. (3) Hyperflexion injuries of the cervical spine, especially C5 to C6, are associated with the rapid deceleration mechanism of injury; C4 and C5 injuries frequently occur in diving accidents. b) Thoracic and lumbar injuries (1) Great force is needed to produce T1 through T10 injuries because of the stability of the rib cage. (2) The most common site of thoracic spinal injury is the T12–L1 junction. (3) Violent flexion of the lumbar spine may occur when wearing a lap belt without a shoulder restraint (e.g., middle passenger in the rear seat) in a motor vehicle crash. C. Mechanisms of injury 1. Primary injury —neurological damage that occurs at the moment of impact. a) Hyperflexion injury—most often caused by a sudden deceleration of the motion of the head (head-on collision) b) Hyperextension injury caused by a forward-and-backward motion of the head (rear-end collision)
(1) A mild form of hyperextension injury is the whiplash injury. c) Flexion–rotation injury caused by severe rotation of the neck (non-belted person in a car hit broadside) d) Compression injury axial loading injury (compression fracture)—caused by a vertical force along the spinal cord (1) This vertical force fractures vertebral bodies that send bony fragments into the spinal cord. (2) Compression fractures typically occur with diving into shallow water, or jumping from tall heights and landing on the feet or buttocks. e) Distraction injury occurs when the vertebrae and spinal cord are stretched excessively, pulling the structures apart. The major example of this type of injury is hanging. 2. Secondary Injury a) The 24-hour period following SCI involves a series of pathophysiologic processes that contribute to secondary SCIs. b) Ischemia—blood flow to the spinal cord decreases immediately on injury as a result of hypotension and vasospasm induced thrombosis. (1) Vasoconstrictive substances, such as norepinephrine, are released post-injury, contributing to decreased circulation and cellular perfusion. (2) The zone of ischemia can spread if perfusion to the cord is not restored. c) Elevated intracellular calcium—an increase in intracellular calcium—calcium ions accumulate in injured cells, contributing to cellular membrane damage. (1) Once the cell membrane is damaged, neuronal death occurs. d) Inflammatory processes —the inflammatory process induces edema, further decreasing blood supply to the injured area. (1) As the cord swells within the bony vertebrae, edema moves up and down the cord. (2) Because edema can extend the level of injury for several cord segments above and below the affected level, the extent of injury might not be determined for several days, until after the cord edema has resolved.
PowerPoint Slides 1. Spinal Cord Injury Epidemiology 2. Types of Spinal Cord Injury 3. Upper and Lower Motor Injuries 4. Primary and Secondary Injuries 5. Types of Primary Cord Injuries 6. Types of Secondary Spinal Cord Injuries
III. Diagnosis and Assessment of Spinal Cord Injury A. Diagnostic testing 1. The diagnosis of spinal cord injury (SCI) begins with a detailed history of events surrounding the incident, radiographic studies of the spine, and an assessment of sensory and motor function.
a) Frequently, diagnostic testing of the SCI patient is completed in the ED. b) Spinal cord injury is frequently associated with closed-head injury. c) It should also be suspected in a patient with maxillofacial injury and clavicle or upper rib fractures. 2. Radiography a) Radiographs (X-rays) document the level of injury and provide information regarding SCI stability. (1) X-rays are needed only for patients who have changes in level of consciousness as a result of injury, alcohol, or drugs, who cannot complain of neck tenderness, or who complain of neck tenderness and have some obvious symptoms of an SCI injury. 3. Computed tomography scan (CT) scan may be ordered after completion of X-rays if the spine is not well visualized, or if there are suspicious findings. a) A CT scan provides superior visualization of bony structures of the spine and identifies spinal fractures. b) The CT scan is more accurate for detecting posterior and central column injuries, as well as cord impingement. c) If radiopaque contrast is used, the nurse must question the patient about dye and seafood allergies and any underlying kidney disease. 4. Magnetic resonance imaging (MRI) identifies injuries to the spinal cord, ligaments, and disks. a) MRI is used to detect tumors, inflammation, infection, degenerative disorders, and vascular interruptions in the spinal cord and brain. 5. Angiography is the traditional modality of diagnosing and in some cases treating vertebral artery injury. a) Angiography is an invasive procedure that carries certain risks because it involves injecting a radiopaque dye into a blood vessel. 6. Somatosensory-evoked potentials (SEPs) are used to establish a functional prognosis after resolution of spinal cord edema. a) The response of the cerebral cortex to stimulation (evoked potential) is recorded using scalp electrodes. b) In complete SCI, SEPs are absent because the stimulus is not transmitted to the cortex. B. Physical assessment 1. Accurate assessment of motor, sensory, and reflex function is important. a) Treatment, and determine realistic functional goals. b) The American Spinal Injury Association (ASIA) Standard Neurological Classification of SCI assessment form is used to document sensory and motor function. (1) This scale remains the most frequently used tool to evaluate both acute and long-term progress. (2) Serial neurologic exams are performed hourly for at least the first 24 hours after SCI. C. Assessing motor status—Motor activity is assessed for strength, movement against gravity, and range of movement. 1. Each side is evaluated and compared.
D. Assessing sensory status 1. Sensory assessment—the most important data to collect in the sensory examination is the exact point on the patient where normal sensation is present. a) Sensation is tested along dermatomes: sections of the body innervated by a particular spinal (or cranial) nerve. b) A cotton swab is used to assess sensation (spinothalamic tract function). A pin prick is used to assess pain (posterior column function). c) Position sense (proprioception) is tested by moving the big toes and thumbs up and down and asking the patient to confirm the direction. E. Assessing reflex activity 1. The presence of deep tendon reflexes below the level of injury indicates an incomplete lesion. 2. The presence of perineal reflexes indicates that bowel and bladder training might be feasible. F. Assessing for shock states 1. It is important to assess the patient for the presence of spinal shock and neurogenic shock. a) Spinal shock occurs within 30–60 minutes after injury. (1) It can take several hours to become clinically apparent. (2) It is manifested by hypotension, bradycardia, flaccid paralysis, absence of muscle contractions, and bowel and bladder dysfunction. (3) This syndrome can last 7–20 days post-injury and resolves spontaneously. (4) The end of this period is seen with the return of some reflexes, spasticity, and increased muscle tone. (5) It is difficult to classify a spinal cord injury accurately until spinal shock has resolved. 2. Neurogenic shock occurs in patients with an injury above T6. a) The patient experiences hypotension, bradycardia, decreased cardiac output, and hypothermia, with the loss of the ability to sweat below the level of the lesion. b) Blood pools in the lower extremities. c) It is important that neurogenic shock be differentiated from hypovolemic shock. d) Treatment will involve both fluid resuscitation and vasopressor medications.
PowerPoint Slides 1. Diagnosis of spinal cord injury (SCI) 2. Radiographs (X-ray) 3. Computed Tomography (CT) Scan 4. Magnetic Resonance Imaging (MRI) 5. Magnetic Resonance Angiography (MRA) 6. Somatosensory-Evoked Potentials (SEPs) 7. Assessment of Motor, Sensory, and Reflex Function 8. Spinal Shock and Neurogenic Shock
IV. Stabilization and Management of Spinal Cord Injury in the Acute Care Phase A. Surgical stabilization 1. Timely spinal cord alignment and stabilization maximize cord recovery, minimize additional damage, and prevent late deformity. a) The spinal cord is stabilized using surgical or manual techniques. b) Stabilization in the high-acuity unit includes bedrest with log rolling maneuvers and a hard cervical collar until the spine has been stabilized with surgery or traction. B. Manual stabilization 1. Evidence suggests that surgery within 24 hours of the injury might reduce length of intensive care unit stay and reduce postinjury medical complications. 2. Spinal segments are fused during surgery. Spinal canal decompression is accomplished. Rods are inserted to stabilize thoracic spinal injuries. External traction might be required postoperatively. 3. Special braces, such as the Jewett orthosis, may be used postoperatively to maintain hyperextension when the patient is not supine. 4. Surgery is reserved for patients not sufficiently aligned with manual stabilization. 5. The spinal cord may be immobilized through the use of manual fixation devices, including tongs, halos, and braces. a) Skull tongs devices, such as Gardner-Wells or Vinke cervical tongs, may be used initially to reduce a fracture. (1) Screws are implanted into the patient’s skull a few centimeters above the ear using a local anesthetic. (2) The patient feels pressure, but usually not pain. Sequential weights are added to these devices. (3) Muscle relaxants promote the efficacy of the traction. b) The halo device is an external fixation device. (1) It keeps the spine aligned and prevents flexion, extension, and rotational movement of the head and neck. (2) It allows for early mobilization. (3) The device is secured with four pins inserted in the skull—two in the frontal lobe and two in the occipital bone. The halo ring is attached to a rigid plastic vest. (4) Patients in these devices require special nursing responsibilities. c) Braces may include a hard cervical collar and a molded plastic body jacket (clam shell); brace might be sufficient for stabilization of some injuries. (1) Braces, such as the Jewett orthosis, are most frequently used with thoracic and lumbar spine injuries. C. Steroid therapy 1. Methylprednisolone, administered post-SCI, can decrease secondary injury to the spinal cord. a) High-dose methylprednisolone has a profound effect on functional level.
b) Secondary injury could be diminished if methylprednisolone is initiated within 8 hours of injury and continuously infused over 24–48 hours. c) Use is weighed against potential adverse reactions, including gastric ulceration, electrolyte imbalance, and delayed wound healing. d) High-dose methylprednisolone is considered a treatment option, rather than a standard.
PowerPoint Slides 1. Timely Spinal Cord Alignment and Stabilization 2. Surgical Stabilization 3. Manual Stabilization 4. Methylprednisolone
V. High-Acuity Nursing Care of the Patient with a Spinal Cord Injury A. Impaired gas exchange, ineffective breathing patterns 1. Obtain initial laboratory assessments. a) Patients with SCI require close monitoring of respiratory drive, ventilation, ability to cough, pulse oximetry, and arterial blood gases. b) Respiratory care should include aggressive interventions to prevent and treat atelectasis, pneumonia, and aspiration. c) Respiratory function testing should be carried out on a periodic basis to monitor lung compliance, volumes, respiratory muscle strength, and need for mechanical ventilation. d) Obtain CBC, coagulation profile, comprehensive metabolic profile, cardiac enzyme profile, urinalysis, and toxicology screen. B. Decreased cardiac output 1. Closely monitor cardiac output. a) The patient with SCI is at great risk for developing decreased cardiac output related to orthostatic hypotension, spinal and neurogenic shock, venous pooling, emboli, and bradycardia. b) In the acute care phase, invasive and noninvasive monitoring may be used to closely monitor cardiac output. c) Patients with a SCI are at risk for developing bradycardia and even asystole during endotracheal tube manipulation, suctioning, or insertion of a nasogastric tube. d) All sensitive patients should be premedicated with atropine before high-risk procedures. e) Inotropic and/or vasopressor support might be required to maintain adequate cardiac output and tissue perfusion. f) MAP should be maintained 85–90 mm Hg for the first 7 days post-SCI. C. Altered urinary elimination and constipation 1. Bladder dysfunction a) Renal disease is a major cause of morbidity and mortality in individuals with SCI (NSCISC, 2011).
b) Complications that can develop, including incontinence, reflux, development of renal stones, and neuronal obstruction, increase the risk for urinary tract infection (UTI). c) Recent improvements in treatments for infection, bladder surveillance, and management techniques have improved outcomes. d) Intermittent catheterization (IC) is one of the safest forms of bladder management for the SCI patient and is considered the gold standard. IC can cause urethral trauma, false passages, urethral strictures, and infections, but use of a hydrophilic-coated catheter will reduce the incidence of these complications (Cardenas et al., 2011). e) Urinary tract infections are a common problem for the SCI patient. UTIs are frequently caused by organisms that colonize the bowel and perineum. (1) Routine nursing care should be performed to keep the catheter and perineum clean. 2. Bowel dysfunction. 3. Constipation is a common problem of SCI. 4. Delayed colonic transit time is present in 32% of upper motor neuron bowel dysfunction and 36% of lower motor neuron bowel dysfunction and can worsen constipation (Vallès & Mearin, 2009). D. Ineffective thermoregulation 1. Interruption in communication between the spinal cord and the hypothalamus results in loss of temperature control. a) The patient might need to be kept warm with passive warming devices. b) Monitor use of warming devices to avoid thermal injury to insensitive skin. E. Imbalanced nutrition 1. A nutrition consult is initiated as soon as possible to help ensure the patient’s nutritional needs are met. a) Nursing care includes monitoring intake, changes in the patient’s weight, assessing electrolyte balance, and administering total parenteral nutrition, or enteral feedings as ordered. b) In some cases, dysphagia is problematic. Thickening food is helpful. F. Self-care deficits 1. Baseline and ongoing motor, sensory, and reflex assessments provide information about the patient’s neurological progress G. Preventing complications 1. Complications related to altered mobility a) Skin breakdown (1) Skin integrity—frequent positioning, specialized beds, and foot and heel protectors help minimize risk of skin breakdown. (a) Routine daily to twice-daily inspection of all skin is important to identify areas at risk of breakdown. b) Decreased joint mobility—this complication is preventable. (1) Deformity and contracture develop if joint mobility is not maintained through range of motion.
c) Thromboembolism—compression hose or pneumatic devices should be applied to the legs of all patients for the first 2 weeks following injury. (1) During every nursing shift, compression devices should be inspected for proper placement and underlying skin conditions. (2) Anticoagulant prophylaxis should be initiated within 72 hours after SCI, provided there is no active bleeding or coagulopathy. (3) Nursing staff should be aware of the signs and symptoms of DVT, and should perform physical assessment to detect this complication. d) Heterotopic ossification —ectopic bone formation (overgrowth of bone) occurs below the level of the SCI, further restricting joint mobility. 2. Pulmonary dysfunction a) Patients with SCIs, especially high thoracic and cervical injuries, have a high incidence of pulmonary complications, including pneumonia, atelectasis, aspiration, and respiratory failure. (1) Pneumonia is now one of the two leading causes of death in patients with SCI (NSCISC, 2012). (2) Other risk factors for pulmonary complications include older age, preexisting pulmonary conditions (e.g., COPD, smoking, and obesity) and chest trauma at the time of admission (Sisto, Druin, & Sliwinski, 2008). 3. Complications related to CNS dysfunction 4. Complications related to abnormal perfusion a) Chronic peripheral vasodilation causes orthostatic (postural) hypotension, an abnormal drop in blood pressure when changing to an upright position, particularly in patients with injuries at T6 or above (Popa et al., 2010). 5. Complications related to abnormal reflex activity a) Bladder dysfunction (1) Goals of bladder management are bladder drainage; low-pressure urine storage; and voiding without urinary leakage, overdistention, or incontinence. (2) At this point, the catheter should be discontinued and a bladder management program initiated. (3) A proper bladder management program can prevent urinary tract infection, bladder wall damage, overdistention, vesicoureteral reflux and development of stones. (4) Strategies to prevent UTIs must include good perineal hygiene. b) Bowel dysfunction (1) Constipation is a common problem of SCI. (a) Delayed colonic transit time is present in 32% of upper motor neuron bowel dysfunction and 36% of lower motor neuron bowel dysfunction can worsen constipation (Vallès & Mearin, 2009). c) Sexual dysfunction (1) Sexual function is still possible for all patients with SCI. (a) Men might have reflexogenic erections, but very few men are able to ejaculate.
i. Fatherhood is a possibility because ejaculation can be stimulated and the sperm used to inseminate the partner. ii. Men should be referred at some point to an urologist for information on new erectile and fertility treatments. (b) Menses can be disrupted for several months post-injury, but after menses return, pregnancy is still possible. 6. Psychosocial issues a) Spinal cord injury results in psychosocial issues. (1) The independent individual becomes a more dependent person. (2) In the initial acute-care phases, patients with SCI experience severe dependency, profound distress, and social isolation. (a) These patients often have feelings of despair that can dominate feelings of hope. (3) The nurse encourages verbalization of feelings and encourages the patient to take an active role in self-care activities and health care decisions. (4) Referral to a local support group or professional counseling also is helpful. 7. Neuropathic pain (referred to as phantom or central pain) is frequently experienced post-SCI. a) Around 40 percent of SCI patients develop persistent neuropathic pain. b) Gabapentin (Neurontin) has shown promising results and is considered a first-line treatment for neuropathic pain. c) Other medications for neuropathic pain include antiepileptics, steroids, and serotonin noradrenalin reuptake inhibitors.
PowerPoint Slides 1. Obtain Initial Laboratory Assessments. 2. Closely Monitor Cardiac Output. 3. Altered Urinary Elimination and Constipation 4. Monitor for Temperature Irregularities. 5. A Nutrition Consult Helps Ensure the Patient’s Nutritional Needs Are Met. 6. Complications Related to a Change in Mobility. 7. Heterotopic Ossification 8. The Goals of Bladder Management Are Bladder Drainage, Low-Pressure Urine Storage, and Voiding without Urinary Leakage, Overdistention, or Incontinence. 9. Constipation and Fecal Impaction Are Major Problems. 10. Sexual Function Is Still Possible for All Patients with SCI. 11. Spinal Cord Injury Results in Psychosocial Issues. 12. Neuropathic Pain Is Frequently Experienced Post-SCI.
VI. Chapter Summary VII. Clinical Reasoning Checkpoint
VIII. Post-Test IX. References
Suggestions for Classroom Activities • Discuss the greatest challenges faced by the patient who experiences a spinal cord injury. Compare and contrast the types of challenges by the level of the cord involved and the degree of lost function. • Divide the students into groups of 2–3. Instruct them to develop a plan of care using the information obtained in the preceding activity.
Suggestions for Clinical Activities • Visit a health care facility that treats a large population of patients with spinal cord injuries (or invite an administrator to visit the classroom). Ask about the most common spinal cord injuries that they see. Discuss how frequently these problems occur and contributing causes. • Review the standards of care for patients requiring spinal cord immobilization in the clinical facility. Determine what procedures/methods are in place for emergency spinal cord immobilization of the patients you care for.
CHAPTER
20
Determinants and Assessment of Gastrointestinal Function
Objectives 1. Describe the gastrointestinal tract, including anatomic structure, physiologic functions, blood supply and innervation, and laboratory assessments. 2. Explain how mechanisms within the gastrointestinal tract protect the integrity of the gut. 3. Describe the liver, including anatomic structure, physiologic functions, blood supply and innervation, and laboratory assessments. 4. Discuss the exocrine pancreas, including anatomic structure, physiologic functions, blood supply and innervation, and laboratory assessments. 5. Determine the diagnostic tests used to evaluate gastrointestinal, liver, and pancreatic function. 6. Apply the components of a focused nursing gastrointestinal database.
I. The Gastrointestinal Tract A. Muscular tube provides nutrition through ingestion, mechanical processing, digestion, secretion, absorption. B. Anatomic structures: upper portion includes oral cavity, teeth, tongue, salivary glands, pharynx, esophagus; lower portion includes stomach, large intestines. 1. Esophagus: muscular structure, contracts and releases during peristalis. a) Facilitates movement of food toward stomach b) Lower esophageal sphincter (LES)/cardiac sphincter: structure with high resting muscle tone at distal end; prevents gastroesophageal reflux 2. Stomach: receives food from esophagus. a) Fundus: top of stomach b) Body: largest part, located beneath fundus, ends at antrum c) Antrum: base of stomach, ends at pyloric sphincter d) Stomach wall: composed of mucosa, submucosa, muscularis and serosa 3. Small intestine: composed of duodenum, jejunum, ileum a) Mucosal/submucosal layers: slow passage of chyme; maximize digestion and absorption b) Villi: fingerlike projections on intestinal folds c) Microvilli: fingerlike projections on villi
4. Large Intestine: composed of cecum, colon, rectum a) Colon: 4 sections; ascending, transverse, descending, sigmoid b) Gastrocolic reflex: colonic contractions when food is consumed c) Haustral churning: movement of intestinal contents to allow absorption C. Physiologic functions 1. Stomach: functions include food storage, digestion and propulsion a) Cholecystokinin (CCK) and gastrin: hormones that relax gastric wall in preparation for receiving food b) Chyme: food material mixed with gastric acid and pepsin c) Parietal cells: secrete hydrochloric acid and intrinsic factor (IF) d) Chief cells: secrete pepsinogen, a precursor to pepsin e) G-cells: contained in antrum; secrete gastrin f) Mucosal barrier: protects gastric mucosa from gastric acid and pepsin 2. Small intestine: primary function is absorption of nutrients and water a) Secretes hormones to regulate digestion (1) Cholecystokinin (CCK): secreted in response to fat, protein, and an acidic pH (a) Stimulates secretion of pancreatic digestive enzymes (b) Increases contractility of gallbladder to aid in absorption of fats (c) Inhibits gastric motility to slow digestive process so absorption can occur (2) Secretin: secreted when gastric acid comes into contact with intestinal mucosa (a) Stimulates release of alkaline pancreatic bicarbonate and water (3) Gastric inhibitory peptide (GIP): secreted in presence of carbohydrates and fats (a) Facilitates digestion of fats and carbohydrates by inhibiting intestinal motility and the secretion of gastric acid (b) Stimulates insulin secretion (c) Maintains environment for pancreatic proteolytic enzymes to metabolize proteins and fats 3. Large intestine: primary function is completion of water and nutrient absorption, manufacture of vitamins; formation of feces; and expulsion of feces from body a) Digestion results from bacterial action (1) Breaks down dietary cellulose (2) Synthesizes folic acid, vitamin K, riboflavin, and nicotinic acid 4. Blood Supply: GI tract is important to splanchnic circulation and hepatic portal system a) Arterial blood for GI tract comes from: (1) Abdominal (descending) aorta (AA) (2) Celiac trunk: distributes blood to stomach and duodenum (a) Divides into 3 smaller arteries: left gastric, splenic, common hepatic (3) Superior and inferior mesenteric arteries: distribute blood to proximal two-thirds of the large intestine and distal one-third of the large intestine
b) Arterial blood for GI is drained from the stomach and intestines by: (1) Superior and inferior mesenteric veins (2) Gastric veins 5. Innervation a) Sympathetic nervous system (SNS) innervation (1) Reroutes blood to more vital organs during periods of stress (2) Decreases gastric and intestinal motility (3) Causes contraction of the sphincters b) Parasympathetic innervation (1) Processing food (2) Propulsion of contents through GI tract (3) Absorption of nutrients D. Laboratory assessment: What Laboratory Tests to Order for a Patient with Acute Gastrointestinal Insult 1. Electrolytes a) Monitor levels of calcium, chloride, magnesium, potassium, and sodium b) Altered serum levels indicate injury to small intestine 2. Blood urea nitrogen (BUN) a) Elevated BUN may indicate significant blood loss. b) Elevated BUN-to-creatinine ratio may indicate hemoconcentration from fluid volume deficit. c) Elevated BUN may indicate bowel obstruction. 3. Enzymes a) Elevated serum enzymes occur when tissues are injured. 4. Hematology a) Hemoglobin (Hgb) and serum hematocrit (Hct): (1) May be abnormal in GI bleeding. (2) Hematocrit may not reflect volume of blood loss in acute hemorrhage. b) Platelets (1) May increase or decrease with GI bleeding. (2) Evaluate prolonged prothrombin time (PT) and partial thromboplastin time (PTT) levels to determine replacement of clotting factors. (3) Decreased mean corpuscular volume (MCV) suggests iron-deficiency anemia secondary to chronic GI blood loss. (4) White blood cell (WBC) count elevations suggest inflammatory or infectious process, e.g., perforated peptic ulcer and ischemic bowel. c) Arterial blood gases (ABGs:) evaluation of respiratory status and acid-base balance (1) Hypoxemia: early sign of sepsis (2) Metabolic acidosis: may indicate sepsis, ischemic bowel, or peptic ulcer perforation (3) High levels of serum lactate: may indicate lactic acidosis
d) Antibodies (1) Helicobacter antibodies in H. pylori infection indicative of peptic ulcer disease
PowerPoint Slides 1. Anatomic Structures 2. Esophagus 3. Stomach 4. Small Intestine 5. Large Intestine 6. Physiologic Functions of the Stomach 7. Physiologic Functions of the Stomach 8. Physiologic Functions of the Small Intestine 9. Physiologic Functions of the Large Intestine 10. Blood Supply 11. Innervation 12. Laboratory Assessment 13. Laboratory Assessment
II. Gut Defenses A. Nonimmunologic defense mechanisms 1. Salivary secretions: active against foreign antigens and bacteria 2. Gastric acidity a) Acid levels deter pathogen growth, inhibits bacteria from entering small intestine 3. Mucosal barrier a) Mucus from goblet cells prevents pathogens from adhering to epithelial surface. b) Joined epithelial mucosal cells prevent pathogens from invading and colonizing tissue. 4. Peristalsis: inhibits pathogen attachment to the gut mucosa a) Pushes contents along b) Reduces time pathogens can invade and colonize c) Prevents stagnation of chyme d) Prevents reflux of duodenal contents back into stomach 5. Commensal bacteria: limit the proliferation and adherence of harmful bacteria a) Bacteroides fragilis: main anaerobic bacteria b) Escherichia coli: main aerobic bacteria B. Immunologic defense mechanisms 1. Gut-associated lymphoid tissue (GALT) a) Tonsils, lymph tissue within intestinal wall, and the appendix
b) Produces immunoglobulins and immunocytes; defense against pathogen penetration of epithelial surfaces 2. Mucosa-associated lymphoid tissue (MALT) a) In respiratory system, urogenital system, and conjunctiva; primarily in the digestive system and the small bowel b) Peyer’s patches: aggregates of MALT (1) Have two lymphoid constituents: B cell follicles and parafollicular T cell areas (2) M cells of epithelial origin with phagocytic functions C. Mechanisms that maintain mucosal integrity 1. Superficial epithelial cells: maintain a pH gradient between lumen and mucosa to protect from gastric acid and pepsin 2. Mucosal blood flow: prostaglandin stimulates secretion of bicarbonate, increasing blood flow to mucosa 3. Risk factors for disruption of intestinal mucosa: shock, trauma, intestinal obstruction, protein malnutrition, and total parenteral nutrition
PowerPoint Slides 1. Nonimmunologic Defense Mechanisms 2. Immunologic Defense Mechanisms 3. Mechanisms That Maintain Mucosal Integrity 4. Risk Factors for Disruption of Intestinal Mucosa
III. The Liver A. The largest abdominal organ; functions include metabolic and hematologic regulation and production of bile B. Anatomic structures 1. Composed of right and left lobe divided by the falciform ligament. a) Right lobe divided into caudate and quadrate lobes 2. Enclosed in visceral peritoneum, covered with Glisson’s capsule. 3. Liver is divided into 8 segments each with own blood vessels and bile ducts. a) Lobule: functional unit of liver (1) Hepatic cells (hepatocytes) secrete bile (2) Bile canaliculi: canals where bile runs that separate the hepatic cellular plates (3) Sinusoids: blood vessels that are the location and conduit for oxygen-rich blood from hepatic artery and the nutrient-rich blood from the portal vein C. Physiologic functions 1. Metabolic functions a) Fat metabolism (1) Synthesizes of phospholipids and cholesterol
(2) Production and excretion of bile (a) Bile salts: assist in absorption of fat products; breakdown of fat molecules (b) Bilirubin: bile pigment b) Carbohydrate metabolism (1) Maintains blood glucose levels (2) Glycogenolysis: process of converting glycogen back into glucose (3) Gluconeogenesis: process of converting amino acids to glucose c) Protein metabolism (1) Synthesizes majority of body’s proteins (2) Deamination: process of degrading amino acids for energy use (a) Ammonia: toxic byproduct of deamination (3) Converts ammonia into nontoxic urea 2. Vitamin- and mineral-related functions a) Bile is needed to absorb vitamins A, D, E, K. b) Liver requires vitamin K to produce clotting factors. c) Plays role in converting vitamin D into 1,25-dihydroxycholecalciferol. d) Major storage center for iron. 3. Blood volume reservoir a) Liver can expand to accept blood overflow from the heart. b) Liver can compress, shifting blood into the intravascular space and increasing circulating fluid volume. 4. Blood filter a) Kupffer’s cells: special fixed macrophages (1) Destroy pathogens before blood returns to circulation (2) Located in sinusoids on endothelial cells; part of tissue macrophage system (reticuloendothelial system) (3) Filter out foreign particles and old cells 5. Blood clotting factors a) Synthesis of vitamin K required for formation of clotting factors. b) Liver produces fibrinogen: protein that produces fibrin threads and blood clots. 6. Drug metabolism and detoxification a) Biotransformation: changing harmful drugs into harmless substances to be secreted by kidneys. b) Liver can detoxify harmful endogenous substances. D. Splanchnic circulation: portal venous and arterial circulatory systems of the viscera 1. Hepatic portal system; venous circulation from digestive organs a) Allows liver to absorb and store nutrients b) Allows liver to process and excrete substances E. Innervation
1. Sympathetic nervous system (SNS) reduces blood flow, metabolic activities. 2. Parasympathetic nervous system (PNS) increases blood flow and metabolic activities. F. Laboratory assessment 1. Liver function panel or liver function tests (LFTs) a) Liver enzymes (1) Not specific to liver: alanine aminotransferase (ALT), aspartate aminotransferase (AST), and alkaline phosphatase (2) Isoenzymes: specific to liver: LDH isoenzymes (LDH4 and LDH5), 5’-nucleotidase (5’NT), and gamma glutamyltransferase (GGT) b) Bilirubin: end product of hemoglobin degradation (1) Fat-soluble: prehepatic (a) Unconjugated bilirubin: before being converted in liver (2) Water-soluble (a) Conjugated bilirubin: joined with glucuronic acid (3) Urobilinogen: bilirubin excreted through urine (4) Jaundice: yellowish discoloration caused by increase in bilirubin levels (5) Bilirubin testing (a) Conjugated measured with direct method (b) Unconjugated measured with indirect method (c) Urobilinogen measured with sensitive test for hepatic damage c) Clotting measures (1) Normal coagulation maintained by liver through production of prothrombin, vitamin K, and other clotting factors (2) Prothrombin time/partial thromboplastin time: blood tests to measure coagulation pathways d) Prothrombin time (PT) and international normalized ratio: measure of extrinsic coagulation pathway (1) Prolonged prothrombin times: sign of chronic liver disease (e.g., cirrhosis) or vitamin K deficiency (2) International normalized ratio (INR): preferred measure of prothrombin time e) Partial thromboplastic time (PTT): measures intrinsic coagulation pathway (1) Activated partial thromboplastin time (APTT): even more sensitive indicator than PTT in the detection of defects in the clotting factors f) Serum ammonia: high levels indicate liver is not converting urea to ammonia for proper elimination in the urine g) Serum albumin: indicator of protein levels
PowerPoint Slides 1. Anatomic Structures 2. Anatomic Structures
3. Physiologic Functions 4. Physiologic Functions 5. Physiologic Functions 6. Physiologic Functions 7. Splanchnic Circulation 8. Innervation 9. Laboratory Assessment
IV. The Exocrine Pancreas A. Pancreas has endocrine and exocrine functions B. Anatomic structures 1. Three divisions: head, body, and tail 2. Acinus: functional exocrine unit of pancreas a) Cells synthesize, store, and secrete digestive enzymes b) Network of ductal cells secrete alkaline fluids c) Pancreatic lobules: clusters of acini, separated by septa 3. Duct of Wirsung: main pancreatic duct 4. Sphincter of Oddi: controls rate of pancreatic enzymes and bile into duodenum C. Physiologic functions 1. Endocrine functions: secretion of insulin and glucagons 2. Exocrine functions: influence gastrointestinal system and accessory organs 3. Pancreatic secretion: responsible for digestion of fats, starches, and protein a) Four major stimuli: gastrin, cholecystokinin (CCK), secretin, and acetylcholine D. Pancreatic enzymes 1. Trypsin, chymotrypsin, and elastase (proteolytic pancreatic enzymes): break down proteins 2. Phospholipase A (lipolytic pancreatic enzyme): breaks down phospholipids into fatty acids a) May contribute to development of pulmonary complications (acute respiratory distress syndrome (ARDS) 3. Amylase (pancreatic amylolytic enzyme): breaks down starch into sugars E. Pancreatic self-protective properties 1. Autodigestion: process of digesting pancreatic and other tissues; occurs in absence of protective mechanism a) Pancreatic proteolytic enzymes are produced in an inactive, precursor form. F. Blood supply 1. Blood comes from splenic artery, common hepatic artery, superior mesenteric artery. 2. Venous blood leaves through portal, splenic, and superior mesenteric veins. G. Innervation 1. SNS innervation: from splanchnic nerves
a) Stimulation inhibits acinar cells, reduces secretion of digestive enzymes. 2. PNS innervation: from CN X, the vagus nerve a) Stimulation increases the secretion of enzymes. H. Laboratory assessment 1. Pancreatic enzymes a) Amylase: elevated levels are a screening test for pancreatitis b) Lipase: elevated if pancreatic inflammation is present, to identify acute pancreatitis 2. Exocrine pancreatic function testing: indication of pancreatic function 3. Secretin stimulation test: measures ability of pancreas to respond to secretin 4. Elastase test: test of pancreas function
PowerPoint Slides 1. Anatomic Structures 2. Physiologic Functions 3. Physiologic Functions 4. Pancreatic Enzymes 5. Pancreatic Self-Protective Properties 6. Blood Supply 7. Innervation 8. Laboratory Assessment
V. Diagnostic Tests A. Exams of the GI system 1. Radiographic exam a) Flat plate X-ray: for intestinal obstruction, rupture, masses, abnormal fluid or air levels, and the presence of foreign bodies b) Contrast medium: for tumors, masses, hernias, obstructions, ulcers, fistulas, and diverticular disease (1) Patient’s allergy status must be known. 2. Computed tomography scan (CT) a) For visualization of the abdomen, retroperitoneal structures, masses, abscesses, and abnormal fluid or air levels b) Barium contrast solution ingested 3. Ultrasound sonography a) Visualization of abdominal and retroperitoneal soft-tissue structures b) Diagnose fluid or air pockets, abscesses, and masses, and to observe movement 4. Magnetic resonance imaging (MRI) a) Assess abdominal and retroperitoneal structures for masses, abscesses, and fluid or air pockets
5. Nuclear scan a) Visualization of organs, gastrointestinal motility, and bleeding b) Nonuniform radioactive uptake in tissues indicative of disease 6. Angiography a) Visualization of blood flow in selected vascular beds 7. Endoscopy a) Allows inspection of internal surfaces of organs. b) Biopsy, sclerotherapy, suction, and cauterization of bleeding vessels may be performed. 8. Gastric tonometry a) Assesses gut perfusion in critically ill patients b) Detects reduced gastric perfusion by measuring pH and CO2 levels of the gut c) Results can be affected if: (1) Acid entering and bicarbonate refluxing back into the stomach from the duodenum (2) Enteral feeding that refluxes into the stomach (3) Continuous aspiration of the stomach by a sump-style nasogastric tube 9. Sublingual capnometry a) Measures partial pressure of sublingual carbon dioxide (PslCO2) B. Additional pancreatic diagnostic studies 1. Standard abdominal X-ray 2. Computed tomography (CT) a) Visualization of the pancreas b) Identifies fluid around the pancreas, an abscess, or a collection of tissue, fluid, and pancreatic enzymes 3. Magnetic resonance cholangiopancreatography (MRCP) a) Provides information on inflammation, calcification, pseudocysts, and lesions of the pancreas 4. Endoscopic retrograde cholangiopancreatography (ERCP) a) Visualization of the pancreatic-biliary duct system 5. Endoscopic ultrasound a) May reveal gallstones; helpful in diagnosing severe pancreatitis 6. Pancreatic biopsy a) Test for inflammation
PowerPoint Slides 1. Exams of the GI System 2. Exams of the GI System 3. Additional Pancreatic Diagnostic Studies
VI. Nursing Assessment A. Focused nursing database 1. Obtain a history of the precipitating events 2. Perform a focused assessment 3. Obtain a full nursing database 4. Take general history 5. Get medication list 6. Take focused health maintenance history 7. Obtain baseline data 8. Discuss value-belief pattern B. Abdominal assessment 1. Inspection: examine for abnormal contour, alteration in skin, pulsations, and peristalsis 2. Auscultation: stethoscope over all four quadrants; listen for bowel sounds 3. Percussion: over all four quadrants; assess the amount of gas and fluid present 4. Palpation: evaluate for tenderness, organs, masses, and any abnormality C. Genetic considerations 1. Copper accumulation 2. Hypercholesteremia 3. Problems with fat metabolism 4. Obesity 5. Crohn’s disease 6. Celiac disease 7. Gaucher’s disease 8. History of cancer of any organ associated with the GI system
PowerPoint Slides 1. Focused Nursing Database 2. Abdominal Assessment 3. Genetic Considerations 4. Genetic Considerations
VII. Chapter Summary VIII. Clinical Reasoning Checkpoint IX. Post-Test X. References
Suggestions for Classroom Activities • Discuss how the functions of the gastrointestinal tract, liver, and pancreas correspond to their anatomical structures. • Search the Internet for images of healthy and unhealthy gastrointestinal tract organs, livers, and pancreases. Compare them. • Compare the immunologic functions of the GI system with the body’s other immune defenses. • Research over-the-counter medications for gastrointestinal problems. Discuss how these products affect natural functions, and their risks and benefits.
Suggestions for Clinical Activities • Assign students to care for patients experiencing gastrointestinal-health-related concerns. Instruct students to review the laboratory tests that were ordered for each of the patients. What tests were ordered? What trends were noted with the findings? • Visit a lab and view testing of hemoglobin, hematocrit, BUN, serum creatinine, serum albumin, bilirubin, serum enzymes, PT, PPT, amylase, and lipase.
CHAPTER
21
Alterations in Gastrointestinal Function Objectives
Objectives: 1. Describe the incidence and clinical manifestations associated with acute gastrointestinal (GI) bleeding. 2. Discuss the etiology and pathophysiology of acute upper GI bleeding due to ulcers. 3. Discuss the etiology and pathophysiology of acute upper GI bleeding due to tress-related mucosal disease and nonulcer etiologies. 4. Explain the etiology and pathophysiology of acute lower GI bleeding. 5. Describe the nursing diagnoses and management of acute GI bleeding. 6. Describe the etiology, pathophysiology, and management of acute intestinal obstruction and paralytic ileus. 7. Describe the etiology, pathophysiology, and management of intra-abdominal hypertension and abdominal compartment syndrome.
I. Incidence and Clinical Manifestations of Acute GI Bleeding A. Incidence and mortality 1. Clinical scenarios where bleeding manifests itself: a) Bleeding is from the upper GI tract. b) Bleeding is from the lower GI tract. c) Bleeding is occult (unknown to the patient). d) Bleeding is obvious, but the site is obscure. B. Etiology and general manifestations of upper GI bleeding 1. Manifestations of bleeding depend on source, rate of bleeding, comorbid disease. 2. 90% of causes of upper bleeding: peptic ulcer, erosive gastritis, Mallory-Weiss tears, esophagogastric varices. 3. Other causes include: tumors, arteriovenous malformations, stress ulcers. 4. Anemia diagnosed according to: syncope, angina, dyspepsia, increasing weakness, fatigue. 5. GI hemorrhage can lead to hypovolemic shock and ultimately death. C. Etiology and General Manifestations of Lower GI Bleeding 1. Hematochezia: most common symptom
a) Bloody diarrhea, blood, and/or clots from the rectum D. Clinical manifestations of upper and lower GI bleeding 1. Gastrointestinal blood loss may be acute or chronic. 2. Acute GI bleeding: a) Occult blood: blood is present in GI tract but not visible (1) Hemoccult/guaiac testing: chemical testing of stool or nasogastric specimen b) Hematemesis: vomiting of bright red blood c) Melena: black, tarry, foul-smelling stools passed after a GI bleed d) Hematochezia: bright red blood or maroon stool from rectum
PowerPoint Slides 1. Incidence and Mortality 2. Etiology and General Manifestations of Upper GI Bleeding 3. Etiology and General Manifestations of Lower GI Bleeding 4. Clinical Manifestations of Upper and Lower GI Bleeding
II. Acute Upper GI Bleeding Due to Ulcers A. Peptic ulcer disease (PUD): Most Common Cause of upper GI Bleeding 1. Risk factors: most common causes of PUDs a) H. pylori infection (1) Urease: enzyme that allows it to survive and thrive in high acid environment (2) Produces cytotoxins and mucolytic enzymes that makes mucosa susceptible to acid damage b) Nonsteroidal anti-inflammatory drugs (NSAIDs) (1) Factors that increase the risk of NSAID-induced ulcers: (a) Previous history of peptic ulcer disease, corticosteroid use, high doses of NSAIDs (2) Inhibits prostaglandin-supported defense mechanisms, causing severe inflammation and erosive injury to the gastric mucosa 2. Other risk factors: family history of PUD, aspirin, smoking, genetic predisposition 3. Classification of ulcers a) Ulcer depth (1) Erosion: superficial injury that is confined to the mucosal layer (2) Acute ulcer: penetrated through the mucosa and submucosa (3) Chronic ulcer/perforating ulcer: penetrated into the muscularis layer (can result in peritonitis) b) Ulcer location (1) Gastric ulcers (prepyloric): chronic, located in the branches of the left gastric artery (2) Duodenal ulcers (postpyloric): located in the gastric pylorus and the first portion of the duodenum
4. Common clinical manifestations a) Pain in the upper abdomen epigastric area, intermittent pain, nausea, vomiting, anorexia, weight loss, GI bleeding: hidden (occult) or gross, evidenced as hematemesis, melena, or hematochezia 5. Diagnosis and treatment a) For PUD: suggested by history, confirmed with visualization: fiberoptic endoscopy, radiographic study b) Tests for H. pylori: serologic testing, carbon-labeled urea breath tests, rapid urease assay (Clotest), culture or histologic analysis of endoscopic biopsies c) General PUD treatment (1) Antibiotic therapy: eradicate H. pylori (2) Proton pump inhibitors (PPIs): acid secretion inhibition (3) Prostaglandins: inhibit acid secretion and enhance the mucosal barrier (4) Bismuth subsalicylate: antisecretory (salicylate) and antimicrobial (bismuth) actions (5) Sucralfate (Carafate): promote the mucosal barrier (6) Antacids: symptomatic relief and raise gastric pH d) H. pylori infection treatment: heal spontaneously or acid-suppressive therapy e) Surgery: only to manage severe bleeding, perforation complications
PowerPoint Slides 1. Causes of Peptic Ulcer Disease (PUD) 2. Classification of Ulcers: Depth 3. Classification of Ulcers: Location 4. Common Clinical Manifestations 5. Diagnosis 6. Treatment 7. Diagnosis of H. Pylori 8. Treatment of H. Pylori
III. Acute Upper GI Bleeding Due to Nonulcer Etiologies A. Stress-Related Mucosal Disease (SRMD) 1. Two types of injury a) Superficial, diffuse erosions b) Stress ulcers: deeper, discrete lesions 2. Pathophysiology: imbalance in hostile and protective factors in stomach and duodenum 3. Prevention and treatment a) Initiate GI prophylactic measures in critically ill with these drug groups: (1) Histamine-2 receptor blockers (2) Proton pump inhibitors
B. Acute erosive or hemorrhagic gastritis: inflammation of the stomach 1. Common causes: NSAIDs, alcohol, acute stress 2. Uncommon causes: radiation, viral infections, caustic ingestion, direct trauma (e.g., irritation from nasogastric tubes) 3. Clinical manifestations a) Upper GI bleeding: most common, presents as hematemesis (“coffee ground” emesis) b) Decreasing hemoglobin and hematocrit levels from slow loss of blood c) Epigastric pain d) Nausea e) Vomiting f) Bleeding 4. Diagnosis: direct visualization with endoscopy 5. Prevention and treatment a) Maintain a gastric pH level above 4.0 accomplished by: (1) Prophylactic administration of histamine receptor antagonists, proton pump inhibitors, or oral antacids b) Sucralfate administered orally to reduce risk of bleeding c) Early enteral feeding for critically ill d) Sclerotherapy: to treat severe bleeding from a localized lesion e) Vasopressin administered intravenously or intra-arterially into bleeding vessel: to manage GI bleeding f) Surgical resection of the involved portions of the stomach g) Conservative treatment for NSAID-induced gastritis: (1) Discontinuation of the drug (2) Reduction to the lowest effective dose (3) Administration with meals (4) Misoprostol: to prevent ulcer formation during long-term NSAID therapy in high risk patients C. Esophageal and gastric varices 1. Upper GI bleeding associated with: a) Cirrhosis: result of alcohol abuse b) Portal hypertension: the development of collateral venous pathways, varices, in the esophagus and stomach c) Portal or splenic vein thrombosis D. Mallory-Weiss tears: small laceration in the mucosa at the gastroesophageal junction 1. Causes: retching or vomiting, alcohol abuse increases risk 2. Diagnosis: upper GI endoscopy 3. Therapy: thermocoagulation or sclerosing injection
E. Arteriovenous malformation (AVM)/Angiodysplasia: abnormal mucosal or submucosal blood vessel with tendency to bleed 1. Location: both the upper and lower GI tracts; most common in cecal region of the lower GI tract 2. Causes: unknown, appears genetic 3. Associated with: chronic renal insufficiency or renal failure, valvular heart disease, specifically aortic stenosis, congestive heart failure 4. Diagnosis: upper GI endoscopy 5. Treatment: definitive treatment of the underlying or concomitant conditions; endoscopic sclerotherapy used palliatively
PowerPoint Slides 1. Stress-Related Mucosal Disease (SRMD) 2. Acute Erosive or Hemorrhagic Gastritis 3. Clinical Manifestations of Acute Erosive or Hemorrhagic Gastritis 4. Acute Erosive or Hemorrhagic Gastritis 5. Esophageal and Gastric Varices 6. Mallory-Weiss Tears 7. Arteriovenous Malformation (AVM)/Angiodysplasia
IV. Acute Lower GI Bleeding A. Bleeding beyond the ligaments of Treitz B. Common causes: diverticulosis, arteriovenous malformations, ischemic colitis, internal hemorrhoids, rectal ulcers, neoplasms C. Less frequent causes: ischemic bowel disease, inflammatory bowel disease D. Diverticular bleeding: most common etiology of major lower gi bleeding 1. Diverticula (diverticulum, singular): herniations in the bowel wall 2. Risk Factors: age older than 60, chronic constipation 3. Complications: diverticulitis (inflammation/infection), rupture 4. Treatment: surgical intervention, angiography with intra-arterial infusion of vasopressin E. Inflammatory bowel disease (IBD) 1. Chronic disorders of the GI tract: ulcerative colitis, Crohn’s disease 2. Diagnoses: colonoscopy, biopsy 3. Symptoms: bloody diarrhea 4. Treatment: managing with corticosteroids, surgical resection of affected portion F. Neoplasms and polyps 1. Bleeding from neoplasms: slow, chronic, and self-limiting G. Arteriovenous malformations (AVM): angiodysplastic lesions located in right colon 1. Symptoms: weakness, fatigue, dyspnea on exertion, guaiac-positive stools
2. Causes: cardiac disease, low-flow states, aging 3. Treatment: arterial embolization using intra-arterial infusion of vasopressin or gelatin sponge, microcoils, and polyvinyl alcohol particles H. Ischemic bowel disease: ischemia of the colon 1. Causes: occlusion of a major artery, small-vessel disease, venous obstruction, low-flow states (e.g., cardiogenic shock), intestinal obstruction 2. Risk factors in elderly: atherosclerosis, atrial fibrillation, hypotension 3. Risk factors in young: diabetes, pancreatitis, heart disease, sickle cell disease, systemic lupus erythematosus 4. Symptoms: intermittent bleeding, fever, abdominal pain 5. Diagnosis: lower GI endoscopy, radiographic X-rays, barium contrast studies 6. Treatment: restoration of blood circulation to the intestines, fluid resuscitation, optimization of cardiac output, treatment of any underlying disease, antibiotics, resection of the affected bowel
PowerPoint Slides 1. Common Causes 2. Less Frequent Causes 3. Diverticular Bleeding 4. Inflammatory Bowel Disease (IBD) 5. Neoplasms and Polyps 6. Arteriovenous Malformations (AVM) 7. Causes of Ischemic Bowel Disease 8. Ischemic Bowel Disease 9. Diagnosis of Ischemic Bowel Disease 10. Treatment of Ischemic Bowel Disease
V. Management of Acute Gastrointestinal Bleeding A. Collaborative management of physiological problems 1. Systematic approach with patient should include: initial assessment, resuscitation, definitive diagnosis, treatment 2. With the physician, the nurse’s role: a) Assessing the severity of blood loss b) Administering prescribed crystalloids and colloids for fluid replacement c) Assisting in determining the cause of the bleeding d) Planning and implementing treatment e) Managing the ongoing plan of care and monitoring progress f) Providing supportive care and education to the patient and significant others because any bleeding experience is potentially life-threatening
b)
3. Initial assessment a) Determine hemodynamic stability; evidence of instability: decreased blood pressure, orthostatic hypotension, altered level of consciousness, decreased urine output Guidelines for admission into ICU or IMC: (1) Clearly documented frank hematemesis (2) Coffee-ground emesis and either melena or hematochezia (3) Hemodynamic instability (hypotension, tachycardia, orthostatic hypotension) (4) Continued drop in hemoglobin and hematocrit (5) Significant unexplained increase in the BUN when GI bleeding is suspected 4. Resuscitation a) Primary goal of early management in hemodynamically unstable patient b) Obtain blood specimens and chemistries c) Assess consciousness and oxygenation status d) Monitor perfusion and blood volume through: vital signs, orthostatic blood pressure changes, urine output, central venous pressures (CVP), pulmonary artery wedge pressures (PAWP) e) Volume resuscitation: accomplished with crystalloid (normal saline or lactated Ringer’s); if still unstable, consider infusion of blood products f) Therapeutic intervention for persistent bleeding: pharmacotherapy, mechanical (balloon) tamponade (Sengstaken–Blakemore tube), endoscopic therapy (sclerotherapy), surgery 5. Definitive diagnosis a) Upper GI bleeding: gastroenterologist b) Lower GI bleeding: general surgeon B. Treatments 1. Endoscopic interventions: viewing structures in GI tract directly 2. Arterial angiotherapy: control massive bleeding from peptic ulcers 3. Sclerotherapy: use of sclerosant to stop bleeding and harden (sclerose) blood vessel 4. Surgery: for severe hemorrhage or recurrent bleeding when other options failed C. Treatments of specific GL bleeding problems 1. Bleeding from esophageal or gastric varices: a) ICU admission b) Endotracheal intubation c) Early endoscopy d) Sclerotherapy with confirmation of variceal bleeding (1) Intravenous vasopressin or octreotide (somatostatin analog) as alternative to sclerotherapy e) Balloon tamponade therapy f) Shunt surgery or transjugular intrahepatic portosystemic shunt (TIPS) 2. Bleeding Mallory-Weiss tears, bleeding AVMs of the colon: therapeutic endoscopy, selective arterial angiotherapy 3. Diverticular bleeding: selective arterial vasopressin, surgery
D. Management of shock 1. Hypovolemic (hemorrhagic) shock a) Maintenance of adequate tissue perfusion/oxygenation b) Prevention of fluid volume deficit related to blood loss, and optimization of hemodynamic status (1) Ensure an open airway and administer supplemental oxygen (2) Initiate continuous monitoring for cardiac dysrhythmias (3) Prepare for insertion of a central venous or pulmonary artery catheter and record and monitor cardiac filling pressures once placement has been achieved (4) Prepare the patient for emergent surgical intervention to control bleeding
PowerPoint Slides 1. Collaborative Management of Physiological Problems 2. Treatments for Acute Gastrointestinal Bleeding 3. Treatments for Bleeding from Esophageal or Gastric Varices 4. Treatments for Bleeding Mallory-Weiss Tears, AVMs of the colon 5. Treatments for Diverticular Bleeding 6. Management of Shock
VI. Acute Intestinal Obstruction A. Types of acute intestinal obstruction 1. Acute small-bowel obstruction a) Causes: adhesions that develop following abdominal surgery, incarcerated hernias, volvulus, intussusception, tumors b) Results: distention with gas and fluid, inflammation, transudation of fluid, fluid and sodium can accumulate within the intestine, fluid losses can lead to hypotension, which can lead to cardiovascular collapse c) Intestinal strangulation: “twist” in intestine resulting in interrupted circulation (1) Results: necrosis, perforation, sepsis (2) Treatment: corrective surgery 2. Acute paralytic ileus: bowel obstruction from a loss of intestinal peristalsis in the absence of any mechanical (physical) obstruction a) Causes: complication of trauma, handling of the bowel during surgery, electrolyte disturbances (hypokalemia, hypocalcemia, and hypomagnesemia), intestinal ischemia, peritonitis, sepsis, medications that reduce gastric motility b) Ogilvie’s syndrome: severe form of ileus in bedridden patients B. Clinical findings in intestinal obstruction 1. Clinical manifestations: abdominal distention, cramping and periumbilical pain in waves, vomiting, electrolyte imbalances and intraluminal loss of fluids, high-pitched tinkles, tender abdomen 2. Laboratory findings
a) Hematology, electrolyte, and chemistry studies to determine inflammation, fluid, and electrolyte imbalances b) WBC elevations c) Serum BUN, creatinine, sodium, and osmolality levels elevated d) Serum amylase levels elevated 3. Radiologic findings: distended bowel loops; “ladderlike” pattern, distention within the colon C. Treatments 1. Initial therapy: oral food and fluids withheld, nasogastric tube to relieve vomiting and decompress abdominal distention 2. Ogilvie’s syndrome: colonoscopy with decompression 3. Isotonic intravenous fluid, electrolytes replaced 4. Antibiotics considered if strangulation suspected
PowerPoint Slides 1. Types of Acute Intestinal Obstruction 2. Clinical Findings in Intestinal Obstruction 3. Laboratory Findings 4. Radiologic Findings 5. Treatments
VII. Intraabdominal Hypertension and Abdominal Compartment Syndrome A. Intra-abdominal hypertension (IAH): Abnormally high pressure within the abdominal cavity 1. Increased abdominal pressure (IAP) causes IAH. B. Abdominal compartment syndrome (ACS): Acute expansion of abdominal contents 1. IAH can impair blood flow, causing tissue ischemia and organ failure. C. IAH/ACS continuum 1. IAH and ACS used interchangeably but represent a continuum of pathophysiologic changes a) Intra-abdominal hypertension—a sustained or repeated pathological elevation of IAP of 12 mm Hg or greater b) Abdominal compartment syndrome—intra-abdominal hypertension greater than 20 mm Hg, causing end-organ dysfunction that is improved by abdominal decompression D. IAH/ACS etiology 1. Causes of IAH: accumulation of fluid, pregnancy, blood clots, third-spacing of fluid into the peritoneal cavity, abdominal surgery or trauma 2. Risk factors for development of IAH and ACS: ruptured abdominal aortic aneurysm, bowel obstruction, hemorrhagic pancreatitis, ascites, intra-abdominal neoplasm a) Therapies that make one at risk: intra-abdominal packing during surgery, pneumatic antishock garments, gas insufflation of the abdominal cavity during laparoscopic procedures b) Nonsurgical patients: bowel edema and distention
E. Multisystem effects of intra-abdominal hypertension 1. Intestinal mucosa becomes ischemic. a) Predisposes patient to systemic inflammatory response syndrome (SIRS) b) Symptoms of SIRS: increased gastric carbon dioxide level, decreased arterial pH, elevated serum lactic acid F. Measurement of intra-abdominal pressure 1. Routine, noninvasive abdominal pressure monitoring 2. Measurement of transurethral bladder pressure 3. Methods of IAP measurement a) Transducer method b) Fluid manometer method—primarily for screening G. Treatments of IAH/ACS: Focuses on decompression and preserving cardiopulmonary and renal function 1. Mild IAH/ACS: elevate head, maintain a state of normovolemia, assist the patient to turn, cough, breathe deeply, and use an incentive spirometer 2. Moderate ACS: transfer patient to an ICU, sedation or neuromuscular blockade, fluid resuscitation 3. Severe ACS: urgent surgical decompression of the abdominal cavity, re-exploration of the abdomen H. Complications of ACS 1. Reperfusion asystole 2. Pulmonary embolism: Symptoms include dyspnea, pleuritic chest pain, and signs of shock I. Nursing implications 1. Abdominal decompression 2. After effective ACS treatment, therapy includes: decreased ventilation pressures, increased oxygenation, and improved cardiovascular and renal function 3. After surgery: maintaining the patient’s oxygenation and hemodynamic stability, caring for the abdominal wound, monitoring for infection, measuring fluid intake and output, mechanical ventilation, aggressive volume resuscitation, vasopressor, inotropic drugs
PowerPoint Slides 1. Intra-abdominal Hypertension (IAH) 2. IAH/ACS Continuum 3. IAH/ACS Etiology 4. Risk Factors for Development of IAH and ACS 5. Multisystem Effects of Intra-abdominal Hypertension 6. Measurement of Intra-abdominal Pressure 7. Treatments of IAH/ACS
8. Complications of ACS 9. Nursing Implications
VIII. Chapter Summary IX. Clinical Reasoning Checkpoint X. Post-Test XI. References
Suggestions for Classroom Activities • Discuss why acute upper GI bleeding might exacerbate the following conditions: CAD, HTN, diabetes mellitus, pulmonary diseases, and renal failure. • Explain how H. pylori and NSAID use can increase the risk of developing peptic ulcer disease. • Compare and contrast the differences between Crohn’s disease and ulcerative colitis. Draw two pictures of the inner lining of the gastrointestinal tract, one picture demonstrating ulcerative colitis and the other picture demonstrating the appearance of Crohn’s disease.
Suggestions for Clinical Activities • The patient with an acute upper GI bleed develops shock. List 3–6 nursing interventions for the patient in shock. • Describe 4–6 specific questions that could be used while assessing a patient with an acute GI bleed. • The patient has a bowel infarction. For what complications does the nurse assess?
CHAPTER
22
Alterations in Liver Function
Objectives: 1. Explain acute liver failure (ALF), including definitions, and identify common causes of ALF define d. 2. Discuss acute liver failure in terms of diagnostic approach and specific treatment strategies. 3. Identify the complications of acute liver failure and their treatment. 4. Discuss the acute complications of chronic liver disease. 5. Describe the nursing considerations for the high-acuity patient with liver failure.
I. Introduction to Acute Liver Failure (ALF) A. Defining ALF 1. coagulation abnormalities, with an international normalized ratio (INR) greater than 1.5, the onset of encephalopathy in someone who has no previously known hepatic cirrhosis; a duration of less than 26 weeks B. Causes of ALF 1. Drug induced: acetaminophen toxicity a) Symptoms: nausea, vomiting, jaundice, elevated ALT and AST enzyme levels 2. Viral infectious a) Hepatitis B virus (HBV): transmitted through contaminated blood serum or body fluids b) Hepatitis E virus (HEV): transmitted by contaminated water and oral–fecal routes c) Hepatitis A virus (HAV): transmitted through the fecal–oral route only during acute infection; transmitted primarily through contaminated water or food, particularly raw shellfish d) Hepatitis C virus (HCV): transmitted primarily through blood and blood products e) Less common: cytomegalovirus (CMV), Epstein–Barr virus (EBV), herpes simplex virus (HSV), parvovirus B19 and yellow-fever 3. Vascular: interferes with the liver’s blood supply a) Shock liver: develops when a patient has been hypotensive; reduced blood flow to the liver b) Heart failure: alteration in blood flow to the liver can lead to backflow of blood or fluid, resulting in liver engorgement c) Vascular obstruction: caused by Budd-Chiari syndrome; blood flow obstruction to the hepatic veins by blood clots, prevents the normal outflow of blood from the liver
4. Metabolic a) HELLP: complication of pregnancy; Hemolysis, Elevated Liver enzymes, and a Low Platelet count b) Reye’s syndrome: severe disease; can cause encephalopathy and liver injury or failure c) Wilson’s disease: genetic, inherited disorder that leads to an accumulation of copper in the body’s tissues 5. Miscellaneous: autoimmune hepatitis and malignancy, idiosyncratic complications of other conditions, e.g., mushroom poisoning C. Pathophysiologic basis of acute liver failure 1. Large number of hepatocytes have been damaged and destroyed. 2. Synthesis of protein disrupted; liver unable to produce clotting factors necessary for coagulation. 3. Liver unable to clear toxins from the blood.
PowerPoint Slides 1. Defining ALF 2. Causes of ALF 3. Viral Infectious Causes of ALF 4. Less Common Viral Infectious Causes 5. Vascular Causes 6. Metabolic Causes 7. Miscellaneous Causes 8. Pathophysiologic Basis of ALF
II. Diagnosis and Treatment Strategies A. Diagnosis of ALF 1. Blood work: routine chemistry values, liver function tests (LFTs), serum amylase and lipase, complete blood count (CBC), PT/INR, hepatitis serologies, and autoimmune markers 2. A type and screen: toxicology screen, including acetaminophen level; arterial blood gas; and lactate level 3. Other tests: pregnancy test, ammonia level, HIV test, blood, urine, and sputum cultures 4. Diagnostic tests: computed tomography (CT) scan or ultrasound B. Specific treatment strategies based on diagnosis 1. Acetaminophen toxicity: decontaminated with activated charcoal and placement of a nasogastric (NG) tube, N-acetylcysteine (NAC) 2. Amanita phalloides mushroom toxicity: penicillin G, silibinin 3. Herpes Simplex Virus: acyclovir 4. HELLP: delivery of the fetus 5. Budd-Chiari syndrome: placement of either a transjugular intrahepatic portosystemic shunt (TIPS) or surgical shunt
PowerPoint Slides 1. Diagnosis of ALF 2. Specific Treatment Strategies Based on Diagnosis
III. Complications and Treatment Strategies A. Hepatic encephalopathy (HE): Defining characteristic of ALF 1. Levels of severity: determined by clinical evaluation a) Grade I: mild personality changes, reduced attention span, lack of coordination, disruption of sleep/wake patterns b) Grade II: disorientation, may be incontinent of urine and stool, lethargic, slurred speech, asterixis c) Grade III: should be in ICU, stuporous, incoherent, marked confusion, noticeable and continuous asterixis d) Grade IV: comatose (1) IVa: respond to noxious stimuli and may exhibit decerebrate posturing (2) IVb: no response to noxious stimuli and flaccid 2. Ammonia: levels serve as surrogate marker in evaluating HE and its severity 3. Treatment: lactulose, antibiotics, neomycin, rifaximin, nutrition B. Cerebral edema: Potential life-threatening complication of alf, severity correlates to severity of HE 1. Clinical findings: pattern of progressive deterioration of brain function, characterized by increasing alterations in level of consciousness, pupils, oculomotor and motor responses, and breathing 2. Treatment: intracranial pressure monitoring, mannitol sedation through propofol, hypothermia C. Coagulopathy 1. Vitamin K given to correct the INR 2. Thrombocytopenia may be seen in patients with ALF 3. Platelets transfused for invasive procedures D. Hypoglycemia and electrolyte abnormalities 1. Hypoglycemia is common—liver cannot clear insulin from the blood or make glucose by gluconeogenesis 2. Maintain continuous IV infusion of 10% dextrose, replace electrolytes as needed E. Infection 1. ALF patients at increased risk for bacterial and fungal infections 2. Intermittently send cultures of blood, urine, and sputum to monitor for infection F. Cardiopulmonary abnormalities 1. Hypotension is common; patients have high cardiac output (CO) with low systemic vascular resistance (SVR) G. Acute kidney injury (AKI) 1. Causes: decreased perfusion of the kidneys related to low systemic vascular resistance (SVR) and hypovolemia
2. Monitor kidney function and avoid nephrotoxic agents such as aminoglycoside antimicrobials and intravenous contrast agents
PowerPoint Slides 1. Hepatic Encephalopathy (HE) 2. TABLE 22-3 Summary of Hepatic Encephalopathy 3. Hepatic Encephalopathy Treatment 4. Cerebral Edema 5. Coagulopathy 6. Hypoglycemia and Electrolyte Abnormalities 7. Infection 8. Cardiopulmonary Abnormalities 9. Acute Kidney Injury (AKI)
IV. The High-Acuity Patient with Chronic Liver Disease A. Hepatic encephalopathy 1. Evaluation and grading same as ALF a) Not the same risk of developing cerebral edema and brain herniation B. Esophageal variceal bleeding 1. Esophageal varices: dilated and tortuous vessels found in the distal esophagus and stomach; a complication of portal hypertension. 2. Rapid increase in pressure can cause varices to rupture; can cause life-threatening hemorrhage. 3. Treatment: intubation and mechanical ventilation, volume resuscitation with crystalloids, blood, and blood products, endoscopy, tamponade the bleeding vessels with a Sengstaken-Blakemore tube. 4. Reduce the risk: medical management to decrease pressure in the portal circulation, or surgical portocaval shunt placement, transjugular intrahepatic portosystemic shunt (TIPS) procedure. C. Ascites: Abnormal collection of fluid in the abdominal (peritoneal) cavity 1. Risk factors: portal hypertension, hypoalbuminemia 2. Large volume of ascites: patient may develop abdominal compartment syndrome a) Treatment: large-volume paracentesis D. Additional complications 1. High risk of developing: coagulopathy, electrolyte abnormalities, infection, and acute kidney injury
PowerPoint Slides 1. Hepatic Encephalopathy 2. Esophageal Variceal Bleeding
3. Ascites 4. Additional Complications
V. Nursing Considerations A. Frequent monitoring of multisystem parameters and frequent evaluation of laboratory trends B. General goals 1. To determine and correct the underlying cause of ALF and prevent worsening of liver function 2. To support organ function until the patient recovers or receives a liver transplant C. Goals of collaborative interventions 1. Promoting stable hemodynamic and ventilatory status 2. Preventing or minimizing secondary complications D. Nurse’s role 1. Responsible for bedside assessment and analysis of the patient’s status on a continual basis 2. Monitor for signs and symptoms of multisystem complications 3. Prepare the patient and family for procedures, assist with procedures, monitor the patient’s status during and after procedures 4. Develop nursing hypotheses and independent nursing diagnoses based on patient’s response to the illness E. The focused nursing database and history 1. General historical data: pre-existing medical conditions, surgeries, recent history information, such as the events leading up to the patient’s admission and patient’s symptoms 2. Focused cognitive–perceptual history: patient’s usual mental status, ability to communicate, and presence of discomfort or pain 3. Focused value–belief history: value–belief patterns of the patient and family; spirituality and quality-of-life beliefs, to help plan appropriate supportive interventions F. The focused nursing assessment 1. Monitoring for potential complications 2. Monitoring the progress of the independent and collaborative nursing diagnoses G. Respiratory/circulatory assessment 1. Signs and symptoms of fluid volume deficit 2. Edema, which may be generalized or may be present in the form of pulmonary edema 3. Diminished or adventitious breath sounds (crackles in particular) 4. Abnormal trends in blood pressure and pulse H. Elimination assessment 1. Observation of ordered laboratory tests (e.g., blood urea nitrogen [BUN] and creatinine) 2. Evaluation of renal function: measuring intake and output balance and urine volume every 1 to 2 hours I. Neurologic assessment 1. Focused cognitive-perceptual assessment
a) Glasgow coma scale (GCS): addresses eye opening, verbal response, and motor response b) Focused muscular-skeletal assessment: coordination, reflexes, movement c) Focused neurosensory assessment: assesses for the presence of seizures d) Gastrointestinal and integumentary assessment (1) Focused GI assessment: Nausea and vomiting, anorexia, diarrhea or constipation, hepatic tenderness and enlargement on palpation (2) Focused integumentary assessment: jaundice, pruritus, edema, assess skin for: evidence of poor wound healing, ecchymosis or petechiae, bleeding gums, pale mucous membranes and nail beds J. The nursing care plan 1. Frequently occurring collaborative problems: hepatic encephalopathy, esophageal varices, ascites, cerebral edema, coagulopathy, metabolic disorders, infection, cardiopulmonary abnormalities, acute kidney injury, hemorrhage, malnutrition 2. Frequently occurring nursing diagnoses: ineffective breathing pattern, fluid volume deficit, activity intolerance, altered nutrition, altered comfort, pain: upper abdominal, altered thought processes, high risk for infection
PowerPoint Slides 1. General Goals 2. Goals of Collaborative Interventions 3. Nurse’s Role 4. The Focused Nursing Database and History 5. The Focused Nursing Assessment 6. Respiratory/Circulatory Assessment 7. Elimination Assessment 8. Neurologic Assessment 9. The Nursing Care Plan
VI. Chapter Summary VII. Clinical Reasoning Checkpoint VIII. Post-Test IX. References
Suggestions for Classroom Activities • Invite a speaker to meet with the class. Contact the local department of health for a nurse to come to talk with the class concerning the incidence of hepatitis in the local community.
• Ask students to develop two NCLEX-style questions each. The subject of the questions must relate to the care of patients experiencing disorders presented in this chapter. Collect the questions and use them in class to prepare for the examination.
Suggestions for Clinical Activities • Develop a game in which students match nursing interventions for the care of a patient experiencing hepatic failure. • Assign students to patients at risk for hepatitis. • Ask students to identify methods of prevention for acute hepatitis.
CHAPTER
23
Alterations in Pancreatic Function
Objectives: 1. Describe the pathophysiologic basis of acute pancreatitis. 2. Analyze diagnostic data used in the determination of acute pancreatitis. 3. Demonstrate assessment of the patient with acute pancreatitis. 4. Explain the complications of acute pancreatitis. 5. Describe the medical management of a patient with acute pancreatitis. 6. Apply the concepts of nursing management for a patient with acute pancreatitis.
I. Pathophysiologic Basis of Acute Pancreatitis A. Pancreatitis: Inflammation of the pancreas, results in injury to pancreas 1. Acute pancreatitis, sudden onset of pancreatic inflammation, progresses to generalized systemic inflammatory response a) Symptoms: abdominal pain, pancreatic tissue edema, necrosis of pancreatic tissue, possibly hemorrhage. b) Mild cases called interstitial or edematous pancreatitis. c) Most severe form is necrotizing or hemorrhagic pancreatitis. (1) Extensive necrosis in and around pancreas, pancreatic cellular necrosis, hemorrhage within the pancreas (2) Over 20% mortality rate d) Recurring acute pancreatitis as common as 19%, most common when resulting from alcohol consumption. B. Etiologies 1. In U.S. 30-60% of cases from gallstones, more commonly in women a) Obstruction of common bile duct by gallstone, increases pancreatic ductal pressure and permeability, leads to premature activation of pancreatic enzymes 2. In U.S. 15-30% of cases from alcohol, more commonly in men a) Triggers spasms of the sphincter of Oddi, resulting in transient obstruction b) Triggers hyperresponsiveness of monocytes, resulting in increased inflammation c) Directly injures the acinar cells
3. Other causes and risk factors: medication complications, hypercalcemia, significant hypertriglyceridemia, pregnancy, total parenteral nutrition, major surgery, major complication of AIDS, endoscopic manipulation of ampulla Vater, specific genetic mutations C. Pathophysiology 1. Pathogenesis includes excessive leukocyte activation and transmigration, microcirculatory disorders, gut endothelial barrier dysfunction, bacterial translocation, and/or acinar cell necrosis and apoptosis 2. First phase: trypsin and other enzymes are prematurely activated a) Autodigestion results from destruction of pancreatic tissue by its own enzymes. b) Cascading effects cause cell wall damage. c) Phospholipase A digests phospholipids on cell membranes. d) Elastase digests elastic tissue of vessel walls. 3. Second phase: intrapancreatic inflammation 4. Third phase: extrapancreatic/systemic injury a) Kallikrein causes vasodilation and increases permeability of blood vessels, pain, and leukocyte invasion. (1) Once kallikrein is activated, systemic hypotension may lead to shock and multiple organ failure.
PowerPoint Slides 1. Pancreatitis 2. Acute Pancreatitis 3. Severity of Acute Pancreatitis 4. TABLE 23-1: Characteristics of Nonhemorrhagic and Hemorrhagic Acute Pancreatitis 5. Etiologies 6. Other Causes and Risk Factors 7. Pathophysiology 8. Kallikrein
II. Diagnosing Acute Pancreatitis A. Requires at least two of the following features: 1. Abdominal pain characteristic of acute pancreatitis 2. Serum amylase and/or lipase more than three times the upper limit of normal 3. Characteristic findings of acute pancreatitis on computed tomography (CT) scan B. Laboratory assessment of acute pancreatitis 1. Pancreatic enzyme levels. a) Serum amylase can increase for several reasons; examined in the context of other supportive data: (1) Can rise within hours of acute pancreatitis and return to normal in as little as three days
b) Serum lipase is considered best pancreatic enzyme parameter: (1) Rise later than amylase and remain elevated for 1-2 weeks 2. Other laboratory tests used include those of the liver and gallbladder. 3. Diagnostic tests include abdominal X-rays, ultrasound, computed tomography (CT) scan, endoscopic retrograde cholangiopancreatography (ERCP), magnetic resonance cholangiopancreatography (MRCP), and aspiration biopsy. a) Abdominal and chest radiography: used to exclude intestinal ileus, perforation, pericardial effusion, and pulmonary disease as causes of pain b) CT scan: confirms diagnosis, used to determine severity, and assesses pancreatic necrosis c) Ultrasound: particularly valuable in viewing bile ducts, identifying gallstones (1) Limited useful in visualization of pancreas because of bowel gas (2) Endoscopic ultrasound (EUS) to evaluate necrotic collections, small gallstones, anatomical abnormalities d) Endoscopic retrograde cholangiopancreatography: particularly useful in diagnosing obstructions, can directly remove mechanical obstructions, place stents, perform biopsy (1) An invasive endoscopic test e) Magnetic resonance cholangiopancreatography (MRCP): produces images used to evaluate the hepatobiliary tree (1) Noninvasive, requires no contrast f) Image-guided aspiration biopsy: used to diagnose the severity of pancreatic tissue damage, diagnose types of lesions, drain pseudocysts, distinguish sterile necrosis from infected necrosis (1) Involves removal of small plug of tissue using syringe-and-needle technique g) Predicting the severity of an episode of acute pancreatitis: clinical severity scoring systems are used to identify those who need high-acuity care (1) Highest incidence of organ failure occurs within first 24 hours of onset. (2) Multifactorial scoring systems: (a) Ranson criteria: used for many years, complete assessment requires 48 hours (b) Acute Physiology and Chronic Health Evaluation scale: useful for assessing severity on admission (c) Computed tomography severity index (CTSI): based on contrast-enhanced CT findings (3) Individual factors that may predict severe acute pancreatitis include: (a) BUN measurement. (b) C-reactive protein greater than 150 mg/dl may predict mortality. (c) Procalcitonin greater than 1.8 can indicate infected pancreatic necrosis. (d) Factors associated with severed necrotizing pancreatitis: obesity, pleural effusion, increased serum creatinine, hemoconcentration.
PowerPoint Slides 1. Pancreatitis Diagnosis 2. Laboratory Assessment 3. Major Diagnostic Tests 4. Prediction of Severity 5. TABLE 23-3: Scoring Systems for Determining Severity of Acute Pancreatitis 6. Individual Factors that May Predict Severity
III. Nursing Assessment of the Patient with Acute Pancreatitis A. Assessment of pain 1. Classic pattern of pain described as sudden onset of sharp, twisting, deep, upper abdominal pain that radiates to the back, with nausea and vomiting. 2. Pain varies greatly from patient to patient; intensity reflects degree to which the disease process has extended beyond the pancreas. 3. Pain is result of edema and distention of the pancreatic capsule, chemical burn of the peritoneum by pancreatic enzymes, and the release of kinin peptides or biliary obstruction. B. Focused history and assessment 1. Ask the patient about: previous symptoms of gallstones, alcohol use, history of hypertriglyceridemia or hypercalcemia, family history of pancreatic disease, drug history, history of trauma, presences of autoimmune disease C. Gastrointestinal assessment 1. GI clinical manifestations may include: anorexia, upper abdominal tenderness, abdominal distention, nausea and vomiting, diarrhea, peritoneal signs (diminished bowel sounds, abdominal rigidity and rebound tenderness) D. Signs of systemic inflammation 1. Assess patient for: leukocytosis, tachycardia, fever, decreased mental status, hypoxemia E. Additional assessments 1. Integumentary signs: a) Cullen's sign: bluish discoloration around the umbilicus, may indicate hemorrhagic pancreatitis. b) Grey Turner's sign: bluish discoloration of the flank region, may indicate hemorrhagic pancreatitis. c) Jaundice and edema may be noted. d) In shock, pale, cold, moist skin. 2. Cardiovascular signs: usually present themselves in conjunction with shock a) Assess for hypovolemic shock, myocardial depression 3. Pulmonary signs: a) Pleural effusion (adventitious breath sounds), respiratory insufficiency or failure, pneumonia 4. Neurologic signs:
a) Confusion, restlessness, agitation b) Glasgow Coma Scale (GCS): to trend alterations in level of consciousness 5. Renal signs: a) Monitor for acute tubular necrosis (1) Urine output, blood urea nitrogen (BUN) levels, creatinine levels, urine color and consistency (brownish, foamy urine when bile is excreted through urine) 6. Hematologic a) Monitor for disseminated intravascular coagulation 7. Endocrine signs: a) Fluctuations in serum glucose levels 8. Electrolyte imbalances: a) Hypocalcaemia may occur with fat necrosis; signs include: (1) Chvostek's sign: facial muscles contract on same side of face as tapping (2) Trousseau's sign: hand flexes (carpopedal spasm) in response to inflated blood pressure cuff on upper arm directly above patient's systolic blood pressure for two minutes b) Hypokalemia and hypomagnesaemia may occur
PowerPoint Slides 1. Assessment of Pain 2. Focused History and Assessment 3. Gastrointestinal Assessment 4. Signs of Systemic Inflammation 5. Nursing Assessment-Integumentary 6. Nursing Assessment—Cardiovascular 7. Nursing Assessment—Pulmonary 8. Nursing Assessment—Neurologic 9. Nursing Assessment—Renal 10. Nursing Assessment—Hematologic 11. Nursing Assessment- Endocrine 12. Nursing Assessment—Electrolyte Imbalances
IV. Complications of Acute Pancreatitis A. Multisystem disease process; complications are common; may be local or systemic; complications mediated by pro-inflammatory cytokines released in early phase B. Local complications 1. Pancreatic abscess: localized infectious process in presence of decreased microvascular circulation and hypoxia 2. Pancreatic necrosis: results from autodigestion without localized infection
3. Pseudocyst: cavity containing pancreatic enzymes, necrotic tissues, possibly blood; enclosed by adjacent tissue or pancreatic tissues a) Some resolve themselves b) May become infected or rupture, may precipitate chemical peritonitis 4. Abdominal compartment syndrome (ACS): serious complication; two types: a) One type: ascites that need to be drained to reduce intra-abdominal pressure and alleviate systemic inflammation b) Other type: bowel ileus and pneumoperitoneum; may lead to reduced cardiac output, decreased renal artery blood supply, decreased glomerular filtration; surgical decompression may be necessary C. Systemic complications: caused by systemic inflammatory response syndrome (sirs) from release of humoral mediators (platelet activating factor, interleukins, myocardial depressant factor, neutrophils, tumor necrosis factor, cytokines) 1. Pulmonary a) Hypoxemia develops in majority of cases within first two days. b) Respiratory insufficiency and failure are common. c) Patient is at risk for pneumonia, pleural effusion, or acute respiratory distress syndrome (ARDS). 2. Cardiovascular a) Myocardial depressant factor (MDF) may be released, has negative inotropic effect on heart muscle 3. Hypovolemic shock a) Hypovolemia, third spacing and hypovolemic shock from: released vasoactive substances, can cause vasodilation, decreased systemic vascular resistance, increased permeability of endothelial linings of vessels allows intravascular fluids to enter other compartments. b) Hemorrhage is also a major cause. 4. Renal a) Acute tubular necrosis (ATN) is fairly common; follows hypotension and hypoxemia. b) Respiratory support of hypoxemia may prevent it. c) In event of ATN, timely and accurate fluid resuscitation, may prevent permanent kidney damage. 5. Neurologic a) Decreased level of consciousness is common. b) Etiologies: analgesia and pancreatic encephalopathy. 6. Hematologic a) Disseminated intravascular coagulation (DIC) may be caused by intravascular consumption of factors secondary to pancreatic enzymes 7. Metabolic a) Hyperglycemia is common.
b) High serum glucose levels and wide glucose level swings are predictors of disease severity and mortality. c) Metabolic acidosis may occur.
PowerPoint Slides 1. Complications of Acute Pancreatitis 2. Local Complications 3. Systemic Complications 4. Systemic Complications-Pulmonary 5. Systemic Complications—Hypovolemic Shock 6. Renal Complications 7. Neurologic Complications 8. Hematologic Complications
V. Medical Management A. Combinations of supportive and curative; depends on underlying problem
(3) 2.
B. Supportive therapy 1. Goal 1: Stabilize the patient's hemodynamic status a) Hypovolemia must be identified and treated. (1) Fluid resuscitation critically important; includes crystalloids, possibly colloids and plasma expanders; initial bolus followed by continuous infusion (2) Monitor hemodynamic status during treatment (a) Vital signs, oxygen saturation, blood gas analysis, pulmonary artery pressure, central venous pressure, cardiac output and index, fluid intake and output, hematocrit, BUN levels, creatinine levels Inotropic therapy also used Goal 2: Control the patient's pain a) Fentanyl, morphine, and hydromorphine are used. b) Opiates usually administered every 2-4 hours. c) Parenteral route, patient-controlled analgesia pumps, used when patient cannot take medications orally. d) Meperidine is not a drug of choice; its neurotoxicity can cause many complications, interacts with many drugs. 3. Goal 3: Minimize pancreatic stimulation a) Keeping GI tract at rest minimizes pancreatic secretion, minimizes pain. b) Organ rest until serum amylase levels return to normal, pain subsides. c) Possible interventions: initial nothing-by-mouth (NPO) status; intravenous fluid hydration; placement of nasogastric tube to intermittent suction (for paralytic ileus or frequent vomiting); drug therapy (antacids, proton pump inhibitors, anticholinergics).
d) Patients often unable to consume sufficient nutrients to meet demand; nutritional support considered when oral nutrition likely to resume within 5 days; route of administration is controversial. e) Enteral nutrition: (1) Advantages: decreased infection rate, need for surgical intervention, mortality rate, hospital length of stay, multiple organ failure, cost (2) Disadvantages: nasojejunal tube may be difficult to place, poorly tolerated f) Total parenteral nutrition (1) Advantages: doesn't require tube (2) Disadvantages: risks associated with intravenous central line access 4. Goal 4: Provide psychosocial support a) Outcome often hard to predict, can be anxiety-producing, patient may enter critical care unit. b) Assess and reassess patient and family psychosocial needs. c) Multidisciplinary plans include education of disease process, updates on status, assistance of basic care needs, education on risk factors for future episodes.
2.
C. Curative therapy 1. Goal 5: Correct underlying problem a) Some events (e.g., binge drinking) may subside with supportive therapy. b) Surgery to correct mechanical obstructions: (1) Biliary obstruction (i.e. gallstone) removed with cholecystectomy (2) ERCP to remove some obstructions c) Drug-induced acute pancreatitis considered as etiology after others are excluded. Goal 6: Prevent or treat complications a) Close patient monitoring is crucial. b) Interventions may include: electrolyte replacement, insulin therapy, antibiotic therapy, antisecretory therapy, arterial blood gases, oxygen therapy, pulmonary hygiene, radiographic studies, cardiac monitoring, pulmonary artery flow-directed catheter. c) For infected pancreatic necrosis: surgical debridement may be indicated, proton-pump inhibitors used. d) For pancreatic abscess: drainage indicated. e) Surgical incisions may result in pancreatic fistulas and complications.
PowerPoint Slides 1. Supportive Therapy 2. Curative Therapy 3. Supportive: 1. Stabilize Hemodynamic Status 4. Supportive: 2. Control Pain 5. Supportive: 3. Minimize Pancreatic Stimulation 6. Supportive: 4. Psychosocial Support
7. Curative: 5. Correct the Underlying Problem 8. Curative: 6. Prevent/Treat Complications
VI. Nursing Care of the Patient with Acute Pancreatitis A. Possible nursing diagnoses include: 1. Risk for decreased cardiac output 2. Deficient fluid volume 3. Ineffective gas exchange 4. Acute pain 5. Altered comfort 6. Imbalanced nutrition 7. Risk for infection 8. Anxiety 9. Risk for injury 10. Risk for electrolyte imbalances B. Care includes frequent assessments for early signs of potential complications; increase of symptoms immediately communicated with team C. Care dependent on etiology
PowerPoint Slides 1. Nursing Diagnoses 2. Nursing Care 3. Pain Control/Relief of Pain 4. Relief of Nausea and Vomiting 5. Optimize Nutrition 6. Optimize Respiratory Status 7. Prevention
VII. Chapter Summary VIII. Clinical reasoning checkpoint IX. Post-Test X. References
Suggestions for Classroom Activities • Have students prepare an algorithm to compare and contrast mild and severe acute pancreatitis. While discussing the algorithm, ask about the ways pathophysiologic changes influence the clinical manifestations of acute pancreatitis.
• Ask students to discuss a teaching plan for informing a patient who has pancreatitis “how the disease develops.” • Ask students to analyze a case study with amylase and lipase values.
Suggestions for Clinical Activities • Assign students to care for patients with pancreatic and abdominal disorders in an acute care unit. During postconference, discuss the care provided to these patients.
CHAPTER
24
Determinants and Assessment of Fluid and Electrolyte Balance
Learning Outcomes: 1. Discuss the composition and distribution of body fluids. 2. Describe the roles of the nervous and endocrine systems in the regulation of fluid balance. 3. Demonstrate assessment of the fluid status in high-acuity patients. 4. Compare and contrast the electrolytes sodium, chloride, calcium, potassium, magnesium, and phosphorus/phosphate. 5. Demonstrate assessment of the electrolyte balance in high-acuity patients.
I. Body Fluid Composition and Distribution A. Composition: water with electrolytes, glucose, urea, creatinine B. Fluids: environment for cells, medium for metabolic reactions, cushion to protect body parts, influence on regulation of heat C. Body water content affected by age, gender, body fat content D. Fluid compartments 1. Intracellular (ICFs): provide cells with nutrients, assist in cellular metabolism a) Regulated by: intracellular proteins, negatively charged ions within cells attract positively charged ions outside cells (1) Sodium/ potassium (Na+/K+) pump is critical 2. Extracellular (ECF) a) Intravascular: plasma composition is 90% water, 7% plasma proteins, other substances b) Interstitial: between cells or tissues (1) Functions: transport medium for nutrients, gases, waste products; backup fluid in case of vascular fluid loss (2) Tissue gel: sponge-like substance, helps even distribution c) Transcellular: cerebral spinal, peritoneal, synovial fluids; about 1% total ECF E. Movement of fluids 1. Osmosis: movement of water across cell membrane 2. Osmolality: concentration of solute in body water; reflects hydration status
a) May be increased or decreased in various disease processes 3. Starling forces: control movement of fluids between interstitial and intravascular compartments a) Capillary hydrostatic pressure: fluid movement in capillaries pushes fluid out of capillary, into interstitial space (1) Responsible for blood pressure b) Capillary oncontic/colloidal osmotic pressure: plasma proteins movement through capillaries draws fluid into capillary c) Interstitial hydrostatic pressure: fluid in interstitial space pushes against capillaries; opposes shift of fluid out of capillaries d) Interstitial oncotic pressure: small amount of proteins in interstitial space attracts fluid out of capillaries
PowerPoint Slides 1. Body Fluids 2. Factors That Affect Water Content 3. Fluids Compartments 4. Intracellular Fluids (ICF) 5. ICF Volume Regulated by Several Mechanisms 6. Extracellular Fluid (ECF) 7. Interstitial Fluid 8. Transcellular Fluid 9. Intercompartmental Fluid Movement—Osmosis 10. Osmolarity 11. Starling Forces
II. Regulation of Fluid Balance A. Hypothalamus regulation 1. Thirst: simulation of osmoreceptors in hypothalamus by decreased blood volume, increased serum osmolality, mouth dryness a) Helps regulate sodium balance (1) Hypernatremia common electrolyte imbalance in high-acuity patients with altered consciousness b) Excess fluids lost in tachypnea, fever, vomiting, diarrhea, kidney malfunction B. Arterial baroreceptors: detect pressure changes in aorta, carotid sinus, pulmonary arteries 1. With blood pressure changes, signals sympathetic nervous system, causes vasoconstriction or vasodilation C. Endocrine regulation 1. Adrenocorticotropic hormone (ACTH): released in event of decreased serum sodium or increased serum potassium
a) Aldosterone (signaled by ACTH), "salt-regulating hormone" b) Blood volume and arterial blood pressure increase 2. Antidiuretic hormone (ADH): vasopressin, increased or decreased in response to change in body fluid concentration a) Affects renal reabsorption of water 3. Renin-angiotensin-aldosterone system: kidneys release renin when sodium concentration in ECF or kidney blood flow decreases a) Renin releases angiotensin I which converts to angiotensin II (vasoconstrictor) b) Angiotensin II releases aldosterone c) Blood pressure increases
PowerPoint Slides 1. Fluid Balance Mechanisms 2. Hypothalamus and Thirst 3. High-Acuity Patients 4. Arterial Barorecptors 5. Endocrine Regulation 6. Adrenocorticotropic Hormone (ACTH) 7. Antidiuretic Hormone (ADH) 8. Renin-Angiotensin-Aldosterone System
III. Assessment of Fluid Balance A. History of factors that can alter fluid and electrolyte balance 1. Injury or disease process 2. Medications 3. Dietary restrictions 4. Intake vs. output of fluids B. Vital signs 1. Temperature: a) Fever can result in excess water loss, increased basal metabolic rate. 2. Pulse: a) Tachycardia is associated with decreased intravascular volume, hypomagnesaemia, hypokalemia. b) Bradycardia is associated with elevated serum levels of those electrolytes. c) Either alteration can lead to dysrhythmias. 3. Respirations a) Alterations in potassium balance and/or low magnesium levels can cause weakness of respiratory muscles. b) Dyspnea may indicate pooling of fluid in lungs.
4. Arterial blood pressure a) Orthostatic hypotension: drop in blood pressure of more than 20 mmHg or an increase in pulse greater than 20 bpm when changing position from lying to standing C. Physical assessment 1. Inspection a) Sunken eyes, dry tongue may indicate fluid volume deficit b) Round edematous face may indicate fluid overload c) Jugular venous pressure observed d) Hand veins observed for distention when hand is elevated; if distention takes over 5 seconds, may indicate hypovolemia 2. Palpation a) Skin flattens more slowly after pinch is released in cases of fluid volume deficit. 3. Capillary refill a) Decreased capillary refill may indicate hypovolemia, has other potential causes. 4. Abnormal extravascular accumulation of fluids a) Second-spacing of fluids/ edema: an excess of accumulation of fluid in interstitial spaces (1) Location: generalized vs. localized (a) Generalized edema: usually the result of decreased plasma protein, protein malnutrition; or from expanded localized process (b) Localized edema: local pathologic condition; e.g., edema of congestive heart failure, pulmonary edema caused by left-sided heart failure (2) Clinical manifestations: depends on location (3) Pitting edema: accumulation of fluid exceeds what can be absorbed by interstitial tissue gel b) Third-spacing of fluids: Shift of fluids from intravascular to transcellular space (usually serous cavity) (1) Common causes: liver failure, myocarditis, pleuritis, peritonitis (2) Clinical manifestations: ascites, pericardial and pleural effusions (a) Difficult to assess because cavities are deep (b) Comprehensive physical examination, chest or abdominal radiography, electrocardiogram, echocardiogram 5. Body weight: gain or loss of 1 kg represents fluid gain or loss of about 1 L 6. Auscultation a) Heart: in fluid volume overload, may reveal third or fourth heart sound; pericardial friction rub may indicate pericardial effusion b) Lungs: crackles may indicate fluid volume overload; pulmonary edema may indicate heart failure or acute respiratory distress syndrome 7. Percussion a) Pain upon percussion of flank area may indicate UTI extended to kidneys. b) Percussion of abdomen can indicate fluid volume status, especially with ascites:
(1) Ascites occur in renal failure, liver failure. 8. Hemodynamic monitoring: measure central venous pressure, pulmonary artery wedge pressure, cardiac output and cardiac index, mean arterial pressure 9. Urine assessment a) Volume: in normal conditions, low urine volume indicates fluid deficit; high urine volume indicates fluid excess (1) Indwelling catheter standard practice (2) Output affected by many conditions b) Concentration (1) Specific gravity: measures ability of kidneys to concentrate urine (2) Normal: 1.005–1.030; greater than 1.030 indicates fluid volume deficit; less than 1.005 indicates fluid volume excess (3) More accurate to measure osmolality in patients with glycosuria, proteinuria, or recent administration of radiocontrast dyes c) Osmolality: the concentration of solutes in urine (1) Normal: 200–800 mOsm/kg H2O 10. Laboratory assessment a) Serum labs (1) Blood urea nitrogen (BUN): in renal dysfunction, levels rise; but they also can because of protein intake or nitrogen metabolism problems (a) Urea: an end product of protein metabolism, excreted by kidneys (2) Creatinine (Cr): in renal dysfunction, levels rise; affected by few conditions than BUN (a) an amino acid compound located in skeletal muscle, metabolized in the liver (3) BUN-to-creatinine ratio: normal ratio is 10:1 to 20:1 (a) Change in ration can help identify renal dysfunction etiology. (4) Osmolality: normal is 280- 300 mOsm/kg (a) Below 240 mOsm/kg suggest fluid excess or hemodilution (b) Above 320 suggests fluid volume deficit or hemoconcentration (5) Anion gap: difference between cations (sodium, potassium) and anions (chloride and bicarbonate) (a) Formula: Na+ - (Cl– + HCO3–). (b) Anion gap increases with decreased excretion or increased production of acid products and with kidney injury. (6) Serum albumin: normal is 3.5-5.0 g/dL (a) Plasma protein, synthesized by liver, represents majority of protein carried in blood. (b) Hypoalbuminemia is caused by chronic inflammation and malnutrition, can lead to generalized edema. b) Urine labs (1) Urinalysis: measures pH, glucose, protein content, heme content, urine sediment content (a) Many factors affect urine content.
(2) Creatinine clearance (CrCl): amount of Cr secreted in urine and amount in the blood over a 24-hour period (a) Reliable measure for estimating glomerular filtration rate (GFR) (b) Formula: CrCl = Urine creatinine (mcg/dL) × Urine volume (dL)/ Serum creatinine (mcg/dL
PowerPoint Slides 1. Assessment 2. History (Factors That Can Alter Fluid/Electrolyte Balance) 3. Vital Signs Associated with Fluid/Electrolyte Imbalances 4. Physical Assessment 5. Physical Assessment Continued 6. Abnormal Extravascular Accumulation of Fluids 7. Urine Assessment 8. Urine Lab Tests 9. Serum Lab Tests
IV. Electrolytes A. Electrically charged microsolutes in body fluids B. Cations: positively charged ions C. Anions: negatively charged ions D. Play vital role in enzyme activities, muscle contraction, metabolism E. Extracellular: sodium (Na), chloride (Cl), calcium (Ca) F. Intracellular: potassium (K), magnesium (Mg), phosphorous (PO4) G. Sodium (Na+): Most abundant cation in extracelluar Fluid 1. Functions: water balance, transmission of muscle and nerve impulses, important role in acidbase balance maintenance 2. With excessive intake, fluid volume in intravascular compartment increases, secretion of ADH by hypothalamus to balance levels 3. With deficient intake, plasma volume decreases, kidneys trigger renin-angiotensin-aldosterone system to balance levels 4. Sodium and water balance a) Water is drawn to sodium. b) Excess sodium level in the extracellular fluid pulls water from the intracellular spaces, intracellular fluid compartment shrinks, extracellular compartment enlarges: (1) May precipitate congestive heart failure and pulmonary edema in patients whose renal or cardiovascular systems cannot tolerate fluid shifts c) Low serum sodium level, leads to excess volume in intracellular compartment, fluid volume deficit in the extracellular compartment.
H. Chloride (Cl–): most abundant anion in the extracellular fluid 1. Functions: role in regulation of body fluids, maintains resting membrane potential of cells, role in maintaining osmolality of extracellular fluid 2. Levels link to sodium, follows sodium in body, regulated by aldosterone indirectly through sodium regulation 3. For acid-base balance, chloride plus bicarbonate equals sodium a) Cl– levels affected by bicarbonate levels I. Calcium (Ca++): located almost entirely within bone 1. Functions: blood coagulation, neuromuscular contraction, enzymatic activities, bone integrity 2. Regulation by parathyroid hormone (PTH), calcitonin, calicitriol a) With low calcium levels, PTH is released, increases bone reabsorption, serum levels, facilitates rapid calcium shifts from bones to extracellular fluids b) With high levels, PTH suppressed, calcitonin secreted, inhibits release from bone to blood, inhibits absorption in small intestines, increases excretion through urine c) Absorption in intestines dependent on vitamin D 3. Total calcium: reflects calcium bound to proteins (albumin) in serum a) If serum protein is low, serum calcium low 4. Ionized calcium: approx. 50% serum calcium exists in ionized state a) Ionized calcium is used in physiologic activities, measurement to monitor in high-acuity patients. b) Acid-base balance affects binding to proteins: (1) Alkalosis state can precipitate hypocalcaemia. (2) Acidotic state can precipitate hypocalcaemia. J. Potassium (K+): almost entirely located within cells, small amount in plasma 1. Functions: affects muscle contraction, maintains normal cardiac and neuromuscular function, influences nerve impulse conduction, vital to carbohydrate metabolism, role in cell membrane function, role in maintaining acid-base balance 2. Excess excreted through kidneys, urine 3. Body intolerant of abnormal serum levels K. Magnesium (Mg++): intracellular electrolyte, similar distribution to K+ 1. Functions: ensures sodium and potassium transportation across cell membranes, role in protein and carbohydrate metabolism, role in nerve cell conduction, neuromuscular activity 2. Balance closely related to potassium and calcium 3. Predominantly excreted through feces, small amount through urine 4. Renal excretion only regulatory mechanism; kidneys can conserve it L. Phosphorus/phosphate: intracellular mineral, phosphate is predominant form 1. Functions: with calcium is an essential component of bones, vital to neuromuscular function, required in ATP production, role in acid-base balance, metabolism of carbohydrates, fats, and proteins. 2. Maintains inverse levels to calcium.
3. Kidneys maintain balance, excrete or reabsorb phosphorus. 4. Age-related changes in parathyroid function, mild hypophosphatemia common in older highacuity patient.
PowerPoint Slides 1. Electrolytes: Electrically Charged Microsolutes 2. Normal Electrolyte Ranges 3. Normal Electrolyte Ranges 4. Sodium (Na+) 5. Sodium Balance 6. Chloride (Cl-) 7. Regulation of Chloride Balance 8. Calcium 9. Regulation of Calcium Level 10. Measuring Serum Calcium 11. Potassium 12. Potassium Regulation 13. Magnesium 14. Magnesium Regulation 15. Phosphorus 16. Phosphorous Regulation
V. Assessment of Electrolyte Balance A. History assessment same as fluid history assessment, emphasis on condition of patient at risk for specific electrolyte imbalances B. Physical assessment 1. Provide clues 2. Several different abnormalities have similar symptoms, testing important to identify specifics C. Vital signs and cardiovascular assessments 1. Abnormal arterial blood pressure and heart rate and rhythm can indicate abnormal levels of sodium, calcium, potassium, magnesium and/or phosphate. 2. With noted abnormalities, 12-lead electrocardiogram (ECG) can indicate significantly abnormal levels of calcium, potassium, and/or magnesium. D. Neurologic assessment 1. Abnormal levels of most electrolytes can cause changes in mental status and level of consciousness: a) E.g., disorientation, confusion, agitation or lethargy, seizures or coma b) Different symptoms for different electrolytes
E. Neuromuscular and musculoskeletal assessments 1. Check deep tendon reflexes, muscle strength and tone, and sensation in extremities 2. Chvostek sign: spasm of cheek and/or lip on tapped side of face, can indicate hypomagnesmia and/or hypocalcaemia 3. Trousseau’s sign: blood pressure cuff on arm inflated to above systolic pressure causes fingers to hyperextend, thumb flex toward palm can indicated hypocalcaemia F. Gastrointestinal assessment 1. Anorexia, nausea, vomiting, diarrhea commonly associated with abnormal serum electrolyte levels a) Vomiting and diarrhea can cause significant losses, also are manifestations of existing imbalances, at risk for acid-base imbalance. G. Laboratory testing: to identify specific electrolyte abnormalities 1. Serum electrolytes: a) Baseline typically obtained upon admission to hospital b) Periodic tests based on patient's needs c) Obtained using 3–5 mL blood sample, red-top blood specimen tube 2. Urine electrolytes a) Obtained to monitor renal function, fluid and electrolyte balance, urine electrolyte composition, diagnostic purposes for some diseases, evaluation of aldosterone disorders b) Measured by collecting 24-hour urine specimen
PowerPoint Slides 1. Physical Assessment 2. Vital signs and Cardiovascular Assessment 3. Other Assessments 4. Laboratory Testing
VI. Chapter Summary VII. Clinical Reasoning Checkpoint VIII. Post-Test IX. References
Suggestion for a Classroom Activity Discuss the factors that affect the elderly patient's body fluid composition: thirst, nutritional intake, diminished renal function, chronic illness, medications, decreased muscle mass, increased fat stores, and reduction in percentage of body fluids.
Suggestion for a Clinical Activity Assign students to care for patients with electrolyte imbalances. During the post conference period, ask the students to report on the care interventions.
CHAPTER
25
Alterations in Fluid and Electrolyte Balance
Learning Outcomes: 1. Apply knowledge of fluid volume deficit when caring for the high-acuity patient. 2. Demonstrate knowledge of fluid volume excess when delivering patient care. 3. Discuss alterations in sodium balance that affect patient care. 4. Apply knowledge of alterations in calcium balance when caring for the high-acuity patient. 5. Demonstrate understanding of alterations in potassium balance. 6. Use knowledge of alterations in magnesium balance when delivering patient care. 7. Apply knowledge of alterations in phosphorus/phosphate balance.
I. Fluid Volume Deficit (FVD) A. Hypovolemia: in this chapter, abnormally low intravascular fluid B. Etiology 1. May be related to gastrointestinal, urinary, integumentary, insensible problems 2. Third spacing, fluids shift to abdominal cavity, caused by liver failure, pancreatitis, peritonitis C. Clinical manifestations 1. Manifestations in Figure 25-1 2. Increased serum osmolality D. Medical treatment 1. Identify and control fluid loss 2. Replenish fluids a) Intravenous, oral or enteral routes E. Intravenous fluid resuscitation 1. Resuscitation fluids: colloidal solutions and crystalloids 2. Osmolality: number of miliosmoles per kilogram of water 3. Tonicity: effect the solution has on the extracelluar fluid and intracellular fluid compartments F. Isotonic solutions 1. Have the same osmolarity as normal serum plasma osmolarity
2. Steady osmolar state maintained between intracellular fluid (ICF) and extracellular fluid (ECF) 3. Used when rapid ECF expansion is needed; in intravascular FVD G. Hypotonic solutions 1. Have low osmolarity, contain a lower concentration of particles than exists in the ICF and ECF. 2. Shifts fluid from intravascular space to intracellular space. 3. Used for cellular dehydration. 4. Overuse can cause cells to burst, increase intracranial pressure. H. Hypertonic solutions 1. Have high osmolarity, contain a higher concentration of particles than exists in ICF and ECF. 2. Fluids shift from ICF and ECF into intravascular space, expand blood volume. 3. Used for water intoxication, can be caused by renal failure or treatment with water or hypotonic solutions. 4. Used for intracranial hypertension, cerebral edema. I. Nursing considerations 1. Diagnoses may include: fluid volume deficit, ineffective tissue perfusion, decreased cardiac output and risk for injury. 2. Interventions may include measures to decrease fluid loss, increase fluid intake, monitoring fluid and electrolyte status. 3. Desired outcomes include vital signs, serum osmolality to reach normal range.
PowerPoint Slides 1. Fluid Compartments 2. Etiology 3. Figure 25-1 4. Medical Treatment 5. Intravenous Fluid Resuscitation 6. Intercompartmental Fluid Movement-Osmosis 7. Fluid Volumes 8. Starling Forces 9. Starling Force-Capillary Hydrostatic Pressure 10. Starling Force- Capillary Colloidal Osmotic Pressure 11. Starling Force- Tissue Hydrostatic Pressure
II. Fluid Volume Excess (FVE) A. Hypervolemia: overhydration of intravascular compartment; both water and sodium are retained B. Etiology 1. Common causes: heart, liver, kidney failure, overuse of IV therapy, side effect of some drugs
C. Clinical manifestations 1. Can be generalized or localized 2. Assessment the same as for FVD, findings will be opposite, except urine output (can decrease with both conditions) 3. Physical manifestations: weight gain, distended neck veins, edema, shortness of breath 4. Lowered serum osmolality, decreased hematocrit and hemoglobin D. Medical treatment 1. Correct underlying cause 2. Restrict sodium and water intake 3. Administer diuretics E. Nursing considerations 1. Diagnoses may include: fluid volume excess, risk for impaired skin integrity, risk for impaired gas exchange 2. Monitor adherence to restrictions, administer drugs 3. Monitor weight gain, intake and output, edema, vital signs 4. Goals: vital signs, hematocrit, BUN levels in normal range; resolution of edema
PowerPoint Slides 1. Hypervolemia 2. Clinical Manifestations 3. Medical Treatment 4. Thirst is Activated By: 5. Thirst is Decreased By: 6. Unconscious Patients
III. Sodium Imbalances A. Result in fluid imbalances B. Hyponatremia 1. Serum sodium < 135 mmol/L 2. Critical value < 120 mmol/L C. Etiology 1. Most common imbalance D. Excessive salt loss relative to water loss 1. Syndrome of inappropriate release of antidiuretic hormone (SIADH) can result from cerebral trauma, lung cancer, certain drugs 2. Replacement of water without replacement of salt (e.g., through IV fluid)
E. Excessive water gain relative to salt gain 1. Rapid ingestion or administration of water that exceeds ability of kidneys to excrete it a) Normal kidneys can excrete 16–20 liters of water/ day F. Clinical manifestations 1. Hypotension, confusion, lethargy, anorexia, vomiting, diarrhea, cramps 2. Alterations in central nervous system function can cause seizures and coma, cerebral edema 3. Changes in muscle tone G. Medical treatment 1. Depends on cause 2. Fluid restriction often implemented 3. Hypertonic fluids for severe cases 4. Conivaptan hydrochloride (Vaprisol) blocks ADH in kidneys, causes excretion of water and retention of sodium H. Nursing considerations 1. Diagnoses include: risk for imbalanced fluid volume, risk for ineffective cerebral perfusion, and risk for complications of electrolyte imbalances. 2. Assessment focuses on CNS functions. 3. If hypertonic fluids are used, monitor patient’s response closely; overuse can cause osmotic demyelination syndrome and/or edema. I. Hypernatremia 1. Serum sodium > 145 mmol/L 2. Critical value ≥ 160 mmol/L 3. Shift of water from intracellular to extracellular space causes cellular dehydration, overloaded extracellular space J. Etiology 1. Administration of sodium bicarbonate solutions or diuretics 2. Water loss: renal, from fever, drainage from wounds, nasogastric suction 3. Can result in renal dysfunction, profuse diaphoresis, increased adrenocorticotropin hormone (ACTH) secretion K. Clinical manifestations 1. Severe: hypertension, tachycardia, coma, seizures 2. Moderate: confusion, thirst, nausea, vomiting, hyperreflexia, muscle twitching L. Medical treatment 1. Water replacement with hypotonic IV fluids, rate depends on severity 2. Diuretics to enhance sodium excretion M. Nursing considerations 1. Diagnoses may include risk for injury, risk for complications of electrolyte imbalances. 2. Monitor for neurologic deterioration, especially with water replacement. 3. Monitor intake and output.
PowerPoint Slides 1. Sodium 2. Hyponatremia Etiology 3. Hyponatremia- Clinical Manifestations 4. Hyponatremia- Medical Treatment 5. Hypernatremia 6. Clinical Manifestations 7. Medical Treatment 8. Nursing Considerations
IV. Calcium Imbalances A. Blood normally contains only 9-11 mg/dL of calcium. B. Abnormalities affect neurologic, skeletal, hematopoietic, and cardiovascular systems. C. Hypocalcemia: 1. Serum calcium < 9 mg/dL 2. Critical value 6.5 mg/dL 3. One of most common imbalances in critically ill patients D. Etiology 1. Trauma, kidney injury or disease, sepsis, hypoparathyroidism, hypomagnesemia, vitamin D deficiency, administration of citrate (stored blood contains citrate), certain drugs E. Clinical manifestations 1. Neuromuscular: increase in irritability, positive Chvotsket’s or Trousseau’s signs, possible seizure 2. Cardiovascular: hypotension, ECG changes 3. Neurologic: reduced cognitive ability, irritability 4. Skeletal: bone fractures F. Medical treatment 1. Correct underlying cause 2. IV calcium gluconate (preferred) or calcium chloride (for emergencies) G. Nursing considerations 1. Often seen with other electrolyte disorders, especially hypomagnesemia 2. Patients will have hyperphosphatemia (phosphorus and calcium inversely related) 3. Monitor for: decreased cardiac output, ECG changes, neurologic and neuromuscular changes H. Hypercalcemia 1. Serum calcium > 11 mg/dL 2. Critical level ≥ 13 mg/dL
I. Etiology 1. Hyperparathyroidism causes about half of cases. 2. Malignancy accounts for many cases, usually breast, lung, and multiple myelomas. 3. Less common causes: immobilization, vitamin A or D intoxication, diuretic use. J. Clinical manifestations 1. Moderate cases: lethargy, anorexia, nausea 2. Severe cases: profound neurologic changes, decreased neuromuscular excitability 3. GI: delayed gastric emptying, risk for duodenal ulcer disease 4. Disturbed renal function can cause polyuria, polydipsia 5. Patients will have accompanying hypophosphatemia K. Medical treatment 1. Correct underlying cause 2. Increase kidney excretion, reduce calcium reabsorption a) IV fluids b) Drugs: diuretics, biophosphonates, calcitonin, sodium phosphate, potassium phosphate L. Nursing considerations 1. Nursing diagnoses may include: risk for injury, impaired memory, risk for dysrhythmias, and risk for complications of electrolyte imbalances. 2. Ensure sufficient intake of fluids. 3. Monitor diet for sufficient fiber.
PowerPoint Slides 1. Calcium 2. Hypocalcemia 3. Medical Treatment 4. Nursing Considerations 5. Hypercalcemia 6. Medical Treatment 7. Nursing Considerations
V. Potassium Imbalances A. Normal serum range: 3.5–5.3 mmol/L. B. Body does not tolerate significant alterations, can cause severe cardiac complications. C. Hypokalemia: 1. Serum potassium < 3.5 mmol/L. 2. Critical value ≤ 2.5 mmol/L. 3. When it occurs, body does not attempt to retain potassium.
D. Etiology: 1. Loss of gastrointestinal secretions, excessive kidney excretion, movement of potassium into cells, prolonged fluid administration, excessive use of potassium-wasting diuretics, drug-related loss E. Clinical manifestations: 1. Cardiovascular: ECG changes 2. Pulmonary: respiratory muscle weakness 3. Patients with existing cardiac disturbances at great risk F. Medical treatment: 1. Prevent emergencies 2. Administration of potassium, orally or IV (for emergencies) G. Nursing considerations: 1. Nursing diagnoses include: decreased cardiac output, acute pain, risk for complications of dysrhythmias, and risk for complications of electrolyte imbalances. 2. Monitor urinary excretion, cardiovascular activity. 3. For digitalis, monitor digitalis toxicity. H. Hyperkalemia: 1. Serum potassium > 5.3 mmol/L 2. Critical value ≥ 6.0 mmol/L I. Etiology: 1. Renal failure 2. Acidosis: hydrogen ions shift into cells, force potassium into serum 3. Medications: beta-adrenergic blockers, ACD inhibitors, NSAIDS for those with renal failure J. Clinical manifestations: 1. Cardiovascular: ECG changes, bradycardia, cardiac arrest 2. Musculoskeletal: muscle weakness, cramps 3. GI: nausea, vomiting, diarrhea 4. Metabolic acidosis K. Medical treatment: 1. Treat underlying cause 2. Eliminate substances that increase serum potassium 3. Medications: a) For emergencies, IV calcium gluconate followed by insulin and glucose, or albuterol b) Sodium polystyrene sufonate, slow acting, somewhat unpredictable results c) Kayexalate with osmotic agent d) Sodium bicarbonate should be avoided for those with fluid overload 4. Dialysis for severe cases
L. Nursing considerations: 1. Nursing diagnoses may include: risk for decreased cardiac output, risk for imbalanced fluid volume, risk for complications of dysrhythmias, risk for complications of electrolyte imbalances 2. Monitor urine potassium excretion, fluid intake, and output levels 3. Review medications, diet 4. For abnormal renal function monitor: BUN, creatinine levels
PowerPoint Slides 1. Potassium 2. Hypokalemia 3. Medical Treatment 4. Nursing Considerations 5. Hyperkalemia 6. Medical Treatment 7. Nursing Considerations
VI. Magnesium Imbalance A. Normal range: 1.8 to 3.0 mg/dL B. Hypomagnesmia 1. Serum magnesium level < 1.5 mEq/L 2. Critical value ≤ 1.0 C. Etiology 1. Common causes: gastrointestinal or renal losses, surgery, trauma, infections or sepsis, burns, transfusions of blood preserved with citrate, alcoholism, malnutrition 2. Medications: diuretics, aminoglycosides, amphotericin B, digoxin, and cyclosporine 3. Hypoparathyroidism can indirectly cause it, linked to hypocalcemia D. Clinical manifestations 1. Cardiovascular: ECG changes, premature ventricular contractions, ventricular tachycardia and/or fibrillation 2. Neuromuscular: tremors, tetany, positive Chvostek’s and Trousseau’s signs E. Medical treatment 1. Assess for renal failure 2. Prevent dysrhythmias, resolve symptoms 3. Intravenous administration for severe cases a) Infusion time is critical. F. Nursing considerations 1. Nursing diagnoses may include risk for injury, risk for complications of dysrhythmias, and risk for complications of electrolyte imbalances.
2. Monitor for development of ventricular dysrhythmias, seizures, and neurologic deterioration. 3. Other imbalances that can occur with it: hypokalemia, hypocalcemia, and hypophosphatemia. G. Hypermagnesmia 1. Serum levels > 3.0 mg/dL 2. Critical value ≥ 9.0 mg/dL 3. Uncommon abnormality 4. Etiologies: a) Renal failure b) Excessive intake (1) Overconsumption of magnesium-containing antacids or laxatives H. Manifestations 1. Cardiovascular: hypotension, ECG changes, complete heart block, bradycardia, cardiac arrest 2. Respiratory depression 3. Neuromuscular: lethargy, absent deep tendon reflexes, drowsiness I. Medical treatment 1. Treat underlying cause 2. Dialysis for severe cases 3. Calcium gluconate can antagonize symptoms J. Nursing considerations 1. Nursing diagnoses may include: decreased cardiac output, risk for complications of electrolyte imbalances 2. Assess for: fluid volume excess, respiratory distress, level of consciousness, blood pressure, apnea
PowerPoint Slides 1. Magnesium 2. Hypomagnesmia 3. Medical Treatment 4. Nursing Considerations 5. Hypermagnesmia 6. Medical Treatment 7. Nursing Considerations
VII. Phosphorus/Phosphate Imbalance A. Usually exists as calcium phosphate B. Normal range: 2.5–4.5 mg/dL C. Hypophosphatemia 1. Serum level < 2.5 mg/dL 2. Critical value ≤ 1 mg/dL
D. Etiology 1. Associated with disorders: a) Gram-negative sepsis, cardiac surgery, malnutrition, acute respiratory alkalosis, diabetic ketoacidosis, alcoholism b) Less commonly: hyperparathyroidism, certain renal tubular defects, metabolic acidosis (including diabetic ketoacidosis), and disorders that cause hypercalcemia (1) From disorder itself, or treatment (a) E.g., hormones such as insulin, glucagon, and cortisol 2. Following cardiac surgery E. Clinical manifestations 1. Cardiovascular: diminished myocardial function, heart failure 2. GI: nausea and vomiting, anorexia 3. Neurologic: disorientation, irritability, coma 4. Neuromuscular: weakness, numbness, tingling 5. Musculoskeletal: pathologic fractures 6. Respiratory failure, hemolysis, blood cell dysfunction F. Medical treatment 1. Treat underlying cause 2. Oral supplements for mild cases 3. IV sodium phosphate or potassium phosphate for severe cases G. Nursing considerations 1. Nursing diagnoses may include: risk for injury, risk for respiratory failure, risk for delayed wound healing, risk of complications of electrolyte imbalances 2. Monitor calcium levels H. Hyperphosphatemia 1. Serum phosphate > 4.5 mg/dL 2. Less common than hypophosphatemia I. Etiology 1. Chronic kidney failure 2. Hypocalcemia caused by hyperthyroidism, hypoparathyroidism, or severe catabolic states J. Clinical manifestations 1. Cardiovascular: hypotension, tachycardia, ECG changes, dysrhythmias 2. GI: diarrhea, nausea, cramping 3. Neurologic: altered mental state, delirium, coma, positive Chvostek’s and Trousseau’s signs, paresthesias 4. Neuromuscular: cramping, tetany, seizures K. Medical treatment 1. Lower serum levels
2. Administration of agents that bind phosphate in the GI a) E.g., calcium salts 3. IV solution with saline to promote renal excretion L. Nursing considerations 1. Nursing diagnoses include: risk for injury, risk for complications of dysrhythmias, risk for complications of electrolyte imbalances 2. Monitor serum values, ECG status, improvements in neuromuscular status 3. Monitor administration of supplements, especially IV
PowerPoint Slides 1. Phosphourous 2. Hypophosphatemia 3. Medical Treatment 4. Nursing Considerations 5. Hyperphosphatemia 6. Medical Treatment 7. Nursing Considerations
VIII. Chapter Summary IX. Clinical Reasoning Checkpoint X. Posttest XI. References
Suggestion for a Classroom Activity • Discuss the factors that affect the elderly patient’s body fluid composition: thirst, nutritional intake, diminished renal function, chronic illness, medications, decreased muscle mass, increased fat stores, and reduction in percentage of body fluids.
Suggestion for a Clinical Activity • Assign students to care for patients with electrolyte imbalances. During the post conference period, ask the students to report on the care interventions.
CHAPTER
26
Acute Kidney Injury
1. Explain the pathophysiology associated with the three types of acute kidney injury: prerenal, intrinsic, and postrenal. 2. Describe the diagnosis and assessment of acute kidney injury. 3. Explain the management of the patient with acute kidney injury. 4. Compare and contrast the types of renal replacement therapy used to treat acute kidney injury. 5. Prioritize nursing interventions when caring for the patient with acute kidney injury. 6. Discuss the clinical implications of caring for a patient with preexisting chronic kidney disease who is admitted with an unrelated acute illness.
I. Pathophysiology of Acute Kidney Injury A. Acute kidney injury (AKI): acute and chronic 1. One of the main causes is sepsis. 2. Identified by: oliguria, elevations of serum blood urea nitrogen (BUN) and creatinine (Cr), reduction in cardiac output. B. Types of AKI 1. Prerenal kidney injury: kidney dysfunction resulting from decrease in effective blood volume, relative decrease in blood volume, or arterial occlusion 2. Adaptive response to organ injury: activation of renin-aldosterone-angiotensin system (RAAS), upregulation of the sympathetic nervous system, stimulation of vasopressin secretion, angiotensin II causing vasoconstriction C. Decreased cardiac output: pathophysiologic problem in majority of prerenal kidney injury cases 1. Monitor arterial blood pressure, mean arterial pressure (MAP), and urine output as indicators of adequate renal blood flow. 2. Failure to maintain adequate MAP results in decreased renal perfusion pressure, loss of kidney autoregulation, and decreased GFR. 3. Mechanisms by which inadequate cardiac output can precipitate prerenal kidney injury: a) Intravascular volume depletion (1) Decreased through: absolute fluid volume loss, relative fluid volume decrease, or translocation of fluid. b) Decreased perfusion: renal tissue ischemia can result when state of low renal blood flow becomes prolonged; ischemic tubular epithelial damage can occur; tubular epithelial cell necrosis occurs in prolonged low blood flow state.
c) Arterial occlusion: results in reduced renal perfusion distal to the obstruction; diminished blood flow to kidney causes glomerular filtration rate to fall and the tubular epithelial cells to become ischemic. d) Drug-induced altered glomerular hemodynamics (1) Drugs that decrease renal perfusion: nonsteroidal anti-inflammatory drugs (NSAIDs) D. Intrinsic renal injury 1. Cause: problems that target the kidney parenchyma (renal tissue) where the injury occurs 2. Acute tubular necrosis (ATN): the major form of intrinsic kidney injury 3. Less common etiologies: vascular problems, acute glomerulonephritis, acute interstitial nephritis, drug allergies, and infections E. Drug-induced injury: kidneys responsible for excretion of most drugs 1. Aminoglycosides and lithium: cytotoxic to the renal tubules 2. NSAIDS and proton-pump inhibitors: target the renal interstitium 3. Management considerations: keep patient hydrated, maintaining adequate hemodynamic status F. Endogenous intrinsic kidney injury 1. Hepatorenal syndrome: cause of endogenous intrinsic kidney injury; complication of advanced liver disease, causes severe renal insufficiency a) Precipitating factors: gastrointestinal bleeding, excessive administration of diuretics, largevolume paracentesis, and infections 2. Rhabdomyolysis: damage to the striated muscle cells (traumatic or nontraumatic), which results in the release of damaged muscle cell contents into systemic circulation a) Myoglobin: ferrous (iron) globin complex in striated muscle that is responsible for the muscle’s ability to store oxygen b) Monitored through serum and urine sampling c) Fluid replacement to increase urine flow can protect kidneys from myoglobin damage G. Postrenal kidney injury: obstruction to the outflow of urine from the kidneys after it has left the tubules 1. Diagnosed by the presence of ureteral and renal pelvic dilation on renal ultrasound
PowerPoint Slides 1. Acute Kidney Injury (AKI) 2. Types of AKI 3. Decreased Cardiac Output 4. Intrinsic Renal Injury 5. Drug-Induced Injury 6. Endogenous Intrinsic Kidney Injury 7. Postrenal Kidney Injury
II. Diagnosis and Assessment of Acute Kidney Injury A. Diagnostic considerations 1. Suspicious symptoms: a rapid onset of decreasing urinary output, increasing azotemia, and development of or worsening electrolyte imbalances (especially hyperkalemia) 2. Diagnosis involves: patient’s past medical and recent history to investigate possible risk factors, a thorough physical examination, and a full range of serum and urine laboratory diagnostic tests 3. RIFLE (i.e., Risk, Injury, Failure, Loss, End-stage kidney disease): criteria for staging of patients with AKI based on changes in glomerular filtration rate (GFR), serum creatinine, and urine output over time B. Laboratory diagnostic tests: measure uremic toxins and renal function C. Blood urea nitrogen and creatinine: most important measures of renal status 1. Blood Urea Nitrogen (BUN) a) BUN levels increase as glomerular filtration decreases. b) BUN is affected by: the individual’s hydration status, level of catabolism, protein intake, gastrointestinal bleeding, drug therapy, and chronic liver disease. c) Not reliable measure of glomerular filtration rate (GFR). 2. Creatinine: end product of muscle metabolism a) Increase in creatinine usually indicates a decrease in glomerular filtration 3. BUN-to-creatinine ratio: usually 10:1 or 15:1; 20:1 may indicate acute kidney injury 4. Creatinine clearance: serum creatinine level is compared with the excretion of creatinine measured in a volume of urine produced over a specified amount of time 5. Osmolality: measure of the number of mOsm per kg of solvent a) Major contributor to serum osmolality: sodium b) Major constituent of urine osmolality: urea c) Normal renal function: urine and blood osmolality in direct relationship d) Manifestations of renal failure: increase in BUN, creatinine or both and a BUN:Cr of greater than 20:1, combined with oliguria or anuria (no urine, as defined as less than 100 mL/day) D. Electrolyte imbalances: problems in neurologic, musculoskeletal, cardiovascular, and gastrointestinal systems 1. Assess: serum and urine electrolytes regarding renal status 2. Serum potassium level: rapid increase can cause lethal dysrhythmias E. Assessment considerations 1. Urine output: a measure of renal success or failure? a) Urine output BUN, and creatinine is not sufficient for diagnosis (1) Could be due to water conservation or due to the inability of the kidneys to excrete water associated with acute kidney injury 2. Health history: high-acuity patients are at moderate to high risk for developing AKI
3. Physical assessment: multisystem assessment a) Uremia: clinical signs and symptoms of kidney failure (1) Clinical findings: fluid overload, sepsis, inflammation, vitamin deficiency, fatigue, anorexia, nausea, vomiting, pruritus, and neurologic changes (2) Pathophysiology: stems from retention of toxins and from deranged hormonal and enzymatic homeostasis (3) Physiologic alterations: cardiovascular, neurologic, hematologic, and immunologic systems 4. Neurologic effects: confusion, delirium, coma, restless leg syndrome, and sensory neuropathies a) Causes: accumulation of nitrogenous waste products and hydrogen ions from impaired renal excretion and metabolic acidosis 5. Cardiovascular and pulmonary effects a) Hypertension: present in 70 to 80% of patients with kidney injury b) Fluid volume excess may cause an exacerbation of heart failure symptoms such as hypertension, peripheral and pulmonary edema c) Close monitoring for pneumonia due to fluid overload, decreased level of consciousness, weakness, decreased cough reflex, and decreased pulmonary macrophage activity 6. Acid-base effects a) Accumulated acid in the body causes the tubules to generate new bicarbonate by generating ammonia, resulting in tubule dysfunction: (1) Results: hyperkalemia, can precipitate cardiac dysrhythmias; the accumulation of hydrogen ions; metabolic acidosis; respiratory system may compensate with hyperventilation 7. Gastrointestinal effects: GI pain, decreased appetite, GI bleeding, nausea, anorexia, bloating, and constipation or diarrhea 8. Hematologic effects a) Erythropoietin produces RBCs; deteriorating kidney function compromises production. b) Blood vessels at risk to injury, risk of blood clots increased, platelet function impaired, risk of bleeding problems increases. c) Anemia due to hematopoietic factors, GI irritation, and blood loss from hemodialysis. 9. Integumentary effects a) Pruritus and dry skin due to lack of calcium and phosphate excreted by the kidneys b) Thin hair, brittle nails, pale skin with yellow hue, bruising, uremic frost (layer of urate crystals under skin) 10. Skeletal effects a) Kidney: primary site for phosphate excretion and hydroxylation of vitamin D b) Abnormalities in bone and mineral metabolism and/or extraskeletal calcification c) Hypocalcemia, hyperphosphatemia, hyperparathyroidism and renal osteodystrophy F. Urine output 1. Hourly monitoring focusing on output trends and whether minimal hourly outputs are being maintained
PowerPoint Slides 1. Diagnostic Considerations 2. Laboratory Diagnostic Tests 3. Blood Urea Nitrogen (BUN) and Creatinine 4. Electrolyte Imbalances 5. Assessment Considerations 6. Neurologic Effects 7. Cardiovascular and Pulmonary Effects 8. Acid-base Effects 9. Gastrointestinal Effects 10. Hematologic Effects 11. Integumentary Effects 12. Skeletal Effects • Renal osteodystrophy 13. Urine Output
III. Medical Treatment A. Treatment of fluid overload 1. Results of fluid overload: development of heart failure and pulmonary edema, abdominal compartment syndrome, and intra-abdominal hypertension 2. Intervention: preventing fluid excess; if overload, restoring optimal fluid balance a) Fluid restriction: restricted to the sum of measured output plus estimate of insensible water loss (about 0.8 to 1 liter per day) (1) Complying with fluid restrictions requires frequent intake and output assessment and consideration of ways to minimize volume of needed intake. b) Diuretic therapy: removes excess fluid volume (1) Types: loop diuretics (e.g.; furosemide) B. Treatment of metabolic imbalance (catabolism) 1. Problems: skeletal muscle breakdown, impaired amino acid transport into skeletal muscles, suppressed protein synthesis, depletion of body energy reserves, increased urea production, and peripheral insulin resistance 2. Treatment: protein intake (limit to prevent azotemia); amino acid intake of 1.5 to1.8 g/kg/day C. Treatment of electrolyte/acid-base imbalance 1. Hyperkalemia: critical elevation of serum potassium; a) Treatment: drug therapy or dialysis (1) Three phases: stabilizing cardiac tissue membrane, shifting K+ back into the cells, and removing excess K+ from the body
(2) Stabilize cardiac tissue membrane: intravenous calcium, calcium gluconate, or calcium chloride (3) Drive potassium into cells: nebulized albuterol, sodium bicarbonate, and a combination of insulin and glucose (4) Remove excess potassium: furosemide or through gastrointestinal excretion using the cation exchange agent sodium polystyrene sulfonate (5) Hemodialysis 2. Sodium imbalances a) Maintain balance to prevent or control hypernatremia b) IV solutions should contain more free water such as 0.45% saline 3. Metabolic acidosis: increases the plasma potassium concentration by inducing a net shift of potassium from the cellular to the intravascular compartment in exchange for hydrogen a) Treatment: dialysis, IV fluid administration, possibly infusion of bicarbonate D. Treatment of infection: sepsis and septic shock 1. Early recognition, identification of the specific pathogen, and careful antibiotic therapy
PowerPoint Slides 1. Treatment of Fluid Overload 2. Treatment of Metabolic Imbalance (Catabolism) 3. Treatment of Electrolyte/Acid-Base Imbalance 4. Treatment of Infection
IV. Renal Replacement Therapy (RRT): treatment option for renal impairment that does not respond to medications and fluids A. Determining the need for RRT 1. Initial screening strategy: diuretic challenge, using an osmotic diuretic or furosemide, or a fluid challenge, using a bolus of IV fluid a) No response to diuretic challenge: indicates intrinsic problem such as acute tubular necrosis B. Types of renal replacement therapy 1. Intermittent hemodialysis (IHD): more efficient clearance of excess fluid and solutes, but more destabilizing to patients’ hemodynamic and electrolyte status a) Requires direct access to vascular system (1) Most common insertion points: internal jugular vein, femoral veins b) Cleans blood by pumping it out of patient via the venous access; passes through a dialyzer, removes fluid and solutes, returns the filtered blood back to the patient c) Dialysate: fluid used to remove or add solute to the plasma water d) Diffusive clearance: wastes diffuse from high concentration to lower one 2. Peritoneal dialysis (PD): utilizes patient’s peritoneal membrane to remove wastes and water a) Selection of peritoneal dialysis vs. hemodialysis: severity of renal failure, indications for therapy, and age.
b) Fluid loss is not predictable. 3. Continuous renal replacement therapy (CRRT): removes small volumes of fluid continuously a) Prevents hemodynamic instability b) Therapies: several methods that clear excess fluid or fluid plus solutes, electrolytes, creatinine, and urea (1) Arteriovenous: does not require external pumping device, requires cannulation of an artery (2) Venovenous: requires external pumping device and cannulation into a vein; safer, less risk than arteriovenuous (a) Continuous venovenous hemofiltration (CVVH): convective clearance of water and wastes; removes not only small solutes but some middle-sized solutes as well (b) Continuous venovenous hemofiltration-dialysis (CVVH-D): results in diffusion of small wastes and water out of dialyzer (c) Continuous venovenous hemodiafiltration (CVVHDF): uses two solutions, replacement fluid and dialysate, to maximize the removal of wastes and water (d) Slow continuous ultrafiltration (SCUF): removes water only, no solutions used; limited to fluid overload conditions such as heart failure
PowerPoint Slides 1. Determining the need 2. Types of RRT 3. TABLE 26-7 Methods of Continuous Replacement Therapy
V. Nursing Care of the Patient with AKI A. Managing fluid overload: monitoring for signs and symptoms of hypervolemia, acute pulmonary edema, and large cumulative positive fluid balance 1. Fluid restriction: careful assessment of input and output balance a) Considerations: timing of medication administration and meals, extreme thirst in uremic patients, oral care 2. Diuretics: monitoring of intake and output (and intake/output balance), blood pressure and serum electrolyte, hypovolemia, signs and symptoms of electrolyte abnormalities 3. Renal replacement therapy (RRT): managing specialized technology, educating patient and family 4. Nursing diagnoses: excess fluid volume, decreased cardiac output, altered gas exchange, alterations in electrolytes, risk of skin breakdown 5. Desired outcomes: reduced edema or absence of edema, clear or improved lung sounds, absence of shortness of breath, weight trend toward baseline, blood pressure tending toward baseline, intact skin 6. Nursing interventions: monitor for fluid volume excess, evidence of heart failure, electrolyte imbalances, inspect skin for breakdown, protect extremity containing graft or fistula, perform blood sampling and blood pressures, check for a bruit or thrill with a stethoscope
B. Managing catabolic processes: hypercatabolic state requires protein intake; nitrogenous wastes from protein metabolism are not excreted efficiently, must be carefully monitored C. Nursing diagnoses: altered nutrition: less than body requirements, altered thought processes, altered bowel elimination: diarrhea, altered bowel elimination: constipation, potential complication: GI bleeding D. Desired outcomes: weight trending toward baseline, serum protein (albumin, prealbumin) trending toward normal ranges, nitrogen balance, mental status trending toward baseline, stools of soft, formed consistency and usual frequency E. Nursing implications: focus on nutritional support, minimizing risk of infection, renal replacement therapy; monitoring weight, serum protein levels, mental status, stool consistency and frequency F. Managing electrolyte/acid imbalance: main concerns in AKI patients are potassium and sodium 1. Hyperkalemia: clinical emergency; can lead to cardiac arrest 2. Hypernatremia: caused by water loss in excess of sodium loss 3. Metabolic acidosis: caused by inability of kidneys to excrete hydrogen ions and reabsorb bicarbonate ions 4. Nursing diagnoses: a) Potential complication: metabolic acidosis b) Potential problem: electrolyte imbalance c) Potential problem: cardiac dysfunction 5. Desired patient outcomes: attain or maintain: a) Serum pH between 7.35 and 7.45 b) Serum electrolytes within normal limits c) Normal cardiac rhythm 6. Nursing implications: monitoring for clinical manifestations of electrolyte imbalances, arterial blood gases for metabolic acidosis (abnormally low pH and HCO3), and continuous cardiac monitoring G. Infection: uremia can increase susceptibility to infection; renal dysfunction increases risk of nosocomial infection 1. Nursing diagnosis: high risk for infection, activity intolerance, high risk for injury, high risk for altered mucous membranes, high risk for altered skin integrity, altered renal tissue perfusion, pain, anxiety, knowledge deficit 2. Desired patient outcomes: all invasive devices removed in a timely fashion, WBC count within acceptable levels, absence of fever, negative cultures, wounds free of purulent drainage 3. Nursing implications: monitoring for signs and symptoms of infection a) Major sources of infection: urinary tract infection, pneumonia, and septicemia from vascular catheters and skin or wound sources b) Routine aspects of acute care: vascular catheter insertion and care, minimizing ventilatorassociated pneumonias, and sepsis care c) Monitoring for therapeutic and nontherapeutic effects of antibiotics
PowerPoint Slides 1. Managing Fluid Overload 2. Fluid Overload: Nursing Diagnoses 3. Fluid Overload: Desired Outcomes 4. Fluid Overload: Nursing Interventions 5. Managing Catabolic Processes 6. Catabolic Processes: Nursing Diagnoses 7. Catabolic Processes: Desired Outcomes 8. Catabolic Processes: Nursing Implications 9. Managing Electrolyte/Acid Imbalance 10. Electrolyte/Acid Imbalance: Nursing Diagnoses 11. Electrolyte/Acid Imbalance: Desired Patient Outcomes 12. Electrolyte/Acid Imbalance: Nursing Implications 13. Nursing Diagnosis for Infection 14. Infection: Desired Patient Outcomes 15. Infection: Nursing Implications
VI. Chronic Kidney Failure (CKF) in the High-Acuity Patient A. CKF: gradual loss of renal function, affects nearly all organ systems 1. CKD patients progress toward end-stage renal disease (ESRD). 2. Risk factors: heart disease, diabetes mellitus, smoking, hypertension, positive family history of kidney disease, obesity, and increasing age. B. Pathophysiology of chronic kidney disease (CKD) 1. Renal failure: reduction in the glomerular filtration rate (GFR), corresponding reduction in the number of functional nephrons 2. Leading causes of CKD: diabetes and hypertension C. Stages of CKD 1. Stage 1: diminished renal reserve; destruction of nephrons and compensatory hyperfiltration: a) Clinical signs: elevated BUN b) Risks: nephrotoxicity from drugs, toxins, or other insults 2. Stage 2: renal insufficiency; GFR is reduced, mild symptoms: a) Parathyroid hormone secretion increases, and renal calcium reabsorption decreases. b) Patient develops hypertension, anemia, and isosthenuria; renal function tests reflect azotemia. 3. Stage 3: renal failure, GFR reduced to 30–59 mL/min/1.73 m2: a) Patient experiences left ventricular hypertrophy and anemia secondary to a decrease in erythropoietin production. b) Manifestations of onset of kidney failure; worsening renal functioning.
4. Stage 4: GFR drops to 15–29 mL/min/1.73 m2: a) Serum triglycerides increase. b) Patient experiences hyperkalemia, hyperphosphatemia, metabolic acidosis, fatigue, nausea, bone pain, worsening manifestations of kidney failure. 5. Stage 5: end-stage renal disease (ESRD), GFR is less than 15mL/min/1.73 m2: a) Patient experiences severe uremic symptoms if not treated with dialysis. b) Total loss of renal function. D. Diagnostic features of CKD 1. Evidence of kidney damage lasting 3 months, as defined by structural or functional abnormalities of the kidney, with or without a decrease in glomerular filtration rate 2. Glomerular filtration rate less than 60 mL/ min/ 1.73m2 for at least 3 months, with or without kidney damage 3. Diagnosis and staging: laboratory analysis, including GFR, BUN and creatinine E. Manifestations of CKD: severe fluid and electrolyte aberrations, multisystem signs and symptoms of uremia, metabolic acidosis, acid-base imbalance 1. Cardiovascular effects: hypertension, atherosclerotic heart disease, hypertensive nephropathy, hyperlipidemia, macrovascular disease, ischemic heart disease, heart failure, stroke, peripheral vascular disease, pericarditis, uremic cardiomyopathy, left ventricular hypertrophy, hyperphosphatemia 2. Hematologic effects: a) Chronic anemia (1) Causes: reduced production of erythropoietin, shortened erythrocyte survival and the erythropoiesis inhibitory effects of accumulating uremic toxins, GI blood loss, potential blood loss in dialysis b) Abnormalities in the systemic homeostasis of iron c) Coagulopathy: easy bruising, nose bleeds, increased menstrual bleeding, GI bleeding in patients with uremia 3. Gastrointestinal effects: malnutrition from anorexia-induced inadequate nutrient intake a) Causes of anorexia: lowered appetite from retention of uremic toxins and various comorbid conditions, elevated parathyroid hormone levels increasing gastric acid production 4. Neurologic effects: sleep disorders, memory loss, impaired judgment, muscle cramps, and twitching, confusion, delirium, seizures, coma, restless leg syndrome and sensory neuropathies 5. Skeletal effects: loss of bone mass due to secondary hyperparathyroidism, excess parathyroid hormone (PTH) leads to brittle bones, hypocalcemia results in hyperphosphatemia 6. Immunologic effects: increased risk of infection due to uremia a) Infection is second-most-common cause of death for patients on dialysis F. Medical treatment 1. Anemia: administration of recombinant human erythropoietin and iron supplementation, parathyroid hormone suppressed through diet modifications, vitamin supplementation with 1,25 dihydroxycholecalciferol (vitamin D)
2. Hyperphosphatemia: administer phosphate binders 3. Hypertension: potassium-wasting diuretics, angiotensin-converting enzyme (ACE) inhibitors, and other pharmacologic vasodilator agents 4. Heart failure: cardioselective beta blocking agents 5. Dialysis: renal replacement therapy (intermittent hemodialysis or peritoneal dialysis) a) Peritoneal dialysis (PD): peritoneal cavity used as the semipermeable membrane to remove waste, excess fluid, and electrolytes from the blood (1) Advantages: performed on regular basis by patient, can happen in home, safer than intermittent hemodialysis (2) Disadvantages: risk of infection, respiratory distress, significant protein depletion, and not predictive of the precise fluid volume or solute that will be removed G. Nursing considerations 1. Dialysis required, hypertension likely, fluid restriction and dietary restrictions of protein, sodium, potassium, and phosphate will be important, hypoxia associated with anemia will be a focus, increased risk of infection, GI disturbances and anorexia are common, can impact nutritional status H. Nursing diagnoses 1. Altered fluid and electrolyte balance, altered nutrition: less than body requirements, activity intolerance, risk for infection, risk for constipation, risk for anemia
PowerPoint Slides 1. Chronic Kidney Failure (CKF) 2. Pathophysiology of Chronic Kidney Disease (CKD) 3. Stages of CKD 4. TABLE 26-8 NKF Classification of Stages of Chronic Kidney Disease 5. Diagnostic Features of CKD 6. Manifestations of CKD 7. Cardiovascular Effects of CKD 8. Cardiovascular Effects of CKD 9. Hematologic Effects of CKD 10. Gastrointestinal Effects of CKD 11. Neurologic Effects of CKD • Sensory neuropathies 12. Skeletal Effects of CKD 13. Immunologic Effects of CKD 14. TABLE 26–10 Physiologic Processes Affected by Chronic Kidney Disease 15. Medical Treatment
16. Nursing Considerations 17. Nursing Diagnoses
VII. Chapter Summary VIII. Clinical reasoning checkpoint IX. Posttest X. References
Suggestions for Classroom Activities • Provide descriptions of AKI patients, and have students break into pairs and determine what nursing interventions are needed. • Invite a patient who has received dialysis in the past to speak to the class about his or her experiences receiving dialysis and how it affected the patient’s overall health and daily activities.
Suggestions for Clinical Activities • Find photos of kidneys scarred by chronic renal failure. Review them during clinical postconference. • Contact a dialysis care unit. Arrange for the clinical group to tour the facility.
CHAPTER
27
Determinants and Assessment of Hematologic Function
Learning Outcomes: 1. Explain the anatomy and physiology of the hematologic system. 2. Describe erythrocytes, the cells of oxygen transport. 3. Explain the characteristics and cells of innate (natural) immunity. 4. Discuss the characteristics and cells of adaptive (acquired) immunity. 5. Describe the characteristics of antigens and antigen-antibody response. 6. Describe the origin and function of platelets and coagulation. 7. Apply the assessment of blood cells and coagulation to patient situations.
I. Review of Anatomy and Physiology A. Composition of blood 1. Plasma (55%), plasma proteins, blood cells (45%) 2. Functions: transports oxygen, glucose, hormones, electrolytes, cell wastes 3. Site of blood cell formation: red bone marrow (found in specific bones) B. Formation of blood cells 1. Erythrocytes: red blood cells (RBCs) 2. Leukocytes: white blood cells (WBCs) a) Neutrophils, eosinophils, basophils, lymphocytes, monocytes 3. Thrombocytes: platelets 4. Pluripotential hematopoietic stem cells (PHSC): type of stem cells that forms all blood cells, found in bone marrow a) When stimulated, divide in two: replacement PHSC and committed stem cell. b) Committed stem cell undergoes cell differentiation, matures into well-differentiated cell: (1) Well differentiated blood cell: has only one function, cannot reproduce c) Growth inducers/ differentiation inducers: proteins required for cell maturation. C. Organs and tissues of the immune system 1. Primary lymphoid organs: bone marrow, thymus gland a) Thymus essential to formation of T lymphocytes (T cells), type of WBC
2. Secondary lymphoid organs: tonsils, adenoids, lymph nodes, spleen, other lymphoid tissue 3. Lymphoid tissues in nonlymphoid organs: e.g., intestinal tissue, circulating immune cells (T cells, B cells, phagocytes) D. Lymph System 1. Filters foreign materials from blood: a) Serous fluid travels through lymph ducts, through lymph nodes. 2. Stores T cells and B cells. 3. Nodes become enlarged with many infectious processes. E. Spleen 1. Destroys injured, old red blood cells 2. Reservoir for B cells, some T cells found too 3. Storage for blood, released in times of demand 4. Responds to primary blood borne antigens
PowerPoint Slides 1. Blood Composition 2. Blood Cell Formation 3. Organs and Tissues of the Immune System 4. Lymph System 5. Spleen
II. Erythrocytes (RBCs)—The Cellular Component of Oxygen Transport A. Erythropoiesis: erythrocyte production, controlled by erythropoietin hormone 1. Kidneys produce erythropoietin, response to decreased arterial oxygen tension and tissue hypoxia 2. Erythrocyte maturation takes 3–5 days 3. Requires adequate protein, certain vitamins and minerals a) Thorough nutritional assessment essential
b)
B. Hemoglobin: respiratory protein, transports oxygen 1. Produced by erythrocytes during maturation; found in mature erythrocytes 2. Components: heme (nonprotein), globin (protein) a) Heme: one ferrous iron atom and one oxygen molecule (1) With deficient iron, reduced oxygen carrying capacity Hemoglobin chain: heme molecule with polypeptide chain (1) 4 in each hemoglobin molecule
PowerPoint Slides 1. Erythrocytes (RBCs) 2. Hemoglobin
III. Innate (Natural) Immunity A. Nonspecific: general, nonadaptive B. First responder white blood cells, recognize foreign cells and attack C. Phagocytosis: phagocytes (WBCs) ingest/destroy invading foreign materials/injured cells 1. Chemotaxis: chemical stimulus alerts phagocytes, move towards antigens 2. Engulfment: phagocyte swallows up antigens 3. Opsonization: antigens modified to be more susceptible to phagocytosis D. Cytokines: cellular proteins, messengers for activation of components of immune system, regulate hematopoiesis, inflammation 1. Types include: interleukins (IL), interferons (INF), granulocyte monocyte colony-stimulating factors (GM-CSF), tumor necrosis factor (TNF) 2. Elevated levels of certain cytokines associated with some disease E. Major cells of innate immunity 1. Neutrophils: first line of defense for acute infection or inflammation a) Polymorphonuclear (multiple nuclei) granulocytes (found in cytoplasm, contain granules, enzymes which break down substances) b) Mature in bone marrow, once released only live 6–8 hours c) Form pus with neutrophil-degrading enzymes, breakdown and liquefaction of local cells and foreign substances 2. Mononuclear phagocyte system/reticuloendothelial system: composed of monocytes, macrophages, certain endothelial cells in spleen, bone marrow, lymph nodes a) Monocytes: large, single-nucleus cells, circulate when immature, move to tissues when mature (1) Develop lysosomes during maturation: sacs of digestive enzymes; breakdown nutrients, bacteria (2) Arrive at injury site after neutrophils (neutrophils within 1.5 hours, monocytes within 5 hours) b) Macrophages: matured monocytes; mobile (circulate in blood supply), fixed (affixed to tissues) c) Macrophages as antigen-presenting cells (APCs) (1) APCs process antigens, present fragment to B and T lymphocytes to increase recognition and reaction (2) Carry antigens to lymph tissue (3) Produce interleukins, link inflammatory response with antibody production and cell mediation
d) Migration properties of neutrophils and macrophages (1) Margination: accumulation of leukocytes and adherence to capillary wall near injury (2) Diapedesis: leukocytes develop pseudopods, squeeze out of capillary using ameboid movement (3) Migration: movement of leukocytes to injury via chemotaxis after exiting capillary wall (4) Chemotaxis: movement of leukocytes towards inflammation according to chemical stimuli 3. Natural Killer Lymphocytes (NKs): kill pathologic cells by chemically rupturing cell membrane a) Aka “large granulated lymphocytes (LGLs)” b) Make up about 2% WBC count F. Complement system: immune mechanism, progresses through stages, results in cellular destruction 1. Damages antigen cell membranes, attracts phagocytes to invading antigen
PowerPoint Slides 1. Innate Immunity 2. Phagocytosis 3. Cytokines 4. TABLE 27-1 Major Cytokines 5. Major Cells of Innate Immunity 6. Neutrophils 7. Mononuclear phagocyte system/reticuloendothelial system 8. Migration Properties of Neutrophils and Macrophages 9. Natural killer lymphocytes (NKs) 10. Complement system
IV. Adaptive (Acquired) Immunity A. Response adapted to specific antigen exposure B. Humoral immunity: production of specific antibodies, response to recognized antigens 1. B lymphocytes: stored in bone marrow, lymph nodes, lymphatic tissue, some circulate a) Antigen exposure: mature B cells differentiate: plasma cells, memory B cells (1) Each plasma cell produces only one type of antibody (key-and-lock relationship). b) Immunoglobulins (Ig): globulin fraction of antibodies (1) Recognize/react to specific antigens because of distinct amino acid chains (a) Sufficient protein critical to functioning (2) Five classes with particular roles C. Primary and secondary response 1. Primary: first exposure, latency period (24–72 hours) before antibody is recognized
2. Secondary: subsequent exposures, memory B cells recognize, initiate immune response almost immediately D. Cell-mediated immunity 1. T Lymphocytes: formed in bone marrow, differentiated in thymus with specific surface antigens, relocate to peripheral lymph tissue when mature a) Make up 70–80% total WBC count, life expectancy of several years b) Clusters of differentiation (CD) markers: identify different types of T cells c) Health depends on thymus, lymph node integrity, nutrition E. Passive and active acquired immunity 1. Passive: transfer of antibodies from external source to an individual a) E.g., breast milk; vaccination of antiserum, antitoxin, or gamma globulin b) Rapid, temporary form of immunity 2. Active: develops on exposure to antigen a) Some forms of vaccines b) Develops over period of days to weeks, often lifetime of immunity 3. Antibody titer: level of particular antibody
PowerPoint Slides 1. Adaptive/Acquired Immunity 2. Humoral Immunity 3. Primary and Secondary Response 4. Cell-Mediated Immunity 5. TABLE 27-3 Major T Lymphocyte Types, CD Marker, and Functions 6. Passive and Active Acquired Immunity
V. Antigens and Antigen–Antibody Response A. Antigens: substances capable of triggering immune response if recognized 1. Immunogenicity: degree to which an antigen stimulates immune response 2. Foreign antigens/pathogens: many bacteria, viruses, parasites, other microorganisms a) Some antigens foreign to body are not pathogenic (e.g., vaccines, transplanted organ). 3. Histocompatibility/Human leukocyte antigens (HLAs): proteins found on the surface of cells in pairs (haplotypes) a) Histocompatibility: ability of cells and tissues to live without interference from the immune system; body recognizes own HLA as self b) Major histocompatibilty complex (MHC): group of genes, code HLA proteins (1) MHC I (Class I) Antigens: on essentially all nucleated cells (2) MHC (Class II) Antigens: on macrophages and B lymphocytes
c) Better HLA match between organ donor and recipient = higher transplantation success (1) HLA inherited from both parents (2) Siblings closest match 4. Tumor-associated antigens: distinguish normal cells from abnormally transformed cells (found in some tumors) a) Typically do not evoke immune response b) Elevated levels helpful in detection of abnormal cells; initial screening tool (1) Possible with nonmalignant disease states, too B. Antigen-antibody responsiveness 1. Antibody binds to antigen, forms antigen-antibody complex, prevents antigen from binding with host cells. 2. Binding results: aggultination, neutralization of antigen toxin, cell lysis, enhanced phagocytosis of antigen by other cells, opsonization, activation of complement system. C. Antigen entry site: a determinant of immune response 1. E.g., some antigens neutralized by digestive processes can be virulent if entering from different site
PowerPoint Slides 1. Antigens 2. Antigen-Antibody Responsiveness
VI. Hemostasis: prevention of blood loss A. Platelets: the cell component of hemostasis 1. Cell fragments composed of cytoplasm from megakaryocytes 2. Thrombopoietin, hormone produced by liver, regulates production 3. Platelets hormonally activated with vessel injury a) Develop pseudopods, adhere to damaged subendothelium b) Form platelet plug: aggregate at injury site c) Form fibrin clot: stabilized, consolidated by fibrinogen B. Coagulation: formation of thrombus (more stable, permanent repair than initial platelet plug) 1. Coagulation cascade: sequence of chemical reactions, results in fibrin clot a) Coagulation factors: plasma proteins, calcium ions, phospholipids (1) Made in liver, vitamin K key for synthesis b) Intrinsic pathway: slow process, blood is exposed to extravascular tissues c) Extrinsic pathway: rapid process d) Pathways join, create clot 2. Clot Retraction and Dissolution a) Clot contraction draws in vessel walls
b) Plasminogen in clot becomes plasmin, destroys clotting factors in clot, allowing dissolution c) Fibroblasts invade clot, forms fibrous tissue (connective tissue), patches injury
PowerPoint Slides 1. Hemostasis 2. Clot Retraction and Dissolution
VII. Assessment of Hematologic Function A. Evaluation of erythrocytes 1. Red blood cell count: healthy adult has 4–6 million cells per mcL red blood cells a) Useful in diagnosing anemias and polycythemias 2. Reticulocyte count: immature erythrocytes a) Only 1% of circulating erythrocytes in healthy adult b) Useful in diagnosing anemias, information on bone marrow function 3. Hemoglobin and hematocrit a) Hemoglobin (Hgb): low levels reduce oxygen-carrying capacity (1) RBC count does not necessarily have direct relationship with hemoglobin count b) Hematocrit (Hct): volume of RBCs in 100 mL of blood (percentage) 4. Other erythrocyte evaluations a) RBC size and color: useful in differentiating types of anemias (1) Mean corpuscular volume (MCV): size (a) Microcytic: smaller than normal (b) Normocytic: normal sized (c) Macrocytic: larger than normal (2) Color (a) Normochromic: normal color, adequate levels of hemoglobin (b) Hypchromic: pale, low hemoglobin level b) Erythrocyte sedimentation rate (ESR): measure of inflammation and infection (1) Abnormal levels associated with variety of disease states; diagnostic testing necessary B. Evaluation of Leukocytes: WBC count adequate for general screening purposes, more specific testing gives in-depth understanding 1. Neutrophils: percentage of mature (segmented) vs. immature (band) cells a) Abnormally high percentage of bands indicates severe infection. b) Neutropenia (abnormally low count) may indicate increased destruction or decreased production. 2. Lymphocytes a) Abnormally low levels occur with viral infections, chronic infections, lymphocytic leukemia. b) Abnormally low levels associated with many diseases, e.g,. cancers, leukemia, aplastic anemia, multiple sclerosis.
3. Monocytes a) Abnormally high levels associated with viral infections, some cancers, parasitic diseases, certain forms of anemia b) Abnormally low levels associated with, e.g., aplastic anemia, lymphocytic leukemia C. Evaluation of hemostasis 1. Platelet count: measured during complete blood cell (CBC) count a) Low levels may result in prolonged bleeding 2. Tests of clotting a) Bleeding time: pressure cuff inflated on arm, small puncture wound in forearm (1) Prolonged with thrombocytopenia, platelet abnormalities, DIC, other hematologic disorders b) Prothrombin time (PT) and (INR): measures factor II (prothrombin), activated in coagulation cascade (1) Test indicated for warfarin anticoagulant therapy c) Partial Thromboplastin Time (PTT) and Activated Partial Thromboplastin Time (APTT): screening test for factors VII, XIII, platelets (1) Sensitive to minor coagulation deficiencies (2) Indicated to monitor heparin anticoagulant therapy d) D-dimer: measure of fibrin degradation, confirms fibrin split products (FSP) present (1) Useful to diagnose disseminated intravascular coagulation (DIC) (2) Increase with fibrinolytic therapy e) Fibrin split (degradation) products (FSP): measurement of anticoagulation (1) Elevated level results in prolonged bleeding D. Evaluation of Bone Marrow 1. Bone marrow aspiration (biopsy) to diagnose bone marrow disorder a) Indicated with suspicious cells in peripheral blood b) Needle aspiration c) Presence, number, type of abnormal cells examined; type of abnormal cells
PowerPoint Slides 1. Evaluation of Erythrocytes 2. TABLE 27-5 Normal Erythrocyte Values and Nursing Implications 3. Evaluation of Leukocytes 4. TABLE 27-6 Normal Leukocyte Values and Nursing Implications 5. Evaluation of Hemostasis 6. Evaluation of Bone Marrow
VIII. Chapter Summary IX. Clinical Reasoning Checkpoint X. Posttest XI. References
Suggestions for Classroom Activities • Invite a guest speaker to the class who has had a transplant performed. Ask the speaker to discuss life activities that have been implemented to reduce her risk for rejection of the new organ. • Review the mechanisms associated with blood clotting. Ask students to describe, in lay terms, their observations when they have experienced a scratch or cut. How do the observations fit with their understanding of clot formation as described in the figures shown in the chapter?
Suggestions for Clinical Activities • Meet with a medical professional who works with transplant patients and the “transplant list.” Ask about the clinical results of the immune response to transplanted organs between family members, between matched individuals on the transplant list, and between random (unmatched) individuals. • Using the Internet and a search engine, search for and watch animations and actual videos of phagocytosis and chemotaxis. Search especially youtube.com.
CHAPTER
28
Alterations in Red Blood Cell Function and Hemostasis
Learning Outcomes: 1. Describe anemia, including types, etiology, pathophysiology, clinical manifestations, and management. 2. Explain sickle cell disease, including etiology, pathophysiology, clinical manifestations, complications, diagnosis, and management. 3. Discuss polycythemia, including types, etiology, pathophysiology, clinical manifestations, complications, diagnosis, and management. 4. Describe thrombocytopenia, including types, etiology, pathophysiology, clinical manifestations, complications, diagnosis, and management. 5. Explain disseminated intravascular coagulation, including etiology, pathophysiology, clinical manifestations, diagnosis, and management. 6. Demonstrate nursing assessment of the patient with actual or potential problems of erythrocytes or hemostasis.
I. Acute Anemias A. Sign of an underlying disorder B. Reduction or dysfunction in erythrocytes
b)
C. Types of acute anemias 1. Anemias of decreased RBC production a) Can result from certain vitamin/ mineral deficiencies, acute onset bone marrow depression, kidney failure Aplastic anemia: reduction in blood cell production (1) Pancytopenia: low levels of all blood cell types (2) Most commonly acquired, some inherited forms (3) Most of idiopathic origin; some secondary to some therapies (e.g., chemotherapy) (4) Diagnosis and treatment (a) Diagnosis by blood cell counts and bone marrow biopsy (b) Severity graded on a scale, for very severe prognosis is poor
(c) Supportive treatment: removal of probable cause, blood transfusions, protection from infection (d) Hematopoietic stem-cell transplantation (HSCT treatment): for severe cases (e) Immunosuppressive therapy: inhibits T cell activity; not concurrently with HSCT (5) Nursing Considerations (a) Physical exam: signs of anemia, thrombocytopenia, infection (b) Patient closely monitored for blood cell levels, complications (c) Nursing diagnoses include those for general anemias, and “risk for infection,” and “risk for bleeding” 2. Anemias of increased destruction of RBCs: hemolytic anemias a) Usually from acquired problems; sometimes from intrinsic b) Sickle cell is subtype c) Categorized by agent that causes RBC destruction d) Antibodies and/or complement coat RBC membrane, causing premature death (1) Antibodies are autoimmune, isoimmune, or drug-induced. e) Diagnosis: CBC count shows decreased RBCs, increased reticulocytes shows bone marrow working correctly (1) Peripheral blood smear: may show RBC fragmentation (schistocytes) (2) Bilirubin drawn to evaluate blood for products of hemolysis (a) Hemoglobinuria and elevated LDH enzyme (3) Palpation of spleen to check for RBCs being sequestered/destroyed in spleen (4) Coombs test for antiglobulin antibodies f) Treatment: depends on underlying cause (1) E.g., drug discontinued (2) E.g., immune system problem: glucocortiocoids, immunosuppressant therapy, blood transfusion for severe cases g) Nursing considerations (1) Patient history for possible etiologies (2) Physical exam for hyperbilirubinemia, manifestations of the underlying problem (3) Urine color for hemoglobin (4) Closely monitor serum blood counts 3. Acute blood loss anemia: from acute or chronic blood loss a) Causes: trauma, surgery, acute GI bleeding. b) Manifestations of acute loss are more severe. c) Diagnosis: Hgh and Hct values only effective measurement after 48-72 hours of acute bleed. d) Treatment: based on hemoglobin level: (1) Underlying problem corrected or controlled (2) Hemodynamic status supported through fluid resuscitation, vasopressors (3) Transfusion for severe cases
e) Nursing considerations (1) Assessment of manifestations of anemia, stress ulcers (2) Monitor CBC for downtrend of RBC and hemoglobin values (3) Monitor vital signs for increased heart rate, blood pressure changes, changes in skin color and temperature, urine output 4. Anemia of inflammation a) Mild-moderate, develops with many disorders b) Reduced production of RBCs, low serum iron, reduced iron-binding capacity despite adequate iron stores c) With inflammation or infection, proinflammatory cytokines are released, hepcidin levels are elevated (1) Hepcidin, iron-regulating hormone, holds iron intracellularly. d) Treatments: Erythropoietin and iron drug therapy 5. Anemia of critical illness a) Majority of critically ill patients develop anemia within 2–3 days post admission. b) More severe the trauma, higher elevation of hepcidin, longer duration of anemia. c) Factors to consider: underlying disease process, blood loss, bone marrow suppression, sequestration of RBCs in spleen. 6. Clinical manifestations of anemia a) Reflect underlying disorder and anemia. b) Ongoing assessment of oxygenation status. c) Impaired oxygen transport causes tissue hypoxia. d) Rate of anemia onset affects severity. 7. Grading anemias a) Degree of severity (mild-severe) based on hemoglobin level 8. Nursing considerations a) Awareness of risk factors b) Treat underlying cause c) Improve oxygenation
PowerPoint Slides 1. Acute Anemias 2. Types of Acute Anemias 3. Anemias of Decreased RBC Production 4. TABLE 28-1 Potential Etiologies of Acquired Aplastic Anemia 5. Hemolytic Anemias 6. Acute Blood Loss Anemia 7. TABLE 28-4 Patient Signs Associated with Stages of Hemorrhage
8. Anemia of Inflammation 9. Anemia of Critical Illness 10. TABLE 28-6 Grading System for Anemia
II. Sickle Cell Disease—A Disorder of Abnormal RBCs A. Normally with age, adult hemoglobin replaces fetal hemoglobin. B. In sickle cell disease, sickle hemoglobin replaces fetal hemoglobin. C. Autosomal recessive mutation, homozygous inheritance pattern. D. Epidemiology: 1. Most prevalent in Africa, the Mediterranean, Middle East, and India. 2. May be result of a genetic adaptation against malaria. E. Pathophysiology: 1. Hemolytic anemia, hemoglobin S has significantly shortened life span. 2. In well-oxygenated state, hemoglobin S (Hb S) functions normally. 3. In hypoxic state, Hb S polymerizes, gives RBCs sickle shape: a) Sickled RBC membrane becomes stiffer, more sticky. b) Sickled RBC adhere to endothelial walls, clump together: (1) Slow down blood flow (2) Cause microvascular occlusion 4. When hypoxia is corrected, most cells return to normal shape. 5. In severe form, cannot return to normal, are destroyed by the spleen: a) Over time, causes ischemia, infarction, eventual destruction of the spleen F. Clinical manifestations and complications 1. Develop between 6 months and 1 year old 2. Microvascular occlusion: “painful crisis,” tachycardia, fever 3. Laboratory value indicators: a) Mean hemoglobin count of 8 g/dL b) Elevated reticulocyte count c) Elevated bilirubin level G. Diagnosis and treatment 1. Hematologic family history 2. Blood tests: a) Sickle cell screening test; does not differentiate between sickle cell trait and sickle cell anemia b) Hemoglobin electrophoresis; when screening test is positive, does differentiate 3. Curative treatment: HSCT a) Very high survival rate with sibling-matched donor
4. Supportive treatment: antibiotic, analgesic drugs; IV fluids; blood transfusions 5. Hydroxyurea: antisickling agent H. Nursing considerations 1. Educate patient and family 2. Prevent anemia complications 3. Provide psychological support 4. Encourage genetic counseling
PowerPoint Slides 1. Sickle Cell Disease 2. TABLE 28-7 Two Major Forms of Sickle Cell Disease 3. TABLE 28-9 Effects of Micro-Obstruction and Infarction on Organs 4. Sickle Cell Disease 5. Sickle Cell Disease—Diagnosis and Treatment
III. Polycythemia—A Disorder of Excessive RBCs A. Primary polycythemia (polycythemia vera) (PV) 1. Rare clonal myeloproliferative disease involving pluripotential hematopoietic stem cells. 2. Excessive production of all blood cell types, especially RBCs. 3. Chronic disease, worsens with time. 4. Risk factors: chemical exposure, unclear genetic influences. 5. Excessive RBCs lead to elevated hematocrit, hypervolemia, increased blood viscosity, splenomegaly, pooling of RBCs. 6. Treatment: phlebotomy, myelosuppression therapy, aspirin therapy. 7. Can lead to thrombosis and acute leukemia, death . B. Secondary polycythemia/erythrocytosis 1. Sign of underlying pathology (e.g., chronic cardiac or pulmonary disease) or environmental factor 2. Frequently occurs as response to chronic tissue hypoxia a) Kidneys produce more erythropoietin b) Stimulates bone marrow to produce more RBCs 3. “Inappropriate” secondary polycythemia caused by some diseases without tissue hypoxia 4. Clinical manifestations: usually from underlying disease a) Symptoms reflect elevated red cell mass, hyperviscosity, and thrombosis 5. Diagnosis and treatment a) Absence of elevations in leukocytes or platelets helps differentiate from primary. b) Health history of chronic conditions that result in chronic hypoxia. c) Treatment focuses on underlying problem. d) Phlebotomy reserved for severe situations.
PowerPoint Slides 1. Polycythemia • Primary 2. Primary Polycythemia/Polycythemia Vera (PV) 3. Secondary Polycythemia/Erythrocytosis
IV. Thrombocytopenia: A Problem of Hemostasis A. An abnormally low platelet count B. Usually an acquired disorder, rare inherited forms C. Underlying processes 1. Problems of decreased production a) Bone marrow suppression leads to reduction in megakaryocytes, which produce thrombocytes. b) Decrease in thrombopoietin (from, e.g., liver disease). c) Megaloblastic anemias result from deficiencies of essential components of blood cell development. 2. Problems of increased destruction a) Most commonly from drug-induced immune-mediated antibody-platelet antigen response b) Sometimes from autoimmune disorders and infections c) Idiopathic (immunologic) thrombocytopenic purpura: a rare autoimmune condition mostly seen in children, or in conjunction with preexisting autoimmune disorder (1) Bone marrow increases thrombocyte production in response to premature platelet destruction. d) Heparin-induced thrombocytopenia: drug-induced; activated platelets become aggregated and are removed from circulation (1) Heparin binds with PF4 protein, forming complex, which binds with antibodies, initiates prothrombic activities. (2) In severe cases, vaso-occlusive complications can develop. 3. Problems of platelet sequestration a) With splenomegaly, large amounts of platelets can become trapped in the spleen. b) Total number of platelets may increase by two to three times to compensate for those pooled in spleen. 4. Clinical findings a) Bleeding is clinical presentation; risk for bleeding depends on platelet count. b) Other signs: petechiae and purpura on the skin and mucous membranes, epistaxis and gingival bleeding, hematuria, menorrhagia, cutaneous bleeding. 5. Diagnosis and treatment a) Complete blood cell count with differential count b) If CBC is normal, except for low platelet count, peripheral blood smear obtained to further examine platelets
c) Medical history, physical exam, drug history to explore etiologies d) Treatment for underlying cause except in extremely low platelet counts e) Treatment for very low platelet counts: corticosteroids, synthetic thrombopoietin, splenectomy 6. Nursing considerations a) Protection from and monitoring of bleeding b) Monitor for signs of internal bleeding c) Invasive procedures avoided, or platelet transfusions considered prior to them d) Assessment of factors that may contribute to thrombocytopenia
PowerPoint Slides 1. Thrombocytopenia 2. TABLE 28-10 Processes Involved in Acquired Thrombocytopenia 3. Thrombocytopenia
V. Disseminated Intravascular Coagulation (DIC): A Problem of Hemostasis A. Systemic activation of the coagulation cascade B. Complication of some underlying condition 1. Sepsis most common cause C Can result in multiple organ dysfunction syndrome (MODS) D. The coagulation cascade and DIC 1. Underlying disorder activates endothelial cells, which produce proinflammatory cytokines, which activate the clotting cascade. 2. Platelet activation: a) Platelets adhere to injured endothelium; degranulate and release mediators, local vasconstriction, platelet plug formation. b) Injured vascular endothelium releases porstacyclin, which counteracts platelet mediators, limits vasoconstriction, platelet aggregation, degranulation to the area of injury. 3. Clot formation and fibrinolysis a) Excessive systemic clotting develops with subsequent depletion of platelets and clotting factors. b) Results in excessive bleeding. c) Development of diffuse microthrombi and thrombi can compromise blood supply to organs, result in organ ischemia or necrosis. 4. Clinical findings of DIC a) Mild cases are only detected with laboratory data. b) Severe cases: clinical manifestations reflect volume of blood being lost, organ-related manifestations, signs and symptoms of the underlying disease. c) Bleeding often first, most obvious sign of DIC.
d) Extensive ischemic organ dysfunction may result. e) Lungs may develop range of problems. f) Cerebral vasculature is at risk for ischemic problems or hemorrhage. g) Shock is possible complication. h) Purpura fulminans may develop. 5. Laboratory studies a) No specific laboratory test definitively diagnoses it. b) Diagnosis based on evaluation of clinical condition and laboratory results of platelet count, clotting time, fibrin, and fibrinogen. 6. Treatment a) Focuses on underlying disease. b) Volume replacement and correction of hypotension to improve blood flow. c) Supportive measures for pulmonary, cardiac, and renal systems. d) Blood components may be administered. e) Heparin therapy sometimes helpful. f) Recombinant human soluble thrombomodulin (rhTM) agent reduces coagulation and activates protein C. 7. Nursing considerations a) Early recognition and aggressive management of the underlying problem b) Monitor for bleeding and microthrombosis-related clinical manifestations
PowerPoint Slides 1. Disseminated Intravascular Coagulation (DIC) 2. Clinical Findings of DIC 3. Treatment of DIC
VI. Nursing Assessment of the Patient with Problems of Erythrocytes or Hemostasis A. The focused nursing assessment 1. Focused neurologic assessment a) Level of consciousness (LOC), pupillary checks, cranial nerve assessment, monitoring for increased intracranial pressure 2. Focused cardiopulmonary assessment a) Check for tachycardia, tachypnea, changes in blood pressure, dyspnea, orthopnea b) If at increased risk for hemorrhage, monitor for hypovolemic shock 3. Focused gastrointestinal assessment a) Palpate for hepatomegaly and splenomegaly b) For bleeding disorders, monitor GI secretions for occult or gross bleeding
4. Focused renal and integumentary assessment a) For bleeding disorders, assess urine routinely for blood b) For anemia, monitor skin, nail bed, mucous membranes for presence and degree of cyanosis c) For thrombocytopenia, examine for petechiae, purpura, ecchymoses B. Nursing plan of care 1. Developed around the manifestations associated with each disorder 2. Tissue hypoxia: associated with anemias a) Can lead to organ ischemia, infarction b) Diagnoses can relate to: fatigue, activity intolerance, altered tissue perfusion, ineffective breathing, pain 3. Hypertension: commonly found in polycythemia a) Can lead to stroke, heart failure, or myocardial infarction, renal dysfunction. b) Diagnoses include: altered tissue perfusion, headache. 4. Stasis of blood flow: associated with polycythemia a) Can cause thrombus and thromboembolism complications b) Diagnosis is: altered tissue perfusion related to decreased systemic blood flow 5. Bleeding: associated with aplastic anemia, leukemia, chemotherapy a) Nursing diagnoses include: fluid volume deficit, decreased cardiac output
PowerPoint Slides 1. The Focused Nursing Assessment 2. Nursing Plan of Care
VII. Chapter Summary VIII. Clinical Reasoning Checkpoint XI. Posttest X. References
Suggestions for Classroom Activities • Discuss the different types of anemia that can affect the high-acuity patient, and the pathophysiology of each. • Invite a guest speaker to meet with the class. Locate a speaker who has sickle-cell anemia. Encourage the speaker to talk about his disease and the care needed. • Discuss the advances in blood handling processes that have occurred in recent years and the consequences of these advances.
Suggestions for Clinical Activities • Visit a hospital unit treating high-acuity patients. Review charts for anemia and review treatments being used. • Assign students a patient with a hematological disorder. Discuss the care of the patient during the scheduled post-conference. • Invite a nurse who has treated cases of HIT type 2 and/or cases of DIC to speak with class. Ask him or her to discuss diagnosis, treatment, and nursing management of these conditions.
CHAPTER
29
Alterations in White Blood Cell Function and Oncologic Emergencies
Learning Outcomes: 1. Discuss the etiology, pathophysiology, clinical manifestations, and management of neutropenia. 2. Explain hypersensitivity responses, including types I through IV and drug-induced. 3. Describe autoimmunity and management considerations for patient with an autoimmune disease. 4. Discuss the etiology, pathophysiology, clinical manifestations, and management of acute leukemias. 5. Apply knowledge of oncologic emergencies and nursing implications to clinical practice. 6. Discuss human immunodeficiency virus (HIV) infection and its nursing implications in high-acuity patients. 7. Relate the effects of aging, malnutrition, stress, and trauma on the functions of the adult immune system. 8. Demonstrate competency in the assessment and care of the immunocompromised patient.
I. Neutropenia (granulocytopenia) A. An abnormally low level of neutrophils, below 50% of total WBC count. B. Patient is at risk for infection. C. Absolute neutrophil count measures number of neutrophils. D. Can be intrinsic or acquired, this section focuses on acquired.
b)
E. Underlying causes: 1. Premature neutrophil destruction a) Most commonly associated with a drug-induced hypersensitivity response (1) Drugs form drug-antibody immune complexes; attach to and destroy neutrophils. Can result from autoimmune process, complication of another autoimmune disorder c) Disorders that cause splenomegaly, spleen entraps and destroys neutrophils 2. Decreased neutrophil production a) From direct injury to bone marrow b) Overcrowding of normal bone marrow components from infiltration of malignant cells c) Bone marrow suppression from cancer chemotherapy or irradiation
d) From severe nutritional deficits e) From chemical exposure or infectious agents F. Clinical manifestations 1. Serious infections can occur from pathogens that use the body as a host, normally harmlessly. 2. Mild to moderate cases: normal inflammatory response to infection, with pus formation. 3. In severe cases: signs of inflammation disappear: a) Fever is exception, from leukocytes rather than neutrophils. b) Diagnosis of acute infections is difficult. 4. Without proper treatment, patient usually develops sepsis. G. Management 1. Early discovery and aggressive treatment of underlying cause 2. Investigation of antibody and bone marrow testing 3. Granulocyte-colony stimulating factor (G-CSF) drugs
PowerPoint Slides 1. Neutropenia 2. TABLE 29-1 Neutropenia Classification Scale 3. Underlying Causes 4. Clinical Manifestations 5. Management
II. Disorders of the Hyperactive Immune Response: Hypersensitivity A. Classified by cell involvement. B. Types I, II, III involve humoral (antibody-mediated) immunity associated with specific immunoglobulins. C. Type IV is T-cell mediated. D. Mild-moderate manifestations: watery eyes, sneezing, nasal congestion. E. Strong manifestations: anaphylactic shock, severe transfusion reaction, allergic asthma response. F. Type I (IgE-Mediated) Hypersensitivity Response: 1. Aka allergic response, anaphylactic response 2. Mast cells: large, granule-containing tissues cells located in connective tissue throughout body a) Contain potent mediators: histamine, heparin, leukotriene; when stimulated trigger vascular smooth muscle and hematologic actions b) Located in skin and mucous membranes 3. Immunoglobin Ige sensitizes mast cells to allergen-antigen upon initial exposure 4. Subsequent exposure: allergic response triggered a) Rapid degradation of primed mast cells, release of mediators and chemotactic factors
5. Local type I a) Allergic rhinitis b) Allergic asthma: chemical mediators cause smooth muscle constriction in the bronchioles, histamine release results in edema of bronchial tissues (1) When severe, can cause death by asphyxiation. c) Antihistamines, corticosteroids to suppress immune response 6. Systemic (anaphylaxis) type I anaphylaxis a) Severe hypersensitivity, massive systemic release of mediators b) Triggers: drugs, insect venom, food proteins c) Response lacks genetic predisposition, occurrence unpredictable d) Mast cells trigger widespread release of histamine and other mediators, cause widespread edema and vascular congestion e) Complement system activated: triggers widespread inflammatory response f) Vasodilation and increased vascular permeability: loss of plasma into interstitial spaces (1) At risk for: hypovolemic shock, hypotension, decreased cardiac output, myocardial ischemia, widespread organ death, asphyxia g) Treatment: immediately (1) Epinephrine, tracheostomy, oxygen and injectable antihistamines, glucocorticoids (2) Keep patient warm G. Type II (cytotoxic/hemolytic) hypersensitivity response 1. Immunoglobulins IgM and IgG react with cell surface antigens; activate complement system, directly injure cell surface 2. Hemolytic transfusion reactions a) Transfusion reactions can be febrile (recipient antibodies act against donor WBCs) or hypersensitivity reactions (recipient antibodies attack donor blood proteins); only kind that is cytotoxic is hemolytic. b) Preexisting antibodies attach to ABO antigens of donor blood RBCs; activates complement cascade: (1) Phagocytes destroy donor RBC. (2) Cause release of hemoglobin. (3) Hemoglobin fragments can obstruct renal tubular blood flow. c) Symptoms occur within first 2-5 minutes of transfusion initiation. (1) Heat and redness at infusion site, nausea, headache, back pain, chills, fever (2) Tachycardia, hypotension, death can follow if not stopped and treated immediately H. Type III (immune complex-mediated) hypersensitivity response 1. Formation of antigen-antibody complexes deposit themselves in tissues, or on vessel walls, set off inflammatory response. 2. Tissue damage from altered blood flow, increased vascular permeability, destruction by inflammatory cells. 3. Commonly seen in chronic organ transplant rejection.
4. Damage from autoimmune disorders. 5. Arthus reaction: antigen-antibody complexes form in vessel walls, trigger inflammatory response in vessels: a) Vessels become more permeable, fluid leaks out, causes edema. b) Neutrophils attempt to destroy complexes, cause tissue damage. c) Localized hemorrhage and clotting, tissue necrosis, may occur. 6. Serum sickness: systemic form: a) Tissue destruction same as in arthus. b) Antigen-antibody complexes deposit in target tissues: (1) Kidneys, joints, blood vessels I. Type IV (delayed) hypersensitivity response 1. In absence of antibody activity, sensitized T cells attack antigen, release lymphokines, which attract and activate macrophages: a) Localized inflammation and edema. b) Tissue injury and destruction occur through T cell toxins, lysosomal enzymes, phagocytosis: 2. Local reactions include contact dermatitis (e.g., from poison ivy). 3. Clinical examples: graft or acute organ transplant rejection in which HLA antigen is principle target 4. Component of some autoimmune disorders a) Hashimoto thryoiditis, rheumatoid arthritis, type I diabetes mellitus J. Drug-induced hypersensitivity reactions 1. Reactions classified: immediate, immune-complex dependent, or delayed 2. Immediate: type I a) Associated with penicillin, NSAIDS, contrast dyes 3. Immune complex–dependent reaction reflect systemic type II response a) Seen with monoclonal antibodies K. Management of hypersensitivity responses 1. Severity varies widely 2. Mild-moderate cases, often no treatment 3. Treatment: antihistamines, glucocorticoids a) Route of delivery dependent on severity 4. For anaphylaxis: epinephrine and antihistamine
PowerPoint Slides 1. Hypersensitivity 2. Type I (Ige-Mediated) Hypersensitivity Response 3. TABLE 29-3 Major Mediators of Type I Hypersensitivity Response 4. Systemic (anaphylaxis) Type I Response
5. Type II (cytoxic/hemolytic) Hypersensitivity Response 6. Type III (immune complex-mediated) Hypersensitivity Response 7. Type IV (delayed) Hypersensitivity Response 8. Drug-Induced Hypersensitivity Reactions 9. Management of Hypersensitivity Responses
III. Disorders of Hyperactivity Immune Response: Autoimmunity A. Intolerance of one’s own body tissue, different disorders B. B cell hyperactivity C. Types II and III most common, any hypersensitivity response possible D. Origin: unknown, some genetic component, triggered by virus or chemical substance, cases increase with age, more women than men affected E. Molecular mimicry theory: cell wall proteins of certain microbes resemble those of certain normal cells in body F. Immunosuppressive treatment: drug-induced, radiation-induced, or surgically induced G. Systemic lupus erythematosus 1. Inflammatory condition; autoantibodies develop against nuclear antigens 2. Affects multiple body systems and organs 3. Can be mild to life-threatening 4. Can be relapsing-remitting or continuously active 5. Onset associated with environmental triggers, certain drugs 6. Pathophysiology a) Cause: unknown, probably multifactorial: genetic predisposition, hormonal and environmental factors, dysregulation of the immune system b) Strong type II hypersensitivity response: antigen-antibody complexes deposit in blood vessels and tissue surfaces, create occlusions and inflammation c) Impaired function of affected organs from local damage from edema, hemorrhage, clotting, accumulation of neutrophils 7. Clinical findings and diagnosis a) Malaise, fatigue, fever, weight loss, joint pain, skin manifestations b) Presentation dependent on which body system is being targeted c) Diagnosis difficult (1) Antinuclear antibody (ANA) test screens for autoimmune disease; doesn’t specifically detect SLE (2) Complement levels tested (3) Diagnosis based on criteria of American Rheumatism Association, laboratory data and organ function findings
8. Management and prognosis a) Treatment depends on severity, body systems affected. b) NSAIDS, antimalarial therapy: (1) Monitor liver, kidney, and eye function on these drugs c) Corticosteroid therapy for severe attacks. d) Immunosuppressive agents for uncontrolled flares. e) In U.S., survival at 10 years following diagnosis for 90%. f) In first few years of onset, death risk from injury to body systems or infections. g) In later years, death risk from accelerated atherosclerosis. 9. Nursing implications a) Nursing history: assessment of underlying SLE condition b) Physical assessment: head-to-toe evaluation of systems, frequent re-evaluation c) Monitor for organ function deterioration, especially heart, lung, kidneys d) Educate patient and family
PowerPoint Slides 1. Autoimmune Disorders 2. TABLE 29-4 Common Autoimmune diseases That Target Specific Body Systems or Tissues 3. Systemic Lupus Erythematosus 4. Systemic Lupus Erythematosus
IV. Acute Leukemia A. Transformation of hematopoietic cells causes unregulated clonal growth. B. Accumulation of dysfunctional cells in bone marrow, decreased production of normal blood cells. C. Aggressive proliferation of immature lymphoid or myeloid blast cells. 1. Chronic cases: production of mature, differentiated cells or either lymphoid or myeloid lineage D. Causes are unknown, likely genetic and environmental. E. Types of acute leukemia: 1. Acute lymphocytic (lymphoblastic) leukemia a) Primarily a disease of childhood, also occurs in middle age. b) Proliferation of immature lymphocytes (lymphoblasts) from B cells or T cells. (1) Do not mature or take on normal immune functions c) Leukemic cells infiltrate other normal tissues. 2. Acute myelogenous (myelocytic) leukemia a) Primary a disease of adulthood. b) Proliferation of malignant blast cells from myeloid stem cells. c) Cells rapidly accumulate in bone marrow, infiltrate into other tissues. d) Bone marrow will show myeloblastic cells and auer rods.
F. Clinical manifestations 1. Initially: fever, fatigue, bruising, bleeding, bone pain, persistent/frequent infections 2. Pancytopenia manifestations a) Tissue hypoxia as anemia develops. b) Risk for infection as normal leukocyte count decreases. c) Manifestations of infection may be diminished with neutropenia. d) Bleeding problems as platelets decrease. e) Infection and hemorrhage: most common causes of death. 3. Malignant cell expansion and infiltration manifestations a) Tenderness or pain from increased pressure in bone b) Malignant cells in CNS cause: nausea, vomiting, headache, seizures, lethargy, papilledema, possible cranial nerve palsies c) Malignant cells in spleen and liver: splenomegaly, hepatomegaly G. Diagnosis and prognosis 1. Difficult to determine if blast cells are myelocytic or lymphocytic. 2. Bone marrow biopsy with aspiration, analysis of cells with immunophenotype and molecular analysis. 3. Complete blood count with differential and peripheral smears. 4. French-American-British (FAB) classification system differentiates types by morphology. 5. Prognosis depends on age, exact subtype. 6. ALL in children 5-year survival rate of 85%; lower in adults. 7. AML has worse prognosis than ALL. H. Management 1. Goals: eliminate malignant cells, restore normal hematopoiesis, produce complete remission 2. Induction chemotherapy: initial stage of chemotherapy, lasts one week a) Aims for complete remission. b) Patients may stay in hospital for about a month. c) Antibiotics, blood products sometimes used during therapy. 3. Consolidation chemotherapy a) Same agents as during induction but at lower doses and shorter durations b) Aims to solidify remission 4. Maintenance chemotherapy a) Primarily required for ALL b) Intrathecal prophylactic treatment of CNS to prevent recurrence in spinal fluid 5. Hematopoietic stem-cell transplantation a) Particularly for patients with AML or relapsed ALL b) Intensive therapy to eradicate hematological malignancy from bone marrow c) Used for many disorders
I. Nursing implications 1. Goals: vigilant assessment, prevention of infection, delivery of therapy and evaluation of effects, management of disease and treatment-associated complications. 2. Rapid recognition of physiologic changes are crucial. 3. Educate patient and family.
PowerPoint Slides 1. Acute Leukemia 2. Clinical Manifestations 3. TABLE 29-6 Clinical Manifestations of Leukemia 4. Diagnosis/Prognosis/Management 5. Management
V. Oncological Emergencies A. Potentially life-threatening complications from cancer, cancer therapy, or comorbid conditions B. Tumor-related emergencies 1. Spinal cord compression a) Caused by direct extension of tumor or by metastatic disease in vertebral column b) Edema and diminished blood supply to spinal cord can lead to paresis and paralysis c) Symptoms: pain, motor weakness, sensory deficit d) Diagnosis by MRI e) Treatment: surgery, chemotherapy, radiation, medications, laminectomy, or spinal fusion for severe cases 2. Superior vena cava syndrome a) Obstruction of SVC from thrombosis, tumor invasion, or external compression by tumor: (1) Most commonly from malignant disease of thorax b) With gradual development, patient may experience just minor symptoms. c) With rapid development patient may present crisis state. d) Treatment of cause of obstruction: radiation or chemotherapy, stent may be placed, thrombolytic therapy may be ordered. 3. Leukostasis a) Obstruction of blood flow from excessive numbers of circulating leukocytes. b) Primarily associated with AML. c) Impaired capillary circulation causes organ damage from increased blood viscosity and aggregation of leukemic cells. d) Symptoms: headache, dizziness, altered level of consciousness, hypoxemia, respiratory distress, respiratory failure, kidney and heart manifestations may develop. e) Treatment: hydration, apheresis therapy, antineoplastic agents, hydroxyurea, radiation for crisis situation.
C. Therapy-related emergencies 1. Cancer chemotherapeutic agents are toxic to organs. 2. Radiation can cause organ and tissue injury. 3. Intestinal neutropenic enterocolitis: a) Intestinal wall damage with neutropenia, bacteria colonize damaged mucosal layer (1) Can result in transmural intestinal wall damage, perforation, peritonitis b) Risk factors: cytotoxic chemotherapy, myeloproliferative neoplasms, bone marrow or solid organ transplant c) Varies from mild to life threatening d) Symptoms: fever, abdominal pain, diarrhea, nausea and vomiting, abdominal distention e) Diagnosis: abdominal CT scan f) Treatment of mild cases: placement of a nasogastric, IV fluid replacement, broad spectrum antibiotics g) Severe cases: surgical resection of affected bowel 4. Urinary bladder a) Caused by chemotherapy and radiation b) Urinary frequency, hematuria, dysuria c) Hemorrhagic cystitis, severe form, may involve gross bleeding d) Preventative therapy: hydration, drug mesna e) Treatment: evacuation clots, continuous bladder irrigation until bleeding stops; in severe cases cystoscopy, hypogastric artery embolization 5. Heart a) Cardiac toxic effects: dysrhythmias, cardiac ischemia, heart failure, cardiomyopathy, pericarditis (1) Specific toxic effects linked with specific drugs b) Cardiac effects from radiation therapy: acute pericarditis, pericardial effusion, pericardial constriction (1) Can cause cardiac tamponade, life-threatening emergency c) Treatment depends on severity; with tamponade emergency removal of pericardial fluid, surgical stripping of affected pericardium 6. Lungs a) Chemotherapeutic agents: acute respiratory distress syndrome (ARDS), interstitial lung disease, pulmonary veno-occlusive disease b) Radiation therapy: radiation pneumonitis and fibrosis c) Treatments: discontinuation of drug, corticosteroids, vasodilator therapy for veno-occlusive disease 7. Liver a) High risk for toxicity problems because liver metabolizes drugs b) Decreased liver function c) Treatment: dose reduction or discontinuation of particular offending agent
D. Other oncologic treatment emergencies 1. Sepsis a) Therapy-induced immunosuppression b) Neutropenic patient at high risk (1) Leukemia and bone marrow transplant patients often neutropenic c) Treatment: IV antibiotics, acyclovir prophylactically, granulocyte-colony stimulating factor for leukocyte recovery 2. Tumor lysis syndrome (TLS) a) Usually associated with treatment for leukemia and lymphoma b) Kidney unable to excrete all destroyed cells from treatment c) Elevations in serum metabolite levels d) Clinical findings: hyperuricemia, hyperphosphatemia, hyperkalemia, hypocalcemia e) Can lead to kidney failure, death f) Treatment: loop diuretics, hydration, antigout drugs, hemodialysis for severe cases 3. Hypercalcemia a) Caused by osteoclastic activities and decreased calcium excretion b) Treatment: volume expansion with saline, biophosphonates, calcitonin, dialysis if other treatments untolerated E. Nursing implications 1. Ability to predict possible complications 2. Multisystem physical assessment, focus on high-risk organs 3. Laboratory data to monitor organ function 4. Patient education on nontherapeutic effects of drugs
PowerPoint Slides 1. Oncological Emergencies 2. Tumor-Related Emergencies 3. Therapy-Related Emergencies 4. Other Treatment Emergencies
VI. HIV Disease: A Disorder of Immunodeficiency A. Immunodeficiency state: impaired immune activity from acute or chronic loss of function of one or more components of the immune system B. Epidemiology and transmission 1. Transmitted through direct contact of infected blood and body secretions, excluding saliva and tears a) Occurs with sexual contact, contaminated needles, mother-infant transmission; in other countries also through contaminated blood product transfusions b) A sufficient viral load needed to develop infection
C. Pathophysiology 1. Retrovirus: carries genetic information in RNA 2. Two forms: HIV-1 is major cause of AIDS globally; HIV-2 isolated to West Africa 3. Viral invasion a) Virus binds with helper T cells, performs reverse transcriptase, viral RNA copied as DNA, inserted into host cell chromosome. b) Eventually destroys T cell, produces massive numbers of copies of virus. c) Viral load and CD4+T cell counts reflect viral activity and disease progression. d) Most antiviral drugs being tested work to inhibit reverse transcriptase. 4. Cellular characteristics of HIV disease a) Depressed T lymphocyte functioning, reduction of helper T cells, impaired cytotoxic T cell activity, increased suppressor T cells. b) Virus damage cells that identify and orchestrated destruction of the virus as an antigen. c) Humor response is less directed affected. d) B cell production does not seem to decrease, but response affected by lack of T cells, D. Progression of HIV infection 1. Early-stage HIV disease: a) Acute Viral (HIV) Syndrome (1) Within about 3–6 weeks of exposure. (2) Transient flu-like or mononucleosis-like symptoms develop in about 50–70% of patients. (3) Virus is actively replicating, increasing serum viral load. (4) Blood test shows positive for HIV, negative for antibodies (seronegative). b) Clinical latency (window) period (1) Period between initial infection and development of symptoms. (2) Mild symptoms may be present. (3) Can last about 10 years, with treatment can last longer. (4) Virus replicates, but immune system keeps viral count low. 2. Progressive HIV disease and AIDS a) Viral load increases, helper T cells decrease. b) Clinical manifestations worsen; more prone to infection. c) AIDS defined as: (1) Seropositive HIV infection (2) CD4+T cell count of less than 200 cells/mL OR (3) Presents of at least one “AIDS-defining” illness (a) Pneumocystis jiroveci pneumonia (PJP) most common d) Without drug therapy, AIDS patient dies within two to three years. E. Clinical manifestations 1. Varies, depending on which infections present
2. With no AIDS-defining illness: lymphadenopathy, mouth lesions, anemia, neurological symptoms 3. Overt AIDS: wasting syndrome, neurological symptoms, malignancies and opportunistic infections, severe fatigue, pharyngitis F. Diagnosis of HIV 1. Laboratory testing of presence of antibody to antigen p24, protein found in HIV that triggers immune response 2. When exposure is suspected, screening test ELISA repeated at 3-6 month intervals a) False-positive can occur with ELISA 3. Western blot test to confirm positive ELISA G. Prognosis and management 1. With treatment, individuals may live an average of 39 years post-diagnosis. 2. Treatment with: antiretroviral therapy, treatment of opportunistic infections, malignancies and other complications, and prophylaxis for opportunistic diseases. 3. Structure of virus is variable, many genetic mutations difficult to target. 4. Antiviral therapy: a) Highly active antiretroviral therapy (HAART): reduces viral replication, does not kill virus (1) 3-5 drugs combined to prolong asymptomatic phase, reduce viral load in overt AIDS phase (a) Nucleoside and nucleotide reverse transcriptase inhibitors; non-nucleoside reverse transcriptase inhibitors; protease inhibitors; entry inhibitors (2) Critical to continue drug therapy without interruption to reduce risk of developing drug resistance (3) Side effects of drugs: peripheral neuropathy, GI distress, rash, hyperlipidemia, organ and bone toxicity 5. Drug prophylaxis a) Primary prophylaxis: to avoid or delay onset of disease symptoms. b) Secondary prophylaxis: to prevent or delay recurrent symptomatic infection. c) Prophylaxis for Pneumocystis jiroveci pneumonia (PJP) indicated when CD4+ count falls below 300 cells/mcL. d) Prevention of toxoplasmosis, tuberculosis, Mycobacterium avium complex, cytomegalovirus, and fungi also guided by CD4+ cell count. e) Vaccines for pneumonia and influenza. f) Vaccines of live viruses may be contraindicated. g) Granulocyte stimulants to counteract neutropenia. H. Nursing implications 1. Early evaluation of immune status is crucial. 2. CDC recommends screening all people. 3. Nurse must be knowledgeable about disease, educate patient and family. 4. Advances, but still significant symptom burden, lingering societal stigma.
5. HIV Exposure in the health care professional: a) Risk is low. b) Treatment approaches and protocols for occupation exposure to needle sticks, blood and body fluids, contaminated instruments. c) Basic postexposure prophylactic (PEP) regimen begins within hours of exposure; antiretroviral therapy (ART) for four weeks.
PowerPoint Slides 1. HIV DiseaseImmunodeficient state 2. Progression of HIV Infection 3. TABLE 29-9: General Clinical Manifestations of Progressive HIV Disease and AIDS 4. Diagnosis of HIV 5. Prognosis and Management 6. TABLE 29-11 Example of HAART Therapy
VII. Aging, Malnutrition, Stress, Trauma, and the Immune System A. Aging 1. Thymus gland begins to atrophy early in life, shrinks until person reaches middle age: a) Maturation and differentiation of T cells decrease. 2. Macrophages continue to function throughout life; takes longer to clear pathogens with age. 3. Ability to determine “self” versus “nonself” decreases with age. 4. Ability to destroy mutated cells decreases. 5. B cell response to antigen declines. 6. Production of immunoglobulin IgM decreases; production if IgA and IgG increases. B. Malnutrition 1. With age: decreased appetite, loss of social supports, decreased ease of access to grocery stores, impaired functional status. 2. Calorie and protein intake play key roles in T cells, immunoglobulins, complement system, macrophage functions. 3. Zinc plays major role in B cells, T cells and wound healing: a) Malabsorption syndromes or inflammatory bowel disease can cause zinc loss. 4. Several vitamins affect function of T cells and B cells. 5. Sepsis develops as malnourished gut atrophies and becomes permeable to bacteria: a) Enteral feeding to reduce risk of sepsis C. Stress and trauma 1. Cortisol: glucocorticoid hormone secreted by adrenal glands in times of stress: a) Inhibits produces of interleukins IL-1 and IL-2 that are necessary for T cell production b) Leads to elevated levels of serum glucose; hyperglycemia known to alter leukocyte function
2. Trauma suppresses T cell an B cell activity, compromises immune function: a) Decreased chemotactic and phagocytic activities, decreased antibody and lymphocyte levels D. Nursing implications 1. Nurse assesses patients for factors that alter system function: a) Nursing history and physical examination b) Monitoring blood results of immune, nutrition, metabolic status 2. Aggressive early treatment of malnutrition: a) For hyperglycemia, insulin therapy sometimes indicated
PowerPoint Slides 1. Aging 2. Malnutrition 3. Stress and Trauma
VIII. Care of the Immunocompromised Patient A. Focused assessment 1. Focus on evidence of infection 2. Patient history a) Signs of inflammation, loss of appetite and weight loss, slow wound healing, disease history, menstrual changes, drug history, allergy history, burn history, family history B. Immunocompetence assessment 1. High risk for immunocompromise in event of: prolonged stress, severe infections, malnutrition, diabetes, other problems 2. History, current symptoms and laboratory tests considered 3. Laboratory findings a) WBC with differential and total lymphocyte count (TLC) b) Nutritional status tests, e.g., serum albumin or prealbumin c) Cell-specific and disorder-specific tests C. Collaborative management 1. Laboratory testing a) Nursing responsibilities before drawing samples 2. Drug therapy a) Immunosuppressive agents: for chronic inflammatory problems, organ transplants, autoimmune disease b) Agents that enhance immunity: cancer therapy 3. Environmental protection a) Severe leukopenia: high risk for infection b) Immunocompromised patient in controlled environment
D. Independent nursing interventions 1. Goals: monitor for and prevent infection, regain or maintain nutrition, meet psychosocial needs of patient and family a) Monitor mucous membranes for infection 2. Clinical findings altered by neutropenic patient 3. Nursing diagnoses relate to risk for infection, altered nutrition, pain, and psychosocial status
PowerPoint Slides 1. Assessment 2. Management
IX. Chapter Summary X. Clinical Reasoning Checkpoint XI. Posttest XII. References
Suggestions for Classroom Activities • Assign students into small work groups of three to four. Ask each student to develop two nursing diagnoses for the patient experiencing neutropenia. Also ask for each student group to list three interventions. After allowing a brief work time, bring the groups together and ask the groups to discuss their work. Compare the findings. • Have students divide into groups of at least four students each, and assign each group a diagnosis contained within Module 7. The group will list presenting signs and symptoms seen in a patient with the assigned diagnosis, develop at least one nursing diagnosis with appropriate interventions, and present the information to the class.
Suggestion for a Clinical Activity • Ask a nurse from the oncology unit to speak to the clinical group. Ask the speaker to discuss the care and treatment of patients experiencing immunosuppression.
CHAPTER
30
Determinants and Assessment of Nutrition and Metabolic Function
Learning Outcomes: 1. Analyse and explain normal metabolism concepts, including anabolism and catabolism, aerobic and anaerobic, and energy. 2. Apply the primary functions of carbohydrates, lipids, and proteins as the body’s fuel sources to the systematic assessment of the high-acuity patient. 3. Analyse neuro-endocrine factors that influence nutrition and metabolism during stress from acute illness. 4. Identify components of a focused nutrition, metabolic nursing history, and physical assessment. 5. Analyse the laboratory assessment of endocrine, nutritional, and metabolic status. 6. Determine appropriate physiologic studies used to measure endocrine, nutrition, and metabolic status.
I. Metabolism A. Transformation of nutrients B. Anabolism and catabolism 1. Anabolism: simple molecules are converted into more complex molecules: a) Requires energy b) Contributes to tissue building 2. Catabolism: complex nutrients and body tissues are broken down into more basic elements: a) Liberates energy for bodily functions b) Creates, e.g,. glucose, fatty acids, amino acids 3. Normally occur simultaneously. 4. Both require enzyme catalysts: a) Substrates: substances acted on by enzymes C. Aerobic and anaerobic metabolism 1. Adenosine triphosphate (ATP): form that energy is used and stored in 2. Aerobic metabolism a) Oxidation of nutrients occurs in mitochondria.
b) Krebs (citric acid) cycle: (1) Glycolysis produces pyruvate. (2) Pyruvate forms 38 molecules of ATP and carbon dioxide and water. c) Electron transport chain biochemical sequence of reactions: (1) Hydrogen atoms are oxidized, form hydrogen ions and water. (2) Converts adenosine diphosphate (ADP) to ATP. (3) Releases greater amount of ATP than Krebs. 3. Anaerobic metabolism a) In cells without mitochondria b) In cases of decreased oxygen delivery to cells c) Oxidation of glucose to pyruvate, converted to ATP (1) Glycolysis: glucose oxidation in cytoplasma (a) Requires nicotinic acid dehydrogenase (NAD+), oxygen-reducing coenzyme d) Produces 2 ATP molecules and pyruvate and lactic acid byproducts (1) Lactic acid: temporary energy source for most body cells 4. Inefficient as energy source; reversible with adequate oxygen; cannot sustain life indefinitely 5. Elevated serum lactate levels indicative of inadequate cellular oxygenation D. Energy: ability to do work 1. Calories: unit of energy needed to raise temperature of 1 gram of water by 1 degree Celsius 2. Kilocalorie: amount of energy required to raise temperature of 1 kg of water by 1 degree Celsius 3. Energy needed to: a) Maintain ion gradients across cell membranes b) Central nervous system functions c) Synthesis of proteins d) Oxidation of nutrients, breathing, cardiac pumping
PowerPoint Slides 1. Metabolism 2. Aerobic metabolism 3. Anaerobic metabolism 4. Energy
II. Nutrition: The Source of Energy A. Involves: ingestion, digestion, absorption, metabolism B. Macronutrients: carbohydrates, proteins, lipids C. Micronutrients: vitamins, minerals, trace elements
6.
D. Carbohydrates 1. Composed of carbon, hydrogen, oxygen 2. Preferred fuel source for most tissues 3. Glycogenesis: storage of excess glucose in the liver and muscle cells 4. Glycogenolysis: utilization of stored glucose (glycogen) a) In times of physiologic stress 5. Insulin and glucagon: pancreatic hormones that regulate glucose metabolism a) Ingestion of glucose causes increase in insulin release 25% of glucose supply used by brain and nervous system a) Extracts glucose from bloodstream b) Can use ketone bodies (from fat) as fuel, but just that is not enough E. Proteins 1. Composed of various combinations of amino acids, nitrogen, carbon, hydrogen, oxygen 2. Required for: formation and maintenance of all cells, tissues, organs; transport mechanisms; contribute to structure of genes, enzymes, hormones, antibodies, hemoglobin; maintain osmotic pressure, blood pH 3. Visceral proteins: found within internal organs 4. Somatic proteins: found in accessory and skeletal muscles 5. Under stress, catabolism increased a) Metabolism influenced by hormones 6. Broken down into amino acid components and produce energy when carbohydrate supply is inadequate F. Lipids (fats) 1. Contribute to cell membrane structure; source of essential vitamins, aid in absorption of certain vitamins; provide insulation; provide structural protection for some organs 2. Reserve energy source a) Stored as triglycerides, phospholipids, cholesterol b) Provide 9kcal energy/gram 3. Influenced by insulin 4. Stored in adipose tissue, liver a) Lipogenesis: liver produces lipids from glucose or amino acids (1) In cases of excess carbohydrates for energy and glycogen storage 5. Lipolytic metabolism, during stress, increases fatty acids and ATP for energy
PowerPoint Slides 1. Nutrition 2. Carbohydrates 3. Proteins 4. Lipids
III. Endocrine Influence on Metabolism A. Endocrine glands secrete hormones, regulate metabolism, growth, fluid and electrolyte balance, energy production. B. Endocrine glands and hormones: 1. Pituitary gland: responds to hormones secreted by hypothalamus: a) Anterior: secretes adrenocorticotropic hormone (ACTH) in response to stress b) Posterior: secretes antidiuretic hormone (ADH) promotes conservation of water 2. Thyroid gland: increases metabolism; responds to hormone secreted by anterior pituitary: a) Secretes calcitonin: regulates calcium levels in blood, mediator of inflammatory response 3. Adrenal glands: a) Adrenal medulla: secretes catecholamines (epinephrine and norepinephrine): fight or flight hormones b) Adrenal cortex: secretes corticosteroids (1) Mineralcorticoids (aldosterone) increases sodium and water retention, increases circulating blood volume. (2) Glucocorticoids (cortisol) regulates glucose use, mobilizes fatty acids for energy production. C. Physiologic response to stress 1. Hypothalamus releases corticotropin-releasing hormone (CRH) → stimulates anterior pituitary to release ACTH → stimulates adrenal to secrete cortisol and aldosterone. 2. SNS stimulates adrenal glands to secrete catecholamines → stimulates pituitary to release ACTH → stimulate adrenal cortex to release cortisol: a) Catecholamines: increase rate and force of cardiac contractions, blood pressure and blood glucose levels; constrict blood vessels in skin, muscous membranes and kidneys; dilate blood vessels in skeletal muscles, coronary arteries and pulmonary arteries 3. Hypothalamus stimulates posterior pituitary to release antidiuretic hormone (ADH) a) Increases water retention, increases blood volume
PowerPoint Slides 1. Endocrine Glands and Hormones 2. Physiologic Response to Stress 3. Effects of Stress Hormones
IV. Focused Nutritional History and Physical Assessment A. History and physical assessment: identify current status, provide baseline, identify patients at risk for complications, allow planning for nutritional support. B. Some diseases are risk factors for malnutrition. C. Medical and nutritional history: 1. Identify underlying risk factors for nutritional depletion or excess 2. Consider social, cultural, ethnic traditions
3. Consider medication history, anthropometric measurements, lab data 4. Review: a) History of food and fluid intake b) Barriers to normal food consumptions c) Alterations in GI anatomy and nutrient absorption d) Recent weigh changes 5. Laboratory tests: lymphocyte count, cholesterol, serum protein 6. Physical assessment: determine if patient is alert, oriented, has adequate gag reflex and ability to swallow a) Assess tissue loss, appearance of wasting, retention of fluid D. Anthropometric measurements 1. Height, weight, waist circumference 2. Can be used to measure recovery from malnutrition, illness 3. Precise measurements require technically sophistocated methods; simple measurements in acute care of skin-fold thickness, height and weight 4. Height and weight a) When head-to-toe not possible, arm span measurement. b) Height determines ideal body weight, energy requirements. c) Weight is one of most useful parameters in illness: (1) May vary drastically with illness, be difficult to obtain (2) Relative weights in cases of equipment, casts, etc. that alter measurements 5. Ideal body weight and body mass index a) Ideal body weight: based on age, sex, height b) Hamwi rule of thumb: calculation method c) Body mass index (BMI): Wt (kg)/ Ht (meters)2
PowerPoint Slides 1. Medical and Nutrition History 2. Anthropometric Measurements 3. Insert Table 30-3: Formulas Used to Calculate Body Mass Index (BMI) 4. Physical Assessment
V. Laboratory Assessment of Endocrine and Nutritional/Metabolic Status A. Protein status measured: albumin, prealbumin, transferrin B. Thyroid and adrenal status: identify patient at risk of impaired metabolic response C. Albumin 1. Plasma protein produced by liver. 2. Primary indicator of overall nutrition status. 3. Hypoalbuminemia: increased occurrences of complications.
4. Little value in assessing acute nutritional changes. 5. Low levels may be detected with adequate protein intake with liver or renal disease. D. Prealbumin (transthyretin) 1. Transport protein, binds retinol-binding protein and thyroxin 2. More reliable indicator of acute changes 3. Not influenced by renal and liver status E. Transferrin 1. Plasma protein binds with and transports iron to cells. 2. Useful for tracking response to therapies. 3. As nutritional indicator, depends on iron level. F. Nitrogen balance 1. Difference between nitrogen output and intake a) Positive: more intake than output b) Negative: more output than intake 2. Indicator of protein status 3. Urine urea nitrogen (UUN) test compared with protein intake a) Not valid in renal failure b) UUN to calculate protein needed G. Vitamin and mineral assays 1. Common in acute patients: low vitamin A, zinc, magnesium 2. Assessed in digestive/absorptive disorder 3. Commonly available tests: vitamin A, E, thiamin, folate, vitamin B12, zinc, magnesium, phosphorus H. Total lymphocyte count 1. Measures effect of protein loss on immune system functioning 2. Indicator of overall immune status when WBC and lymphocyte counts are relatively stable 3. Lymphoctye count should be 20–40% of WBC count. 4. Malnutrition depresses neutrophil chemotaxis, total lymphocyte count, delay hypersensitivity reactivity. I. Anergy screen 1. Delayed cutaneous hypersensitivity screening (skin testing) evaluates cell-mediated immunity status: a) Test dose of antigen administered, evaluated 24 to 48 hours later 2. No skin reaction = anergic response, cellular immunity may be affected by malnutrition
PowerPoint Slides 1. Protein Status 2. Nitrogen Balance
3. Vitamin and Mineral Assays 4. Total Lymphocyte Count 5. Anergy Screen
VI. Physiologic Studies of Nutrition and Metabolic Status A. Goal of nutrition support for high acuity: avoidance of catabolism during metabolic stress B. Registered dietician/nutritionist: consultation about nutritional needs C. Nurse knowledgeable about effects of metabolic stress for implementation D. Healthy individual: 25 kcal/kg/day; 0.8-1 gram protein/day; 1 mL fluid per calorie E. Oxygen consumption and energy expenditure 1. Indicators of metabolic state 2. Events/situations that increase oxygen demands increase energy expenditure a) E.g., fever, shivering, infection, pain 3. Calorimetry: measurement a) Direct calorimetry: measures whole body heat production; room specifically equipped for procedure, impractical in clinical setting b) Indirect calorimetry: portable unit estimates resting energy expenditure (REE) by measuring respiratory gas exchange (1) Measures amount of oxygen consumed and amount of carbon dioxide produced (2) Determines energy requirements (3) Respiratory quotient (RQ): ratio of carbon dioxide produced to oxygen consumed (a) Normal value: 0.85 (b) Greater the amount of glucose being used, higher the RQ (c) Above 0.85 means overfeeding; below means underfeeding (d) Hypercapnia: carbon dioxide retention, can occur with excess carbohydrate intake c) Fick equation: blood gas analysis of arterial and venous blood (1) substitute for indirect caliometry when unavailable F. Oxygen extraction 1. At rest, oxygen delivered (DO2) via arterial blood is about 1,000 mL/min. a) Tissues extract about 250 mL/m2/min of this. b) After gas exchange at capillary bed, about 750 mL/m2/min returned to venous blood. c) Normal oxygen saturation of venous blood (S V 02) about 60–80%. 2. Increased oxygen consumption means decreased venous oxygen return (S V 02). 3. S V 02 monitored at bedside with thermodilution fiberoptic catheter. G. Harris-Benedict equation 1. One of more commonly used formulas for resting energy expenditure 2. Male: 66 + (13.7 × weight kg) + (5.0 (height) cm) – (6.8 × age) 3. Female: 665 + (9.6 × weight kg) + (1.8 × height cm) – (4.7 × age)
4. Assumes person is in ideal weight range; if not, adjusted weight equation: a) Adjusted weight = (Actual weight – ideal weight) × 0.25 + Ideal weight 5. Stress factors added to adjust for metabolic changes in stress
PowerPoint Slides 1. Healthy Individual 2. Oxygen Consumption and Energy Expenditure 3. BOX 30-2 Fick Equation for Oxygen Consumption 4. Oxygen Extraction 5. Harris-Benedict Equation
VII. Chapter Summary VIII. Clinical Reasoning Checkpoint IX. Posttest X. References
Suggestions for Classroom Activities • Assign students into small work groups of three to four. Ask each student to develop two nursing diagnoses for the patient experiencing neutropenia. Also ask for each student group to list three interventions. After allowing a brief work time, bring the groups together and ask the groups to discuss their work. Compare the findings. • Have students divide into groups of at least four students each, and assign each group a diagnosis contained within Module 7. The group will list presenting signs and symptoms seen in a patient with the assigned diagnosis, develop at least one nursing diagnosis with appropriate interventions, and present the information to the class.
Suggestions for Clinical Activities • After providing care to patients with one of the diagnoses discussed in Module 7, ask the clinical group to compare information in the text with that for the real patient situation seen in clinical. Does the patient have all the symptoms as described in the text? What treatments are different from those suggested in the text? • Ask a nurse from the oncology unit to speak to the clinical group. Ask the speaker to discuss the care and treatment of patients experiencing immunosuppression.
CHAPTER
31
Metabolic Response to Stress
Learning Outcomes: 1. Examine the neuroendocrine response of the hypothalamic-pituitary-adrenal axis, thyroid, pancreas, and liver to acute and prolonged stress from critical illness. 2. Demonstrate knowledge of the diagnosis and collaborative management of adrenal dysfunction in critical illness. 3. Demonstrate clinical judgment and critical thinking around the diagnosis and collaborative management of thyroid dysfunction in critical illness. 4. Examine the evidence base supporting the collaborative management of hyperglycemic syndromes during critical illness.
I. Introduction to Responses to Stress in Acute and Critical Illness A. Neuroendocrine stress response 1. “Fight or flight” response activates: hypothalamic-pituitary-adrenal axis, thyroid system, pancreatic systems 2. Acute response: rapid release of catecholamines a) Epinephrine: a.k.a. adrenalin b) Norepinephrine 3. Hypothalamic-pituitary-adrenal axis a) Integrated negative feedback hormone mechanism. b) Hypothalamus secretes corticotropin-releasing hormone (CRH) → anterior pituitary secretes adrenocorticotropic hormone (ACTH) → adrenal cortex secretes cortisol. (1) With cortisol rise, hypothalamus reduces CRH. c) Cortisol: makes energy available, increases glucose circulation level, increases serum sodium, increases insulin resistance. d) Hypothalamus stimulates posterior pituitary to release antidiuretic hormone (ADH), anabolic growth hormone (GH), endogenous opioids: (1) ADH and catecholamines: increase heart rate, raise blood pressure (2) GH: protein used for tissue repair (3) Endogenous opioids: analgesia e) Adrenal dysfunction common in critical illness: (1) Elevated cortisol level, decreased corticotropin or GH
B. Liver, pancreas, thyroid gland function impaired during prolonged stress 1. Insulin resistance common, can lead to hyperglycemia. 2. Levels of circulating thyroid hormone decrease, thyroid stimulating hormone secretion suppressed: a) Associated with poor prognosis C. The metabolic stress response 1. Ebb phase a) Lasts about 24 hours after tissue injury b) Metabolic rate unchanged or slightly decreased (1) Exception: burns, severe head injury c) Hyperglycemia from increased glucose production (for wound healing), insulin resistance in peripheral tissues d) Controversy regarding providing nutrition (1) Arguments of risk of hemodynamic instability are unsupported. (2) Benefits: decreased hypermetabolic response, better nutritional outcomes. (3) Disadvantages: associated with more severe infections. e) Fat stores oxidized for energy needs (1) Lactate levels increase, contribute to hyperglycemia. 2. Flow phase a) Increased oxygen and calorie demands for wound healing b) Symptoms: tachycardia, tachypnea, increased cardiac output, fever c) Hypermetabolism: increased oxygen consumption and energy expenditure and hypercatabolism (1) Peak usually 3–4 days following event (2) Lasts about 7–10 days in patient without complications (3) In high-acuity patient, usually complications (a) Adequate nutritional support essential
PowerPoint Slides 1. Neuroendocrine Stress Response 2. Hypothalamic-Pituitary-Adrenal Axis 3. Prolonged Stress 4. Metabolic Stress Response 5. Metabolic Stress Response 6. TABLE 31-2: Summary of Hypermetabolism
II. Acute Adrenal Insufficiency During Critical Illness A. Types of adrenal insufficiency 1. Primary or secondary disorder 2. From preexisting chronic disease or acute conditions 3. May be caused by insufficiency of cortisol or aldosterone a) Usually reverses with recovery from illness
3.
B. Signs and symptoms of adrenal insufficiency 1. Recognition difficult 2. Alterations in vital signs, GI symptoms, abnormal lab values a) Increased serum creatinine and blood urea nitrogen (BUN) b) Unspecific lab values, overlap with other critical illnesses If caused by adrenal hemorrhage: back, flank, abdominal pain 4. Hypotension that does not respond to fluid resuscitation and vasopressor agents C. Evaluation of adrenal insufficiency 1. Diagnostic test: rapid ACTH stimulation test with baseline serum cortisol levels a) If abnormal, plasma ACTH levels drawn to differentiate primary (ACTH levels elevated) versus secondary (ACTH levels normal or low) D. Diagnostic criteria for adrenal insufficiency 1. Very low (<3mcg/dL) baseline plasma cortisol with critical illness 2. Low (15 mcg/dL) cortisol with hypotension and refractory shock 3. Cortisol >23 mcg/dL rules it out 4. After synthetic ACTH, cortisol increase < 9 mcg/dL E. Treatment 1. Hydrocortisone, drug of choice a) If status improves, continue drug for up to 7 days 2. Patients with persistent cases, critical illness, oral steroid therapy
PowerPoint Slides 1. Types of Adrenal Insufficiency 2. TABLE 31-3: Chronic and Acute Conditions that Cause Adrenal Insufficiency 3. Signs/Symptoms of Adrenal Insufficiency 4. TABLE 31-4 Clinical Manifestations Suggesting Adrenal Insufficiency 5. Evaluation of Adrenal Insufficiency 6. Treatment of Adrenal Insufficiency
III. Thyroid Dysfunction During Critical Illness A. Can develop as primary or secondary disorder B. Thyroid hormones 1. Regulates metabolic rate, increases myocardial contractility, heart rate, regulates systemic vascular resistance (SVR) 2. T4 (levothyroxine) and T3 (triiodothyronine) stored as thyroglobulin a) T3: active form b) T4: exerts little metabolic activity, pro-hormone c) T4 converted to T3 in peripheral tissues 3. Regulated by: hypothalamus secretes thyrototropin-regulating hormone (TRH), stimulates anterior pituitary to release thryotropin-regulating hormone (TRH) C. Primary hyperthyroidism and hypothyroidism 1. Hyperthyroidism: overproduction of thyroid hormones a) Causes: autoimmune disorders b) Symptoms: from systemic increases in metabolic functions 2. Hyperthyroid crisis/thyroid (thyrotoxic) storm: severe exacerbation of hyperthyroid symptoms a) Precipitated by acute illness, infection, withdrawal of antithyroid medications, surgery b) Severe agitation, high fever, tachyarrhythmias, heart failure, can progress to shock, coma, death c) Treatment: decrease thyroid hormone production; inhibit conversion of T4 to T3; block effects d) Supportive care: treatment of fever, fluid resuscitation, nutritional support 3. Hypothyroidism: deficiency of thyroid hormone a) Causes: iodine deficiency, autoimmune disease, overtreatment of hyperthyroidism b) Slowing of metabolism, systemic reduction in body functions c) At increased risk for hyponatremia d) May be increased risk of adrenal insufficiency with thyroid hormone replacement e) Hypothyroid crisis/myxedema coma: extreme case (1) Altered mental status ranging from lethargy to psychosis, hypothermia, bradycardia, hypotension, hypoventilation, hyponatremia, hypoglycemia (2) Physiological stress from acute illness, cold temperature, sedative drugs in those with hypothyroidism (3) Can lead to severe ileus, respiratory failure, heart failure, coma (4) Treatment: IV thyroid hormone, supportive treatment for symptoms, assess adrenal function D. Non-thyroid illness syndrome (NTIS) 1. Abnormal thyroid findings with absence of underlying thyroid disease 2. Most common thyroid dysfunction in critically ill population
3. Decreased T3 levels, normal T4 and TSH levels; in severe critical illness, T4 may drop too a) Directly from illness, drugs, abnormal glucocorticoid levels 4. Laboratory assessment a) Thyroid function tests may not be diagnostic. b) Tests for T3, T4, and TSH levels. 5. Treatment considerations a) Thyroid hormone replacement NOT beneficial b) Assess for primary thyroid dysfunction c) Endocrine consultation helpful
PowerPoint Slides 1. Thyroid Hormones 2. Primary Hyperthyroidism 3. Hypothyroidism 4. TABLE 31-5 Comparison of Characteristics of Hypothyroidism and Hyperthyroidism 5. Non-Thyroid Illness Syndrome (NTIS)
IV. Hyperglycemia Syndromes in the High-Acuity Patient A. Normal blood glucose: 70–110 mg/dL, not over 200 mg/dL B. Occurs with insulin resistance (type 2 diabetes, critical illness) and release of circulating hormones and inflammatory mediators 1. In critical illness: increased cortisol from stress response, pro-inflammatory mediators released by endothelial system from stress response, glucocorticoid therapy, excessive caloric intake with immobility C. Risks: poor wound healing, impaired immune response to infection, increased inflammation, endothelial dysfunction 1. Risk for illness and death
3.
D. Hyperglycemia and patient outcomes: the evidence 1. Marker of severity of illness, associated with worse patient outcomes 2. Unclear whether measures to control it improve patient outcomes a) Some studies show intensive glucose control beneficial, others do not In critically ill patients, IV insulin therapy for persistent hyperglycemia a) maintain blood glucose at 140-10 mg/dL E. Prevention of insulin-induced hypoglycemia 1. Insulin “drip” or continuous infusions a) Hourly blood glucose measurement, hand-held device measures finger stick of drop of blood b) Serial tests with venipuncture, minimum every 12 hours c) Administer source of glucose with nutrition d) Follow protocol for transitioning patients from drip to subcutaneous infusion
F. Hyperglycemic syndromes: collaborative management 1. Diabetic ketoacidosis (DKA): metabolic acidosis, excess ketone production 2. Hyperglycemic hyperosmolar state (HHS) 3. Both conditions: hyperosmolality, osmotic diuresis, fluid and electrolyte imbalance, dehydration 4. Assess mental status, volume status, CBC, electrolytes, renal function, blood glucose, serum ketones, arterial blood gas, cultures to determine source of infection 5. Treatment goals: restore fluid and electrolyte balance; IV insulin; identify causative factors
PowerPoint Slides 1. Hyperglycemia 2. Hyperglycemia • Risks 3. Hyperglycemic Syndromes
V. Chapter Summary VI. Clinical Reasoning Checkpoint VII. Posttest VIII. References
Suggestions for Classroom Activities • Provide models or diagrams to illustrate the differences between TPN and PPN catheters. • Ask small student groups to prepare teaching plans for patients receiving TPN, PPN, and fat emulsions, including advantages and rationale for each topic.
Suggestions for Clinical Activities • Assign students to care for patients with TPN or PPN to enable them to identify potential complications for each patient and how to prevent the complications. • Ask students to compute calorie and nutritional requirements of patients receiving TPN and PPN with patients on oral feedings.
CHAPTER
32
Diabetic Crises
Learning Outcomes: 1. Differentiate the two major types of diabetes mellitus and the effects of insulin deficit on the body. 2. Discuss the precipitating factors, pathophysiology, clinical presentation, and collaborative management of hypoglycemic crisis. 3. Describe the precipitating factors, pathophysiology, and clinical presentation of diabetic ketoacidosis. 4. Discuss the precipitating factors, pathophysiology, and clinical presentation of hyperglycemic hyperosmolar state. 5. Apply knowledge of the collaborative management to the patient experiencing a hyperglycemic crisis. 6. Explain the use of exogenous insulin therapy as a treatment strategy for management of the patient with hyperglycemic crisis and the use of insulin for glycemic control in the critical care patient. 7. Demonstrate an understanding of the acute care nursing implications of caring for the diabetic patient with chronic diabetes complications.
I. Review of Diabetes Mellitus and Insulin Deficit A. Complex metabolic disorder: insulin deficit with insulin resistance B. Types of Diabetes Mellitus 1. Type 1 Diabetes Mellitus a) Absolute lack of endogenous insulin b) Caused by destruction of the pancreatic beta cells of autoimmune or idiopathic origin c) Develops before age 30, 5–10% all DM cases d) Risk factors: family history and leukocyte antigen (HLA) genotype with trigger (viral, chemical, environmental) e) Treatment: replacement insulin therapy and dietary management 2. Type 2 Diabetes Mellitus a) Set of disorders including: insulin resistance, increased glucose production by liver, impaired insulin secretion, abnormal fat metabolism b) 90–95% of all U.S. DM cases c) Usually diagnosed after age 30, increasingly found in children and adolescents
d) Risk factors: hereditary tendencies concurrent with obesity, history of impaired metabolism, older age, race (black), ethnicity (Hispanic), and physical inactivity e) Primary Treatment: weight loss, dietary management, and healthy life-style changes C. Effects of Insulin Deficit 1. Can lead to hyperglycemic diabetic crises 2. Insulin deficit and carbohydrate metabolism a) Impaired cellular uptake and use of glucose b) Causes hyperglycemia (rapid increase of serum glucose by liver) (1) Conversion of glycogen to glucose (2) Increased gluconeogenesis (production of glucose from noncarbohydrate sources) c) Insulin-dependent cells cannot access potential energy; resort first to fatty acids, then amino acids d) Uncontrolled hyperglycemia may lead to elevated ketone bodies (ketosis) and elevated blood amino acids (aminoacidemia) 3. Insulin deficit and fat metabolism a) Increased lipolysis (fat breakdown) of stored triglycerides by lipase due to decreased availability of intracellular glucose (1) Evidence: increased blood levels of free fatty acids and glycerol (2) Liver converts excess fatty acids into cholesterol and phospholipids causing increased levels of acetyl-CoA used by liver for energy (3) Excess converted into acetoacetic acid, which converts into β-hydroxybutyric acid and acetone (all three are ketone bodies when in circulation) b) Clinical consequence: ketosis; increase of ketone bodies potentially resulting in severe metabolic acidosis and coma (e.g., diabetic ketoacidosis) c) Evidence of use of fat as energy: increase in plasma lipoproteins (up to three times normal) d) Long-term effects: rapid onset of atherosclerosis especially when concurrent with high cholesterol (1) Complications of DM are often secondary to atherosclerotic changes 4. Insulin deficit and protein metabolism a) Protein cannot be stored, cessation of protein synthesis b) Increase in protein catabolism, large quantities of amino acid move into circulation (1) Amino acids used as energy source or in gluconeogenesis c) Clinical consequence of protein catabolism: muscle wasting, multiple organ dysfunction, aminoacidemia, increased urine nitrogen, altered level of consciousness d) As gluconeogenesis is initiated, hyperglycemia is aggravated 5. Insulin deficit and fluid and electrolyte balance a) Increased plasma osmotic pressure, body fluids shift from tissues to the intravascular compartment (1) Result: extracellular and intracellular dehydration
(2) Glycosuria; polyuria (from osmotic diuresis produced by hyperglycemia); polydipsia develop b) Electrolyte imbalance: excessive loss of water, potassium, sodium, chloride, and phosphate ions cause weakness and fatigue c) Circulatory failure may arise from critically low cardiac output (CO) (1) Results in poor tissue perfusion; cerebral hypoxia occurs (2) Hypotension: decreased renal perfusion and potential acute kidney failure (3) Fatal if adequate CO not reestablished quickly
PowerPoint Slides 1. Diabetes Mellitus 2. Type I 3. Type 2 4. Insulin Deficit: Carbohydrate Metabolism 5. Insulin Deficit: Fat Metabolism 6. Insulin Deficit: Protein Metabolism 7. Insulin Deficit: Fluid and Electrolyte Balance
II. Hypoglycemic Crisis A. Abnormally low blood glucose level potentially occurring with any type of diabetes, most commonly caused by excessive administration of insulin or oral antidiabetes agents B. Clinical diagnosis and presentation 1. Occurs from excess of insulin in the blood and results in low blood glucose levels. 2. Onset of symptoms is usually rapid, reflect sympathetic nervous system (SNS) and catecholamine effects. 3. Severe hypoglycemia: stuporous or comatose state may result (hypoglycemic coma), irreversible brain damage and death. 4. Treatment: rapid recognition, administration of glucose. 5. SNS Effects: a) Reflect the inability of brain cells to function normally without glucose energy source. b) Diminished cognitive abilities and altered balance and coordination occur. 6. Catecholamine Effects a) Lack of glucose triggers secretion of stress hormones. b) Glucose production from alternate body sources. c) Increase in hormone epinephrine (a catecholamine), which triggers “fight-or-flight” symptoms. 7. Hypoglycemia Unawareness a) A blunted response to hypoglycemia with absolute insulin deficiency.
b) Glucose levels fall, insulin secretion is not suppressed, glucagon is not secreted, and epinephrine secretion is not suppressed as normal. c) Especially life-threatening when intensive insulin therapy (ITT) is being used to regulate serum glucose levels. d) Recommendation by American Diabetes Association: reset target level for glycemic control to higher range in patients with history of sever hypoglycemia or hypoglycemic unawareness. C. Other determinants of hypoglycemic symptoms 1. Rate of onset: rapid a) Predominance of SNS symptoms b) Secretion of epinephrine causes gluconeogenesis in the liver: increase in serum glucose level c) Growth hormone and cortisol secreted to increase glucose levels by decreasing glucose use by cells 2. Rate of onset: slow a) Body adapts to slow decline in blood glucose. b) Brain is not insulin dependent and takes in glucose directly. c) SNS symptoms caused by lack of available glucose. d) Brain can sustain minor or severe permanent damage. 3. The influence of age a) Elderly: more severe symptoms, symptomatic at higher serum glucose levels. b) SNS (cognitive) symptoms may be misdiagnosed for dementia when onset is slow. D. Collaborative interventions 1. Goal of intervention: rapid restoration of intravascular fluid levels and normal serum glucose levels 2. Interventions for adult with diabetes and acute onset of mental alterations or hypoglycemia: a) Evaluate ABCs (airway, breathing, and circulation) b) Reposition unconscious patients to side-lying position c) Obtain STAT blood glucose level 3. The alert hypoglycemic patient a) Use high glucose content food or glucose replacement product to orally administer glucose replacement 4. The unconscious hypoglycemic patient a) Emergency glucose therapy: intravenous dextrose b) Glucagon can be substituted in absence of IV access (1) Longer onset time (2) Ineffective if glycogen stores have been depleted
PowerPoint Slides 1. Clinical Diagnosis and Presentation 2. TABLE 32-2: Hypoglycemia Levels of Security
3. Collaborative Interventions 4. Collaborative Interventions
III. Hyperglycemic Crises: Diabetic Ketoacidosis (DKA) A. Most common crises associated with high serum glucose levels 1. Results from deficiency and resistance to insulin 2. Characterized by ketosis, metabolic acidosis, uncontrolled hyperglycemia 3. Mortality rate less than 1% amongst adults B. Patient profile and precipitating factors 1. Patient profile a) Most common with type 1 diabetes b) Less than 45 years old, nonwhite, and female (though almost equal distribution amongst males) 2. Precipitating factors a) Insufficient insulin therapy coverage, infection, stroke, myocardial infarction, trauma, alcohol abuse, certain drugs b) New onset type 1 diabetes, omission of exogenous insulin in diagnosed type 1 individuals c) Unprovoked DKA: 20% of cases no precipitating event found d) Infection and stress (1) Infection is most common precipitating factor. (2) Increase gluconeogenesis, epinephrine, and norepinephrine (and glycogenolysis as a result). (3) Increase stress hormones (epinephrine, growth hormone, cortisol); increase blood glucose, precipitating an imbalance in glucose/insulin relationship. (4) If fever occurs, metabolic rate increases, thus increasing cellular need for insulin: (a) Increased production of glucose and increased need does not result in balance, but an increase in circulating glucose while cells become starved. (b) Balance only regained when sufficient exogenous insulin is made available to meet the increased glucose needs of the cells. (5) Type 2 diabetes: high stress situations (e.g., infection, trauma, surgery) may trigger DKA (a) Insulin secretion insufficient to meet the increased supply of and demand for glucose, creating a relative endogenous insulin deficiency (b) Treatment: temporary exogenous insulin therapy C. Pathophysiologic basis of DKA 1. Hyperglycemia a) Results from deficit in insulin. b) Glucose is unused by cells and circulates and accumulates, increasing serum glucose levels. c) Fat used as energy source, conversion of glycose to glucose (glycogenolysis) occurs, and hyperglycemia worsens.
2. Ketosis a) Use of fat as energy source produces free fatty acids (FFAs), producing needed energy, and acidic ketone bodies. b) Acetone: contained in ketone bodies excreted by lungs (ketone breath) and the kidneys (ketonuria). 3. Metabolic acidosis (high anion gap type) a) pH decreases as a result of circulating ketone bodies. b) pH<7.2 respiratory center excretes carbonic acid and water (Kussmaul breathing). c) Body conserves and secretes bicarbonate to compensate for ketosis, eventually becoming exhausted by prolonged acidosis; clinically evidenced by drop in serum bicarbonate and further lowering of pH. d) Measure anion gap: the level of unmeasurable anion excess in body
(
) (
)
(1) Anion gap = Na + + K + − Cl− + HCO−3 ; normal range: 10–17 mEq/L (2) Normal anion gap acidosis (loss of bicarbonate ions) (3) High anion gap acidosis (accumulation of fixed acids in the serum) (a) Greater than 17 mEq/L: accumulation of unmeasured anions: immediate medical attention; possible causes: starvation, lactic acidosis, and DKA (4) Anion gap calculation performed to use as adjunctive data for differential diagnosis of DKA; not specific to DKA 4. Osmotic diuresis a) Increased intravascular osmotic pressure b) Kidneys respond to increase excretion of glucose and urine: increased loss of electrolytes, hemoconcentration, increasing dehydration, and a drop in blood pressure c) Renin–angiotensin–aldosterone system (RAAS) activated: increases sodium and water reabsorption d) Antidiuretic hormone (ADH) secreted by the posterior pituitary: retention of water and sodium e) Compensatory vasoconstriction: renal blood flow limitation, which controls urine output; increased blood pressure, pulse, and respirations 5. Prolonged or severe DKA: patient decompensates: exhaustion of compensatory mechanisms a) Cardiovascular failure and death; consciousness deteriorates, blood pressure and pulse can no longer maintain adequate organ perfusion, body cannot maintain peripheral vasoconstriction due to exhausted supply of catecholamines, kidneys fail as a result of hypoperfusion 6. Laboratory parameters a) Standard parameters: serum glucose, ketones (acetone and acetoacetate), arterial blood gases (pH and bicarbonate), and serum electrolytes (particularly potassium). b) Complete blood cell count (CBC) with focus on WBC count since infection often precipitates hyperglycemic crisis. c) Leukocytosis (10,000–15,000 mm3) expected during hyperglycemic crises related to an increase in circulating proinflammatory factors.
d) Additional parameters: serum osmolality, anion gap, blood urea nitrogen (BUN), free fatty acids, and serum β-hydroxybutyrate. e) Stress hormone levels (e.g., cortisol, human growth hormone, and catecholamines).
PowerPoint Slides 1. Patient Profile and Precipitating Factors 2. Pathophysiology of DKA 3. Prolonged or Severe DKA 4. TABLE 32-8 Levels of Severity of Diabetic Ketoacidosis 5. Laboratory Parameters
IV. Hyperglycemic Crises: Hyperglycemic Hyperosmolar State A. HSS: hyperglycemic complication of diabetes; less common, higher mortality and slower onset than DKA B. Patient profile and precipitating factors 1. Elderly with new onset or previously undiagnosed type 2 diabetes 2. Underlying diseases; often debilitated physically and/or mentally: misunderstood for dementia 3. Frequently residing in long-term care facility without easy access to fluids 4. Precipitating factors like DKA; infection leading trigger C. Pathophysiologic basis of HHS 1. Extreme hyperglycemia: worse in HHS than DKA; usually over 600 mg/dL but may be in excess of 2,000 mg/dL a) Patient produces some insulin (type 2); relative lack caused by precipitating event (e.g., infection) causes accelerated hepatic gluconeogenesis and decreased peripheral glucose use 2. Osmotic diuresis: typically worse with HHS than DKA due to extreme hyperglycemia a) Excess glucose accumulates in extracellular space resulting in increase in osmolality: water is pulled from intracellular space to extracellular space. b) Renal threshold is exceeded: dehydration of intracellular and extracellular spaces and significant loss of electrolytes. 3. Neurological alterations a) More severe neurologic signs than DKA (stupor, coma, seizures) changing over period of days b) Direct relationship between serum osmolality and level of consciousness c) Hyperosmolar coma: serum osmolality of 320 mOsm/L or higher 4. Absence of ketoacidosis a) Pancreas produces sufficient insulin to minimize lipolysis and formation of ketone bodies; yet not sufficient to prevent increasing serum glucose levels. D. Clinical presentation 1. Important to use diagnostic criteria to differentiate between DKA and HHS
PowerPoint Slides 1. Hyperglycemic Hyperosmolar State (HSS) 2. Patient Profile and Precipitating Factors 3. Pathophysiology of HHS
V. Management of Hyperglycemic Crises A. Same protocol for management of HHS and DKA B. Collaborative interventions 1. Recommendations regarding IV fluids, insulin therapy, and electrolyte replacement 2. Treatment goals for hyperglycemic crisis a) Restore intravascular fluid volume (1) Highest priority, initial fluid replacement will be with one-half normal (0.45%) or normal (0.9%) saline, once glucose serum levels reach 200 mg/dL, IV fluids containing glucose replace normal saline intravenous fluids. b) Correct electrolyte imbalances (1) Major electrolytes requiring replacement during DKA: potassium, sodium, and phosphate c) Clear ketones and correct acidosis (1) Insulin, electrolyte therapy, and IV fluid replacement (2) Severe cases arterial pH is 6.9 or less: treat with sodium bicarbonate; controversial because too rapid correction of ketoacidosis can precipitate cerebrospinal fluid (CSF) acidosis with potentially severe neurologic complications d) Normalize serum glucose (1) IV insulin used to correct hyperglycemic state. (2) During crisis state: use short-acting insulin due to rapid onset and short half-life, facilitating better titration control and rapid reduction of glucose levels. (3) Insulin orders change as glucose levels approach normal and ketosis is resolved. (4) Monitor for development of hypoglycemia. e) Closely monitor patient’s status (1) Initial: frequent monitoring of serum pH, glucose, ketone bodies (e.g., acetone and β-hydroxybutyrate), osmolality, and electrolytes (2) Electrocardiogram (ECG) and cardiac monitoring: effects of serum potassium on heart (3) Culture and gram stain of potentially infected secretions to inform antibiotic treatment (4) Frequent blood samples for serum analysis f) Identify precipitating cause (1) Treat precipitating cause (infection, wound); diabetes makes healing difficult only worsening infection; potential for sepsis (2) History and physical assessment obtained g) Prevent further complications (1) Obtain information on chronic medical conditions and current medication regimen that may impact the hyperglycemic crisis therapeutic plan
C. Nursing considerations 1. Fluid volume deficit a) Assess for signs and symptoms of fluid volume deficit; report abnormalities b) Monitor hemodynamic status: pulmonary artery pressure, pulmonary artery wedge pressure, and central venous pressure c) Monitor laboratory and other test results: blood urea nitrogen (BUN) and creatinine, electrolytes, hemoglobin, and hematocrit d) Monitor for therapeutic and nontherapeutic effects of fluid replacement therapy e) When taking oral fluids, force fluids if status permits 2. Altered nutrition: less than body requirements a) Monitor for: therapeutic and nontherapeutic effects of insulin therapy; dietary intake. b) Monitor laboratory tests: serum glucose, ketones, albumin, transferrin, CBC. c) Encourage intake of prescribed diet. d) Avoid painful procedures immediately before meals or feedings. e) Administer pain medications before meals, when needed; assess effectiveness of PRN pain medications. f) Implement measures to reduce energy requirements. 3. Collaborative intervention: electrolyte imbalances: metabolic acidosis (specific to DKA) a) Assess for signs and symptoms of electrolyte imbalances and metabolic acidosis b) Monitor laboratory (e.g., serum electrolytes) and other test results c) Monitor for therapeutic and nontherapeutic effects of drug therapy d) Monitor ECG for changes consistent with electrolyte imbalance e) Encourage intake of appropriate nutrients and restrict intake of undesirable nutrients based on electrolyte levels f) Encourage intake of fluids if fluid volume deficit exists
PowerPoint Slides 1. Management 2. Nursing Considerations
VI. Insulin Therapy During the Crisis A. Key part of emergency treatment strategy for hyperglycemic crisis B. Continuous low-dose intravenous insulin infusion 1. Provides better control of glucose levels than large dose 2. Fewer complications of hypokalemia and hypoglycemia; rapid rate of insulin dissipation 3. Only regular insulin administered; binds to polyvinylchloride in IV bags and tubing, lowering the insulin concentration in the fluid, Velosulin buffered with phosphate, which prevents the insulin from binding to plastic tubing, monitor glucose at least hourly to prevent hypoglycemia C. Subcutaneous insulin in DKA 1. Rapid acting; administered in mild-to-moderate uncomplicated DKA
2. Injections every one to two hours until glucose normalized D. Sliding-scale insulin administration 1. Physiologic stress may cause extremely unstable glucose levels in both type 1 and type 2 2. Based on blood glucose levels, not urine; insulin adjusted, or titrated to specific insulin levels E. Intensive insulin therapy (ITT) 1. Continuous intravenous insulin therapy followed by subcutaneous insulin injections 2. Labor intensive, frequent monitoring of blood glucose levels, titrating the insulin infusion according protocol, monitoring patient for development of hypoglycemia 3. Treats stress hyperglycemia in critically ill diabetic and nondiabetic patients 4. Cardioprotective effects: positive inotropic, anti-inflammatory, antioxidant, vascular benefits 5. No universally accepted titration algorithm; tight glycemic control (target glucose less than 110 mg/dL), less restrictive glycemic control (target glucose less than 180 mg/dL)
PowerPoint Slides 1. Continuous Low-Dose IV Insulin Infusion 2. Subcutaneous Insulin in DKA 3. Sliding-Scale Insulin Administration 4. TABLE 32-10 Example of Sliding-Scale Insulin Regimen 5. Intensive Insulin Therapy
VII. Acute Care Implications of Chronic Complications A. Many acute and chronic complications can result from diabetes: broad implications for nursing care regardless of primary diagnosis. B. Underlying chronic pathologic processes: peripheral neuropathies, microvascular disease, and macrovascular disease; resulting in heart disease, stroke, hypertension, blindness, kidney disease, nervous system disease, and peripheral vascular disease (amputation) . C. Diabetic peripheral neuropathies: 1. Affect both type 1 and 2, complication occurring early in disease, alter sensory perception, causes pain and/or abnormal sensation 2. Loss of the ability to discriminate fine touch, decrease in proprioception, local anesthesia 3. Affects autonomic nervous system: increase in gut motility and diarrhea, postural hypotension 4. Poorly understood but possible causes: thickening vessel walls supplying peripheral nerves, segmental demyelinization, or accumulation of sorbitol affecting conduction 5. Neuropathies vary in type, severity, and clinical manifestations 6. Acute care implications a) Neuropathy may mask presence of injury or infection, must protect patient from injury since they cannot sense it (i.e., burns from heating pads) b) Reversible (glucose level balanced) or irreversible neuropathies
D. Microvascular disease 1. Microangiopathy (small blood vessel disease) occurs with microvascular disease (associated with capillary membrane thickening); degree of disease influences by duration of diabetes 2. Tissues become hypoperfused, organs become hypoxic and ischemic (leading to infarction (death of tissue) 3. Retinopathy a) Retinopathy secondary to diabetes responsible for significant portion of newly diagnosed blindness in U.S.; occurring in type 1 and type 2 b) Caused by microangiopathy of retina (1) Stage 1: increased capillary permeability, aneurysm formation, and hemorrhage (2) Stage 2: increasing retinal ischemia and eventual infarction, causing blindness c) Acute care implications (1) Acutely ill patient may have moderate to severe visual impairment and must be assessed to determine care management. (2) Blindness affects pupillary changes and neurological assessment. (3) Reorient and verbally explain critical care environment to visually impaired patients. 4. Nephropathy a) Glomerular basement membrane thickens: intracapillary glomerulosclerosis (hardening and thickening of the glomeruli) b) Glomeruli enlarge and eventually are destroyed: renal failure c) Decreased insulin dosage to prevent hypoglycemia: reduced renal function decreases ability of kidneys to metabolize insulin d) Acute care implications (1) Must regularly monitor kidney function especially in acutely ill patients with preexisting renal impairment, and alter drug therapy E. Macrovascular disease 1. Macrovascular disease (macroangiopathy) refers to atherosclerosis, a form of arteriosclerosis (thickening and hardening of medium and large arterial walls excluding arterioles) 2. Plaque deposits of lipids, fibrous connective tissue, calcium, and other blood substances 3. Associated with development of coronary artery disease, peripheral vascular disease, brain attack (stroke), and increased risk of infection 4. Associated more with type 2 diabetes 5. Peripheral vascular disease a) Decrease in blood flow to peripheral tissue b) Small arteries become occluded: precipitating a tissue ischemia/infarction sequence c) Gangrene in feet and toes; may necessitate amputation d) Acute care implications (1) Careful limb positioning, excellent skin hygiene, and close monitoring of skin integrity are extremely important to prevent development of decubitus ulcers and infection.
F. Increased risk of infection 1. Acutely ill diabetic patient may be admitted to hospital with infection or easily develop infection after hospitalization. 2. Acute care implications: a) Increased risk for severe, difficult-to-treat infections; minor infections may become lifethreatening. b) Decreased kidney function can be complicating factor in aggressive antibiotic therapy. c) Impaired tissue perfusion in extremities may impair wound healing due to lack of circulation and tissue hypoxia. d) Hyperglycemia interferes with collagen concentrations in a wound, impairing healing.
PowerPoint Slides 1. Underlying Chronic Pathologic Process 2. Diabetic Peripheral Neuropathies 3. Microvascular Disease 4. Macrovascular Disease
VIII. Chapter Summary IX. Clinical Reasoning Checkpoint X. Posttest XI. References
Suggestions for Classroom Activities • Instruct each student to draw a rendition of the need and use of insulin by cells in the body. Ask the students to select the top three drawings for presentation to the class. • Divide the students into small groups of three or four. Instruct the groups to develop a teaching care plan for the patient with diabetic ketoacidosis. After the students have developed their plans, ask them to share their work with the class.
Suggestions for Clinical Acitivities • Assign the students to shadow a nurse performing an admission assessment of a diabetic patient. What types of questions are asked? What are the priorities for the patient’s plan of care? • Assign students to care for patients diagnosed with diabetes. After clinical, discuss the type of diabetes their assigned patient had. What characteristics did the patients have that were common in their disease type?
CHAPTER
33
Determinants and Assessment of Oxygenation
Objectives: 1. Explain the concept of oxygenation. 2. Discuss the process of pulmonary gas exchange. 3. Describe the physiologic components of oxygen delivery. 4. Describe oxygen consumption in terms of aerobic and anaerobic metabolism.
I. Introduction to Oxygenation A. Oxygenation: the use of oxygen for energy through aerobic metabolism 1. Oxidative phosphorylation: metabolic process used to obtain energy a) Mitochondria: organelles located within cells that produce energy for cells to carry out their activities b) Krebs (or citric acid) cycle: respiratory enzymes convert adenosine diphosphate (ADP) to ATP, the energy source 2. Oxygen supply: lungs, heart, and blood a) Ventilation: oxygen brought into internal environment via respiratory system 3. Physiologic components for the intake, delivery and use of oxygen a) Pulmonary gas exchange: inhalation of oxygen from external to internal environment (1) Uses ventilation, diffusion, and pulmonary perfusion b) Oxygen delivery (DO2): transportation of oxygen to the cells (1) Cardiac output, oxygen content of arterial blood, autoregulation, and autonomic nervous system innervation c) Oxygen consumption (VO2): use of oxygen at cellular level to generate energy for cells to perform specific functions 4. Impaired oxygenation: results from impaired pulmonary gas exchange, decreased oxygen delivery or impaired oxygen consumption 5. Assessment goals a) To determine the overall adequacy of oxygenation b) To determine which component of oxygenation dysfunction should be manipulated
PowerPoint Slides 1. Oxygenation 2. Oxidative Phosphorylation 3. Oxygen Supply 4. Physiologic Components 5. Impaired Oxygenation 6. Assessment goals
II. Pulmonary Gas Exchange A. Components of pulmonary gas exchange 1. Ventilation: movement of air between the atmosphere and the lungs a) Requires functioning of ventilatory muscles, thorax, lungs, conducting airways, and nervous system 2. Diffusion: movement of gas across a pressure gradient from an area of high concentration to one of low concentration a) Three factors affect diffusion across the alveolar–capillary membrane: pressure gradient, surface area, and thickness 3. Perfusion: oxygen binding to iron atoms in hemoglobin in red blood cells a) Affected by three factors: hemoglobin (Hb) concentration, affinity of oxygen to Hb, and blood flow B. Factors that impair pulmonary gas exchange 1. Conditions that produce ventilation-perfusion mismatching: a) Pulmonary embolus: decreases perfusion b) Pneumothorax: decreases ventilation 2. Can lead to: hypoxemia, can result in hypoxia C. Assessment of pulmonary gas exchange 1. Ventilation a) Auscultation of the lungs: detects change in airflow (1) Adventitious sounds can indicate: airway edema, bronchoconstriction, bronchospasm, airway obstruction, and airway fluid or secretions. (2) No lung sounds: airway may be sufficiently obstructed by any of these conditions. b) Measurement of carbon dioxide (CO2) (1) Ventilatory failure: PaCO2 greater than 50 mm Hg with a pH of less than 7.30 c) Pulmonary function tests (PFTs): evaluate respiratory muscle strength, endurance, efficiency (1) Tool for diagnosing pulmonary diseases, identifying and quantifying changing pulmonary status, and monitoring the effects of therapies. (2) Bedside tests include: tidal volume (VT), minute ventilation ( and maximum inspiratory pressure (MIP). 2. Estimation of intrapulmonary shunt
E), vital capacity (VC),
a) Intrapulmonary shunt: proportion of blood that flows past alveoli without participating in gas exchange b) Contributor to hypoxemia c) PaO2/FIO2 (P/F) ratio: measurement to estimate shunt
PowerPoint Slides 1. Components of Pulmonary Gas Exchange 2. Factors That Impair Pulmonary Gas Exchange 3. TABLE 33-2 Conditions that Impair Pulmonary Gas Exchange 4. Assessment of Pulmonary Gas Exchange 5. Assessment of Pulmonary Gas Exchange 6. Assessment of Pulmonary Gas Exchange 7. Assessment of Pulmonary Gas Exchange 8. Assessment of Pulmonary Gas Exchange 9. BOX 33-1 Assessment of Pulmonary Exchange
III. Oxygen Delivery (DO2) A. Components of oxygen delivery 1. Cardiac output (CO): the amount of blood pumped by the heart each minute a) Determining factors: heart rate and stroke volume (consisting of preload, afterload, and contractility) b) Calculating CO: CO = SV × HR 2. Autoregulation: the mechanism by which tissues regulate their own blood supply by dilating or constricting local blood vessels 3. Oxygen content of arterial blood (CaO2) a) Oxygen is carried in arterial blood in two forms: combined with hemoglobin or dissolved in the plasma. b) Total oxygen content in the blood manipulated by two interventions: administering red blood cells to increase hemoglobin or supplementing oxygen to increase SaO2 and PaO2. 4. Oxyhemoglobin (HbO2 or COHb): formed when hemoglobin is fully saturated with oxygen a) Condition or disease that decreases hemoglobin content severely decreases the amount of oxygen carried to the tissues. b) Condition that reduces the amount of available iron (e.g., iron-deficiency anemia) reduces oxygen-carrying capacity. 5. Automatic nervous system innervation: autonomic nervous system exerts partial control of oxygen delivery through excitatory or inhibitory effects on the heart, lungs, and blood vessels a) Drugs can manipulate receptors through mechanisms for action (e.g., adrenergic agonist drugs, adrenergic antagonist agents).
B. Factors that impair oxygen delivery 1. A decrease in heart function: dysrhythmias or heart failure 2. An uncompensated decrease in cardiac output, hemoglobin, or SaO2 3. Drugs that cause vasoconstriction (e.g., norepinephrine or vasopressin) or vasodilation (e.g., nitroglycerin) C. Assessment of oxygen delivery: direct (invasive or noninvasive technology) or indirect (focused cardiovascular assessment) 1. Assessing cardiac output a) Indirect measurement (1) Evaluation of heart rate, components of stroke volume (preload and afterload) (2) Check for cardiac ischemia or acute MI: can cause decreased contractility (3) Check level of consciousness (LOC): inadequate cardiac output reduces cerebral blood flow, results in reduction of LOC b) Direct measurement (1) Catheterization of the pulmonary artery: thermodilution methods (2) Measurements obtained from hemodynamic monitoring: heart pressures (e.g., pulmonary artery pressure and pulmonary artery wedge pressure, central venous pressure, cardiac output/cardiac index, and systemic vascular resistance [SVR]) (3) Impedance cardiography: measures CO and other hemodynamic parameters through highfrequency electrical current (4) Doppler echocardiography: measures blood flow velocity, determining CO, preload, afterload, and contractility through ultrasound 2. Assessing hemoglobin, PaO2 and SaO2 a) Direct measure of PaO2 and SaO2: obtained through arterial blood gas (ABG) b) Direct measure of hemoglobin: obtained as part of a complete blood cell count or separately, in a venous or capillary blood specimen c) Indirect measure of oxygen saturation (1) Pulse oximetry (SpO2): used for continuous (or intermittent) noninvasive measurement of arterial oxygenation saturation (2) Recommended for patients at risk for hypoxemia (3) Factors that can alter accuracy of SpO2: cardiac output, anemia (low Hb), HbCO, shock, vasoconstriction at the location of the sensor, and hypothermia 3. Calculating oxygen delivery (DO2) a) Not usually nurse’s responsibility b) Requires a CO measurement, serum hemoglobin analysis, and ABG analysis for SaO2 and PaO2
PowerPoint Slides 1. Components of Oxygen Delivery 2. Components of Oxygen Delivery
3. Components of Oxygen Delivery 4. Components of Oxygen Delivery 5. Components of Oxygen Delivery 6. Factors That Impair Oxygen Delivery 7. Assessment of Oxygen Delivery 8. Assessment of Oxygen Delivery 9. Assessment of Oxygen Delivery 10. Calculating Oxygen Delivery
IV. Oxygen Consumption (
O2 )
A. Oxygen extraction: the process of taking oxygen to the cells once it has been delivered to the tissuelevel circulation B. Aerobic metabolism: with oxygen, ingested carbohydrates, fats, and proteins are converted in the Krebs cycle into energy (ATP) 1. Byproducts: water and carbon dioxide C. Anaerobic metabolism: the process of producing small amounts of energy as backup in the absence of oxygen 1. Carbohydrates: only food substrate that can generate ATP without use of oxygen 2. Byproducts: pyruvate and lactate a) Accumulated lactate can lead to local tissue lactic acidosis (e.g., ischemic stroke). b) Global lactic acidosis: can result when a patient becomes globally hypoxic (e.g., cardiopulmonary arrest). D. Oxygen extraction: process by which cells take oxygen from the blood 1. 25% of oxygen is taken up by cells; 75% returns to the right side of the heart in venous circulation E. Oxyhemoglobin dissociation curve and oxygen extraction 1. Affinity: degree to which hemoglobin and oxygen are attracted 2. Oxyhemoglobin dissociation curve: represents relationship between oxyhemoglobin and PaO2 a) Left shift: increases the affinity of hemoglobin for oxygen and decreases the unloading of oxygen to the tissues (1) Physiologic factors: alkalosis, hypothermia, hypocapnia (decreased PaCO2), and decreased 2,3 DPG b) Right shift: results in decreased affinity of hemoglobin for oxygen, and oxygen is readily released from hemoglobin at the tissue level (1) Physiologic factors: acidosis, hyperthermia (fever), hypercapnia (elevated PaCO2), and increased 2,3 DPG c) Clinical implications (1) Curve shifts are significant if they are prolonged or severe due to factors that alter acid-base balance, body temperature, PaCO2, or 2,3 DPG.
(2) High acuity patients: right shift more common. (3) Body temperature can be controlled to reduce oxygen consumption. F. Factors that alter oxygen consumption 1. Nursing care (e.g., ventilator-related procedures, hygiene, and changing the patient’s position): increases oxygen consumption in critically ill patients G. Assessment of oxygen consumption: no physical assessment parameters to evaluate oxygen consumption, limited to indirect methods 1. Serum lactate levels: used as an indicator of improving or worsening oxygen delivery in relation to oxygen consumption a) Use with caution in patients with: cancer, liver failure, renal disease, and alcoholism 2. Base deficit: the amount of base (mmol) required to titrate one liter of arterial blood to a normal pH a) Approximates metabolic acidosis 3. Venous Oxygen Saturation (SvO2 and ScvO2): reflects oxygen extraction by the tissues and the balance between oxygen supply and oxygen demand a) Measuring SaO2 or SpO2: provides information about oxygen saturation of arterial blood b) The physiologic basis of SvO2: each organ system requires a different amount of oxygen, and extracts a percentage of the oxygen according to its metabolic rate c) The clinical significance of SvO2 (1) Adequate oxygen delivery to tissues: oxygen saturation of the blood in pulmonary artery will be 70% (2) Four factors that influence SvO2: SaO2, Hb, CO, and oxygen consumption (3) Treatment to increase SvO2: blood transfusion and inotropic drug therapy d) Measuring SvO2: provides information about oxygen saturation of venous blood, two ways to measure: (1) Mixed venous oxygen saturation (mixed SvO2): an average of the venous saturation of blood from all parts of the body (a) Measured by blood gas analysis of a mixed venous blood sample drawn from the distal port of a pulmonary artery catheter (b) Measured continuously through the use of a special fiber-optic pulmonary artery catheter (2) Central venous oxygen saturation (ScvO2): measures venous oxygen saturation only from the upper body, minimally invasive (a) Measured by obtaining a venous blood gas or with a special monitoring system
PowerPoint Slides 1. Oxygen Extraction 2. Aerobic Metabolism 3. Anaerobic Metabolism 4. Oxyhemoglobin Dissociation Curve
5. Oxyhemoglobin Dissociation Curve 6. TABLE 33–7 Conditions That Alter Oxygen Consumption 7. Factors That Alter Oxygen Consumption 8. TABLE 33-8 Activities That Increase Oxygen Consumption 9. Assessment of Oxygen Consumption 10. Venous Oxygen Saturation (SvO2 and ScvO2) 11. The Clinical Significance of SvO2 12. Measuring SvO2
V. Chapter Summary VI. Clinical Reasoning Checkpoint VII. Post Test VIII. References
Suggestions for Classroom Activities • Divide students into groups of three to four. Ask each group to develop five questions related to oxygen delivery and consumption. Allow only 10 minutes for this portion of the activity Next, allow the groups to share their questions with other groups for small study sessions. Ask each group to nominate what they feel is the best question from another group. Share these “challenge” questions with the entire class. • Create a case scenario for the patient experiencing impaired oxygen delivery disorders. Ask the class to develop a nursing care plan for this patient.
Suggestions for Clinical Activities • Assign students to care for patients with oxygen delivery or oxygen consumption alterations. Review the care of the assigned patients in class. • Review the arterial blood gas results of patients on the acute care unit. Ask students to make inferences about their conditions.
CHAPTER
34
Multiple Trauma
Objectives: 1. Discuss traumatic injury, including categories of injury and risk factors that influence injury patterns. 2. Describe blunt trauma, including its associated forces and the clinical assessment of a patient with blunt trauma. 3. Discuss penetrating trauma, including its associated forces and the clinical assessment of a patient with penetrating trauma. 4. Demonstrate an understanding of the mechanisms of injury and mediators of the response to injury when caring for a patient with traumatic injury. 5. Apply the clinical assessment format used to identify life-threatening injuries during the primary and secondary surveys of an injured patient. 6. Describe trauma resuscitation and nursing responsibilities based on the trimodal distribution of trauma-related mortalities. 7. Discuss the management of selected traumatic injuries, including chest, pulmonary, cardiac, abdominal, and pelvic. 8. Link posttrauma complications and interventions with the physiology of a traumatic injury and preexisting risk factors.
I. Overview of the Injured Patient A. Traumatic injury: injuries caused by kinetic energy B. Categories of kinetic injury 1. Blunt trauma 2. Penetrating trauma C. Risk factors for traumatic injury 1. Age 2. Gender 3. Alcohol use 4. Race, income, and geography
PowerPoint Slides 1. Traumatic Injury 2. Risk Factors for Traumatic Injury
II. Mechanism of Injury: Blunt Trauma A. Forces associated with blunt trauma 1. Shearing: two structures, or parts of the same structure slide in opposite directions or at different speeds 2. Acceleration and deceleration forces: velocity is the most significant determinant of the amount of injury sustained a) Deceleration: decrease in rate of velocity of moving object 3. Compression force: process of being pressed or squeezed together with a resulting reduction in volume or size B. Injuries associated with blunt trauma 1. Head injuries, spinal cord injuries, fractures, abdominal injuries 2. Tensile forces: stretch and extend tissue 3. Tensile strength: the greatest longitudinal stretch or stress tissue can stand without tearing
PowerPoint Slides 1. Forces Associated with Blunt Trauma 2. Injuries Associated with Blunt Trauma
III. Mechanism of Injury: Penetrating Trauma A. Forces associated with penetrating trauma 1. Kinetic energy available to be transmitted to tissues depends on: a) Surface area of the point of impact b) Density of the tissue c) Velocity of the projectile at the time of impact B. Low-to-medium-energy missiles: travel less than 2,000 feet per second C. High energy missiles (high velocity missiles): travel more than 2,000 feet per second 1. Cavitation: process where the transmission of kinetic energy displaces tissues forward and laterally to form a temporary cavity 2. “Blast effect”: the phenomenon of injury to structures outside the direct missile path D. Missile trajectory 1. Yaw: the deviation of a missile either horizontally or vertically about its axis 2. Tumble: the action of forward rotation around the center of a mass (somersaulting) E. Secondary missiles F. Injuries associated with penetrating trauma 1. Characteristics of a wound depend on velocity, cavitation, and blast effect
PowerPoint Slides 1. Forces Associated with Penetrating Trauma 2. Low-to-Medium-Energy Missiles 3. High-Energy Missiles (High Velocity Missiles) 4. Missile Trajectory 5. Secondary Missiles 6. Injuries Associated with Penetrating Trauma
IV. Mechanism of Injury Patterns and Mediators of Injury Response A. Mechanisms of injury and injury patterns: certain mechanisms result in predictable injury patterns 1. Pedestrian/motor vehicle injuries, motor vehicle driver and passenger injuries, fall injuries, and missile injuries B. Factors affecting the response to injury 1. Comorbidities (underlying medical conditions) 2. Substance abuse a) Defined according to following criteria within 12-month period: (1) Results in failing to meet major role obligations (2) Physically hazardous situations (e.g., driving, working with machinery) (3) Substance-abuse related legal problems (4) Continued substance use in the face of continuing interpersonal or social problems b) Blood alcohol concentration (BAC) c) History of alcohol abuse 3. Pregnancy a) Anatomic changes (1) Uterus enlarges in anterior abdomen and presses abdominal organs to a more posterior abdominal location. (2) Later pregnancy: uterus and fetus are at higher risk of injury. b) Hemodynamic changes (1) High-output, low-resistance hemodynamic state is characteristic in pregnancy. (2) Vena cava syndrome: profound hypotension when placed in the supine position. c) Blood volume and composition (1) Maternal blood volume increases by 50% at end of third trimester. (2) Physiological anemia results during pregnancy. 4. Advancing age a) Chance of traumatic injury increased due to delayed reaction times, disturbances of gait and balance, diminished visual acuity, and hearing loss b) Age-related deterioration in body systems c) Chronic disease states
(1) Most common: hypertension, heart disease, stroke, cancer, diabetes, chronic obstructive pulmonary disease (COPD), arthritis, and asthma d) Limited physiologic reserve (1) Cardiorespiratory changes: (2) Neurological changes (3) Musculoskeletal changes e) Shock
PowerPoint Slides 1. Mechanisms of Injury and Injury Patterns 2. Factors Affecting the Response to Injury
V. Primary and Secondary Surveys A. Primary survey: identify life-threatening injuries and intervene appropriately 1. A-Airway (with cervical spine immobilization): maintain open airway while protecting cervical spine a) Airway obstruction: tongue falling into oropharynx, blood, vomiting, secretions, or foreign object b) Airway management techniques (1) Simple airways: chin lift or modified jaw thrust (2) Endotracheal intubation: orally or nasally (3) Surgical airway: needle cricothyroidotomy, surgical cricothyroidotomy, or tracheostomy 2. B-Breathing: assess adequacy of ventilation through look, listen, and feel parameters a) Evaluate Pao2 and Paco2 obtained from an arterial blood gas (ABG) b) Monitor end-tidal carbon dioxide and arterial oxygen saturation using noninvasive measures 3. C-Circulation: identify hypovolemia and search for etiology a) Assessment includes: (1) Palpate for strength, rate, rhythm, and symmetry of carotid, radial, femoral, and pedal pulses (2) Evaluate skin temperature (3) Evaluate capillary refill (4) Evaluate level of consciousness b) Shock from trauma: the consequence of insufficient tissue perfusion that results in inadequate cellular oxygenation and the accumulation of metabolic wastes (1) Exsanguination: most extreme form of hemorrhage 4. D-Disability: neurological disability a) APVU scale (1) A—alert (2) V—responds to verbal stimulation
(3) P—responds to painful stimulation (4) U—unresponsive 5. E-Exposure and evacuation: danger of hypothermia due to cold conditions B. The Secondary Survey: head-to-toe approach examining each body system
PowerPoint Slides 1. Primary Survey 2. A-Airway 3. B-Breathing 4. C-Circulation 5. D-Disability 6. E-Exposure and Evacuation 7. The Secondary Survey
VI. Trauma Resuscitation A. Trimodal distribution of trauma deaths: death from trauma has three peak periods of occurrence 1. First peak: within minutes of injury 2. Second peak: minutes or hours after arrival in emergency department, usually the result of blood loss 3. Third peak: days or weeks after injury, usually in ICU from complications of SIRS, MODS, or sepsis B. Trauma resuscitation 1. Hemorrhage is predominant cause of early postinjury deaths. 2. Most common cause of shock is hypovolemia resulting from acute blood loss. 3. Recognition of source of blood loss is critical. 4. Resuscitation of exsanguinating patient based on basic principles of circulation management. 5. Critical analysis of assessment data. 6. Quick recognition of traumatic shock. C.
End points of resuscitation 1. Goal is to treat shock. 2. Best indicators of adequate tissue perfusion in shock: traditional hemodynamic parameters, global parameters, and organ-specific parameters.
PowerPoint Slides 1. Trimodal Distribution of Trauma Deaths 2. Trauma Resuscitation 3. TABLE 34-3 Estimating Potential Blood Volume Loss 4. End Points of Resuscitation
VII. Management of Selected Injuries A. Chest injuries 1. Rib fractures: typically from blunt trauma a) Can develop atelectasis, at risk for pneumonia b) Pain management: nonsteroidal anti-inflammatory agents, intercostal nerve block, thoracic epidural analgesia, and narcotics c) Incentive spirometer 2. Flail chest: two or more rib fractures occur in two or more places a) Can develop hypoxemia. b) Signs include: uncoordinated, paradoxical movement of the flail portion of the chest wall, crepitus, and hypoxemia on blood gas. c) Treatment: stabilize breathing, prevent and treat hypoxemia, positive-pressure mechanical ventilation. B. Pulmonary injuries 1. Pulmonary contusions: can result from blunt trauma to lung parenchyma a) Bruising can lead to alveolar hemorrhage, edema, and inflammation within the lung. b) Chest X-rays to reveal pulmonary infiltrates. c) Treatment: improve gas exchange through deep breathing exercises, ambulation, and removal of secretions; intubation and mechanical ventilation may be required. 2. Tension pneumothorax: air leaks from the lungs or chest wall, can collapse the affected lung a) Clinical manifestations: chest pain, air hunger, respiratory distress, tachycardia, neck vein distention, trachea displaced from midline, and absent breath sounds on the affected side b) Pulsus paradoxus: paradoxical pulse 3. Open pneumothorax: penetrating chest wall injury that sucks air, causing intrathoracic pressure and atmospheric pressure to equilibrate a) Clinical manifestations same as tension pneumothorax b) Treatment: covering the wound with a sterile occlusive dressing taped on 3 sides, surgery may be required 4. Massive hemothorax: accumulation of more than 1,500 mL of blood in the chest cavity a) Caused by penetrating wound that disrupts great blood vessels b) Clinical manifestations: decreased breath sounds or dullness to percussion on the affected side and hypotension c) Treatment: restore blood volume and decompress the chest cavity with a chest tube, an autotransfusion device may be attached to the chest tube collection chamber, surgery may be required C. Cardiac injuries 1. Cardiac tamponade: causes pericardium to fill with blood, restricting heart’s ability to pump and impedes venous return a) Symptoms: Beck’s triad, pulsus paradoxus, pulseless electrical activity (PEA) b) Treatment: volume resusctation until percardiocentesis can be performed
2. Blunt cardiac injury: bruising of the myocardium a) Symptoms: chest discomfort, sinus tachycardia, hypotension, electrocardiogram (ECG) changes D. Abdominal injuries 1. Spleen injuries a) Organ most commonly injured from blunt trauma to abdomen b) Should be left to heal rather than removed c) Diagnosis: CT scan, monitor vital signs and hemocrit d) Splenectomy patients at risk for infections and require vaccinations 2. Liver injuries a) Majority are minor and don’t require surgery. b) Death is often result of hemorrhage. c) Medical management: hepatic arteriography, surgery. d) Hypovolemic shock: volume resuscitation, crystalloids and blood, correct coagulopathies with frozen plasma, platelets, or cryoprecipitate. 3. Damage control surgery a) Three phases: (1) Initial operation: control hemorrhage (2) Resuscitation: correct hypothermia, acidosis, coagulopathies (3) Definitive restoration b) Abdominal compartment syndrome (ACS): intra-abdominal hypertension (1) Symptoms: taut distended abdomen, decreased cardiac output, increased peak pulmonary pressures, decreased urine output E. Pelvic injuries 1. High risk for hemorrhage 2. Symptoms: perianal ecchymosis, pain on palpation or “rocking” of the iliac crests, hematuria, and lower extremity rotation or paresis 3. Diagnosis: CT scan 4. Initial management: prevention or treatment of life-threatening hemorrhage, stabilization with a pelvic binder or external fixation device, internal fixation 5. Nursing management: monitor for signs of continued hemorrhage and resuscitation with fluids, monitor the color, motion, and sensitivity of the bilateral lower extremities for signs of neurological or vascular compromise
PowerPoint Slides 1. Chest Injuries 2. Pulmonary Injuries 3. Cardiac Injuries 4. Abdominal Injuries
5. Abdominal Injuries: Damage-Control Surgery 6. Pelvic Injuries 7. Pelvic Injuries
VIII. Complications of Traumatic Injury A. Risks for complications 1. Thoracic trauma: high risk for DIC and ARDS 2. Abdominal trauma: high risk of hemorrhage, abdominal compartment syndrome, and infection 3. Orthopedic trauma: predisposes patient to VTE and prolonged immobility B.
Metabolic response to injury: risk for undernutrition 1. Ebb phase: first 3 days during acute resuscitation 2. Flow phase: characterized by hypermetabolic response a) Results in catabolism of lean body mass, negative nitrogen balance, and altered glucose metabolism C. Venous thromboembolism (VTE) 1. Encompasses deep vein thrombosis (DVT) and pulmonary embolism (PE) D. Sepsis 1. SIRS phenomenon in the presence of bloodborne infection 2. Septic shock: severe physiologic response to an infection that results in hemodynamic instability E. Acute respiratory distress syndrome (ARDS) 1. Presence of bilateral pulmonary infiltrates, a pulmonary artery wedge pressure (PAWP) of 18 mm Hg or less (in the absence of left atrial hypertension), and a Pao2/Fio2 ratio less than 200, regardless of the amount of positive end-expiratory pressure, or PEEP 2. Result of direct and indirect lung injury F. Disseminated intravascular coagulation (DIC) 1. Exaggerated response to a condition such as sepsis or multiple trauma that causes excessive clotting G. Acute kidney injury 1. Causes: acute tubular necrosis from renal hypoperfusion or toxin-mediated damage to the tubules
H.
Systemic inflammatory response syndrome (SIRS)/multiple organ dysfunction (MODS) 1. SIRS: pathophysiologic basis explains injury and failure of organs, leads to MODS 2. Risk factors: severe injury; massive volumes of fluid resuscitation, including blood products, crystalloids, and fresh-frozen plasma; multiple preexisting comorbidities, particularly liver disease; and development of significant shock I. Assessment and nursing diagnosis 1. Assessment data: Elevation of white blood cell count, fever, change in characteristics of wound drainage, decreasing oxygenation, decreasing level of responsiveness, decreased urine output,
diaphoresis, cool, mottled skin, presence of bleeding, changing trends in vital signs/hemodynamic readings 2. Ventilation a) Impaired gas exchange b) Ineffective breathing c) Ineffective airway clearance 3. Perfusion a) Fluid volume deficit related to vasodilation, bleeding, or interstitial fluid shift b) Decreased tissue perfusion related to capillary obstruction and vasoconstriction c) Increased cardiac output related to stress-response-related catecholamine release or increased systemic vascular resistance d) Decreased cardiac output related to decreased vascular volume or decreased systemic vascular resistance e) Altered urinary elimination patterns related to obstruction of renal blood flow or renal tissue necrosis f) Altered nutrition: less than body requirements related to catecholamine release, activation of inflammatory response resulting in a hypermetabolic state, and decreased or absent oral intake g) Risk of Infection J. Psychosocial nursing considerations 1. Susceptible to sensory disturbances, extensive rehabilitation, quality-of-life issues, financial factors affecting family’s standard of living
PowerPoint Slides 1. Risks for Complications 2. Metabolic Response to Injury 3. Venous Thromboembolism (VTE) 4. Sepsis 5. Acute Respiratory Distress Syndrome (ARDS) 6. Disseminated Intravascular Coagulation (DIC) 7. Acute Kidney Injury 8. Systemic Inflammatory Response Syndrome (SIRS)/Multiple Organ Dysfunction (MODS) 9. Assessment and Nursing Diagnosis 10. Psychosocial Nursing Considerations
IX. Chapter Summary X. Clinical Reasoning Checkpoint
XI. Post Test XII. References
Suggestions for Classroom Activities • Discuss the different forces associated with blunt trauma and the injuries caused by each. • Discuss the different mechanisms of injury, and the risk factors associated with different types of injury. • Discuss the linkages between posttrauma complications, physiology of a traumatic injury, and preexisting risk factors. Discuss interventions to prevent complications of traumatic injury. • Discuss mechanisms of injury and the types of injuries each of these mechanisms suggests for both blunt and penetrating injuries.
Suggestions for Clinical Activities • Visit an area trauma center. Discuss the different kinds of blunt trauma injuries and the different types of forces associated with each. • Visit a local area trauma unit. Discuss with nursing staff the linkages between post-trauma complications, physiology of a traumatic injury, and preexisting risk factors. Discuss interventions they use to prevent complications of traumatic injury. Where possible, discuss actual patient cases. • Visit an area trauma center. Discuss with nursing staff the clinical assessment format used to identify life-threatening injuries during primary assessment.
CHAPTER
35
Acute Burn Injury
Objectives: 1. Explain the mechanisms of burn injury. 2. Differentiate burn wound descriptors based on the level of dermis and tissue involved, including criteria for transferring a burn patient to a burn center. 3. Discuss the cardiovascular and pulmonary effects of burn injury during the resuscitative phase. 4. Describe neurologic and psychologic effects of burn injury during the resuscitative phase. 5. Discuss the metabolic and renal effects of burn injury during the resuscitative phase. 6. Explain burn wound healing, wound care, and closure. 7. Describe the psychosocial and physical mobility needs of the patient with burn injury during the acute rehabilitative phase. 8. Discuss nursing interventions related to physical conditioning, protection of new skin, scar management, and psychosocial adjustment during the long-term rehabilitative phase of burn care.
I. Mechanisms of Burn Injury A. Thermal burns: result of exposure to flame or hot object that leads to microvascular and inflammatory responses within minutes 1. Burn edema: limited to the injured tissues in smaller burns, develops in uninjured tissue in larger burns 2. Burn shock: hypovolemic shock state that results from fluid shift from intravascular to interstitial spaces B. Chemical burns: result of exposure to acid, alkali, or organic substances 1. Extent of injury depends on: amount and concentration of the substance, length of exposure, and mechanism of chemical action. 2. Eschar: dead sloughing tissue type of wound caused by acid. C. Electrical burns: result from the conversion of electrical energy into heat 1. Extent of injury depends on: type of current, pathway of current flow, local tissue resistance, and the duration of contact. 2. Low-voltage injuries a) AC causes a more severe injury than DC. 3. High-voltage injuries
a) Caused by a current that moves from the electrical source in an arc, either into or over the person b) Can cause thermal injuries 4. Electrical flash burn a) True thermal injury (involves no electrical contact) D. Radiation and extreme cold burns 1. Radiation injuries: result from the transfer of radiant energy to the body and the production of cellular toxins 2. Frostbite injuries: result from exposure to severe cold temperatures a) Results from microvascular stasis and occlusion, direct damage to cells from cold and the formation of ice crystals, and reperfusion injury. b) Treatment is similar to burn injuries. c) Conditions that increase susceptibility: decreased muscle and fat, poor nutrition, alcohol and drug abuse, diminished ability to shiver, age.
PowerPoint Slides 1. Thermal Burns 2. Chemical Burns 3. Electrical Burns 4. Radiation and Extreme Cold Burns
II. Burn Wound Classification and Burn Center Transfer A. Initial management goals 1. Stop the burning 2. Protect the airway 3. Stabilize breathing and circulation 4. Assess extent of injuries 5. Treatment, possible transfer to a burn center B. Burn classification 1. Burn depth a) First-, second-, or third-degree (1) Superficial burns: only epidermis tissues (2) Superficial partial-thickness burns: epidermis and superficial layer of the dermis (3) Deep partial-thickness burns: epidermis and deep layer of the dermis (4) Full-thickness burns: epidermis, dermis, and subcutaneous layers of skin and tissue (5) Subdermal burns (deep full-thickness burns): all layers of the skin and may include injury to muscle, tendons, or bone b) Wound conversion (wound progression): spontaneous progression of a burn wound into deeper tissue after the initial burn insult
(1) Causes: complex pathophysiological activities that may include decreased tissue perfusion, prolonged inflammation, hypercoagulability with thrombosis, and oxidative stress, infection, hypothermia, and external pressure c) Zones of injury (1) Zone of coagulation: innermost area (2) Zone of stasis: surrounds central zone (3) Zone of hyperemia: outermost area 2. Total body surface area (TBSA) a) Lund and Browder Chart (1) Assess partial- and full-thickness burns and shade the figure. (2) The percentage of each anatomic area involved is determined, percentages are totaled. b) Rule of Nines (1) Divide body into areas of 9% or multiples of 9% c) Palmar surface of patient’s hand C. Burn center transfer 1. Burn center referral criteria a) Burn center: specific area in the hospital with specialized equipment, resources, and staff for burn injury patients b) More than 10% of the TBSA is covered with partial-thickness burns 2. Structure of the burn unit a) Promotes isolation from pathogens and prevents infection. b) Rooms provide positive airflow, individual controls for temperature and humidity, and standard invasive monitoring and ventilatory support. c) Hydrotherapy or whirlpool facilities. 3. Burn team members a) Nurses, physicians (plastic and general surgeons), physical therapists (PTs), occupational therapists (OTs), pharmacists, dietitians, discharge planners, social workers, chaplains, and psychologists b) Advanced Burn Life Support (ABLS): personnel in burn center should be trained under these principles
PowerPoint Slides 1. Initial Management Goals 2. Burn Classification 3. Burn Classification 4. Total Body Surface Area (TBSA) 5. Burn Center Transfer
III. Resuscitative Phase: Vascular and Pulmonary Effects
3.
A. Cardiovascular effects: significant myocardial dysfunction when burns cover more than 40% of body surface area 1. Related pathophysiology a) Chemical and vasoactive mediators cause arterial constriction b) Vasodilation and increased capillary permeability (loss of capillary seal) c) Massive fluid and electrolyte shifts from intravascular spaces to the interstitium d) Hypovolemic shock e) Heart undergoes myocardial depression, decreased CO (1) Myocardinal depressant factor (MDF) 2. Related assessment findings a) Adults with large burns often tachycardic b) Generalized edema develops Related management a) Fluid resuscitation (1) Guided by urine output, vital signs, mentation, capillary refill, and peripheral pulses, laboratory values, body weight changes, clinical examination, and intake and output records (2) Parkland formula: guides crystalloid fluid administration (3) Isotonic crystalloid fluids: used for patients with less than 40% TBSA involvement and no pulmonary injury b) Maintain vital organ perfusion without exacerbating tissue edema 4. Electrical burns a) Predisposed to cardiac dysrhythmias, including sinus tachycardia, nonspecific or wave changes, segment prolongation, ventricular ectopy, atrial fibrillation, bundle branch block, ventricular fibrillation, varying degrees of atrioventricular heart blocks, supraventricular tachycardia, and asystole b) Cardiac monitoring required for 24 hours B. Peripheral vascular effects 1. Symptoms of limb tissue ischemia: pain on passive stretching of muscle, reduced sensation, weakness, swelling, and pain beyond injury sustained a) Limb ischemia can be caused from compromised peripheral blood flow in the limbs by eschar or compartment syndrome 2. Eschar: stiff (nonelastic), tough, dead tissue covering a full-thickness burn that is unable to expand in response to increasing edema a) Escharotomy: incision is made through the eschar to expose the fatty tissue below, thereby relieving the pressure and returning blood flow (1) Also can be used to relieve pulmonary compromise from circumferential burns of chest 3. Burn-induced compartment syndrome: the tissue pressure within a muscle compartment exceeds microvascular pressure causing an interruption in perfusion at the cellular level a) Treatment: escharotomy, possibly fasciotomy
(1) Fasciotomy: surgical incision is made into the fascia to relieve pressure or tension C. Pulmonary effects 1. Increased systemic vascular resistance, corresponding increase in pulmonary vascular resistance, increased pulmonary artery pressure and pulmonary artery wedge pressure, pulmonary edema 2. Upper-airway injury: supraglottic, resulting from either heat or chemicals dissolved in water a) Symptoms: facial burns, singed nasal hairs, facial erythema and edema, tachypnea, dyspnea, hoarseness, a brassy cough or stridor, and ulceration, especially of the nasopharynx b) Initial treatment: humidified 100% oxygen via a nonrebreather mask c) Inhalation injury: below the glottis caused by products of combustion (1) Diagnosis: bronchoscopy reveals evidence of carbonaceous material or signs of edema or ulceration below the glottis 3. Lower-airway injury: infraglottic, caused by the gaseous and chemical by-products of combustion contained in inhaled smoke a) Problems: ulceration of mucous membranes, edema, excessive secretions, decreased ciliary action, reactive bronchospasms, inactivation of surfactant, and atelectasis. b) Airflow obstruction can cause: hypoxemia and deteriorating pulmonary function. c) Leads to: respiratory failure, acute respiratory distress syndrome (ARDS), and pulmonary infections. d) Symptoms: symptoms of upper-airway injury, in addition to cough, carbonaceous (sooty) sputum, signs of hypoxemia, chest tightness, flaring nostrils, grunting, crackles, rhonchi, or wheezing. e) Diagnosis: physical examination, arterial blood gases, serial chest radiographs, fiberoptic bronchoscopy, ventilation–perfusion scan, carboxyhemoglobin levels, and cyanide levels. f) Treatment: high-flow humidified oxygen (100% by nonrebreather mask), preparations for endotracheal intubation, mechanical ventilation, high-frequency percussive ventilation may be initiated. g) Nursing care goals: aggressive pulmonary hygiene, repeated assessment and documentation of respiratory status, ventilatory support. 4. Carbon monoxide (CO) poisoning: chemical inhalation injury that has an action different from other inhaled chemicals a) Diagnosis: obtain history of exposure to by-products of combustion, draw a serum carboxyhemoglobin level (1) Carboxyhemoglobin level: percentage of CO bound to hemoglobin b) Symptoms: headache, malaise, nausea, difficulties with memory, personality changes, and gross neurologic dysfunction c) Treatment: administration of high fractional concentrations of supplemental oxygen, hyperbaric oxygen therapy (HBOT)
PowerPoint Slides 1. Cardiovascular Effects
2. Cardiovascular Effects 3. Cardiovascular Effects 4. Peripheral Vascular Effects 5. Pulmonary Effects 6. Pulmonary Effects 7. Pulmonary Effects
IV. Resuscitative Phase: Neurologic and Psychologic Effects A. Neurologic effects 1. Most common with electrical and lightning injuries 2. Confusion, exhibit a flat affect, lose the ability to concentrate, short-term memory problems, seizures, headaches, peripheral nerve damage, loss of muscle strength, long-term or permanent numbness, prickling, tingling, heightened sensitivity, or paralysis 3. Spinal cord injuries: may include direct nerve injury or injury to the vessels supplying blood to the cord 4. Pain and itching a) Full-thickness burns: insensate, except for the edge of the wound b) Partial-thickness burns: exceptionally sensitive and painful c) Rate pain as procedural or nonprocedural (1) Procedural pain: related to wound care or stretching of scar tissue (2) Nonprocedural pain: discomfort experienced at rest d) Pain medication (1) Emergency phase: IV (morphine, fentanyl) (2) Resuscitative phase: patient-controlled analgesia (3) Rehabilitative phase: mild opioid analgesics, acetaminophen, or nonsteroidal antiinflammatory drugs e) Nonpharmacologic therapies: address psychological factors (1) Classical conditioning, relaxation therapy, cognitive interventions, distraction (music therapy), hypnosis, and massage therapy f) Pruritus: most common subjective symptom after burn injury (1) Treatment: moisturizing body shampoos and lotions, topical steroids, antihistamines (oral or topical) and colloid and oatmeal baths B. Anxiety and psychiatric issues 1. Psychiatric symptoms: delirium, acute stress and posttraumatic stress disorder symptoms, sleep disturbances, and depression a) PTSD in acute phase is common 2. Treatment: antipsychotic phenothiazines, antidepressants, relaxation techniques
PowerPoint Slides 1. Neurologic Effects 2. Anxiety and Psychiatric Issues
V. Resuscitative Phase: Metabolic and Renal Effects A. Metabolic effects 1. Glycolysis, proteolysis, lipolysis, and hypermetabolism 2. Two phases of metabolic stress response a) Ebb phase: a state of hypometabolism, with a decrease in both oxygen consumption and metabolic rate b) Flow phase: a hyperdynamic state that stems from massive heat loss from the burn wounds characterized by an extreme state of hypermetabolism and catabolism, with persistent elevation of cortisol, cytokines, catecholamines, and glucose 3. Meeting nutritional needs a) Major fuel source: skeletal muscle protein, visceral proteins also consumed b) Needs: adequate protein intake, considerable caloric needs for wound healing and maintaining the immune system, trace elements and vitamins c) Enteral nutrition: reduces cumulative caloric deficits, stimulates insulin secretion, and conserves lean body mass (1) calorie-to-nitrogen ration of 110:1 d) Parenteral nutrition: for patients with prolonged ileus or intolerance to enteral feedings B. Renal effects 1. Renal blood flow and glomerular filtration rate increase, drug dosages must be increased 2. Acute renal failure: major complication in burn injury patients caused by prerenal conditions or intrarenal parenchymal damage 3. Myoglobinuria: myoglobin present in urine, turning it reddish-brown 4. Hemoglobin may also appear in urine, turning it reddish-brown
PowerPoint Slides 1. Metabolic Effects 2. Renal Effects
VI. Burn Wound Healing A. Phases of wound healing 1. Inflammatory phase: lasts 2 weeks 2. Proliferative phase: 1 month, collagen synthesis, revascularization, and reepithelialization occur 3. Maturation phase: 6–18 months, new collagen layers are formed, old collagen layers are broken down, hypertrophic scars are produced B. Initial wound care 1. Ensure burning process has stopped.
2. Burned extremities are elevated above the level of the heart, head of the bed is elevated, tetanus prophylaxis administered. 3. Clean white sheet used to cover patients to be transferred to burn center. 4. Wound cleansed with sterile saline or soap. 5. Circumferential burn may require escharotomy. C. Acute rehabilitative phase wound management 1. Goals: prevention and control of infection, preservation of viable tissue, and promotion of wound closure with minimal complications a) Interventions: wound cleansing, debridement, topical antimicrobial therapy, and wound closure 2. Wound debridement: removal of debris and nonviable tissue from a wound a) Mechanical debridement (1) Hydrotherapy: water softens and removes dead tissue to improve healing (a) Whirlpool (b) Pulsatile lavage (2) Wound irrigation: apply water (or other solution) to a local wound area in a steady positive pressure flow b) Biodebridement aka biosurgical or maggot debridement therapy (MDT) (1) Sterilized living fly larvae to ingest dead tissue and wound debris while sparing healthy tissues c) Chemical debridement (1) Application of an enzymatic or fibrinolytic preparation to the burn eschar to digest necrotic tissue and hasten eschar separation d) Surgical debridement (1) Tangential: shaving away thin layers of eschar until viable tissue is exposed (2) Fascial: removing nonviable tissue down to the fascial or subcutaneous planes 3. Infection a) Invasive infection: presence of pathogens in a burn wound at sufficient concentrations to cause supportive separation of eschar or graft loss, invasion of adjacent unburned tissue, or the systemic response of sepsis syndrome b) Topical antimicrobial therapy: used to control bacterial proliferation (1) Open dressing method: leaves the antimicrobial-covered wound open to air (2) Closed dressing method: application of gauze dressings over the antimicrobial agent 4. Temporary burn coverings a) Xenografts, heterografts: biological dressings obtained from animals b) Allografts, homografts: biological dressings obtained from humans c) Autografting: process of transplanting skin from one part of the body to another injured part d) Synthetic thin film dressings: cover donor sites and protect small, clean, superficial wounds e) Biosynthetic dressings: cover clean, superficial partial-thickness burns, meshed autografts, donor sites, and exudative wounds
f) Nonbiologic dressings: used on superficial and superficial partial-thickness burns g) Negative pressure wound therapy, Vacuum Assisted Closure (V.A.C.®): promotes the formation of granulation tissue, decreases wound size, removes exudate, and provides an environment for moist wound healing h) Growth factor: stimulates healing i) Nursing care: periodic application and removal of dressing material 5. Wound closure a) Superficial partial-thickness burns: heal by spontaneous reepithelialization within 7 to 10 days b) Small full-thickness: heal on their own by granulation tissue formation and contraction c) Full-thickness burns: grafted d) Large TBSA or a deep partial-thickness burn: grafted e) Full-thickness skin graft: skin is removed down to subcutaneous layer f) Split-thickness skin grafts: used as a sheet graft or meshed graft 6. Nursing considerations: monitor for infection
PowerPoint Slides 1. Phases of Wound Healing 2. Initial Wound Care 3. Acute Rehabilitative Phase Wound Management 4. Acute Rehabilitative Phase Wound Management 5. Acute Rehabilitative Phase Wound Management 6. BOX 35-3 Functions of Temporary Wound Coverings 7. Acute Rehabilitative Phase Wound Management 8. Acute Rehabilitative Phase Wound Management
VII. Acute Rehabilitative Phase: Psychosocial Needs and Physical Mobility A. Psychosocial needs 1. Most common problems: anxiety, fear, grief, depression, sleep problems, acute stress disorder, and aggressive or regressive behavior a) Problems minimized through: (1) Self-care activities: wound care, feeding, exercising, and administering medications (2) Repeated and consistent explanations (3) Visits by recovered burn patients 2. Pain a) Diminished in acute rehabilitative phase, but continues as chronic or background and procedural pain b) Nonpharmacologic interventions: biofeedback, hypnosis, relaxation therapy, and guided imagery
B. Physical mobility 1. Treatment goals: a) Returning to the pre-injury level of functioning b) Maintaining musculoskeletal, cardiopulmonary, and respiratory function c) Promoting wound healing d) Protecting healing skin grafts e) Preventing contractures and soft tissue deformity f) Preserving and strengthening extremity function g) Scar management h) Achieving maximum functional recovery i) Patient and family education 2. Role of nursing staff a) Integrate treatment plan into their delivery of care b) Provide assessment feedback to the OT and PT 3. Interventions a) Antideformity positioning: reduces scar contracture across flexor surfaces that often compromises joint mobility and functional capacity b) Active and passive range-of-motion exercises to preserve joint function c) Early total body mobilization d) Application of compression wraps on lower extremities before patient leaves bed
PowerPoint Slides 1. Psychosocial Needs 2. Psychosocial Needs 3. Physical Mobility
VIII. Overview of Long-Term Rehabilitative Phase A. Physical conditioning: body requires conditioning to regain lost strength and mobility B. Care of healing skin 1. Interventions: protection of newly formed epithelium, scar management, and prevention of burn scar contractures C. Scar management: wearing compression garments 1. Compression garments 2. Preventive measures for burn wounds over a joint: compression garments, night splinting, silicone, serial splinting/casting, and range-of-motion exercises 3. Surgery: to provide full mobility when burn scar contracture and functional deficit occur D. Psychosocial adjustment 1. Adapting to postburn alterations in appearance, level of physical functioning, and role concept 2. Psychological distress syndromes: acute stress disorder and posttraumatic stress disorder
PowerPoint Slides 1. Physical Conditioning 2. Care of Healing Skin 3. Scar Management: Wearing Compression Garments 4. Psychosocial Adjustment
IX. Chapter Summary X. Clinical Reasoning Checkpoint XI. Post Test XII. References
Suggestions for Classroom Activities • Discuss the five mechanisms of burn injury and the characteristics for each type. • Review medical photographs of different kinds of burn injuries, noting the differences among them. • What are the priority cardiovascular and pulmonary assessments and interventions used in the resuscitative phase of a burn injury? Develop nursing diagnoses as a class group that will incorporate these assessments. • Review the different methods of calculating extent of burn injury. Use the three methods to calculate extent of injury for two different hypothetical patients.
Suggestions for Clinical Activities • Visit with the nursing staff at a local hospital Emergency Department. Discuss the priority assessments and interventions of the cardiovascular and pulmonary systems that are used in the resuscitative phase of a burn injury. If possible, review the chart of a patient receiving these assessments and treatments. • Contact the Phoenix Society and ask to speak with a patient in the rehabilitation phase of recovery. Discuss that individual’s psychological needs and concerns, as well as his or her level of pain. • Visit a hospital burn unit. Inquire about the method(s) used to calculate extent of burn injury. Observe patients with different extents of injury.
CHAPTER
36
Shock States
Objectives: 1. Discuss the general concepts associated with shock states, including physiologic response to shock, and shock progression. 2. Assess a patient who may be experiencing signs of shock. 3. Demonstrate competency in collaborative management of the patient experiencing shock based on interventions that optimize oxygen delivery and reduce oxygen consumption. 4. Discuss the use of pharmacotherapy in the management of shock states. 5. Describe cardiogenic shock, including pathophysiology, clinical manifestations, diagnosis, and management. 6. Discuss hypovolemic shock, including pathophysiology, clinical manifestations, diagnosis, and management. 7. Explain the septic type of distributive shock, including pathophysiology, clinical manifestations, diagnosis, and management. 8. Discuss the neurologic and anaphylactic types of distributive shock, including the pathophysiology, clinical manifestations, diagnosis, and management of each type. 9. Describe the major causes of obstructive shock, including the pathophysiology, clinical manifestations, diagnosis, and management of each cause.
I. Introduction to Shock States A. Shock: circulatory insufficiency (circulatory failure) that creates an imbalance between tissue oxygen supply (delivery) and oxygen demand (consumption); inadequate oxygen delivery to meet cellular oxygen demands, resulting in end-organ injury 1. Classified into four categories: cardiogenic, hypovolemic, distributive, obstructive B. Physiological response to shock 1. Compensation in shock a) Low-pressure stretch receptors in the right atrium sense a decrease in circulating blood. b) Baroreceptors in the aorta and carotid arteries sense a decrease in blood volume and cardiac output (CO). c) Carotid body chemoreceptors sense alterations in pH and partial pressure of arterial carbon dioxide.
d) Baroreceptors and chemoreceptors alert the hypothalamus to activate the sympathetic nervous system’s fight-or-flight response. e) Endocrine system is activated to increase oxygen delivery by increasing blood volume. f) Cardiac output (CO) augmented to ensure adequate tissue perfusion. g) Renin–angiotensin–aldosterone system (RAAS) activated to increase blood volume and venous return. 2. Progression of shock a) Initial stage: decreased cardiac output and decreased tissue perfusion are evident. b) Compensatory stage: neuroendocrine responses are activated, compensatory signs and symptoms are evident. c) Progressive stage: results in multiple organ dysfunction syndrome (MODS). d) Refractory stage: shock state and cell destruction so severe that death is inevitable.
PowerPoint Slides 1. Shock 2. TABLE 36-1 Types of Shock 3. Physiological Response to Shock 4. Physiological Response to Shock
II. Assessment of Shock States A. Traditional parameters: appearance, vital signs, level of consciousness, and low urine output 1. Inadequate to accurately assess shock states, can underestimate degree of physiologic abnormalities a) Hard to evaluate: patient’s blood pressure, mentation, urine output since they can be influenced by many other factors B. Objective parameters of shock 1. Arterial pH: measure of hydrogen ions that determines the acid or alkaline state of the arterial blood 2. Serum lactate: indirect measure of impaired oxygenation and shock a) Lactic acidosis: elevated lactate level of greater than 5 mmol/L with an arterial pH of less than 7.35 (1) Type A: from impaired tissue oxygenation (2) Type B: normal tissue oxygenation, but presence of elevated metabolic acids 3. Base excess/base deficit: amount of base required to titrate 1 liter of arterial blood to a normal pH of 7.40 a) Obtained from arterial blood gas, identified as base excess (BE) 4. Venous oxygen saturation (SvO2): indirectly measures the amount of oxygen uploaded into the tissues before the venous blood returns to the lungs for reoxygenation a) Mixed venous saturation (SmvO2) b) Central venous saturation (ScvO2)
C. Emerging technologies 1. Gastric tonometry: minimally invasive technology used to estimate gastric tissue perfusion a) Drawbacks: cost, cumbersome equipment, based on assumptions of questionable validity 2. Near-infrared spectroscopy (NIRS): noninvasive technology that measures tissue oxygenation regionally, through light wavelengths a) Evaluates perfusion to the brain, mesentery, and muscle 3. Sublingual capnometry: experimental noninvasive monitoring technique that is an indirect measure of splanchnic perfusion
PowerPoint Slides 1. Traditional Parameters 2. Objective Parameters of Shock 3. Emerging Technologies
III. General Management of Shock States A. Interventions to optimize oxygen delivery 1. Oxygen therapy a) Conscious patient: oxygen delivered by nasal cannula or mask b) Unconscious patient, or one with moderate-to-severe shock or respiratory distress: intubation and mechanical ventilation (1) Hyperoxia: caused by the delivery of oxygen at too high a concentration 2. Fluid resuscitation: administration of IV fluids to assist in restoring optimal tissue perfusion a) Crystalloid solutions: restore interstitial and intravascular fluid volumes and increase preload and CO. b) Colloids and artificial plasma expanders: have oncotic capabilities not inherent in crystalloids. c) Blood or blood products: provide adequate hemoglobin concentration and increase oxygencarrying capacity or maintain adequate circulatory volume. d) Vasopressor therapy. e) Assess response to treatment: oxygen delivery, including improving trends in cardiac output/cardiac index, arterial blood gases (especially PaO2 and SaO2), hemoglobin, urine output, and mean arterial pressure (MAP) B. Interventions to decrease oxygen consumption 1. Decreasing total body work a) Mechanical ventilation b) Neuromuscular blocking agents (NMBAs): paralyze the muscles (1) Pancuronium (Pavulon) or vecuronium (Norcuron) (2) Requires intubation and mechanical ventilation (3) No sedation or analgesia properties (4) “Train of four” (TOF) series of electrical impulses to measure level of paralysis
(5) High-alert drugs, used when more conservative therapies fail to meet therapeutic goals c) Sedation (1) Propofol (Diprivan): IV anesthetic agent (2) Lorazepam: long-term sedation using benzodiazepines 2. Reducing pain and anxiety a) Administer analgesics and anxiolytics 3. Maintaining normothermia a) Control hyperthermia: antipyretic drugs or physical cooling measures b) Manage shivering 4. Maintaining normal serum glucose level a) IV insulin therapy if the patient’s blood glucose rises above 180 mg/dL C. Nursing considerations 1. Fluid resuscitation a) Monitor hemodynamic and oxygenation status b) Signs of continued or renewed bleeding c) Warm fluids used in massive resuscitation d) Monitor IV bags e) Monitor intravenous catheter insertion sites for infection 2. Maintain patient’s comfort 3. Reduce risk of deep vein thrombosis and stress ulcers
PowerPoint Slides 1. Interventions to Optimize Oxygen Delivery 2. Interventions to Optimize Oxygen Delivery 3. Interventions to Decrease Oxygen Consumption 4. Interventions to Decrease Oxygen Consumption 5. Interventions to Decrease Oxygen Consumption 6. Interventions to Decrease Oxygen Consumption 7. Nursing Considerations
IV. Vasoactive Pharmacotherapy in Shock Treatment A. Vasoactive drugs: alter blood vessel diameter through vasodilation or vasoconstriction 1. Vasopressors: causes peripheral vasoconstriction a) General actions (1) Adrenergic agonists (sympathomimetics): directly bind to and activate adrenergic receptors, mimicking nervous system stimulation (a) Catecholamines: cannot be administered orally, have a brief duration of action, and do not cross the blood–brain barrier
(b) Noncatecholamines: can be administered orally, have a longer duration of action, and are able to cross the blood–brain barrier (2) Nonselective: stimulate more than one type of receptor (3) Selective: stimulate only one type b) Adverse effects of vasopressor therapy (1) Norepinephrine: stimulates all four adrenergic receptor sites, beta effects increase heart rate and cardiac oxygen demand (2) Alpha vasopressors: can cause visceral and peripheral tissue ischemia and necrosis c) Vasopressin or antidiuretic hormone (ADH): naturally occurring hormone (1) Causes water conservation, decreased urine output, increased intravascular water (2) Higher concentrations: systemic vasoconstriction of the arterioles and inhibits production of nitric oxide (NO) B. Inotropics: manipulate heart contractility, and therefore cardiac output 1. Negative (decrease contractility) 2. Positive (increase contractility) a) Cardiac glycoside: used for long-term heart failure therapy b) Sympathomimetics: both vasopressor and intropic actions c) Phosphodiesterase (PDE3) inhibitors: influence intracellular cyclic AMP (cAMP) C. Vasodilators 1. Afterload-reducing drugs: improve cardiac output and oxygen delivery 2. Peripheral arterial vasodilators: decrease systemic vascular resistance (SVR) 3. Only used in patients with adequate fluid volume D. Vasoactive agents: nursing implications 1. IV vasoactive agents incompatibility with other drugs should be checked 2. Monitor for therapeutic and nontherapeutic effects of each agent 3. Wean patient from vasoactive drug therapy in small increments and monitor the response 4. Hemodynamic monitoring 5. Monitor peripheral oxygenation 6. Monitor indirect measures of tissue oxygenation 7. Infuse vasopressors through a central venous catheter (CVC)
PowerPoint Slides 1. Vasoactive Drugs 2. Vasopressors 3. TABLE 36-3 Effects of Alpha1 and Beta1 Adrenergic Receptor Stimulation 4. Vasopressors 5. TABLE 36-4 Common Vasopressor Agents Used in Shock States 6. Vasopressors
7. Inotropics 8. TABLE 36-5 Positive Inotropic Agents 9. Vasodilators 10. Vasoactive Agents: Nursing Implications
V. Cardiogenic Shock A. Cardiogenic shock: when the heart fails to function as a pump to deliver oxygenated blood to tissues 1. Most common cause: extensive left ventricular myocardial infarction (MI), particularly ST-elevation MI (STEMI) 2. Other causes: papillary muscle rupture, mitral or aortic stenosis, and ventricular septal rupture; or other pathologic heart conditions B. Pathophysiology 1. Myocardial infarction impairs cardiac contractility and cardiac output. 2. Progressive ischemia. 3. Decreased blood pressure results in decreased aortic diastolic pressure. 4. Decline in coronary artery perfusion causes decrease in oxygen delivery to the myocardium. 5. Blood backs up in pulmonary system, pulmonary congestion. 6. SIRS can develop, causing the release of nitric oxide (NO). 7. Progressive ischemia results in lactic acidosis. C. Clinical manifestations and diagnosis 1. Hemodynamic criteria for cardiogenic shock: sustained hypotension, elevated pulmonary artery wedge pressure (PAWP), and low cardiac index 2. Common clinical findings: continued chest pain and manifestations of pulmonary congestion 3. General signs: reduced mentation, mottled and cool skin, diaphoresis, weak peripheral pulses, and tachycardia 4. Diagnosis: electrocardiogram (ECG), cardiac echocardiogram, serial cardiac enzymes, chest X-ray, arterial blood gases, and electrolytes D. Management 1. Decrease myocardial oxygen demand, improve myocardial oxygen supply 2. Initial management: reduce pulmonary edema, increase systemic blood pressure and cardiac output, and prevent cardiac dysrhythmias 3. Supporting circulation a) Drug therapy: vasopressors and positive inotropes, possibly a vasodilator and diuretics b) Hemodynamic monitoring (1) Monitor cardiac rhythm status and oxygen saturation, end-tidal CO2 (ETCO2), central venous pressure (CVP) and central venous oxygen saturation (ScvO2) cardiac output (2) Pulmonary artery catheter: cardiac output, stroke volume, and ejection fraction 4. Aortic counterpulsation a) Intra-aortic balloon pump (IABP): reduces afterload and augments coronary perfusion, which increases cardiac output and improves coronary blood flow.
5. Revascularization and ventricular assist options a) Percutaneous coronary intervention (PCI) procedure (1) Improves wall motion in the infarct area and increases perfusion of infarct zone b) Coronary artery bypass surgery (CABG) c) Surgically placed left ventricular assist devices (LVAD) used for: (1) Short-term mechanism to rest the injured myocardium (2) Bridge to cardiac transplantation when the myocardium does not sufficiently recover (3) Permanent cardiac support device d) Percutaneous ventricular assist device (pVAD)
PowerPoint Slides 1. Cardiogenic Shock 2. Pathophysiology 3. Pathophysiology 4. Clinical Manifestations and Diagnosis 5. Clinical Manifestations and Diagnosis 6. Clinical Manifestations and Diagnosis 7. Diagnosis 8. Initial Management 9. Management 10. Management 11. Management
VI. Hypovolemic Shock A. Hypovolemic shock: inadequate circulating volume results in inadequate cardiac output to meet tissue oxygenation 1. Most common form: hemorrhage B. Pathophysiology 1. Acute loss or displacement of a significant volume of intravascular fluid 2. Inhibition of baroreceptors in the large arteries 3. Compensatory peripheral vasoconstriction and stimulation of the sympathetic nervous system (NS) with the release of catecholamines C. Clinical manifestations 1. Due primarily to decreased circulating volume and sympathetic NS stimulation. 2. Systemic vascular resistance (SVR) is elevated as vasoconstriction occurs to increase venous return and CO. D. Treatment
1. Priorities: secure the patient’s airway and support breathing, control bleeding and restore fluid volume 2. Fluid resuscitation a) Hemorrhage: blood products used to achieve hemoglobin level of 7-9 g/dL. b) Overaggressive volume resuscitation can reopen injured vessels.
PowerPoint Slides 1. Hypovolemic Shock 2. Pathophysiology 3. Clinical Manifestations 4. Treatment
VII. Distributive Shock: Septic A. Introduction to distributive shock 1. Three types of distributive shock: septic, anaphylactic, and neurogenic. 2. Distributive shock states: impaired oxygenation due to altered blood flow distribution. 3. Vascular smooth muscle fails to constrict due to one of the following: a) Endothelial insult b) Loss of sympathetic nervous system response 4. Primary characteristic: massive vasodilation. B. Introduction to septic shock 1. Sepsis: the body’s response to an infection or the presence of pathogenic organisms or their toxins in the blood and tissues 2. Most common causes: gram-positive and gram-negative bacteria C. Pathophysiologic basis of septic shock 1. Three forms of sepsis: uncomplicated sepsis, severe sepsis, and septic shock 2. Characteristics: a) Altered fluid volume related to vasodilation b) Increased capillary permeability c) Maldistribution of circulating volume, (some organs receive more blood than required as a result of vasodilation while others do not receive the blood they require) 3. AACP/SCCM definition: SIRS phenomenon in the presence of an actual or suspected infection 4. PIRO: definition based on four characteristics rather than SIRS a) Predisposition (e.g., age and certain comorbidities) b) Infection (or insult) c) Response (e.g., respiratory and heart rates and leukocyte band levels) d) Organ dysfunction D. Clinical manifestations 1. Early stages
a) Hemodynamic status may become hyperdynamic. b) Patient feels warm, and, hemodynamically, the CO is normal or high. c) Tachycardia is present, stroke volumes (SV) are normal, and systemic vascular resistance (SVR) is decreased (vasodilation). d) Patient’s diastolic blood pressure decreases, causing a widening pulse pressure. 2. Later stages (dynamic or cold phase) a) Compensatory mechanisms fail. b) Myocardial depressant and hypoxemic effects predominate. c) Tissue hypoperfusion develops. d) Extremities are cold, and mottling may be present. e) Serum lactate levels increase, and ScvO2 decreases. E. Treatment 1. Nursing priorities a) Administer antibiotics within 1 hour after a HCP initiates order b) Serum lactate level obtained immediately c) Monitor venous oxygen saturation (SvO2), either mixed (SmvO2) or central (ScvO2) 2. Fluid resuscitation a) Goals: raise the central venous pressure (CVP) to greater than 8 mm Hg, relieve hypotension 3. Pharmacotherapy interventions a) Hydrocortisone therapy (1) For patients who haven’t responded well to fluid resuscitation and vasopressor therapy (2) High-dose therapy not recommended b) Activated protein C (APC): during septic shock consumed at such a rate that clot dissolution is impeded 4. Other supportive interventions a) Minute-to-minute management at bedside b) Monitor physiologic and laboratory parameters and their trends c) Interpret the results and consult with other team members d) Monitor for therapeutic and nontherapeutic effects of interventions e) Monitor for the physiologic effects of the drug therapies
PowerPoint Slides 1. Introduction to Distributive Shock 2. Introduction to Septic Shock 3. Pathophysiologic Basis of Septic Shock 4. Pathophysiologic Basis of Septic Shock 5. Pathophysiologic Basis of Septic Shock 6. Clinical Manifestations: Early Stages
7. Clinical Manifestations: Later Stages (dynamic or cold phase) 8. Treatment 9. Treatment 10. Treatment 11. Treatment
VIII. Distributive Shock: Neurogenic and Anaphylactic A. Neurogenic shock 1. Associated with acute spinal cord injury (SCI) 2. Nontraumatic causes: tumors, disk degeneration, and inflammation/infection 3. Related pathophysiology a) Spinal shock: temporary loss of spinal reflex activity that develops below the level of cord injury (1) Characteristics: sensorimotor function loss, hypertension followed by hypotension, and flaccid paralysis that includes the bladder and bowel b) Neurogenic shock: spinal cord injury above the midthoracic region, impulses from the sympathetic nervous system cannot reach the arterioles, resulting in unopposed vagal stimulation and loss of vasomotor tone (1) Characteristics: prohibits vasoconstriction of blood vessels, relative hypovolemia, decrease in cardiac output (CO), hypovolemic state results in hypoperfusion 4. Clinical manifestations a) Signs: hypotension, bradycardia, and hypothermia 5. Treatment a) Goals: maintain stability of the spine, optimize oxygen delivery, and restore intravascular volume b) Continuous cardiac monitoring required c) Protection may be required for patient’s airway and mechanical ventilation support B. Anaphylactic shock: severe systemic allergic reaction to allergens such as foods, drugs, blood products, insect venom, and latex 1. Related pathophysiology a) Severe type I (anaphylactic) hypersensitivity response involving immunoglobulin IgE and mast cells. b) Massive vasodilation and increased capillary permeability results in a decrease in venous return, decrease in CO, and decrease in oxygen delivery. 2. Clinical manifestations a) Hypotension, upper airway obstruction, flushing, urticaria and pruritus, abdominal cramping, and diarrhea b) Greatest threat: severe upper airway obstruction 3. Treatment a) Goals: maintain airway and support blood pressure
b) Administer oxygen as needed c) Early intubation in case of respiratory distress d) Aggressive fluid resuscitation in case of hypotensive patient e) Drug therapies
PowerPoint Slides 1. Neurogenic Shock: Causes 2. Neurogenic Shock: Related Pathophysiology 3. Neurogenic Shock: Clinical Manifestations 4. Neurogenic Shock: Treatment 5. Anaphylactic Shock 6. Anaphylactic Shock: Related Pathophysiology 7. Anaphylactic Shock: Clinical manifestations 8. Anaphylactic Shock: Treatment
IX. Obstructive Shock States A. Pulmonary embolism: clot, air, or tissue that obstructs blood flow through any part of the lungs 1. Related pathophysiology a) Hypercoagulability: leads to the formation of thrombi in the deep veins of the legs, pelvis, or arms. b) Thrombi cause an embolism, obstructing affected pulmonary arteries, resulting in impaired gas exchange and right ventricular dysfunction. c) PVR result of hypoxia and pulmonary vasoconstriction. d) Shock states develop from impaired gas exchange and cardiac dysfunction. 2. Clinical manifestations a) Signs and symptoms: dyspnea, tachypnea, pleuritic pain, cough, wheezing, crackles, tachycardia, and evidence of deep vein thrombosis b) Right ventricular failure: right ventricular enlargement and pulmonary hypertension 3. Treatment a) Early initiation of anticoagulant therapy b) Inferior vena cava filters c) Thrombolytic therapy or emergency surgical embolectomy B. Tension pneumothorax: collapse of an area of the lung caused by increased pressure within the thoracic cavity 1. Related pathophysiology a) Air enters the pleural space during inspiration but cannot leave during expiration. b) Accumulated air in thoracic cavity causes shift of the mediastinal structures and compression of the opposite lung and soft tissues on the affected side. 2. Clinical manifestations
a) Direct pressure placed on the heart, vena cava, and contralateral lung. b) Decrease in venous return and CO. c) Chest pain and air hunger. d) Develops respiratory distress. e) Lung sounds absent on the affected side. f) Tracheal deviation may develop. 3. Treatment a) Needle thoracostomy: trapped air is decompressed with the insertion of a 14-gauge needle or a chest tube. C. Cardiac tamponade: pressure exerted on the heart, compressing the heart wall and restricting heart actions 1. Related pathophysiology a) Develops secondary to an accumulation of fluid, such as blood, in the pericardial sac b) Most common cause: chest trauma, blunt or penetrating 2. Clinical manifestations a) Pulsus paradoxus: classic sign of cardiac tamponade (1) Exaggerated decrease of the systolic blood pressure during inspiration (2) May be present: Beck’s triad—elevated RAP, decreased blood pressure, and muffled heart sounds 3. Treatment a) Volume resuscitation during preparation for emergency removal of pericardial fluid b) Needle pericardiocentesis c) Thoracotomy
PowerPoint Slides 1. Pulmonary Embolism: Related pathophysiology 2. Pulmonary Embolism: Clinical manifestations 3. Pulmonary Embolism: Treatment 4. Tension Pneumothorax 5. Tension Pneumothorax: Related Pathophysiology 6. Tension Pneumothorax: Clinical Manifestations 7. Tension Pneumothorax: Treatment 8. Cardiac Tamponade 9. Cardiac Tamponade: Related Pathophysiology 10. Cardiac Tamponade: Clinical Manifestations 11. Cardiac Tamponade: Treatment
X. Chapter Summary XI. Clinical Reasoning Checkpoint XII. Post Test XIII. References
Suggestions for Classroom Activities • Discuss the differences and similarities in treating the four functional shock states. • Discuss the four functional shock states and signs and symptoms of each. • Discuss the differences and similarities in the treatment of each of the four functional shock types. • Ask each student to develop three NCLEX-style questions. Collect the questions and use them in a “Q&A” game in the class. Provide a small prize, such as candy, for the two students who get the most answers correct.
Suggestions for Clinical Activities • At a hospital Emergency Department, inquire about or read charts of patients being treated for one of the four functional shock states. • Rotate students to the intensive care unit. Assign students to patients who have experienced shock. During the postconference, discuss the care delivered to the patients. Encourage students to address the rationale for the interventions in the care being provided. • Speak with an Emergency Department nurse about his or her role in caring for the patient presenting with manifestations consistent with shock.
CHAPTER
37
Multiple Organ Dysfunction Syndrome
1. Describe the inflammatory process and the role of endothelium in that process. 2. Identify the physiologic changes that occur with the systemic inflammatory response syndrome (SIRS). 3. Discuss four pathophysiologic changes that occur with multiple organ dysfunction syndrome. 4. Identify the seven most common organ systems that fail as a result of the SIRS process. 5. Describe the collaborative management of the patient with multiple organ dysfunction syndrome.
I. Inflammatory Response and Endothelium A. Review of the inflammatory response 1. Inflammation: localized immunologic response to tissue injury or infection a) Defense mechanism for protecting body, restoring homeostasis and tissue repair 2. Sequence of events a) Mast cells: initiate the inflammatory process by releasing chemical mediators b) Chemical mediators: histamine, bradykinin, and prostaglandins (1) Mediators trigger local vasodilation and increased vascular permeability. (2) Chemotaxis and migration of immune cells to injury. 3. Clinical manifestations a) Localized: redness (rubor), heat (calor), swelling (tumor), pain (dolor), and loss of function (functio laesa) b) Systemic: elevated leukocyte count, fever, malaise, and anorexia B. Endothelium: provides major barrier and chemical support to the vascular system as well as inflammatory response 1. Review of anatomy and physiology a) Thin, single-cell layer of cells that comprise the inner lining of all veins and arteries (tunica intima) b) Referred to as an organ system due to important local homeostatic functions c) Endothelial cells (1) Endothelial cell activation: adaptive response under physiologic conditions; also occurs in response to pathophysiologic conditions (2) Necrosis and apoptosis: programmed cell death of endothelial cells during inflammation
PowerPoint Slides 1. Review of the Inflammatory Response 2. Review of the Inflammatory Response 3. Endothelium 4. BOX 37–1 Major Functions of Endothelial Cells
II. Systemic Inflammatory Response Syndrome (SIRS) A. SIRS: proinflammatory response precipitated by a nonspecific insult B. Etiology and risk factors 1. SIRS-triggering insults: infection, trauma, major surgery, acute pancreatitis, and burns 2. Sepsis: when underlying cause is infection (most common cause of SIRS) 3. Patient-related risk factors: older age, baseline organ dysfunction, malnutrition, immunosuppression, gut hypoperfusion, smoking, and increased body mass index 4. Therapy risk factors: massive transfusions in trauma patients, and cardiopulmonary bypass C. Clinical manifestations 1. Criteria for SIRS: vital signs (temperature, heart rate, and respiratory rate) and leukocyte count. 2. Other common manifestations: decreased urine output and altered level of consciousness. 3. Mild to severe manifestation depends on: etiology and comorbidities. D. The SIRS-MODS connection: severe SIRS can progress to multiple organ dysfunction syndrome (MODS) when body’s ability to physiologically manage the widespread inflammation is overwhelmed
PowerPoint Slides 1. SIRS 2. Etiology and Risk Factors 3. Clinical Manifestations 4. BOX 37–2 Definition of SIRS in Adults 5. The SIRS-MODS Connection
III. Multiple Organ Dysfunction Syndrome (MODS) A. MODS: progressive dysfunction of two or more organ systems that persists beyond 24 hours B. Risk factors 1. Primary MODS: severity of injury, shock and SIRS 2. Secondary MODS: infection, transfusion, and multiple surgical operations 3. Host factors: age older than 45 years and a higher number of preexisting conditions C. Pathophysiologic considerations 1. MODS pathways a) Primary MODS pathway
(1) Develops early (within the first 72 hours) as the direct consequence of a well-defined initiating event, such as injury, hemorrhage, or hypoxemia (2) Result of inadequate oxygen delivery to cells and failure of microcirculation to remove metabolic end products b) Secondary MODS pathway (1) Consequence of the SIRS phenomenon. (2) Onset is often weeks after the initial acute insult. 2. Pathologic changes a) Uncontrolled systemic inflammation (1) Sepsis: early activation of immune cells is followed by down regulation of their activity that leads to a state of immune deficiency and an increased risk of superinfection. (2) Proinflammatory mediators: cause the release of nitric oxide from endothelial cells, which results in vasodilation. (3) Neutrophils: induce the release of oxygen radicals and proteolytic enzymes and also potentiate increased vascular permeability. b) Tissue hypoxia (1) May result from derangements in the cellular use of oxygen in the presence of adequate oxygen delivery. (2) A state of metabolic shutdown occurs because of an inadequate supply of energy to power the various cellular processes. c) Unregulated apoptosis (1) Results in reduced levels of certain immune cells and an overabundance of others d) Microvascular coagulopathy (1) Abnormal clotting in the small blood vessels (microcirculation) that results in microthrombosis that obstructs blood flow
PowerPoint Slides 1. MODS 2. Risk Factors 3. Pathophysiologic Considerations 4. Pathophysiologic Considerations
IV. Sequential Organ Involvement and Failure A. “Cross talk” between organs through the activities of the chemical mediators facilitates the spread of injury from one organ to the next B. Assessing the severity of organ dysfunction 1. Assess six major organ systems: respiratory, cardiovascular, neurologic, renal, hepatic, and hematologic 2. Sequential Organ Failure Assessment (SOFA): determines the extent of organ function and predict the outcome
C. Sequential organ injury: order in which organs fail impacted by primary illness and comorbidities 1. Pulmonary dysfunction a) Lungs are usually first to show signs of dysfunction. b) ARDS can progress rapidly from mild to severe. c) Common direct predisposing factors: pneumonia and gastric aspiration. d) Common indirect predisposing factors: sepsis and traumatic injury with shock that requires massive blood transfusions. e) Tissue damage (1) Injury to alveolar-capillary membrane, resulting in refractory pulmonary shunt, causing hypoxia (2) Injury to the surfactant-producing cells, resulting in widespread alveolar collapse and atelectasis f) Commonly monitored indicators of lung status in ARDS: arterial blood gases and the PaO2/FiO2 ratio 2. Cardiovascular dysfunction a) Dysrhythmias and hypotension that is unresponsive to fluid administration b) Peripheral vascular dysfunction c) Pressure-adjusted heart rate (PAR): product of heart rate (HR) times the central venous pressure (CVP) divided by the mean arterial pressure (MAP) (1) Calculates cardiovascular failure (2) Analogous to Pao2/Fio2 ratio with ARDS 3. Acute kidney dysfunction a) Most frequently accompanies respiratory failure b) Sign of renal failure: rise in serum levels of substances excreted by kidneys 4. Neurologic dysfunction a) Alterations in level of consciousness, confusion, and psychosis b) May occur as a result of: hypoperfusion, microvascular coagulopathy, or cerebral ischemia c) Risk factors: prolonged sedation or theraputic paralysis and bed rest, aminoglycoside therapy, malnutrition, electrolyte abnormalities, and muscle deconditioning from disuse and lack of exercise d) Glasgow Coma Scale: most widely used measure of neurologic function 5. Liver dysfunction a) Abnormalities of protein synthesis functions: low serum albumin, fibrinogen, and other clotting factors. b) Liver injury contributes to development of sepsis. c) Manifests as high levels of serum bilirubin. 6. Gut dysfunction a) Gut injury: driving force in development of critical illness and SIRS b) Results in damage to intestinal epithelial lining with release of proinflammatory mediators, leading to SIRS
c) Contributes to development of sepsis 7. Hemotologic dysfunction a) Most common hemotologic dysfunction: thrombocytopenia b) Other dysfunctions: increased platelet consumption, sequestration of platelets in the vasculature, and impaired thrombopoiesis c) Disseminated intravascular coagulation (DIC): widespread intravascular clotting with bleeding secondary to consumption of coagulation factors
PowerPoint Slides 1. Assessing the Severity of Organ Dysfunction 2. Sequential Organ Injury: Pulmonary Dysfunction 3. Sequential Organ Injury: Cardiovascular Dysfunction 4. Sequential Organ Injury: Acute Kidney Dysfunction 5. Sequential Organ Injury: Neurologic Dysfunction 6. Sequential Organ Injury: Liver Dysfunction 7. Sequential Organ Injury: Gut Dysfunction 8. Sequential Organ Injury: Hemotologic Dysfunction
V. Management of MODS A. Prevent SIRS and sepsis 1. Prevent infection a) Meticulous adherence to hand hygiene and universal precautions b) In case of mechanical ventilation: implement an evidence-based ventilator bundle to minimize the risk of ventilator-associated pneumonia (VAP) c) Other significant potential sources of infection: urinary catheters, central venous catheters, and pressure ulcers d) Follow hospital policies regarding assessment and management of invasive catheters and maintenance of skin integrity B. Detect early SIRS, sepsis, and MODS 1. Assess and monitor patients at risk for MODS for physiologic parameters, early recognition of changes, and early interventions 2. Monitor vital signs: temperature and mean arterial pressure (MAP), electrocardiograms, oxygen saturation (arterial [SaO2], central venous [ScvO2], or mixed venous [SmvO2]), central venous pressure, serum lactate, and cardiac output 3. Monitor for infection: consider potential sources for infection, temperature changes for signs of sepsis, serum white blood cell (WBC) count, blood cultures obtained prior to antibiotic therapy 4. Evaluate organ-function-specific parameters C. Implement a treatment plan: no definitive treatment for MODS, focus on correcting underlying problem while supporting organ function
1. Glycemic control a) Hypoglycemia: common problem associated with aggressive glycemic control (1) Results in increased morbidity and mortality (2) Insulin therapy should be used to maintain blood glucose below 180 mg/dL 2. Activated protein C (drotrecogin alfa) therapy a) Recombinant form of human activated protein C that reduces inflammation, inhibits abnormal clot formation, and facilitates clot breakdown 3. Nursing considerations a) Patient may not survive, even with best care. b) Be responsive to and supportive of family members. c) Answer questions promptly and honestly, provide regular updates.
PowerPoint Slides 1. Prevent SIRS and Sepsis 2. Detect Early SIRS, Sepsis, and MODS 3. Implement a Treatment Plan
VI. Chapter Summary VII. Clinical Reasoning Checkpoint VIII. Post Test IX. References
Suggestions for Classroom Activities • Discuss the risk factors for developing SIRS and any warning signs. • Invite a representative from the hospital’s infection control department to speak to the class about tracking of nosocomial infections. • Review the coagulation cascade and its related factors.
Suggestions for Clinical Activities • Ask a clinical nurse to describe steps that can be taken to protect against SIRS in a hospital setting. • Invite a clinical nurse to speak with the students concerning MODS in each of the organ systems.
CHAPTER
38
Solid Organ and Hematopoietic Stem Cell Transplantation
Objectives: 1. Discuss the history of organ transplantation. 2. Describe types of donors and transplant-related legal considerations. 3. Define brain and cardiac death and explain how death is determined. 4. Discuss organ donor management. 5. Explain the general organ procurement process and organ preservation. 6. Discuss the immunologic considerations of organ transplantation. 7. Describe how the need for organ transplantation is determined. 8. Discuss the major complications associated with organ transplantation. 9. Describe immunosuppressant therapy for prevention of graft rejection. 10. Explain hematopoietic stem cell transplantation. 11. Discuss the general concepts related to kidney transplantation, including implications for postprocedure management.
I. Brief History of Organ Transplantation A. 1910–1930: The beginnings 1. Kidney was early focal point 2. 1912: Dr. Alexis Carrel develops method, successfully sutures and transplants blood vessels and organs B. 1930–1950: In search of long-term success 1. 1930s, skin grafts for burns, from family member donors survived longer 2. 1936: first kidney transplant, rejected by receiver, patient dies, reasons then unknown 3. 1940s: research focused on allograft rejection a) Common antigen between skin and kidney discovered, sensitized recipient for grafting b) Transplanted kidneys surviving up to 6 months C. 1950–1960: The isograft and the immunosuppressant discovery years 1. 1954: first isograft (transplant between identical twins), renal transplant 2. Research on tissue incompatibility
3. Development of immunosuppressants, 1950s a) 1960: Azathioprine (Imuran) introduced, early use associated with deaths, correct dose later established, still used today b) Corticosteroids introduced as adjunctive therapy 4. 1957: Dr. E Donnall Thomas performs first allogeneic hematopoietic marrow transplantations in sibling patients with leukemia D. 1961–1979: The expansion years 1. 1960s: Renal transplant survival rates rise greatly; immunosuppressant therapy expanded; organ procurement programs initiated 2. Mid-late 1960s: first successful pancreas, liver, heart transplantations E. 1980–the present 1. 1977: Cyclosporine (drug with immunomodulating properties) discovered, approved in U.S. in 1983 2. Early 1980s: heart-lung, single-lung, and double lung transplants 3. 1989: first living-donor liver transplant 4. 1990: first living-donor lung transplant
PowerPoint Slides 1. 1910–1930 2. 1930–1950 3. 1950–1960 4. 1961–1979 5. 1980–Present
II. The Organ Donor: Graft, Immunologic, and Legal Considerations A. Types of grafts 1. Autograft: transplantation of tissue from one part of a person’s body to another part a) Ideal for tissue compatibility and graft survival b) Common for skin 2. Heterograft (a.k.a. xenograft): transplantation of tissue between two different species a) E.g., porcine skin grafts, experimental baboon heart transplants b) Primarily temporary transplantations until permanent allograft available 3. Allograft (a.k.a. homograft): transplantation of tissue between members of the same species a) Isograft/syngraft: transplantation between identical twins b) When not isograft, trigger immune reaction, rejection of graft c) Obtained from live or deceased donors B.
Types of donors 1. Living donor a) Ideally, donor is related to recipient.
(1) Increased histocompatibility b) Kidney is primary solid organ recovered from living donor. c) Segmental (partial) organ donation (e.g., lobe of a liver or lung, part of pancreas). d) Donor risks: (1) Major surgical procedure; postoperative complications (2) Financial ramifications: missing work, insurance rate may change (3) Coercion from family members 2. Deceased donor a) Usually healthy, die from traumatic event or sudden death b) Donors who die of cardiac death (1) Transplantable tissues may be limited to heart valves, corneas, eyes, saphenous veins, skin, bones; sometimes organs can be recovered. (2) Tissues must be recovered within 12–24 hours post death. c) Donors who die of brain death (1) Majority of deceased-donor organ transplants
b)
C. Legal aspects of donation and transplantation 1. Uniform Anatomical Gift Act (UAGA) (1968) a) Provides way for individuals to make wish for donation known (1) Consent used to be made by next-of-kin; now electronic registries b) Donate Life America: nonprofit, national and state teams, goal to increase organ, eye, tissue donation. c) “First person consent” prevents person other than donor from altering donation wish. d) Prohibits trafficking human organs for profit. 2. Required-Request Legislation (section of UAGA) a) Stipulates hospitals' responsibilities for identifying potential donors, providing information about donation to families 3. National Organ Transplant Act (1984) a) Set up National Organ Procurement and Transplantation Network (OPTN): establishes national registries, tracks potential recipients and posttransplantation recipients (1) Matches organs and potential recipients Prohibits selling human organs and tissues 4. Uniform Determination of Death Act a) Guideline for states to establish legal definition of death 5. Conditions of participation: organ, tissue, and eye procurement a) 1998: Federal guidelines, address responsibilities of hospitals for notifying and working with organ procurement organization (OPO) (1) Must report deaths and imminent deaths to OPO in timely manner (2) Must inform families if they can donate to family member (3) OPO dictates care of potential organ donor
PowerPoint Slides 1. Types of Grafts 2. Types of Donors 3. Legal Aspects of Donation and Transplantation
III. Determination of Death A. Confirmation of brain death more complex than cardiac death B. Definition of death 1. Uniform Determination of Death Act (UDDA): either (1) total irreversible failure of cardiorespiratory system, or (2) irreversible loss of all brain functions 2. Most states have adopted UDDA, have own statutes about determining death C. Determination of death 1. Brain death: clinical exam, cerebral blood perfusion study, or EEG 2. Prerequisite diagnostic criteria a) Clinical or neuroimaging evidence of acute CNS catastrophe b) Exclusion of complication medical conditions that may confound clinical assessment c) No drug intoxication or poisoning d) Core temperature ≥ 32°C (90° F) e) “Accepted medical standards” to meet 4 criteria D. Brain death clinical diagnosis 1. Cannot be used if patient has toxic or metabolic CNS depression, cannot initiate respiratory because of other injuries or pathology 2. Coma or unresponsiveness a) Rule out reversible causes (e.g., drugs, hypothermia) 3. Absence of brainstem reflexes a) Glasgow coma score of 3 b) No response to painful or verbal stimuli c) Absent reflexes (e.g., eye and gag reflexes) 4. Apnea a) Test determines if patient's respiratory drive is stimulated by elevated PaCO2 (1) Patient preoxygenated with 100% oxygen concentration. (2) Disconnected from ventilator, passive oxygen maintained, observed for respiratory movement as PaCO2 rises. (3) If no respiratory effort seen and arterial blood gas (ABG) shows PaCO2 above 60 mm Hg, patient is apneic. (4) If respiratory effort seen, reconnected to ventilator. 5. Confirmatory tests a) Not required, may be used when clinical testing cannot be reliably performed
b) Cerebral blood flow tests: cerebral angiopathy, cerebral scintigraphy (HMPAO SPECT), transcranial Doppler ultrasonography (TCD) c) Other tests: CT angiography (CTA), magnetic resonance imaging (MRI)/magnetic resonance angiography (MRA), somatosensory evoked potentials, electroencephalography (EEG) 6. Documenting time of death a) Upon completion and interpretation of apnea tests or confirmatory tests b) Documented in medical history, family informed
PowerPoint Slides 1. Death 2. Brain Death Clinical Diagnosis
IV. Donor Management A. Goal: maintaining organ function when brain death occurs 1. Meet oxygenation and perfusion needs through interventions B. Hemodynamic instability 1. Develops with physiologic events from brain death a) E.g., diabetes insipidus, initial hypertension followed by hypotension, inability to regulate body temperature, neurogenic pulmonary edema 2. Goals: maintain normal hemodynamic parameters a) Failure does not necessarily mean donation cannot occur. b) Hemodynamic dysfunction controlled with early aggressive fluid resuscitation, thyroid hormone therapy and vasopressor therapy: (1) Ionotropin (dopamine) used for hypotension (2) Norepinphrine or epinephrine used after
3.
C. Loss of thermoregulation 1. Hypothermia most often seen a) Reduces cardiac output and organ perfusion 2. Hyperthermia occasionally seen a) Vasodilation and worsening of hypotension Goal: temperature maintained at 96°F to 100°F D. Fluid and electrolyte instability 1. Diabetes insipidus (DI) from pituitary gland ceasing functioning, antidiuretic hormone (ADH) not secreted a) Monitor fluid status (CVP or PAWP) b) Treatment goal: urine output maintained at 0.5–3 mL/kg/hr (1) Replacement ADH, desmopressin acetate (DDAVP). (2) Choosing correct IV fluid challenging. (3) Hyperosmolar diuresis can develop.
(4) Monitor serum glucose levels, treated appropriately. c) Potassium, calcium, phosphorus, magnesium lost, sodium retained (1) Monitor and replace as necessary E. Pulmonary dysfunction 1. Neurogenic pulmonary edema may occur: a) Crackles, pink frothy secretions, and a decreasing PaO2 and SpO2, chest X-ray shows “whited-out” lungs. b) Treatment goal: maintain the PaO2 above 100 mm Hg: (1) Ventilator support F. Hematopoietic dysfunction 1. Coagulopathies common from release of large amounts of tissue plasminogen activator (tPA) a) Monitor: hemograms, prothrombin time (PT), partial thromboplastin time (PTT), and international normalized ratio (INR) b) Treatment: blood or blood component therapy G. Loss of endocrine function 1. Shift from aerobic to anaerobic metabolism from loss of thyroid hormone, cortisol, insulin production a) Cellular death from oxygen-depleted myocardial cells b) Treatment: thyroid protocol to reverse this process; Levothyroxine (T4), Solu-Medrol, insulin, and 50% dextrose are given in a bolus; T4 drip continued throughout the organ recovery 2. Nursing considerations a) Unit nurse responsible for maintaining organ donor’s hemodynamic and physiologic status until patient is taken to the surgical suite for organ recovery b) Monitors status closely, intervenes as necessary
PowerPoint Slides 1. Maintain Organ Function When Brain Death Occurs 2. Table 38-1 3. Hemodynamic Instability 4. Loss of Thermoregulation 5. Fluid and Electrolyte Instability 6. Pulmonary Dysfunction 7. Hematopoietic Dysfunction 8. Loss of Endocrine Function
V. Organ Procurement A. Referral to the organ procurement organization 1. All imminent deaths referred to organ procurement organization (OPO).
2. OPO makes determination of suitability for organ donation, develops a plan of care with the medical staff. 3. Often emergency department or critical care nurse first identifies a patient as a potential organ donor. B. Determination of the patient’s suitability for organ donation 1. Type of death, general health status, age, weight, medical and social history, compliance with medical treatments 2. Medical and social history a) Illnesses and behaviors that affect function and transmission of diseases b) Cancer does not necessarily eliminate a person as a potential donor C. Obtaining consent 1. Uniform Anatomical Gift Act defines the order of priority. 2. If patient has not indicated a wish for donation in a legal document, responsibility of consent lies with the legal next-of-kin: a) Order of priority: spouse, adult children, parent, adult sibling(s), and guardian 3. Who obtains consent? a) Persons who are employed by the OPO or have received training from the OPO. b) Initial interactions focus on educating family’s of the patient’s brain injury, poor prognosis, imminent death. D. Donor testing 1. Serologic testing to determine absence or presence of transmittable diseases 2. Blood type and human leukocyte antigen (HLA) typing 3. Health history examined for possible organ problems 4. Each organ requires its own battery of tests 5. Specific algorithm matches each organ to a recipient a) Considerations: tissue and blood types, organ size, the potential recipient’s medical urgency, time on the waiting list, and the geographic distance between the donor and the potential recipient E. The organ recovery process 1. Organ recovery a) Donor to OR with required documentation (date and time of death declaration, consent form). b) Each transplant team receiving an organ may be present for the organ recovery. c) Patient is kept on mechanical ventilation with anesthesia to maintain hemodynamic stability. d) Abdominal surgical team begins the recovery process with an incision. e) Surgeon inspects for the presence of unexpected disease, begins the process of removing each organ. 2. Organ preservation a) When organs are ready to be removed: cannulas placed in the thoracic aorta, pulmonary artery, portal vein, and abdominal aorta; clamp placed on aorta
b) Perfusion of the organs with a cold preservation solution, blood removed c) Once removed, organ packed in preservative solution, sterile-triple-bagged, placed on ice, transported to the recipient’s hospital d) Cold ischemic time: window of time an organ can safely remain outside the body (1) Different for each organ
PowerPoint Slides 1. Organ Procurement Organization (OPO) 2. The Organ Recovery Process 3. Table 38-4
VI. The Organ Recipient: Immunologic Considerations A. Donor-recipient compatibility testing 1. Tissue typing: a) Identification of the HLA (histocompatibility) antigens of both the donor and the transplant candidate; evaluates degree to which the two sets of tissues are HLA matched (1) Histocompatibility: immunologic similarities between cells, allow the body to distinguish self from nonself (2) Human leukocyte antigens (HLA): cell surface antigens, identify histocompatibility (a) Twins have good HLA match (b) First-degree relations have good HLA match 2. Crossmatching a) Tests potential recipient for antidonor (preformed) antibodies. b) Evaluating degree of reactivity of the immune response of donor and recipient cells and serum: (1) Serum: sample of recipient’s serum exposed to serum from sample of donor's blood; analyzed for formation of preformed antibodies (PRA) (2) Normal value is 0%; prospective crossmatch performed immediately prior to the transplant with a PRA of 10% or higher c) Treatment modalities to suppress PRA: plasmapheresis, intravenous immunoglobulin (IVIg), immunosuppressant therapy. d) Candidate can become sensitized to foreign HLA antigens through prior organ transplantation, blood transfusions, pregnancy. 3. ABO typing a) Identifies the blood group of the donor and the transplant candidate b) Initial criterion for transplantation c) Type O: universal transplant donor type d) Type AB: universal recipient e) Types A and B: only from the same blood type or type O donors
PowerPoint Slides 1. Donor-Recipient Compatibility Testing
VII. Determination of Transplant Needed A. Primary eligibility: end stage organ disease; transplantation final option B. Clinical status 1. Organ-specific diagnostic studies and laboratory testing. 2. Preexisting or concurrent medical problems are considered. C. Nutritional status 1. Malnourished transplant candidates at high risk for perioperative complications 2. Nutritional intervention crucial in the pretransplant stage 3. Assessments: physical assessments, weights, anthropometric measurements, laboratory tests D. Psychosocial status 1. May adversely affect recipient outcomes: active psychiatric problem (especially mood disorders), history of poor adherence to treatment plan, inability to comprehend complex transplant management, problems of financial support 2. Stresses associated with organ transplantation strain the recipient’s coping abilities E. Financial status 1. Costs: 30 days pretransplant care, organ procurement, hospital admission, physician costs during transplant, 180 days posttransplant admission, immunosuppressant costs 2. Estimated average charges per transplant in 2011: $260,000 (kidney transplant) to more than $1,206,000 (intestine transplant) 3. Nonmedical costs: transportation to and from the transplant center, food and lodging, child care, lost wages 4. Many transplant programs offer financial and social services to the public, provide information and other forms of support F. Placement on UNOS waiting list 1. United Network for Organ Sharing (UNOS): charged with distributing organs in equitable and nondiscriminatory manner 2. Crucial that transplant candidate and family have thorough and realistic understanding of entire process, including its risks and benefits, waiting time, costs, expectations, tests, procedures a) Nurse key in providing information G. Waiting time 1. Hundreds, possibly thousands, of transplant candidates on waiting list for the same organ at any time 2. Waiting times vary widely, depend on the patient’s tissue and blood type, organ to be transplanted a) From 30 days on list to over 5 years 3. Allocation for kidney transplants: length of time on list; whether candidate is child; body size of donor and candidate; tissue match between donor and candidate; blood type; antibody types
H. Transplant resources and support 1. Online resources from national organizations a) E.g., National Kidney Foundation, American Diabetes Association
PowerPoint Slides 1. Primary Eligibility 2. Eligibility 3. United Network for Organ Sharing (UNOS) Waiting List 4. Table 38-7
VIII. Posttransplantation Complications A. Technical complications 1. Vascular thrombosis a) Blood clot in vasculature of graft, often major artery. b) May not be detected initially, patient frequently asymptomatic. c) Diagnostic testing may be performed soon after surgery. d) Early detection, immediate thrombectomy essential; even then, graft at high risk for failure. 2. Bleeding a) Managed same way as in other postsurgery patients b) Exception: liver transplants: (1) Bleeding may occur from surgical problem or secondary to coagulopathy from dysfunctional liver; difficult to determine which (2) Allow bleeding to continue until coagulopathy resolves with liver function returning or exploratory surgery if surgical reason assumed 3. Anastomosis leakage a) Anastomosis: site at which graft is sutured to patient. b) Failure of the anastomosis to seal completely results in leakage of fluids: (1) Inadequate healing from deficient blood supply or steroid therapy c) Usually require surgical repair B. Graft rejection 1. Hyperacute rejection a) Type III hypersensitivity response (B lymphocytes produce antibodies). b) Occurs within minutes to hours following transplantation from graft-specific or cytotoxic antibodies. c) Immune system recognizes foreign tissue, increases graft-specific antibody production; trigger the agglutination of platelets, complement system, phagocytic activities. d) Rare in U.S. because of donor-recipient screening. 2. Acute rejection a) Sudden onset, within days or months of transplant
b) Begins as a type IV hypersensitivity response (T lymphocytes and macrophages of the host attack and destroy the graft) c) Graft-specific cytotoxic antibodies produced, further aggravate rejection d) If recognized, treated promptly, organ function preserved 3. Chronic rejection a) Humoral immune response, antibodies slowly attack the graft b) May begin at any time following transplantation and may take years to render the graft nonfunctional (1) Organ becomes ischemic and dies. C. Immunosuppressant-related complications 1. Infection a) CREDIT framework: C—community acquired; R Anastomosis reactivated pathogens; E— epidemiologic exposures; D—Donor organ source; and I—iatrogenic infections; T—travelassociated infections b) Long-term immunosuppressant therapy with frequent use of antibiotics may precipitate fungal infection, development of resistant strains of pathogens (1) Cytomegalovirus (CMV) infection: may be mild or severe; severe can cause dysfunction of multiple organs c) Immunosuppressed patient unable to muster same response to acute infection as a person who is immunocompetent; infection subtle presentation (1) Fever primary symptom; also tachypnea, fatigue, tachycardia, pain 2. Organ dysfunction a) Some degree of graft dysfunction common immediately following organ transplantation. b) Nephrotoxicity and hepatotoxicity can occur with any organ transplant: (1) Especially serious in kidney and liver transplants 3. Malignancy a) Increased risk from: long-term immunosuppressant therapy, persistent viral infection (1) Immunosuppressants restrict detection, destruction of neoplastic cells. (2) Certain viruses associated with development of cancer. b) Most common: non-Hodgkin’s lymphoma, cancers of the lung, liver, and kidney, with the highest incidence in the transplanted organ (1) Cancers increased regardless of which organ transplanted c) May develop within 6 months to a year, or 10-15 years after transplantation 4. Posttransplant diabetes mellitus a) Relatively common complication b) Risk factors: older age, higher BMI following transplantation, positive family history for diabetes, use of steroid therapy or tacrolimus (immunosuppressant), hepatitis C infection , organ rejection, possibly CMV infection 5. Steroid-induced problems a) Common: steroid-induced hyperglycemia, significant weight gain, metabolic bone disease
PowerPoint Slides 1. Technical Complications 2. Graft Rejection 3. Immunosuppressant-Related Complications
IX. Immunosuppressant Therapy A. Calcineurin inhibitors 1. Inhibit interleukin-2 (IL-2) production, leads to suppression of cytotoxic T cells and B cells 2. Considered most effective of the immunosuppressant agents 3. Do not suppress bone marrow function 4. Adverse effects: renal toxicity, infection, cancer (lymphoma) 5. Cyclosporine: the major immunosuppressant agent for many years a) Highly incompatible with other drugs 6. Tacrolimus: newer drug, more powerful immunosuppressant a) More toxic, similar adverse effects (compared with cyclosporine) 7. Sirolimus: only for kidney transplants; in conjunction with cyclosporine and prednisone a) Hyperlipidemia notable side effect B. Glucocorticoids 1. Steroid hormones produced by adrenal glands 2. Prednisone commonly used as adjunct immunosuppressant 3. Administered in large doses posttransplant 4. Adverse effects: severe bone disorders, diabetes mellitus, cataracts, and others C. Cytotoxic agents 1. Capable of destroying target cells 2. Azathioprine: formerly drug of choice, no longer because of serious adverse effects 3. Mycophenolate mofetil (MMF): targets B and T lymphocytes, inhibits proliferation D. Antibodies (Monoclonal and Polyclonal) 1. Newer form of therapy 2. Foreign proteins derived from animals 3. May cause recipient antibodies to form against them, resulting in sensitization, possible development of serum sickness, anaphylactic reactions 4. Target lymphocyte subsets responsible for the immune rejection reaction 5. Muromonab-CD3: monoclonal, derived from mouse proteins, attacks T cells a) For organ transplants, preparation for hematopoietic stem cell transplantation b) “First-dose effect” may occur; anaphylaxis rare 6. Basiliximab and daclizumab: modified monoclonal antibodies, bind to the IL-2 receptors on T lymphocytes, preventing T cell activation a) In acute period of kidney transplant in conjunction with cyclosporine and glucocorticoid therapy
b) No “first-dose effect”; anaphylaxis possible 7. Lymphocyte immune globulin (antithymocyte globulin): reduces function of T lymphocytes a) For renal transplants; off label for aplastic anemia, GVHD, skin graft rejection prophylaxis b) Mild to moderate reactions can occur; anaphylaxis possible E. Nursing Considerations 1. Recipients have rigid, lifelong medication regimen 2. Risk factors for nonadherence: psychosocial, educational, age, medication, provider factors 3. Early identification of high-risk posttransplant patients, increased intensity of adherence monitoring
PowerPoint Slides 1. Calcineurin Inhibitors 2. Glucocorticoids 3. Cytotoxic Agents 4. Antibodies 5. Nursing Considerations
X. Hematopoietic Stem Cell Transplantation (HSCT) (“bone marrow transplantation”) A. Healthy stem cells infused into recipient with hematologic malignancy or bone marrow failure 1. E.g., leukemia, multiple myeloma, lymphomas, autoimmune disorders, aplastic anemia B. Allows patients to receive higher doses of chemotherapy C. Types of HSCT 1. Autologous transplantation: from own blood or bone marrow a) Blood/bone marrow must be free of malignant cells b) Advantages: perfect HLA match, reduced morbidity and mortality c) Disadvantages: increased potential for malignancy relapse 2. Allogenic transplantation: donor is not recipient a) Close HLA matching, siblings tested first, unrelated donor through registry b) Possible complications: host-vs.-graft (HVG) effect or graft-versus-host disease (GVHD) D. Sources of hematopoietic stem cells 1. Bone marrow a) Harvesting under general anesthesia, 2 hour procedure b) Volume depends on size, up to a liter c) Large-bore needle inserted multiple times d) Complications rare; bleeding, infection, localized discomfort possible 2. Peripheral blood a) Now more common source b) Stem cells: identified as CD34+, exist in low numbers in peripheral blood
c) Growth factors increase stem cells in circulation (1) Granulocyte colony-stimulating factor (G-CSF) (Filgrastim) d) Apheresis: harvesting method, can be performed in ambulatory setting, 3–4 hour procedure, no anesthesia e) Cells can be frozen for extended periods E. Transplanting procedure 1. Preparing for HSCT a) Eradicating disease (1) High dose chemotherapy, possible radiation therapy including total body irradiation (TBI) b) Immunosuppressant therapy: to prevent graft rejection 2. Stem cell delivery and engraftment a) Simple transfusion process, central line in large blood vessel. b) Donor stem cells migrate to bone marrow. c) Period of waiting for engraftment can take as long as 5 weeks. 3. Post-HSCT complications a) Graft failure: marrow does not successfully graft: (1) About 1 to 5% of autologous grafts and 5 to 20% of allogeneic grafts fail. b) Outcomes depend on patient’s overall clinical status, age, disease process, and compatibility with the donor. c) Graft-vs-host disease: donor marrow attacks patient’s tissues: (1) Donor T-cells see recipient's tissue as nonself, attack (2) Can be acute or chronic (3) Difficult to treat, prophylactic therapy used F. Management of the immediate post-allogenic HSCT patient 1. Until engraftment occurs, patient at extreme risk of contracting fatal infections a) Protective environment needed 2. Nursing considerations a) Focus: prevention of complications b) With low bone marrow function anemia (erythrocytopenia), infection (leukopenia), and bleeding (thrombocytopenia) possible c) Complete blood count (CBC) monitored for bone marrow status d) Meticulous hand hygiene, protective clothing worn e) Psychosocial support
PowerPoint Slides 1. HSCT 2. Types of HSCT 3. Sources of Hematopoietic Stem Cells 4. Transplanting Procedure
5. Nursing Considerations for Immediate Post-Allogenic HSCT Patient
XI. Kidney Transplantation: An Overview A. Almost 80% of all organ transplantations B. Major indications for renal transplantation 1. End-stage renal disease (ESRD) a) Most commonly caused by: hypertension, diabetes mellitus, glomerulonephritis C. Preparation of the recipient 1. With living donor, admission to hospital a day before surgery 2. With deceased donor, preparation much shorter 3. Preoperative hemodialysis to normalize fluid and electrolyte balance 4. Crossmatching before surgery a) Negative results: initial immunosuppressant dose, prophylactic antibiotics D. Postoperative management 1. Intensive care unit for 24 hours, close monitoring. 2. Risks for complications higher with deceased than living donors; highest when the graft has undergone long cold ischemic time. 3. Renal ischemia may lead to acute tubular necrosis, causes oliguria or anuria: a) Hemodialysis may be necessary until the graft begins functioning sufficiently. 4. Recovery takes about 2 weeks. 5. Hypertension common; antihypertensive agents used. 6. Nutrition status considered. 7. Evaluation of kidney function: a) Laboratory tests b) Needle biopsy using ultrasound to look for hydronephrosis, obstruction, or collections of fluid c) Renal scan using radioactive isotropes 8. Postrenal transplant complications a) Graft rejection most common. b) One-year graft survival rate for deceased donor is about 93 %. c) Living-donor transplants, survival rate is about 97%.
PowerPoint Slides 1. Renal Transplantation 2. Postoperative Management 3. Evaluation of Kidney Function
XI. Chapter Summary XII. Clinical Reasoning Checkpoint XIII. Post Test XIV. References
Suggestions for Classroom Activities • Discuss the preoperative and postoperative procedures for each type of organ transplant. • Review the history of each type of organ transplant. What are some of the reasons why progress was made in transplanting certain organs prior to transplantation of others? • Discuss the potential problems to specific organs that might occur as brain death approaches. • Discuss the major categories of immunosuppressant drugs. Which drugs that are currently in use have replaced older drugs? What have been the benefits of these replacements?
Suggestions for Clinical Activities • In an organ transplant unit, review pre- and postoperative nursing management notes for specific patients. • Obtain a copy of the documents used to counsel the family members who are considering making an organ donation for their family member. • Invite a representative from the organ procurement agency to come to speak with the class about the work that he or she does. • Visit a hospital transplant unit. Review patient records for information about complications of the transplant. Discuss with nursing staff.
Chapter 1 \\ MC A \ The patient who had surgery yesterday reports his chest feels tight. Assessment reveals respiratory rate of 29, inspiratory wheezes, stridor, and an oxygenation saturation of 80%. The nurse would consider this patient to be which priority for transfer to the intensive care unit (ICU)? \ Priority 1 \ Priority 2 \ Priority 3 \ Priority 4 \ \ This patient is exhibiting signs of an acute respiratory event for which intubation or other intensive treatment may be necessary. Priority 1 patients are acutely ill and need intensive treatment and monitoring not provided outside of the ICU. Priority 2 refers to patients needing intensive monitoring and may potentially need additional interventions. They are typically not evolving an acute event as is the case with this patient. Priority 3 patients are critically ill but have little chance of recovery from their illnesses. Limits are placed on therapeutic interventions and they can be cared for in areas other than the ICU if necessary. Priority 4 patients have no signs or symptoms that indicate intensive monitoring or treatment are necessary. \ 0 0 0 0
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\\ MC C \ The daughter of a patient who is dying questions the placement of her father on the medical–surgical care unit (MSCU). She requests he be placed in the intensive care unit (ICU) because of concern her father may not receive close observation on a busy hospital unit. Which action is indicated by the nurse? \ Notify the intensive care unit of an impending transfer. \ Tell the daughter that her father does not meet criteria for placement in the more expensive ICU. \ Discuss the care that can be provided on the unit with the family member. \ Contact the physician. \ \ The nurse cannot make this transfer decision independently. Telling the daughter that her father does not meet criteria for transfer is not therapeutic. Bringing up the issue of cost may cause the daughter to offer to pay the difference between the costs of the two units. This would create a serious ethical dilemma. The best initial response is to help the daughter understand the level of care and observation that will be provided on the MSCU so as to help her understand that her father’s care will be a priority. The nurse should try to intervene in this situation before involving the physician. \ 0 0 0 0
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0 \\ MC A \ A nurse who is contemplating taking a position in an intensive care unit is reviewing her strengths and weaknesses. Which characteristics of the nurse will be of the greatest benefit in the intensive care environment? \ Feels comfortable in ever changing situations \ Closely evaluates the pros and cons of each decision for a long period of time before making a decision \ Is quiet and introverted \ Is excited about all new experiences \ \ The nurse in the intensive care unit must be open to ever-changing situations. The nurse must be flexible. The rapid changes in the intensive care unit do not allow for extended time when considering actions. A quiet and introverted nurse may not be a good match for the high paced high-acuity care unit due to the need for teamwork and interaction. Excitement about all experiences is a beneficial characteristic in healthcare but is not the most important factor for this particular care unit. \ 0 0 0 0
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0 \\ MC D \ The registered nurse is working as charge nurse on a busy high-acuity care unit. Unexpectedly, a coworker becomes ill and needs to leave. There is a period of time in which the unit is short staffed while the ill coworker's replacement travels in to work. What action by the charge nurse is indicated? \ Make no changes until the replacement nurse arrives. \ Assign the less acute patients to be cared for by the unlicensed assistive personnel. \ Assign the unlicensed assistive personnel to watch the monitors and call for help if a patient "gets into trouble." \ Contact the house supervisor and ask for a float nurse to be sent to the unit. \ \ The unit is understaffed. Replacement help must be provided. It is inappropriate to wait for the replacement nurse. The unlicensed assistive personnel are only able to provide care under the direct supervision of the nurse. Watching monitors is not within the job description of the unlicensed assistive personnel and is not appropriate. The manager would be putting both patient safety and the unlicensed assistive personnel at risk. The manager should obtain help until the replacement nurse arrives. Contacting the house supervisor and asking for a temporary float nurse is the best intervention. \ 0 0 0 0
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0 \\ MC C \ A recent nursing school graduate reports having an interview with a magnet hospital. When preparing for the interview, the graduate nurse researches the concept of magnet status. Which perceptions by the nurse indicate an adequate understanding? \ Magnet status is an accreditation from the National League for Nurses. \ Magnet status facilities pay substantial recruitment bonuses. \ Magnet status facilities promote the interests of professional nursing. \ Magnet status hospitals must establish nurse-to-patient ratios. \ \ Magnet status is a designation developed by the American Nurses Credentialing Center. Facilities with magnet designation attract nurses because of their work environment. Often there is no need to pay recruitment bonuses. Magnet status is awarded to hospitals that are able to prove their commitment to professional nursing practices. Nurse-to-patient ratios are not part of the magnet hospital designation. \ 0 0 0 0
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0 \\ MC D \ A team of nurses would like to research outcomes of intensive care that expand beyond those that are normally studied. This team would recognize which outcome as most commonly studied? \ Patient comfort \ Patient perceived quality of life \ Functional status \ Mortality \ \ Patient comfort is a very important outcome, but is not the one most commonly studied. Quality of life after intensive care is a very important outcome, but is not the one most commonly studied. Functional status after treatment in the intensive care unit is a very important outcome, but is not the one most commonly studied. Mortality is the most commonly studied outcome of intensive care treatment. \ 0 0 0 0
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\\ MC A \ A newly employed nurse is working with an experienced registered nurse. During the shift, the experienced nurse routinely uses her personal digital assistant. How would the nurse explain the use of this device to the novice nurse? \ “I use my PDA as a reference tool several times every day.” \ “I can access my patient’s old medical records on this PDA.” \ “I use my PDA to let the pharmacy know when I need medications.” \ “I use my PDA to write nursing notes.” \ \ The personal digital assistant (PDA) is used to provide quick bedside information to the nurse. The patient’s personal medical records would not be accessible through the PDA. The PDA would not be useful for this application. The nurse should not record nursing notes on the PDA. \ 0 0 0 0
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MC C \ A nurse says, “I worry that all of these machines in the intensive care unit interfere with my ability to to establish a therapeutic relationship with my patients.” What response by the nurse manager is indicated? \ "Technology improves our patient outcomes." \ "I completely understand how you feel." \ "There are ways to increase your interaction with your assigned patients." \ "These feelings may be a sign that this is not the work environment for you." \ \ Technology does improve outcomes but the nurse has more immediate concerns. Telling the nurse that "you understand" his feelings does little to meet his need for education. The use of technology can lead the nurse to feel distanced from the patient. There are strategies the nurse can use to personalize care. He should be reminded that the use of machines does not take away the need for nursing assessment and care. It is premature to decide that this nurse is not suited to the intensive care work environment. \ 0 0 0 0
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\\ MC D \ A recently hired nurse has been overheard saying she does not need to check as closely on her assigned patients as there are many machines that will "just do it for you." What action by the nurse manager is indicated? \ The nurse manager should plan a skills check off for the nurse. \ The nurse should have a notation placed in her file indicating a lack of due care to assigned patients. \ The manager should issue a verbal warning to the nurse. \ The nurse manager should discuss assessment priorities with the nurse. \ \ At this time the nurse has not demonstrated a lack of clinical ability and a skills check off is premature. It is premature to give a written or verbal warning to the nurse. It is premature to give a written or verbal warning to the nurse. The use of technology must be accompanied by nursing care and assessment. Failure to provide hands-on care may reflect over-reliance on technology. The nurse manager will need to assess the nurse's perceptions of responsibilities related to these areas. \ 0 0 0 0
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0 \\ MC A \ The nurse who transferred to the intensive care environment 6 months ago tells the nurse manager that she feels "burned out." The nurse voices curiosity about how this could happen after such a short time in the unit. The charge nurse's response should contain which information? \ Burnout is not limited to long-term exposure to a work environment. \ Burnout cannot be predicted. \ The nurse most likely is not a good candidate for the intensive care unit. \ The nurse is having a delayed response to change in work environment. \ \ Burnout may result not only from remaining in a work environment for a long period of time but also from working in a stressful environment in which a great deal of flexibility is expected and patient conditions change rapidly. Burnout can be predicted to occur in high-stress work environments. The nurse may be a good candidate to work in the intensive care unit if techniques to manage stress and feeling of burn-out are learned. There is no indication the nurse is reacting to the change itself, but rather to the stress in the new environment. \ 0 0 0 0
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\\ MC A \ A group of nurses have been asked to meet with the emergency department manager for stress debriefing after working an accident in which several children were killed. One of the nurses says, “I don’t know why this is necessary. We are all comfortable with our role in trying to save those kids.” What response by the manager is indicated? \ “We need to meet so everyone can share their feelings about our response.” \ “I thought we could use this situation to discuss who would be the best nurse to act as charge nurse when I am away from the department.” \ “We need to meet so that you will have documented stress management education for your next pay raise consideration.” \ “We need to review everyone’s actions during the incident to be sure that no one did anything wrong.” \ \ Debriefing sessions are used to allow the nurses a confidential location to explore their feelings and discuss the experience. These sessions are an effort to prevent stress related burnout. This debriefing session should focus on the incident, not on future department plans. This meeting should focus on response to the incident. The benefits of the meeting should not be devalued as “documentation” for future pay raise considerations. Reviews of actions during incidents are conducted, but this is not the purpose of a critical stress debriefing. \ 0 0 0 0
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\\ MC D \ The nurse executive is planning education for new nurse managers regarding the AACN Standards for a Healthy Work Environment. Which information should be included? \ The critical partners in the organization are physicians, members of the administration, and nurse managers. \ Staff nurses must embrace authentic leadership and value it to ensure an effectively running patient care unit. \ In critical care units the need for expert clinical skills is more important than simple communication skills. \ True collaboration must be promoted to ensure a healthy work environment. \ \ The AACN standards indicated that nurses must be valued and committed partners in making policy, directing and evaluating clinical care, and leading organizational operations. The nurse leader must embrace authentic leadership and lead by example to ensure effectively running patient care areas. Communication skills and clinical skills have equal importance. The AACN Standards for a Healthy Work Environment stress the value of true collaboration. \ 0 0 0 0
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\\ MC C \ A nurse who made an error is concerned about what will happen when the mistake is brought to light. What information should the nurse manager provide to this nurse? \ "If an error is small I see no reason to report it." \ "All errors are serious and will likely result in some disciplinary action." \ "No one likes to admit errors but reporting helps others avoid the same mistake." \ "Errors are human and there is no need to dwell on them." \ \ Errors both large and small must be reported. Errors are serious, but there is not enough information to determine if disciplinary action will be necessary. The current culture of health care considers error reporting the responsible action to take. Awareness of errors is a way to initiate performance improvement. Errors are human, but it is important to process the information concerning the error, as it will prevent them from happening in the future. \ 0 0 0 0
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\\ MC D \ While orienting to the critical care unit, the newly hired nurse notices that the preceptor is using a tablet computer during medication administration. The new nurse says, “That looks awkward and time consuming.” How should the preceptor reply? \ “It is awkward but it is required and I am getting accustomed to it.” \ "I use it to make certain I am medicating the right patient." \ "Using a tablet computer actually increases the speed at which I can deliver care." \ "I use the tablet computer to check on dosing and side effect information when I am giving new medications." \ \ The preceptor should not focus on the difficulties associated with using a table computer. The tablet computer will not help prevent “wrong patient” medication errors. The purpose of using a tablet computer is not to increase the speed of care. The nurse can use a tablet computer for many activities, including checking drug information. \ 0 0 0 0
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\\ MC D \ A group of nurse managers are concerned about a series of recent errors made by several nurses in the critical care units. The mangers should advocate for which change to help promote patient safety? \ Increased unlicensed personnel for the unit \ Reduction of the presence of managerial input to encourage staff nurses to assume responsibility for outcomes \ Pay increases to attract better nurses \ Increase in the number of nurses on the unit who have baccalaureate degrees \ \ Having sufficient help is important but reduction of errors is more closely linked to higher nurse–patient ratios. The unit experiencing errors will need more nurse manager input not less. Pay is not linked to reducing nursing errors. Facilities with higher numbers of nurses educated at the baccalaureate level or higher have lower mortality rates. Having well-educated nurses leads to lower accident rates. \ 0 0 0 0
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\\ MC A+C+E \ The nurse manager of an emergency department has been notified that a patient is being transferred from a rural ED. What should the manager check before responding to this notification? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Has a physician at this hospital agreed to accept the patient? \ Does the patient have insurance? \ When is the patient supposed to arrive? \ Is the patient likely to survive transfer? \ Is a bed available in the appropriate unit to provide care for the patient? \ • In order for a transfer to occur legally a physician at the receiving hospital must agree to accept the patient. • The patient’s insurance status is not a part of the decision-making tree. • The receiving hospital must be made aware of the estimated time the patient will arrive. • Therapeutic interventions to minimize complications in route must be taken, but there is no guarantee of survival through the transfer. • Bed availability in the receiving hospital is a consideration before transfer. \ 0 0 0 0
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\\ MC B+C+E \ Every bed in the intensive care unit is occupied when a call comes from the emergency department about admitting a patient who was critically injured in an explosion. Which patients would the manager evaluate as a possible transfer to a less acute unit? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ A 70-year-old man who remains hemodynamically unstable after cardiac surgery yesterday \ A 48-year-old patient who was admitted for diabetic ketoacidosis whose blood glucose is now 240 mg/dL \ A 40-year-old patient admitted for an unintentional overdose of blood pressure medication who is now conscious and alert \ An 18 year-old patient who developed a pulmonary embolism this morning and is being mechanically ventilated \ A 40-year-old patient with severe sepsis secondary to renal failure for whom the family has requested “no code” status \ • Age alone does not determine whether or not this patient should be transferred out of the ICU. The patient is hemodynamically unstable so intensive care is justified. • This patient is more stable now and may be able to tolerate transfer. The manager should contact the physician about transfer to a step-down unit. • This patient can likely be cared for adequately in a lower intensity unit. • In some facilities mechanical ventilation can be managed in a lower acuity setting, however this patient is still in the emergent phase of pulmonary embolism and requires intensive care. • If intensive care level interventions such as mechanical ventilation and cardiopulmonary resuscitation are refused, the patient generally can be cared for in a less intense environment.
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0000000000 0000000000 0 \\ MC A+C \ Which actions would the charge nurse evaluate as indicating “alarm fatigue” in a nurse who works in an intensive care unit (ICU)? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ The nurse completes measuring a patient’s urine before responding to a ventilator alarm in the next cubicle. \ The nurse says, “Would you check this patient’s IV? The controller alarm keeps sounding.” \ The manager discovers deactivation of a heart rate alarm in the rooms of two patients assigned to the nurse. \ The nurse responds to the wrong cubicle when a ventilator alarm sounds. \ The nurse responds to an alarm while saying, “I wish this patient would stop moving his arm around. It makes his IV alarm sound.” \ • Ignoring alarms may result from “alarm fatigue.” • This nurse is responding to the alarm, so “alarm fatigue” is not evident. • If the alarm was deactivated in one room, an error may be to blame. Deactivation in two rooms increases the probability that the deactivation was intentional. Intentional deactivation of alarms can be caused by “alarm fatigue.” • In a unit where alarms sound frequently it is possible to respond to the wrong cubicle. This would not indicate alarm fatigue.
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There is no indication that the nurse is ignoring the alarm or is intending to disable the alarm, so “alarm fatigue” is not yet a critical issue.
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0000000000 0000000000 0 \\ MC A+B+D+E \ The charge nurse is concerned that a nurse may be developing “burnout” from work in the intensive care unit. Which behaviors would the charge nurse watch for in this nurse? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ The nurse is drinking more coffee than earlier in the year. \ The nurse has gained a noticeable amount of weight in the last 6 months. \ The nurse volunteers to precept a newly hired nurse. \ The nurse says, “I’m not going to take care of stupid drug addicts anymore.” \ The nurse has made two minor medication errors in the last week. \ • Increased use of caffeine may be an indicator of burnout. • Appetite changes resulting in weight gain or weight loss are findings associated with burnout. • The nurse suffering burnout would be more likely to show lack of initiative and to be unwilling to take on additional responsibilities. • Stereotyping patients is a sign of burnout. • Forgetfulness, poor judgment, and decreased ability to make decisions are all symptoms of burnout.
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0000000000 0000000000 0 \\ MC B+C+D \ During the formal time-out process before beginning bedside placement of a transvenous pacemaker, the nurse identifies a piece of equipment that is not working. What actions are indicated? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Ask the physician if the equipment is necessary for the procedure. \ Replace the equipment. \ Tag the equipment as faulty. \ Report the faulty equipment. \ Quickly try to diagnose what is wrong with the equipment. \ • If the equipment is supposed to be present for the procedure it should be present in good working order. • The nurse should replace the faulty equipment with one that is working. • The piece of equipment should be clearly marked as faulty until it is repaired. • The faulty equipment should be reported to the department charged with its maintenance and repair. • Equipment that is not working should be repaired by persons with expertise in that repair. The nurse should not try to repair medical equipment.
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Chapter 2 \\ MC A \ The spouse of a patient recently diagnosed with terminal cancer has voiced concerns about her husband's continual denial of his disease. What should the nurse consider when planning a response to this concern? \ It may be helpful for the patient's emotional state at this time to be in a state of denial. \ Denial is abnormal and the patient needs to have a consultation with a therapist. \ It will be helpful to plan an intervention to force the patient to acknowledge his disease. \ There is a limited amount of time left in the patient's life so the denial must be rapidly worked through. \ \ It is believed that denial may be therapeutic as it allows the patient to have a removal from worry. Denial is a normal state experienced by patients having critical diagnoses. It is not therapeutic to force the patient to acknowledge his disease. Each patient will work through denial at an individualized pace. It is not therapeutic to rush this stage. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ A patient in Suchman's awareness stage has become argumentative and demanding. The nursing staff is becoming frustrated with the behaviors. What actions by the nurse are indicated? \ The nurse should accept the behaviors and attempt to open the lines of communication.
\ Rotate the nursing assignments frequently to limit each nurse's exposure to the behaviors. \ Confront the patient about his demeanor. \ Consolidate care so the nurse is in the room for shorter periods. \ \ The patient is acting in a manner consistent with the stage of awareness. The patient is attempting to exert control over the situation and will benefit most from a supportive environment. Rotating nursing assignments interrupts the therapeutic environment this patient requires. Confrontation is not indicated at this time. The patient needs to move through this stage of illness with support and understanding. This patient needs support to work through these feelings. Reducing the amount of time the nurse is in the room does not allow for interactions that may help with this process. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+E \ A patient says, “I’ve been hearing about aromatherapy as part of treatment for serious illness. What do you think about me trying it?” Which nursing responses are indicated? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ “Some studies have shown that using lavender oil can reduce anxiety.” \ “I would focus my energy on more traditional forms of healing.” \
“Other than jasmine oil, you are probably safe using aromatherapy.” \ “You should discuss this plan with your physician before purchasing anything.” \ “I know that some massage therapists use essential oils.” \ • Some small, limited studies have shown lavender oil to reduce stress and anxiety in acutely ill patients. • Some studies have shown that some oils do help to reduce stress and anxiety in acutely ill patients. The nurse should not devalue this patient’s attempts at self-help. • Jasmine oil has been shown, in small studies, to reduce stress and anxiety in acutely ill patients. • The nurse should be able to discuss this topic with the patient. • These oils may be inhaled or used as an enhancement to massage therapy. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ A newly licensed nurse has overheard a nurse telling a patient a joke. The nurse tells the preceptor, "I don't think that nurse is being respectful of the patient's diagnosis by telling jokes." What response by the preceptor is indicated? \ “When you have more experience you will understand the value of a good joke.” \ "We try not to eavesdrop on other nurse’s conversations with patients." \ "Some times that nurse’s jokes do get old.” \ "Sometimes laughing and joking can help us connect better with the patient." \ \
The preceptor should discuss the value of humor without demeaning the newly licensed nurse’s level of experience. The preceptor should address the newly licensed nurse’s concerns as this is a teaching opportunity. The preceptor should not make any statements that could be interpreted as critical of the nurse since the preceptor is not aware of the nurse’s intent. The nurse and patient were engaging in humor. Humor can be used to lighten the moment and is associated with positive patient outcomes. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+B+D+E \ A patient is being kept on bedrest during treatment for deep vein thrombosis. The patient is uncomfortable because being in bed is stressful and has made his arthritis worse. Which complementary and alternative therapies might the nurse suggest to help treat this discomfort? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Aromatherapy \ Therapeutic humor \ Massage \ Guided imagery \ Music therapy \ • The scents of lavender and jasmine have been shown in some studies to help reduce stress and anxiety.
• • • •
Watching comedies on television or reading humorous books may help distract the patient from discomfort. Because this patient is being treated for deep vein thrombosis, massage is not indicated. Guided imagery may help the patient relax. Music may help distract the patient from discomfort. Music can also be calming.
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0000000000 0000000000 0 \\ MC A \ A patient is being treated for a massive myocardial infarction. His wife has just arrived in the emergency department and grabs the nurse’s arm demanding to know what is happening. Which initial nursing response is indicated? \ “Your husband needs my full attention right now.” \ “Someone call security.” \ “Take your hands off of me.” \ “Please go back to the waiting area.” \ \ The patient's physiological needs take precedence over the psychological needs of the spouse. There is no indication that security is needed at this time. There is no indication that security is needed at this time. Telling the wife to go back to the waiting room is not the best nursing response. She does have the right to information about her husband. \
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0000000000 0000000000 0 \\ MC A \ A newly licensed nurse says, “Every time I go into my trauma patient’s room his wife asks the same questions about his medication.” How should the preceptor evaluate this statement? \ Anxiety about the husband’s condition has affected the wife’s ability to retain information. \ The preceptor should present the information so that it is more understandable. \ When serious injuries have occurred, new nurses often make the mistake of talking to the patient instead of the family. \ The nurse and wife are not communicating well with one another. \ \ When faced with serious illness or injury, patients and their families are stressed and may have problems retaining information presented. There is no indication that the nurse did not present the information well. The nurse should talk to the patient, so this is not a mistake. The information should be directed to the patient and the family. There is no indication that the nurse is not attempting communication with the wife. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ The nurse is attempting to provide discharge teaching to a patient recently diagnosed with a terminal illness. The patient says, “I would rather talk to my usual nurse about my discharge.” What action by the nurse is indicated? \ Ask the patient to sign a refusal of information form. \ Continue to provide the information to the patient. \ Ask the patient what efforts could be taken to make him feel more comfortable. \ Contact the health care provider. \ \ The nurse is responsible to attempt education of this patient and would not simply ask the patient to sign a refusal form. Forcing the information on the patient would be counterproductive and cause more anxiety. The patient is not feeling secure. Acutely ill patients need to feel comfortable and secure in order to learn. There is no reason to contact the health care provider. \ 0 0 0 0
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0000000000 0 \\ MC B+C+E \ The nurse is conducting assessment on a patient who appears to be of Asian ancestry. Which questions are indicated? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ “How long have you been in the United States?” \ “How do you describe your ethnicity?” \ “How does your culture influence your health care choices?” \ “Do you speak English or do I need to try to find an interpreter?” \ “Would you like for someone from your family to be in the room during your assessment?”\ \ • This question is premature until the nurse determines if the patient was not born in the U.S. • The nurse should base discussion of culture and ethnicity on the patient’s self-description. • This is an open-ended question that allows the patient to either list some examples or to say there are no influences. • This statement could be interpreted as indicating that accommodating language differences is a problem. The nurse should be able to assess for the need for an interpreter and should provide this service if necessary and possible. • The nurse should ask about the desire for family presence. This is part of determining the patient’s support system. \ 0 0 0 0
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0000000000 0 \\ MC C \ A nurse questions why socioeconomic status has been included in the admission assessment form.What response by the nurse manager is most appropriate? \ Socioeconomic status helps the business office determine the likelihood of receiving payment. \ Socioeconomic status will provide helpful information in choosing a room and roommate for the patient. \ Socioeconomic status may provide information about previous access to care. \ Socioeconomic status will reveal the patient’s health care priorities. \ \ While the ability to manage hospital related costs might be impacted by the socioeconomic status it is not the primary reason for the assessment. Roommate selection is not the focus of this line of questioning. The socioeconomic status of a patient will provide information about the health care beliefs and access to health care. The patient’s socioeconomic status does not automatically determine health care priorities. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+B+C+E \
The nurse manager is holding educational sessions to improve staff nurse competency in providing culturally sensitive care. Which myths will the manager identify in these sessions? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Cultural competence increases the cost of the nursing care provided. \ Cultural competence is difficult to achieve when working with patients who are victims of trauma or violence. \ Cultural competence is focused on providing sensitive care to minorities. \ The first step of cultural competence is self-awareness. \ The nurse who provides the same level of care to every patient is providing culturally competent care. \ • There is no reason that providing culturally competent care will increase the cost of nursing services. • The nurse can provide culturally competent care to any patient with any illness or injury. • All people have a culture and have the right to be cared for in a culturally competent manner. • The nurse must be aware of personal thoughts and feelings in order to provide culturally competent care. • Culturally competent care requires differences in the kind and amount of care provided. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ Which interventions would the nurse use to help the patient get at least 2 hours of uninterrupted REM sleep? \ Work with ancillary services such as physical therapy to establish a predictable routine. \
Keep the lights in the unit dim at all times. \ Turn alarms down or off during sleep periods. \ Restrict visitation to a short time in the morning, the afternoon, and evening. \ \ If the nurse is aware of the routine times ancillary services will be provided, nursing care can be arranged to allow for the patient to have extended rest periods. The health care team must be able to see the patient well during assessment and care. Dimming the lights during portions of the day and night is indicated, but keeping the dim at all times in not possible. The nurse should never turn alarms off. Alarms must be loud enough to allow the nurse to hear them from areas outside the room. Strict visitation rules are not necessary, but the nurse might suggest visiting at another time if the patient is resting. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ A patient has decided to explore palliative care. After this decision is announced, the nurse notices that not all of the disciplines of the health care team seem to be supportive of the decision. What action by the nurse is indicated? \ Contact the physician to report the discrepancies in the plan of care. \ Discuss the patient’s wishes in the next multidisciplinary meeting. \ Develop a plan of care and distribute it to the other disciplines of the health care team. \
Advise the patient to contact the social services department. \ \ Calling the physician does not address the need for the differing disciplines to work together to benefit the patient. When a patient seeks palliative care, a multidisciplinary team should meet to formulate the plan of care. Distributing the plan of care without input from all of the participating fields will be ineffective and does little to promote collaboration. The social services department may be represented on the team but the patient does not have the responsibility to contact them. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ The family of a critically ill patient reports to the nurse concerns that none of the health care team members seem to be listening to their wishes. Which nursing response is indicted? \ “You have to stand up for yourself and for your loved one.” \ “It is time for us to meet in a patient care conference.” \ “I will talk to the hospital administrator about your complaint.” \ “I know this whole thing has been very hard on your family.” \ \
The family is in a time of crisis and should not be required to “stand up” for themselves and the patient. A patient care conference is indicated to ensure that all members of the health care team are communicating actions. The nurse should not characterize this report as a complaint; it is a statement of the facts as they are perceived by the family. There is no reason to contact the administrator as steps to correct this problem can begin at the unit level. Offering emotional support is important but does not address the root cause of the problems being perceived by the family. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ The charge nurse on a busy high-acuity care unit is reviewing the plan of care for four patients. The nurse would evaluate that which patient is at highest risk for sensory perceptual alterations (SPAs)? \ 52-year-old male patient who has been hospitalized for complications related to diabetes \ 41-year-old female patient admitted with severe abdominal pain \ 65-year-old male patient diagnosed with pulmonary embolism. \ 79-year-old female patient who is unresponsive after a stroke \ \
The patient is at risk for SPAs because of being cared for on a high-acuity unit. However, the patient’s diagnosis does not put him at highest risk in this group. The patient is at risk for SPAs because of being cared for on a high-acuity unit. However the diagnosis and age do not put her at highest risk in this group. This patient is at risk for SPAs because of being cared for on a high-acuity unit. However this diagnosis does not put him at highest risk in this group. Patients who are very young, very old, and postoperative or unresponsive are at the greatest risk for experiencing sensory perceptual alterations (SPAs). The 79-year-old patient is at the greatest risk as a result of age and diagnosis. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+B+C+E \ The nurse manager is planning an educational program to address noise levels on the unit. What information should be given about the recommended noise levels? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ It is recommended that noise levels in the hospital should be below 45 dBA during daytime hours. \ Normal conversation exceeds the recommended daytime noise level. \ At night it should be quieter, no more than 35 dBA are recommended. \ The recommended noise levels in high-acuity areas are higher due to increase noise from alarms and machines. \ The biggest patient complaint about noise is in regard to staff conversation. \
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The Environmental Protection Agency recommends hospitals maintain noise levels of 45 dBA during the day. Normal conversation is around 60 dBA, which exceeds the recommended daytime level in the hospital. The Environmental Protection Agency recommends that hospitals maintain noise levels no higher than 35 dBA at night. The Environmental Protection Agency has set levels for hospitals in general. Patients complain that staff conversations wake them from sleep.
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0000000000 0000000000 0 \\ MC A \ The wife of a critically ill patient asks the nurse for help in making end-of-life care decisions for her husband. What action by the nurse is indicated? \ Encourage the wife to recall any discussions with her husband about his wishes. \ Encourage the wife to discontinue aggressive medical treatments as soon as possible. \ Tell the wife what most other families have done in similar situations in the past \ Refer the wife to social services for information about end of life. \ \ The nurse should refer to the patient’s wishes as being of utmost importance. The nurse should not offer advice about end-of-life decisions, but rather should offer information. The actions taken by other families are not pertinent to this family. The nurse should be prepared to discuss end-of-life issues with the family. Referral to social services is not necessary for this discussion. \
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0000000000 0000000000 0 \\ MC A \ The nurse has been assigned to care for a patient who is unresponsive. The patient has no living will and the family has requested no resuscitative measures be implemented. No “do not resuscitate” order has been written and the nurse feels confident that life saving measures would likely be successful if implemented. What action by the nurse is indicated if this patient suffers a cardiopulmonary arrest? \ Begin resuscitation interventions. \ Discuss the situation with the unit manager. \ Contact the hospital attorney. \ Tell the family that resuscitation efforts are indicated and would likely be successful. \ \ Since there is no living will, the nurse must begin resuscitation interventions if indicated. Discussing the situation with the unit manager does not relieve the nurse of the responsibility of attempting resuscitation. At the time of need for resuscitation it is too late to discuss an action plan with the unit manager. It would be inappropriate for the nurse to contact the hospital attorney. The nurse should not share these beliefs with the family. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A patient has decided to forgo additional treatments for his terminal disease. The patient has presented a valid living will. The family is unhappy and tells the nurse they think the patient made the decision as a result of his depression. What response by the nurse is indicated? \ "You need to let him make his own decisions." \ "Do you think if we talked to him he would change his mind?" \ "My role is to assure your loved one’s wishes are followed." \ "You need to talk to his physician about revising the do not resuscitate order.” \ \ This statement is not the most therapeutic and does not address the family’s concern. To encourage the family to try to change the family member's mind actually encourages them to pressure the patient at this serious time. This is not an action of a true patient advocate. The nurse must act as an advocate for the patient and uphold his documented requests. Referring the family to the physician to overturn the plans is not correct. A conference, however, may be indicated. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ A nurse manager has recently held an educational program regarding palliative care for newly hired nurses on the high-acuity care unit. Which statement by a participant indicates the need for further education? \ "The goals of medical care should be included in the palliative plan of care." \ "Advanced directives are not included in the palliative plan of care." \ "The plan of care should ensure the wishes of the patient at the time of death." \ "The palliative care plan should seek to ensure the patient and family understands the disease status." \ \ Medical care goals are included in the palliative plan of care. The goals are no longer curative, but are focused on quality of life. Patient and family-centered decision making is a domain of palliative care. The nurse making this statement requires additional education. The focus of palliative care is that the patient’s wishes are honored. Education regarding the disease process is an essential part of the communication between caregiver and family. \ 0 0 0 0
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Chapter 3 \\ MC B \ A nurse is assessing an 85-year-old patient who presented to the emergency department with a complaint of “not feeling like myself.” What should the nurse consider during this assessment? \ Aging causes sudden loss of function in organ systems. \ In older adults diseases often present with uncharacteristic symptoms. \ Many older adults do not participate in activities to support wellness. \ Since the majority of 85-year-old patients live in an institutional setting they are exposed to more communicable diseases. \ \ Aging itself, in the absence of true pathology, causes a gradual reduction in the function of organ systems. Older adults often manifest diseases in uncharacteristic ways, so diagnosis can be difficult or may be missed. The propensity to participate in wellness activities is not age related. The majority of older patients do not live in institutional settings. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ An older adult has been prescribed medication to control hypertension. Today she says, “I took this same medication years ago, but I’m having more side effects this time.” What should the nurse consider before replying?
\ Many antihypertensive medications have similar names so the patient could have confused the drugs. \ Older women often decrease oral fluid intake, which would change response to the drug. \ The older pancreas cannot supply enzymes to metabolize the drugs as early in the digestive system. \ Changes in the blood–brain barrier may make older patients more sensitive to some side effects. \ \ The names of some drugs are similar, but there is no reason to believe that this patient is confused. Some women do reduce fluid intake because of fears of incontinence, but the reduction is not sufficient to make this extensive a difference in response to the medication. There is no evidence that pancreatic insufficiency would increase side effects. The side effects of antihypertensive drugs are generally problems with dizziness or weakness. The blood–brain barrier changes allow the drug to have more of these effects in older patients. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ An older adult being treated for a burn on her lower leg and foot is surprised at its severity. She says, “It really didn’t hurt very badly when I did it.” What should the nurse consider before responding? \ Patients can block out portions of painful stimuli if it is overwhelming. \ Aging can decrease touch sensitivity to the feet and lower legs. \ Poor circulation has probably resulted in death of the nerve endings in the patient’s legs. \
Burns on the legs often appear very severe because the skin is so thin. \ \ This is not the most likely reason for this patient’s statement. An age-related change to the neurosensory status is reduced sensitivity in the fingertips, palms, and feet. This is the response the nurse should make to the patient. The nerves do not die, but may change. The burn is just as severe as it looks. Thinness of the skin can make burns more severe. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ An older adult says, “I cannot believe that I have had a heart attack. I thought I had stomach flu and a backache.” What nursing response is indicated? \ “I am also surprised that you had a heart attack. Your symptoms did not sound that severe.” \ “Usually a patient has chest and arm pain with a heart attack.” \ “The symptoms of heart attack change as people age and may include back pain or stomach problems.” \ “It is rare but a backache and a stomach ache can occur as a signal of a heart attack.” \ \ The nurse should not say that the diagnosis is a surprise, but should take this opportunity to teach the patient about heart attack symptoms. This is true of younger patients, but should not be generalized as “usual” for an older patient. Elderly patients with cardiac ischemia and an acute myocardial infarction or heart attack may have atypical symptoms. These symptoms include shortness of breath, abdominal, throat, or back pain, syncope, acute
confusion, flulike symptoms, stroke, and/or falls. Because these symptoms are atypical, diagnosis and treatment might be delayed. The nurse should not characterize these symptoms as rare indications of cardiac ischemia. The symptoms are not rare in older patients. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ An older patient says, “I seem to get chest colds so often now.” How should the nurse respond to this report? \ “How often do you wash your hands?” \ “Risk for colds and infections increase as we age.” \ “Do other people you are around have frequent colds?” \ “Maybe you should consider taking antibiotics during the winter.” \ \ This response seems to blame the patient for having poor hygiene and causing infection. This is a true statement and helps the patient understand that the colds may be a reflection of aging. It opens the discussion of how to reduce exposure. This statement may be interpreted as blaming the patient’s surroundings for the infections. Most colds and upper respiratory infections are viral so antibiotics are not preventative. This statement also does not offer the patient information to understand the frequency of illness. \ 0 0
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0000000000 0000000000 0 \\ MC A+B+D+E \ An older adult patient remarks that he has been experiencing constipation, which has never been a problem for him before now. What questions should the nurse ask? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ “Do you have a list of your medications?” \ “How many fluids do you drink each day?” \ “Do you get enough rest at night?” \ “What kinds of fruits and vegetables do you eat daily?” \ “How often do you have a bowel movement?” \ • The nurse should review the patient’s medications for those that can cause constipation. • Constipation can be the result of inadequate fluid intake. • Rest is not closely associated with constipation. • Fruits and vegetables contain fiber, which helps to prevent and treat constipation. • The nurse should assess the patient’s bowel habits to compare them to what is normal range. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+B+C \ The nurse suspects urinary tract infection in an older adult patient who has sudden onset of incontinence. Which symptoms, atypical in a younger adult, would the nurse assess for in this patient? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Confusion \ Vomiting \ Chills \ Flank pain \ Fever \ • Urinary tract infection can affect the older patient’s mentation resulting in confusion. • Urinary tract infection can result in vomiting in the older patient. • Chills are a typical finding of urinary tract infection. • Flank pain is a typical finding in younger patients with urinary tract infection. • Fever is a typical sign of infections. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ A 70-year-old patient had a pneumonia vaccination 10 years ago. Which information should the nurse provide about this vaccination? \ ”A booster vaccination is warranted.” \ “As long as your kidney function is good you do not need a second immunization.” \ “You will never need another pneumonia vaccination.” \ ”You should plan to get a pneumonia vaccination every year after September.” \ \ The pneumonia vaccination should be provided to those who are age 65 or older. Since this patient is currently 70 years old and had the initial vaccination 10 years ago, the pneumonia booster should be provided. Renal function does not guide the need for pneumonia vaccination. The pneumonia vaccine is not a one-time for life immunization. There is no need to get an annual pneumonia vaccine. \ 0 0 0 0
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\ After being medicated for postoperative pain an older patient becomes agitated and combative. Since this behavior has not been previously demonstrated the nurse conducts additional assessment for which most likely condition? \ Depression \ Delirium \ Drug toxicity \ Dementia \ \ Depression is characterized by low mood and is related to chronic stress or losses. It is not related to medications used to treat situational pain. Delirium is also called acute confusion and is the rapid onset of problems with cognition. Medications can be implicated in the development of delirium. Since this patient has an illness, an invasive procedure, and pain medication, the most likely condition is delirium. Since there is no information about which medication was administered, the dose, or the frequency of administration it is not possible to determine if this patient’s agitation is related to drug toxicity. Dementia has gradual onset over months to years. Since this is the first episode of behavior change, dementia is not the most likely cause. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \
An older adult with osteoarthritis has been told that he cannot have his painful knee replaced because of his cardiac status. The patient is having progressive difficulty with normal self-care activities. The nurse should monitor this patient for which condition? \ Depression \ Noncompliance \ Dementia \ Delirium \ \ Older adults are at risk for depression when they suffer multiple losses. This patient has lost the ability to easily care for himself, has been told his physical condition is poor, and has been denied the surgical procedure to replace his knee. This situation places the older adult at risk for depression. There is no indication that this patient will be noncompliant with the suggested regimen. Dementia is a slowly developing change in ability to interpret and deal with environmental stimuli. There is no assessment information that indicates this patient is at risk for dementia. Delirium is related to a situational health change. This patient has been experiencing knee discomfort and decreased mobility for some time. Delirium is not likely. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ The nurse manages an acute care unit that is beginning to provide care for more and more older adults after surgery. The nurse manager would encourage nurses to add which interventions to the plan of care for these patients? \
Use of restraints to prevent falls and disruption of invasive lines \ Early return to ambulation and self-care activities \ Get patients out of bed to a chair for most of the day \ Keep patients on bedrest until strength returns \ \ Use of restraints does not prevent falls and is associated with increased risk of injury. Immobility and bedrest in the older patient can contribute to a cascade of dependence. For each day of immobility, 5% of muscle strength is lost. The best intervention for these patients would be an early return to ambulation and self-care activities to limit the loss of muscle strength. Having the patient sit out of bed in a chair is not enough activity to limit disability. The patient should not be kept on bedrest. This would encourage further disability and muscle loss. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ An older adult patient tells the nurse that he is "tired" of having his medication doses changed so many times and wants to find a doctor who "knows what he's doing.” How should the nurse respond to this patient? \ “Have you thought about cutting pills or add pills together to get the correct dose?” \ “If you seriously want to change providers know some of the other doctors in the building are taking new patients.” \ “Frequent dose changes are necessary until the correct dose for you is determined.” \
“I know what you mean. It is annoying, but it is necessary.” \ \ Before making this suggestion the nurse should carefully consider the medication and dosages. Some drugs should not be split. If the patient is to take more than one pill to achieve the dosage, the prescription should be written to indicate how many pills. It is not appropriate for the nurse to make this suggestion. The patient is complaining about the physician's plan to "start low and go slow" when prescribing medications. The nurse's best response would be to explain how the different doses react in the body and the physician's attempt to prevent side effects or other pharmacological effects from the medications. The nurse should not just agree with the patient, but should instead explain why the changes are necessary. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ The primary nurse reports to the team caring for an older adult that the patient has a low Braden Scale score. The nurse would instruct the team to start interventions to prevent which complication? \ Skin breakdown \ Dehydration \ Falls \ Drug–food interactions \ \
The Braden Scale is used to predict risk for pressure ulcer development. The Braden Scale does not predict risk for dehydration. The Braden Scale does not predict risk for falls. The Braden Scale does not predict risk of drug–food interactions. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C+D+E \ The nurse is admitting an older adult female who uses two canes for ambulation. The patient is attended by her daughter who quietly reorients her mother several times during the assessment process. The daughter reports that her mother was a smoker for many years, but has not smoked for the last 5 years. The patient wears incontinence underwear and has problems with constipation. The nurse would evaluate which of these findings as key risk factors from the Hendrich II Fall Risk Model? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ The patient is female. \ The patient has a history of using tobacco. \ The patient wears incontinence underwear. \ The patient requires frequent reorientation. \ The patient uses a cane. \ • Male gender is a key risk factor according to the Hendrich II Fall Risk Model. • There is no indication that previous tobacco use increases fall risk according to this model.
• • •
Alteration in elimination is considered a key risk factor for falls by this model. Disorientation and confusion are key risk factors for falls according to the Hendrich II Fall Risk Model. The Hendrich II Fall Risk Model lists difficulty walking around as a risk for falls. Use of canes indicates difficulty walking around.
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0000000000 0000000000 0 \\ MC D \ The daughter of an older adult calls the emergency department (ED) triage nurse and reports that her mother hit her head “very hard” while getting into the car about 10 minutes ago. There is no bleeding. The daughter asks what she should watch for in her mother. How should the nurse respond? \ “As long as she does not develop a severe headache she is probably okay. Be sure to bring her to the ED if that happens.” \ “As long as your mother does not begin vomiting she is probably not severely injured. If she does begin to vomit, bring her in immediately.” \ “Watch her for the next hour or two. If she seems okay after that she is not likely to have a severe injury. Bring her in to the ED if you are concerned.” \ “In older adults the changes are very subtle and can develop over several hours or even days. Bring her to the ED if you have any concerns.” \ \
Older adults may not develop the severe headache that younger people experience with intracranial bleeding. Older adults may not develop the severe headache that younger people experience with intracranial bleeding. In older patients it may take some time before symptoms of severe head injury occur. In older adults the changes that indicate severe head injury may be very subtle. Any change is significant and should be investigated. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ An older adult is admitted to the emergency department (ED) after being the restrained front seat passenger in a motor vehicle accident. The nurse assessing this patient should consider that which physiologic response to hypovolemia is not as likely in an older adult? \ Decreased blood pressure \ Tachycardia \ Decreased cardiac output by hemodynamic monitor \ Decreased urine output \ \ Decrease in blood pressure can be related to decreased cardiac output from hypovolemia. This reaction does occur in older adults as well as younger adults. The older adult heart may not respond to hypovolemia by increasing rate. Hemodynamic monitoring will reveal decreased cardiac output regardless of the patient’s age. The older adult kidney, just like the younger adult kidney, must be perfused to produce urine. \
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0000000000 0000000000 0 \\ MC A+B+D+E \ The nurse has assessed that an older adult patient is at risk for impaired skin integrity. Which interventions are indicated? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Secure IV catheters with paper tape. \ Apply transparent film dressings to pressure prone areas. \ Pull the patient up in bed every hour. \ Keep the patient warm. \ Monitor IV sites for infiltration. \ • Paper tape is less difficult to remove and less irritating to the skin than is silk tape. • The application of these film dressings adds a layer of protection in areas that are prone to breakdown. • Pulling the patient up in bed causes friction and shear on the skin. The patient should be lifted and moved up in bed. • Cold temperatures cause constriction of the blood vessels in the skin and can lead to increased fragility of tissues. • IV sites in older adults may infiltrate quickly due to poor integrity of vessels and tissues. The nurse should increase surveillance of these sites. \ 0
0 0 0
0000000000 0000000000 0 \\ MC B \ An older adult patient’s testing reveals decreased absorption of calcium, which is a common age-related change. The nurse would consider which nursing diagnosis when creating a care plan for this patient? \ Impaired Swallowing \ Risk for Constipation \ Risk for Incontinence \ Activity Intolerance \ \ Decreased calcium absorption does not impair swallowing. Decreased absorption of calcium leaves more free calcium in the gastrointestinal tract. Calcium can be constipating. Decreased calcium absorption would not increase risk for incontinence. Decreased calcium absorption does make the patient intolerant of activity. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ The nurse has received emergency admission orders for an older adult patient who was severely injured in a fall. The nurse would question the use of which medication in this patient? \ Digoxin 0.125 mg po daily \ Diazepam 5 mg po every 6 hours prn agitation \ Morphine sulfate 2 mg IV every hour prn severe pain \ Furosemide 20 mg po daily \ \ Digoxin doses over 0.125 mg should be questioned.. Diazepam has a long half-life in older patients and should be avoided. Morphine is a short acting opioid when given IV. This dose is not excessive. Furosemide is not contraindicated for use in older adults. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D
\ Results of the CAM-ICU testing reveal that an older adult hospitalized in the intensive care unit has delirium. Which nursing interventions should be instituted? \ Increase environmental stimuli in the patient’s room. \ Limit visiting hours. \ Sedate the patient until ready for discharge from the intensive care unit. \ Manage the patient’s pain effectively. \ \ The environmental stimuli present in the intensive care unit can contribute to delirium. The nurse should intervene to reduce these stimuli. Presence of a calm family member may help to reorient the patient. Sedation will not benefit the patient in the long run and may increase delirium when reduced. Unrelieved pain is often the cause of delirium in the older patient. \ 0 0 0 0
0000000000 0000000000 0
Chapter 4 \\ MC B \ A patient complains of a dull, aching sensation in the lower back after long periods of sitting. The nurse anticipates the administration of medication to suppress pain impulse transmission in which fibers to treat the patient's complaint? \ A delta fibers \ C fibers \ Myelinated fibers \ Enkephalins \ \ A delta fibers conduct impulses rapidly. Sharp, pinprick-like pain is conducted along these fibers. C fibers have a slow conduction rate and transmit aching, throbbing sensations. Nerves termed unmyelinated C fibers transmit aching and throbbing sensations to the brain. Enkephalins are endogenous opioid peptides that participate in the modulation of pain. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ A patient has received a pain medication that blocks pain signals from the spinal cord. The nurse anticipates the effects of this medication will result in which level of pain?
1
\ 0 on a scale from 0–10 \ 8 on a scale from 0–10 \ 5 on a scale from 0–10 \ 2 on a scale from 0–10 \ \ Pain signals that are blocked at the spinal cord will not be transmitted to the brain so these signals will not cause pain. Since the pain signal is being blocked or interrupted at the spinal cord, the pain will not be severe. Since the pain signal is being blocked and not transmitted to the brain pain will not be moderate. Since the pain signal is blocked at the spinal cord and is not being transmitted to the brain mild pain will not be present. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ The intensive care nurse plans to test nociception in the patient with a closed-head injury. Which nursing action is indicated? \ Move an object across the patient’s visual field. \ Place a container of ground coffee close to the patient’s nostrils. \ Ask the patient to squeeze and release the nurse's hand. \
2
Press the patient's nail bed. \ \ Testing ocular movement is not associated with nociception. Observing the patient’s reaction when a scent is placed close to the nostril is not painful, so it does not test nociception. Squeezing and releasing the nurse's hand on command provides neurological assessment data; however, this action should not be painful to the patient. Nociception refers to the activation of pain receptors to the point of pain. Pressing the patient's nail bed can elicit a motor response to pain that provides evidence of nociception. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ The nurse observes the patient during a major abdominal dressing change. Which facets of pain can be observed by the nurse during this procedure? \ Expressing behaviors \ Pain \ Nociception \ Suffering \ \
3
The nurse can observe pain-expressing behaviors. Grimacing and crying are pain-expressing behaviors. The patient must provide subjective data to confirm the presence of pain. Nociception is the activation of pain receptors. The nurse cannot observe this during a dressing change. Suffering is a subjective experience. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ Admission vital signs for the mechanically ventilated patient in the neurosurgery intensive care unit are heart rate: 60 beats per minute, blood pressure: 110/82, and respiratory rate: 20 breaths per minute. Which statement by the nurse reflects an accurate understanding of the patient's current pain experience? \ “This patient’s vital signs reflect a sympathetic nervous system response to pain.” \ “Since the vital signs are normal; the patient is not experiencing pain.” \ “This patient needs further assessment to determine if pain is present.” \ “Since the patient is mechanically ventilated, pain is unlikely.” \ \ The normal heart rate and blood pressure values in this scenario do not reflect a tachycardic or hypertensive sympathetic nervous system response to pain. Parasympathetic nervous system influences on vital signs can cause vital signs to be within normal limits in the presence of pain. The nurse must complete additional assessments to determine if the patient is experiencing pain. Intubation and mechanical ventilation are painful stimuli that are frequently experienced by patients in the intensive care setting. \
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0 0 0 0
0000000000 0000000000 0 \\ MC A \ A patient tells the nurse that his back has not "bothered" him for months but now that he's in the intensive care unit, his back is "killing" him. The nurse considers which cause of this pain when designing interventions? \ Lack of mobility due to hospitalization \ Worsening of the disease process that caused the hospital admission \ An undiagnosed injury to the back \ Tolerance to pain medication \ \ Forced immobility because of the serious or critical nature of an illness and attachment to multiple tubes may exacerbate more chronic conditions, such as back or arthritic pain. There is not enough information to indicate that this back pain is related to the disease process the resulted in admission. The patient indicates previous back “problems” so the presence of an undiagnosed injury is not the most likely reason for the patient’s current back pain. Tolerance to pain medication is not suggested by this scenario. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC B \ While giving an end-of-shift report, the exiting nurse describes treatment for a patient’s complaint of arm pain. The nurse receiving the report should question the validity of which statement? \ "The patient is resting quietly in bed." \ "The patient's blood pressure is normal so the pain is gone." \ "I administered 800 mg of ibuprofen." \ “I also applied a hot pack to the arm at the patient’s request.” \ \ This statement reports the patient’s response to treatment. Judgments regarding patients' pain levels that are based solely on objective data, such as vital sign changes, can be misleading and faulty. The nurse should indicate the medication given and the amount. The nurse should report all treatments for pain, not just pain medication. \ 0 0 0 0
0000000000
6
0000000000 0 \\ MC B \ A trauma patient has just been sedated, intubated, and placed on mechanical ventilation. The nurse documents the patient’s pain level as 9 on the 1–10 scale. How should this action be interpreted? \ The patient should receive the highest dose of analgesic medication ordered. \ The nurse has inappropriately scaled the patient’s pain. \ The nurse should wait until the patient has adapted to the mechanical ventilator before scaling the level of pain. \ Pain will decrease now that the patient does not have to work to breathe. \ \ Not enough information is presented to make the determination that the highest dose of analgesic should the administered. The unidimensional pain assessment scale is not indicated for use in this patient. Unidimensional pain assessment requires input from the patient. The presence of severe pain will likely interfere with the patient’s ability to adapt to the mechanical ventilator. There is no evidence that pain will decrease once the patient is being mechanically ventilated. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+C+D+E \
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The nurse prepares to administer a nonsteroidal anti-inflammatory drug to the patient with postoperative knee pain. The nurse should consider which pharmacological properties of NSAIDs? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ NSAIDs inhibit the manufacture of bradykinins. \ NSAIDs bind with opioid receptors throughout the nervous system. \ NSAIDs exert peripheral effects. \ NSAIDs inhibit the formation of prostaglandins. \ NSAIDS exert CNS effects. \ • One of the mechanisms by which NSAIDs relieve pain is by inhibiting bradykinin production. • The opioid class of drugs, such as morphine and dilaudid, not NSAIDs, bind with opioid receptors to relieve pain. • NSAIDs work peripherally at the site of injury. • One of the mechanisms by which NSAIDS relieve pain is by inhibiting prostaglandin formation. • NSAIDS have a CNS effect. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ A semi-conscious patient with pancreatic cancer requires pain management. After multiple attempts, the oncology nurses are unable to establish venous access. What is the best alternative route for pain medication administration until venous access can be obtained?
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\ Rectal suppository \ Injection in deltoid muscle \ Subcutaneous injection in abdominal tissue \ Oral liquid \ \ When the IV route is not possible, rectal and sublingual routes should be considered. Intramuscular routes cause additional pain and can cause tissue damage. This route is not recommended. Subcutaneous injections cause pain and, in some instances, tissue damage; therefore, this route is not recommended. Because the patient is semi-conscious there is risk of aspiration if oral liquids are administered. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ A patient with a tension pneumothorax requires insertion of a pleural chest tube. The nurse assists the physician as multiple doses of a local anesthetic are administered prior to tube insertion. Which observation by the nurse warrants immediate physician attention? \ The patient's respiratory rate changes from 22 to 26 breaths per minute. \ The patient complains of pain during anesthetic injections. \ The patient's systolic blood pressure changes from 156 to 138 mm Hg. \
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The patient's heart rate changes from 100 beats per minute to 75 beats per minute. \ \ The change is respiratory rate should be monitored, but is not currently the most significant finding. Local injection of anesthetics is painful. This drop in blood pressure should be monitored, but is currently not the most significant finding. A 25 percent drop in baseline heart rate is a sign of systemic anesthetic toxicity. Other symptoms of this complication are tinnitus, slurred speech, thick tongue, and mental confusion. This finding should be reported to the physician to ensure appropriate treatment. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ Emergency department nurses are monitoring a patient for signs of pseudoaddiction to opioid substances. Which observation about the patient's behavior can help confirm the diagnosis of pseudoaddiction? \ The patient requires increasingly larger doses of medication for pain relief. \ The patient appears sedated. \ The patient appears less angry after pain relief is reported. \ The patient appears intoxicated or drugged. \ \
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Patients who need increases in pain medication doses to relieve pain have developed a tolerance for a drug; they are not pseudoaddicts. Sedation can occur with appropriate use of pain medications or can indicate addiction. Sedation is not a finding specifically associated with pseudoaddiction. Pseudoaddiction can cause the patient to express anger toward health care providers. This anger results from the unrelieved pain characteristic of pseudoaddiction. Appearing intoxicated or drugged can indicated substance addiction. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ A patient with myocardial infarction is treated with intravenous morphine sulfate for chest pain. Which nursing action has the highest priority when administering this medication? \ Determine the patient's sedation level. \ Check breath sounds every 15 minutes. \ Observe for signs of opioid addiction. \ Assess for medication infiltration into tissues. \ \
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Extreme sedation typically precedes respiratory depression; therefore, it is important to monitor the patient who receives opioid substances for oversedation. It is not necessary to assess breath sounds at frequent intervals when pulmonary pathology is not an immediate concern. Acute pain requires treatment and typically does not result in narcotic addiction. Drug infiltration into tissues is an important assessment for any intravenous therapy; however, early detection of symptoms that precede respiratory depression has a higher priority. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+B+C+E \ Which actions should be considered by the nurse planning pain relief interventions for the patient with a history of substance abuse? (Select all that apply). Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Planning for comorbid psychiatric disorder treatment \ Administering long-acting analgesics \ Using oral medications in place of intravenous ones when possible \ Treating pain with NSAIDs instead of opioid drugs \ Avoid using drugs that are similar in action to the abuse drug \ • Management of pain in a patient with a history of substance abuse requires a multidisciplinary approach.
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• • • •
The use of long-acting analgesics is recommended. Short-acting opiates should be reserved for breakthrough pain. When treating patients with previous substance abuse the nurse should plan to use oral medications whenever possible. Patients with a history of substance abuse are not immune to acute pain, and they may require opioid therapy following surgery, trauma, or other painful events. The nurse should avoid using a drug that is similar to the abused drug if possible.
\ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ A patient, with a history of drug addiction, has just been admitted following abdominal surgery. The patient is complaining of aching joints and muscles, and has a sudden onset of a runny nose. The nurse realizes these symptoms are seen during withdrawal from which commonly abused substance? \ Barbiturates \ Opiates \ Cocaine \ Alcohol \ \
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Manifestations of barbiturate withdrawal include headache, anxiety, depression, nervousness, shakiness, blank facial expression, and flat affect. Manifestations of opiate withdrawal are initially mild and become more severe to include runny nose, diarrhea, abdominal pain, chills, gooseflesh, insomnia, aching joints and muscles, nausea and vomiting, muscle twitching and tremors, and mental depression. Manifestations of cocaine withdrawal are primarily psychological and include rapid onset of depression, fatigue, sleepiness, strong craving for more cocaine, loss of pleasure, and also experiencing paranoia or agitation. Manifestations of alcohol withdrawal include headache, anxiety, depression, nervousness, shakiness, irritability, depression, fatigue, clouded thinking, and nausea, vomiting, and anorexia. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A patient, receiving moderate sedation for a colonoscopy, has progressed to a state of deep anesthesia. The nurse administering this sedation has which priority intervention? \ Monitor the heart rate. \ Contact the rapid response team. \ Manage the airway and provide ventilation. \ Monitor the blood pressure. \ \
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While monitoring the heart rate is part of all sedation procedures it is not the priority in this situation. The nurse who is administering moderate sedation must be prepared to rescue a patient who progresses to a state of deep analgesia. The nurse should be prepared to care for this patient without calling the rapid response team. The transition from moderate sedation to deep sedation compromises the airway so this is the priority intervention. Blood pressure is part of the continuous monitoring of all patients receiving moderate sedation. It is not specifically more important because of the change in level of sedation described in this question. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B+C \ A nurse is providing moderate sedation for a patient having a diagnostic endoscopy. Which actions should the nurse anticipate? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Bolus of a sedative \ Using a drug with rapid onset \ Titration of pain medication \ Use of a combination of drugs in a single IV line \ Monitor a slow continuous dose of medication \ • Titration of the sedative will result in less risk for respiratory and cardiovascular depression.
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• • • •
The use of a drug with rapid onset allows for adjustments in dose and dose interval. Medications that produce a state of sedation may not control pain. The IV medications used in this procedure should be administered through separate IV lines. Titrating the medication involve administering small intermittent doses of medication.
\ 0 0 0 0
0000000000 0000000000 0 \\ MC B+C \ A patient has achieved pain control with an oral opioid and is tolerant of its sedative effects but is having severe constipation. The nurse has contacted the health care provider about prescribing a different opioid. What should the nurse anticipate regarding the new drug? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ The new opioid will be administered by the intravenous route. \ There will be an increased need to observe the patient for sedation. \ The starting dose of the new medication will be lower than the equianalgesic dose of the original medication. \ It will be necessary to add an adjuvant medication to achieve equal pain control. \ The newly prescribed medication will be a pure opioid agonist. \ • The oral route is the preferred route. The IV route is used when oral administration is no longer possible. • Even if the patient was tolerant of the sedative effects of the first opioid, that tolerance may be incomplete with the new drug.
16
• • •
The starting dose of the new medication will likely need to be lower than the equianalgesic dose of the old medication until the patient’s tolerance is determined. There is no reason to expect that the patient will not achieve pain control with the new medication. The choice of medication will depend upon which medications have already be used.
\ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A nurse is administering naloxone (Narcan) to a patient who is minimally responsive after receiving an opioid. Which nursing action is indicated? \ Bolus the medication over 1–2 minutes. \ Give the medication without dilution. \ Discontinue the naloxone as soon as the patient’s respirations normalize. \ Plan to repeat the dose every hour for the next 4 hours. \ \ Naloxone should be administered slowly. Naloxone should be diluted in normal saline. Naloxone may cause return of pain and opioid withdrawal, so only the amount necessary to achieve the desired results should be administered. The medication should be effective in one dose. There is no need to repeat the dose four times. \ 0 0
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0 0
0000000000 0000000000 0
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Chapter 5 \\ MC A \ An older adult patient was hospitalized for 2 weeks before having abdominal surgery 3 days ago. The nurse notes the patient’s hair is broken and dull. Which intervention is indicated? \ Increase vigilance for dehiscence. \ Talk to the family about trimming the patient’s hair. \ Use a protein-based shampoo. \ Increase the patient’s oral fluid intake. \ \ Broken and dull hair may indicate protein-calorie malnutrition. If this condition exists it increases risk for dehiscence of the patient’s abdominal incision. Trimming the hair will not reverse the process that is likely occurring. External application of protein will not correct the probable source of this change in the patient’s hair. Increasing fluid will not change this situation. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ A patient with a BMI of 32 is in the intensive care unit recovering from surgery to repair an abdominal aortic aneurysm. What should be the nurse’s focus regarding this patient’s nutritional needs? \
1
Support elevated nutrient needs. \ Maintain on intravenous fluids and clear liquids. \ Limit food and fluid intake to three mealtimes daily. \ Begin a weight-reduction program immediately. \ \ During acute illness it is crucial to meet the elevated nutrient needs of obese patients to optimize outcomes. Weight loss is not the focus of the patient’s current needs. There is no reason to limit food to three daily meals. Fluids should not be restricted unless there is a comorbid condition that requires decrease in fluid intake. Weight loss is not the focus of the postoperative period. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ A patient admitted for a gunshot wound to the leg and multiple abdominal stab wounds is transferred to the intensive care unit after surgery. The nurse would evaluate which finding as expected but as requiring monitoring? \ Blood pressure 170/104 mm Hg \ Elevated blood glucose level \ Serum potassium of 5.4 mEq/L \ Increase in body temperature
2
\ \ This blood pressure reading would not be expected with this patient’s mechanism of injury. The first 24 hours after a body injury, the body responds with an increase in mobilization of carbohydrates and lipids. Glucose production increases in efforts to support wound healing. The body also responds by decreasing the amount of insulin produced. Because of these bodily responses, the nurse will most likely observe an elevated blood glucose level that will impact the patient's nutritional needs at this time. This finding is physiologically normal but will require monitoring as the patient heals. This potassium level is elevated and is not an expected finding. The first 24 hours after a body injury, the body responds with a drop in body temperature. Increased temperature is not an expected finding. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ The nurse is planning a refeeding program for a patient diagnosed with cachexia from AIDS. Which nursing interventions are indicated? \ Encourage the patient to eat as much as possible during each meal. \ Plan to increase the patient’s calorie intake to goal in 2 or 3 days. \ Limit the patient's intake of fluids so to encourage a normal appetite. \ Each day offer foods that provide 20kcal/kg of the patient’s actual body weight. \ \
3
If the patient ingests as much food as possible during each meal, the risk of refeeding syndrome will increase. The increase in calories to the established goal should be done slowly and may take as long as a week. Restriction of fluids is not indicated, will not necessarily stimulate a normal appetite, and may place the patient at risk for fluid volume deficit. The patient with cachexia from AIDS is at risk for developing refeeding syndrome. In efforts to reduce this risk, the patient's daily calorie intake should equal 20 kcal/kg of body weight. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ The nurse is caring for a patient with a history of hypercapnea. What should the nurse include when planning for this patient's nutritional needs? \ Monitor carbohydrate intake to reduce body carbon dioxide levels. \ Encourage fat intake. \ Minimize vitamin supplements. \ Limit protein. \ \ Limiting the carbohydrate intake in a patient with a history of hypercapnea would be beneficial in efforts to reduce the body's carbon dioxide load. Fat is calorie intense and patients with excessive overall calorie intake may have increased carbon dioxide levels. Vitamin supplements should be provided according to the patient's needs and not minimized unless necessary. The patient's protein should not be limited but rather calculated to meet the patient's needs. \
4
0 0 0 0
0000000000 0000000000 0 \\ MC A \ The nurse is caring for a patient diagnosed with chronic renal failure and being treated with hemodialysis who weighs 100 kg. What would be an appropriate intake of protein for this patient? \ 120 g per day \ 75 g per day \ 240 g per day \ 60 g per day \ \ The patient with renal failure receiving maintenance hemodialysis would benefit from receiving a protein intake of 0.8 to 2.0 g/kg per day. The patient weighs 100 kg and therefore a daily intake of 120 g of protein per day would be appropriate. 75 g of protein is equal to 0.75 g/kg, which is too low for this patient. 240 g of protein is equal to 2.4 g/kg, which is too high for this patient. 60 g of protein is 0.6 g/kg and is too low for this patient. \ 0 0 0 0
5
0000000000 0000000000 0 \\ MC B \ A patient, being treated for multiple injuries in the intensive care unit, had been NPO for several days. Clear liquids are started today, but the patient only takes a few sips before refusing additional fluids and then vomiting. The patient’s temperature is also elevated. The nurse would assess for findings associated with which disorder? \ Gastric ulcer \ Gut failure \ Electrolyte imbalance \ Diabetes insipidus \ \ Inability to tolerate fluids after being NPO would not be a primary indicator of gastric ulcer. During periods of high stress, the body will shunt blood to the organs to maintain maximum functioning. When this occurs, the gastrointestinal tract could develop ischemia and atrophy. The introduction of food or fluids at this time could cause the patient to vomit and have complaints of early satiety. With an ischemic gut, the patient is prone to developing bacterial translocation, which means bacteria enter the general circulation from the gastrointestinal tract. This is a major cause of sepsis with the body response as an increase in temperature. Inability to tolerate fluids after being NPO would not indicate an electrolyte imbalance. Inability to tolerate fluids after being NPO would not indicate diabetes insipidus. \ 0 0 0 0
6
0000000000 0000000000 0 \\ MC B \ The nurse is caring for a patient who sustained burns of 40% of the total body surface area. What would the nurse plan to meet this patient's nutritional needs? \ Supply with balanced nutrients to meet current body weight needs. \ Complete a nutritional assessment and supply with high-calorie, high-protein supplements. \ Provide high dose therapy of vitamins C and B. \ Supply with high-fat and high-carbohydrate supplements. \ \ Because of the hypermetabolic status of the patient, the patient needs more calories than those needed to meet current body weight needs. The patient recovering from a burn injury of 40% of the total body surface should have a complete nutritional assessment and then be supplied with high calorie, high protein supplements to meet the body's hypermetabolic and healing needs. Standardized protocols for vitamin supplementation should be followed. High fat and high carbohydrate are not the primary needs for this patient. \ 0 0 0 0
0000000000 0000000000 0
7
\\ MC B \ The nurse is caring for a patient who is comatose after a traumatic brain injury. What is important for the nurse to include when planning for this patient's nutritional needs? \ Provide adequate calories in the form of carbohydrates and fats. \ Ensure adequate protein intake to maintain a positive nitrogen balance. \ Plan to implement parenteral nutrition as soon as possible. \ Increase dietary supply of cortisol. \ \ Calories should be provided to support all nutritional needs and not focus on carbohydrates and fats. In the patient with a traumatic brain injury, providing adequate energy and protein for a positive nitrogen balance is paramount to successful treatment, and aggressive nutrition support is recommended. Because patients with traumatic brain injury often have poor cough or gag reflex they are at risk of pulmonary aspiration. Enteral nutrition is the preferred alternative to oral nutrition. Patients with traumatic brain injury have massive release of catecholamines and cortisol. Cortisol in not added by nutritional means. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A patient, in the intensive care unit, has been NPO for several days. The nurse is unable to assess bowel sounds. What should be included in to the plan to support this patient’s nutritional needs?
8
\ Maintain NPO status. \ Prepare to assist with implementation of a large bore venous access device to support total parenteral nutrition. \ Determine best enteral feeding approach and plan implementation. \ Begin oral feeding with a diet as tolerated as soon as bowel sounds return. \ \ The patient should not be maintained on NPO status only because of the absence of bowel sounds. Total parenteral nutrition might expose the patient to unnecessary pathogens which could compromise the healing process. Readiness for enteral feeding should not be determined by the presence of bowel sounds. Active bowel sounds have been used as criteria to initiate feeding, but there is no scientific evidence to support this practice. Bowel sounds are a poor indicator of small bowel motility and nutrient absorption, as they are the result of air passing through the intestinal tract. The patient may or may not be able to tolerate oral feedings with a diet as tolerated. Nutritional support should not wait until the presence of bowel sounds. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C+D+E \ The nurse is assessing a patient's ability to receive enteral feedings. Which findings would the nurse evaluate as potential contraindications to this intervention? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \
9
The patient has a history of Crohn's disease. \ The patient has a gastric ulcer. \ There is a mechanical obstruction. \ The patient has developed hemorrhagic pancreatitis. \ The patient has had severe intractable diarrhea for 3 days. \ • History of Crohn’s disease is not a contraindication for enteral therapy. • Presence of gastric ulcer is not a contraindication to enteral feeding but may be a determinant of type of feeding tube chosen. • Contraindications to enteral nutrition have diminished as its safety and efficacy has been demonstrated in many types of high-acuity patients. Mechanical obstruction is the only absolute contraindication to enteral feedings. • Severe hemorrhagic pancreatitis is a relative contraindication to enteral feeding. • Severe intractable diarrhea is a relative contraindication to enteral feeding. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ A patient, with a history of aspiration pneumonia, is going to receive enteral feedings. What should be considered regarding the tube and placement for this patient? \ Postpyloric feedings need to be interrupted and would not support the patient's nutritional needs. \ Postpyloric feedings have less incidence of pneumonia in some groups and would be preferred for this patient. \
10
Gastric feedings provide more calories and better tolerance. \ Gastric feedings are ideal as long as the patient is receiving a proton pump inhibitor. \ \ Postpyloric feedings do not need to be interrupted as much as gastric feedings. Because it is documented that postpyloric feedings can be provided with less interruption and a higher nutritional intake and there is a lower incidence of pneumonia in some patients this technique should be considered for the patient. Gastric feedings are usually interrupted and would not necessarily provide more calories for the patient. The use of a proton pump inhibitor does not decrease the risk of gastric feeding related pneumonia. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ A patient receiving nasogastric tube feedings has a gastric residual volume of 450 mL. Which nursing intervention is indicated? \ Hold the tube feeding until the gastric aspirate is less than 100 mL. \ Provide the tube feeding as a bolus. \ Hold the tube feeding until the gastric aspirate is less than 250 mL. \ Provide the tube feeding as a continuous infusion. \ \
11
It is not necessary to wait until the gastric residual volume is less than 100 mL since this is a nasogastric tube and not a gastrostomy tube. Introducing a bolus feeding would quickly increase the amount of feeding in the stomach and is not indicated. A common intervention for high gastric residual volume is to hold the enteral feeding for 1 to 2 hours until the residual volume is less than 200 to 250 mL from a nasogastric tube. Additional tube feeding should not be introduced at this time. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A patient has a clogged postpyloric feeding tube. Which nursing intervention is indicated? \ Irrigate the tube with a large amount of pressure to break the clog. \ Pull the tube and insert another. \ Slowly attempt to irrigate the tube with warm water. \ Use a stylet to break through the clog. \ \ The nurse should not irrigate the tube with large amounts of pressure. Efforts should be undertaken to dislodge the clog before pulling the tube and inserting another. To dislodge a clogged tube, irrigate the tube with warm water, cola, or juice. Also, using a syringe with alternating positive and negative pressure can dislodge a clog. Using a stylet to break up a clog can cause an esophageal or gastric mucosa tear. \ 0
12
0 0 0
0000000000 0000000000 0 \\ MC A+B+C+E \ The nurse is caring for a patient with a large bore catheter for total parenteral nutrition. Which findings would indicate to the nurse that the patient might be experiencing catheter related sepsis? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Sudden glucose intolerance \ Leukocytosis \ Sudden onset of chills \ Sudden onset chest pain \ Tenderness at the insertion site \ • Sudden glucose intolerance may occur up to 12 hours before a temperature elevation occurs and is an indicator of catheter-related sepsis. • Leukocytosis will occur as the patient’s immune system begins to fight the infection. • The patient may be experiencing chills for a number of reasons, but the nurse should consider the possibility of catheter-related sepsis. • Sudden onset chest pain may occur if a pneumothorax develops but is not associated with catheter related sepsis. • Infection at the site of insertion can be manifested by tenderness or erythema. Infection at this site is considered a catheter-related infection and can lead to sepsis. \ 0
13
0 0 0
0000000000 0000000000 0 \\ MC A \ A patient receiving total parenteral nutrition has elevated serum blood urea nitrogen and serum sodium levels. The nurse would conduct additional assessment for which complication? \ Prerenal azotemia \ Hyperglycemia \ Catheter related sepsis \ Hepatic dysfunction \ \ Prerenal azotemia is caused by overaggressive protein administration and is aggravated by underlying dehydration. Presenting signs and symptoms include an elevated serum BUN, serum sodium, and clinical signs of dehydration. Hyperglycemia is indicated by blood glucose level of greater than 220 mg/dL while receiving total parenteral nutrition. Signs and symptoms of catheter related sepsis include sudden onset of fever, rigors, or chills that coincide with parenteral infusion; erythema, swelling, tenderness, or purulent drainage from the catheter site; sudden temperature elevation that resolves on catheter removal; leukocytosis; sudden glucose intolerance that may occur up to 12 hours before temperature elevation; and bacteremia/septicemia/septic shock. Hepatic dysfunction would be assessed with serum liver function tests and bilirubin levels. \ 0 0 0 0
14
0000000000 0000000000 0 \\ MC A+B+C \ After the insertion of a central venous catheter for total parenteral nutrition, the patient demonstrates dyspnea. The nurse is concerned that pneumothorax may be occurring. Which assessment findings would support this concern? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Restlessness \ Chest pain \ Decrease in pulse oximetry reading \ Severe headache \ Combativeness \ • Restlessness may occur as pneumothorax increases in size. • Chest pain is a common finding during pneumothorax. • Hypoxia will occur as pneumothorax size increases. • Headache is not associated with development of pneumothorax. • Combativeness is not a common result of pneumothorax. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC A+B+C \ A patient is suspected of having an air emboli from a central venous line inserted for total parenteral nutrition. What nursing interventions are indicated? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Place the patient on the left side. \ Place the patient in Trendelenburg position. \ Occlude the catheter nearest to the entry site of the skin. \ Notify the physician and prepare to take the patient to surgery. \ Prepare to assist with chest tube insertion. \ • When air embolus is suspected, immediate action is required. The patient should be placed on the left side. This allows an air embolus to float into the right ventricle of the heart, away from the pulmonary artery. • When air embolus is suspected, immediate action is required. The patient should be placed in the Trendelenburg position. This allows an air embolus to float into the right ventricle of the heart, away from the pulmonary artery. • The nurse should prevent additional air from entering the circulatory system by occluding the catheter as close as possible to where it enters the skin. • Surgical intervention is not necessary. • Chest tubes are not used in the treatment of air embolism. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC A+C \ The nurse is concerned that refeeding syndrome may be occurring in a patient receiving enteral nutrition. Which laboratory values would support this concern? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Serum potassium is 3.4 mEq/L \ Fasting blood glucose is 98mg/dL \ Hemoglobin is 10.8 g/100mL \ Serum sodium of 138 mEq/L \ Chloride of 98 mmol/L \ • Hypokalemia is one of the electrolyte imbalances associated with refeeding syndrome. • Hyperglycemia is more likely to occur with refeeding syndrome. • Anemia can occur as a result of refeeding syndrome. • This is a normal serum sodium level. • This is a normal chloride level. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC A \ A patient has been started on tube feeding by nasogastric tube. When his wife visits she says, “I need to tell you that my husband is lactose intolerant so that feeding will make him sick.” What nursing response is indicated? \ “Even though the tube feeding fluid looks like milk it is lactose-free.” \ “We did not know that. I will contact his physician immediately.” \ “Since he is being fed by tube, the fact that he is lactose intolerant is not an issue.” \ “We will watch to see if he has any symptoms of lactose intolerance.” \ \ Commonly used tube feedings are lactose-free. There is no need to contact the physician. The process of tube feeding does not change the concern over the patient being lactose intolerant. The nurse should educate the wife about tube feeding. \ 0 0 0 0
0000000000 0000000000 0
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Chapter 6 \\ MC D \ A patient in the emergency department (ED) becomes suddenly unresponsive. CPR is initiated. Arterial blood gas results reveal pH 7.225, PaCO2 55, HCO 15, PaO2 45, SaO2 76 percent. The nurse would prepare for which priority intervention? \ Call for a rapid response team. \ Auscultate the patient’s lungs. \ Place the patient on a 50 percent humidified mask. \ Administer endotracheal intubation. \ \ This situation is not uncommon in the ED and personnel should be prepared to intervene without the support of a rapid response team. Auscultation of the lungs is not the priority. A humidified mask will not be effective for the patient who is not ventilating well. The patient is unresponsive. Based on the blood gas results, it is obvious that the patient is suffering from acute ventilatory failure and is in urgent need of intubation and mechanical ventilation. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+B+E \
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An adult patient has suffered a respiratory arrest and requires endotracheal intubation. The nurse should obtain which equipment for this procedure? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Topical anesthetic \ Magill forceps \ Cuffless endotracheal tube \ Oxygen cannula \ Water-soluble lubricant \ • A topical anesthetic may be administered to decrease gagging. • Magill forceps may be used to help guide the tube through the larynx. • Since this patient is an adult a soft-cuffed ET tube will be used. • Although an oxygen source would be appropriate for providing manual bagging of the patient, a nasal cannula is useless for this patient. • Water-soluble lubricant can be used to help advance the endotracheal tube. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ A patient aspirated while eating and suffered a respiratory arrest. A code blue was called, the obstruction was removed, but the patient required endotracheal intubation. Postintubation the nurse hears breath sounds
2
bilaterally, but the carbon dioxide monitor indicates a higher than expected level. Which patient history could account for this discrepancy? \ The patient’s original admittance diagnosis was dehydration. \ The patient’s wife reports, “We were talking and laughing when he choked.” \ The patient has history of calcium deficiency requiring dietary supplementation. \ The patient’s wife says, “He had some heartburn earlier, so the nurse had given him a lemon-lime soda to drink with his supper.” \ \ Dehydration would not result in high carbon dioxide levels. Laughing and talking while eating could explain why the obstruction occurred, but would not explain why the discrepancy between auscultation and carbon dioxide monitor. Calcium deficiency is not related to the discrepancy in this scenario. Drinking a carbonated beverage just before intubation can cause a false positive carbon dioxide monitor report. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ The nurse manager teaches newly hired nurses about findings associated with barotrauma. The manager would include that this complication is most common in which type of mechanical ventilation? \ Volume \ Time \
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Pressure \ Flow \ \ Volume-cycled ventilation delivers a preset volume of gas to the lungs. Volume ventilation has the potential to generate high pressures, especially in less compliant lungs in order to deliver the set volume, which increases the risk of barotrauma. Time-cycled ventilators also limit the maximum amount of pressure that can be delivered, which offers protection against barotrauma. Pressure-cycled ventilation is increasingly used as a method to protect the injured lung from further damage from high pressures. Flow-cycled ventilators augment the patient’s inspiratory effort as long as the patient continues to inhale at a certain flow rate. The risk of barotrauma is not as significant as with another type of ventilator. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ The nurse caring for a patient who is ventilated via the assist-control mode monitors for which complication specifically related to this intervention? \ Pneumonia \ Anxiety \ Pneumothorax \ Respiratory alkalosis \
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\ Ventilator associated pneumonia is a risk for all modes of mechanical ventilation. Anxiety may be present with all modes of mechanical ventilation and is not specific to the mode used with this patient. Pneumothorax is a risk of all mechanical ventilation modes if the tidal volume is not appropriate for the patient. With assist-control, every breath is a ventilator breath. Therefore, if a patient attempts to initiate spontaneous breaths, each attempt will result in a breath of full tidal volume. The ultimate effect, if untreated, is hyperventilation. Hyperventilation causes the patient to blow off carbon dioxide, leading to the development of respiratory alkalosis. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ The nurse is admitting a patient who sustained a traumatic brain injury and who is now deeply sedated. The nurse would anticipate managing which mode of ventilation during this patient’s initial care? \ Pressure support ventilation \ Assist-control ventilation \ Pressure support ventilation (PSV) \ Synchronized intermittent mandatory ventilation (SIMV) \ \
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Pressure support ventilation requires that the patient have spontaneous respiratory effort. That will not be the case with a deeply sedated patient. With assist-control ventilation, every breath is a machine breath. At the appropriate settings, this is desirable for a deeply sedated head-injured patient who is unlikely to initiate spontaneous breaths. PSV is an adjunctive weaning mode which requires spontaneous breathing attempts which would not be present in a deeply sedated patient. SIMV relies on the patient spontaneously breathing through the circuit to do much of the work of breathing. This will not happen in a deeply sedated patient. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ The nurse is preparing to care for a patient returning from elective surgery who will require mechanical ventilation for a few more hours. The nurse would initiate which ventilator setting orders without question? \ SIMV with a rate of 12, tidal volume 750 mL, FIO2 0.60 \ Assist-control with a rate of 16, tidal volume 1,000 mL, FIO2 0.40 \ Assist-control with a rate of 20, tidal volume 1,200 mL, FIO2 0.60 \ SIMV with a rate of 4, tidal volume 1,200 mL, FIO2 0.60 \ \
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It is most likely that the ventilator settings would include the SIMV mode, which is often used for weaning patients from ventilators. A tidal volume of 750 is appropriate for an adult and FIO2 of 0.60 is reasonable. Assist control mode would not be a likely choice since it is anticipated that this patient will only require mechanical ventilation for a few more hours. Tidal volume of 1,000 mL is too high. Assist control mode would not be a likely choice for a patient only expected to need mechanical ventilation for a few more hours. It is most likely that the ventilator settings would include the SIMV mode, which is often used for weaning patients from ventilators. The SIMV mode with a tidal volume of 1,200 mL is too high. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ A patient’s ventilator settings are going to be modified to include positive end expiratory pressure (PEEP). What nursing action is most important? \ Suction the patient before and after the change. \ Monitor vital signs frequently. \ Notify the physician of abrupt increases in oxygenation. \ Monitor breath sounds at least every 15 minutes. \ \
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The nurse is expected to suction the patient as needed. However, this does not imply that it should be done before and after instituting PEEP. It is most important for the nurse to monitor vital signs frequently because the addition of PEEP increases intrathoracic pressure, which decreases venous return and, therefore, compromises cardiac output. The nurse would not notify the physician of an abrupt increase in oxygenation. This would be a desirable outcome. Although the nurse would certainly auscultate breath sounds on a routine basis, it would not typically be expected every 15 minutes and would not be particularly associated with instituting PEEP. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ The nurse responds to a ventilator pressure alarm by going to the patient’s room. What should be the nurse’s first action? \ Turn off the ventilator alarm to help calm the patient. \ Administer intravenous sedation according to prn prescription. \ Assess for the cause of the alarm. \ Manually bag the patient until the cause of the alarm is detected. \ \
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The ventilator alarm should not be turned off. Most systems have a mechanism by which the alarm can be temporarily muted. Attending to the alarm is not the nurse’s priority action. The nurse cannot ascertain the need for sedation without additional action. The nurse’s first action should always be to assess the patient. Manual bagging would be used after the patient is assessed and if the nurse could not quickly discover the reason for the alarm. This step is not indicated at this time. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A patient who has been extubated postoperatively is retaining carbon dioxide. In order to avoid reintubating this patient the nurse would expect to manage which intervention? \ Insertion of an oral airway \ Insertion of a nasal airway \ Use of noninvasive intermittent positive pressure ventilation (NIPPV) \ Use of continuous positive airway ventilation (CPAP) \ \ Inserting an oral airway may be indicated, but it will not reduce the retention of carbon dioxide if used alone. A nasal airway may be indicated, but will not reverse carbon dioxide retention alone. In the ICU setting, noninvasive intermittent positive pressure ventilation is used for patients in acute respiratory distress as a treatment option to avoid intubation. Noninvasive positive pressure ventilation has been used successfully for patients with hypercapnic failure. Continuous positive airway pressure ventilation is most commonly used to treat obstructive sleep apnea. It does not provide assisted ventilation on inspiration as does NIPPV.
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\ 0 0 0 0
0000000000 0000000000 0 \\ MC A+B+E \ A patient in respiratory failure has a heart rate of 124, respirations of 24, blood pressure of 168/98, blood pH of 7.28 and oxygen saturation of 84%. The patient is can be aroused, but returns to sleep quickly. Noninvasive intermittent positive pressure (NIPPV) is initiated. On reassessment, which findings would the nurse evaluate as indicating that this therapy is having the desired outcomes? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Respiratory rate is 22. \ The patient is not using accessory muscles. \ The patient is somnolent. \ Blood pH is 7.26. \ O2 saturation is 90%. \ • The respiratory rate is trending downward which is an indicator that NIPPV is being effective. • Decreased use of accessory muscles indicates the patient is not working as hard to breath. This is a positive effect of NIPPV. • NIPPV should help reduce carbon dioxide retention which would manifest as the patient being easier to arouse. • A blood pH of 7.26 would indicate worsening acidosis, possibly caused by retaining carbon dioxide. • Improved oxygenation would indicate the therapy is working.
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\ 0 0 0 0
0000000000 0000000000 0 \\ MC B+C+E \ A patient who is mechanically ventilated requires a high level of PEEP. The nurse would monitor for which findings indicating possible barotrauma? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Sudden increase in systolic blood pressure. \ Absent breath sounds. \ Subcutaneous emphysema across the anterior chest. \ Patient is somnolent. \ Sudden deterioration of ABGs. \ • Deterioration of blood pressure that occurs suddenly may indicate barotrauma. • Sudden absence of breath sounds may indicate barotrauma. • Development of subcutaneous emphysema on the anterior neck or chest may be related to barotrauma. • Sudden onset of agitation is a more likely manifestation of barotrauma. • Barotrauma will result in sudden deterioration of ABGs. \ 0 0
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0 0
0000000000 0000000000 0 \\ MC B \ The nurse monitors all mechanically ventilated patients for the development of oxygen toxicity. Which patient would the nurse determine to be at highest risk? \ The patient has required FiO2 of 0.7 for the first 2 hours after being intubated. \ A patient has required FiO2 of 1.0 for the last 8 hours. \ The patient’s ventilator was set at FiO2 of 0.4 for the last 2 days. \ The patient has required FiO2 of 0.8 for 24 hours after intubation. \ \ While this FiO2 is high the length of time it was used is short so the risk of oxygen toxicity is not high. The use of FiO2 of 1.0 can cause pulmonary changes within 6 hours. This FiO2 does not represent a high risk for oxygen toxicity. This is a high FiO2 but the duration is rather short. This patient is not at highest risk for oxygen toxicity. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC A+C+D+E \ A patient is being admitted to the intensive care unit after being resuscitated in the emergency department. The patient is being mechanically ventilated. Which information provided by the transferring nurse would the nurse evaluate as increasing this patient’s risk of developing ventilator associated pneumonia (VAP) (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ “The patient is intubated nasally.” \ “The patient arrested after having a myocardial infarction.” \ “The patient required placement of a nasogastric tube to relieve persistent gastric distention.” \ “The patient’s home medications include a proton pump inhibitor.” \ “The patient has a history of COPD.” \ • The presence of an endotracheal tube is a risk factor for VAP. • There is no particular increase in risk because the etiology of the arrest was a myocardial infarction. • Placement of a nasogastric tube increases risk for gastroesophageal reflux. • Medications to prevent stress ulcer formation create an alkaline pH in which bacteria multiply. • COPD increases risk for VAP. \ 0 0 0 0
0000000000 0000000000
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0 \\ MC C \ Which nursing intervention will help to decrease the risk of tracheal and laryngeal injuries in an intubated patient? \ Use an endotracheal tube equipped for continuous removal of subglottic secretions. \ Deflate the cuff for 5 minutes every 8 hours. \ Use the minimal occluding pressure technique to maintain cuff pressure at 20 to 25 mm Hg. \ Test cuff pressure by assessing firmness of the inflation balloon. \ \ Removal of subglottic secretions will help prevent ventilator associated pneumonia but will not protect the integrity of the tracheal and laryngeal tissues. Deflating the cuff will allow pooled secretions to enter the lower airways and increases risk for ventilator associated pneumonia. There is no evidence that decreasing cuff pressure this infrequently will protect tracheal or laryngeal tissues. The minimal occluding pressure technique can be used and cuff pressures should be maintained in the 20 to 25 mm Hg range. Firmness of the inflation balloon is a subjective measure of cuff pressure. The pressure should be checked at least once per shift via a cuff manometer. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A
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\ A patient who is endotracheally intubated and on mechanical ventilation has a decreasing oxygen saturation level with an increasing heart rate. What is the nurse’s priority action? \ Ensure the airway is clear. \ Auscultate lung sounds. \ Reposition the patient. \ Reposition the endotracheal tube. \ \ Airway clearance is a top-priority nursing goal in management of the patient with an artificial airway. If airway patency is not maintained, the patient's breathing and cardiovascular status eventually will fail as a result of hypoxia or hypercapnia. Auscultation of lung sounds is an important intervention for this patient, but is not the first priority. Repositioning the patient may improve alertness and therefore oxygenation if the patient is on an assist ventilator mode. However, repositioning is not the first nursing priority. Repositioning the airway may be indicated, but the nurse must take another action to determine if that is the correct intervention. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+D \ The health care team has planned to begin weaning a patient from the mechanical ventilator in the morning. The nurse should alert the team to which situations that could decrease the chance of successful weaning? (Select all that apply.)
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Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ The patient has developed a fever. \ The patient was suctioned twice during the night for a small amount of thin secretions. \ ABGs reveal a pH of 7.34. \ The patient is constipated. \ The patient’s serum sodium level is 138 mEq/L. \ • Fever increases metabolic rate and decreases the chance of successful weaning. • It is normal for the patient to require suctioning. Twice during the night is not excessive and the secretions are thin. This finding should not impede weaning. • pH between 7.30 and 7.45 offer the best chance of successful weaning. • Bowel problems such a diarrhea or constipation can decrease successful weaning. • Normal electrolyte measurements, such as this normal sodium level, increase the chance that weaning will be successful. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A patient is being manually weaned from mechanical ventilation. What nursing intervention is indicated? \ Suction the patient once the ventilator is removed. \ Have intubation equipment at the bedside. \
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Project a calm and confident manner. \ Change the ventilator settings so the patient can breathe spontaneously between set breaths. \ \ Suctioning removes oxygen as well as removing secretions. If suctioning is needed it should be done prior to the weaning period. The patient remains intubated during this weaning so having intubation equipment at the bedside is not necessary. The nurse’s calm and confident presence is reassuring to the patient during this stressful time. Manual weaning involves removing the patient from the ventilator so settings are not changed. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ A patient who will require long-term mechanical ventilation has had a tracheostomy for 2 weeks. The nurse is concerned that stoma erosion is occurring. Which nursing assessment would support the nurse’s concern? \ Secretions are present at the stoma opening. \ Granulation tissue is noted at the stoma site. \ The patient has developed a dry cough. \ The skin at the stoma opening is flaky. \ \
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The presence of excessive secretions at the stoma opening indicates that the stoma size in increasing. Granulation tissue is more likely to result in obstruction or stricture. Dry cough does not indicate stoma erosion. Flakiness indicates dryness. In stoma erosion the skin is excoriated from constant moisture. \ 0 0 0 0
0000000000 0000000000 0
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Chapter 7 \\ MC A \ The nurse is preparing to use a patient’s pulmonary artery catheter to obtain hemodynamic measurements. Which nursing action is indicated? \ Zero the transducer at the phlebostatic axis. \ Place the patient in Trendelenburg position. \ Warm cardiac output injectate fluid to body temperature. \ Prepare 20 mL of injectate. \ \ The phlebostatic axis approximates the level of the right atrium and is considered to represent the level of the catheter tip. Trendelenburg position or the head down position may be used during insertion of the catheter to make visualization of the jugular approach easier. However, supine is the recommended position for hemodynamic readings. Injectate should be iced or room temperature but not warmed. The traditional method of thermodilution cardiac output uses a 10mL bolus of injectate. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \
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The preceptor nurse is assisting a newly hired nurse with completion of hemodynamic assessment using a pulmonary artery catheter. Which action would require the preceptor to intervene? \ Inflating the pressure bag to 300 mm Hg \ Infusing a vasoactive drug through the proximal injectate port \ Obtaining a pulmonary artery wedge pressure reading through the distal port \ Using iced normal saline to obtain a cardiac output \ \ In order to overcome arterial pressure and prevent blood from backing up into the pressure tubing, the pressure bag placed around the flush solution should be inflated to 300 mm Hg. The proximal injectate port is the primary port used for obtaining cardiac output via boluses of iced or room temperature normal saline. Because of the risk of inadvertent bolus of potent medications, neither vasopressor nor vasodilators should be administered through the same port used for obtaining cardiac output. It would be safer to infuse vasoactive drugs through the proximal infusion port. The distal port is the designated port for continuous monitoring of the pulmonary artery pressure and for obtaining the pulmonary artery wedge pressure. Either iced or room temperature normal saline can effectively be used to obtain accurate cardiac output measurements. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ While caring for a patient being hemodynamically monitored the nurse notices that the systemic vascular resistance has risen to 1,800 dynes/sec/cm5, whereas the patient's cardiac output remains at 6.0 liters per minute. What would the nurse expect the patient's blood pressure to be?
2
\ Increased \ Unchanged \ Decreased \ Initially decreased, and then increased \ \ Systemic vascular resistance or afterload is the pressure the heart pumps against to get volume out to the lungs or the body. If that pressure is increased, but volume, measured by cardiac output stays the same, it means that the heart is working harder to get volume out and the blood pressure will go up. Increasing systemic vascular resistance with no change in cardiac output does indicate a change in blood pressure. Since the heart is working harder, blood pressure will not decrease immediately. The blood pressure would increase initially in response to the increased workload. If treatment is not initiated, the heart will eventually tire, and a decrease in blood pressure could be expected. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ The nurse is reviewing the results of a patient’s cardiac output curve and notes that the size of the curve is small. Which of the following does this finding indicate? \ A low cardiac output \ Poor injection technique \
3
Incorrect placement of the catheter \ A high cardiac output \ \ A large curve indicates a slow return to baseline temperature and, therefore, a low cardiac output. The size of the curve does not indicate poor injection technique. A small cardiac output curve does not indicate incorrect placement of the catheter. A small curve indicates a rapid return of the blood to its baseline temperature and, therefore, a high cardiac output. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+E \ The nurse is performing an assessment on a patient whose right atrial pressure is 12 mm Hg. Which findings would the nurse anticipate? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Jugular vein distention \ Weak, thready pulse \ Presence of rales and rhonchi \ Poor skin turgor \ Hepatomegaly
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\
• • • • •
Elevation of right arterial pressure indicates high right ventricular preload which results in fluid back up into the venous system. Jugular vein distention is a sign of increased right ventricular preload. The pulse is usually full and bounding when right atrial pressure is increased. Rales and rhonchi are signs of left-sided heart failure. Skin turgor is a manifestation of hydration status. Elevation of right arterial pressure indicates high right ventricular preload, which results in fluid back up into the venous system. Hepatomegaly is a sign of increased right ventricular preload.
\ 0 0 0 0
0000000000 0000000000 0 \\ MC A+B+C \ A patient who was stabbed multiple times in the chest and abdomen has just returned from emergency surgery. Hemodynamic monitoring was initiated during surgery and now reveals that the patient’s right atrial pressure has dropped to 2 mmHg. The nurse would assess for findings of which conditions? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Internal hemorrhage \ Fluid loss during surgery \ Vasodilation from drugs administered during surgery \ Left heart failure \ Cardiac tamponade \
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• • • • •
Hemorrhage is a cause of absolute fluid deficit and will be reflected in a low right atrial pressure. If the patient lost a significant amount of blood or other fluids during surgery the right atrial pressure could drop. Vasodilation reduces venous return to the right atrium, resulting in decrease of right atrial pressure. Left heart failure results in an increased volume in the pulmonary circulation which increases right atrial pressure. Cardiac tamponade or rapid fluid buildup in the pericardial space increases pressures on the heart and would result in increased right atrial pressure.
\ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ While evaluating a patient's pulmonary artery waveforms, the nurse notes a sudden onset of right ventricular waves. Which nursing intervention is indicated? \ Assist the patient to a left side-lying position. \ Notify the physician for repositioning. \ Increase intravenous fluids. \ Nothing, since this is an expected occurrence. \ \
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Assisting the patient to a left side-lying position is not going to reposition the catheter. The right ventricular waveform will appear when the catheter tip retreats from the pulmonary artery into the right ventricle. Should the waveform appear, as in the case with the patient, the nurse should notify the physician for repositioning. There is nothing to indicate that the patient needs an increase in intravenous fluids. This is not an expected occurrence and should not be ignored. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ A patient with congestive heart failure is receiving scheduled doses of an intravenous diuretic. After administering the drug, which finding would indicate to the nurse that the drug was effective? \ A pulmonary artery wedge pressure of 16 mm Hg \ Pulmonary artery pressure of 34/16 mm Hg \ Systemic vascular resistance of 1,400 dynes/sec/cm-5 \ A right atrial pressure of 5 mm Hg \ \ Normal pulmonary arterial wedge pressure is 4 to 12; 16 is high and would indicate high preload. Normal pulmonary artery pressure is 20 to 30 mm Hg/8 to 15 mm Hg. These pressures should decrease with diuretic administration. Normal systemic vascular resistance is 800 to 1,200 dynes/sec/cm-5. With diuretic use, the systemic vascular resistance should also normalize. A right atrial pressure of 5 is a normal reading and would indicate the diuretic is having its intended effect. \
7
0 0 0 0
0000000000 0000000000 0 \\ MC D \ The nurse is caring for a patient who is being monitored with a pulmonary artery catheter. Which change requires immediate intervention? \ Systemic vascular resistance of 900 dynes/sec/cm5 \ Appearance of an "a" wave on the pulmonary artery waveform \ Pulmonary artery wedge pressure of 10 mm Hg \ Spontaneous development of a pulmonary artery wedge pressure waveform \ \ A systemic vascular resistance of 900 is normal. The "a" wave is indicative of the rise in atrial pressure produced by left atrial contraction and is normal. A pulmonary arterial wedge pressure of 10 mm Hg is within normal limits. A permanent wedge waveform is an indication of catheter migration further into the pulmonary artery causing occlusion. Immediate intervention is needed to prevent pulmonary infarction. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC A \ A patient is admitted for evaluation of hypotension. Which assessment by the nurse would require immediate attention? \ Pulmonary artery wedge pressure of 2 mm Hg \ Heart rate of 112 \ Urine output of 25 mL/hr \ Presence of rales at both lung bases \ \ The normal pulmonary artery wedge pressure is 4 to 12 mm Hg. A wedge pressure of 2 mm Hg is indicative of significant hypovolemia. Additional assessment is critical. Although a heart rate of 112 is abnormal it is not the most significant of the findings provided. Urine output of 25 mL/hr is low to low normal, but is not the most significant finding provided. Rales at lung bases are an abnormal finding, but unless the patient has significant respiratory distress, they would not require immediate intervention. This is not the most significant finding provided. \ 0 0 0 0
0000000000 0000000000
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0 \\ MC A+E \ Which nursing interventions are indicated when measuring pulmonary artery wedge pressure (PAWP)? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Use no more than 1.25 mL of air to inflate the balloon. \ Pull back on the syringe to deflate the balloon. \ Leave the balloon slightly inflated to maintain integrity. \ Maintain balloon inflation for 3 to 5 minutes to obtain a stable reading. \ If there is any resistance during inflation do not continue. \ Using the smallest inflation volume possible, typically less than 1.25 mL, reduces the risk of balloon rupture. Passive deflation should be used to avoid damage to the balloon. The balloon should be completely deflated to avoid a continuous wedge, which could lead to pulmonary infarction. The balloon should be inflated only long enough to obtain a stable reading. Resistance may indicate that the balloon is compromising the artery. The nurse should stop inflation, allow the balloon to passively deflate and call the health care provider. \ 0 0 0 0
0000000000 0000000000 0 \\ MC
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D \ The nurse is caring for a patient whose pulmonary artery wedge pressure is 16 mm Hg. The patient’s neck veins are flat, lungs are clear, and the pulse pressure is low. Which intervention would the nurse anticipate? \ Administer a 500 mL normal saline fluid bolus. \ Repeat the reading after recalibrating the system. \ Repeat the reading after repositioning the patient. \ Administer a diuretic and a vasodilator. \ \ Administering a 500 mL normal saline fluid bolus would be expected if preload were low. The assessment findings presented match the PAWP reading, so no repeat of the measurement is necessary. The patient should be placed in the supine position whenever completing a hemodynamic assessment. Repositioning the patient is unlikely to affect the reading. The normal pulmonary artery wedge pressure is 4 to 12 mm Hg. A reading of 16 mm Hg indicates high preload, and the nurse can anticipate administering a diuretic and a vasodilator to help reduce preload. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ A patient who has a radial artery catheter in place is complaining of numbness and tingling in the fingers. What is the nurse’s priority assessment? \ Is there a palpable pulse? \
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Is blood is easily obtained from the catheter? \ Does the patient have a fever? \ Does the waveform have a characteristic appearance? \ \ Monitoring circulation distal to the arterial insertion site is the priority nursing function. Skin color and temperature and all pulses should be regularly assessed and documented. It is important to be able to easily access blood from the catheter, but this is not the priority assessment. Fever might indicate an infection at the insertion site, but if this is occurring it will take time to treat. This is a very important assessment, but is not the highest priority. An appropriate and normal waveform is an assurance that the system is functioning and measurements would be accurate. However, this is not the most important for the patient's safety and prevention of complications. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+E \ The nurse is assessing a patient's arterial waveform and notes a notch on the descending portion of the waveform. The nurse associates this notch with which physiological events? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Closure of the aortic valve \ The highest systolic pressure \ Systolic ejection of blood
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\ The diastolic pressure \ Beginning of ventricular diastole \ • This “dicrotic” notch represents closure of the aortic valve. • When the aortic valve opens, blood is ejected into the aorta. This forms a steep upstroke on the arterial waveform, called the anacrotic limb. The top of this limb represents the peak, or highest systolic pressure. • After the waveform reaches its peak, it begins to descend. This descent forms the dicrotic limb and represents systolic ejection of blood that is continuing at a reduced force. • The lowest portion of the waveform represents the diastolic pressure and is reflected digitally on the monitor. • This “dicrotic notch” represents the beginning of ventricular diastole. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ A patient who has a pulmonary artery catheter in place is to receive the drug nitroprusside. The nurse would assess for which indicator of the drug’s effectiveness? \ Decreased systemic vascular resistance \ Decreased cardiac output \ Increased right atrial pressure \ Increased pulmonary artery wedge pressure \
13
\ Nitroprusside is a potent systemic vasodilator with primary action on decreasing afterload, which is measured by systemic vascular resistance. Nitroprusside should decrease cardiac workload and increase stroke volume which will increase cardiac output. Nitroprusside administration should result in right atrial pressure decrease. Pulmonary artery wedge pressure should decrease. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ The nurse is caring for a patient with sepsis. On completing the hemodynamic assessment the nurse notes that the patient's afterload, measured by the systemic vascular resistance, is 400 dynes/sec/cm-5. The nurse evaluates this finding to be primarily the result of which change associated with sepsis? \ Decreased circulating volume \ Reaction to antibiotics used to treat sepsis \ Marked vasodilation \ Decreased ventricular contractility \ \ Hemodynamic changes associated with sepsis are not caused by low circulating volume. The primary reason for decreased vascular resistance is not related to reaction to medications. Sepsis, through its release of inflammatory mediators, causes vasodilation, resulting in the markedly low systemic vascular resistance. Ventricular contractility may be reduced following the release of myocardial depressant factor as a result of sepsis. However, this is not the primary cause of decreased vascular resistance.
14
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0000000000 0000000000 0 \\ MC D \ A patient is being prepared for impedance cardiography. Which information will the nurse provide? \ “This technology will use ultrasound to measure your heart rate and blood flow.” \ “We are preparing to measure the oxygenation of your peripheral tissues.” \ “A catheter will be inserted into a vein in your neck.” \ “Electrodes will be placed on your neck and your lateral chest.” \ \ Doppler technology uses ultrasound through a probe to measure heart rate and blood flow. Pulse oximetry is used to measure peripheral oxygenation of tissues. Cannulation of the right subclavian or internal jugular vein is necessary for placement of a central venous catheter. Impedance cardiography is used to assess cardiac function through the use of a high-frequency, low-amplitude current to measure the resistance to flow of the electrical current. The procedure includes placing electrodes bilaterally at the base of the neck and on the lateral chest at the level of the diaphragm. \ 0 0 0 0
15
0000000000 0000000000 0 \\ MC C \ A patient is admitted to the emergency department after fainting. Vital signs are blood pressure 86/60, heart rate 160 bpm, and respirations 20. The patient’s skin is cool to the touch. Which nursing diagnosis (NDX) is priority? \ Risk for Falls \ Fluid Volume Deficient \ Decreased Cardiac Output \ Impaired Gas Exchange \ \ This patient does have risk for injury from falling, but this NDX is not the current priority. Interventions to reverse the primary NDX will help to reduce this risk. Hypovolemia may result in syncope, but there is not enough information to evaluate whether this is occurring with this patient. Loss of consciousness, cool skin, low blood pressure, and increased heart rate all indicate decreased cardiac output. Tachycardia can result in decreased cardiac output by shortening ventricular filling time during diastole. The scenario does not present arterial blood gases, so a diagnosis of impaired gas exchange is not supported. \ 0 0 0 0
16
0000000000 0000000000 0 \\ MC A+D \ Which nursing actions are necessary to collect information needed to figure the patient’s cardiac index? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Weigh the patient. \ Take the patient’s temperature. \ Measure the patient’s blood pressure. \ Measure the patient’s height. \ Determine the patient’s age. \ • Calculating cardiac index requires knowledge of the patient’s weight. • Body temperature is not used to figure cardiac index. • Blood pressure is not used to figure cardiac index. • In order to figure the cardiac index, the nurse must know that patient’s height. • It is not necessary to know the patient’s age in order to determine cardiac index. \ 0 0 0 0
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17
\\ MC B \ A patient requires insertion of a pulmonary artery catheter. Which nursing action is indicated? \ Instill air in all stopcocks. \ Prime the pressure monitoring system. \ Call for the rapid response team. \ Obtain sterile gowns, gloves, caps, and masks for all persons who will be present during the insertion.\ \ Air should be removed from all stopcocks. The pressure monitoring system should be primed to remove all air. There is no need for rapid response team intervention. The people inserting the catheter will wear sterile gowns, gloves, caps, and masks. Others in the room should wear a cap and mask. \ 0 0 0 0
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18
Chapter 8 \\ MC C \ A patient has been diagnosed with premature ventricular contractions. The nurse realizes that this dysrhythmia can result from a weaker than normal stimulus during which action potential period? \ Absolute refractory period \ Relative refractory period \ Supranormal period \ Subnormal period \ \ During the absolute refractory period the cell cannot deal with any new electrical impulses and is completely “resistant” to stimuli. In the relative refractory period a stronger than normal electrical stimuli is needed to trigger depolarization. This stimulus could result in premature ventricular contraction. During the supranormal period a weaker than normal stimulus can produce depolarization and can result in premature ventricular contractions. "Subnormal" is not used to describe a phase or period of the action potential. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \
A patient's electrocardiogram ST segment tracing is deflected from baseline. The nurse would conduct assessment for which condition? \ Ventricular muscle injury \ Atrial muscle injury \ Respiratory acidosis \ Hypocalcemia \ \ The ST segment represents the completion of ventricular depolarization and the beginning of ventricular repolarization. The segment should be isoelectric, or consistent with the baseline. There should be no deflections present because positive and negative charges are balanced. Deflections in the ST segment usually indicate ventricular muscle injury. The ST segment is not associated with atrial depolarization or repolarization. The ST segment is not associated with respiratory acidosis. Deflection of the ST segment is not associated with calcium levels. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ A patient’s heart rate averages 86 beats per minute. If this patient is to have continuous electrocardiogram monitoring the nurse will set the rate alarms at which level? \ Low 76, high 96 \ Low 66, high 106
\ Low 60, high 100 \ Low 80, high 100 \ \ Setting the alarms at these levels does not reflect the usual protocol. Alarms on the monitor are set typically at 20 bpm higher and lower than the patient's baseline rates. The alarms are left on and audible to the nurse. If the patient's normal heart rate is 86 beats per minute, the alarms should be set to low 66 and high 106. Setting the alarms at these levels does not reflect the usual protocol. Setting the alarms at these levels does not reflect the usual protocol. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ The nurse has determined that the patient has a bundle branch block. In order for this determination which condition must exist? \ The PR interval must be longer than 0.20 seconds. \ The ST segment must be elevated. \ QRS segment should not be longer than 0.128 seconds. \ The PR interval lengthens with each beat. \ \
The length of the PR interval is not associated with bundle branch block. Presence of a bundle branch block is not determined by the position of the ST segment. The QRS complex should be 0.12 seconds or less in length unless there is a delay in the impulse reaching the ventricles. A widened QRS complex means delayed conduction through the bundle branches or a bundle branch block, abnormal conduction within the ventricles, or early activation of the ventricles through a bypass route. Lengthening PR interval is related to heart block, not bundle branch block. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ The nurse interpreting a patient’s electrocardiogram has just examined the P waves. What is the nurse’s next step? \ Determine if each P wave is followed by a QRS complex. \ Measure the PR interval. \ Diagnose the rhythm. \ Examine and measure the QRS complex. \ \
It is important to determine if each P wave is followed by a QRS complex, but this is not the next step of rhythm interpretation. The next structure of importance in the rhythm is the PR interval. The nurse should measure its length. In order to make an accurate diagnosis of rhythm, the nurse should follow the standard interpretation sequence. The nurse does not examine the QRS complex until the P wave and PR interval have been addressed. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C+E \ A patient is diagnosed with hypermagnesemia. The nurse would assess for which changes on the patient’s cardiac rhythm strip? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Prolonged QT interval \ Flattened T waves \ Tall peaked T waves \ Short QT interval \ Prolonged PR interval \
• • • • •
Hypercalcemia, not hypermagnesemia, can produce a shortened QT interval. Hypocalcemia can produce a prolonged QT interval. Decreased levels of magnesium increase the irritability of the nervous system and can produce a flattened T wave. Increased levels of magnesium can produce tall, peaked T waves. Hypercalcemia, not hypermagnesemia, can produce a shortened QT interval. Hypermagnesemia can result in lengthening of the PR interval.
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0000000000 0000000000 0 \\ MC A \ A patient’s admission vital signs were blood pressure 128/64 mm Hg; HR 86 bpm, respirations 16, and temperature 98.6°F. The patient has spiked a temperature of 101.6°F. Which change in heart rate would the nurse anticipate? \ Increase to 116 bpm \ Increase to 100 bpm \ Decrease to 76 bpm \ Increase or decrease of no more than 5 bpm \ \
Hyperthermia increases electrical activity of the heart. Heart rate increases about 10 bpm for each degree Fahrenheit.T his patient’s temperature has elevated by 3 degrees F, so a 30 bpm increase to 116 would be expected. The nurse would expect a different heart rate change. Temperature elevation causes an elevation of heart rate. The nurse would anticipate a greater change than 5 bpm. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ A patient presents to the emergency department and says, “I am so dizzy that it is scaring me.” Monitoring reveals the patient’s blood pressure is 78/52 mm Hg and heart rate is 50 beats per minutes. Which nursing intervention is indicated? \ Administer anti-anxiety medication. \ Administer atropine. \ Instruct the patient to cough forcefully. \ Monitor the patient while contacting the primary care provider. \ \ The patient’s anxiety is likely due to fear of the unknown. Anti-anxiety medication is not indicated. Sinus bradycardia is not treated unless the person experiences symptoms of decreased cardiac output, such as syncope, hypotension, and angina. Symptomatic sinus bradycardia is treated by administering atropine because it blocks the parasympathetic innervation to the SA node,
allowing normal sympathetic innervation to gain control and increase SA node firing. The patient is symptomatic so atropine is indicated. Forceful coughing will not reverse this patient’s symptoms. The patient requires intervention. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+C+D \ A patient in the emergency department has a heart rate of 140 bpm. Which nursing interventions are indicated? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Assess the patient’s temperature. \ Administer atropine. \ Present a calm demeanor. \ Assess the patient for pain. \ Prepare for intubation. \ • Increased temperature can result in tachycardia. • Atropine is not indicated for tachycardia. • Anxiety can result in tachycardia. The nurse should present a calm and confident demeanor. • Pain can result in tachycardia. If pain is present it should be treated promptly.
•
Unless there are other assessment findings indicating the need for intubation this intervention is not necessary.
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0000000000 0000000000 0 \\ MC D \ A patient’s cardiac monitor reveals a regular rhythm with a rate of 240 bpm. No P waves are distinguishable. The patient is alert and says, “My heart is racing.” What nursing intervention is indicated? \ Gather equipment to begin anticoagulant therapy. \ Defibrillate the patient. \ Prepare the patient for immediate cardioversion. \ Ask the patient to bear down as if moving the bowels. \ \ This rhythm is supraventricular tachycardia. At this point anticoagulant therapy is not indicated. The patient is alert and responsive. Defibrillation is not indicated. If the patient was in extreme distress elective cardioversion would be indicated. Since this patient is alert, cardioversion is not indicated. This patient has supraventricular tachycardia. This rhythm can be treated with Valsalva's maneuver, which is elicited by having the patient bear down as if moving the bowels. \ 0 0
0 0
0000000000 0000000000 0 \\ MC B \ A patient’s atrial fibrillation has been refractory to treatment. The nurse would prioritize which discharge instructions? \ Avoiding stressful situations \ Anticoagulant therapy precautions \ The importance of daily weights \ How to check blood pressure at home \ \ There is no specific reason the patient should avoid stressful situations any more than any other patient with a cardiac disorder. Patients in atrial fibrillation require anticoagulation such as warfarin therapy. The nurse must provide instructions regarding precautions that are made necessary by this therapy. This patient has potential for developing congestive heart failure, so daily weights may be necessary. However, this is not the instruction with the highest priority. The patient who is in atrial fibrillation may be instructed to monitor blood pressure, but this is not the priority discharge teaching. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ A patient has a normal QRS complex on an electrocardiogram which is followed by the P wave. Heart rate is 80 bpm and regular and the patient has no complaints. What nursing action is indicated? \ Document presence of atrial escape rhythm. \ Review the patient’s medication history. \ STAT page the patient’s health care provider. \ Notify the nurse manager that it may become necessary to call the rapid response team. \ \ When the normal QRS is followed by a P wave the rhythm is junctional. Junctional rhythm may be caused by several medications. The nurse should review the medication list for possible causative drugs. The health care provider should be altered to the presence of junctional rhythm, but there is no cause for a STAT page. This assessment indicates presence of junctional rhythm. The patient is asymptomatic with an adequate ventricular rate, so it is not likely that the nurse will need to call the rapid response team. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A patient’s cardiac rhythm strip reveals rate of 78, PR interval of 0.08 seconds, a normally configured QRS, and an upright T wave. Which medication does the nurse recognize as most often associated with development of this rhythm? \ Potassium supplement \ Warfarin \ Digoxin \ Tocainide \ \ High potassium levels may be implicated in slow junctional escape rhythms, but this rate is normal. Warfarin does not cause junctional rhythm. Digitalis decreases the automaticity of the AV node and slows conduction between the SA and AV node so therefore, digitalis toxicity can precipitate junctional rhythms. The dysrhythmia is treated by withholding the medication. Tocanide is a class 1B drug that has few ECG effects. \ 0 0 0 0
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MC A+D+E \ A patient is having multifocal premature ventricular contractions (PVCs). What nursing interventions are indicated? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Administer oxygen. \ Withhold the next digoxin dose. \ Administer atropine. \ Monitor the patient closely for other dysrhythmias. \ Consult with the health care provider. \ • Hypoxemia can cause PVCs. The nurse should implement emergency orders for oxygen therapy. • Multifocal PVCs are not associated with use of digoxin. • Atropine is used to increase heart rate. It is not indicated for use in patients with ventricular irritability. • Multifocal PVCs may herald additional dysrhythmias such as ventricular tachycardia or ventricular fibrillation. • Presence of multifocal PVCs indicates increased ventricular irritability. The nurse should contact the health care provider and discuss treatment options, such as adding medications. \ 0 0 0 0
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\\ MC D \ A patient develops ventricular tachycardia on the cardiac monitor. The patient says “My heart is racing” as the nurse determines a rapid pulse is present. What is the nurse’s priority intervention? \ Call respiratory therapy to prepare a mechanical ventilator. \ Draw blood for arterial blood gases. \ Prepare to for a change in intravenous fluid being administered. \ Monitor the patient for loss of consciousness. \ \ This patient may arrest and need mechanical ventilation, but this is not the nurse’s first priority. The patient may need multiple lab tests, but this is not the nurse’s priority intervention. This patient may need a different IV fluid, but this is not the priority intervention. Patients can be alert while experiencing ventricular tachycardia; however, as cardiac output falls, a loss of consciousness may occur. When this occurs cardioversion may be necessary. The nurse’s priority is to assess the patient. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ A patient, experiencing ventricular fibrillation, was resuscitated with lidocaine, then magnesium, and lastly amiodarone. Which medication will the nurse most likely provide as a continuous infusion for this patient?
\ Lidocaine \ Magnesium \ Atropine \ Amiodarone \ \ Lidocaine was not successful in converting the patient’s rhythm and would probably not prevent the return of ventricular fibrillation. Magnesium did not successfully stop the patient’s ventricular fibrillation and is not likely to be administered in an attempt to control the rhythm. The patient did not receive atropine during the resuscitation. It is not indicated now. Once the patient has converted from ventricular fibrillation and has a pulse, a continuous infusion of the last drug used to convert the rhythm is initiated. Since the patient last received amiodarone, the nurse will most likely provide a continuous infusion of the medication for the patient. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+C+D \ A patient’s cardiac monitor reveals heart rate of 40 bpm with an irregular rate. The PR intervals are constant and there are P waves with no QRS to follow. The QRS complexes are wider than normal. The patient complains of severe dizziness and nausea. Which nursing interventions are indicated? (Select all that apply.)
Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Administer atropine. \ Prepare to cardiovert the patient. \ Prepare for placement of a temporary pacemaker. \ Administer epinephrine. \ Ask the patient to cough forcefully. \ • This rhythm represents Mobitz type II second-degree AV block and the patient is symptomatic. Atropine is indicated. • Cardioversion is not used to treat this type of dysrhythmia. • This rhythm is a Mobitz type II second-degree block and the patient is symptomatic. Type II second-degree blocks are generally treated by inserting a pacemaker. • Dopamine or epinephrine is used in severe symptomatic bradycardia like the patient is experiencing. • Forceful coughing will not improve this patient’s cardiac status. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A patient has a new onset of a left bundle branch block (LBBB) seen on a 12 lead ECG. What is the nurse’s primary intervention? \ Increase oxygen. \
Elevate the head of the bed to a 30-degree angle. \ Ask the patient if he is having chest pain. \ Reposition the chest leads and assess for any changes. \ \ The patient may or may not need an increase in oxygen, so this is not the primary nursing interventon. Elevation of the head of the patient’s bed will not correct a bundle branch block. New onset left bundle branch block may indicate a myocardial infarction is occurring. The priority intervention is to assess for chest pain or other findings associated with MI. There is no indication that repositioning of the chest leads is indicated or that it will change the presence of a LBBB. \ 0 0 0 0
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Chapter 9 \\ MC C \ Assessment of the patient’s sternal surgical incision reveals that the skin between sutures is opened. There is a small amount of drainage present on the dressing. The nurse would anticipate caring for this wound as it heals in which manner? \ Tertiary intention \ Primary intention \ Secondary intention \ Recurrent surgical debridement \ \ Tertiary intention combines primary and secondary intention, often requiring the wound to be left open for a period of time, such as a few days. Primary intention healing occurs when the wound is closed and heals without interruption. This wound has dehisced, which means that it has not healed as expected and the suture line is opened. This may occur because of stretching of the skin, poor skin integrity, or because the wound is infection. Dehisced sternal wounds are allowed to heal by second intention. Future surgical debridement may be necessary if the wound does not heal, but this is not an expected part of the plan of care. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C
\ A patient is to receive pulsatile lavage treatments for a chronic ulcer on the left heel. Which explanation would the nurse provide for this treatment? \ “This treatment is a form of autolytic debridement to remove dead tissue from your heel.” \ “Your foot will be submersed in a whirlpool tub for this treatment.” \ “This treatment will help cleanse the wound bed.” \ “This treatment will inject medications into the deep crevices of your wound.” \ \ Pulsatile lavage is not a form of autolytic debridement. Whirlpool tubs are not used for pulsatile lavage. Whirlpool treatments increase risk of cross contamination of the wound. Pulsatile lavage is used to clean materials out of the wound bed. Pulsatile lavage is not used to inject medications into the wound. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ The surgical wound of a patient recovering from an appendectomy has several steri-strips across it with a small amount of dried blood over the incision line. How would the nurse dress this wound? \ Hydrocolloid dressing \ Wet-to-dry dressing
\ Alginate dressing \ Dry, sterile dressing \ \ Hydrocolloid dressings are used on moderate to heavily exudating wounds. This wound is dry. Wet-to-dry dressings are used for wounds that are healing by second intention. Alginate dressings are used to absorb secretions and form a covering for the wound bed. This wound bed is dry. The patient's wound is healing by primary intention. Dry, sterile dressings are the standard for wounds healing by this method, offering protection from contamination and the absorption of the minimal amount of exudate expected. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+B+D \ A patient presents to the emergency department with a large leg wound. The nurse identifies which factors as increasing this patient’s risk of complications with wound healing? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ The patient smokes eight cigarettes a day. \ The patient has peripheral artery disease. \ The patient has osteoarthritis in his knees. \
The patient’s average blood sugar measurements are over 200mcg/dL. \ The patient lost some blood during the injury but the loss was not excessive. \ • Smoking byproducts such as nicotine, carbon monoxide, and hydrogen cyanide reduce oxygenation, impair immune response, reduce fibroblast activity, and increase platelet adhesion and thrombus formation. This reduces oxygenation to the tissues. Smoking is also associated with significantly higher infection rates. • Peripheral artery disease decreases oxygenation of the tissues, increasing risk of complications. • The presence of osteoarthritis is related to overuse of the joint and is not a significant risk factor for problems healing. • Poor glycemic control as evidenced by average blood sugar measurements over 200 mcg/dL is a factor in healing problems. • Significant blood loss to the point of hypovolemia can cause decreased oxygenation of tissues, leading to difficulties with healing. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ There is dead tissue throughout the patient’s nonhealing abdominal wound. The nurse prepares for which intervention needed to encourage this wound to heal? \ Diet analysis for protein adequacy \ Keeping the wound covered to increase oxygen to the wound bed \ Debridement of devitalized tissue \
Introduction of air into the wound for drying \ \ The patient does need adequate protein in order for healing to occur, but this is not the most problematic issue at present. Keeping the wound covered does help to maintain oxygen levels in the wound bed, but this is not the most problematic issue present. The patient has a compromised wound that contains devitalized tissue. Devitalized tissue is tissue that has been separated from the circulation and the body's antimicrobial defenses. Bacteria proliferate on wounds that contain dead tissue and debridement of these materials is essential to prevent an environment conducive to bacterial growth. The wound bed should be kept moist. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ The nurse caring for a patient with a pressure ulcer notes the wound is increasing in redness and has more swelling around the wound edges. Which nursing intervention is indicated? \ Encourage the patient to ingest more fluids. \ Assess for pain and warmth. \ Cover the wound with a sterile dry dressing. \ Dress the wound as prescribed. \ \
Encouraging fluids will not reduce the inflammation that is occurring in the wound. The cardinal signs of an inflammation exist in a wound that is infected and include redness, edema, pain, and warmth. Since the patient's wound is demonstrating redness and edema, the nurse needs to assess for pain and warmth to aid in determining if the wound is inflamed and infected. Covering the wound with a sterile dry dressing will not address the potential for infection that exists. Simply dressing the wound according to previous order will not address the change that has occurred. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ The nurse manager has noted an increase in wound infections in a postoperative unit. What instruction to the unit staff is the most important? \ Wear gloves at all times. \ Administer antibiotics as prescribed. \ Assess patients for infection risk upon admission. \ Follow hand washing protocols. \ \
Wearing gloves at all times could increase infection rate by creating a false sense of security among staff. If other infection control methods are not used, the constant presence of gloves could increase cross-contamination. Antibiotics should be given as prescribed, but this is not the most important intervention. Knowing which patients are at highest risk for infection is helpful, but is not the most critical intervention. Correct hand washing is still considered one of the most important methods of preventing wound infections. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B+D+E \ A patient has a wound on his thigh that is swollen and red. The nurse assesses that the surrounding tissue has a dusky blue color with a few small dark blisters. Which other assessment findings would cause the nurse to alert the health care provider about possible necrotizing fasciitis (NF)? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Blood pressure is 140/90 mm Hg. \ The patient reports recently taking steroids for a severe ear infection. \ The patient works in an elementary school. \ The patient reports pain as a 9 on the 1 to 10 pain scale. \ The patient’s body mass index is 31.
\
• • • • •
If the patient is in pain this blood pressure would not be unexpected. Steroid use increases the risk for necrotizing fasciitis. Exposure to young children is not a risk factor for developing necrotizing fasciitis. Pain that is out of proportion to the physical clinical presentation is an important warning sign of NF. A body mass index (BMI) over 30 indicates obesity. Obesity is a risk factor for development of NF.
\ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ A male patient tells the nurse that he has "excruciating pain" in his perineal region that started a few days after having an indwelling urinary catheter removed. Upon inspection, the nurse sees a dime-sized reddened area on the patient's perineum below the scrotal sac. What nursing intervention is priority? \ Have the wound further evaluated for possible Fournier's gangrene. \ Apply ice to the region. \ Give the patient prn acetaminophen. \ Place a scrotal support on the patient. \ \ The one clinical symptom of Fournier's gangrene is pain out of proportion to the wound. The other clinical symptom is that this type of disorder affects males more than females. These two pieces of information should lead the nurse to contact the patient's physician for further
evaluation of the wound for possible Fournier's gangrene. The patient did have an indwelling urinary catheter removed a few days ago and this type of disorder is associated with genitourinary procedures or manipulation. Applying ice to the region is not indicated. The nurse would treat the patient’s pain, but a different intervention is the priority. There is no indication that use of a scrotal support would relieve this patient’s pain or change the underlying reason for the pain. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ A patient being treated for necrotizing fasciitis has signs of granulation tissue appearing in a large abdominal wound. The nurse anticipates providing which care for this patient’s wound? \ Irrigating the wound twice daily before applying dry dressing \ Caring for a split thickness skin graft \ Applying wet-to-dry dressings \ Caring for a suture line created by surgical closure of the wound \ \
Granualtion tissue should be kept moist. Once systemic manifestations of the infectious process associated with necrotizing fasciitis disappear, healthy granulation tissue appears. The next phase is to restore dermal and fascial integrity and the best way to achieve wound closure rapidly and safely is with split thickness skin grafts. Skin is taken from a donor site and placed on healthy granulation tissue to cover the defect. The wounds associated with necrotizing fasciitis are large and would not easily be treated with wet-to-dry dressings. This wound will be extensive and is not closed in the normal manner of creating a suture line. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ A patient is admitted for a repair of an abdominal aortic aneurysm. Which assessment finding would the nurse evaluate as indicating this patient is at increased risk for developing an enterocutaneous fistula (ECF)? \ Diagnosis of type 2 diabetes mellitus \ Daily use of NSAIDs for arthritis symptoms \ Diagnosis of peripheral vascular disease \ History of radiation therapy to treat colon cancer \ \
While diabetes mellitus can result in impaired healing, it is not a specific risk for development of ECF. There is no specific connection between use of NSAIDs and increased risk for ECF. Peripheral vascular disease can result in problems with skin integrity, but is not a specific risk for development of ECF. Radiation therapy to the abdomen increases the patient’s risk for development of ECF. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ The patient’s colectomyincision is red and the skin around the sutures is taut and shiny. What nursing intervention is indicated? \ Assess for the presence of drainage or odor. \ Clean this healing wound and redress as ordered. \ Collaborate with the health care provider regarding suture removal. \ Instruct the patient to use additional splinting for deep breathing and coughing. \ \ Since this patient’s surgical wound is closed with sutures the nurse should assess for the odor of GI contents or for seepage around the sutures. If this finding is present and enterocutaneous fistula may be present. These findings do not indicate a healing wound. These findings are not those normally associated with a wound ready for suture removal. These findings do not indicate stress from coughing and they will not be changed by additional splinting.
\ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ A patient has a wound that extends into the subcutaneous fatty tissue. The nurse plans care for this wound with the knowledge that it has penetrated to which skin level? \ Epidermis \ Hypodermis \ Dermis \ Cartilage \ \ The epidermis, the outermost layer, contains epithelial cells. The hypodermis contains blood vessels, nerves, muscle, and adipose tissue. The dermis contains connective tissue and elastic fibers, sensory and motor nerve endings, and a complex network of capillary and lymphatic vessels and muscles. Cartilage is not a layer of the skin. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ The nurse measures a patient’s wound diameter and notes that it has reduced in size. The nurse evaluates this information to indicate the wound has entered which phase? \ Remodeling \ Inflammatory \ Maturation \ Proliferative \ \ The remodeling phase is the third phase of the wound healing process occurs after the wound has closed. The inflammatory phase prepares the wound environment for subsequent tissue development. This sign is recognized by the four cardinal signs of inflammation: heat, redness, swelling, and pain. The maturation stage is also known as the remodeling stage. Wound contraction occurs during the proliferative phase of wound healing. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ A patient with several burn scars tells the nurse that the scars are prone to injury and don’t seem as tough as the rest of his skin. Which nursing response is indicated? \ “Even when healed, the scar will only regain about 80% of the strength of normal skin.” \ “Your body is still making new blood vessels for the wound.” \ “Your body is trying to remove additional bacteria from the wound area.” \ “Your healing process hasn't been completed.” \ \ Remodeling/maturation is the final repair process and can last months to years. The final product of remodeling is the scar, which has covered the defect and restored the protective barrier against the external environment. Even when the wound is completely healed, only about 80% of the tensile strength of normal skin is regained and the patient is at risk for recurrent breakdown. Angiogenesis takes place in the proliferative stage of wound healing, not after scars have developed. Bacterial are normally removed from the wound during the inflammatory phase. The patient’s healing process may take months or years, but this is not the best answer to address the patient’s concerns. \ 0 0 0 0
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MC B+C \ A nurse documents a stage 1 pressure ulcer on a patient’s lateral malleolus. What assessment findings would indicate that this ulcer has progressed to stage II? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ The subcutaneous fat layer is exposed. \ A fluid-filled blister is present. \ A shallow open ulcer is present. \ There is an area of boggy purple skin on the bony prominence. \ There is an area of skin that does not turn white with pressure. \ • Exposure of the subcutaneous fat layer occurs in stage III ulcers. • Presence of a fluid-filled blister indicates a stage II ulcer. • Shallow open ulcers are stage II ulcers. • Boggy purple skin over a bony prominence is a deep-tissue injury. • Nonblanchable erythema indicates a stage I ulcer. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \
The wound care specialist has assessed a patient’s pressure ulcer and recommends using a hydrocolloid wafer to encourage autolytic debridement. The nurse would plan interventions associated with which stage pressure ulcer? \ Stage I \ Stage II \ Stage III \ Stage IV \ \ Stage I ulcers are treated with turning and removal of pressure. Stage II ulcers need a moist environment but not debridement. Stage III ulcers need a moist environment but not debridement. Stage IV ulcers may require debridement as well as packing to fill dead space and to absorb exudate. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+B+D \ During initial assessment the nurse notes that the edges of a wound are hard to palpation. The nurse would continue assessment for which conditions? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Infection
\ Necrosis \ Osteomyelitis \ Deep tissue injury \ Maceration \ • Indurated wound edges may indicate infection. • Indurated edges may indicate necrosis. • Osteomyelitis is considered when bone is visible or palpable. • Indurated wound edges may occur when there is deep tissue injury. • Maceration is softening of the skin associated with chronic exposure to moisture. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ The patient has been prescribed IV gentamicin for treatment of an aerobic gram-negative wound infection. Which nursing intervention is indicated? \ Draw peak and trough concentrations as indicated. \ Give the medication over a 2-hour period. \ Hold the medication if the patient experiences nausea. \ Monitor for increase in creatinine clearance. \
\ Gentamicin has a narrow therapeutic range. Peak and trough concentrations should be drawn. There is no indication that it is necessary to give this medication over 2 hours. There is no indication that nausea will require interrupting therapy. Decreased creatinine clearance is the adverse effect associated with gentamicin. \ 0 0 0 0
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Chapter 10 \\ MC B+E \ The nurse is assessing a patient with an endotracheal tube and notes decreased breath sounds on the left with normal sounds on the right. Which condition may cause this? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Pressure from a right pneumothorax \ Misplacement of the endotracheal tube \ High pulmonary pressures \ Partial obstruction of the endotracheal tube \ A large infiltrate in the left lung \ • A right pneumothorax would present with decreased sounds on the right. • The right bronchus is larger than the left bronchus and is at almost a straight angle with the trachea. This anatomical difference makes it easy for the tip of the endotracheal tube to slip into the right bronchus, depriving the left lung from air. This results in decreased breath sounds on the left. • High pulmonary pressures would affect both sides equally. • A partially obstructed endotracheal tube would affect both sides equally. • A large infiltrate in the left lung will decrease air movement through the tissues. This change in air movement will decrease breath sounds on the affected side. \ 0 0 0 0
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\\ MC D \ A patient with pulmonary edema has a respiratory rate of 28 per minute. The nurse plans care for this patient based on which change in the lungs? \ Decreased work of breathing \ Reduced muscle activity \ Dehydration of lung tissues \ Decreased compliance \ \ A respiratory rate of 28 is evidence of increased work of breathing. It requires more muscle activity to breath at a rate of 28. Pulmonary edema results from retention of fluid in the lung tissues. Decreased compliance increases the work of breathing and causes a decreased tidal volume. The breathing rate increases to compensate for the decreased tidal volume. Examples of pulmonary disorders causing decreased lung compliance include pulmonary edema. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ The patient has been diagnosed with early stage pneumonia. The nurse would anticipate which laboratory results? \
2
Increased PaO2 and increased PaCO2 \ Decreased PaO2 and normal PaCO2 \ Normal PaO2 and elevated PaCO2 \ Decreased PaO2 and increased PaCO2 \ \ Presence of pneumonia will not result in an increase in oxygen. In the early stages of pneumonia the alveolar surface area is reduced and the alveolar–capillary membrane begins to thicken causing diffusion abnormalities. Oxygen and carbon dioxide do not diffuse at the same rate. Carbon dioxide diffuses 20 times faster than oxygen; therefore, hypoxemia may be present with a normal PaCO2. Only when the condition progresses untreated will the PaCO2 rise. PaCO2 will rise only after the disease has progressed. Oxygen will decrease, but PaCO2 will not rise initially. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C+D \ The nurse is assessing an 80-year-old patient who has no underlying respiratory pathology but whose carbon dioxide level is slightly elevated. The nurse would contribute this increase to which changes associated with normal aging? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Increase in alveolar–capillary membrane thins \
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Increase in total lung surface area \ Increase in size of the airways \ Increase in air trapping \ Overgrowth of alveoli \ • The alveolar–capillary membrane thickens with aging, which may result in hypoxemia and/or hypercapnia if the older patient becomes ill. • As a person ages there is a normal decrease in the total lung surface area. • Aging results in an increase in size of the airways, which increases dead space ventilation. This can lead to carbon dioxide retention. • Older patients may have increased air trapping due to normal loss of terminal airway supportive structures. • As a person ages, alveoli are destroyed. Overgrowth does not occur. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ The arterial blood gases of a patient with a large mass in the right lung show increasing hypoxemia and the patient will be intubated for placement on a mechanical ventilator. In which position should the nurse place this patient until intubation is begun? \ Flat in bed lying on the left side \ Flat in bed lying on the right side \ Lying on the left side with the head of the bed elevated to 30 degrees
4
\ Lying on the right side with the head of the bed elevated 30 degrees \ \ Being placed flat in bed will not improve ventilation perfusion. The patient should benefit from being on the left side. This position will not take advantage of gravity or of the body’s natural ventilation tendencies. Positioning the patient at 30 degrees and left side down will lower the diaphragm allowing more expansion and redirect blood flow to the healthy lung because of gravity. Air is naturally drawn toward the diaphragm and because blood is gravity dependent the ventilation–perfusion ratio will be improved. If the right lung is not capable of normal ventilation, redirecting blood flow would result in a mismatch. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A patient, diagnosed with diabetic ketoacidosis, presents with Kussmaul respirations at a rate of 28. A newly licensed nurse asks the patient to try to slow his breathing. What instruction should the preceptor provide? \ “Keep trying to slow the patient’s respirations because breathing so fast is hard on his heart.” \ “If he keeps breathing like that he will develop respiratory acidosis.” \ “Let the patient set his respiratory rate as rapid breathing helps to compensate for his acidosis.” \ “The patient is breathing deeply to help offset diabetes-induced hypoxemia.” \ \
5
Breathing rapidly does increase strain on the heart, but the rapid respirations in this situation are helpful to the patient and should not be discouraged. Breathing rapidly and deeply as in Kussmaul’s respirations will not result in respiratory acidosis. A patient with diabetic ketoacidosis has a primary metabolic acidosis. As a compensatory mechanism to regain acid–base homeostasis, alveolar hyperventilation occurs in an attempt to blow off carbon dioxide and drive the pH upward toward alkaline. The respiratory buffer system is a rapid-response compensatory mechanism for metabolic acid–base disturbances. The patient does not have diabetes-induced hypoxemia. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ A postoperative patient’s nasogastric drainage has been 500 mL in the last 8 hours. The nurse would assess this patient for findings associated with which acid–base imbalance? \ Metabolic alkalosis \ Metabolic acidosis \ Respiratory acidosis \ Respiratory alkalosis \ \ The loss of gastric fluid from nasogastric suction can result in metabolic alkalosis. Loss of body fluids from lower abdominal drains would result in loss of bicarbonate and produce metabolic acidosis. The respiratory system is not involved in the development of this acid–base imbalance. The respiratory system is not involved in this acid–base imbalance.
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\ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A patient was extubated in the postanesthesia recovery room prior to transfer to the intensive care unit (ICU). Upon admission to the ICU the patient is sedated, but will arouse when stimulated. Blood pressure is 106/68 mm/Hg, heart rate is 68 and regular, temperature is 97.8 F, and respirations are 12 bpm. The nurse would monitor this patient for which changes in arterial blood gases? \ Increase in pH and decrease in PaCO2 \ Increase in pH and increase in HCO3 \ Decrease in pH and increase in PaCO2 \ Decrease in pH and decrease in HCO3 \ \ An increase in pH and decrease in PaCO2 indicates respiratory alkalosis is occurring. This is not the expected change with this patient. These ABG results indicate metabolic alkalosis. This is not the expected change with this patient. The patient is at risk for respiratory acidosis, which is associated with these ABG changes, as a result of decreased, shallow respirations that can cause alveolar hypoventilation. Carbon dioxide is not being blown off and carbonic acid levels can rise. These ABG results indicate metabolic acidosis. This is not the expected change in this patient. \ 0 0
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0 0
0000000000 0000000000 0 \\ MC C \ A patient’s arterial blood gases (ABGs) are as follows: pH 7.30, PaCO2 30 mm Hg, HCO3 14 mEq/L, and PaO2 50. The nurse evaluates these ABGs as representing which acid–base imbalance? \ Uncompensated respiratory alkalosis with moderate hypoxemia \ Compensated metabolic acidosis with severe hypoxemia \ Partially compensated metabolic acidosis with moderate hypoxemia \ Partially compensated respiratory alkalosis with mild hypoxemia \ \ These ABGs do not represent an uncompensated state. These ABGs do not represent a fully compensated state because the pH is not normal. The patient has a partially compensated metabolic acidosis with moderate hypoxemia because the pH is still within the acid range. The HCO3 is the primary acidic metabolic component causing the acidic pH. In an attempt to correct the metabolic acidosis, the CO2 is being blown off as indicated by the alkaline PaCO2. The PaO2 falls within the moderate range of hypoxemia (60 to 40 mm Hg). These ABGs do not indicate respiratory alkalosis. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC A \ A patient's PaO2 level is 76 mm Hg. The nurse would be least concerned regarding this finding in which patient? \ The patient is 83 years old. \ The patient is recovering from anesthesia. \ The patient is a smoker. \ The patient is intubated. \ \ Age affects normal ABG values. The older adult has a 25 to 30% decrease in PaO2 between the ages of 30 and 80 years. Low oxygen levels in a patient who is recovering from anesthesia would alert the nurse to a possible problem. Smoking can decrease oxygenation, but the nurse would be concerned if the level was this low. The patient who is intubated should have a PaO2 higher than 76 mm Hg. The nurse would be concerned about an obstruction in the tube or developing pathology. \ 0 0 0 0
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0000000000 0 \\ MC C \ The nurse is assessing the nutritional intake of a patient diagnosed with chronic carbon dioxide retention. Which patient report indicates the patient requires additional information about dietary choices? \ “I try to eat salad with lunch every day.” \ “I drink a cup of coffee in the morning with breakfast.” \ “I usually eat a sandwich and pasta salad for lunch.” \ “I have been trying to increase the protein in my diet.” \ \ Salad is a low fat, high fiber option that would benefit this patient’s nutrition. There is no indication that coffee is not appropriate for this patient. The patient who retains carbon dioxide should avoid high carbohydrate meals. Carbohydrates increase the overall carbon dioxide load in the body. A protein–calorie deficit weakens muscles, including respiratory muscles. The patient’s attempts to increase protein in the diet should be reinforced. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \
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The patient complains that he awakens “two or three” times every night because he is so short of breath. The nurse would ask additional assessment questions about which condition? \ Paroxysmal nocturnal dyspnea \ Pneumonia \ Stroke \ Kidney infection \ \ The patient is describing episodes of paroxysmal nocturnal dyspnea, which is related to left ventricular failure. The prolonged supine position allows dependent fluid from the lower extremities to recirculate causing volume overload and sudden severe dyspnea. Pneumonia results in consolidation of lung tissue. It is not associated with sudden dyspnea during the night. There is no indication that a neurological problem is causing this patient’s symptoms. There is no indication that this patient is experiencing shortness of breath at night due to a kidney infection. Kidney infection might result in need to urinate frequently during the night. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ The nurse is auscultating a patient’s lung fields and hears a coarse sound like bubbling water. The sounds are heard best on expiration and in the center of the patient’s chest. How should the nurse document these sounds? \ Crackles \ Rhonchi
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\ Wheeze \ Stridor \ \ Crackles are discrete, delicate popping sounds heard best on inspiration. Rhonchi are course bubbly sounds that frequently occur during expiration and are heard over the larger airways. Wheezes are musical sounds that may be high-pitched or low-pitched. They are heard both on inspiration and expiration and are of long duration. Stridor is a type of wheeze. It is high-pitched, inspiratory, and heard best over the neck. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ The nurse is planning to use a respiratory spirometer to measure the amount of air that moves in and out of a patient’s lungs with each normal breath. How will the nurse document the results of this test? \ Tidal volume \ Vital capacity \ Forced expiratory volume \ Minute ventilation \ \
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Tidal volume is the amount of air that moves in and out of the lungs with each normal breath. Vital capacity is the maximum amount of air expired after a maximal inspiration. Forced expiratory volume testing generally is not conducted as a bedside trending parameter. Minute ventilation is the total volume of expired air in 1 minute and is not a direct measurement but a simple calculation. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ A patient is undergoing testing to differentiate her airway disorder as being restrictive or obstructive. The nurse would evaluate a normal result on which test to indicate a restrictive disorder is present? \ Vital capacity \ Tidal volume \ Minute ventilation \ Forced expiratory volume \ \
13
Vital capacity is the maximum amount of air expired after a maximal inspiration. Vital capacity decreases in the presence of restrictive pulmonary diseases. Tidal volume is the amount of air that moves in and out of the lungs with each normal breath. Tidal volume decreases when lung diseases exist. Results do not differentiate between restrictive and obstructive disorders. Minute ventilation measures total lung ventilation changes. It may be abnormal in either restrictive or obstructive diseases. Forced expiratory volume measures how rapidly a person can forcefully exhale air after a maximal inhalation, measuring volume over time. Patients who have a restrictive airway problem are able to push air forcefully out of their lungs at a normal rate. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A 40-year-old postoperative patient has a hemoglobin level of 8 g/dL and a SaO2 of 95 percent. Considering all aspects, what conclusion would the nurse make about this patient’s condition? \ The patient is stable and at no special risk. \ Oxygenation is adequate for a postoperative patient. \ This patient has a potential risk of hypoxia. \ The patient’s SaO2 is higher than expected for the patient’s age. \ \ This patient’s test results do indicate a risk potential. It is not possible to accurately assess this patient’s true oxygenation status from the test results provided. The patient has a potential risk for hypoxia because SaO2 is the measure of percentage of oxygen combined with hemoglobin compared to the total amount it could carry. Although the patient's SaO2 is within normal
14
range, the hemoglobin is only 8 g/dL, indicating that all 8 grams are adequately being saturated. Should the patient's oxygen demand increase, as it frequently will in a postoperative patient, the potential for hypoxia may exist because of the lower hemoglobin and inability to carry more oxygen to meet the demand. The SaO2 is within normal limits for the patient’s age; however, its accuracy is at doubt. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B+C+D \ A nurse is participating on a committee charged with the task of choosing capnography equipment for a new emergency department. The nurse should present which information regarding these choices? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Sidestream analyzers provide direct real-time measurements of ETCO2. \ Mainstream analyzers require the patient to be intubated. \ Colorimetric capnography is useful for determining accurate placement of endotracheal tubes. \ Mainstream analyzers provide continuous ETCO2 measurements. \ Colorimetric measurement provides a wide range of color results that are compared to a standard chart. \ • The major disadvantage of sidestream analyzers is that values are indirect estimated measurements. • A major disadvantage to the mainstream technique is that it requires the patient to be intubated. • Colorimetric capnography can be used in the ED or in the field to determine accurate placement of endotracheal tubes.
15
• •
Mainstream analyzers are placed in-line as part of the airway circuit and continuously measure the ETCO2. The measurement is real-time. Colorimetric measurement responds to the patient’s exhaled CO2 with three color ranges.
\ 0 0 0 0
0000000000 0000000000 0 \\ MC A+B+C \ A patient with severe chronic respiratory illness suddenly develops a high fever. The nurse would plan care for this patient based upon which understanding of the fever’s impact on the oxyhemoglobin dissociation curve? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Increased temperature causes increased oxygen demand which shifts the curve to the right. \ Increasing body temperature increases oxygen demand, so additional oxygen will be released to the tissue to meet this demand. \ Severe and rapid shifts in the curve can result in life-threatening tissue hypoxia. \ Alkalosis causes an opposite response in the oxyhemoglobin dissociation curve and inhibits oxygen release at the tissue level. \ Hemoglobin binds more readily to oxygen in the lungs when the patient is hypothermic. \ • Increased temperature causes increased oxygen demand which shifts the curve to the right. • Increasing body temperature increases oxygen demand, so additional oxygen will be released to the tissue to meet this demand. • Severe and rapid shifts in the curve can result in life-threatening tissue hypoxia.
16
• •
Alkalosis causes an opposite response in the oxyhemoglobin dissociation curve and inhibits oxygen release at the tissue level. Hemoglobin binds more readily to oxygen in the lungs when the patient is hypothermic.
\ 0 0 0 0
0000000000 0000000000 0 \\ MC A+C \ A patient’s PaO2 is 88 mm Hg while on FiO2 of 0.50. What can the nurse conclude about this patient’s intrapulmonary shunt? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ The shunt is estimated to be 176. \ The shunt is estimated to be 568. \ The shunt is below the minimum acceptable level. \ This data has little use in determining oxygenation status of the patient who is retaining CO2. \ No determination of intrapulmonary shunt can be made from this data. \ • Calculating the P/F ratio is the simplest way to estimate intrapulmonary shunt. In this case the value is 176. • This is not a valid estimation of intrapulmonary shunt. • The minimum acceptable level is higher than this estimation of intrapulmonary shunt. • As long as the PaCO2 is stable this estimation is valid and is applicable to oxygenation status. • Intrapulmonary shunt can be estimated by comparing this data.
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0000000000 0000000000 0 \\ MC C \ A nurse who is evaluating a patient’s arterial blood gases has determined that the patient’s pH is acidic. What is the next question the nurse would ask in this interpretation? \ Is the patient symptomatic of an acidic condition? \ Which individual ABG component matches the pH acid–base state? \ Is the PaCO2 within normal range? \ Is HCO3 within normal range? \ \ The patient’s symptoms are not considered at this point in the evaluation. The nurse has not yet assessed the components, so this question is premature. After determining the pH status, the next step is evaluation of PaCO2. The HCO3 is not assessed at this point. \ 0 0 0 0
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Chapter 11 \\ MC C \ A patient is being admitted for treatment of pneumothorax. The nurse would anticipate providing care for a patient with which pathophysiology? \ Prolonged expiratory time \ Increased lung compliance \ Reduced tidal volume \ Hyper-inflated lungs \ \ Expiratory time is dependent upon airflow with remains normal in the patient with a restrictive lung disorder such as pneumothorax. With restrictive lung disorders such as pneumothorax the air cannot move into the alveoli because of decreased lung compliance. Restrictive disorders such as pneumothorax are problems of volume rather than airflow. The patient’s tidal volume will be reduced. Restrictive lung disorders such as pneumothorax result in decrease in the air capacity of the lungs. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \
A patient is diagnosed with cystic fibrosis. The nurse will anticipate providing care for a patient with which change in lung function? \ Decreased total lung capacity \ Progressive respiratory alkalosis \ Increased PaCO2 \ Increased forced expiratory volume (FEV) \ \ The air trapping associated with obstructive lung disorders such as cystic fibrosis results in increase in total lung capacity. Obstructive pulmonary disorders such as cystic fibrosis tends to produce progressive respiratory acidosis. In obstructive lung disorders such as cystic fibrosis PaCO2 levels increase as a result of air trapping. Obstructive disorders such as cystic fibrosis cause inability to exhale trapped air. This results in a decreased FEV. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ A patient tells the nurse that when he is exposed to cigarette smoke he begins to get short of breath, starts coughing, and gets a "high pitched noise" in his lungs when he breathes. The nurse would ask additional assessment questions about which pulmonary disorder? \ COPD \ Asthma
\ Emphysema \ Pneumonia \ \ COPD also is an obstructive disorder but does not typically become exacerbated with a trigger to cause the onset of symptoms. The classic triad of asthma symptoms includes paroxysmal episodes of dyspnea, wheeze, and cough triggered by a stimulus. The stimulus, or trigger, for the patient is cigarette smoke. This patient most likely is describing the symptoms of asthma. Emphysema also is an obstructive disorder but does not typically become exacerbated with a trigger to cause the onset of symptoms. Pneumonia will not "suddenly appear" after exposure to cigarette smoke to cause the onset of the patient's symptoms. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ The nurse is caring for a patient with obstructive pulmonary disease who had tachycardia, tachypnea, and restlessness. The patient has become very lethargic, but has a normal respiratory rate. The nurse should evaluate this change as indicating which condition? \ The patient is now able to rest and sleep. \ The patient’s condition has significantly deteriorated. \ The patient’s condition shows some slight improvement. \
The patient’s condition has stabilized significantly. \ \ These findings do not indicate that the patient is resting and now able to sleep. The patient's condition has deteriorated as evidenced by lethargy and decreased respiratory rate. The elevated carbon dioxide levels have affected the central nervous system causing lethargy, which may progress to coma. The patient has become exhausted and is unable to maintain the compensatory mechanisms needed to maintain acid–base balance. These findings do not indicate that the patient’s condition is improving. These findings do not indicate significant stabilization of the patient’s condition. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B+D \ A patient with pneumonia is restless and confused with increased blood pressure and respiratory rate. PaO2 is less than 60 mm Hg with a normal PaCO2. What conclusion can the nurse draw regarding this patient? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ The patient has ventilation failure. \ Without treatment the patient’s oxygen saturation is likely to drop rapidly. \ The patient has decreased airflow. \ The patient is at risk for respiratory muscle fatigue. \ Acute respiratory failure is present.
\
• • • • •
Ventilation failure is reflected by an increased PaCO2. Once the PaO2 drops below 60 mm Hg oxygen’s affinity to hemoglobin drops. When the patient has ventilatory failure (decreased airflow) carbon dioxide levels increase. This patient has a normal PaCO2. As respiratory rate increases the risk of respiratory muscle fatigue also increases. Currently the patient does not have acute respiratory failure because the PaCO2 is normal.
\ 0 0 0 0
0000000000 0000000000 0 \\ MC D+E \ The nurse working in an intensive care unit is alert to the development of ALI/ARDS. The nurse would monitor which patients most closely for this complication? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ A patient who sustained a severe chest contusion. \ A patient hospitalized for treatment of drug overdose. \ A patient who sustained severe head trauma. \ A patient hospitalized for treatment of pneumonia. \ A patient diagnosed with sepsis. \ • Chest contusion can result in ALI/ARDS, but this is not the patient of most concern. • Drug overdose can result in ALI/ARDS, but this is not the patient of most concern.
• • •
Head trauma can result in ALI/ARDS, but this is not the patient of most concern. Pneumonia is one of the most common predisposing disorders in the development of ALI/ARDS. Sepsis is one of the most common predisposing disorders in the development of ALI/ARDS.
\ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ The nurse is caring for a patient with ARDS. Which finding would indicate that the disease is progressing? \ Increased lung compliance \ Decrease in heart rate \ Hypoxemia refractory to oxygen therapy \ Respiratory acidosis \ \ Pulmonary function tests would indicate decreased lung compliance because of the restrictive component of the disease. The heart rate increases as the work of breathing increases. In progressive ARDS there is a pattern of increasing hypoxemia that is refractory to increasing concentrations of oxygen because of collapsed alveoli, decreased lung compliance, and significant shunting. In the early onset of ARDS, respiratory alkalosis, and not acidosis, predominates as a result of compensatory mechanisms. \ 0 0
0 0
0000000000 0000000000 0 \\ MC D \ A patient diagnosed with ARDS is being mechanically ventilated with 12 cm of PEEP. On assessment, the nurse notes deterioration of vital signs and absent breath sounds in the right lung field. The nurse intervenes immediately due to the presence of which most likely complication? \ Obstructed endotracheal tube \ Increased severity of ARDS \ Decreased cardiac output \ Pneumothorax \ \ An obstructed endotracheal tube would affect both lung fields. If the disease process was worsening it would be likely that both lung fields would be involved. Decreased cardiac output would affect vital signs but not breath sounds. A complication of PEEP may be a pneumothorax as a result of overdistention of the alveoli. Pneumothorax could be manifested by deterioration of vital signs and loss of air movement in the affected lung. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ The nurse is caring for a patient who sustained a fractured femur from a motor vehicle accident 1 day ago. The patient is anxious, restless, appears short of breath, and requests pain medication for chest discomfort. Which nursing intervention is priority? \ Administer pain medication as ordered. \ Increase intravenous fluids. \ Evaluate the patient’s oxygen saturation. \ Help the patient assume a more comfortable position. \ \ The patient’s pain should be treated but this is not the priority intervention. Intravenous fluids may be increased, but this is not the priority intervention. The patient may be experiencing a fat embolism from the previous long bone fracture. The nurse should do a thorough assessment noting lung sounds, conjunctivae and pulse oximetry before calling the physician. Anticipate orders for supplemental oxygen, arterial blood gases, serum laboratory values, chest x-rays, electrocardiogram, a V/Q scan, and angiography. Positioning is not the priority intervention. \ 0 0 0 0
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0 \\ MC C+D+E \ The patient’s Wells Score indicate intermediate risk for the development of pulmonary embolism. Which nursing interventions would help reduce this risk? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Monitor daily D-dimer levels. \ Strictly measure all intake and output. \ Encourage ambulation. \ Instruct the patient on use of antiembolism stockings. \ Prevention of leg injury \ • D-dimer elevation indicates presence of thrombolytic activity, but will not help to prevent occurrence of thrombus. • Measuring intake and output will not prevent development of thrombus. • Ambulation will help to support circulation and prevent clot development. • Proper use of antiembolism stocking is helpful in decreasing development of thrombus. • One of the risk factors for development of deep vein thrombosis in the leg is injury. This injury can occur from trauma from striking the bed or other objects in the room. The nurse should intervene to prevent this trauma. \ 0 0 0 0
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\\ MC A \ The emergency department has treated two patients in the last day with symptoms that may be SARS. The nurse manager is updating staff on the pathophysiology of this disease. Which information would the nurse include? \ It is thought that SARS is a nonhuman virus that has crossed species. \ SARS is more common in patients also infected with HIV. \ SARS is a form of influenza virus, so additional cases are probable. \ SARS is related to RSV, so young children will be the most likely patients. \ \ Although the origin of SARS-CoV is unknown, it is suspected to be a nonhuman virus that jumped to humans. SARS is not associated with HIV. SARS is not a form on influenza virus. SARS is not related to RSV. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+B+E \ The nurse is preparing to participate in evaluation of the severity of a patient’s community acquired pneumonia using the CURB-65 criteria. Which information will the nurse collect for this evaluation? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected.
\ The patient’s respiratory rates for the last several hours \ BUN results \ If the patient has a history of smoking \ The patient’s gender. \ The patient’s age \ • CURB-65 evaluates the patient’s respiratory rate. Rate of 30 or over is scored as a 1. • CURB-65 evaluates that patient’s BUN level. BUN greater than 19.6 mg/dL is scored as a 1. • Tobacco use history is not considered in CURB-65 scoring. • Gender is not considered in CURB-65 scoring. • The patient’s age is considered in CURB-65 scoring. If the patient is 65 or older, a score of 1 is assigned. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ The nurse is caring for a patient with a chest tube and a three-chamber disposable drainage system. The physician orders an AP chest x-ray to be done in the x-ray department. How would the nurse transport the patient? \ Do a portable film in the patient's room. \ Clamp the chest tube after full exhalation and call the department so they can be ready when you arrive. \
Disconnect the drainage system from the wall suction and transport. \ Clamp the chest tube after full inspiration and call the department so they can be ready when you arrive. \ \ Changing of a physician's order is not within the scope of practice of the nurse. Clamping a chest tube for any length of time will obstruct the exit of air, causing pressure to build up in the pleural space, resulting in a tension pneumothorax. The nurse would disconnect the drainage system from wall suction and transport with the drainage system in an upright position, placed below the level of the heart. The suction chamber does not require attachment to an external suction source, although it does make the system more effective. As long as the water seal chamber is intact, air is not permitted to reenter the chest cavity. Clamping a chest tube for any length of time will obstruct the exit of air, causing pressure to build up in the pleural space, resulting in a tension pneumothorax. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ A patient has been uncooperative with pulmonary hygiene following thoracic surgery because “it hurts more than I can bear.” Which intervention should the nurse employ? \ Instruct the patient to cough 3 to 4 times with each exhalation. \ Assist the patient to a sitting position to lean over the bedside table while coughing. \ Provide the patient with a pillow to splint the incision while coughing. \ Guide the patient to cough with the glottis open. \
\ The "cascade" cough is a series of 3 to 4 coughs on one exhalation. This type of cough could cause the patient more discomfort. Positioning the patient over the bedside table might cause injury during coughing. A pillow is too soft to effectively splint the incision for best pain relief. Pulmonary hygiene is an integral part of post-thoracic surgery care. Patients must be able to take a deep breath and generate an exhalation sufficiently strong to clear secretions. There are two types of coughs however the "huff" cough or coughing with the glottis open is a gentle maneuver, and is effective. This is the type of cough the nurse should assist the patient with performing. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ The nurse is caring for a patient who has recently undergone major abdominal surgery. The patient is exhibiting shallow breathing and is hesitant to cough and deep breathe. Which nursing diagnosis (NDX) should the nurse choose for this patient? \ Ineffective Breathing Pattern \ Ineffective Airway Clearance \ Potential for Pneumonia \ Impaired Gas Exchange \ \
The patient has documented shallow breathing, indicative of an ineffective breathing pattern. Since there is no evidence of inability to clear secretions, this is not the best NDX choice for this patient. Potential for pneumonia is not a nursing diagnosis. In order to support the NDX Impaired Gas Exchange, the patient must exhibit cyanosis or have arterial blood gas evidence of poor oxygenation or carbon dioxide retention. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B+D \ A patient has a diagnosis of Ineffective Airway Clearance as evidenced by the inability to clear thick secretions effectively. Which nursing interventions are appropriate to address this nursing diagnosis? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Encourage bedrest to conserve energy. \ Administer pain medications as needed. \ Position the patient on the unaffected side. \ Encourage the patient to provide as much self-care as possible. \ Encourage slow, deep breaths \ • Bedrest will impair the patient’s ability to mobilize secretions. Activity as tolerated will help mobilize secretions. • The nurse should treat the patient’s pain but avoid oversedation.
• • •
Positioning the patient on the unaffected side is an intervention to improve gas exchange. Ineffective airway clearance generally involved both lungs and the trachea. Providing care for self encourages the patient to move within the environment even if it is limited to the bed or bedside. Movement encourages mobilization of secretions. Slow, deep breaths will support a healthier breathing pattern, but is not necessarily indicated for impaired gas exchange.
\ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ A patient recovering from thoracic surgery is demonstrating evidence of Impaired Gas exchange with a dropping oxygen saturation level. Which nursing intervention is most suited to addressing this nursing diagnosis? \ Teach the patient to use the incentive spirometer every 1 to 2 hours. \ Suction as necessary. \ Splint the chest when coughing. \ Encourage fluids up to 2.5 liters per day. \ \
Using the incentive spirometer correctly every 1 to 2 hours will help to improve gas exchange. Suctioning is related more to Ineffective Airway Clearance. Using a splint with coughing will help reduce pain so that the airway can be cleared. This intervention is most related to Ineffective Airway Clearance. Increasing fluids will help to thin secretions so that they are more easily mobilized. This intervention is most related to Ineffective Airway Clearance. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ An older adult presents to the emergency department with cough, fever, and elevated temperature. A diagnosis of pneumonia is made, antibiotics are prescribed, and the patient will be admitted to the acute care unit. When should the nurse start the prescribed intravenous antibiotic? \ Whenever the drug is received from the pharmacy \ After the preliminary results of the sputum specimen are obtained \ Within 30 minutes of the order being received \ Within 4 hours of diagnosis \ \
There is a standard by which this drug should be started. If the drug is delayed from the pharmacy this standard might not be met. The nurse should advise pharmacy of the patient’s diagnosis and need to start the antibiotic quickly. The nurse should not wait for sputum specimen results. There is no standard by which the antibiotic must be started within 30 minutes of the order being received. Standards indicate that antibiotic therapy for pneumonia should be started within 4 hours of diagnosis or while the patient is in the setting where the diagnosis is made. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A patient had chest tube insertion for a pneumothorax. External suction was discontinued yesterday. This morning the nurse assesses cessation of tidling in the water-seal chamber. What nursing action is indicated? \ Collaborate with the health care provide regarding need to reinstitute the external suction. \ Check the connections between the chest tube and the drainage system. \ No action is necessary as this is an expected occurrence. \ Have the patient cough forcefully. \ \ There is no need for external suction. The nurse should always check these connections, but there is no special need for that action related to this assessment. The cessation of tidling in this patient likely indicates successful reinflation of the lung which is the desired outcome. This assessment does not indicate that coughing is necessary.
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0000000000 0000000000 0 \\ MC B \ A patient presents to the emergency department after falling from a ladder at home. He has multiple contusions and abrasion on his right side and is holding his right arm tightly across his chest. On inspection the nurse notes that the patient’s trachea is slight displaced toward the left. Which nursing intervention is priority? \ Have the patient release his arm and sit up straight for reassessment. \ Notify the emergency room physician immediately. \ Auscultate the patient’s lung fields. \ Position the patient flat in bed without a pillow. \ \ Reassessment is not the priority in this situation. Deviation of the trachea away from the injured side indicates pressure on the affected side which may be from a developing pneumothorax or hemothorax. If so the patient may require immediate placement of a chest tube. Delay could be detrimental to the patient’s condition. The nurse will auscultate the lungs, but another intervention is the priority. This position is not indicated for this patient. Positioning is not the immediate priority. \ 0 0 0 0
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Chapter 12 \\ MC A+C+E \ A patient’s cardiac index will be calculated. What nursing interventions are necessary before this calculation is completed? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Assure that there is an accurate current weight on the medical record. \ Compare fluid input and output for the last 12 hours. \ Measure the patient’s height. \ Figure the patient’s age in years and months. \ Obtain the patient’s current heart rate. \ • Weight is a component of cardiac index. • There is no need to compare fluid intake and output in order to calculate cardiac index. • Height is used to calculate cardiac index. • Age is not a consideration when calculating cardiac index. • Heart rate is a component of cardiac index. \ 0 0 0 0
0000000000 0000000000 0 \\ MC
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B \ A patient is scheduled for an echocardiogram with measurement of ejection fraction. The nurse explains to the patient that this test will provide the most information about which cardiac characteristic? \ The amount of blood the heart pumps every minute \ The strength of the heartbeat \ The amount of resistance the heart beats against \ The amount of blood in the heart before it beats \ \ The amount of blood the heart pumps every minute is the cardiac output. Ejection fraction is related to cardiac output, but describing cardiac output does not fully explain ejection fraction. Contractility is defined as the force of myocardial contraction and reflects the ability of the heart muscle to work independently of preload and afterload; the ability to function as a pump. Ejection fraction is a measure of the percent of blood ejected with each stroke volume and is used as an index of myocardial function. Afterload is the amount of resistance the heart must beat against. Increasing afterload will affect both ejection fraction and cardiac output. Preload represents the volume of blood in the ventricle at the end of diastole. A low preload can result in low cardiac output and may also affect ejection fraction. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C+D \ Testing indicates that a patient has a high preload. What changes would the nurse expect in this patient’s cardiac function?
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(Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Heart rate will decrease. \ Afterload will increase. \ Stroke volume will decrease. \ Stoke volume will increase. \ Blood pressure will decrease. \ • It is not possible to predict what change in heart rate will occur in the face of increased preload. Depending upon the pathophysiology causing the increased preload, the rate may increase, may decrease, or may stay the same. • Afterload represents the force the heart must overcome to pump blood. It is not affected by preload. • If the increase in preload is high enough that a critical point is reached stroke volume will decrease. • The greater the volume of blood in the ventricle, the greater the amount of stretch that the fibers experience. To a point, this increase in stretch will result in an increase in stroke volume. • It is not possible to determine if an increase in preload will cause a decrease in blood pressure. In most cases, increased preload will result in increased stroke volume which will result in increased blood pressure. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \
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A patient, with a steadily increasing preload, was experiencing a corresponding increase in stroke volume but it has now begun to decrease. Which rationale would the nurse provide for this occurrence? \ This fluctuation will occur until maximum preload has been reached. \ The patient’s heart rate is increasing, which causes a drop in stroke volume. \ The patient’s preload has reached a critical point and now stroke volume will decrease. \ It is necessary to assess for a secondary pathophysiological event causing the stroke volume to decrease. \ \ There is a point of maximum preload, but the cardiac output does not fluctuate until it is reached. The information in this question does not support increase in the heart rate. Until a critical point is reached, as preload increases, so does stroke volume. An optimal preload leads to an optimal stroke volume. Once past this point, an increase in preload results in a decrease in stroke volume. If the heart receives too much preload, it cannot effectively pump out that volume and stroke volume decreases. Stroke volume decreases because too much volume causes excessive stretching of the myocardial fibers and the ventricles cannot effectively contract. There is no need to look for a different pathophysiological event as the event at present is sufficient to cause decrease in cardiac output. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+D \ A patient is diagnosed with septic shock and has a decrease in afterload. The nurse would expect which initial changes in the patient’s cardiac status? (Select all that apply.)
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Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Increase in cardiac output \ Increase in blood pressure \ Decrease in cardiac output \ Decrease in blood pressure \ No change in blood pressure or cardiac output \ • Decreased afterload causes cardiac output to increase. This will occur initially in septic shock, but will change as sepsis continues. • Since blood pressure is a product of cardiac output and afterload, a decrease in afterload causes a decrease in blood pressure. • Initially the decrease in afterload will increase cardiac output. • Decrease in afterload results in decrease in blood pressure. • Changes in afterload will change both blood pressure and cardiac output. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+C+D \ It is determined that a patient has poor cardiac contractility. The nurse would anticipate administering which type of drugs to improve contractility? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \
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Cardiac glycosides \ Loop diuretics \ Sympathomimetic agents \ Phosphodiesterase inhibitors \ Ace-inhibitors \ • Cardiac glycosides such as digoxin are positive inotropes and improve cardiac contractility. • Diuretics are given to decrease the work load on the heart by decreasing fluid overload. They are not given to specifically improve cardiac contractility. • Dopamine and dobutamine are sympathomimetic agents given to improve cardiac contractility. • Phosphodiesterase inhibitors such as inamrinone and milrinone improve cardiac contractility. • ACE inhibitors affect afterload and preload, but do not directly affect myocardial contractility. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ A patient is admitted with the complaint of chest pain. Questions about which history will best help the nurse determine if the pain is from cardiac or pulmonary origin? \ Deficits in movement, timing of the pain, and dietary changes in the last 24 hours \ What precipitated the pain, what it feels like, and where it is located \ Changes in dietary habits, smoking history, and presence of cough \
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What home remedies were tried, activity level, and fluid intake changes \ \ Deficits in movement, timing of the pain, and dietary changes in the last 24 hours are not associated with either cardiac or pulmonary pain. Precipitating factors, quality, and location will help the health care team discriminate between pain of cardiac origin and pain of respiratory origin. This is important information to obtain, but would not help differentiate between pain of cardiac origin and pain of respiratory origin. This is important information, but will not help to differentiate between pain of cardiac origin and pain of respiratory origin. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+B+D+E \ Which assessment techniques will the nurse use to evaluate the patient’s cardiac output? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Inspection of color changes in the periphery \ Strength of pulses \ Percussion of heart borders \ Auscultation of heart sounds \ Pulse pressure determination
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\
• • • • •
Color changes in the periphery can indicate decreased cardiac output. Strength of pulse is an indirect measure of cardiac output and contractility. Percussion is incorrect because it measures heart size very crudely but not output. Auscultation helps the nurse assess heart rate and rhythm which can alter cardiac output. Determination of pulse pressure is an indirect measure of stroke volume which is a component of cardiac output.
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0000000000 0000000000 0 \\ MC A \ A patient has been admitted with chest pain and generalized discomfort. Which assessment is essential in order for the nurse to set realistic goals for patient therapy and education? \ The patient's functional status prior to illness \ Family history of disease, diet history, and prior medical history \ Demographic data including age, sex, race, and weight of patient \ Cardiovascular risk factors, such as history of smoking and stress level \ \
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Knowledge of the patient's functional status prior to illness assists the nurse in setting goals that are realistic for the patient. The nurse must know the patient’s pre-illness capabilities. Family history, diet history, and prior medical history are important assessment components but do not directly indicate the patient’s capabilities. Demographic data is not as important as other assessment components for use in determining realistic goals. Cardiovascular risk factors, smoking history, and stress level may indicate areas in which education is needed but does not specifically address goals of therapy. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ The nurse has auscultated the patient’s heart sounds and has measured vital signs. Which finding would the nurse evaluate as indicating greatest need for additional assessment? \ Pulse pressure of 38 mm Hg \ Bounding, vigorous pulse \ Split of S2 \ Apical pulse of 66 \ \
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The pulse pressure reflects how much the heart is able to raise the pressure in the arterial system with each beat. Pulse pressure of 30 to 40 mm Hg does not indicate cause for concern because it is within the normal pulse pressure range. A bounding vigorous pulse indicates increased myocardial contractility and would require additional assessment. This is not the priority need for reassessment. The split of S2 indicates that one ventricle is emptying earlier or later than another and that contractility may, therefore, be diminished. This may be a result of a structural defect, a mechanical defect, or an electrical defect. This is the priority need for additional assessment. The normal range of apical pulse is 60 to 80, so this is not a priority for additional assessment. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ A patient is admitted with a decrease in cardiac output. Which assessment findings would the nurse attribute to that condition? \ Increased output of very clear urine \ Changes in skin color \ Localized edema in the calf \ Skin that is warm and damp \ \ A decrease in cardiac output generally results in a decrease in urine output. Changes in skin color can be a sign of hemodynamic compromise and a decrease in cardiac output. Localized edema in the calf is indicative of obstruction of venous blood flow from a clot in a leg vein. Cool skin is a finding associated with decreased cardiac output.
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0000000000 0000000000 0 \\ MC D \ It is suspected that a patient who was severely injured in an automobile accident may have had a myocardial infarction prior to the crash. Which laboratory test result drawn while the patient was in the emergency department would the nurse evaluate as supporting that theory? \ Increased serum potassium \ Increased creatine kinase level \ Increased BNP level \ Increased troponin level \ \ Potassium level changes may indicate damage to muscle tissue, but is not specific to heart muscle. Creatine kinase levels do not rise until 4 to 12 hours after onset of myocardial necrosis. Unless a CK-MB level was drawn, the CK level is not specific to cardiac muscle. BNP level is assessed for the presence of heart failure. Troponin is a protein found in cardiac muscle and can appear in the blood as early as 1 to 3 hours after symptoms of MI. Troponin has a higher sensitivity and specificity of identifying myocardial damage than does creatine kinase. \ 0 0 0
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0
0000000000 0000000000 0 \\ MC B \ The nurse is instructing a patient who is scheduled for a cardiac catheterization. Which comment made by the patient would indicate the need for additional education? \ "The nurse will check my feet very often after the procedure." \ "I will place a warm pack at the puncture site for pain relief." \ "I should let the nurse know if I need to cough after the procedure is done.” \ "I will have someone available to drive me home following the procedure." \ \ Pedal pulses are checked bilaterally after the procedure. The vasodilatory effect of a warm pack would cause vessel rupture and, therefore, is the choice that indicates a need for further education. In order to minimize stress on the insertion site, it should be manually compressed when the patient coughs. Many of these procedures are done as outpatient procedures, which would require someone to drive the patient home. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC A \ A patient admitted with a cardiac arrhythmia is scheduled to have an electrophysiology study (EPS). The nurse would reinforce which teaching about this test? \ This test will be helpful in determining if you need a pacemaker. \ This test will help us determine how your heart responds to stress. \ We can learn about the strength of your heart valves with this test. \ This test will reveal the health of your heart’s blood supply system. \ \ The electrophysiology study is an invasive procedure that evaluates the cardiac conduction system and helps classify cardiac arrhythmias. The findings from this study help to determine if the patient would benefit from further interventions such as a pacemaker, implantable cardiodefibrillator, and radiofrequency ablation or medication therapy. Exercise electrocardiograms evaluate heart muscle and its blood supply during physical stress. Echocardiograms are used to visualize blood, cardiac valves, the myocardium, and the pericardium. Cardiac catheterization is performed to determine the presence and extent of coronary artery disease, evaluate left ventricular function, and to evaluate valvular or myocardial disorders. \ 0 0 0 0
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\\ MC B \ A patient is scheduled for an exercise electrocardiogram. The nurse will ensure that which objects are in the room prior to the beginning of the test? \ Oral fluids \ A defibrillator \ External pacemaker \ Portable chest x-ray machine \ \ There is no reason that oral fluids are required for this test. Emergency medications and a defibrillator should be present in the room during an exercise electrocardiogram test. The patient may respond poorly to the stress placed on the heart during exercise and may require an emergency response with this equipment. There is no specific indication that it is necessary to have an external pacemaker present when this testing is taking place. There is no reason for a portable x-ray machine to be present in the room during this test. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ The nurse is caring for a patient having a transesophageal echocardiogram (TEE). What is an appropriate nursing intervention for the care of this patient?
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\ Dim the lights in the room. \ Monitor for bradycardia and hypotension. \ Assess pedal pulses bilaterally. \ Apply pressure to the puncture site. \ \ There is no specific reason to dim the room lights. The TEE is done under conscious sedation. During and immediately after the procedure, the nurse assesses for bradycardia and hypotension because of possible stimulation of the patient's vagus nerve. There is no specific indication that assessing pedal pulses is necessary during this procedure. There is no puncture site in a TEE. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ A patient with left-sided heart failure is hospitalized with pulmonary edema. The nurse providing this patient’s care would consider which physiology when explaining this disorder to the patient’s family? \ The normally high-pressure pulmonary circuit can damage lung tissue and cause pulmonary edema. \ Since pulmonary veins have no valves, blood can back up into the lungs causing pulmonary edema. \ The oxygen-rich blood that enters the pulmonary circuit tends to increase pressures in the tissue, causing pulmonary edema. \
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The arteries of the pulmonary circuit are single layer. \ \ The pulmonary circuit is normally a low-pressure system. There are no valves in the pulmonary veins so when pressures elevate in the left heart (left heart failure) it results in blood backing up into the lungs and increased pulmonary vascular pressure. This pressure results in pulmonary edema. The blood that enters the pulmonary circuit oxygen-poor. The capillaries in the lungs are single layer, but the arteries have three layers. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ Testing reveals that a patient’s myocardial infarction damaged the papillary muscles of the mitral valve. The nurse plans care based on the knowledge that the patient is at high risk for which complication? \ Extension of the myocardial damage \ Catastrophic left heart failure \ Pulmonary edema from right heart failure \ Pulmonary embolism from clots in the left atrium \ \
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All patients who have MI are at risk for extension of the damage. It is not specific to this patient. The mitral valve is between the left ventricle and the left atrium. If the mitral valve suddenly becomes incompetent because of papillary muscle failure, catastrophic left heart failure will occur. The mitral valve is on the left side of the heart. The blood that goes through the mitral valve has already returned from the lungs and is about to be pumped to the systemic circulation. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ Cardiac catheterization reveals that a patient has an isolated lesion in the right coronary artery that occludes 90% of the vessels’ lumen. The nurse plans care for this patient based on the knowledge that total occlusion of the artery will result in damage to which portion of the heart? \ Right ventricle \ Anterior aspect of the left ventricle \ The septum \ The lateral wall of the left ventricle \ \ The right coronary artery supplies the right ventricle. The left anterior descending artery supplies the anterior aspect of the left ventricle. The left anterior descending artery supplies the septum. The left circumflex artery supplies the lateral wall of the left ventricle. \
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0000000000 0000000000 0 \\ MC D \ Review of the medical record reveals that a patient has a summation gallop. Which pattern of heart sounds would the nurse expect? \ S1 followed closely by S2 \ S1 followed closely by S2 followed closely by S3 \ S1 followed closely by a split S2 \ S4 followed by S1 followed by S2 followed by S3 followed by S4 \ \ S1-S2 is the normal lub-dub sound of the heart and does not represent a summation gallop. Presence of a third heart sound is documented as a ventricular gallop. Splitting of S2 does occur, but this is not documented as a summation gallop. The S4 heart sound is heart during atrial contraction, so it sounds as if it occurs before S1. \ 0 0 0 0
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Chapter 13 \\ MC B \ Which clinical manifestation would the nurse evaluate as most significant in a patient with mitral valve stenosis? \ Edema of the lower extremities \ A heart rate of 110 beats per minute \ Altered deep tendon reflexes \ Bounding peripheral pulse \ \ Development of edema is important but is not the most significant finding listed. If a patient with mitral valve stenosis experiences a sudden increase in heart rate, the diastolic filling time is shortened, which results in a substantial decrease in cardiac output. A heart rate of 110 beats per minute would be the most significant finding when assessing this patient. Alteration of deep tendon reflexes could indicate electrolyte imbalances, which is a serious development. However, a different complication is more significant. A bounding peripheral pulse indicates increased contractility, which should not be a problem for this patient. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \
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When conducting a health history on a patient with aortic valve stenosis, which question would be most important for the nurse to ask? \ "Do you have a family history of coronary artery disease?" \ "Do any of your family members have valvular problems?" \ "Have you ever been diagnosed with rheumatic fever?" \ "Have you ever been diagnosed with high blood pressure?" \ \ Family history of coronary artery disease is not the most significant finding for this patient. History of valvular problems is significant, but not as significant as another finding. A primary etiology of aortic valve stenosis is rheumatic fever. History of high blood pressure is always significant, but is not the most significant finding for this patient. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ A patient with history of mitral valve stenosis is placed on a cardiac monitor. Which arrhythmia would the nurse anticipate since it is a common rhythm for patients with this history? \ Ventricular tachycardia \ Third-degree heart block \ Junctional rhythm \
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Atrial fibrillation \ \ Ventricular tachycardia is not associated with mitral valve stenosis. Third-degree heart block is not associated with mitral valve stenosis. Junctional rhythm is not associated with mitral valve stenosis. With mitral valve stenosis the left atrial pressure raises and leads to changes in the left atrial electrical refractory period, which may precipitate atrial fibrillation. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ A patient is diagnosed with an acute myocardial infarction and ruptured papillary muscle. Which action is the highest priority for the nurse to complete? \ Obtain an electrocardiogram. \ Measure the patient’s cardiac output. \ Assess the patient’s neurological status. \ Assess respiratory status. \ \
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This patient will have need for an electrocardiogram if one has not already been done, but this is not the highest priority. Cardiac output measurement is important, but is not the highest priority intervention. Assessment of the neurological system is very important but is not the highest priority. In an acute situation, such as a myocardial infarction with papillary muscle damage, the left atrium and left ventricle cannot acutely compensate, which leads to backup pressure in the pulmonary vasculature, and acute pulmonary edema occurs. The nurse would detect this change on respiratory assessment. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+C+D \ The nurse is collecting the health history of a patient hospitalized for possible infective endocarditis. Which findings would the nurse evaluate as supporting this presumptive diagnosis? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ The patient reports having rheumatic heart disease as a child. \ The patient has asthma. \ The patient had a routine screening colonoscopy 1 month ago. \ The patient is maintained on hemodialysis. \ The patient has developed osteoarthritis over the last 2 years. \ • Infective endocarditis is caused initially by damage to the endothelium of the heart valve, such as that with congenital diseases, one of which is rheumatic heart disease.
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• • • •
Asthma in itself is not a risk factor for development of infective endocarditis. Dental or gastrointestinal procedures may provide the portal for bacteria to enter the blood and colonize the heart. Patients who require hemodialysis are at risk for development of infective endocarditis due to the frequent venous access required for treatments. Development of osteoarthritis is not associated with infective endocarditis.
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0000000000 0000000000 0 \\ MC D \ The nurse has completed discharge teaching with a patient who had a mechanical valve replacement. Which patient behavior would the nurse evaluate as indicating additional teaching is necessary? \ The patient asks his wife to purchase a blood pressure monitor from their pharmacy. \ The patient tells the nurse of his plans to visit Rome next year. \ The patient orders a pasta salad with broiled salmon for lunch. \ The patient makes plans to stay with his daughter in her three story condominium for a few weeks after discharge. \ \ The patient with a mechanical valve replacement must learn to monitor blood pressure and heart rate. There is no reason the patient cannot travel. There is no reason a patient with a valve replacement should avoid pasta salad or salmon. The patient with valve replacement should avoid exertion, so staying in a condominium that has three stories may not be the best choice. \
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0000000000 0000000000 0 \\ MC C \ A patient is admitted for treatment of heart failure. The nurse would attribute which patient complaint to this diagnosis? \ “I often have headaches early in the morning.” \ “I have some numbness in my feet.” \ “I wake up a lot at night.” \ “I find I bruise more easily now.” \ \ Morning headaches are not associated with heart failure. Sensation loss is not associated with heart failure. Paroxysmal nocturnal dyspnea or sudden dyspnea at night is a classic symptom of heart failure and can awaken a patient from sleep. Bleeding tendencies are not associated with heart failure. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC D \ A patient diagnosed with heart failure makes the following comments. Which statement requires additional assessment by the nurse? \ “I still sleep better in a recliner.” \ “I do pretty well as long as I don’t try to do too much at one time.” \ “My heart rate runs around 60 to 64 most of the time.” \ “I’ve gained 4 pounds since yesterday.” \ \ Since this patient says “I still” there is no indication of change in status. Spacing out of activities is a technique taught to patients with heart failure. This patient is reporting success with this strategy. A heart rate of 60 to 64 is common in patients with heart failure due to the effects of medication. A weight gain of 3 to 4 pounds in 24 hours indicates an increase in fluid volume status and should be further evaluated. \ 0 0 0 0
0000000000 0000000000
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0 \\ MC D \ A patient has been diagnosed with dilated cardiomyopathy. The nurse would provide which instruction? \ “It will be necessary for you to rest more and to limit exercise.” \ “In some cases, this condition is treated with a surgical procedure to remove part of the ventricular septum.” \ “You will need to take calcium channel blockers exactly as prescribed for the rest of your life.” \ “A common treatment for your condition is the implantation of a cardioverter-defibrillator.” \ \ Exercise restriction is indicated in the management of the patient with restrictive cardiomyopathy. Surgery to remove a part of the ventricular septum is indicated in the care of the patient with hypertrophic cardiomyopathy. Calcium channel blockers are used in treatment of hypertrophic cardiomyopathy. The management of a patient diagnosed with dilated cardiomyopathy includes management of the heart failure and use of an implantable cardioversion defibrillator as needed. Additional management includes a heart transplant if indicated. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A patient with heart failure tells the nurse that she is "allergic" to ACE inhibitors because they make her cough "all of the time." What does this information suggest to the nurse?
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\ The patient should not take an angiotensin receptor blocker because of the ACE inhibitor allergy. \ The patient’s asthma has been exacerbated by the use of an ACE inhibitors. \ The patient experienced a side effect of the ACE inhibitor, which is a cough. \ The patient’s cough is due to long-standing heart failure. \ \ Patients who cannot tolerate ACE inhibitors often are prescribed angiotensin receptor blockers since they do not cause the side effect of a cough. There is no evidence to suggest that this cough is related to asthma. Cough is a side effect of ACE inhibitors, not an allergy. Coughing is the result of the release of kinins that cause coughing with prolonged therapy. This cough is not likely to be due to heart failure. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C+D+E \ A nurse has completed instruction regarding the DASH eating plan for a patient with hypertension. Which patient statements would indicate additional education is required? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ "I will take walks several times a week." \ "I can drink a glass of wine weekly."
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\ “I will avoid dairy products.” \ “I will avoid changing my intake of green leafy vegetables until my medication is stabilized.” \ “I will limit my intake of sodium and potassium.” \ • Physical activity is included in the DASH eating plan. • The patient following a DASH diet should moderate alcohol consumption. One glass of wine weekly is considered moderate intake. • The DASH diet encourages intake of calcium. Dairy products are a good source of this mineral. • The patient taking anticoagulants should eat a stable amount of green leafy vegetables due to vitamin K content. This is not necessary for the patient on the DASH diet for control of hypertension. • Intake of sodium should be restricted, but intake of potassium is encouraged. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ A patient’s blood pressure is measured as 138/88 mm Hg in the right arm. The nurse will anticipate which action as a result of this finding? \ Initiation of therapy with a thiazide diuretic \ Repeating the measurement in the left arm \ Diagnosis of prehypertension will be made \ Instructing the patient to follow the DASH diet \
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\ Thiazide diuretics are used for stage 1 hypertension. This patient has not met criteria for this diagnosis. Before staging of hypertension can occur the patient’s blood pressure is taken in both arms and on three separate occasions. The patient must be further assessed before prehypertension is diagnosed. Additional assessment is required before prescribing a diet for this patient. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ A patient is prescribed Carvedilol for hypertension. Which medication education should the nurse provide? \ “Let me know if this medication causes you to have a headache.” \ “This medication’s main side effect is dizziness, so be careful when you first sit up.” \ “Some people get a mild skin rash for a few days after starting this therapy.” \ “You should avoid eating foods high in vitamin K while on this medication.” \ \ Headache is not an expected side effect of carvedilol. Carvedilol is a beta-blocker medication used to treat heart failure and hypertension. The main side effect is dizziness. Skin rash is not an expected adverse effect of this medication. There is no reason to avoid foods high in vitamin K when taking Carvedilol. 254. d.How well has the patient’s hypertension been controlled in the past?, b.Has the patient been following the prescribed therapy?, e.What therapy was the patient prescribed? \
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0000000000 0000000000 0 \\ MC A+C+D \ A patient admitted in hypertensive crisis is being cared for by a newly licensed nurse and his preceptor. The preceptor would consider which information when explaining the potential etiology of this crisis? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ How well has the patient’s hypertension been controlled in the past? \ How old is the patient? \ Has the patient been following the prescribed therapy? \ What therapy was the patient prescribed? \ How long has the patient been hypertensive? \ • A history of poorly controlled hypertension is often associated with the development of hypertensive crisis. • Patient age is not a determining factor in risk for development of hypertensive crisis. • Inadequate adherence to prescribed therapy for hypertension is related to development of hypertensive crisis. • Inadequate treatment of existing hypertension may result in hypertensive crisis. • The length of time a patient has had hypertension is not a significant factor. Many people with longstanding hypertension manage it well and never experience a crisis. \
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0000000000 0000000000 0 \\ MC B \ A patient who was admitted in hypertensive crisis in now normotensive. The nurse notes the patient’s output from the indwelling urinary catheter has been 15 mL over the last hour and was 20 mL the previous hour. What nursing intervention is necessary? \ Assess the patient for development of stroke findings. \ Discuss these findings with the primary care provider. \ Increase the patient’s intravenous fluid rate. \ Irrigate the patient’s indwelling urinary catheter. \ \ There is no indication that the patient has had a stroke. The nurse should alert the primary care provider about this low output as it may indicate poor organ perfusion. A patient in hypertensive crisis generally has chronic hypertension which increases the “normal” autoregulation range. Dropping the blood pressure to normal range may result in inadequate perfusion pressures. This intervention may be necessary, but is not the primary intervention indicated? There is no indication that irrigation of the urinary catheter is necessary or that it will improve output. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC A+C \ A patient was sent to a rural emergency department after screening by the occupational health nurse revealed a blood pressure of 185/115 mm Hg. The patient reports feeling “fine” and denies associated symptoms. The nurse would anticipate which interventions for this patient? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Administration of oral antihypertensive medications \ Admission to the hospital for monitoring \ Teaching the patient how to monitor blood pressure at home \ IV administration of antihypertensive medications \ Transfer to an intensive care unit in a larger hospital \ • This blood pressure level and the lack of associated symptoms meet the definition of hypertensive urgency. Hypertensive urgency is treated with oral antihypertensive medications. • Because no symptoms are present, the patient can be managed in an outpatient setting. • The patient has no symptoms, so home management, including monitoring blood pressure, is indicated. • This blood pressure level and the lack of associated symptoms meet the criteria for hypertensive urgency. IV medications are given for hypertensive emergency. • There is no reason to admit this patient to an intensive care unit. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC C \ A patient is admitted for a severe headache and is found to have a blood pressure of 185/115 mm Hg. The nurse would prepare to management administration of which drug most likely to be prescribed? \ Clonodine \ Oral furosemide \ Nitroprusside \ Captopril \ \ Clonodine would be used for hypertensive urgency. This situation represents hypertensive emergency. IV furosemide would be used for this patient who is experiencing hypertensive emergency. Oral furosemide is given for hypertensive urgency. Nitroprusside is an IV medication that can be titrated and is used for hypertensive emergency. Captopril is an oral agent used for hypertensive urgency. This patient is experiencing hypertensive emergency. \ 0 0 0 0
0000000000 0000000000 0
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\\ MC A \ A patient has been diagnosed with an abdominal aortic aneurysm (AAA) that is not large enough to be treated surgically. What is the most important teaching for the nurse to provide this patient on discharge? \ Information about smoking cessation \ Information on how to monitor radial pulses \ Need for frequent blood pressure measurements in both arms \ Need to eat a very low-fat diet \ \ There is a strong association between ongoing smoking and more rapid expansion and rupture of aortic aneurysm. Smoking cessation is essential. Radial pulses are not monitored in AAA. It is important to monitor pedal pulses. The nurse would teach the patient to measure blood pressure in both arms if a thoracic aneurysm was present. The patient should eat a healthy diet, but dietary control is not as important as another teaching topic. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+B+C+D \ A patient is diagnosed with rupture of an aortic aneurysm and surgery is imminent. What interventions would the nurse anticipate prior to surgery? (Select all that apply.)
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Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Starting intravenous lines for fluid resuscitation \ Administration of blood \ Administration of IV narcotic for pain \ Preparation for endotracheal intubation \ Administration of anticoagulants to prevent clots in the prosthesis \ • The patient with a ruptured aortic aneurysm will likely need fluid resuscitation until the rupture can be repaired. • Blood replacement therapy is initiated when a patient has a ruptured aortic aneurysm. • The patient will likely be in pain and will require IV narcotics. • The patient who has had rupture of an aortic aneurysm may have cardiac or respiratory arrest, which will require endotracheal intubation. • The administration of anticoagulants will be started after surgery. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ It is suspected that a patient has an aortic aneurysm that may be dissecting or rupturing. Which assessment finding would the nurse evaluate as suggesting the aneurysm is in the thoracic region? \ The patient has severe pain. \ The patient becomes rapidly hypotensive.
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\ Syncope occurs \ The blood pressure reading is different from arm to arm. \ \ Pain can be severe in dissections in any portion of the aorta. Hypotension can occur if an aneurysm in any area of the aorta progresses from dissection to rupture. Syncope can occur with dissection or rupture in an aneurysm in any portion of the aorta. Blood pressure differences greater than 15 mm Hg from arm to arm suggests that the aneurysm is thoracic. \ 0 0 0 0
0000000000 0000000000 0
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Chapter 14 \\ MC B \ A patient is diagnosed with atherosclerosis. How would the nurse explain the area injured by this inflammatory disorder? \ “Your arteries have three layers that are all damaged by atherosclerosis.” \ “Atherosclerosis damages the lining of your arteries.” \ “Atherosclerosis is also called ‘hardening of the arteries’ because it damages the outside layer, making it hard for your artery to stretch.” \ “The middle layer of the wall of your arteries is injured by atherosclerosis, which allows plaque to build up.” \ \ Atherosclerosis does not damage all three layers of the arteries. Atherosclerosis is a chronic inflammatory disorder associated with injury to the intimal lining. It is a progressive disease characterized by formation of plaque in the intimal lining of medium and large arteries, including those in the aorta and its branches, the coronary arteries, and large vessels that supply the brain. Atherosclerosis does not damage the outer layer of the artery. Atherosclerosis does not damage the middle layer of the artery. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \
1
A lipid panel has been drawn on a patient who has a family history of atherosclerosis. The nurse would explain that which value on the panel is most implicated in development of atherosclerosis? \ High-density lipoprotein \ Total cholesterol level \ Triglyceride level \ Low-density lipoprotein \ \ High-density lipoprotein is a desirable component of the lipid profile. Total cholesterol level includes both “good” and “bad” cholesterol and is not as specific as another level when predicting risk for atherosclerosis. High triglycerides are implicated in the development of coronary disease, but are not as specific as another value. Once an artery has been inflamed by hypertension, smoking, viruses, high cholesterol, or high glucose, the body sends macrophages to the site of inflammation. The macrophages oxidize low-density lipoprotein. The engulfing of the low-density lipoproteins by the macrophages creates foam cells, which are the basic structure behind the fatty streaks of atherosclerosis. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+C+D+E \ The nurse is performing a cardiovascular assessment. Which patient findings would indicate significant risk factors for the development of atherosclerosis? (Select all that apply.)
2
Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ The patient is diabetic. \ The patient tends to become anemic. \ The patient’s mother and sister had myocardial infarctions before age 50. \ The patient has high levels of low-density lipoproteins. \ The patient is a 50-year-old male. \ • Diabetes mellitus increases coronary artery/atherosclerotic disease risk by two-to fourfold. Diabetes can be controlled but is not curable. • Anemia is not a risk factor for coronary artery disease. • Family history of myocardial infarction increases risk for disease development. • LDL, or “bad” cholesterol, increases risk for development of coronary artery disease. • Being male is a nonmodifiable risk factor for development of coronary artery disease. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ The nurse is assessing a patient whose body mass index is 28 kg/m2. Which nursing diagnosis is appropriate for this patient? \ Imbalanced Nutrition: More than Body Requirements \ Altered Health Maintenance \
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Imbalanced Nutrition: Less than Body Requirements. \ Risk for Exercise Intolerance \ \ The American Heart Association goal for BMI is less than 25. Since this patient’s BMI is above 25, the diagnosis of Imbalanced Nutrition: More than Body Requirements is appropriate. There is a more specific nursing diagnosis to address this patient’s BMI. This patient’s BMI does not support this diagnosis and the American Heart Association goals for a healthy heart. There is no evidence that this patient cannot tolerate exercise. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A patient tells the nurse that he smokes two packs per day, works 10-hour work days most days of the week, eats out twice a day when working, and has no time to exercise. Which nursing diagnosis is appropriate for this patient? \ Anxiety \ Ineffective Coping \ Altered Health Maintenance \ Imbalanced Nutrition: More than Body Requirements \ \
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The nurse has no information that would support the choice of Anxiety as a nursing diagnosis. The nurse has no information that would support Ineffective Coping as a nursing diagnosis. The patient has several modifiable risk factors for the development of coronary artery disease that include smoking and lack of exercise. These risk factors would suggest to the nurse that the nursing diagnoses of Altered Health Maintenance would be appropriate for the patient. The nurse would also ask additional assessment questions about diet and stress, which would support other NDX. It is difficult to eat out often and maintain a healthy diet, but there is currently not enough information to support a diagnosis regarding nutrition. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ The nurse has completed teaching regarding cardiac risk factor reduction. Which patient statement would best indicate an understanding of the instructions? \ "I am going to start walking my dog for 30 or 40 minutes every day." \ "I will substitute vegetables for some of the fruit I have been eating." \ "I will increase weight bearing activities." \ "I will avoid becoming dependent upon laxatives." \ \ Unless contraindicated, patients should exercise at least 30 minutes a day, 5 to 6 days a week. The goal is 4.5 or more cups of fruits or vegetables daily. There is no reason to substitute one for the other. Increasing weight bearing activities will help increase muscle mass and bone strength and may or may not help with reducing the risk of developing coronary artery disease, so this is not the best answer. Avoiding laxatives will not reduce the patient's risk of developing coronary artery disease.
5
\ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ The nurse is providing medication education for a patient who has been prescribed atorvastatin (Lipitor). Which information should be included? \ This is one of the few medications that will not need to be monitored with periodic blood tests. \ Contact your physician if you develop muscle pain. \ It will take about 6 months before this medication will improve your low density lipoprotein level. \ This medication helps your liver break down LDL. \ \ Liver function tests should be monitored when taking this medication at weeks 6 and 12 and periodically thereafter, especially when the dose is changed. Lipitor is a medication that works on the low-density lipoprotein receptors in the liver. Major side effects include muscle pain. The patient should be instructed to contact the physician if muscle pain occurs. This medication will lower lipid levels within 2 to 4 weeks. Lipitor is a medication that increases the low-density lipoprotein receptors in the liver. The LDL from the blood is brought into liver cells where it is further broken down. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC A+C \ A patient tells the nurse that he had chest pain into his left arm while moving a heavy trash can that lasted for about 10 seconds and stopped when he put the trash can down. This information would be included in which aspects of the PQRST assessment for chest pain? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ P \ Q \ R \ S \ T \ • The PQRST mnemonic is a tool used to assess chest pain. P represents provoked pain or precipitating factors. The patient stated that the pain occurred when moving the trash can so P is one aspect that is used. • The PQRST mnemonic is a tool used to assess chest pain. The patient did not provide any information regarding the quality of the pain (Q). • The PQRST mnemonic is a tool used to assess chest pain. The patient provided information about the region and radiation (R) of the pain in his chest and down his arm. • The PQRST mnemonic is a tool used to assess chest pain. The patient did not provide any information about the severity of the pain (S). • The PQRST mnemonic is a tool used to assess chest pain. The patient did provide information about the timing of the pain by stating it occurred when the trash can was picked up and went away when it was put down. \
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0 0 0 0
0000000000 0000000000 0 \\ MC A \ A patient tells the nurse that he has been experiencing a "pain in the chest" for the last 3 hours. What does this information suggest to the nurse? \ The pain is of non-cardiac origin. \ The patient is in the midst of an acute myocardial infarction. \ The patient is going to have a myocardial infarction within hours. \ The patient is having continuous angina. \ \ Chest pain that lasts several seconds or constant pain over a period of hours is not typical pain associated with altered myocardial tissue perfusion. This information should suggest to the nurse that the pain is of non-cardiac origin. Pain associated with myocardial infarction will generally not last for 3 hours without deterioration of the patient’s condition. Anginal pain can herald myocardial infarction, but generally does not last for several hours. Angina is not continuous. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC D+E \ A patient is diagnosed with Prinzmetal's angina. Which assessment findings would the nurse attribute to this diagnosis? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ The patient experiences lightheadedness that occurs at rest. \ The patient has chest pain that lasts several hours. \ The patient can predict the level of activity that will cause the pain. \ The patient is awakened from sleep by chest pain. \ The patient has chest pain that is not related to physical activity. \ • Lightheadedness with rest is not characteristic of angina. • Chest pain that lasts several hours is not characteristic of angina. • Stable angina is chest pain that occurs with a predictable amount of exertion. • Prinzmetal's angina, or variant angina, is not common, and is a form of unstable angina. It is chest pain that occurs at rest and often occurs at night. • Prinzmetal’s angina is chest pain that is not related to physical activity. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC D \ A patient with diabetes is surprised to learn that he has been having angina when the only problem he has been experiencing is a "bit of fatigue and shortness of breath." How should the nurse explain to this patient? \ Shortness of breath is the first symptom of angina. \ There is no classic symptom of angina. \ Slight fatigue is usually the first symptom of angina. \ Persons with diabetes may experience pain differently. \ \ Anginal symptomology varies among patients. Shortness of breath may not occur in some patients. Classic symptoms of angina include chest pain and shortness of breath. Fatigue may occur in some patients, but is not a classic symptom associated with angina. Not all patients with altered myocardial tissue perfusion have classic anginal chest pain symptoms. Diabetics are especially prone to having silent ischemia and usually present with shortness of breath and fatigue because of the microvascular changes associated with diabetes leading to neuropathies and decreased sensitivity to pain. \ 0 0 0 0
0000000000 0000000000 0 \\
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MC A+B+D+E \ A female patient presents to the emergency department with complaint of chest pain. Which findings would raise the nurse’s suspicion that the chest pain is of cardiac origin? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ The patient has 2+ edema in her ankles. \ The patient has bilateral xanthomas. \ The chest pain is described as a “burning” in the center of the chest that is worse when supine. \ The patient has an S3 heart sound. \ The patient has a dull humming sound just below the xiphoid process. \ • Peripheral edema may indicate peripheral vascular disease of left ventricular dysfunction. This finding increases concern that the patient’s chest pain may be cardiac. • Xanthomas are cholesterol filled lesions commonly seen around the eyes and could indicate elevated lipids. Presence of these lesions would increase the likelihood that the patient’s chest pain is cardiac. • Burning pain in the chest that is worse when supine is often related to esophageal reflux disease rather than of cardiac origin. • Presence of an S3 heart sound is not normal in an adult and increases concern that the chest pain is cardiac in origin. • A dull humming sound below the xiphoid process may be an abdominal bruit, which increases the concern for cardiovascular disease. \ 0 0 0 0
0000000000 0000000000 0
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\\ MC C \ Which assessment finding would indicate to the nurse that the patient has an altered blood supply to the right coronary artery affecting the posterior wall of the myocardium? \ cTnT of 0.0 mcg/L \ CK-MB of 4% \ ST segment depression in V1 and V2 \ Peaked T waves in Avf \ \ A troponin level (cTnT) of 0.00 mcg/L is a normal result. A CK-MB level of 4% is within normal limits. ST segment depression in V1 and V2 is seen when there is an altered blood supply to the right coronary artery that supplies the posterior wall of the heart. Ischemia of the inferior wall is reflected in leads II, III and aVF. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ A patient is admitted with chest pain of approximately 2 hours in duration. The CK level was 8 U/L. Which additional order should the nurse expect in order for assessment of this patient to be adequate? \ Repeat CK level in 48 hours
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\ CTnT level \ CK-MB in the a.m. \ LDL and HDL levels \ \ The CK level peaks in 12 to 24 hours, so repeating the level 50 hours after chest pain began is not indicated. The cardiac marker troponin-T has an onset of 2 to 4 hours and peaks in 24 to 36 hours. Since the patient has been experiencing chest pain for approximately 2 hours, this test should most likely be drawn to adequately assess the patient. CK-MB will still be elevated in the morning if the pain is cardiac in origin, however, the patient should be diagnosed and treated more rapidly that would occur with this order. LDL and HDL levels will reveal information about cholesterol levels, but not about heart damage. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ A patient, admitted with chest pain, has a baseline cTnT level of 1.1 mcg/L. Which explanation would the nurse provide the patient for redrawing this level in 6 hours? \ “Trends in this value will help us determine your diagnosis.” \ “If this level goes down we know your pain medication is working.” \ “Hopefully we will see this level rise as an indicator that your oxygen therapy has been effective.” \ “If this level does not increase, we will need to increase the rate of your intravenous fluid replacement.”
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\ \ Cardiac markers are obtained on admission when a patient complains of chest pain. Cardiac markers are redrawn approximately every 6 hours to evaluate for trends in elevation or decline that signals continued or resolving myocardial damage. Serial levels help determine the extent of myocardial damage. Response to pain medication is not determined by cTnT level. The effectiveness of oxygen therapy is not determined by cTnT level. Adequacy of intravenous fluid replacement is not gauged by changes in cTnT level. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C+D \ A patient has presented for a scheduled exercise stress test. Which patient comments should the nurse communicate immediately to the health care provider performing the test? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ “I did tell you that I am allergic to iodine didn’t I?” \ “I’m pretty hungry since I didn’t eat breakfast.” \ “I had a cup of tea this morning instead of coffee.” \ “I took my propranolol early this morning when I first woke up.” \ “I am determined to quit smoking. I haven’t had a cigarette for 2 days.” \ • Radionuclide injections are not part of an exercise stress test.
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• • • •
The patient should not eat for several hours prior to the test. The patient should not drink beverages containing caffeine for several hours prior to the test. Certain drugs, like beta blockers, should be held for 24 hours prior to the procedure. Propranolol is a beta blocker. The patient should not smoke for several hours prior to the test.
\ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ At the conclusion of a stress echocardiogram it was determined that the patient has dyskinesis. The nurse would reinforce which explanation of this finding? \ The patient’s heart moves too slowly. \ The patient’s heart wall moves very quickly to impulses. \ The patient’s heart wall moves opposite from normal. \ A portion of the patient’s heart does not move at all. \ \ Hypokinesis is when there is a decrease in movement of the heart muscle. Dyskinesis is not associated with rapid response to stimuli. Dyskinesis means that the patient’s heart wall moves in the opposite direction from what is normal. If a portion of the heart wall does not move at all it is called akinesis. \ 0 0
15
0 0
0000000000 0000000000 0 \\ MC A \ A patient's is admitted with complaint of chest pain. The electrocardiogram reveals ST segment elevation. What is the nurse’s priority intervention? \ Give the patient 162 mg of aspirin. \ Draw blood for serum cardiac markers. \ Draw blood for serum cardiac markers. \ Call for a portable chest x-ray. \ \ As soon as the ECG is done the patient should receive aspirin. Blood should be drawn for serum cardiac markers, but this is not the priority action The patient should be placed on a cardiac monitor, but this is not the priority intervention. The patient should be placed on a cardiac monitor, but this is not the priority intervention. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC A \ During the first 24 hours after a patient has received thrombolytic therapy. What is a priority nursing intervention? \ Monitor level of consciousness. \ Administer pain medications. \ Monitor for decreased output. \ Monitor for pulmonary emboli. \ \ The first 24 hours after thrombolytic administration holds the highest risk for intracranial hemorrhage. The intervention that has the highest priority for the first 24 hours after thrombolytic therapy is assessing level of consciousness. The nurse should treat the patient’s pain, but this is not the highest priority intervention. Monitoring for decreased output is an important intervention, but is not the highest priority. The nurse should monitor for the development of pulmonary emboli, but this is not the highest priority intervention. \ 0 0 0 0
0000000000 0000000000 0 \\ MC
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B+C+D \ A patient with acute coronary syndrome has received thrombolytic therapy. The nurse would monitor and report which findings that indicate this therapy was successful? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Respiratory rate of 18 per minute \ Resolution of ST segment elevation \ Resolution of chest pain \ Occurrence of premature ventricular complexes \ Occurrence of a headache \ • Respiratory rate of 18 per minute is a normal respiratory rate and is not an indicator of the therapeutic effectiveness of thrombolytic therapy. • Resolution of ST segment elevation would indicate that ischemia is reduced and that the therapy is successful. • When the cardiac tissues are reperfused, pain abates. • Thrombolysis and reperfusion of the effected myocardium may be indicated by the occurrence of reperfusion arrhythmias, such as premature ventricular complexes or ventricular tachycardia. • Presence of a headache does not indicate reperfusion and may indicate an adverse effect is occurring. \ 0 0 0 0
0000000000 0000000000 0
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Chapter 15 \\ MC D \ A patient, admitted with the diagnosis of stroke, has left hemiparesis involving the face, arm, and leg. The nurse explains that this stroke most likely involves which artery? \ Right vertebral \ Left posterior communicating \ Left middle cerebral \ Right middle cerebral \ \ The right vertebral area is not the most common site of damage causing a stroke. The posterior communicating arteries are part of the circle of Willis, but are not the most common areas involved in stroke. The middle cerebral arteries supply blood to the lateral surfaces of the frontal, temporal, and parietal lobes. These arteries are often involved in stroke. The motor fibers cross so the left side of the brain controls the right side of the body. The middle cerebral arteries supply blood to the lateral surfaces of the frontal, temporal, and parietal lobes. These arteries are often involved in stroke. The motor fibers cross so the right side of the brain controls the left side of the body. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D
1
\ A patient recovering from a frontal craniotomy is positioned with the head of the bed elevated 45 degrees at all times. What rationale would the nurse provide for this position? \ The brain will compress the cerebral veins less in this position. \ The ventricles of the brain will drain better in this position. \ This position allows for less pain for the patient. \ The cerebral spinal veins are valveless and drain by gravity. \ \ This statement is not physiologically correct. This statement is not physiologically correct. There is no reason that pain would be reduced in this position. The cerebral spinal veins drain best via gravity, an important characteristic to remember when caring for patients with the risk for increased intracranial pressure as would be present in intracranial surgeries. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ The nurse is providing care for a patient who sustained a severe head injury. The nurse would intervene to prevent which occurrence that increases cerebral blood flow? \ Oversedation \ Hypothermia \
2
Fever \ Paralysis \ \ Sedation will decrease cerebral blood flow. Hypothermia will decrease cerebral blood flow. Fever increases the body’s metabolic rate and will increase cerebral blood flow. Paralysis, often initiated chemically, will decrease cerebral blood flow. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ The nurse is providing care for a patient who is at risk for developing an increase in intracranial pressure due to swelling of the brain. The nurse is aware that this increased brain size must be accompanied by which other change if intracranial pressure is to remain stable? \ There will be an increase in the blood flow to the brain. \ There is a decrease in the blood–brain barrier. \ There must be a decrease in another of the intracranial compartments. \ There will be an increase in the production of cerebrospinal fluid. \ \
3
Blood flow to the brain would decrease as more space is taken up by the brain. The blood–brain barrier does not increase or decrease in response to changes in the brain. The contents of the intracranial vault include the brain, cerebral blood volume, and cerebrospinal fluid. The Monro–Kellie hypothesis states that as the content of one of the intrancranial compartments increases, it is at the expense of the other two. The correct answer is that if there is an increase in the volume of brain tissue, there will need to be a decrease in another of the intracranial compartments. An increased amount of cerebrospinal fluid would increase the pressure in the intracranial vault. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ A nurse is monitoring the intracranial pressure of a patient with a closed-head injury. Which pressure would the nurse evaluate as requiring no additional intervention? \ 12 mm Hg \ 22 mm Hg \ 25 mm Hg \ 30 mm Hg \ \ The normal intracranial pressure ranges from 0 to 15 mm Hg. This pressure exceeds normal. This pressure exceeds normal. This pressure exceeds normal. \
4
0 0 0 0
0000000000 0000000000 0 \\ MC B \ A nurse is providing care for a patient with increased intracranial pressure and is monitoring cerebral perfusion pressure. The nurse compares measurements to which critical normal value? \ 50 mm Hg \ 70 mm Hg \ 120 mm Hg \ 30 mm Hg \ \ The CPP critical value is higher than 50 mm Hg. In order to ensure adequate cerebral oxygenation, the cerebral perfusion pressure must be maintained at greater than 70 mm Hg. CPP of 120 mm Hg is high and will result in a loss of autoregulation. This is not the critical value to which the nurse compares actual measurements. A CPP of 30 mm Hg is low and will result in loss of autoregulation. This is not the critical value to which the nurse compares actual measurements. \ 0 0 0 0
5
0000000000 0000000000 0 \\ MC A \ A patient with a head injury has a mean arterial pressure of 70 mm Hg and an intracranial pressure of 20 mm Hg. Which cerebral perfusion pressure would the nurse document for this patient? \ 50 mm Hg \ 90 mm Hg \ 70/40 mm Hg \ 40/70 mm Hg \ \ The cerebral perfusion pressure is calculated as the mean arterial pressure minus the intracranial pressure. In this patient the cerebral perfusion pressure would be inadequate and intervention is needed. This calculation is incorrect for the values given. This calculation is incorrect for the values given. This calculation is incorrect for the values given. \ 0 0 0 0
0000000000 0000000000
6
0 \\ MC A \ A nurse is monitoring a patient who sustained a head injury. The nurse recognizes which finding as the earliest sign of change in neurologic status? \ The patient cannot remember where he is. \ The patient’s pupil size is increased. \ The patient’s blood pressure has increased. \ The patient exhibits decorticate posturing when stimulated. \ \ The level of consciousness is the most important indicator of neurological function in the high-acuity patient. Pupillary changes do occur with neurological damage but are not the earliest signs. Changes in vital sign can indicate neurological damage, but are not the earliest signs. Posturing is an important finding associated with neurologic damage, but is not the earliest sign. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A nurse is monitoring a patient’s Glasgow Coma Scale (GSC). At which point would the nurse document that the patient is comatose? \ 11
7
\ 15 \ 7 \ 9 \ \ A score of 11 indicates some impairment, but does not indicate coma. A GCS of 15 is normal. A score of 7 or less indicates a significant alteration in the level of consciousness and the development of coma. A GCS score of 9 indicates significant neurological changes, but does not indicate coma. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C+E \ The nurse, assessing a patient with a Glasgow Coma Score 4, finds the patient's pupils to be pinpoint and nonreactive to light. The nurse takes into consideration that this finding can be due to which situations? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ The patient was given atropine sulfate for bradycardia. \ The patient has increased blood glucose. \ The patient may have taken an opioid drug overdose. \ The patient has sustained compression of the oculomotor nerve.
8
\ The patient has sustained damage to the pons. \ • Recent administration of atropine sulfate leads to dilated pupils. • Metabolic disorders cause small but reactive pupils. • Opiod drug overdose will result in pinpoint, nonreactive pupils. • Compression of the oculomotor nerve causes a unilateral fixed and dilated pupil. • Damages to the pons will result in fixed and pinpoint pupils. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+D \ A patient who has suffered a temporal lobe stroke will soon be transferred from the emergency department to the neurointensive care unit. The nurse should prepare for which patient conditions? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Respiratory depression or arrest \ Respiratory depression or arrest \ Uncontrollable fits of crying or laughter \ Deafness \ Bradycardia \ • The temporal lobe does not control respiratory effort.
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• • • •
The ability to smell is controlled by the temporal lobe. A stroke in this area may cause decreased ability to smell or anosomia. Mediation of emotional response is controlled by the diencephalon. Hearing is controlled by the temporal lobe of the cerebrum. A temporal lobe stroke is unlikely to affect cardiac rate. Heartrate is controlled by the medulla oblongata which is part of the brainstem.
\ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ A patient with a head injury is being monitored with an intraventricular catheter. The nurse would design interventions based upon which priority nursing diagnosis (NDX)? \ Risk for Injury \ Decreased Intracranial Adaptive Capacity \ Altered Comfort, Acute Pain \ Risk for Infection \ \ This patient is at risk for injury, but this is not the priority NDX. This patient likely has at risk for decreased intracranial adaptive capacity but this is not the priority NDX. This patient may have altered comfort due to injury, procedures, or positioning, but this is not the priority NDX. The placement of an intraventricular catheter to monitor intracranial pressure places the patient at risk for infection. The nurse must practice meticulous infection control measures while caring for these patients. \
10
0 0 0 0
0000000000 0000000000 0 \\ MC A+B+E \ A patient with an intraventricular catheter for the assessment of increased intracranial pressure is demonstrating is demonstrating A waves. The nurse would assess for which other findings? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Decreasing level of consciousness \ Pupillary changes \ Posturing \ Variations in blood pressure \ Changes in the wave associated with respiration \ • A waves are clinically significant and typically occur when ICP is elevated. A decreasing level of consciousness may occur with this elevation. • A waves are clinically significant and typically occur when ICP is elevated. Pupillary changes may occur with this elevation. • A waves are clinically significant and typically occur when ICP is elevated. Posturing may occur with this elevation. • C waves occur with variations in blood pressure. • C waves vary according to respiration. \ 0
11
0 0 0
0000000000 0000000000 0 \\ MC D \ A patient who sustained a traumatic brain injury is being sent for a CT scan. Which nursing statements would help the patient’s spouse understand the rationale for a CT scan rather than an MRI? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ “CT scans are easier for patients with head injuries because movement is allowed.” \ “We can get results from a CT scan quicker than from an MRI.” \ “MRIs are more costly so the least expensive test is always done first.” \ “CT scans are noninvasive.” \ “CT scans show more detail than an MRI.” \ • CT scans do not necessarily provide more patient movement while the test is being conducted. • The CT scan is the test of choice with head injury patients because MRIs take longer. • MRIs are typically more expensive, but the nurse should not use this as a rationale for the choice when talking with the family. • CT scans are noninvasive. • MRIs show more tissue detail than do CT scans. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC A \ The family of a comatose patient asks the nurse if there is any way to know if their loved one will ever “wake up.” The nurse should consider which test when formulating a response to this concern? \ Evoked potentials \ CT scan \ Electroencephalogram \ Lumbar puncture \ \ Evoked potentials are recordings of cerebral electrical impulses generated in response to visual, auditory, or somatosensory stimuli. They are used to assist in the evaluation of the location and extent of brain dysfunction after head injury. Evoked potentials may be useful in predicting coma outcome. A CT scan can help diagnose structural changes, but does not help predict outcome of a coma. Electroencephalography allows recording of the electrical activity of the brain using electrodes attached to the scalp but is not used to help predict the outcome of a coma. Lumbar puncture can help determine cause of coma but does not help predict outcome of coma. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC B \ A patient was the unrestrained driver of a car that was struck head on by another vehicle. During initial assessment the nurse observes another nurse using supraorbital pressure to assess for response. What nursing intervention is indicated? \ Hold the patient’s head still so that the test will be valid. \ Stop the procedure. \ Ask the nurse to repeat the procedure on the other orbit. \ Document the response as 1+, 2+, 3+, or 4+. \ \ The nurse should not attempt to hold the patient’s head still. Since this patient is at high risk for facial fractures, supraorbital pressure should not be used. The procedure should not be repeated. The nurse should intervene in a different manner. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+B+C+D
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\ A nurse is preparing to conduct a neurological assessment on a patient who is not suspected for having neurological impairment. Which tests should the nurse perform? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Observation for level of consciousness \ Checking pupillary response to light \ Ability to count by serial 7s \ Assessing the blood pressure \ Visual acuity \ • Simple testing for level of consciousness includes observing the patient for response to auditory or tactile stimuli. • Simple penlight testing for pupillary response to light is a part of the abbreviated neuro check. • Ability to count by serial 7s is not part of the abbreviated neuro check. • Vital sign assessment is part of the abbreviated neuro check. • Visual acuity is not a part of the abbreviated neuro check. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ Following a stroke a patient is diagnosed with expressive aphasia. What nursing intervention is indicated? \
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Speak slowly and face the patient directly when speaking. \ Speak at a slightly louder volume. \ Watch the patient carefully for behavioral clues. \ Decrease environmental stimuli before attempting to communicate with the patient. \ \ The patient with expressive aphasia can understand speech, so this action is not necessary. The patient with expressive aphasia can understand speech, so it is not necessary to speak at a louder volume. The patient with expressive aphasia cannot write or use language. The nurse should observe for behavioral clues to the patient’s needs. The patient with expressive aphasia can understand speech, so decreasing environmental stimuli is not necessary for the purpose of communication. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A nurse is starting an intravenous line in a patient being treated for a head injury. Suddenly the patient extends his legs and demonstrates extreme plantar flexion. What action should be taken by the nurse? \ Document the presence of decorticate posturing. \ Immediately stop the attempt at intravenous insertion and obtain a blood pressure reading. \ Assess the position of the patient’s arms. \ Administer intravenous sedation as quickly as possible after access is obtained.
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\ \ It is not possible to assess decorticate posturing from this scenario. It is important to gain IV access for this patient. Posturing to noxious stimuli indicates brain damage. Blood pressure is not pertinent at this time. The nurse should assess the position of the patient’s arms to determine if decorticate or decerebrate posturing is present. Administering sedation is not indicated at this time as assessment is continuing. 300. d.Ensure that cervical spine injury has been ruled out., c.Obtain cold water and a syringe, e.Be certain there is no perforation of the tympanic membrane in the side being tested. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B+C+D \ A nurse is assisting with a patient’s oculocephalic and oculovestibular reflex assessment. How should the nurse prepare for this testing? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Prepare for oculocephalic testing to be done after oculovestibular testing. \ Ensure that cervical spine injury has been ruled out. \ Obtain cold water and a syringe \ Be certain there is no perforation of the tympanic membrane in the side being tested. \ Tell the patient he will be asked to report any feeling of numbness or vertigo.
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\
• • • • •
Patients with an absent oculocephalic reflex may have a normal oculovestibular reflex, so testing for oculovestibular reflex should follow oculocephalic reflex. Oculocephalic testing requires moving the patient’s head from side-to-side, so it should not be performed until the cervical spine is cleared of injury. Oculovestibular reflex testing includes injecting cold water into the patient’s ear. Since oculovestibular testing includes placing water in the ear, it is contraindicated if there is a perforation or tear in the tympanic membrane. Oculovestibular and oculocephalic testing is done on patients with suspected brain stem depression. The patients are not conscious.
\ 0 0 0 0
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Chapter 16 \\ MC A+D \ A patient is demonstrating confusion and difficulty focusing. Which assessment findings would the nurse evaluate as supporting a diagnosis of delirium rather than dementia? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ The confusion cleared when the patient was rehydrated. \ The patient does not recognize her daughter. \ The patient’s daughter reports that her mother has been becoming increasingly confused over the last 6 months. \ The patient’s mentation was clear yesterday. \ The patient does not recognize that she is confused. \ • Delirium is an acute state of mental status change that can be triggered by metabolic conditions such as dehydration. Since the confusion cleared with rehydration, the diagnosis of delirium is supported. • It is not possible to determine if the inability to recognize familiar people is due to delirium, dementia, or another physiologic cause. • Increasing confusion is more likely to support the diagnosis of dementia. • Delirium is situational, reversible, and acute. Since the patient’s mentation was clear yesterday, it is more likely to reflect delirium rather than dementia. • Ability to recognize that one is confused does not differentiate between delirium and dementia. \ 0 0 0 0
0000000000 0000000000 0
1
\\ MC D \ A patient being treated with haloperidol for symptoms of delirium has a blood pressure reading of 190/110 mm Hg. Which nursing action is priority? \ Encourage the patient to drink at least 240 mL of fluids. \ Contact the prescriber about an increase in the haloperidol dosage. \ Place the patient on seizure precautions. \ Hold the haloperidol dose and collaborate with the prescriber. \ \ There is no indication that fluid intake will treat this drug reaction. The patient may be experiencing an adverse drug reaction, so increasing the dose is not indicated. Seizure is a possibility, but is not the primary nursing action. One nursing indication for a patient prescribed haloperidol is to monitor for neuroleptic malignant syndrome especially in those patients who take lithium or who have hypertension. One indicator of neuroleptic malignant syndrome is instability of blood pressure. The nurse should contact the prescriber and discuss discontinuing the drug. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ A ventilator-dependent patient has been in a coma for several weeks. Which finding would the nurse evaluate as indicating there is possibility of reversing this coma state?
2
\ Testing indicates that the patient has brain function. \ The patient has clear breath sounds with no indications of pneumonia. \ The patient cardiac rhythm strip reveals normal sinus rhythm. \ The patient’s urinary output has remained adequate throughout the coma state. \ \ Coma is characterized by the absence of arousal and awareness and may be reversible as long as brain function continues. Since the patient has been assessed to have brain function, the patient is not brain dead and the coma can be reversed. While the complication of pneumonia would be a compounding factor in reversing coma, the absence of pneumonia does not indicate potential for reversal. Presence of cardiac dysrhythmias is a compounding factor in reversing coma, but absence of dysrhythmia does not indicate potential for reversal. Development of renal failure would compound the reversal of the coma state, but presence of normal kidney function is does not indicate potential for reversal. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A patient is admitted to the intensive care unit accompanied by a family member who says, “He suddenly started acting funny and couldn’t remember where he was.” The nurse would anticipate that first assessment efforts would focus on which condition?\ Hypovolemic shock \ Cerebral infection
3
\ Ischemic stroke \ Drug overdose \ \ Hypovolemic shock is not the most common cause of changes in mentation in patients admitted to the ICU. Cerebral infection is not the most common cause of changes in mentation in patients admitted to the ICU. Even though there are many causes of impaired mentation in patients who have not sustained a head injury, ischemic stroke has been found to be the most frequent cause of impaired mentation on admission to the intensive care unit. The patient should be assessed first for an ischemic stroke. Drug overdose is not the most common cause of changes in mentation in patients admitted to the ICU. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ A patient in the intensive care unit has pulled out his peripheral intravenous line twice and continually picks at his abdominal dressing. How should the nurse describe this behavior? \ As hyperactive dementia \ As hyperactive delirium \ As hypoactive delirium \ As mixed dementia \ \
4
There is no indication that this patient has dementia. Hyperactive delirium, also referred to as ICU psychosis, is characterized by agitation, restlessness, and "picking" at monitoring, feeding, or intravenous devices. Hypoactive delirium is characterized by lethargy rather than agitation, withdrawal, flat affect, apathy, and decreased responsiveness. There is no indication that this patient suffers from dementia. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ An elderly patient in the intensive care unit recovering from an abdominal aortic aneurysm repair begins to show signs of decreased responsiveness. The nurse realizes that which situation is the most likely cause of this change in mentation? \ The patient’s intravenous line is infiltrated. \ The patient has been NPO for an extended period of time. \ The patient’s oxygen saturation has dropped from 96% to 90%. \ The patient was started on a PCA pump with morphine. \ \
5
Infiltration of an intravenous line would not be a likely cause of change in mentation. NPO status, as long as the patient is receiving fluids and nutrition parenterally, is not a likely etiology for this change in mentation. This amount of change in oxygen saturation is not the likely cause of the patient’s mental status change since the level is still within normal limits. Medications are seen as the most prevalent modifiable risk factor for delirium in acute or critically ill elderly patients. Opioid narcotics, such as morphine and fentanyl, are linked to the development of delirium. This is what the nurse should suspect as the cause of the patient's new onset of decreasing responsiveness. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ From the use of the CAM-ICU assessment tool, a patient is found to have hypoactive delirium. Which nursing intervention is indicated? \ Use the prn order for morphine to control the patient’s pain. \ Use wrist restraints to maintain monitoring devices and lines. \ Restrict visitors to times when the patient’s mentation is clearest. \ Reorient the patient to the environment as needed. \ \
6
Morphine has been linked to an increase in delirium and should be avoided if it is suspected as being the cause for the patient's delirium. Delirium can be worsened by the use of physical restraints. The presence of family and significant others often helps to reassure and reorient the patient. Visitation should be encouraged even during times of decreased mentation. One of the causative factors of delirium is change in environment. The nurse should reorient the patient as needed in a calm and reassuring manner. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ A patient diagnosed with delirium has a history of adverse reaction to haloperidol. Which medication would the nurse anticipate using instead of haloperidol? \ Phenytoin \ Risperidone \ Morphine \ Amiodarone \ \ Phenytoin is used to manage seizures. For patients unable to tolerate haloperidol for delirium, risperidone is an alternative. Morphine is prescribed to control pain may cause a worsening of delirium. Amiodarone is a cardiac medication. \
7
0 0 0 0
0000000000 0000000000 0 \\ MC C \ A patient who was in a coma for one week after surgery is unable to tell the nurse where he lives or what he did for a living. The nurse evaluates this condition as suggesting which change resulting from the coma? \ The patient now has a learning deficit. \ The patient has instability of emotions. \ The patient’s cognition is impaired. \ The patient was near brain death before the coma resolved. \ \ The patient should be able to remember basic facts about his life. He would not have to relearn these facts, so this scenario does not indicate that a learning deficit exists. There is no indication that the patient has responded emotionally to his change in mental status. Inability to remember basic facts indicates that the patient’s cognition is impaired. Simple inability to remember facts cannot be construed to mean that patient was near brain death. This might have been the case, but there are not enough facts to support this option. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC B \ An elderly patient is admitted to the intensive care unit with acute respiratory injury from aspiration. The nurse monitors this patient very carefully to avoid onset of polyneuropathy because the patient has history of which disorder? \ Hypertension \ Type 2 diabetes mellitus \ Urinary urgency \ Congestive heart failure \ \ History of hypertension is not known to increase risk for development of polyneuropathy in critically ill patients. It is believed that tight glucose control with intensive insulin therapy can reduce the incidence of critical illness polyneuropathy by 44%. Therefore, the patient with history of type 2 diabetes is at higher risk for developing polyneuropathy when critically ill. There is no indication that urinary urgency is associated with increased risk of polyneuropathy in critically ill patients. There is no evidence to suggest that history of congestive heart failure increases risk of polyneuropathy in critically ill patients. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC A \ Upon assessment of a patient in the intensive care unit, the nurse suspects critical illness polyneuropathy is developing. Which finding would support this suspicion? \ The patient exhibits facial grimacing to painful stimuli but does not withdrawal from the stimuli. \ There is bilateral absence of deep tendon reflexes. \ Laboratory results reveal elevation of creatine kinase level. \ The patient exhibits diffuse weakness. \ \ One symptom of critical illness polyneuropathy is the demonstration of a painful stimuli being present, such as facial grimacing, without the ability to withdraw from the stimuli. This is because of a distal loss of pain reception abilities. Deep tendon reflexes are preserved in critical illness polyneuropathy. There is no laboratory test to diagnose critical illness polyneuropathy. Electrodiagnostic testing is necessary for diagnosis. Critical illness polyneuropathy that mainly affects the lower limb nerves. Diffuse weakness is characteristic of critical illness myelopathy. \ 0 0 0 0
0000000000 0000000000 0
10
\\ MC D+E \ An initiative for early identification of critical illness myopathy has been undertaken by the nurses in the intensive care unit. These nurses would be most watchful of this complication in which patients? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Patients with history of type 1 diabetes mellitus \ Patients with documented presence of renal calculi \ Patients admitted with the diagnosis of chronic bronchitis \ Patents sedated with neuromuscular blocking agents \ Patients who have received high dose corticosteroid therapy \ • Elevated glucose levels have been associated with critical illness polyneuropathy. • Renal calculi are not associated with critical illness myelopathy. • Chronic bronchitis is not associated with the development of critical illness myopathy. • Critical illness myelopathy is a spectrum of muscle disorders that present with diffuse weakness, depressed deep tendon reflexes, and mildly elevated creatine kinase levels. It has been associated with neuromuscular blocking agent use. • Critical illness myopathy is associated with use of high dose corticosteroid therapy. \ 0 0 0 0
0000000000 0000000000 0 \\ MC
11
B \ The nurse is providing care to a patient receiving a neuromuscular blocking agent. Which nursing intervention is most important specifically due to this medical intervention? \ Monitor urine output. \ Provide eye care. \ Move the patient as little as possible. \ Provide mouth care. \ \ Urine output should be monitored for all critically ill patients. This monitoring is not specific to patients under neuromuscular block. Nursing care of a patient receiving a neuromuscular blocking agent should include prophylactic eye care. The nurse should keep the eyes closed and covered with a soft eye pad and use eye lubricants or artificial tears. The patient receiving neuromuscular blockage will be unable to move self. The nurse must intervene with actions to prevent muscle contractures and skin breakdown. Mouth care is an essential component of the care of all critically ill patients. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ A patient in the intensive care unit begins to seize. The nurse would anticipate initial management of this seizure to include which intravenous medication? \ Fosphenytoin
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\ Lorazepam \ Propofol \ Diazepam \ \ Fosphenytoin would be administered if the first line class of drugs was ineffective in controlling the seizure. Intravenous benzodiazepines are effective in stopping seizures 65–80% of the time. Lorazepam is the treatment of choice over diazepam because it lasts longer. Propofol could be administered if the first and second line drugs are ineffective in controlling the seizure. Diazepam is a benzodiazepine that can be administered intravenously; however, it does not last as long as the preferred drug. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B+D \ A patient in the intensive care unit begins exhibiting seizure activity. What nursing interventions are indicated? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Hold the patient as still as possible to prevent tissue damage. \ Roll the patient to the side if possible. \ Place a padded tongue blade in the patient’s mouth. \
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Time the seizure from beginning to end. \ Call the rapid response team. \ • The nurse should remove hard objects if possible and pad objects that cannot or should not be removed. This action will help prevent injury. The nurse should not attempt to hold the patient still. • Rolling the patient to the side will allow secretions to clear the mouth and will help prevent aspiration. • No attempt to place anything in the patient’s mouth should be made. • Length of seizure is important assessment information that can be collected by the nurse. • The nurse working in the intensive care unit should be adequately prepared to manage a patient having a seizure. There is no need to call for a rapid response team for a simple seizure. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A patient in the critical care unit has a seizure that was determined to be caused by a low blood glucose level. The patient's blood glucose level is currently normal. Which additional intervention should be implemented to prevent future seizure activity in this patient? \ Administer valium orally twice each day. \ Establish a low-dose continuous phenytoin infusion. \ Increase the frequency of blood glucose assessment. \ Frequently monitor brain wave activity. \ \
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If the cause of the seizure is identified and corrected, pharmacologic intervention for seizure prevention is often not indicated. Since the cause of the seizure was identified and corrected pharmacological intervention is often not necessary. The cause of the patient’s seizure has been identified as low blood glucose. The best plan of action is to prevent low blood glucose. An effective intervention is to increase frequency of blood glucose measurement to ensure early intervention for hypoglycemia. The cause of the patient’s seizure has been identified and corrected. It is not necessary to undertake frequent monitoring of brain wave activity. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ A patient in the intensive care unit continues to seizure after receiving lorazepam. He currently has an intravenous infusion of dextrose 5% and 0.45 normal saline infusing at a rate of 125 mL/hr. The nurse would anticipate providing which medication? \ Fosphenytoin \ Phenytoin and diazepam \ Haloperidol \ Additional lorazepam \ \
15
If administration of a benzodiazepine is not effective in controlling seizure activity administration of a phenytoin is indicated. Fosphenytoin can be administered quickly and does not cause the same cardiovascular depression as other phenytoins. It is also compatible with dextrose solutions. Phenytoin is not compatible with dextrose solutions. Haloperidol is not effective in controlling seizure activity. If the initial dose of lorazepam is not effective in controlling the seizure an additional medication is indicated. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C+E \ A patient with seizure activity is receiving intravenous phenytoin (Dilantin). Which nursing interventions are indicated? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Assess deep tendon reflexes. \ Keep blood glucose level within normal limits. \ Monitor injection site frequently. \ Turn and reposition every hour. \ Monitor for the development of hypotension. \ • Assessment of deep tendon reflexes is not a particular intervention necessary for the patient receiving phenytoin. • Phenytoin does not adversely affect blood glucose levels.
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• • •
Infiltration of phenytoin will cause tissue vesication and necrosis. The nurse must increase frequency of intravenous site assessment. There is no need to increase frequency of repositioning when patients are receiving phenytoin. Phenytoin contains propylene glycol which can cause cardiac suppression. Cardiac suppression can be evidenced by the development of hypotension.
\ 0 0 0 0
0000000000 0000000000 0 \\ MC A+B+C+E \ A patient newly admitted to the intensive care unit reports that he has not been sleeping well at home. The nurse would conduct assessment for which preexisting conditions? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Taking a beta blocker \ Use of a bronchodilator \ Snoring \ Hypothyroidism \ Alcoholism \ • Beta blockers can be implicated in development of insomnia. • Bronchdilators can be implicated in development of insomnia. • Snoring is associated with sleep apnea, which can cause insomnia. • Hyperthyroidism is a more likely cause of insomnia.
17
•
Substance abuse may cause insomnia.
\ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ A nurse is about to administer flumazenil to a patient who has experienced oversedation from benzodiazepine use. Before administering this drug the nurse should prepare to manage which patient response? \ Hypertension \ Seizure \ Sudden temperature elevation \ Bradycardia \ \ Hypertension is not the response most likely to occur when flumazenil is administered. Seizures and delirium are more likely to occur with sudden discontinuation of benzodiazepines which will occur when flumazenil is administered. Sudden temperature elevation does not occur with administration of flumazenil. Bradycardia does not occur with administration of flumazenil. \ 0 0 0 0
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0000000000 0000000000 0
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Chapter 17 \\ MC A+B+D+E \ The nurse is providing community education regarding stroke. Which information should be included? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Stroke is caused by interruption of blood flow to the brain. \ Stroke is the third-leading cause of death in the United States. \ Stroke usually occurs simultaneously with myocardial infarction. \ Rapid recognition of stroke symptoms can help decrease poor outcomes. \ Stroke causes neurological defects. \ • Stroke occurs when a localized area of the brain is not receiving adequate blood flow. The resultant ischemia causes injury to the brain tissue. • Stroke is the third cause of death and a leading cause of disability in the United States. • There is no evidence that stroke and MI generally occur together. • Rapid recognition of stroke symptoms along with rapid intervention can help to decrease poor outcomes from stroke. • Neurological changes and deficits are common when stroke occurs. \ 0 0 0 0
0000000000 0000000000 0 \\ MC
1
B \ A patient comes into the emergency department with complaints of partial loss of vision in one eye, numbness and tingling of the arm and leg, and dizziness. Which additional information should the nurse initially seek from the patient? \ If the patient has high blood pressure \ If the symptoms are still present \ If this is a recurrent problem \ If the patient fell \ \ Although important, determining if the patient has a history of high blood pressure can be determined at a later time. Although all of these issues are important in the assessment of the patient, it is essential to determine if the patient still has the symptoms or if they were time limited. If symptoms are no longer present they are still significant as the patient may have experienced a transient ischemic attack. It is important to discern if the patient has ever experienced these symptoms before, but this is not the most important information. Assessing if the patient has fallen is not important for the nurse to ask initially. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ When developing a teaching plan for a patient who had an embolic stroke, the nurse considers which history as a significant risk factor?
2
\ Hypertension \ Use of anticoagulants \ History of atherosclerosis of cerebral arteries \ Atrial fibrillation \ \ Hypertension is more likely associated with thrombotic stroke. Use of anticoagulants and hypertension together are associated with hemorrhagic cerebral vascular accidents. Atherosclerosis of cerebral arteries is associated with ischemic stroke. Atrial fibrillation, in addition to endocarditis, rheumatic heart disease, and recent myocardial infarction, are the most common causes of embolic cerebral vascular accidents. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ When planning nursing care for a patient with a cerebral vascular accident, the nurse should consider which primary goal of medical management? \ Restoration of cerebral blood flow and limiting the size of the infarcted area of the brain \ Keeping the blood pressure under control pharmacologically \ Transferring the patient for rehabilitation as soon as medically stable \ Reestablishing blood flow to the infarcted area surgically
3
\ \ The goal is to recover as much function as possible. The most vulnerable area of the brain is the penumbra, and the sooner the circulation can be restored to that area the better the cells in that area will recover. The patient’s blood pressure should be controlled, but this goal is not global enough to be the primary goal. Transferring the patient to a long-term care facility as soon as medically stable is a goal for patients to recover enough function to return to their former settings. This is not the primary goal for medical management. Surgical options are not available for most stroke patients. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ Diagnostic testing reveals that a patient has areas of cerebral focal infarctions. The nurse plans care with the realization that which outcome is likely? \ The patient will likely deteriorate into multiple system organ failure. \ These areas of ischemia will likely extend into the brainstem. \ The patient’s symptoms will likely resolve with treatment. \ The patient’s symptoms will progress rapidly. \ \
4
Multiple system organ failure is not the most likely outcome for this patient. Extension of these ischemic areas into the brainstem is not the most likely scenario. In focal ischemia there is some degree of collateral circulation that remains. This allows for the survival of neurons and for reversal of neuronal damage after periods of ischemia. Focal ischemia is treatable because of the potential for recovery therefore the patient's symptoms will most likely resolve with treatment. There is no indication that this patient’s symptoms will progress rapidly. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ A patient with cerebral infarction is experiencing an acceleration of symptoms indicating death of cerebral tissue. The nurse would explain this acceleration as due to which pathophysiology? \ Increased concentration of sodium, chloride, and calcium in the brain cells \ Reduced ability of the macrophages to reach the site of injury \ Reduced concentration of magnesium and phosphorus in the brain cells \ Increased concentration of potassium in the brain cells \ \ Increased intracellular concentrations of sodium, chloride, and calcium are due to the lack of oxygen reaching the cerebral tissues. Without oxygen, these electrolytes accumulate leading to toxicity within the mitochondria. This leads to further cerebral tissue death. Cell death due to ischemia is not related to reduced ability of macrophages to reach the site of tissue injury. Cell death from ischemia is not related to reduced levels of phosphorus and magnesium in the injured tissue. Accelerated cerebral tissue death is not due to an increased concentration of potassium in the brain cells. \
5
0 0 0 0
0000000000 0000000000 0 \\ MC B \ The nurse is instructing a patient on stroke prevention. Which patient statement would the nurse evaluate as indicating understanding of the presence of a nonmodifiable risk factor for stroke development? \ “I have hypertension just like my mom and her family.” \ “Lots of people of my ethnicity suffer strokes.” \ “I have tried several times to quit smoking, but I just can’t seem to do it.” \ “It is going to be hard to give up eating red meat and my favorite family meals just to lower my cholesterol.” \ \ Even familial hypertension can be modified or controlled to help prevent stroke development. Ethnicity is a nonmodifiable risk factor for the development of stroke. Smoking cessation is difficult, but achievable and is a modifiable risk factor for stroke development. Hyperlipidemia is a controllable risk factor for the development of stroke. \ 0 0 0 0
6
0000000000 0000000000 0 \\ MC A+B+E \ The nurse is assessing a newly admitted older patient for modifiable risk factors for stroke development. The nurse would include teaching about which findings? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Blood pressure is consistently above 95 diastolic. \ The patient has had two recent hospital admissions to treat dehydration. \ The patient reports drinking a glass of wine with dinner every evening. \ The patient uses smokeless tobacco. \ Testing has previously indicated the patient has hypercholesterolemia. \ • Diastolic hypertension (consistent readings above 95) is a modifiable risk factor for stroke development. • Dehydration may cause dangerous lowering of blood pressure and decrease cerebral perfusion, especially in older patients. This decrease in cerebral perfusion may precipitate stroke. • Moderate alcohol use, such as one glass of wine per day, is not associated with stroke development. • While smoking does increase risk for stroke, the use of smokeless tobacco has not been shown to have the same effect. • Hypercholesterolemia is a risk factor for atherosclerosis in the cerebral vascular beds and increases risk for stroke. \ 0 0 0 0
7
0000000000 0000000000 0 \\ MC B \ The nurse is triaging a patient who just presented to the emergency department. Which cluster of assessment findings would the nurse evaluate as indicated the greatest possibility that this patient is having a stroke? \ Radicular pain, decreased deep tendon reflexes, loss of bladder control \ Dysphagia, hemianopsia, hemiparesis \ Dystonia, dysphagia, dysarthria \ Paresthesia, priaprism, loss of reflexes \ \ Radicular pain, decreased deep tendon reflexes, and loss of bladder control are more likely associated with other neurologic conditions rather than stroke. The most common cluster of symptoms seen in a stroke is dysphagia, hemianopsia, and hemiparesis. Dysphagia is common in stroke, but dystonia and dyarthria are not common findings associated with stroke. The patient having stroke may have some paresthesia, but priapism and loss of reflexes are not common initial findings. \ 0 0 0 0
0000000000 0000000000 0 \\
8
MC D \ A patient, admitted with syncope, is diagnosed with an 80% stenosis of the left carotid artery. In addition to assessing the patient's speech, the nurse should focus the assessment on the presence or development of which other findings? \ Vertigo and cranial nerve palsies \ Monocular blindness and left-sided sensory loss \ Double vision and ataxia \ Right sided hemineglect, sensory and motor loss \ \ Vertigo and cranial nerve palsies are seen with an altered vertebrobasilar circulation. The sensory-motor fibers cross, which means that the sensory and motor deficits will be on the side opposite the stroke, so left-sided sensory or motor loss will not be seen. Double vision and ataxia are seen with an altered vertebrobasilar circulation. The sensory-motor fibers cross, which means that the sensory and motor deficits will be on the side opposite the stroke. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ The nurse is planning care for a patient with a thrombotic stroke in the distribution of the right middle cerebral artery. Which nursing diagnosis is the priority for care in the acute phase of this disease process? \
9
Altered Nutrition: Less than Body Requirements \ Total Self-Care Deficit \ Decreased Intracranial Aadaptive Capacity \ Altered Cerebral Tissue Perfusion \ \ While alteration of nutrition may occur, it is not the priority in the initial treatment of this condition. The patient may experience self-care deficits, but this is not the priority for the initial treatment of this condition. In this type of stroke, increased intracranial pressure is generally not a major concern; therefore, decreased intracranial adaptive capacity is not the priority. The priority for care in the early and acute phase of a thrombotic stroke is to maintain the effect perfusion to the area near the infarct, the penumbra. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ A patient who has been admitted with symptoms of stroke is to have a CT scan. What rationale for this testing would the nurse provide to the patient and family? \ CT scans are used to determine the effectiveness of the cerebral circulation to perfuse all areas of the brain. \ The CT scan will evaluate how much brain swelling is associated with this stroke. \ The CT scan will pinpoint the exact area of the brain affected by the stroke. \
10
The CT scan can guide treatment by differentiating hemorrhagic from ischemic causes of the stroke. \ \ A CT alone will not determine the effectiveness of cerebral circulation. CT scans cannot determine the extent of brain swelling. CT scans cannot pinpoint the exact area of the brain affected by stroke, but can help to establish the anatomical region in which the stroke occurred. A CT scan will be used to rule out a hemorrhagic stroke from an ischemic stroke especially if thrombolytic therapy is being considered and to determine any areas of localized hematoma formation as a result of a hemorrhage. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ A patient is receiving tissue plasminogen activator (tPA) for the treatment of an ischemic stroke. Which nursing interventions are indicated? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Insert a nasogastric tube for nutritional support. \ Monitor for renal stone formation. \ Monitor for deterioration of neurological status. \ Reposition every 15 minutes. \ \
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• • • •
Insertion of a nasogastric tube can cause injury and should be avoided in this patient. Renal stone formation is not a complication of this medication. Deterioration of neurological status can occur as a result of bleeding or if tPA is not effective in lysing the clot. The nurse should monitor for this evolving situation. Frequent moving can increase the risk of bleeding therefore the patient should not be repositioned every 15 minutes.
\ 0 0 0 0
0000000000 0000000000 0 \\ MC B+C+D \ Which nursing interventions are indicated when providing care for a patient recovering from right carotid endarterectomy? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Position the patient supine on the left side. \ Teach the patient to hold his head for support when changing positions. \ Conduct frequent assessments for facial drooping or tongue deviation. \ Monitor blood pressure level frequently. \ Perform frequent tracheostomy care. \ • This patient should be positioned on the right side with the head of the bed elevated 30 degrees to reduce operative site edema.
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• • • •
Support prevents additional tension on the operative side which could result in bleeding and hematoma formation. The nurse should support the patient’s head when assisting with position changes and should teach the patient to do so for independent position changes. Temporary deficits in cranial nerve function may indicate stretching of these nerves. The nurse should assess for these changes that may indicate need for further intervention. Patients who have this procedure are at risk for blood pressure instability due to disruption of the carotid sinus. This procedure does not require placement of a tracheostomy.
\ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ A patient is recovering from surgery to clip an aneurysm. The nurse would anticipate managing which interventions to help prevent cerebral vasospasm? \ Infusion of packed red blood cells \ Diuretic therapy \ Oral fluid restriction \ Intravenous fluid augmentation \ \
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While support of volume is important in these patients, nothing in the scenario indicates need for packed red blood cells in this particular situation. Diuretic therapy is not indicated as it may result in hypovolemia, which is contraindicated. Oral fluid restriction will not support the desired effect of hypervolemia and hemodilution that is indicated for this patient. Postoperative complications associated with the clipping of an aneurysm include cerebral vasospasm. Vasospasm decreases perfusion to brain tissue and is prevented and treated with "triple H therapy": hypervolemia, hypertension, and hemodilution. This combination of therapies is used to augment cerebral perfusion pressure by raising systolic blood pressure, cardiac output, and intravascular volume to increase cerebral blood flow and minimize cerebral ischemia. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ A patient is diagnosed with bleeding into the cerebellum. The nurse would prepare this patient for which medical intervention? \ Angioplasty \ Immediate surgery to remove the blood from the cerebellum \ Stent placement \ Aggressive diuretic therapy to dehydrate cerebral tissues \ \
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Angioplasty is used to reverse neurological deficits caused by artherosclerotic lesions in the cerebral arteries. It is not indicated for cerebellar bleeding. Cerebellar lesions are critical because a hemorrhage or infarction can rapidly become life threatening by compromising the brainstem. Patients with large hemorrhages or infarctions are more likely to have brainstem compression and an urgent need for surgery. Stents are placed to hold arteries open. This intervention is not indicated in the face of cerebellar bleeding. Diuretic therapy will not decrease the compression of brain tissue that will result from cerebellar bleeding. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ A patient with spasticity of the upper extremity after a stroke asks why a sling is not used to support the arm. Which rationale should the nurse provide? \ The use of a sling will reinforce the spasticity and may promote a contracture. \ A sling will alter your center of balance when standing. \ The presence of a sling will make it difficult for you to assume responsibility for activities of daily living like dressing. \ You will not be able to participate in therapy if you get accustomed to your arm being in a sling. \ \ Slings limit activity and assist in forming a contracture of the shoulder that will hinder the patient's ability to participate in activities of daily living during and after recovery. Slings will also reinforce muscle spasticity. Slings do not alter the center of balance. Difficulty with assuming responsibilities of daily living is not the rationale for avoiding the use of slings. A sling could be removed for therapy sessions, but this is not the correct information to provide to this patient.
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\ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ Which assessment finding supports the nursing diagnosis of Risk for Aspiration in a patient with a cerebral vascular accident? \ Eating only foods on one side of the tray \ Refusal to allow the nurse to assist with feeding \ Absence of interest in eating or drinking \ Continuous clearing of the throat \ \ Eating foods only on one side of a tray represents a sensory perceptual problem related to the stroke. Refusal to allow the nurse to assist with feeding indicates psychosocial changes associated with stroke. Absence of interest in eating indicates an altered mood, such as depression, related to an altered neurological or health status. Continuous clearing of the throat or coughing while eating or drinking indicates that food or fluids are entering the trachea or pooling in the back of the throat. The nurse needs to stop feeding when this is noted and speech therapy should be consulted for a swallowing exam. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC C \ Which goal would the nurse rank as priority for a patient with stroke-related sensory perception alterations? \ The patient and caregivers will discuss methods to avoid hazards in the environment. \ The patient will work to increase perception of sensations. \ The patient will not experience further loss of sensation. \ The patient will understand the risk of injury related to decreased sensation. \ \ This patient has decreased ability to perceiveenvironmental hazards, so the patients and caregivers need to discussmethods to avoid injury related to perception loss. The patient has no control over the loss of sensations, so he or she is not able to work to increase perception. The patient and the nurse have no control over loss of sensation. This goal is not realistic. Thenurse cannot measure the patient’s understanding, so this goal is notcorrectly written. Even if correctly written, simply understanding the risk is not as important as taking action to avoid risk. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC C+E \ A patient had a stroke which resulted in Broca’s aphasia. What instructions should the nurse provide when teaching the family how to communicate with this patient? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Speak slowly and loudly to the patient. \ Use paper and pencil for all communication. \ Ask the patient “yes-no” questions. \ Anticipate the patient's answers and finish questions and sentences. \ Give the patient time to search for words. \ • Patients who are aphasic often complain that people shout at them as if they cannot hear. A hearing deficit is not a part of Broca’s aphasia and speaking loudly is not indicated. • Writing ability may also be impaired with Broca’s aphasia. • The patient with Broca’s aphasia is able to comprehend speech, but has difficulty responding verbally. Asking “yes-no” questions allows the patient to respond nonverbally. • The patient with Broca’s aphasia may retain some speech. It is not helpful, however, for others to complete the patient’s questions or sentences. • Allowing the patient time to search for words may result in adequate expression of needs. It may also help the patient improve word finding, which would improve speech. \ 0 0 0 0
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Chapter 18 \\ MC D \ A patient comes into the emergency department with complaints of headache, lethargy, and vomiting. He reports being hit in the head by a batted baseball during a company picnic “about 6 weeks ago.” The nurse would ask additional assessment questions regarding which condition? \ Acute subdural hematoma \ Subacute subdural hematoma \ Epidural hematoma \ Chronic subdural hematoma \ \ An acute subdural hematoma occurs less than 48 hours from injury so this is an unlikely injury pattern. Subacute subdural hematoma occurs 48 hours to 2 weeks from injury so this is an unlikely injury pattern. With an epidural hematoma, there is a brief loss of consciousness immediately following the injury, followed by an episode of being alert and oriented, and then a loss of consciousness again. The patient did not describe a loss of consciousness. There are three categories of subdural hematoma, based on time of onset of symptoms. Chronic hematoma develops greater than 2 weeks from injury. Since the patient had a head injury a few weeks prior, the nurse would have highest concern regarding a chronic subdural hematoma. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D
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\ The nurse is caring for a patient recovering from surgery to evacuate an epidural hematoma. Which assessment finding would warrant immediate collaboration with the surgeon? \ Urine output has dropped from 100 mL each hour to 60 mL per hour. \ The patient’s hand grasps are weak bilaterally. \ Fine crackles can be auscultated in the lung bases bilaterally. \ The pupil on the side of the injury has become fixed and dilated. \ \ Urine output of 60 mL per hour is considered normal and would not require emergency collaboration. If urine output continues to drop, increasing intravenous fluid administration rate may be considered. Weak hand grasps bilaterally may or may not indicate a worsening neurological condition. Bilateral weakness is not as significant for emergent conditions as is unilateral weakness. Fine crackles auscultated bilaterally in lung bases can be due several conditions, such as immobility, and is not indicative of an emergent neurological condition. Nursing care associated with epidural hematoma focuses on diligent neurological assessment. The nurse must look for sudden changes in level of consciousness and for the presence of a fixed and dilated pupil on the side of injury. These findings suggest bleeding has recurred and represents an emergent medical situation. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ The family of a patient with a concussion is concerned that the patient continues to complain of and demonstrate ongoing neurological deficits even though the injury occurred 6 weeks ago. What information should the nurse provide?
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\ Symptoms of the concussion will continue for most of the patient's life. \ The concussion might be healed; however, the patient will not recover from the symptoms. \ Symptoms of the concussion will come and go depending upon the patient's health status. \ Symptoms of a concussion can last 3 months or more. \ \ Symptoms of the concussion will not continue for most of the patient's life. The patient will recover from the symptoms. The symptoms of the concussion will not come and go depending upon the patient's health status. Since almost half of patients with concussion develop postconcussive syndromes that include symptoms similar to those on presentation to the emergency department; these symptoms may continue for 3 months or more after injury. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ A patient diagnosed with mild diffuse axonal injury is being admitted to the intensive care unit. The nurse would anticipate which assessment findings? \ The accident causing this injury occurred several weeks ago. \ There are symptoms that are similar to those demonstrated by a patient who sustained a concussion. \ There is dilation of the pupils for several hours post injury. \
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There is presence of coma that may last for an extended period of time. \ \ Mild diffuse axonal injury generally manifests quickly after the accident. Onset of symptoms weeks after injury is more likely seen in patients with chronic subdural hematoma. Mild diffuse axonal injury may contribute to post-concussive syndrome experienced by many patients following a brain concussion. Dilated pupils are not necessarily associated with any degree of diffuse axonal injury. A long term comatose state is seen in severe diffuse axonal injuries. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ A patient with a moderate diffuse head injury is demonstrating a variety of neurological symptoms. What is the priority when caring for this patient? \ Electrolyte replacements \ Maintain adequate fluid volume. \ Supporting nutritional needs \ Maintain stable cerebral perfusion pressure. \ \
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Electrolyte management is important to patients with head injury but is not the intervention of highest priority. Fluid volume management is important when caring for patients with brain injury, but is not the highest priority. Support of nutritional needs is important for all patients, but is not the intervention of highest priority for patients with brain injury. Since diffuse head injuries are not limited to a localized area, this makes them more difficult to detect and treat. Management in the acute care phase includes diligent and frequent neurological assessments and pain management. When moderate-to-severe injury is present, priority management includes interventions to lower intracranial pressure, increase cerebral perfusion pressure, and stabilize vital signs, which all contribute to an improved outcome. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ A patient is admitted with a traumatic brain injury. The nurse would anticipate participating in interventions toward which immediate goal? \ Reducing cerebral swelling \ Confining inflammation to one area \ Supporting absorption of debris from neuronal death \ Limiting ischemic tissue injury \ \
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Cerebral swelling can cause secondary injury, but this is not the immediate goal. Inflammation can cause secondary injury but this is not the immediate goal when caring for someone with TBI. Eventually the body will rid itself for debris from death of any cells, but this is not the immediate goal. The first goal in treating traumatic brain injury is to limit the primary ischemic tissue injury by aggressive prevention and treatment of hypoxia and hypotension. If efforts to meet this goal are successful, cerebral swelling neuronal death and cerebral inflammation can be limited as well. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+B+D+E \ A patient with traumatic brain injury has had placement of an intraventricular catheter (IVC). The nurse participates in level two interventions to reduce intracranial pressure (ICP) through which uses of this catheter? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Assessing of color of the cerebral spinal fluid \ Assessing of the amount of cerebral spinal fluid \ Instillation of hyperosmolar therapy via the catheter \ Draining CSF \ Directly monitoring the ICP \ • By assessing the color of the cerebral spinal fluid the nurse can identify variation from normal. These variations may indicate bleeding or infection that would increase ICP. • By using IVC measurements, the nurse can monitor amount of CSF.
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• • •
Hyperosmolar therapy is not instilled via this catheter. Therapeutic drainage of CSF via the IVC can reduce ICP. Insertion of an IVC allows for direct measurement of the ICP.
\ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ A patient with traumatic brain injury continues to have increased intracranial pressure despite conventional therapeutic interventions. The nurse would anticipate which level four intervention? \ High-dose barbiturate therapy \ High-volume intravenous fluids \ Hyperbaric oxygen therapy \ Hyperosmolar therapy \ \ Medical intervention for the treatment of increased intracranial pressure refractory to all other medical interventions may include the use of high-dose barbiturates. This intervention induces a comatose state and significantly decreases cerebral oxygen requirements. High-volume intravenous fluid administration would be more likely to increase intracranial pressure. Hyperbaric oxygen therapy is not a treatment identified to help with refractory increased intracranial pressure. Hyperosmolar therapy is used as a level two intervention, not to treat refractory increase in intracranial pressure. \ 0 0
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0 0
0000000000 0000000000 0 \\ MC D \ A patient diagnosed with a traumatic brain injury is receiving mannitol. The nurse would evaluate which findings as indicating this therapy is having its desired effects? \ ICP is increasing \ Serum sodium is 148 mEq/L \ Serum osmolality is 300 mOsm \ Osmotic gap is 12 \ \ Mannitol is given to decrease ICP. The desired response is serum sodium above 160 mEq/L. The desired effect is serum osmolality greater than 320 mOsm. The desired effect is an osmotic gap greater than 10. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC A \ A patient being treated for increased intracranial pressure from a traumatic brain injury demonstrates an increase in pressure with minimal care activity. What instruction should the nurse provide the nursing student assisting with care for this patient? \ “We will let this patient rest between his bath and changing his linens.” \ “We are going to bath this patient, get his linens changed, suction him, and do all of our other care early this morning, so he can get a long rest this afternoon.” \ “Be certain that we don’t raise this patient’s head above 10 degrees during his bath.” \ “You have to learn to suction patients with traumatic brain injury very quickly, taking no more than 30 seconds.” \ \ When simple activities result in an increase in intracranial pressure it is necessary to space care in such a way to allow the patient’s ICP to recover between events. Stacking care activities will be detrimental to this patient. The head of the bed should be elevated to 30 degrees to reduce intracranial pressure without compromising cerebral perfusion pressure. The patient should be suctioned for 10 seconds or less to reduce an increase in intracranial pressure caused by the suctioning. \ 0 0 0 0
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0 \\ MC C+E \ The admission orders for a patient with traumatic brain injury say to keep the patient’s head elevated with neutral body positioning. Which patient positioning would the nurse consider as meeting this requirement? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ The patient’s head is supported on two pillows. \ The head of the patient’s bed is elevated to 20 degrees. \ The patient’s hips are flexed at less than 90 degrees. \ The neck is in the patient’s position of comfort, which is rotated to the left. \ The patient is facing forward. \ • Placing the head on two pillows flexes the neck which violates the idea of a “neutral” position. • Typically the head of the patient’s bed should be elevated to 30 degrees. • Hip flexion of greater than 90 degrees should be avoided. • The neck should not be rotated. • INeutral positioning for the head and neck is a forward facing position. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C
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\ A patient being treated for a traumatic brain injury is febrile with a temperature of 100°F. What is the priority nursing intervention? \ Culture the patient’s urine. \ Contact the primary health care provider. \ Administer the prn antipyretic. \ Have the patient cough and deep breath more frequently. \ \ Urinary tract infection will cause increased temperature and this may be a necessary intervention. It is not, however, the primary intervention. It is important to keep the primary health care provider apprised of the patient’s condition, but this is not the primary intervention. Hyperthermia will increase cerebral metabolic rates, which will increase cerebral oxygen demands. The patient with a temperature should be provided with antipyretics or other measures to cool the body and reduce the temperature. Implementing pulmonary hygiene activities will not reduce the patient's body temperature. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+C \ The patient with traumatic brain injury has been intubated and placed on mechanical ventilation. Which nursing interventions would help optimize oxygenation? (Select all that apply.)
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Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Preoxygenate the patient prior to suctioning. \ Use very low vacuum pressure when suctioning the patient. \ Limit suction passes to 10 seconds or less. \ Suction when PaCO2 levels rise above 40 mm Hg. \ Suction the patient before and after scheduled turns. \ • To maintain adequate oxygenation during suctioning, preoxygenation is indicated. • Low vacuum pressure will not adequately remove secretions, making suctioning ineffective or necessary more often. This will not increase oxygenation. • For patients at risk for increased ICP, total suction time should be limited to no more than 10 seconds. • Increased PaCO2 level may or may not be associated with need to suction. Desired PaCO2 level is 35 to 45 mm Hg. • The patient should be suctioned as needed, but nursing activities should be spaced as much as possible. Routine suctioning both before and after scheduled turns is not likely to be necessary and would decrease oxygenation. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ A patient being treated for a traumatic brain injury is demonstrating signs of contractures as a complication associated with immobility. Which nursing intervention is indicated? \ Maintain neutral body position.
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\ Turn and reposition every 4 hours. \ Apply antiembolism stockings. \ Ensure oxygen saturation level of 92%. \ \ A neutral body position will help prevent contractures in that it avoids flexion. The patient should be turned and repositioned every 2 hours to help prevent contractures. Applying antiembolism stockings will prevent the immobility complication of deep vein thrombosis development and not prevent contractures. The patient's oxygen saturation should be maintained at 92% or higher however this will not prevent the complication of contracture. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ A patient with a traumatic brain injury is being treated for diabetes insipidus. Which finding would the nurse evaluate as indicating treatment is effective? \ Potassium level has decreased. \ Blood pressure has decreased. \ Serum sodium level is increased. \ Urine output has decreased. \
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\ Potassium level assessment is not an essential indicator of success in the treatment of a patient with diabetes insipidus. The large amount of fluid lost in diabetes insipidus causes hypotension. Continued decrease in blood pressure does not indicate that treatment is successful. Continued elevation of serum sodium level would indicate that treatment is not effective. Treatment for diabetes insipidus includes replacing intravascular volume and providing synthetic antidiuretic hormone. Evidence that a patient is improving would include a decrease in urine output with an increase in specific gravity. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B+C+D \ A patient is admitted to the emergency department after sustaining injury in a fall. Which assessment findings would the nurse immediately communicate to the emergency department physician? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ The patient is taking a sulfa drug for urinary tract infection. \ The patient has a bluish discoloration behind his ear. \ The patient’s nose is running. \ The patient’s smile is crooked. \ The patient’s tongue is lacerated. \
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• • • • •
Medication history is not the most important information during emergent assessment. Mastoid ecchymosis or “Battle’s sign” can indicate basilar skull fracture. This assessment requires immediate attention. The fluid in the patient’s nose may be cerebral spinal fluid, not mucous. This is an important assessment of basilar skull fracture. Facial nerve paralysis may indicate basilar skull fracture. Tongue laceration is important, but is not an emergent problem.
\ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A patient diagnosed with a traumatic brain injury is demonstrating signs of cerebral salt wasting. Which interventions would the nurse include in this patient’s plan of care? \ Restrict fluids. \ Restrict sodium. \ Monitor intravenous normal saline administration. \ Provide potassium chloride intravenous replacements. \ \ The patient's fluids should not be restricted since this will exacerbate the hypovolemia characteristic of this disorder. The patient should not be on a sodium restriction. Cerebral salt wasting is a state of hypovolemia so the patient should be treated with salt replacement via intravenous saline and oral salt tablets. Potassium replacements are not indicated in the treatment of this complication.
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\ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ A patient has been diagnosed with a benign brain tumor with resultant increase in intracranial pressure. The patient is confused and occasionally combative. His wife expresses concern about how to tell their two young sons. Which nursing diagnosis will guide initial selection of nursing interventions? \ Ineffective Breathing Pattern \ Decreased Intracranial Adaptive Capacity \ Impaired Physical Mobility \ Risk for Aspiration \ \ There is no assessment information that indicates this patient’s breathing pattern is altered. Increased ICP is a result of decreased ability of the intracranial protective mechanisms to compensate for the increase in brain volume caused by the presence of a mass. There is no information given that supports the nursing diagnosis of Impaired Mobility. There is no current evidence that this patient is at risk for aspiration. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC A+B+C+E \ A patient is brought to the hospital after being found in the floor at the bottom of a flight of stairs. The patient has an obvious depressed skull fracture and is bleeding from her right ear. Initially, the nurse assesses the patency of the patient’s airway, her breathing, and the rate and rhythm of her pulse. What assessments and questions will be part of the nurse’s secondary survey? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ “How did the injury occur?” \ “What care was provided at the site of the injury?” \ “Has anything like this ever happened before?” \ Blood pressure measurement will occur. \ A general systems assessment will occur. \ • The most obvious answer to this question is that the patient fell down the stairs, but this may be an incorrect assumption. The patient may have been injured in some other manner and it was a coincidence that it occurred at the bottom of a flight of stairs. Determining mechanism of injury is a part of the secondary survey. • The nurse should determine what care has already been provided. • Comorbid conditions or previous history is a part of the secondary survey. • Blood pressure measurement is part of the primary survey. • The general systems assessment is part of the secondary survey. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC B \ A patient being treated for a traumatic brain injury for 3 days begins to seize. Which intervention is the nurse’s priority? \ Administer fosphenytoin (Cerebyx) 4 mg per kg of patient body weight. \ Keep the patient safe and maintain the airway. \ Lower the head of the bed. \ Initiate a recording of the patient’s cardiac rhythm. \ \ The first medication administered is more likely to be a benzodiazepine. Medication administration is not the highest priority. Priorities for the care of a patient with a traumatic brain injury that begins to demonstrate seizure activity include keeping the patient safe and maintain airway, breathing, and circulation. Lowering the head of the bed may or may not be indicated and is not the priority intervention. Seizure activity will interfere with an accurate recording of the patient’s cardiac rhythm. \ 0 0 0 0
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0000000000 0000000000 0
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Chapter 19 \\ MC A \ A patient is admitted for a lumbar laminectomy. The nurse reinforces teaching that which portion of the vertebra will be removed? \ Roof of the arch \ Cartilage inside the vertebra \ Pedicles that attach the arch to the body \ Spinous process \ \ Each vertebra consists of a body that is anterior and an arch that is posterior. The arch section is composed of two pedicles that attach the arch to the body and two laminae that form the roof of the arch. Cartilage is not a part of the vertebra. The pedicles attach the arch to the body of the vertebra. This is not the site of a laminectomy. The spinous process is located at the rear of the vertebrae. This is not the site of the laminae. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ A patient is diagnosed with a fracture of anterior and posterior columns of three cervical vertebrae. How would the nurse describe this injury? \
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As life threatening \ As stable \ As minor \ As unstable \ \ In itself, this injury is not life threatening. If secondary damage occurs, it could become life threatening. This injury is significant and would not be considered stable. Damage to two columns of three vertebrae is not a minor injury. The spine is conceptualized as having three columns: an anterior column that includes the anterior part of the vertebral body, a middle column that houses the posterior wall of the vertebral body, and a posterior column that includes the vertebral arch. If two or more of these columns are damaged, the injury is considered to be unstable. The patient has an unstable spinal cord injury. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ A patient is diagnosed with damage to the spinothalamic tract of the spinal cord. Which assessment finding would the nurse attribute to this damage? \ The patient reports an unusual amount of pain. \ Muscle spasms are occurring in the patient’s right leg. \ The patient has ataxia. \
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The patient is complaining of vertigo. \ \ The spinothalamic tract originates in the spinal cord, crosses over with segments of entry and ascends to the thalamus in the brain. It transmits pain and temperature. The patient with damage to the spinothalamic tract of the spinal cord will manifest an unusual amount of pain. The corticospinal tract originates in the brain and crosses over in the brainstem to innervate the opposite side of the body. It transmits motor activity, which would be the cause for the muscle spasms in the patient. The posterior horn contains axons from the peripheral sensory neurons and is responsible for position sense. Damage to this portion of the cord could manifest as ataxia. The posterior horn contains axons from the peripheral sensory neurons and is responsible for position sense. Damage to this portion of the cord could manifest as vertigo in the patient. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ The nurse is caring for a patient with a fractured sacrum. The nurse would assess for which changes as a result of this fracture? \ Altered sympathetic responses \ Alteration in pain responses \ Alteration in position sense \ Altered parasympathetic responses \ \
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The sympathetic nervous system is located in the gray matter of the first thoracic through the second lumbar section of the cord. The patient does not have an injury to this region. Alteration in pain responses would be seen with damage to the spinothalamic tracts. Alteration in position sense would be seen with damage to the posterior column tracts. The parasympathetic nervous system originates in a group of neurons located in the brainstem and in a group located between the second and fourth sacral segments of the cord. The patient with a fractured sacrum could experience alterations in the parasympathetic responses. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ A patient is diagnosed with central cord syndrome. Which assessment finding would the nurse anticipate from this injury? \ Complete paralysis of lower extremities \ Loss of bladder and bowel function \ Motor function intact in upper extremities \ Variable motor function in lower extremities \ \ Complete paralysis of lower extremities does not result from central cord syndrome. Patients with central cord injury typically retain some bladder and bowel function. The upper extremities will demonstrate spastic paralysis and not an intact upper extremity motor status. In central cord syndrome the patient will demonstrate variable motor function of the lower extremities. \
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0 0 0 0
0000000000 0000000000 0 \\ MC D \ A patient comes into the emergency department after being injured in an automobile crash in which a semitruck hit her car from behind. The nurse will assess this patient for findings associated with which type of injury? \ Ankylosing spondylitis \ Axial loading \ Hyperflexion \ Hyperextension \ \ Ankylosing spondylitis can cause a nontraumatic hyperextension injury. Axial loading injury, or compression fracture, is caused by a vertical force along the spinal cord and is seen after diving into shallow water or jumping from tall heights and landing on the feet or buttocks. Hyperflexion injury is most often caused by a sudden deceleration of the motion of the head or a head-on collision. Hyperextension injuries are caused by a forward and backward motion of the head as seen in rear-end collisions. With this injury, the anterior ligaments are torn and the spinal cord is stretched. A mild form of hyperextension injury is the whiplash injury. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC B \ A patient was admitted this morning after sustaining an acute spinal cord injury. This afternoon his neurological assessment shows some deterioration of function. How would the nurse explain this to the patient’s family? \ “Injured cells release potassium that causes destruction of the covering of nerves in the area injured.” \ “Decreased blood flow increases the size of the affected area.” \ “The body’s inflammatory response has caused blood vessels in the area to dilate.” \ “Injury to nerves impairs the body’s healing responses.” \ \ Calcium is released in a spinal cord injury and is responsible for demyelization. Blood flow to the spinal cord decreases immediately on injury as a result of hypotension and vasospasm induced thrombosis. Thrombi in the microcirculation impede blood flow. The zone of ischemia can spread if perfusion to the cord is not restored. Dilation of vessels would improve blood flow to the region and would not result in deterioration of neurological condition. This statement is not true. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC B \ A patient suffered an acute T6 spinal cord injury. Family has been told that the patient will likely be paraplegic. However, this morning the patient has limited use of his arms. How should the nurse explain this change? \ “There must be a second area of fracture higher in the spine.” \ “The spinal cord is probably swollen above the area of original injury.” \ “These changes are due to the low blood pressure he had before he got to the hospital.” \ “This is a sign that he is dehydrated and will go away as we give him more IV fluids.” \ \ It would be premature to suggest that a second area of injury exists. In a spinal cord injury, as the cord swells within the bony vertebrae, edema moves up and down the cord. A patient may exhibit symptoms as a result of the edema and not the initial injury. Because edema can extend the level of injury for several cord segments above and below the affected level, the extent of injury may not be determined for several days, until after the cord edema has resolved. There is no evidence that this change in neurological status is associated with prehospital hypotension. This change is not likely due to hypovolemia. \ 0 0 0 0
0000000000 0000000000 0 \\
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MC C \ A patient is admitted with a fractured mandible and several fractured ribs. Which priority intervention would the nurse anticipate? \ Providing pain medication \ Determining lung function by chest x-ray \ Maintaining spinal cord injury precautions \ Stabilizing the rib fractures \ \ Provision of pain medication is indicated for this patient, but it is not the highest priority. It is important to determine the status of this patient’s lung function but this is not the intervention of highest priority. Since a spinal cord injury should be suspected in a patient with maxillofacial injury and clavicle or upper rib fractures, the patient should be maintained on spinal cord injury precautions until the injury has been ruled out. It is important to stabilize rib fractures, but this is not the intervention of highest priority. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ It is suspected that a patient admitted with spinal cord injury has severe cord injury. The nurse would prepare the patient for which diagnostic test to determine the extent of this edema? \ Angiography
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\ Somatosensory-evoked potentials \ CT scan \ MRI \ \ Angiography is useful for patients with complex cervical spine fractures involving subluxation, extension into the foramen transversarium, or upper C1 to C3 fractures. Somatosensory-evoked potentials are used to establish a functional prognosis after resolution of spinal cord edema. CT scans are not the most sensitive tests for determination of cord edema. The MRI has greater sensitivity than a CT scan for diagnosing contusions, hematomas, and edema. The diagnostic test that would be the most helpful for this patient would be the MRI. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ A patient is admitted with a spinal cord injury located at the 4th thoracic vertebral area. When assessing this patient, the nurse will expect to find sensory deficits at which anatomical area? \ Anterior thigh \ Nipple line \ Umbilicus \ Groin
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\ \ Innervation to the anterior thigh is at the 2nd lumbar vertebra. The nerve root for the 4th thoracic vertebra is approximately at the level of the nipple line. The nerve root for the umbilical region is the 10th thoracic vertebra. Innervation to the groin is at the 1st lumbar vertebra. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B+E \ A patient is diagnosed with a spinal cord injury located at the 1st and 2nd thoracic vertebra. The nurse will expect to find which deep tendon reflexes affected by this injury? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Supinator \ Patellar \ Triceps \ Biceps \ Achilles \ • The supinator reflex originates at the 6th cervical vertebra, which is above the area injured. • The patellar reflex originates at the 3rd lumbar vertebra. The patient has an injury at the 1st and 2nd thoracic vertebra, which means reflexes below this region will be affected.
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• • •
The triceps reflex originates at the 7th cervical vertebra, which is above the injured area. The biceps reflex originates at the 5th cervical vertebra which is above the injured area. The Achilles reflex originates at S1. The patient has an injury at the 1st and 2nd thoracic vertebra which means reflexes below this region will be affected.
\ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A patient diagnosed with several fractured vertebra is having surgical stabilization. The nurse would reinforce which information about this surgery? \ “You will be required to wear a hard cervical collar for several months after the surgery.” \ “After surgery you will be fitted for a halo device.” \ “The fusion generally requires insertion of rods to stabilize your spine internally.” \ “This is the first of a series of surgeries you will require.” \ \ A hard cervical collar is a manual fixation device. Whether this device is required and how long it is required is variable and is likely not known prior to surgery. The patient may or may not require a halo device. Surgery is reserved for patients not sufficiently aligned with manual stabilization. Typically, spinal segments are fused, spinal canal is decompressed, and rods are inserted to stabilize thoracic spinal injuries. There is no indication that this patient will require a series of surgeries. \ 0
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0 0 0
0000000000 0000000000 0 \\ MC D+E \ What interventions will the nurse include in the plan of care for a patient with a newly applied halo device and vest? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Assess motor and sensory function every shift. \ Have the patient hold onto the halo struts during turns and repositioning. \ Keep the pins and traction bars slightly loose to prevent pressure ulcers. \ Tape a halo vest wrench to the front of the vest. \ Use a moist cloth to clean the skin under the vest. \ • Motor function and sensation should be assessed every 2 to 4 hours. • Pulling on the struts can disrupt the device integrity and possible result in spinal cord damage. Having the patient hold onto the struts would likely cause stress to the device. • The pins and traction bars should be firmly attached to provide stabilization. • A halo vest wrench is to be taped to the front of the vest to be able to remove the vest in the event the patient needs to receive cardiopulmonary resuscitation. • The vest is not removed for bathing, so a moist cloth is used to clean the skin under the vest. \ 0 0 0
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0
0000000000 0000000000 0 \\ MC B \ A patient recovering from surgery to stabilize a lumbar spinal cord injury is fitted with a clam shell brace. How would the nurse explain the purpose of this brace? \ “Wearing this brace will eliminate the need for further surgery.” \ “You need to wear this device to support your surgical site.” \ “This brace will maximize your range of motion.” \ “You need to wear this brace to protect your surgical incision.” \ \ It is premature to assure the patient that wearing a brace will eliminate need for further surgery. A clam shell brace after surgery to stabilize a lumbar spinal cord injury is prescribed to specifically support the surgical site. Stabilization devices do not necessarily maximize the patient's range of motion but rather limit range of motion. The brace is not prescribed for the purpose of protecting the surgical incision. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC A+B \ A patient who injured his cervical spine was first taken to the emergency department of a small hospital where methylprednisolone (MPSS) was started intravenously. The patient has now been transferred to a neurointensive care unit in a large hospital. What interventions would the nurse in the receiving agency include in the plan of care? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Assess the patient’s breath sounds every 2 hours. \ Check all stools for blood. \ Keep the patient NPO. \ Insert an indwelling urinary catheter so accurate intake and output can be measured. \ Monitor for the development of hypotension. \ • Steroid use is related to increased risk for pneumonia. The nurse should increase surveillance for changes in breath sounds. • Use of steroids increases the patient’s risk for gastrointestinal bleeding. The nurse should check all stools, vomitus, or nasogastric drainage for the presence of blood. • Use of steroids does not require the patient to be NPO. • Use of steroids does not signify need for I&O measurement. • Steroid use does not increase risk for hypotension. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC A+C \ A patient has a spinal cord injury at C6–T1. During his bath the nurse notes piloerection. What nursing interventions are indicated? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Ask the patient about the presence of a headache. \ Ignore the occurrence and continue with the bath. \ Determine if the patient’s indwelling urinary catheter tubing is twisted. \ Lower the head of the patient’s bed. \ Cover the exposed portions of the patient’s body with a warm bath blanket. \ • Piloerection and headache may be indicators of autonomic dysreflexia. • Piloerection may indicate a serious complication and should not be ignored. • Occlusion of the tubing from an indwelling urinary catheter may result in a full bladder, which is sufficient noxious stimulus to trigger a serious complication. Simply untwisting the tubing and allowing the bladder to drain may reverse this complication. • The head of the bed should be raised. • If this patient is experiencing a complication of spinal cord injury, piloerection is not related to cool environment. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC D \ A patient is admitted with a possible 2nd cervical vertebra injury. The nurse prepares for which most likely method to manage the patient’s respiratory system? \ Incentive spirometer every hour while awake. \ Quad coughing \ Humidified oxygen via face mask \ Intubation and mechanical ventilation \ \ Incentive spirometer is not the most likely method of managing this patient’s respiratory system. Quad coughing is not the most likely method for managing this patient’s respiratory system. Humidified oxygen via face mask will not be sufficient to manage this patient’s respiratory system. Patients with 1st or 2nd cervical injuries will require mechanical ventilation because of loss of phrenic nerve enervation to the diaphragm. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \
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A patient in the intensive care unit with a spinal cord injury is receiving intravenous fluid therapy for hypotension. Which finding would the nurse evaluate as indicating the therapy has had its desired effect? \ Normal temperature \ Systolic blood pressure of 85 mm Hg \ Systolic blood pressure of 120 mm Hg \ Mean arterial pressure of 88 Hg \ \ Temperature is not a good way to assess for therapeutic effect in this intervention. Systolic pressure of 120 mm Hg may be difficult to obtain without administering so much fluid that the patient develops pulmonary edema. Judicious use of intravenous fluids is required when treating hypotension because too much fluid can precipitate pulmonary edema. However, medications might be needed to maintain adequate cardiac output and tissue perfusion. Current guidelines recommend that the mean arterial pressure be maintained 85 to 90 mm Hg for the first 7 days post–spinal cord injury. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+B+D+E \ The nurse is helping a patient who is recovering from a 2nd to 4th thoracic vertebral injury with transferring from bed to sitting in a chair. Which nursing interventions are indicated to prevent the onset of orthostatic hypotension? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected.
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\ Apply a binder around the patient’s abdomen. \ Be certain the patient is wearing compression stockings. \ Swing the patient’s legs to the side of the bed in one swift, smooth movement. \ Gradually raise the head of the bed. \ Allow the patient to sit on the side of the bed with feet dangling before moving to a chair. \ • The patient should be wearing an abdominal binder when moving from a lying to a sitting position. • The patient should be wearing compression hose prior to moving from a lying to a sitting position. • The patient will likely not tolerate a rapid movement to a sitting position as is indicated by this action. • Chronic peripheral vasodilation causes orthostatic hypotension, particularly for patients with injuries at T6 or above. Chronic vasodilation in combination with a quick position change results in a loss of consciousness. Therefore, initial attempts to mobilize the patient are done slowly. Gradually raising the head of bed is indicated. • Allowing the patient to side on the side of the bed with feet dangling until the blood pressure accommodates a sitting position will help prevent orthostatic hypotension. \ 0 0 0 0
0000000000 0000000000 0
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Chapter 20 \\ MC C \ A patient is diagnosed with esophageal reflux. The nurse explains to the patient that there is an impairment in which structure? \ Fundus \ Duct of Wirsung \ Cardiac sphincter \ Antrum \ \ The fundus is part of the stomach and is not involved in esophageal reflux. The Duct of Wirsung is the main pancreatic duct and is not involved in esophageal reflux. The lower esophageal sphincter, also known as the cardiac sphincter, has high resting muscle tone at the distal end, which prevents gastroesophageal reflux. The patient diagnosed with esophageal reflux would have an impairment of this sphincter. The antrum is part of the stomach and is not involved in esophageal reflux. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A patient is diagnosed with a gastric ulcer located on the antrum. The nurse is aware that the ulcer may also affect the function of which adjacent structure?
1
\ Sphincter of Oddi \ Acinus \ Pyloric sphincter \ Lower esophageal sphincter \ \ The Sphincter of Oddi is located in the pancreas and is not anatomically close to the antrum. The acinus is the functional unit of the pancreas and is not anatomically close to the antrum. The antrum is located at the base of the stomach, ending at the pyloric sphincter. Depending upon the extent of the ulcer, the function of the pyloric sphincter may be affected. The lower esophageal sphincter is located at the gastroesophageal juncture and is not the structure closest to the antrum. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+B \ A patient has been diagnosed with deficiency of the hormone cholecystokinin (CCK). The nurse would expect this patient to have difficulty digesting which nutrients? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Fats \ Proteins
2
\ Carbohydrates \ Vitamins \ Minerals \ • CCK is secreted in response to the presence of fat in the duodenum. • CCK is secreted in response to the presence of protein in the duodenum. • Gastric inhibitory peptide (GIP) is secreted in response to the presence of carbohydrates. • Vitamins are not digested, but are absorbed from or synthesized by the GI tract. • Minerals are not digested, but are absorbed from the GI tract. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ A patient is demonstrating hepatic encephalopathy due to buildup of ammonia. The nurse anticipates intervention to support which function of the liver? \ Protein metabolism \ Vitamin synthesis \ Fat metabolism \ Carbohydrate metabolism \ \
3
The liver is responsible for synthesis of the majority of the body's proteins and for degrading amino acids for energy use through the process of deamination. The major by-product of deamination is ammonia, which is toxic to tissues. The liver is responsible for converting ammonia into urea, a nontoxic substance. Urea diffuses from the liver into the circulation for urinary excretion. When liver failure occurs, ammonia cannot be converted to urea and levels rapidly build in the blood. If the liver is not synthesizing vitamins, the patient would demonstrate findings related to vitamin A, D, E, and K deficiency. Fat metabolism is not related to the development of hepatic encephalopathy or a buildup of ammonia. Alterations in ability to metabolize carbohydrates would not result in hepatic encephalopathy, but rather in changes such as serum glucose levels. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ A patient is diagnosed with duodenal ulcers caused by a highly acidic gastrointestinal environment. The nurse explains that this condition may be related to deficiency in which hormone? \ Secretin \ Lipase \ Elastase \ Amylase \ \
4
The release of secretin is stimulated by a drop in the intestinal mucosa pH to less than 4.5. When intestinal pH becomes too acidic, secretin stimulates the pancreas to secrete large quantities of bicarbonate and water. Bicarbonate raises the intestinal pH, which protects the mucosa. Lipase is a pancreatic enzyme that helps break down fats. Elastase is a pancreatic enzyme that helps to break down proteins. Amylase is a pancreatic enzyme that splits glycogen into disaccharides. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B+C+E \ A patient is diagnosed with a splenic artery aneurysm. The nurse would assess for dysfunction in which organs? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Gallbladder \ Stomach \ Pancreas \ Transverse colon \ Spleen \ • The gallbladder is supplied by the cystic artery. • The splenic artery supplies the stomach, so disruption would possibly result in dysfunction of the stomach.
5
• • •
The splenic artery supplies the pancreas, so disruption would possibly result in dysfunction of the pancreas. The superior and inferior mesenteric arteries supply the transverse colon. The spleen is supplied by the splenic artery, so disruption would possibly affect splenic function.
\ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ The nurse is caring for a patient with an injury to cranial nerve X. Which assessment finding would the nurse attribute to that injury? \ Rectal bleeding \ Dry mouth \ A metallic taste in the mouth \ Decreased bowel sounds \ \ Rectal bleeding is not associated with cranial nerve X dysfunction. Salivary secretion is not controlled by cranial nerve X. Ability to taste is not controlled by cranial nerve X. Parasympathetic innervation to the gastrointestinal tract comes from cranial nerve X, the vagus nerve. Parasympathetic stimulation of the organs within the gastrointestinal system is responsible for stimulating the normal functions of the gastrointestinal system, such as processing of food, propulsion of contents through the gastrointestinal tract, and absorption of nutrients. Injury to cranial nerve X may result in decreased bowel sounds. \
6
0 0 0 0
0000000000 0000000000 0 \\ MC C \ A patient tells the nurse that after eating some food that tasted “off” he experienced a severe stomachache. However, after a few hours the discomfort was gone and he felt fine. Which information should the nurse consider when formulating a response to this report? \ Decreased production of mucous in the duodenum likely propelled the organism through the system in a few hours. \ The duodenal pH of 4.0 killed the offending organism. \ The acidic stomach environment likely killed any offending organisms in the ingested food. \ Chyme blocked the offending organism from attaching to the walls of the GI tract. \ \ The production of mucus provides a protective barrier, which prevents potential pathogens from adhering to the epithelial surface. The pH of the small intestine must remain at 7.0 or greater to allow the pancreatic proteolytic enzymes to be active. The acidic environment of the stomach (pH lower than 4.0) is hostile to most pathogens. Chyme is partially digested food. The presence of chyme does not block pathogens from adhering to the walls of the GI tract. \ 0 0 0
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0
0000000000 0000000000 0 \\ MC B \ A patient with a history of tonsillectomy and appendectomy is admitted with a possible infection. Which etiological factor would the nurse select for the nursing diagnosis Infection, Risk for? \ Decreased prostaglandin production \ Impairment of gut-associated lymphoid tissue \ Decrease in mucosa-associated lymphoid tissue \ Degradation of superficial epithelial cells \ \ Prostaglandins protect the mucosal barrier of the GI tract by stimulating secretion of bicarbonate, increasing blood flow to the mucosa, and stimulating mucus secretion. Removal of the tonsils and appendix would not affect production of prostaglandins. Immunologic defense is provided by the gut-associated lymphoid tissue. This tissue includes the tonsils, lymph tissue within the intestinal wall, and the appendix and produce immunoglobulins and immunocytes that migrate to the gastrointestinal tract, tear ducts, and salivary glands to defend against pathogen penetration of epithelial surfaces. Mucosa-associated lymphoid tissue is found in the respiratory system, urogenital system, and conjunctiva but are primarily located in the digestive system and the small bowel. Removal of the tonsils and appendix would not decrease the amount of these tissues. Superficial epithelial cells secrete mucous and bicarbonate, which helps to protect the lining of the GI tract, but removal of the tonsils and adenoids would not affect these cells. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC C \ The nurse is planning care for a patient at risk for developing an infection because of an interruption in the intestinal mucosa. Which patient history would the nurse evaluate as most likely to exacerbate this risk? \ The patient has a history of type 2 diabetes mellitus. \ The patient was hospitalized 2 months ago for congestive heart failure. \ The patient was hospitalized for treatment of severe trauma sustained in a motor vehicle accident. \ The patient has been treated for hypertension for the last 10 years. \ \ A history of type 2 diabetes mellitus is not the most significant factor to consider in this patient’s history. Congestive heart failure is not known to cause interruption in the intestinal mucosa. Risk factors for disruption of intestinal mucosa include shock, trauma, intestinal obstruction, protein malnutrition, and total parenteral nutrition. History of treatment for hypertension is not a significant risk factor for the development of mucosal disruption. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC C \ A male patient admitted with a gastrointestinal bleed and a hematocrit level of 40% receives fluid resuscitation. In a few hours, the hematocrit level drops to 32%. How should the nurse evaluate this finding? \ It is very likely that this patient has underlying renal disease. \ There must be an undiagnosed second site of bleeding. \ The patient is experiencing hemodilution caused by fluid resuscitation. \ Efforts to stop the bleeding have not been successful. \ \ Alterations in the blood urea nitrogen level could indicate underlying renal disease. This drop is hematocrit level is not unexpected, so a secondary source of bleeding is not a likely causative factor. During acute hemorrhage, the hematocrit may not reflect the volume of blood loss. Prior to fluid resuscitation, the hematocrit may be higher than expected as a result of hemoconcentration from volume loss. The hematocrit may fall precipitously after aggressive fluid resuscitation because of hemodilution effects. It takes up to 72 hours for the hematocrit to equilibrate following a sudden loss of blood. This change in hematocrit is not unexpected, so continued bleeding is not a likely reason for the result. \ 0 0 0 0
0000000000 0000000000 0 \\ MC
10
C \ A patient with liver disease has a decline in his previously elevated urobilinogen levels. The nurse would anticipate further testing for which condition? \ Overhydration \ Gastrointestinal bleeding \ Worsening of the liver failure \ Protein catabolism \ \ Overhydration will not result in dropping urobilinogen levels. Decrease in a previously increased urobilinogen level does not indicate gastrointestinal bleeding. Urobilinogen is measured as a sensitive test for hepatic damage. It may increase before serum bilirubin levels increase. In early hepatitis or mild liver cell damage, the urine urobilinogen level will increase despite an unchanged serum bilirubin level. However, with severe liver failure, the urine urobilinogen level may start to decrease because less bile will be produced. A drop in the level of a previously increased urobilinogen does not infer that protein catabolism is occurring. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D+E \ A patient was admitted with acute abdominal and back pain. Which test results would the nurse evaluate as indicating additional testing for acute pancreatitis is likely? (Select all that apply.)
11
Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Secretin stimulation test \ Hematocrit level \ Hemoglobin level \ Serum lipase level \ Amylase \ • The secretin stimulation test helps determine pancreatic activity but will not necessarily aid in the diagnosis of acute pancreatitis. • Hematocrit level is not used to help diagnose the presence of acute pancreatitis. • Hemoglobin level is not used to help diagnose the presence of acute pancreatitis. • Lipase levels in the serum will be elevated if pancreatic inflammation is present. Lipase is currently the best enzyme to identify acute pancreatitis. • Amylase is often used as a screening test for pancreatitis. Elevated amylase levels indicate the need for additional testing as they can be elevated for multiple reasons. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A patient has just received an upper GI series diagnostic test. What nursing intervention is indicated? \ Keep on bed rest for 6 hours postprocedure. \ Monitor urine output.
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\ Administer the prescribed cathartic. \ Keep the patient on nothing by mouth status. \ \ It is not necessary to keep a patient on bed rest after an upper GI series. Monitoring urine output is not particularly indicated after this diagnostic test. An upper GI series with contrast medium is a type of x-ray that allows visualization of the GI tract in order to diagnose tumors, masses, hernias, obstructions, ulcers, fistulas, or diverticular disease. Because the patient ingests a contrast material prior to the actual x-ray, it is important to assist the patient in expelling the contrast medium after the test. The nurse should administer the prescribed cathartic to aid in the expelling of the barium. Maintaining NPO status is not necessary unless findings from the examination indicate so. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D+E \ A patient is admitted with acute abdominal pain. Which preexisting conditions would prevent this patient from having a nuclear scan to diagnose the cause of the abdominal pain? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ The patient is being treated for congestive heart failure. \ The patient has severe rheumatoid arthritis. \ The patient had an appendectomy 6 months ago. \
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The patient has bilateral titanium hip replacements \ The patient had a similar scan done last week. \ • Congestive heart failure is not a contraindication for nuclear scanning. • Rheumatoid arthritis is not a contraindication for a nuclear scan. • History of appendectomy is not a contraindication for a nuclear scan. • A nuclear scan allows visualization of organs, gastrointestinal motility, and bleeding. A nuclear scan is contraindicated in patients with metal implants. • Recent nuclear exposure is a contraindication to nuclear scanning. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C+E \ The nurse is assessing a patient admitted with acute abdominal pain. Which information would the nurse associate with changes in the gastrointestinal system? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ The patient is taking more of the proton pump inhibitor than is typically indicated for gastroesophageal reflux. \ The patient reports that his mother was just diagnosed with renal failure. \ The patient reports an itchy red rash over his thigh that has been present for several weeks. \ The patient works as an insurance agent. \ The patient often repeats himself and seems confused at times.
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\
• • • • •
Taking more or less of a medication associated with gastrointestinal symptoms may indicate that the patient’s symptoms are changing. There is not enough information to determine if the renal failure suffered by the patient’s mother is familial or if it is associated with gastrointestinal changes. Skin disturbances can be associated with gastrointestinal ailments. Occupation is not directly connected with gastrointestinal ailments. Lack of mental clarity is always an important consideration during assessment. If the patient is not able to answer questions correctly, information collection may not be valid.
\ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ The nurse has completed the focused history for a patient admitted with acute abdominal pain. How should the nurse continue with the assessment? \ Palpate for abdominal masses or tenderness. \ Auscultate for bowel sounds. \ Inspect the abdomen. \ Percuss for abdominal tones. \ \
15
Palpation should not be the first step of physical examination of the abdomen. Auscultation is not the first step of the physical examination of the abdomen. A focused abdominal assessment should begin with inspection, followed by auscultation, percussion, and palpation. During inspection, the abdomen should be examined for abnormal contour, alteration in skin, pulsations, and peristalsis. Percussion is not the first step of the physical examination of the abdomen. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A patient is in congestive heart failure due to damage from a myocardial infarction. Which gastrointestinal manifestation would the nurse expect on assessment? \ Severe stomach cramping \ Decreased bowel sounds \ Enlargement of the liver \ Esophageal reflux \ \ Stomach cramping is not an expected effect of congestive heart failure. Congestive heart failure does not result in decreased bowel sounds. The liver is a fluid reservoir. During periods of high fluid volume in the right heart, the liver is able to accept approximately one liter of excess volume by distending. Esophageal reflux is not directly correlated with congestive heart failure. \
16
0 0 0 0
0000000000 0000000000 0 \\ MC A \ A patient will undergo an elastase test for pancreatic function. The nurse will collect which sample? \ Stool \ Serum \ Saliva \ Urine \ \ The elastase test requires a stool sample. The elastase test does not require a serum sample. The elastase test does not require a saliva sample. The elastase test does not require a urine sample. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC A \ A patient is scheduled to have sublingual capnometry. How would the nurse explain the purpose of this test? \ This test will help us learn about the blood flow to your gastrointestinal organs. \ This test will monitor the acidity of your gastric acids. \ This test will determine if your pancreas if functioning. \ This test will help us determine if you have an infection in your gastrointestinal tract. \ \ Sublingual capnometry uses a special probe to provide an alternative to invasive gastric tonometry monitoring of splanchnic perfusion. Sublingual capnometry is not associated with acidity of gastric acids. Sublingual capnometry is not associated with pancreatic function. Sublingual capnometry is not associated with discovering infections. \ 0 0 0 0
0000000000 0000000000 0
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Chapter 21 \\ MC A \ Which assessment finding would the nurse evaluate as most likely occurring due to a lower gastrointestinal bleed? \ Hematochezia \ Hematemesis \ Dark brown guaiac positive stools \ Melena \ \ Hematochezia or bloody diarrhea is the most common sign of lower gastrointestinal bleed. However, 10% of patients with severe hematochezia have an upper GI source of bleeding. Hematemesis or vomiting of bright red blood or blood that looks like coffee grounds generally indicates bleeding from a source proximal to the ligament of Treitz in the upper GI tract. Dark brown stools are normal and would not be thought to contain blood. When these stools test positive the stool is considered to contain occult blood. Occult blood indicates bleeding is occurring somewhere in the GI tract and is not limited to lower GI bleeding. Melena or black, tarry, foul-smelling stools generally indicate an upper GI bleed. The small intestine or the right colon may be the source, but this is not as likely a sign of lower GI bleed as another type of stools. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C
1
\ A patient admitted with fatigue, dyspnea, and a hemoglobin level of 8.6 mg/dL tells the nurse that he occasionally has dark, smelly stools but they "go away" in a few days. The nurse would conduct additional assessment for which most common cause of this history? \ Inability to absorb protein \ Lower gastrointestinal bleed \ Chronic gastrointestinal bleed \ Upper gastrointestinal bleed \ \ There is no indication that this patient’s history relates to inability to absorb protein. There is a different, common reason for these findings. Typically, lower GI bleeds present with red or bright red stools. The patient with a chronic gastrointestinal bleed may exhibit recurrent episodes of melena or hematochezia. Patients may have no signs or symptoms of acute blood loss but may present with manifestations associated with anemia, such as fatigue, dyspnea, and low red blood cell count and hemoglobin. While this patient may have an upper GI bleed, there is a more specific answer to this question. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C+D \ A patient diagnosed with gastric ulcer is prescribed sucralfate (Carafate). Which patient teaching should the nurse provide? (Select all that apply.)
2
Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ “Watch for systemic effects such as hypotension.” \ “Plan to take this medicine for the rest of your life.” \ “Increase your water intake to 8 to 10 glasses per day.” \ “Do not take this medication within 30 minutes of other drugs.” \ “Rest quietly in an upright position for at least 30 minutes after taking this medication.” \ • The effects of sucralfate are almost exclusively local. • Sucralfate is used for short-term management of ulcers. • A major adverse effect of sucralfate is constipation. Increasing fluid intake is indicated. • A portable chest x-ray will be taken, but this is not the priority intervention. • There is no reason to rest after taking this medication. Physical exercise should be increased. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ A patient admitted with possible ulcer disease tells the nurse that he has frequent nausea and vomiting and “just can’t eat.” The nurse would suspect this patient’s ulcer to be in which area? \ Colon \ Gastric \ Duodenal
3
\ Esophageal \ \ Ulcers in the colon or ulcerative colitis would not manifest with nausea and vomiting. Gastric ulcers often manifest with nausea, vomiting, anorexia, and weight loss. Duodenal ulcers may cause pain, but nausea, vomiting, and anorexia are findings associated with ulcers in a different location. Esophageal ulcers generally manifest with pain that makes swallowing difficult. However, those findings associated with nausea and vomiting suggest an ulcer in a different position. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+C \ A patient is hospitalized with recurrent gastric ulcers. Which education should the nurse provide? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ “You may need to consider treating your chronic headaches with some therapy besides NSAIDs.” \ “You should try to avoid eating spicy foods.” \ “It is time for you to seriously consider smoking cessation.” \ “You should contact a personal trainer to get your body in shape.” \ “Take the prescribed antibiotic until you are pain free.” \
4
• • • • •
Chronic NSAID ingestion increases risk for ulcer disease. Spicy foods are no longer considered causative of ulcer disease. Smoking increases risk for ulcer disease. Being out of physical shape does not increase risk for ulcer disease. The prescribed antibiotic should be taken until the prescription is completed, not discontinued when the patient feels better.
\ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ A patient with a history of atrial fibrillation is experiencing a massive gastrointestinal bleed. The patient is prescribed vasopressin. The nurse would be most concerned about the development of which adverse effect? \ Abdominal cramping \ Nausea \ Vertigo \ Increase blood pressure \ \ Abdominal cramping is an adverse effect of vasopressin, but it is not the complication of greatest concern. Nausea is an adverse effect of vasopressin, but it is not the complication of greatest concern. Vertigo is an adverse effect of vasopressin, but it is not the complication of greatest concern. Hypertension could increase this patient's risk of developing or exacerbating an arrhythmia. This is the side effect that the nurse should be most concerned about with this patient. \
5
0 0 0 0
0000000000 0000000000 0 \\ MC B \ A patient taking NSAIDs for osteoarthritis is admitted with acute erosive gastritis caused by alcohol ingestion. Which nursing instruction is indicated? \ “Limit your alcohol intake to one glass of wine with dinner.” \ “Avoid alcohol use while you are taking NSAIDs.” \ “It is important that we find a different method of controlling pain from your arthritis.” \ “In some people, having a couple of drinks can reduce arthritis pain enough that NSAIDs are not necessary.” \ \ The patient being treated for gastritis should eliminate alcohol consumption. Acute erosive gastritis, or a transient inflammation of the gastric mucosa, is commonly caused by NSAIDs, alcohol, and acute stress. Chronic alcohol ingestion can result in inflammation of the gastric mucosa and the inflammation can progress to erosions and hemorrhage. Episodes of upper gastrointestinal bleeding as a result of this alcohol-induced gastritis are usually mild. But since the risk for bleeding significantly increases if a person continues to drink alcohol while on long term NSAID therapy, the nurse should instruct the patient to avoid the ingestion of alcohol when taking NSAIDs. The nurse could assess other pain control measures that could help with the patient's arthritis; however, the main issue is ingesting alcohol with NSAIDs. The nurse should not encourage the patient to use alcohol for pain relief. \ 0 0 0
6
0
0000000000 0000000000 0 \\ MC A \ A patient with a massive gastrointestinal bleed is diagnosed with a Mallory-Weiss tear. The nurse would anticipate which patient history? \ Chronic alcohol ingestion \ Ingestion of spicy foods \ Aspirin use \ 20 pack-year smoking history \ \ A Mallory-Weiss tear, a small laceration in the mucosa at the gastroesophageal junction, is commonly thought to be caused by retching or vomiting; however, high-risk patients are those with a history of alcohol abuse. Mallory-Weiss tears are not associated with the ingestion of spicy foods. Mallory-Weiss tears are not associated with aspirin use. Mallory-Weiss tears are not associated with smoking. \ 0 0 0 0
7
0000000000 0000000000 0 \\ MC A \ A patient experiencing massive amounts of bloody diarrhea from the rectum is diagnosed with inflammation of the mucosa and submucosa after a colonoscopy and biopsy. The nurse prepares to provide care for a patient with which condition? \ Ulcerative colitis \ Crohn's disease \ Arteriovenous malformation \ Polyps \ \ The patient is presenting with classical signs of ulcerative colitis, which include being confined to the mucosa and submucosa. Crohn's disease is more likely to extend deeper into the intestinal wall and is less likely to be associated with massive bleeding. Arteriovenous malformations are less likely to result in obvious bleeding and would not be described as superficial mucosal conditions. Polyps are less likely to result in obvious bleeding and would not be described as superficial mucosal conditions. \ 0 0 0 0
0000000000 0000000000 0
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\\ MC B \ A patient is recovering from a colonoscopy with removal of polyps. Which teaching should the nurse provide? \ “Rectal bleeding can occur up to a year after the polyps are removed.” \ “Rectal bleeding can occur up to 1 month after polyp removal.” \ “Contact the surgeon if any rectal bleeding occurs.” \ “Polyp removal weakens the intestinal wall, so bleeding may occur off and on indefinitely.” \ \ Rectal bleeding a year after polyp removal is not normal and should be investigated. Bleeding is relatively common following surgical removal of polyps and may continue up to a month after surgery. Rectal bleeding is common following polyp removal and is not a cause for concern. It is not normal to experience episodes of bleeding indefinitely after polyp removal. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ The nurse is caring for a patient diagnosed with an arteriovenous malformation of the ascending colon. The nurse would prepare to implement which intervention? \ Administration of blood products \
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Administration of cytoprotective medication \ Administration of H2 receptor blocking medication \ Administration of antisecretory medication \ \ Bleeding from an arteriovenous malformation is rarely massive. A typical bleeding episode requires less than 2 to 4 units of blood and is not associated with hypotension. The nurse should be prepared to administer blood products as prescribed. Cytoprotective medication is prescribed to provide a protective coating on irritated gastric mucosa and would not be therapeutic in this scenario. H2 receptor blocking medication is prescribed for gastric mucosa irritation and is not indicated in this situation. Antisecretory medication is prescribed to increase the bicarbonate protective coating on the gastric mucosa and is not indicated in this situation. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ A patient recovering from an open cholecystectomy 3 days prior has not passed any flatus since surgery. Which finding suggests to the nurse that the patient may be experiencing a life-threatening condition? \ Anorexia \ Falling blood pressure \ Respiratory rate of 24 \ Hypoactive bowel sounds
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\ \ It would not be unusual for a patient to have anorexia in this situation. Anorexia does not indicate a serious complication is occurring. This patient is experiencing a possible small bowel obstruction. The patient has had abdominal surgery and the lack of flatus indicates that peristalsis has not returned. Hypotension is one characteristic of a "mass effect" that occurs within the intestines. Electrolyte imbalances and abdominal distention are other criteria of the "mass effect" which could lead to cardiovascular collapse and perforation of the intestinal wall. A respiratory rate of 24 is not normal, but it could be caused by easily treatable situations like pain. It is not the most significant indicator of complication. It would not be unusual for a patient to have hypoactive bowel sounds 3 days after an open abdominal surgery. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ A patient recovering from thyroid surgery is now experiencing numbness and tingling around the mouth with an increase in irritability. Which additional assessment finding would cause the nurse the most concern? \ Decreased creatinine and BUN levels \ Abdominal distention and pain \ Hyperactive bowel sounds \ Diarrhea \ \
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Changes in BUN and creatinine levels are more of an indicator of renal function. This patient may be experiencing symptoms of hypocalcemia related to manipulation of the parathyroid glands. Hypocalcemia is a risk factor for the development of an acute paralytic ileus. Abdominal distention and pain are hallmark findings of bowel obstruction. Hyperactive bowel sounds do not occur in bowel obstruction. Diarrhea occurs when the bowel is irritated, not when a bowel obstruction is present. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ A patient with a history of coronary artery disease is admitted with vomiting, abdominal distention, and hypoactive bowel sounds. Which assessment would provide the nurse with the most accurate information about the patient's fluid volume status? \ Skin turgor assessment \ Hourly urine output measurements \ Daily weights \ Pulmonary artery catheter \ \
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Skin turgor assessment is subjective and does not provide the more accurate information. Urine output is an acceptable method of assessing fluid status in most patients. However, it is not the most accurate assessment for this patient. Daily weights are used to assess fluid volume trends, but they are not the most accurate measurement for this patient. The patient has a history of coronary artery disease. The best way to determine fluid volume status and needs in this type of patient is by tracking central venous pressure. This measurement is achieved through placement of a pulmonary artery catheter. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B+C+D \ The conventional transducer method will be used to measure a patient’s intra-abdominal pressure. Which interventions will the nurse use in this measurement? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Connect the transducer to the patient’s peripheral intravenous line. \ Place the head of the patient’s bed flat. \ Inject 20-25 mL of saline into the indwelling urinary catheter port. \ Calibrate the transducer at the level of the patient’s pubis. \ Obtain the measurement at the beginning of respiration. \ • ChronicThe patient’s peripheral intravenous line is not used in this measurement.
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• • • •
The patient should be supine with the head of the bed flat. The nurse should inject 20-25 mL of saline into the port on the patient’s indwelling urinary catheter to begin this measurement. The standard level for calibration of the transducer is the patient’s pubis. Measurement is obtained at end expiration.
\ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ A trauma patient’s intra-abdominal pressure (IAP) measures 26 mm Hg. How would the nurse explain needed treatment to the patient’s family? \ “This pressure reading is normal and will help to get oxygen to the damaged internal organs.” \ “If we reduce the amount of IV fluid he is getting, the IAP will decrease.” \ “We will raise the head of his bed and have him cough more frequently to reduce this pressure.” \ “It is very likely that he will be taken back to surgery to relieve the pressure building in his abdomen.” \ \ An IAP of 26 mm Hg is not normal and will decrease perfusion to damaged organs. Once IAP is this high, simply reducing the amount of IV fluids will not bring it down. This pressure is too high to be treated conservatively. The patient had severe abdominal compartment syndrome that necessitates decompression surgery. The abdomen may be reexplored and left open to allow for expansion. \ 0
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0 0 0
0000000000 0000000000 0 \\ MC B+E \ The nurse is assessing a patient recovering from surgery for abdominal compartment syndrome. Which findings could indicate a life-threatening condition may be developing in this patient? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Temperature 100.7° F \ Complaint of dyspnea \ Poor skin turgor \ Blood pressure 146/88 mm Hg \ Complaint of chest pain \ • A temperature of 100.7° F at this point does not indicate an acute infection. • Complaint of dyspnea is an indicator of a life-threatening complication related to abdominal compartment syndrome since this symptom may indicate that a pulmonary embolism has developed. • Poor skin turgor is not an indicator of a life-threatening condition and may indicate that reperfusion of the abdomen is occurring. • A blood pressure of 146/88 should be carefully compared to baseline readings and the blood pressure should continue to be assessed frequently. However, this single reading does not indicate development of a life-threatening emergency. • One of the serious complications related to abdominal compartment syndrome is reperfusion asystole, which occurs when byproducts from ischemic areas circulate to the heart. This can be manifested by chest pain. \
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0 0 0 0
0000000000 0000000000 0 \\ MC A+B+E \ A patient presents to the emergency department with reports of bloody diarrhea. During assessment, the patient becomes increasingly lethargic. The nurse’s emergency interventions are based upon which nursing diagnoses? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Altered Tissue Perfusion: Cerebral \ Impaired Gas Exchange \ Risk for Infection \ Nutrition, Less than Body Requirements \ Altered Thought Processes \ • The loss of blood has resulted in decreased oxygenation to cerebral tissues as manifested by decreased mentation. • Hypovolemia, secondary to blood loss, has resulted in impairment of gas exchange. There is insufficient hemoglobin to accept and carry oxygen to tissues. • There is a possibility that this patient is at increased risk for infection, but this is not an emergent problem. • This patient will likely experience imbalance in nutrition, but this is not the emergent problem. • Hypoxia related to anemia results in alteration of thought processes. This is an emergent problem that will affect assessment and cooperation with interventions. \
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0 0 0 0
0000000000 0000000000 0 \\ MC B \ A patient vomiting bright red blood is scheduled for an endoscopy sclerotherapy. The patient asks the nurse what the procedure will do. The nurse would reinforce which teaching? \ “The area of bleeding can be seen so surgery can be planned to remove it.” \ “A chemical can be injected into the bleeding vessel to stop it from bleeding.” \ “A cold material can be applied to the bleeding area to stop the bleeding.” \ “A laser can be used on the bleeding areas to stop any possibilities of bleeding again.” \ \ This intervention is designed to identify and treat the bleeding area, not to collect information for future surgery. Sclerotherapy includes injection of a chemical or sclerosing agent into the bleeding vessel. This chemical will scar the vessel to cause closure of the bleed. In some endoscopy procedures, heat is applied to coagulate the bleeding area. Sclerotherapy does not include use of lasers. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC B \ The nurse is providing care to a patient admitted with hematemesis, melena, and abdominal pain. Which nursing diagnosis is the highest priority for this patient? \ Risk for Anxiety related to fear of bleeding \ Risk for Aspiration related to potential changes in level of consciousness \ Risk for Fatigue related to decreased oxygenation \ Pain related to disruption of gastrointestinal tissues \ \ Anxiety is important and should be monitored and treated appropriately; however, is not as important as other problems. The most important nursing diagnosis for the patient at this time is the risk for aspiration because it falls into the category of "airway, breathing, circulation." The patient may experience fatigue and other anemia-related signs and symptoms, but this is not the most important problem. It is very important to consider the patient’s pain, but this is not currently the most important problem. \ 0 0 0 0
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0000000000 0000000000 0
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Chapter 22 \\ MC C \ A patient admitted with general malaise, nausea, and vomiting tells the nurse that he started to feel sick a few weeks after getting a new tattoo on his leg. Which type of hepatitis should the nurse suspect is causing this patient's symptoms? \ A \ E \ C \ A combination of A and D \ \ Hepatitis A is transmitted through the fecal–oral route. Tattooing is not considered a risk factor for HAV. Hepatitis E is transmitted by contaminated water and fecal–oral routes. It is most prevalent in India, China, and Southeast Asia. Hepatitis C is transmitted primarily through blood and blood products. Risk factors for the development of the illness include tattoos conducted in nonprofessional settings. There is no indication that HAV and HDV are associated with receiving a tattoo. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \
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The nurse is caring for a patient admitted with acute hepatic dysfunction caused by acetaminophen toxicity. Which clinical findings would indicate that the patient's condition is deteriorating? \ Sweet odor on the breath \ Tachycardia \ Hyperresponsive pupillary responses \ Change in level of consciousness \ \ A sweet odor on the breath is not associated with liver failure. Bradycardia is a finding associated with Cushing’s triad, which indicates increased intracranial pressure. Pupillary responses typically become sluggish. In acute hepatic dysfunction caused by fulminant hepatic failure, manifestations are the result of cerebral edema and include elevated intracranial pressure and could result in brainstem herniation. One of the first indications that the patient is deteriorating would be a change in level of consciousness. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ A patient with acute hepatic dysfunction is having difficulty completing his menu and "can't seem to remember" how to use the bed controls. The nurse realizes these changes might indicate which stage of hepatic encephalopathy? \ I \ II
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\ III \ IV \ \ Manifestations of stage I hepatic encephalopathy are subtle and include impaired handwriting and intellectual function changes. Manifestations of stage II hepatic encephalopathy include a decreased level of consciousness and disorientation to time and place. In stage III hepatic encephalopathy, the nurse would assess stupor and abnormal posturing. Stage IV hepatic encephalopathy is manifested by coma, seizures, and severe electroencephalogram abnormalities. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D+E \ A patient is admitted with suspected acute hepatic failure. Which findings would the nurse evaluate as supporting this suspected diagnosis? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ The patient complains of thirst. \ The patient has a dry cough. \ The patient’s hemoglobin is elevated. \
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The patient’s PT is prolonged. \ The patient has new onset of confusion. \ • Thirst is not a documented effect of acute hepatic failure on any major body system. • Crackles and tachypnea are respiratory effects of acute hepatic failure and not a dry cough. • Elevation of hemoglobin is not an expected effect of acute liver failure. • Within the hematologic system, assessment findings would include impaired coagulation with a prolonged PT. • Development of encephalopathy is a hallmark of acute liver failure. New onset confusion may herald development of hepatic encephalopathy. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ A patient with history of chronic liver disease is admitted with acute hemorrhage from esophageal varices. The nurse would expect treatment interventions for which causative condition? \ The patient has developed gall stones as a result of poor liver function. \ The patient has portal hypertension with shunting of blood. \ The NSAID use that caused the patient’s chronic liver failure has also resulted in gastritis. \ The abdominal distention caused by ascites has resulted in reflux esophagitis. \ \
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Esophageal varices are not associated with gall stones. Esophageal varices are a complication of portal hypertension. Since the esophageal veins in the lower part of the esophagus are a common collateral flow diversion, any rapid increase in pressure of the engorged veins will lead to an acute hemorrhage. Gastritis is not associated with esophageal varices. Esophageal varices are not caused by reflux esophagitis. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ A patient with acute hepatic dysfunction has abdominal ascites. The nurse would anticipate which laboratory finding? \ Serum sodium less than135 mEq/L \ Hematocrit less than 36% \ HDL level greater than 40 mg/dL \ Albumin level lower than 3.5 g/L \ \ Hyponatremia is not associated with abdominal ascites. Hematocrit will generally rise as fluid is shifted out of the circulating system and into the abdomen. An elevated high density lipoprotein level is not typically associated with ascites. Ascites, an abnormal collection of fluid in the abdominal cavity, develops from decreased colloid osmotic pressure and portal hypertension. Colloid osmotic pressure decreases as a result of a reduction in albumin. Hypoalbuminemia is caused by the inability of the liver to carry out its usual protein metabolism functions
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causing a drop in colloid osmotic pressure and shifting fluid from the intravascular compartment into other body compartments. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D+E \ A patient with acute hepatic dysfunction is prescribed lactulose (Cephulac) 45 mL by mouth four times a day. Which findings will the nurse evaluate as indicating the medication is having its desired effect? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ The patient’s abdominal girth is smaller. \ The patient has no more oozing from esophageal varices. \ The patient’s hemoglobin has increased. \ The patient’s mentation is clearer. \ The patient has had three stools in the last 24 hours. \ • Reduction in abdominal girth is not the intended effect of administration of lactulose; however, some reduction may occur. • Decrease in oozing from esophageal varices is not the intended effect of administration of lactulose. • Lactulose is not intended to increase the patient’s hemoglobin. • Lactulose helps to decrease ammonia, which will result in clearer mentation.
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•
Lactulose, a synthetic disaccharide, helps prevent the absorption of ammonia through the bowel by moving the stool through the intestines more rapidly to prevent bacteria from breaking down. Three to five stools daily is the intended effect.
\ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ A patient with acute hepatic dysfunction demonstrates slow slurred speech and cold clammy skin. The nurse would collaborate with the primary care provider for treatment of which condition? \ Cerebral embolism \ Hypoglycemia \ Bleeding esophageal varices \ Increased ammonia level \ \ Cerebral embolism is not a common occurrence in acute hepatic dysfunction and is not supported by these assessment findings. Since liver failure interferes with normal carbohydrate metabolism, the patient may develop hypoglycemia secondary to decreased gluconeogenesis. The patient should be closely monitored for the development of hypoglycemic symptoms which include slow thinking, slurred speech, nervousness, tachycardia, and cold clammy skin. If esophageal varices exist and begin bleeding the patient will experience hematemesis. Liver failure can result in increased serum ammonia levels, which will cloud mentation. It will not result in cold clammy skin at the level in which the patient will still be able to speak. \
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0 0 0 0
0000000000 0000000000 0 \\ MC D+E \ A patient with acute hepatic dysfunction is experiencing a gastrointestinal bleed. The nurse should be prepared to administer which products? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Mannitol \ Antibiotics \ Albumin \ Vitamin K \ Fresh frozen plasma \ • Mannitol would be administered for increased cerebral edema, not bleeding. • The patient may require antibiotics, but this is not the immediate priority. • Albumin is not administered to treat GI bleed. • Treatment for an acute gastrointestinal bleed due to acute hepatic dysfunction includes the administration of vitamin K. • Since this patient is actively bleeding the administration of fresh frozen plasma is indicated. \ 0 0
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0 0
0000000000 0000000000 0 \\ MC B \ While assessing a patient admitted with acute hepatic dysfunction, the nurse notes abnormal involuntary movements of the patient's hands. How should the nurse document this finding? \ As seizure activity \ As asterixis \ As decorticate posturing \ As hyperreflexia \ \ This abnormal movement does not represent a seizure. Asterixis, or liver flap, refers to an involuntary tremor that is particularly noted in the hands but may also be seen in the feet and tongue. Abnormal posturing would affect all four extremities. There finding represents a tremor, not a reflex. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC A+C+D \ A patient has been admitted to the intensive care unit with the diagnosis of hyperacute liver failure. Which assessment findings would the nurse anticipate in this patient? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ INR greater than 1.5 \ History of alcohol abuse \ Jaundice \ Mental status changes \ Serum glucose greater than 125 mg/dL \ • By definition, acute renal failure results in an INR greater than 1.5. • Acute liver failure has many etiologies. The nurse should not assume this patient has abused alcohol. • The designation of hyperacute liver failure is based upon the amount of time between onset of jaundice and another finding. Therefore, jaundice exists in this patient. • The designation of hyperacute liver failure is based upon the amount of time between onset of an assessment finding and the development of hepatic encephalopathy. Mental status changes are found in hepatic encephalopathy. • Serum glucose is not a factor in determining the classification of acute liver failure. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC B \ A patient reports taking two 500 mg acetaminophen tablets “at least 3 or 4 times a day” to treat muscle pain in his back. What nursing assessment question is priority? \ “Do you drink plenty of water when you take these pills?” \ “What other medications do you take?” \ “Have you had your back reassessed lately?” \ “What other measures do you take to relieve your back pain?” \ \ The patient should drink a full glass of water with these pills, but this is not the priority assessment question. The nurse should assess this patient for unintended acetaminophen overdose by asking about other medications the patient takes. If these other medications also contain acetaminophen the patient may be in danger of overdose. The nurse would ask questions to follow up on chronic back pain, but this is not the highest priority. The nurse should ask about additional pain relief measures and may discover problems such as alcohol use. This question is a priority, but it is not the highest priority. \ 0 0 0 0
0000000000 0000000000 0 \\ MC
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A+B+C \ A pregnant woman is admitted to the high risk maternity unit with HELLP syndrome. The nurse would provide which interventions? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Protect the woman from inadvertent injury. \ Monitor IV sticks for bleeding. \ Monitor the woman for development of seizure. \ Monitor the patient for the development of hypernatremia. \ Prepare the woman for immediate intubation and mechanical ventilation. \ • The woman with HELLP syndrome has a low platelet count. She should be protected from injury.; The woman with HELLP syndrome has a low platelet count. Invasive lines should be monitored for bleeding. • HELLP syndrome is associated with preeclampsia. This patient should be monitored for development of seizure, which would indicate development of eclampsia. • Monitoring for hypernatremia is not associated with HELLP syndrome. • There is nothing in the scenario that indicates the woman is not breathing well on her own. Intubation is not necessary. • Development of encephalopathy is a hallmark of acute liver failure. New onset confusion may herald development of hepatic encephalopathy. \ 0 0 0 0
0000000000 0000000000 0 \\
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MC C \ A teenage girl is admitted to the intensive care unit after taking an overdose of acetaminophen. What nursing assessment question is priority? \ “Did you take the pills on purpose?” \ “Are you diabetic?” \ “Could you be pregnant?” \ “Do you feel at all sick to your stomach?” \ \ It is important to determine intent to harm oneself, but this is a question better left until later. The knowledge of whether or not the patient is diabetic is not essential at this point. This is an important question and will be followed up by a pregnancy test. Nausea may occur with acetaminophen overdose, but this is not a priority question. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A patient is prescribed N-acetylcysteine (NAC) 140 mg/kg via nasogastric tube. What is the priority nursing intervention? \ Give the dose slowly over at least 15 minutes. \ Warn the patient that the medication smells like burning rubber.
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\ Give all follow-up doses exactly on time. \ Ask the patient what he weighs. \ \ There is no indication that this medication must be given slowly. This medication smells like rotten eggs. It is very important that the remaining 17 doses of NAC be given every 4 hours as directed and on time. The nurse should weigh the patient, not depend upon an estimated weight. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ The nurse is assessing a patient admitted with acute liver failure of unknown etiology. Which statement made by the family requires additional investigation? \ “I thought her skin color change was due to going to the indoor tanning booth.” \ “She has been exercising by gathering wild berries and greens for salads.” \ “We went to the mall last week and she got pretty tired while shopping.” \ “She was exposed to influenza last week when she went to visit her sister.” \ \
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There is no association with indoor tanning booths and acute liver failure. This statement may reveal that the patient has ingested mushrooms that can cause liver toxicity. The nurse should ask additional assessment questions. Being tired and intolerant of exercise would be expected if the patient was in acute liver failure. Exposure to influenza is not a significant risk factor for development of acute liver failure. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ The nurse is monitoring a patient for progression through the grades of hepatic encephalopathy (HE). This morning the patient is exhibiting a positive Babinski reflex. The nurse would conduct additional assessment about with HE grade? \ I \ II \ HE grade IVa \ HE grade IVb \ \ Reflexes are likely to be normal in HE grade I. A positive Babinski reflex may be seen in grade II HE. By grade IV reflexes are decreased to absent. In grade IVb patients are flaccid. \ 0
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0 0 0
0000000000 0000000000 0 \\ MC B \ A patient is admitted to the intensive care unit following lower extremity injury in a motor vehicle accident. The patient has history of chronic renal failure. Which nutritional support would the nurse provide? \ High fat \ Moderate protein \ Fluids only for the first 24 hours \ Low carbohydrate \ \ There is no indication that a high-fat diet is correct for this patient. This patient needs careful monitoring of protein intake to prevent exacerbation of liver failure. There is no information in the question to indicate that this patient should be restricted to fluids only. There is no indication that this patient requires low carbohydrates. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC B \ A patient will be given rifaximin (Xifaxan) to reduce ammonia production by intestinal bacteria. The nurse would add which intervention to this patient’s plan of care? \ Monitor IV site for infiltration. \ Monitor for development of abdominal cramping. \ Increase fluids to reduce risk of constipation. \ Monitor serum potassium levels daily. \ \ This medication is given orally. An adverse effect of ammonia-reducing agents is the development of abdominal cramping. Diarrhea is the more common adverse reaction from these medications. There is no indication that serum potassium levels will be affected by this medication. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \
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A patient in acute liver failure has developed increased intracranial pressure. Hypothermia has been induced. Which nursing intervention should be added to the patient’s plan of care? \ Keep the patient’s temperature below 33° C. \ Monitor the patient for development of frostbite. \ Stimulate the patient at least every 1 hour to assess for neurological changes. \ Monitor for the development of infection. \ \ The patient’s temperature should not be allowed to go below 33° C. The patient’s temperature will not be low enough to development frostbite. The patient has increased intracranial pressure. Sedation, not stimulation, is indicated. Induced hypothermia increases risk for infection. \ 0 0 0 0
0000000000 0000000000 0
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Chapter 23 \\ MC B \ A patient is diagnosed with acute interstitial pancreatitis. The nurse would reinforce which information about this patient’s prognosis? \ This disorder often progresses to multiple organ dysfunction with a poor outcome. \ This disorder often causes pancreatic edema, which will resolve with good results. \ Extensive fat and tissue necrosis occurs with this type of pancreatitis. \ The patient will most likely have irreversible damage to the pancreas. \ \ A patient with hemorrhagic pancreatitis has a poor prognosis with the potential to develop multiple organ dysfunction. Nonhemorrhagic or interstitial acute pancreatitis is a short-term illness characterized by pancreatic edema and little to no necrosis. Inflammation is localized and the condition is reversible with a good prognosis. Hemorrhagic acute pancreatitis is characterized by extensive fat and tissue necrosis with severe damage to the pancreas. Hemorrhagic acute pancreatitis results in irreversible damage to the pancreas. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \
A 55-year-old female patient is admitted with the diagnosis of acute pancreatitis. The nurse anticipates which treatment to be necessary for this patient? \ Introduction of medication to reduce high-density lipoprotein level \ Assessment of gall bladder functioning \ Encouragement to reduce daily alcohol intake \ Assessment for hypocalcemia \ \ Acute pancreatitis is associated with elevated triglyceride levels and not elevated high-density lipoprotein levels. Since gallstone-induced pancreatitis is more common in women, assessment of the patient's gall bladder functioning should be included in the care of this patient. Since alcohol-induced acute pancreatitis is more common in men, encouragement to reduce daily alcohol intake would not be indicated for this patient. Acute pancreatitis is associated with hypercalcemia and not hypocalcemia. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ A patient is diagnosed with acute pancreatitis. Which education about the basic mechanism of this disease would the nurse provide? \ “The chemicals being produced by your pancreas are going to work too early and they are damaging the pancreatic tissues.” \
“Your pancreas has lost the ability to produce insulin.” \ “A major part of your inflammatory system is inhibited.” \ “Your blood pressure is elevated because of increased blood flow to your pancreas.” \ \ Acute pancreatitis develops when pancreatic enzymes become prematurely activated resulting in autodigestion of the pancreas and surrounding tissues. Acute pancreatitis develops when pancreatic enzymes become prematurely activated resulting in autodigestion of the pancreas and surrounding tissues. Acute pancreatitis is not caused by the pancreas's inability to produce insulin. The activation of kallikrein, and not the inhibition of kallikrein, causes systemic hypotension. The activation of kallikrein, a major part of the inflammatory system, and not the inhibition of kallikrein, causes systemic hypotension. The multisystem effects of acute pancreatitis generally result in hypotension, not hypertension. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A patient is being assessed for acute pancreatic dysfunction. Which preparation should the nurse ensure before serum laboratory samples are collected? \ The patient should be maintained on bedrest for at least 4 hours prior to the samples being drawn. \ Schedule the serum amylase level to be drawn first. \ Keep the patient NPO for at least 8 hours before the lipase sample is drawn. \ Ensure that a serum lipase P level is drawn.
\ \ There is no reason to maintain the patient on bedrest prior to collecting these serum samples. There is no reason to draw the serum amylase first. Lipase is a more accurate predictor of pancreatic function. The pancreas is stimulated to secrete enzymes by the presence of food. If the patient has eaten, the levels will be falsely elevated. Serum amylase P and not lipase P is used to help rule out non-pancreatic elevations in amylase levels. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ A patient with symptoms of acute pancreatitis is scheduled for an abdominal ultrasound and a CT scan. The ultrasound department is very busy, so the patient is asked to wait. What rationale would the nurse provide for not doing the CT scan first? \ The ultrasound is the only way to assess the severity of damage to the pancreas. \ The ultrasound can assess for gallstones as the cause of the pain. \ Once the patient has had a CT scan the ultrasound must be delayed for at least 72 hours. \ The CT scan will be done only after the ultrasound has demonstrated that complications such as hemorrhage do not exist. \ \ An ultrasound cannot determine the severity of the damage to the pancreas.An ultrasound cannot determine the severity of the damage to the pancreas. An ultrasound on admission can assess for gallstones as the etiology of the pain rather than establishing a diagnosis of acute pancreatitis. If this is the case, the CT scan may not be necessary.An ultrasound on admission
can assess for gallstones as the etiology of the pain rather than establishing a diagnosis of acute pancreatitis. If this is the case, the CT scan may not be necessary. There is no reason why the ultrasound should be delayed if a CT scan has already been done. There is no reason why the ultrasound should be delayed if a CT scan has already been done. The ultrasound cannot diagnose these complications. The CT scan is more specific.The ultrasound cannot diagnose these complications. The CT scan is more specific. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A patient comes into the emergency department with complaints of abdominal pain that have become very severe. Which observation would the nurse evaluate as supporting the tentative diagnosis of acute pancreatitis? \ The patient is most comfortable sitting on side of the bed with arms extended back and legs dangling. \ The patient is most comfortable lying flat in bed. \ The patient is most comfortable lying on left side, knees pulled up to the chest. \ The patient is only comfortable while walking around the perimeter of the room with arms wrapped around the abdomen. \ \ Sitting on the side of the bed with the arms extended behind and legs dangling might increase intra-abdominal pressure, which would increase pain. Even though the pain intensity varies greatly from patient to patient, many patients cannot tolerate lying completely flat in bed. The classic pattern of pain is described as a sudden onset of sharp, knifelike, twisting and deep, epigastric pain that frequently radiates to the back, and is often associated with nausea and vomiting. The patient may report
some degree of relief by assuming a leaning forward or knee/chest position and may report an increase in pain when doing activities that increase abdominal pressure. The knee–chest position reduces pressure in the abdomen. Walking around with the arms wrapped around the abdomen would increase intra-abdominal pressure, which would make the pain of pancreatitis more intense. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A patient is admitted with the diagnosis of possible acute pancreatitis. Upon assessment, the nurse notes faint bruising over the patient's flank region. How would the nurse report and document this finding? \ Homan's sign \ Cullen's sign \ Grey Turner's sign \ Chvostek's sign \ \ Homan’s sign is an indicator of the presence of deep vein thrombosis, not acute pancreatitis. The Cullen's sign is a bluish discoloration around the umbilicus. While assessing the patient's integumentary status, the nurse might observe a bluish discoloration over the patient's flank region. This discoloration is considered the Grey Turner's sign. Chvostek's sign is seen in hypocalcemia and is characterized by numbness and tingling around the mouth. \ 0
0 0 0
0000000000 0000000000 0 \\ MC A+E \ A patient with acute pancreatitis begins to demonstrate confusion and agitation. How will the nurse evaluate this finding? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Neurological changes are a common finding in acute pancreatitis. \ Confusion is due to the increases of serum ammonia common in pancreatitis. \ An acute cerebral vascular accident is imminent and the health care provider should be contacted. \ The patient’s intracranial pressure is rising sharply. \ The patient’s mental status should be documented using the Glasgow Coma Scale. \ • The patient with acute pancreatitis frequently develops an alteration in level of consciousness. • Increased serum ammonia levels are not associated with pancreatic dysfunction but rather hepatic dysfunction. • Confusion and agitation in this patient are not related to an impending acute cerebral vascular accident. • Confusion and agitation in this patient do not indicate increasing intracranial pressure but are probably related to pain and anxiety. • The nurse should use the Glasgow Coma Scale to document current neurological status so that changes can be trended. \ 0 0
0 0
0000000000 0000000000 0 \\ MC D+E \ The nurse is monitoring the laboratory values of a patient with acute pancreatic dysfunction. Which values would indicate further assessment is required? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Hemoglobin level 13.5 mg/dL \ Serum sodium level 143 mEq/L \ Serum potassium level 4.0 mEq/L \ Serum calcium level 8.0 mg/dL \ BUN level is 80 mg/dL \ • This is a normal hemoglobin level, as would be expected with acute pancreatitis. • This is a normal serum sodium level and does not require additional assessment. • Electrolyte disturbances do occur with acute pancreatitis; however, this is a normal potassium level so no additional assessment is currently required. • Hypocalcemia may develop as a result of fat necrosis because serum calcium migrates to the extravascular space surrounding the pancreas where the fat necrosis is taking place.The nurse should assess the patient further with the serum calcium level of 8.0 mg/dL. • Increased BUN level can have many etiologies. Additional nursing assessment is indicated. \ 0 0 0
0
0000000000 0000000000 0 \\ MC B \ A patient with acute pancreatitis is diagnosed with a pseudocyst. Which nursing intervention should be added to this patient’s plan of care? \ Monitor urine output. \ Increase assessment for signs and symptoms of infection. \ Limit protein intake. \ Reduce fluid intake. \ \ Monitoring urine output is not specific to the care of this patient. A pancreatic pseudocyst is composed of pancreatic enzymes, necrotic tissue, and possibly blood. Some pseudocysts resolve on their own; however, while they are present, they may become infected or rupture into the peritoneal cavity, which can precipitate chemical peritonitis. Because of this, the nurse should increase assessment for signs and symptoms of infection. There is no reason to limit the amount of protein this patient is consuming. There is no reason to limit the amount of fluids this patient is consuming. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+B+D+E \ A patient diagnosed with acute pancreatitis is demonstrating signs of respiratory distress. What physiologic rationale would the nurse explain for this change in respiratory assessment? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Pancreatic enzymes can destroy a component of surfactant. \ Increase in the size of the abdomen may cause atelectasis. \ Increased intracranial pressure from pancreatic damage reduces neurological control of respiratory rate and depth. \ Inflammation of the diaphragm may result in pleural effusion. \ Lung damage may occur from factors released systemically. \ • Respiratory insufficiency and failure are common complications of acute pancreatitis and are attributed to the release of pancreatic enzyme phospholipase A, which destroys the phospholipid component of surfactant. • The increase in abdominal size resultant from inflammation of tissues may reduce respiratory excursion sufficiently to cause pressure on the lung and atelectasis. • A decreased level of consciousness may change respiratory pattern, but this change is not due to increased intracranial pressure. • Enzyme irritation of the diaphragm may result in pleural effusion, which will cause respiratory distress. • Factors such as trypsin, cytokines, and free-fatty acids are released during pancreatitis and can result in lung damage. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ A patient with acute pancreatitis is demonstrating signs of hypovolemic shock. The nurse will conduct additional assessment for which expected cause of this hypovolemia? \ Increased urine output \ Undiagnosed gastrointestinal ulcerations \ Pulmonary edema \ Fluid shifts and decreased vascular resistance \ \ An increase in urine output will not place a patient into hypovolemic shock in this situation. Even though hypovolemic shock can be caused by undiagnosed gastrointestinal ulcerations, there is not enough information to support this reason in the patient. Pulmonary edema would be another symptom of third spacing of fluid being shifted from compartments. Vasoactive substances, released from damaged pancreatic tissue, are responsible for vasodilation, decreased systemic vascular resistance, and increased permeability of endothelial linings of vessels. As vessels become more porous, intravascular fluids shift into other compartments and into the retroperitoneal cavity, causing hypovolemia, third spacing and hypovolemic shock. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B+C+E \ The nurse is caring for a patient with acute pancreatitis demonstrating signs of hypovolemic shock. Which interventions will be included in this patient's plan of care? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Administer high doses of potassium. \ Monitor pulmonary arterial wedge pressure. \ Administer several liters of intravenous fluids in the first few hours of treatment. \ Administer anticholinergic medication. \ Monitor central venous pressure. \ • Administering electrolyte replacements as prescribed would be useful to prevent or treat complications. Which electrolytes and the amount of electrolytes will be guided by laboratory results. High doses of potassium are not likely. • In hypovolemia, the goal is to stabilize the patient's hemodynamic status. Monitoring pulmonary wedge pressure will provide valuable information about fluid balance. • Fluid resuscitation generally involves an initial several-liter fluid bolus followed by 250–500 mL/hour continuous infusion. • Administering anticholinergic medication may decrease pancreatic stimulation but is not indicated to treat hypovolemia. • Central venous pressure is a standard intervention for monitoring hydration status. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A patient is diagnosed with subtotal pancreatic necrosis. Which intervention would the nurse include in this patient’s plan of care? \ Maintain bedrest. \ Restrict fluids. \ Administer proton pump inhibitor. \ Monitor arterial blood gases. \ \ Bedrest is not necessary for this patient. There is no evidence to suggest this patient should be on a fluid restriction. Patients with subtotal pancreatic necrosis usually require a proton pump inhibitor on a daily basis as the bicarbonate secretion of the pancreas is severely diminished putting the patient at risk for duodenal ulcer. Therefore, the nurse should administer proton pump inhibitors as prescribed. Arterial blood gas assessment might help determine the presence of acidosis because of the reduction of bicarbonate secretion of the pancreas but a different intervention is the most important at this time. \ 0 0 0 0
0000000000 0000000000 0 \\ MC
D \ The nurse is caring for a patient with acute pancreatitis experiencing pain. How would the nurse expect to treat this pain? \ Acetaminophen \ NSAIDs \ Demerol \ Morphine \ \ The pain of acute pancreatitis is not likely to be controlled with acetaminophen. The pain of acute pancreatitis is not likely to be controlled with NSAIDs. Meperidine (Demerol) is not considered a drug of choice as its major metabolite can accumulate in the body and is neurotoxic. Since acute pancreatitis is extremely painful, pain control is needed for comfort and to decrease the secretion of pancreatic enzymes. Fentanyl, morphine, and hydromorphone are effective pain relievers for patients with acute pancreatitis. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+C+D+E \ The nurse has chosen Ineffective Gas Exchange for a patient with acute pancreatitis. What interventions are indicated for this patient? (Select all that apply.)
Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Administer analgesics as prescribed. \ Monitor for ileus development. \ Treat inflammatory response. \ Ambulate as tolerated. \ Avoid opioid medications. \ • Ineffective gas exchange can occur because the patient is in pain. Treating pain may allow for deeper and more regular respirations. • Development of ileus is not directly related to ineffective gas exchange. • Inflammatory changes can result in ineffective gas exchange due to thickening of the alveolar membrane. • Ambulation will help the patient mobilize fluids and will help to open airways. • Opioid medications are necessary for the control of pain. They do have depressant effects but should be used as needed for comfort. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ A patient diagnosed with acute pancreatitis is nauseated and frequently vomits. The nurse would assign with nursing diagnosis? \ Altered Comfort \
Acute Pain \ Risk for Injury \ Risk for Infection \ \ The patient is demonstrating nausea and vomiting, which would indicate an alteration in comfort related to stimulation of the vomiting center. Nausea and vomiting may or may not be associated with acute pain. In general, nausea and vomiting is not a risk for injury. Risk for injury is related to infection, hemorrhage, or shock. Nausea and vomiting is not related to risk for infection. Risk for infection is related to peritonitis or abscess. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ A patient will have a magnetic resonance cholangiopancreatography (MRCP) to evaluate for pancreatitis. What information would the nurse provide regarding this test? \ A small plug of tissue will be removed for biopsy. \ This test is invasive and will require conscious sedation. \ This test will allow direct visualization of the pancreatic duct. \ No contrast is used for this test. \ \
No tissue is removed in this study. This test in not invasive. MRCP uses magnetic resonance imaging, not direct visualization. No contrast is required for this test. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ A patient with acute pancreatitis has been treated to minimize pancreatic stimulation, but vomiting continues. The nurse would anticipate which intervention? \ NPO status \ Placement of a nasogastric tube to intermittent suction \ Administration of morphine \ Increased ambulation \ \ NPO status is part of resting the GI tract and would already be part of minimizing pancreatic stimulation. Vomiting should stop when the patient is placed on GI tract rest. If this does not occur placement of a nasogastric tube to intermittent suction is considered. Drug therapy will include antacids, proton pump inhibitors, or anticholinergics. Increasing ambulation is not indicated when the patient is vomiting. \ 0 0
0 0
0000000000 0000000000 0 \\ MC A \ The nurse is participating in the use of Ranson’s criteria to assess a patient with pancreatitis. Which statement reflects a disadvantage of using these criteria? \ It takes 48 hours for complete assessment. \ Ranson’s criteria are not valid for patients over 55. \ This scoring system is not useful for persons with renal disease. \ Invasive testing is necessary as part of Ranson’s criteria. \ \ The complete assessment of Ranson’s criteria requires 48 hours after initial symptoms appear. Ranson’s criteria are valid for older patients. Age over 55 increases risk. There is no indication that these criteria is not valid for those with renal disease. No invasive testing is necessary for this scoring. \ 0 0 0 0
0000000000 0000000000 0
Chapter 24 \\ MC B \ A patient with hypoxia is at risk for disruption of the sodium potassium pump. Which would the nurse expect if this occurs? \ Decreased serum potassium \ Cell death \ Increase in the cells’ ability to use active transport \ Decreased extracellular fluid \ \ The amount of potassium in the extracellular fluids would increase. Without the counterregulating forces provided by the sodium potassium pump, cells will fill with fluid and will rupture and die. Dysfunction of the sodium potassium pump will not increase the cells’ ability to use active transport. Since the cells can no longer hold fluid, the extracellular fluid component increases. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ A patient is admitted with bleeding from the gastrointestinal tract. The nurse plans interventions to support the balance of which fluid volume compartment? \
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Transcellular \ Intravascular \ Interstitial \ Intracellular \ \ Transcellular fluid is cerebral spinal fluid, peritoneal fluid, and synovial fluid. Intravascular fluid is one extracellular compartment that consists of plasma. In the case of bleeding, the fluid compartment that will be affected first will be the intravascular fluid. Interstitial fluid is found between the cells. Intracellular fluid is that fluid found within the cells. Interstitial fluid is found between the cells. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ The nurse is planning the care of a patient in the intensive care unit. With regards to maintaining adequate fluid volume for this patient, the nurse realizes that interventions should be planned to reduce the risk of which condition? \ Retention of potassium \ Retention of sodium \ Loss of calcium \ Loss of magnesium
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\ \ Most intensive care patients experience a reduced potassium level and do not retain potassium. As retention of a different electrolyte occurs, potassium is excreted by the kidney. Under normal situations, the regulation of water is through the thirst mechanism. In the intensive care unit, however, many patients have altered levels of consciousness and will not have this mechanism in place. Because of this, hypernatremia or retention of sodium is a common electrolyte imbalance in these types of patients. Calcium balance is not typically associated with fluid volume. Magnesium balance is not typically associated with fluid volume. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ A patient in the intensive care unit has low blood pressure. If the patient's baroreceptors are functioning appropriately, what will the nurse assess in this patient? \ Reduced urine output \ Weak hand grasps \ Decreased level of consciousness \ Peripheral edema \ \ Arterial baroreceptors are located in the arch of the aorta and carotid sinus. These receptors detect arterial pressure changes. When they sense a decrease in arterial blood pressure, they signal the autonomic nervous
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system, which will cause peripheral vasoconstriction to raise the blood pressure. Vasoconstriction of the renal arteries decreases glomerular filtration, which will reduce the urine output. Weak hand grasps may or may not occur in the patient with hypotension and are not associated with baroreceptor response. Decreased LOC is not always present in patients with hypotension. Decreased LOC is not related to baroreceptor response. Peripheral edema may or may not be seen in patients with low blood pressure. Peripheral edema is not related to baroreceptor response. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+B \ The nurse is reviewing laboratory results for a patient just admitted to the intensive care unit. The nurse would anticipate interventions to be necessary for which values? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Calcium 8.0 mg/dL \ Potassium 3.0 mEq/L \ Sodium 142 mEq/L \ Phosphate 1.8 mEq/L \ Magnesium 2.1 mEq/L \ • The normal range for serum calcium is 8.5 to 10 mg/dL. A low value may indicate need for intervention.
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• • • •
The normal range for potassium is 3.5 to 5.0 mEq/L. A low value would indicate need for supplementation. The normal range for serum sodium is between 135 to 145 mEq/L. The normal range for serum phosphate is 1.7 to 2.6 mEq/L. The normal range for serum magnesium is 1.5 to 2.5 mEq/L
\ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ Which laboratory value would require that the nurse closely monitor a patient’s cardiac rhythm? \ Chloride 94 mEq/L \ Calcium 2.2 mmol/L \ Potassium 3.3 mEq/L \ Phosphate 3.0 mg/dL \ \ This chloride level is slightly lower than normal but would not cause cardiac rhythm disturbances. This normal calcium level would not be implicated in cardiac rhythm disturbances. Both high and low potassium levels can adversely affect cardiac rhythm. This normal phosphate level would not adversely affect cardiac rhythm. \ 0 0 0
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0000000000 0000000000 0 \\ MC B \ The nurse notes that a patient’s serum albumin level is elevated. Which other lab result should the nurse review? \ Potassium \ Calcium \ Sodium \ Chloride \ \ Changes in albumin level should not change potassium level. Ionized calcium is the calcium used in physiological activities such as neuromuscular activity. The concentration of ionized calcium is inversely proportional to the albumin concentration, so the higher the serum albumin, the lower the plasma ionized calcium. Albumin level does not affect sodium level. Chloride level is not affected by albumin level. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC C \ A patient's potassium and calcium levels are below the normal range. The nurse should check for a decreased level of which other electrolyte? \ Phosphorous \ Sodium \ Magnesium \ Chloride \ \ The phosphorous level might be elevated since phosphorous has an inverse relationship to calcium. Sodium level will not be affected. Because magnesium is mainly excreted in the feces and a small amount is excreted through the urine, these mechanisms of excretion and conservation are similar to those of potassium and calcium. If the patient's potassium and calcium levels are low, the patient might also demonstrate a low magnesium level since magnesium balance is closely related to potassium and calcium balance. Chloride level will not be affected. \ 0 0 0 0
0000000000 0000000000 0 \\
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MC C \ While assessing a high-acuity patient, the nurse learns the patient has a history of arthritis. Which question would provide the most information regarding potential impact on the patient’s fluid and electrolyte balance? \ “How well are you able to take care of your daily needs?” \ “How well do you sleep?” \ “How often do you take nonsteroidal anti-inflammatory medications?” \ “Does your arthritis affect mostly your hands or your feet and legs?” \ \ Ability to take care of ADLs would not have much impact on fluid and electrolyte balance. Sleep has little relationship to fluid and electrolyte balance. One question asked during the nursing history that relates to fluid and electrolyte assessment is if the patient is taking or receiving any medications that can alter the fluid and electrolyte balance. One such medication is NSAIDs. The patient has arthritis and could be taking NSAIDs on a regular basis. Therefore, the nurse should assess the patient's frequency of taking this category of medication which could impact the fluid and electrolyte status. The body part affected by arthritis would not have an impact on fluid and electrolyte status. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A patient admitted to the intensive care unit has been taking high levels of magnesium supplements. The nurse would add which information to this patient’s plan of care?
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\ Monitor closely for hypotension. \ Monitor for sudden decrease in respiratory rate. \ Monitor for bradycardia. \ Monitor for hyperthermia. \ \ Magnesium levels do not affect blood pressure directly. A low respiratory rate can be seen with a low magnesium level. A low pulse rate has been associated with a high magnesium level. Magnesium does not affect temperature. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ A patient's temperature has been elevated for the past 24 hours. The nurse should monitor which electrolyte? \ Phosphorous \ Sodium \ Potassium \ Magnesium \ \
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It is unlikely that temperature elevation will affect phosphorus levels. With an elevated temperature, there can be a loss of water and sodium through diaphoresis. The nurse should assess the patient's sodium level. It is unlikely that temperature elevation will affect potassium level. It is unlikely that temperature level will affect magnesium level. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C+D+E \ Which findings would the nurse evaluate as indication that a pregnant female is hypovolemic? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Flat neck veins \ Bilateral adventitious lung sounds \ Flat hand veins when dependent \ Sunken eyes \ Tenting of the skin \ • Flat neck veins are normal and do not indicate hypovolemia. Distended neck veins do indicate hypervolemia. • Adventitious lung sounds indicate hypervolemia. • If hand veins remain flat when in the dependent position, the nurse should suspect that the patient is hypovolemic.
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• •
Eyes that are sunken in their sockets may indicate hypovolemia. Tenting of the skin reveals poor skin turgor, which can be a result of hypovolemia. This finding is not reliable in older adults.
\ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ When assessing the patient's edema of the lower extremities, the nurse notes that it takes 3 minutes before the indentation created by applying pressure above the ankles disappears. This information should be documented as being which type of pitting edema? \ +2 \ +1 \ +4 \ +3 \ \ Indentations that disappear within 10 to 15 seconds would be considered +2 pitting edema. Indentations that disappear rapidly would be considered +1 pitting edema. Indentations that disappear after 2 to 5 minutes would be considered +4 pitting edema. Indentations that disappear within 1 to 2 minutes would be considered +3 pitting edema. \ 0 0 0
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0
0000000000 0000000000 0 \\ MC C \ A patient's BUN/creatinine ratio is 13:1. How would the nurse interpret this finding? \ The patient is hypervolemic. \ Renal tubule dysfunction may be present. \ The patient is normovolemic. \ The patient’s glomerular filtration rate is decreased. \ \ A BUN/creatinine ratio of 13:1 does not indicate hypervolemia. There is no information that supports this interpretation. The normal ration of BUN to creatinine is 10:1 to 20:1. Based on this value alone, the nurse would evaluate this patient as normovolemic. There is not enough information to make this determination. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC C \ After reviewing a patient's laboratory values, the nurse determines the patient is experiencing fluid volume deficit. Which laboratory value would the nurse cite as supporting this determination? \ Serum sodium 140 mEq/L \ Urine specific gravity of 1.003 \ Urine osmolality 1500 mOsm/L \ Serum potassium 4.3 mEq/L \ \ This serum sodium level is within normal limits and would not help determine the patient’s hydration status. Low urine specific gravity develops in conditions that cause fluid volume excess. Normal urine osmolality is 300 to 1200 mOsm/L. The urine osmolality will increase during fluid volume deficit because the kidneys hold onto water. This is the laboratory value that indicates the patient is experiencing fluid volume deficit. This normal serum potassium level would not help determine if the patient is experiencing a fluid volume deficit. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+B+D+E
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\ A patient’s laboratory report indicates critically low serum calcium levels. The nurse would conduct further assessment for which conditions? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Disruption of the parathyroid glands \ Decreased supply of vitamin D \ Low levels of calcitonin \ Insufficient levels of calcitriol \ Insufficient levels of calcidiol \ • Parathyroid hormone is essential to the release of calcium from bony tissue into the blood and the conversion of calcidiol to calcitriol. • If insufficient amounts of vitamin D are present, calcium absorption in the intestine is reduced. • Low levels of calcitonin would result in high calcium levels. • Calcitriol is the active form of vitamin D, which causes the small intestine to absorb more calcium. Insufficient levels of calcitriol would result in low serum calcium levels. • Calcidiol converts to calcitriol. Insufficient levels would result in low calcium levels. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B+C \
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The nurse is assessing for the presence of Trousseau sign. Which findings would the nurse evaluate as indicating this sign is present? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ The fingers hyperflex. \ The thumb flexes toward the palm. \ The fingers hyperextend. \ The thumb hyperextends. \ The hand makes a fist. \ • Flexion of the fingers does not indicate positive Trousseau sign. • Flexion of the thumb toward the palm indicates a positive Trousseau sign. • Hyperextension of the fingers indicates a positive Trousseau sign. • Hyperextension of the thumb does not indicate a positive Trousseau sign. • Fisting of the hand does not indicate a positive Trousseau sign. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ A urine electrolyte test is ordered to evaluate aldosterone disorder in a patient just admitted to the intensive care unit. How would the nurse collect this specimen? \ Collect the first specimen voided in the morning.
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\ Prepare a 24-hour urine collection system. \ Collect the specimen from the indwelling urinary catheter inserted in the emergency department. \ Use a temporary straight catheter to collect the specimen. \ \ This specimen should be collected in a different manner. Urine electrolytes typically require a 24-hour urine specimen. This specimen is not collected in this manner. This specimen is not collected in this manner. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ Which patient would the nurse expect to have the least amount of body fluid? \ A 75-year-old woman with a BMI in the obese range \ A 23-year-old female with history of type 1 diabetes \ A 72-year-old male who had a myocardial infarction at age 50 \ A 16-year-old male who plays football on his high school team \ \
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Fat cells contain little water, so obese individuals have less fluid. Women have more body fat than men, so they have less fluid. Older patients tend to have reduced body water. Since this female is young, she will have more body fluid than older females. Diabetes is not a factor. Since this older adult is male, he tends to have less body fluid than women at that age. This patient is young and male, which tends to decrease fluid level. The fact that he plays football is not a factor. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+D \ Laboratory testing reveals a patient’s serum osmolality to be 240 mOsm/kg. The nurse would assess for which conditions? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Excessive infusion of D5W \ Dehydration \ Hyperglycemia \ Syndrome of inappropriate ADH (SIADH) \ Acute kidney injury \ • Excessive D5W IV intake will result in decrease serum osmolality. • Dehydration results in increased serum osmolality. • Hyperglycemia results in increased serum osmolality.
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• •
SIADH will result in serum osmolality. Acute kidney injury results in decreased urine osmolality.
\ 0 0 0 0
0000000000 0000000000 0
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Chapter 25 \\ MC D \ The nurse is planning the care of a 50-year-old patient with the risk of developing fluid volume deficit. Which assessment finding would have the greatest contribution to this risk? \ Loose bowel movement one per day \ First-degree steam burn on hand and forearm \ Temperature of 99.6° F \ Diuretic therapy two doses per day \ \ Diarrhea does contribute to fluid volume deficit, but one loose bowel movement per day does not constitute diarrhea. Burns also can cause a fluid volume deficit but it is unlikely that a first-degree burn on the hand forearm will produce a significant amount of fluid loss. Fever does increase fluid loss, but this is a low-grade temperature whose affect would be minimal. The patient receiving two doses of diuretic therapy per day is at risk for high volumes of urine output that could increase the risk of developing a fluid volume deficit. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \
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A patient in the intensive care unit has developed gastrointestinal hemorrhage. The nurse would prepare to fluid resuscitate this patient with which intravenous fluid? \ 5% dextrose and 0.45% normal saline \ 2.5% dextrose \ 0.45% normal saline \ 0.9% normal saline \ \ The solution 5% dextrose and 0.45% normal saline is a hypertonic solution and is not the best choice for expanding the patient’s blood volume. The 2.5% dextrose is a hypotonic solution and would not help expand the patient's blood volume. The 0.45% normal saline is a hypotonic solution and would not help expand the patient's blood volume. The patient needs an isotonic solution to expand the blood volume. The appropriate intravenous solution is 0.9% normal saline. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B+C+E \ The nurse is assessing the effectiveness of fluid replacement therapy in a patient with the nursing diagnosis of Fluid Volume Deficit. Which assessment findings would indicate the therapy is effective? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Blood pressure 90/48 mm Hg
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\ Weight gain of 2 pounds since yesterday \ Urine output increase to 40 mL per hour \ Tenting of skin \ Serum osmolality of 284 mOm/kg \ • Low blood pressure indicates that the therapy has not been effective. • Increase in weight of 2 pounds in 1 day indicates a change in fluid balance. • Increase in urine output indicates improvement of fluid balance status. • Tenting of skin indicates poor skin turgor and fluid volume deficit. • Normal serum osmolality is 280–300 mOm/kg. Presence of normal serum osmolality indicates normal fluid volume status. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ A patient with fluid volume excess has a hemoglobin level of 9.0 mg/dL. How would the nurse explain the more likely cause of this laboratory value? \ An undiagnosed bleeding disorder exists. \ The patient has chronic anemia. \ The patient has iron deficiency anemia. \ Plasma dilution has occurred due to excess fluid.
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\ \ While this may be the case it is not the most likely reason for this lab value. While this may be the case it is not the most likely reason for this lab value. While this may be the case it is not the most likely reason for this lab value. Since this patient has fluid volume excess the most likely etiology of a low hemoglobin level is plasma dilution from excess extracellular fluid volume. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ A patient being treated for fluid volume excess has blood glucose elevation. The nurse would review the patient’s medication history for which medication? \ Furosemide (Lasix) \ Spironolactone (Aldactone) \ Potassium chloride (K-Dur) \ Hydrochlorothiazide (Esidrix) \ \ Furosemide does not cause hyperglycemia. Spironolactone does not result in hyperglycemia. Potassium supplements do not cause hyperglycemia. Hydrochlorothiazide has hyperglycemia as a major side effect. \
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0 0 0 0
0000000000 0000000000 0 \\ MC A \ A patient comes into the emergency department with complaints of feeling weak, confused, and having abdominal cramps after spending several hours in the hot sun attending a baseball game. The patient's blood pressure is 96/58 mm Hg. The nurse would conduct additional assessment for which condition? \ Hyponatremia \ Hypercalcemia \ Hypernatremia \ Hypocalcemia \ \ Manifestations of hyponatremia include hypotension, confusion, headache, lethargy, seizures, decreased muscle tone, muscle twitching, tremors, vomiting, diarrhea, and cramping. The patient is complaining of feeling weak and confused with abdominal cramps, which are symptoms associated with hyponatremia. The blood pressure of 96/58 mm Hg is another indication of hyponatremia. Because of these findings and the patient history the nurse should assess for additional symptoms of hyponatremia. The symptoms and the patient history do not suggest hypercalcemia. Manifestations of hypernatremia include hypertension, thirst, nausea, and vomiting. Hypernatremia would be unlikely in the patient with this history. These symptoms and this history do not support a diagnosis of hypocalcemia. \ 0 0 0
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0
0000000000 0000000000 0 \\ MC C \ The nurse is preparing intravenous fluids for a patient whose serum sodium is 156 mmol/L. Which types of fluid would the nurse select? \ 10% dextrose in water \ Lactated Ringer's \ 0.45% normal saline \ 5% dextrose and 0.45% normal saline \ \ Hypertonic solutions such as 10% dextrose in water are not used to treat hypernatremia. Lactated Ringer's is an isotonic solution and would not be effective when treating hypernatremia. To effectively treat hypernatremia, the patient will need to be provided with hypotonic intravenous fluids. The fluid 0.45% normal saline is a hypotonic fluid. Hypertonic fluids such as 5% dextrose and 0.45% normal saline would not be used to treat hypernatremia. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC D \ A patient is receiving several units of packed red blood cells over several days to replace the blood lost during an active gastrointestinal bleed. The nurse would assess this patient for findings associated with which electrolyte imbalance? \ Hyponatremia \ Hypercalcemia \ Hypokalemia \ Hypomagnesaemia \ \ Blood is administered with normal saline so hypernatremia would be a more likely condition. Blood administration is not a primary cause of hypercalcemia. Blood transfusion is not a likely cause of hypokalemia. Hypomagnesaemia can be induced by the administration of large amounts of stored blood because stored blood is preserved with citrate. Citrate is added to stored blood as a preservative. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C+E
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\ A patient has a serum calcium level of 7.9 mg/dL. Which nursing interventions would be appropriate for this patient? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Treat tachycardia. \ Monitor for the development of hypertension. \ Place on seizure precautions. \ Strain all urine. \ Reorient as indicated. \ • Bradycardia is the expected result of this calcium level. • Hypotension is the expected effect of this calcium level. • A serum calcium level of less than 8.5 mg/dL is indicative of hypocalcemia. Nursing interventions appropriate for the patient would include monitoring the patient for seizures. • Straining urine is associated with the possibility of kidney stones. This calcium level is not associated with kidney stone development. • This calcium level indicates hypocalcemia. Reduce cognitive ability is a common finding associated with hypocalcemia. The nurse should reorient this patient as needed. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+B+E \
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A patient has a serum calcium level of 11.0 mg/dL. The nurse would review this patient’s medical record for which conditions? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ History of taking thiazide diuretics \ Diagnosis of hyperparathyroidism \ Diagnosis of acute pancreatitis \ Low serum magnesium level \ Long term bedrest \ • Hypercalcemia may result from use of thiazide diuretics. • Primary hyperparathyroidism is associated with hypercalcemia. • The diagnosis acute pancreatitis is associated with hypocalcemia. • A low serum magnesium level is also seen in hypocalcemia. • Immobility can cause hypercalcemia. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ The nurse caring for a patient receiving digoxin plans to monitor which electrolyte because of increased risk of digitalis toxicity? \ Potassium
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\ Chloride \ Calcium \ Sodium \ \ In patients receiving digoxin therapy, low serum potassium levels can increase the risk for development of dysrhythmias. Chloride levels do not increase risk for digitalis toxicity. Calcium levels do not increase risk for digitalis toxicity. Sodium levels do not increase risk for digitalis toxicity. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ The nurse is concerned that a patient's arterial blood carbon dioxide level is increasing because this can contribute to the development of which electrolyte imbalance? \ Hyperkalemia \ Hypokalemia \ Hypercalcemia \ Hypocalcemia \ \
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A rise in arterial blood carbon dioxide is a diagnostic indicator of acidosis. Acidosis contributes to hyperkalemia because excess hydrogen ions shift into the cells, forcing potassium out into the serum. The nurse should be concerned about the patient developing hyperkalemia. Acidosis does not contribute to the development of hypokalemia. Acidosis does not contribute to the development of hypercalcemia. Acidosis does not contribute to the development of hypocalcemia. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ A patient’s electrocardiogram reveals a prolonged P-R interval and ST segment depression. The nurse should review laboratory results for which electrolyte imbalance? \ Hypokalemia \ Hyperkalemia \ Hypocalcemia \ Hypernatremia \ \ Prolongation of the PR interval is not an ECG finding associated with hypokalemia. Cardiovascular manifestations of hyperkalemia include prolonged P-R interval; flat or absent P wave; slurring of QRS; tall peaked T wave; and ST segment depression. Hypocalcemia causes prolongation of the QT interval and a long ST segment. Cardiovascular manifestations of hypernatremia include hypertension and tachycardia. \
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0 0 0 0
0000000000 0000000000 0 \\ MC C \ A patient is demonstrating tremors and a positive Chvostek's sign even though the serum calcium level is low normal. The nurse would review the medical record for which electrolyte imbalance? \ Low phosphate \ Low potassium \ Low magnesium \ Elevated sodium \ \ A positive Chvostek’s sign is associated with hyperphosphatemia. Potassium levels are not associated with a positive Chvostek’s sign. The symptoms associated with a low magnesium level are similar to those seen in a low calcium level. Therefore, the nurse should suspect that the patient is experiencing a low magnesium level since tremors and a positive Chvostek's sign is also seen with a low calcium level. Sodium level is not associated with a positive Chvostek’s sign. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC D \ A patient diagnosed with chronic renal failure has a magnesium level of 6.0 mg/dL. Which history data would the nurse evaluate as contributing to this electrolyte imbalance? \ The patient had an episode of nasal congestion last week and took decongestant. \ The patient had a resent sprain injury treated with rest and compression wrapping. \ The patient has been trying to reduce intake of caffeine-containing fluids. \ The patient has been taking over-the-counter laxative for chronic constipation. \ \ Taking a decongestant would not contribute to hypermagnesemia. A sprain injury treated with rest and compression would not cause hypermagnesemia. Reduction of caffeine-containing beverages would not contribute to hypermagnesemia. Many over-the-counter laxatives contain magnesium. Chronic overuse of these laxatives may result in hypermagnesemia. \ 0 0 0 0
0000000000 0000000000 0
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\\ MC B+E \ A patient who was admitted to the intensive care unit has a magnesium level of 8.4 mg/dL. The nurse would prepare for which interventions? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Maintenance of strict bedrest \ Administration of calcium gluconate \ Observation for tetany \ Intravenous administration of magnesium \ Initiation of dialysis \ • While ambulation may not be indicated for this patient due to changes in neuromuscular function, strict bedrest is not required. The patient may be able to sit on the side of the bed, use a bedside commode, or sit in a bedside chair. • The neuromuscular and cardiac toxicity of hypermagnesemia can be antagonized by the administration of 10–20 mL of calcium gluconate over 10 minutes. • Tetany is seen in hypomagnesaemia and not hypermagnesemia. • This magnesium level is elevated, so additional magnesium is not indicated. • Dialysis may be required to remove magnesium in severe cases. \ 0 0 0 0
0000000000 0000000000 0 \\
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MC B \ A patient with a history of heart failure is admitted with dehydration, malnutrition, and fatigue. The nurse learns that the patient has been taking multiple doses of a thiazide diuretic. The nurse would review laboratory reports for which electrolyte imbalance? \ Hypernatremia \ Hypophosphatemia \ Hypocalcemia \ Hypermagnesemia \ \ Hypernatremia is not associated with dehydration. Hypophosphatemia is associated with malnourished states and is a relatively common imbalance in the highacuity patient. Other conditions that can cause hypophosphatemia include those disorders that cause hypercalcemia, such as taking thiazide diuretics. Thiazide diuretics can cause hypercalcemia. Dehydration, malnutrition, and fatigue are not directly linked to hypermagnesemia. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+B \ A hospitalized patient has a phosphorus level of 4.8 mg/dL. The nurse would review this patient’s history for the presence of which conditions? (Select all that apply.)
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Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Chronic kidney failure \ Hyperthyroidism \ Recent cardiac surgery \ Alcoholism \ Treatment for gram-negative sepsis \ • Hyperphosphatemia is predominantly associated with chronic kidney failure. • Hyperthyroidism can precipitate hypocalcemia, which leads to hyperphosphatemia. • Cardiac surgery is associated with hypophosphatemia. • Alcoholism is associated with hypophosphatemia. • Gram-negative sepsis is associated with hypophosphatemia. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ A patient admitted with hyperphosphatemia is to be treated with the administration of intravenous fluids. Which fluid would the nurse anticipate providing? \ 0.9% normal saline \ Lactated Ringer's solute \
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5% dextrose and 0.25% normal saline \ 5% dextrose and water \ \ Treatment of hyperphosphatemia is directed at lowering serum levels. This is accomplished by either administering agents that bind phosphate in the gastrointestinal tract or administering an intravenous solution with saline since saline promotes the renal excretion of phosphate. The intravenous solution of choice for this patient would be 0.9% normal saline. Lactated Ringer’s solution does not provide the most benefit to this patient. 5% dextrose and 0.25% normal saline is not the best fluid choice as it has insufficient amounts of an essential ingredient. 5% dextrose and water is not the best fluid choice as it lacks an essential ingredient. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ Potassium phosphate IV has been prescribed for a patient who has hypophosphatemia. Which nursing interventions are indicated when administering this medication? \ Dilute the dose in 100 mL of normal saline and administer over 20 minutes. \ Monitor the patient for respiratory distress. \ Monitor for the development of hypotension. \ Ensure that pharmacy has mixed the medication with a local anesthetic. \ \
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The dose should be diluted in 500 mL of 0.45 NS and given over 6 hours. Replacement of phosphorus may cause respiratory changes. The patient should be monitored for respiratory distress. Hypotension is not an expected effect of phosphorus replacement. There is no indication that mixing this medication with a local anesthetic is required. \ 0 0 0 0
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Chapter 26 \\ MC C \ A patient who has acute kidney injury and who weighs 90 kg had a urine output of 25 mL over the last 12 hours. The nurse would place this patient in which RIFLE category? \ Injury \ Risk \ Failure \ Loss \ \ The injury level of RIFLE criteria is urine output less than 0.5mL/kg for 12 hours. This patient’s output is lower than that level. The risk level of RIFLE criteria is urine output less than 0.5 mL/kg for 6 hours. This patient’s output is lower than that level. According to the RIFLE criteria, failure is a urine output of less than 0.3 ml per kg of body weight or anuria for 12 hours. The patient's urine output over the last 12 hours has been 25 mL, which would be comparable to the failure category within the RIFLE criteria. Loss is considered a complete loss of renal function for at least 4 weeks. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \
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An elderly patient is scheduled for a CT scan with contrast. The nurse would anticipate preprocedure administration of which medication to help prevent renal damage? \ N-acetylcysteine \ Vitamin B12 \ Intravenous infusion of 5% dextrose \ Vitamin D \ \ Since the use of contrast dyes can be nephrotoxic, steps must be taken to minimize nephrotoxicity. Nacetylcysteine may be given orally or intravenously before contrast administration. N-acetylcysteine acts as a free radical scavenger, counteracts vasoconstriction from contrast agents, and indirectly exhibits cytoprotective effects. Vitamin B12 does not offer kidney protection from contrast dyes. Since the use of contrast dyes can be nephrotoxic, steps must be taken to minimize nephrotoxicity. The patient should be adequately hydrated with sodium chloride. Vitamin D does not provide kidney protection from contrast dyes. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D+E \ A patient’s acute kidney injury is suspected of being of postrenal etiology. Which medical history would support this diagnosis? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected.
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\ The patient has been taking NSAIDs for arthritis pain. \ The patient was diagnosed with heart failure last week. \ The patient reports having the “flu” with vomiting and diarrhea for the last 6 days. \ The patient has large renal calculi in the kidney and ureter. \ The patient was just diagnosed with prostate cancer. \ • The intake of NSAIDs for arthritis would contribute to an intrinsic cause for an acute kidney injury. • The diagnosis of heart failure would be considered a prerenal cause for an acute kidney injury. • Vomiting and diarrhea for the last 6 days is considered a prerenal cause for an acute kidney injury. • Large renal calculi in the kidney and ureter are considered a mechanical cause for a postrenal acute kidney injury since they affect urine drainage from the kidney. • Prostate cancer can cause obstruction of the urethra, which can result in postrenal acute renal failure. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ A patient's serum creatinine level is increasing, but the urine creatinine clearance is decreasing. How would the nurse evaluate these two findings? \ The patient may be experiencing the onset of heart failure. \ The patient will probably have associated hypokalemia. \ The patient is malnourished.
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\ There is a decrease in glomerular function. \ \ These two laboratory values would not be indicative of heart failure. There is no reason to assume that a patient with these two laboratory findings would also be hypokalemic. Malnutrition cannot be diagnosed with these two findings. Creatinine is the end-product of muscle metabolism and is released into the blood at a constant rate. Creatinine is larger in size compared to urea and is not reabsorbed back into the blood, but is eliminated at a rate related to the level of renal function. For this reason, it is a more reliable measure of the state of renal health. A decrease in the urinary creatinine clearance rate indicates a decrease in glomerular function. A rise in serum creatinine level also indicates a decrease in glomerular functioning. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ A patient with reduced glomerular filtration has a blood pressure of 168/100 mm Hg. The nurse suspects which pathophysiological effect is occurring? \ Rebound hypertension due to fluid volume deficit \ Sluggish response by the renin-angiotensin system \ Kidneys hyper-excreting hydrogen ions \ Increased renin production causing the retention of water and electrolytes \ \
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The patient has fluid volume excess and not deficit. In the presence of renal ischemia, the renin-angiotensin system is triggered and not sluggish. The kidneys are not able to excrete hydrogen ions or hyper-excreting hydrogen ions. Hypertension is a common manifestation of renal failure. It is caused by systemic and central fluid volume excess and increased renin production. In the presence of renal ischemia, the renin-angiotensin system is triggered. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A patient with acute kidney injury is demonstrating signs of gastrointestinal bleeding. The nurse would explain this bleeding to be secondary to which event? \ Low creatinine level \ Elevated potassium level \ Increased ammonia level \ Low calcium level \ \ Gastrointestinal bleeding in the patient with an acute kidney injury is not due to low creatinine level. Elevated potassium level results in cardiac dysrhythmia, not gastrointestinal bleeding. Electrolyte imbalances and increasing levels of uremic toxins are the primary contributors to gastrointestinal manifestations. As urea decomposes in the gastrointestinal tract, it releases ammonia. Ammonia in the gastrointestinal tract increases capillary fragility and gastrointestinal mucosal irritation resulting in small mucosal ulcerations and the potential for pain, decreased appetite, and gastrointestinal bleeding. Low calcium levels do not cause gastrointestinal bleeding.
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\ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ A patient with acute kidney injury has a hemoglobin level of 9.0 mg/dL. How would the nurse explain this change to the patient? \ “Your kidneys may not be making enough of a hormone that is required to build red blood cells.” \ “Since you are retaining so much fluid, your blood is more dilute.” \ “I am afraid you may have some bleeding we have not found as of yet.” \ “Your lungs are not exchanging oxygen as well as they should, so your body is not producing hemoglobin.” \ \ The kidneys produce erythropoietin in response to decreased oxygen delivery to the kidneys. Erythropoietin is necessary for red blood cell production and also plays a role in maintaining healthy endothelium, which promotes angiogenesis and anti-apoptosis. When kidney function deteriorates, red blood cell production is compromised and the life span of the existing red blood cells may decrease. When the nurse is explaining pathophysiological events to the patient, every effort should be made to provide accurate information that helps the patient understand changes. The statement about “more dilute” blood does explain a change in hemoglobin, but it might explain a change in hematocrit. It is unlikely that this low hemoglobin is related to undiagnosed bleeding. It is premature to worry a patient about that occurrence. There is no indication that this patient’s lungs are not exchanging oxygen well. Problems with oxygenation would increase hemoglobin levels. \
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0 0 0 0
0000000000 0000000000 0 \\ MC C \ The nurse is transferring to a high-acuity unit where many patients receive intermittent hemodialysis. Which patient characteristic would the nurse expect? \ Patients whose hemodynamic status requires slow removal of waste products \ Patients whose kidney injury will resolve since intermittent dialysis is only done temporarily \ Patients whose blood pressure and heart rate can be stabilized \ Patients who have few imbalances in electrolyte levels \ \ Intermittent hemodialysis will result in rapid removal of waste products. Intermittent hemodialysis may be performed temporarily or the patient may require intermittent dialysis on an outpatient basis for life. Even though intermittent hemodialysis provides more efficient and effective clearance of excess fluids and solutes, it is destabilizing to the hemodynamic and electrolyte status of the patient. The patient receiving intermittent hemodialysis will need to have a stable blood pressure and heart rate. One of the indications for intermittent dialysis is to balance electrolyte levels. There is no indication that this will be successful only if the patient has few imbalances. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC A+C \ A patient is scheduled for arteriovenous access continuous renal replacement therapy (CRRT). Which nursing intervention should the nurse add to the patient’s plan of care? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Monitor the access site for leaking or hemorrhage. \ Check settings on the external pump every 2 hours. \ Monitor pulses in distal extremities. \ Monitor for hemodynamic instability from rapid removal of water and wastes from the blood. \ Monitor the tube for clotting. \ • Arteriovenous CRRT requires cannulation of an artery, so hemorrhage is a risk for which the nurse should monitor. • Arteriovenous CRRT does not require use of an external pump. • Arteriovenous CRRT increases risk of limb ischemia, so the nurse must monitor for distal pulses regularly. • Hemodynamic instability from rapid removal of water and wastes is an adverse effect of intermittent dialysis. Continuous dialysis does not have this same adverse effect. Hemodynamic instability in continuous dialysis is more likely related to hemorrhage. • Tube clotting is more associated with venovenous CRRT. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC A \ A patient is receiving slow continuous ultrafiltration to treat an acute kidney injury. Which nursing assessment will this treatment specifically require? \ Electrolyte levels \ White blood cell count \ Appetite \ Urine output \ \ Slow continuous ultrafiltration is a method of continuous renal replacement that uses both arterial and venous access and, using the patient's blood pressure, circulates blood through the hemofilter. The goal of this therapy is to remove fluid only, and the patient does not receive any replacement fluid. Toxins are not removed with this treatment and urea levels and electrolytes are not corrected. The nurse will need to continue to assess this patient's electrolyte levels. The white blood count is monitored for development of infection in all patients. This level is not the most specific assessment necessary for this patient. Appetite assessment is necessary for all patients who are able to eat. This assessment is not specifically indicated for this patient. The patient is experiencing acute renal failure and may or may not have a urine output. Introduction of this technique to filter the blood will not change whether output is or is not present. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC C \ A patient in the intensive care unit is receiving continuous venovenous hemofiltration for acute kidney injury. In order for the nurse to successfully provide the treatment for the patient, what needs to occur? \ Infusion of a dialysate through the hemofilter \ Creation of a fistula \ Connection to a small pump \ Successful placement of the catheter in an artery and a vein \ \ Continuous venovenous hemofiltration uses a pressure gradient rather than a concentration gradient (dialysate). A fistula is needed when the patient will be on long-term hemodialysis. Without the arterial pressure to "drive" the system, a small pump propels the blood from one lumen of the catheter through the hemofilter and back into the vein through the second lumen. The pump controls the blood flow and therefore the fluid removal rate. Continuous venovenous hemofiltration uses a double-lumen catheter placed in a vein. This eliminates the need for an arterial catheter and the associated risks of this device. \ 0 0 0 0
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0000000000 0 \\ MC D \ A patient with an acute kidney injury is experiencing fluid volume overload. When administering furosemide (Lasix) therapy to this patient, the nurse should set the continuous infusion device in which manner? \ According to a calculation based upon the patient's weight \ According to a calculation based upon the patient's potassium and sodium levels \ At no more than 20 mg/minute \ At a rate of 4 mg/minute \ \ Furosemide dosage is not calculated according to the patient’s weight. Furosemide dosage is not calculated according to the potassium and sodium levels. Intravenous push furosemide is given at a rate of 20 mg or less over 1 to 2 minutes. The nurse should set the continuous infusion to provide 4 mg of the medication per minute. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ A patient with acute kidney injury is receiving renal replacement therapy. Which assessment finding would the nurse evaluate as best indicating this therapy is having its desired effects? \
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The patient had a soft formed stool this morning. \ The patient’s lung sounds have improved. \ The patient slept for 2 hours without awakening. \ The patient’s serum protein level is normal. \ \ Soft formed stools are outcome criteria for the nursing diagnosis of altered nutrition. In fluid volume overload, the patient will demonstrate signs of pulmonary edema, peripheral edema, and increased weight. Evidence of successful treatment would be improved lung sounds, reduction in peripheral edema, and stabilization of weight towards normal. Improved quality of sleep is not an outcome measure for CRRT. A normal serum protein level would be outcome criteria for the nursing diagnosis of altered nutrition. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B+E \ A patient diagnosed with kidney injury is on fluid restriction. Which nursing interventions should the nurse add to the patient’s plan of care? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Provide all fluid in the form of ice chips. \ Provide frequent oral care. \
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Allow the patient to decide when the fluid will be ingested. \ Provide fluids only when the patient complains of thirst. \ Consider the amount of fluids that can be provided over a shift. \ • Using small amounts of ice chips or frozen popsicles can provide comfort with less volume, but there is no indication that all fluids should be in this form. • Oral care is an extremely important intervention to minimize oral mucosal damage and to increase patient comfort. • The nurse should not let the patient decide when the fluid will be ingested since there might not be available fluid for medications and treatments. • Fluids must be provided for medication administration, so providing fluids only when the patient complains of thirst is not a logical intervention. • The nurse must consider individual patient variants such as treatments and medication administration to determine how to divide the available free water over a 24-hour period. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C+E \ A patient with an acute kidney injury is identified as being at risk for infection. Which nursing interventions are indicated? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Turn and reposition when necessary. \ Avoid manipulation of venous access devices.
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\ Post signs to remind visitors and staff to wash their hands. \ Limit the use of antibiotic therapy. \ Remove invasive devices as soon as medically possible. \ • The patient should be turned and repositioned every 2 hours to prevent the pooling of secretions in the lungs and reduce the likelihood of pressure ulcer development. • Vascular access devices should receive routine care according to agency policies. • Frequent scrupulous hand washing is necessary to protect this patient. Hand washing is necessary for both staff and visitors. • Antibiotic therapy is indicated in the patient with an acute kidney injury; however, the dosage will need adjustment according to the patient's renal clearance rate. • The nurse should attend to orders for removal of invasive devices as soon as possible. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ The nurse is assessing the neurological status of a patient with chronic renal failure. Which finding would the nurse attribute to chronic renal failure? \ Numbness and pain of the lower extremities \ Expressive aphasia \ Flaccid paralysis on the left side \ Weak hand grasps
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\ \ Neurological symptoms are nonspecific and progressive in the patient with CRF. These symptoms include: sleep disorders, memory loss, impaired judgment, muscle cramps, and twitching. These may progress to asterixis, seizures, and coma. Peripheral neuropathy is also a component of chronic renal failure and is evidenced by numbness, tingling, or pain, especially in the lower extremities. The development of expressive aphasia is not normal in a patient with chronic renal failure and should be further evaluated. Flaccid paralysis is not normal in a patient with chronic renal failure and should be further evaluated. The development of weak hand grasps is not normal in a patient with chronic renal failure and should the further evaluated. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A patient with chronic renal failure is diagnosed with anemia. The nurse anticipates providing which therapy for this patient? \ Vitamin B12 injections \ Routine whole blood transfusions \ Recombinant erythropoietin supplementation \ Protein restriction \ \
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Vitamin B12 injections would not help treat the anemia associated with renal failure. Routine whole blood transfusions are not indicated for this patient. The anemia of chronic renal failure is treated with recombinant human erythropoietin and iron supplementation. Protein restriction may be necessary for this patient, but it is not done to treat anemia. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ A patient with chronic renal failure and a blood pressure of 158/98 mm Hg refuses to take medication for the blood pressure. What information should the nurse provide for this patient? \ “One of the problems associated with high blood pressure in people with renal failure is the development of heart failure.” \ “Some people with chronic renal failure and high blood pressure end up with an infection around their heart.” \ “You must realize that untreated hypertension may cause you to develop pneumonia.” \ “There is a significant increase in risk for anemia if hypertension is not treated.” \ \ Hypertension, commonly seen in chronic renal failure, can progress to heart failure if left untreated. Pericarditis is a complication of end-stage renal disease, but it is inflammatory and not infectious. Pneumonia is not a potential problem because of untreated hypertension. The patient with chronic renal failure is at high risk for anemia, but this complication is not due to the presence of untreated hypertension. \ 0
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0 0 0
0000000000 0000000000 0 \\ MC B+C \ The nurse is assessing the integumentary system of a patient with chronic renal failure. Which findings would the nurse associate with this disease history? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Flushed, ruddy color \ Yellow-brown hue \ Areas of excoriation \ Moist, clammy skin \ Rubbery consistency \ • Pale skin is associated with chronic renal failure due to anemia. • The yellow-brown coloring associated with chronic renal failure is related to uremia. • The patient with chronic kidney failure often experiences pruritus associated with the presence of urea in the skin. This causes itching and the resultant scratching causes skin breaks and excoriation. • Skin is typically dry and maybe flaky. • There is no effect that changes the skin to a rubbery consistency. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC C \ A patient’s potassium level is 6.5 mEq/L. The nurse would prepare for which intervention? \ Administration of intravenous fluids supplemented with 40 mEq of potassium in each liter of fluid \ Administration of oral potassium 2 or 3 times daily until levels are normal \ Administration of Kayexalate by rectum \ Administration of a D50W bolus \ \ This patient does not require additional intravenous potassium. This patient does not require administration of oral potassium. Kayexalate is a sodium polystyrene sulfonate used to bind to and eliminate excess potassium. It is given orally or by enema. Since this patient’s potassium level is elevated, this intervention is indicated. D50W is not given to reduce potassium. \ 0 0 0 0
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Chapter 27 \\ MC A \ A patient was admitted through the emergency department with fractures of the skull, ribs, and both femurs sustained from a motor vehicle accident. The nurse provides care based upon changes in which pathophysiological process? \ Formation of red blood cells \ Cellular and humoral immune responses \ Formation of plasma \ Antigen–antibody formation \ \ Blood cells are formed in the bone marrow which exists within all bones. Because the patient sustained fractures to the skull, ribs, and both femurs, red blood cell formation will be impacted. Cellular and humoral immune responses occur in secondary lymphoid organs such as the tonsils, adenoids, lymph nodes, and spleen. This patient’s injuries are not focused in these areas. Plasma is a clear fluid that remains once all of the blood cells are removed. Formation of plasma should not be affected by these injuries. Antigen–antibody response is what occurs when an infectious organism is introduced into the body. The ability to mount this response will continue despite these injuries. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C
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\ A patient diagnosed with leukemia has minimal white blood cells. The nurse realizes which intervention may be indicated for this patient? \ Infusion of fresh frozen plasma \ Infusion of red blood cells \ Bone marrow transplant \ Immunizations \ \ Infusion of fresh frozen plasma would expand intravascular volume but would not add white blood cells. There is no indication that this patient needs additional red blood cells. Blood cells include red cells, white cells, and platelets. All three of these elements of blood are created in the bone marrow. The patient with low white blood cells would benefit from a bone marrow transplant since each of these types of cells originates from a stem cell. Individuals with low white blood cell counts usually do not receive immunizations. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ A patient is admitted with left lower thoracic rib injuries. The nurse realizes this injury could result in which problem for this patient? \ Decrease in platelet maturation \ Decreased availability of B cells
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\ Reduction in T cell formation \ Reduction in filtering of foreign matter in the blood \ \ Platelet maturation does not occur in this area. The spleen sits behind the 9th, 10th, and 11th left ribs and serves three functions: destroy injured or worn out red blood cells, store extra blood for use by the body, and store B cells. With an injury to the left lower thoracic rib area, the patient could have an injury to the spleen. There is a possibility of splenic injury. Splenic injuries do not cause a reduction in T cell formation. Lymph tissue is where the blood is filtered of foreign matter. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ A patient is diagnosed with a low red blood cell count. The nurse should assess this patient for which finding? \ History of fractures \ Carbohydrate intake \ Location of joint replacements \ Renal functioning \ \
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A history of fractures will not impact the patient's current red blood cell formation. Production of red blood cells requires certain levels of adequate nutrients which include protein, multivitamins, and nutrients. The patient's carbohydrate intake will not affect red blood cell production. Even though red blood cells do originate in the marrow of the ribs, sternum, and femur, joint replacements will most likely not impact red blood cell formation. Red blood cells arise from the myeloid cell line in the red bone marrow and mature in the blood or spleen. Erythrocyte production is tightly regulated by erythropoietin, a circulating hormone that is primarily produced by the kidneys. It is believed that erythropoietin may be produced in the renal tubular cells, which are major consumers of oxygen that are particularly sensitive to lowering oxygen levels. In a patient with a low red blood cell count, the patient's renal function should be further assessed. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ A patient is admitted with iron deficiency anemia. The nurse assesses this patient for the presence of which most likely finding? \ Hypoxia \ Reduced urine output \ Bleeding \ Dehydration \ \ Each red blood cell contains hemoglobin. Hemoglobin has two parts: the heme portion that contains oxygen and iron and the globin part which is a protein. The oxygen will adhere to the portion of the hemoglobin with the iron molecule. In the event of iron deficiency anemia, the patient has reduced iron molecules which means less
4
oxygen molecules will be available for body use. Because of this, the patient will most likely demonstrate signs of hypoxia. Iron deficiency anemia is not related to reduced urine output. Iron deficiency anemia will not result in bleeding. Iron deficiency anemia has not been linked to dehydration. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ A patient is prescribed vitamin B12 injections. What information should the nurse provide when starting this medication? \ “Vitamin B12 will strengthen the red blood cells’ membranes and prevent them from being damaged so easily.” \ “Vitamin B12 is needed for normal manufacture of red blood cells.” \ “Vitamin B12 will increase the ability of your blood to carry oxygen.” \ “Vitamin B12 helps build the components of white blood cells.” \ \ Iron and copper strengthen the plasma membrane. Vitamin B12 is one vitamin needed for normal red blood cell synthesis, development of DNA and RNA, and cell maturation. Iron increases the oxygen-carrying capacity of the blood. Vitamin B12 does not impact white blood cell synthesis. \ 0
5
0 0 0
0000000000 0000000000 0 \\ MC B \ A patient is concerned that the disease that has affected his horses will cause him to become ill. What information should the nurse provide? \ “You will probably contract the same illness but in a milder form.” \ “Many illnesses are species specific and it is not likely that you will contract the same illness as your horses.” \ “All illnesses can be transmitted between animals and humans, so I am glad you came in to be checked.” \ “There are vaccinations against diseases caused by horses. I would talk with the veterinarian.” \ \ There is no way of knowing if the patient will contract the same illness as the horses or if the illness will be in a milder form. Innate immunity is species specific which means that human beings are immune to a variety of diseases to which certain animals are susceptible, and vice versa. The nurse should explain this concept to the patient. All illnesses cannot be transmitted between animals and humans. It is unknown if there is a vaccine to provide immunity against diseases caused by horses. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC C \ A patient is admitted with a leg wound with a large amount of pus exudate. The nurse assesses that which part of the immune process is functioning? \ The complement system causing cellular destruction \ The natural killer lymphocytes circulating through the lymph \ The neutrophils arriving at the wound as the first line of defense \ The macrophages circulating in the blood \ \ The complement system is an immune mechanism that resembles the blood coagulation cascade by progressing through several sequential stages, each contributing to the immune response and resulting in cellular destruction or cytolysis. Activation of the complement system does not result in pus formation. Natural killer lymphocytes protect the body from pathologic cells such as microbes and cancer cells through cytolytic activities and secretion of cytokines. They do not produce pus. Neutrophils are responsible for the formation of pus. As they die, the neutrophil-degrading enzymes are released, causing breakdown and liquefaction of local cells as well as foreign substances. This forms pus, a thin liquid residue that is an important indicator of inflammation. Mobile macrophages circulate in the blood supply and migrate out of the vessels into the tissues when required through the process of chemotaxis. They do not produce pus. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC B \ The nurse caring for a patient with an infected leg wound realizes that neutrophils and macrophages will arrive to the wound as a part of the natural body response. How would the nurse explain this process to the patient? \ “Your white blood cells will travel through your lymph system to the wound.” \ “Chemical signals from the injured tissue help guide the white blood cells to where they are needed.” \ “Only the white blood cells already in your system will be able to fight this infection.” \ “The white blood cells attach to red blood cells for transport to the wound.” \ \ The white blood cells do not travel through the lymph system. Circulating neutrophils and monocytes have to arrive where they are needed and then they must be able to transfer from the blood vessels to the site of injury. After the leukocyte is outside the capillary, it requires guidance to move to the correct location. This is accomplished through chemotaxis, which refers to movement as a result of some type of chemical stimulus. Infection stimulates the production of additional white blood cells. White blood cells are independent of red blood cells. \ 0 0 0 0
0000000000 0000000000 0 \\ MC
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D+E \ A patient tells the nurse that he thought he had a varicella vaccine as a child. His daughter has just developed varicella. What information should the nurse provide? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ “Since you were vaccinated you won’t contract varicella from your daughter.” \ “Your innate immunity will protect you from contracting this disease.” \ “It is dangerous to give a second injection of vaccines.” \ “You may need an injection to boost your immunity.” \ “We can check your blood titer to check your immunity.” \ • Vaccinations do not always provide life-long immunity. • The immunity that this patient may have against varicella is not innate immunity. • There is no indication that a second injection of vaccines is dangerous if it is needed. • In some cases, there is need for a second injection. • Antibody titers can be compared to pre-established norms to see if repeated immunizations are necessary. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \
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The mother of a young child tells the nurse that when she was breastfeeding her baby, he never had any colds or infections but now that he is weaned, he seems to be sick all of the time. What should the nurse explain to the mother? \ The breast milk provided passive immunity to the baby that he no longer is receiving. \ The child should be immunized to prevent these common illnesses. \ Some children are just prone to getting more infections than others. \ Most babies won't get sick until they are past the age of 12 months. \ \ Passive immunity is a temporary immunity involving the transfer of antibodies from one individual to another or from some other source to an individual. An infant receives passive immunity both in utero and from breast milk. There are no immunizations against many of these common illnesses. This information is not accurate and should not be provided to the mother This information is not accurate and should not be provided to the mother. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ A patient is scheduled to have his tonsils removed. The nurse realizes that this procedure could result in deficiency of which immunoglobulin? \ Immunoglobulin D \ Immunoglobulin A
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\ Immunoglobulin E \ Immunoglobulin G \ \ Immunoglobulin D is a trace antibody found primarily in the blood. Immunoglobulin A protects mucous membranes from invading organisms and is found in the tonsils. Immunoglobulin E plays a role in the allergic response and is extremely powerful even though it is present in the body in very small quantities. Immunoglobulin G is the chief immunoglobulin and is produced on a secondary exposure to an antigen. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ A patient is being evaluated for a kidney transplant. Which individual is most likely the best candidate to donate this organ? \ A live donor from a donor bank \ Live kidney transplant from the patient’s spouse \ Cadaver kidney transplant \ Live kidney transplant from a brother \ \
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A person willing to donate a kidney, but who is unrelated to the recipient, is not likely to be a match. A spouse may or may not be a match for this donation. Cadaver kidneys may or may not match the donor. Because full siblings share the same biological parents, they often have some degree of human leukocyte antigen matching. The closer the human leukocyte antigen combination matches between two people, the more the "fingerprint" is recognized as self. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C+D \ A man with assessment findings associated with prostate cancer is having the tumor-associated antigen PSA drawn. The nurse anticipates this level will be used for which purposes? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ To confirm the diagnosis of prostate cancer \ To rule out the presence of prostate cancer \ To screen for the probability of prostate cancer \ To assess efficacy of treatment \ To determine presence of metastasis \ • PSA levels are not diagnostic of prostate cancer. • Even if the level of PSA is low, it does not rule out prostate cancer.
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• • •
PSA is best used as a screening tool. If levels are high, additional assessment should be done. If levels are low, but other findings indicate strong suspicion of prostate cancer, additional assessment should be done. Monitoring PSA levels after treatment for prostate cancer has begun can help to monitor the effects of treatment. PSA does not help to identify metastasis.
\ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ A patient being admitted for knee surgery says, “Everyone in my office is sick all of the time, but I never get sick.” How would the nurse evaluate this statement? \ The patient may have a strong antigen–antibody response. \ This patient’s poorly differentiated histocompatibility antigens may be a problem during postoperative recovery. \ The patient’s coworkers must have immune system compromise. \ The patient must have strong passive immunity. \ \
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Normally, an antibody circulates in the bloodstream until it encounters an appropriate antigen to bind. This binding results in antigen–antibody complexes, or immune complexes. The process of binding is such that the antibody binds to specifically conformed antigenic determinant sites on the antigen, which prevents the antigen from binding to receptors on host cells. The outcome is the host is protected from an infection. Histocompatibility antigens are surface antigens which are genetically determined and are proteins found on the surface of a cell. These antigens would not impact the patient's inability to get colds or other illnesses, nor would they cause complications postoperatively. Immune system compromise does result in frequent illnesses, but there is not enough information for the nurse to make this determination. Passive immunity is a temporary immunity involving the transfer of antibodies from one individual to another or from some other source to an individual. Passive immunity can be transferred also through vaccination either of antiserum, an antitoxin, or as gamma globulin. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+E \ A patient’s admission laboratory work reveals a platelet count of 90,000/mcL. Which interventions should the nurse implement? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Implement bleeding precautions. \ Monitor urine output. \ Limit the ingestion of green leafy vegetables. \ Restrict fluids.
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\ Review the patient’s medication history. \ • Platelets play a crucial role in hemostasis or blood clotting. Since the normal platelet count in an adult is 150,000 to 400,000/mcL, a count of 90,000/mcL means the patient is prone to bleeding. Bleeding precautions should be implemented for this patient. • There is no evidence that monitoring urine output is an essential part of this patient’s care. • Green leafy vegetables contain vitamin K which is needed by the liver to form coagulation factors. Since these factors are needed for the coagulation cascade, vitamin K should not be limited in this patient. • There is no evidence to suggest that fluids should be restricted for this patient. • Medications can be implicated in low platelet counts, so reviewing medication history is indicated. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ A wound on a patient's leg has stopped bleeding. The nurse would attribute this to which physiologic occurrence? \ Tumor necrosis factor has sealed the wound. \ Neutrophils have invaded the wound. \ Macrophages have been released into the general circulation. \ Platelets retracted the clot, reducing leakage. \ \
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Tumor necrosis factor will not seal a wound. Neutrophils do not impact the amount of bleeding from a wound. Macrophages in the general circulation do not impact the amount of bleeding from a wound. Shortly after bleeding has stopped and the clot has formed, it retracts, drawing the torn vessel walls into closer proximity, reducing leakage. Clot retraction is largely a function of platelets. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+B+C \ A patient suffered severe trunk and lower extremity injury in a motor vehicle accident. Which injuries would indicate to the nurse that this patient may have dysfunction of normal hemostasis? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Contusion of the spleen \ Laceration of the liver \ Femur fractures \ Bruising of the heart \ Pneumothorax \ • The spleen provides storage for platelets. If the spleen is damaged and unable to hold or release platelets, normal hemostasis will be disrupted. • The liver produces most of the clotting factors so injury would affect normal hemostasis.
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• • •
The marrow of long bones support blood cell development. This patient may have disruption of all three cell lines. Bruising of the heart should not affect hemostasis. Pneumothorax should not affect hemostasis.
\ 0 0 0 0
0000000000 0000000000 0 \\ MC B+E \ A patient is being treated for anemia after a postpartum hemorrhage. The nurse would expect that this patient’s erythrocytes would have which appearance? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Microcytic \ Normochromic \ Macrocytic \ Hypochromic \ Normocytic \ • Blood loss would not result in change in the size of the RBCs. • Since the RBCs are lost, not changed due to a physiological problem, they will have a normal color. • There is no reason for these RBCs to be bigger than normal. • The cells should not appear hypochromic. • The RBCs should be of normal size.
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\ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ The patient has developed a “shift to the left.” The nurse would expect which value on the complete blood count? \ Increased bands \ Increased eosinophils \ Decreased lymphocytes \ Increased monocytes \ \ When an infection exists and the body needs neutrophils, the production is increased, but many immature cells or “bands” are released. This release results in a “shift to the left.” Eosinophils are not involved in the “shift to the left.” A decrease in lymphocytes is not reported as a shift. An increase in monocytes is not reported as a shift. \ 0 0 0 0
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0000000000 0000000000 0
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Chapter 28 \\ MC D \ A patient diagnosed with chronic renal insufficiency has a hemoglobin level of 8.6 mg/dL. The nurse plans care for a patient with which level of anemia? \ Grade 1 or mild \ Grade 3 or severe \ Grade 4 or life threatening \ Grade 2 or moderate \ \ Anemia is considered grade 1 or mild if the hemoglobin level is 10.0 g/dL or higher to normal. Anemia is considered grade 3 or severe if the hemoglobin level is between 6.5 and 7.0 g/dL. Anemia is considered grade 4 or life threatening if the hemoglobin is less than 6.5 g/dL. Anemia is considered grade 2 or moderate if the hemoglobin level is 8.0 to 9.9 g/dL. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B+D \ A patient with rheumatoid arthritis has a hemoglobin level of 10.0 g/dL. The nurse would consider this anemia to be related to inflammation if which other findings are present? (Select all that apply.)
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Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ The patient has low vitamin B12 levels. \ Laboratory testing shows low hepcidin level. \ Increased destruction of erythrocytes is occurring. \ Serum iron levels are low. \ The patient’s stools are guaiac positive. \ • Low vitamin B12 levels are associated with anemia of decreased red blood cell production. • Hepcidin is an iron-regulating hormone produced in the liver. Some of the cytokines due to inflammation regulate hepciden, resulting in low levels. • Anemia caused by increased red blood cell destruction can occur from congenital or acquired problems and is not typically associated with rheumatoid arthritis. • Anemia of inflammation is associated with low serum iron levels. • Stools that are positive for blood may indicate blood loss anemia is present. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ A patient receiving chemotherapy for cancer is diagnosed with anemia secondary to bone marrow depression. The nurse would expect which intervention? \ Recombinant erythropoietin therapy \ Iron supplements
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\ Fresh frozen plasma \ Hematopoietic stem-cell transplantation \ \ Recombinant erythropoietin therapy, such as Procrit or Epogen, has been used for some time for treatment of blood loss anemia seen in some cancers. Iron supplementation is not likely to be effective in reversing this anemia. Fresh frozen plasma may help to expand volume, but will not improve oxygen carrying capacity. Hematopoietic stem-cell transplantation is the definitive treatment for aplastic anemia, but is not indicated during chemotherapy. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ A patient with sickle cell disease tells the nurse that she knows when the disease is going to flare because she has pain in her arms and legs. Which explanation would the nurse provide? \ “The shape of your blood cells blocks the small capillaries in your arms and legs.” \ “The pain is really due to your history of malaria along with having sickle cell anemia.” \ “Your spleen is destroying all the malformed red blood cells which makes you anemic and causes arm and leg pain.” \ “The chronic blood loss associated with sickle cell anemia causes pain in the arms and legs.” \ \
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In sickle cell disease, the red blood cell membrane is stiffer and cells are misshapen which slows down or obstructs blood flow in the small capillaries. This can lead to microvascular occlusion leading to pain in the arms and legs as well as other body areas. Having a history of malaria is related to disease development as a genetic adaptation. The spleen does destroy the malformed red blood cells but this does not cause pain in the arms and legs. Blood loss is not typically seen in sickle cell disease. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C+E \ The nurse is planning to instruct a patient with sickle cell disease on ways to avoid a painful crisis. What should the nurse include in this instruction? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Do not drink alcohol. \ Eat a diet low in protein. \ Avoid tiring exercise. \ Avoid carbohydrates. \ Do not smoke. \ • Alcohol ingestion is not implicated in development of a painful crisis. • Dietary changes do not impact the onset of a painful crisis. • Excessive exercise can result in painful crisis.
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• •
Dietary changes do not impact the onset of a painful crisis. Smoking is associated with vessel constriction and development of painful crisis.
\ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A 25-year-old patient with sickle cell disease says, “My sister is having a baby. I can’t wait until I have kids of my own.” Which nursing response is indicated? \ “You should use barrier protection until you are ready to have a child.” \ “Have you thought about adopting children?” \ “Genetic counseling will be important for you and your partner.” \ “I hope that infertility does not cause problems for you.” \ \ This is not the best information to provide in this situation. This is not the best topic for the nurse to introduce. A patient with sickle cell disease has inherited the trait from both parents which means that it can be genetically transmitted to any children. The patient should receive information about genetic counseling. There is no evidence to suggest the patient needs information about infertility. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC A+B+C \ A patient is admitted with the tentative diagnosis of polycythemia vera. Which assessment findings would the nurse evaluate as supporting that diagnosis? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Plethora \ Fingers that are dark and cool to touch \ Report of night sweats \ Complaint of shortness of breath \ Hypotension \ • Plethora, or a ruddy coloration, is caused by the presence of red blood cells in superficial tissues. • Dark coloration and coolness to touch is a manifestation of the chronic tissue hypoxia seen in polycythemia. • Night sweats are a finding associated with polycythemia. • Shortness of breath is not a common complaint in polycythemia. • Hypertension is more commonly seen in polycythemia. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC D \ A patient with a 40-pack-year smoking history has increased hemoglobin and hematocrit. The nurse expects that which test will be done to assess for erythrocytosis? \ Serum electrolytes \ Sedimentation rate \ Platelet count \ Carboxyhemoglobin level \ \ Serum electrolytes will not aid in the diagnosis of erythrocytosis. Results of sedimentation rate testing will not help to diagnose erythrocytosis. Platelet count will not aid in the diagnosis of erythrocytosis. A carboxyhemoglobin level may be drawn if smoking-related polycythemia or erythrocytosis is suspected. \ 0 0 0 0
0000000000 0000000000 0 \\
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MC C \ The nurse is providing care for a patient diagnosed with secondary polycythemia. Which finding is most significant for the nurse to discuss with the primary health care provider immediately? \ The patient becomes short of breath on exertion. \ The patient has had no appetite for the last two days. \ The patient is confused. \ The patient’s fingers are red and warm to touch. \ \ Shortness of breath on exertion is not associated with major complications of polycythemia. If the patient was experiencing a pulmonary embolism, the shortness of breath would be constant. Loss of appetite is not associated with polycythemia. Confusion could be caused by transient ischemic attack which is a complication of polycythemia. Polycythemia results in a reddened color and warm skin. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ The nurse is providing care for a young woman diagnosed with idiopathic thrombocytopenia. Which information should the nurse provide? \ Take a low-dose aspirin daily. \
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Use pads during menstrual cycle instead of tampons. \ Brush and floss teeth carefully. \ Use glycerin suppositories to prevent constipation. \ \ Aspirin is contraindicated when idiopathic thrombocytopenia is diagnosed. Tampon use is contraindicated when the patient is at risk for bleeding. Patients diagnosed with idiopathic thrombocytopenia should use toothettes for oral care. Suppository use is contraindicated in this patient. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A patient being treated for thrombocytopenia is not responding to therapy. The nurse would begin to prepare the patient for which medical intervention? \ Intravenous fluids \ Bone marrow transplant \ Splenectomy \ Blood transfusion \ \
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The patient will most likely already be receiving intravenous fluids as a part of cardiovascular fluid volume support. Bone marrow transplant is not included as a course of treatment for a patient with thrombocytopenia. Treatment for thrombocytopenia includes steroids, immune anti-D antibody infusion, and intravenous immune globulin. If unresponsive to therapy, a splenectomy is indicated. Blood transfusions are not included as a course of treatment for a patient with thrombocytopenia. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ A critically ill patient who is being mechanically ventilated was started on an antibiotic, a steroid, and intravenous heparin one week ago. This morning the nurse notes the patient has red rashlike eruptions across his abdomen and chest. What nursing action is indicated? \ Notify the primary care provider immediately. \ Monitor the rash to see if it spreads. \ Apply a nonpetroleum–based lotion over the affected area. \ Hold the antibiotic. \ \ This rash may indicate the development of heparin-induced thrombocytopenia. The nurse should collaborate with the primary care provider immediately. The rash may spread, but monitoring is not the best intervention. It is not likely that lotion will be effective in treating this rash. It is not likely that this rash is related to an antibiotic that was started a week ago. \
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0 0 0 0
0000000000 0000000000 0 \\ MC A \ A critically ill patient is diagnosed with disseminated intravascular coagulation. Which history would the nurse evaluate as indicating increased risk for this development? \ The patient had a transfusion reaction yesterday. \ The patient was intubated and placed on mechanical ventilation 2 days ago. \ The patient has a long history of hypertension. \ The patient passed a kidney stone this morning. \ \ Transfusion reaction is a risk factor for development of DIC. Intubation and mechanical ventilation are not risk factors for DIC. Hypertension is not associated with development of DIC. Renal calculi are not a risk factor for development of DIC. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC B \ A patient has developed disseminated intravascular coagulation. Which assessment would the nurse evaluate as reflecting the microthrombosis results of this disorder? \ Oozing from older intravenous access sites \ Jaundice \ Petechiae \ Ecchymoses \ \ Oozing from old puncture sites is a bleeding-related finding of DIC. Clinical manifestations of disseminated intravascular coagulation related to microthrombosis include oliguria, anuria, hematuria, and jaundice. Petechiae result from bleeding in the skin. Ecchymoses results from bleeding into the skin. \ 0 0 0 0
0000000000 0000000000 0 \\
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MC B \ The nurse is caring for a patient with disseminated intravascular coagulation who is bleeding from the gastrointestinal tract with a platelet count of 45,000. The nurse would anticipate which intervention for this patient? \ Heparin \ Intravenous platelets \ Warfarin \ Aspirin \ \ Heparin is beneficial when disseminated intravascular coagulation is secondary to metastatic carcinoma, dead fetus syndrome, and aortic aneurysm. Thrombocytopenia may be treated with the administration of concentrated platelets if the patient is actively bleeding or has a platelet count of less than 50,000. Warfarin is not indicated for use in DIC. Aspirin is not indicated in the treatment of this disorder. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+B+C+E \ A patient arrives at the emergency department following a gunshot wound to the abdomen. He is unresponsive and has cool, clammy skin. Paramedics were unable to initiate a peripheral IV and the patient’s abdominal wound is bleeding briskly. The nurse bases emergency interventions on which priority nursing diagnoses?
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(Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Decreased Cardiac Output \ Fluid Volume Deficit \ Risk for Shock \ Ineffective Breathing Pattern \ Altered Tissue Perfusion: Cerebral \ • Blood loss has decreased this patient’s cardiac output as evidenced by cool and clammy skin. • Due to the loss of blood through a “briskly” bleeding abdominal wound, the patient has fluid volume deficit. Decreased consciousness and cool, clammy skin are evidence of this diagnosis. • The patient is at risk for hypovolemic shock due to the nature of this wound. • There is no evidence presented that supports this nursing diagnosis. The patient may still be breathing at an acceptable rate and depth. • Lack of responsiveness may indicate poor perfusion to the brain. Since the patient is losing blood rapidly the nurse would act to support cerebral perfusion. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ A patient with thrombocytopenia has developed a nose bleed. She is confused and keeps trying to get out of bed. Which nursing diagnosis is appropriate for this situation? \
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Activity Intolerance \ Altered Comfort: Pain \ Ineffective Individual Coping \ Altered Tissue Perfusion \ \ There is no evidence that this patient is not tolerating activity. There is no information in this scenario to support the diagnosis of pain. The confusion and behaviors described in this scenario are not associated with coping dysfunction. The confusion noted in this scenario is an indicator that cerebral tissues are not being well perfused. Low platelets have resulted in a nose bleed and the patient may be bleeding occultly as well. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+B+E \ The nurse is making a follow-up call to a patient recently released from the acute care unit following treatment for thrombocytopenia. Which patient statements would the nurse consider reason to suggest contacting the primary health provider? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ “You didn’t tell me that I would have such bad, smelly diarrhea once I got home.” \ “I feel fine but my skin is a little off color.” \
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“My appetite is coming back slowly.” \ “I was able to take a walk with my dog yesterday.” \ “I keep getting headaches in the late afternoon if I am tired.” \ • Diarrhea, particularly diarrhea with a very bad smell, may indicate gastrointestinal bleeding. This finding requires further assessment. • Skin condition can reveal information about health. This comment may indicate the patient has jaundice, petechiae, or other findings associated with bleeding. This finding requires further assessment. • Return to pre-illness appetite may take time, so this is a positive statement. • This statement reveals activity tolerance and a desire for activity which indicate positive recovery. • Headaches should be investigated further as they may indicate bleeding disorders. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ A patient has been admitted with a tentative diagnosis of thrombocytopenia. Which patient statement would the nurse evaluate as significant to that disorder? \ “I started taking cimetidine for heartburn about a month ago.” \ “My family and I just got back from a vacation in the mountains.” \ “I spend a lot of time working at my computer.” \ “I have been taking a new calcium supplement.” \ \
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Cimetidine can be associated with thrombocytopenia. Change of altitude is not associated with development of thrombocytopenia. Computer work and sedentary work are not associated with development of thrombocytopenia. Calcium supplements are not associated with thrombocytopenia. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A patient has been brought to the emergency department after a traumatic amputation of his leg. His skin is pale and very cool, heart rate is 120, respirations are 28, and systolic blood pressure is dropping. From these findings the nurse would estimate that this patient has lost which percent of blood? \ Less than 15% \ 15– 30% \ 30– 40% \ Over 40% \ \ With blood loss of less than 15% the patient’s blood pressure would be stable and respirations would be stable. The patient would be cool and clammy. Heart rate elevation would be milder and systolic blood pressure would be stable. Once the patient has lost 30–40% of blood, they become severely cool and pale. Heart rate is markedly increased and systolic blood pressure begins to fall. Respiratory rate is also markedly increased. A patient who has lost over 40% of blood volume will be severely cold, pale, and mottled. Heart rate will be very high or may drop, systolic blood pressure will be low, and respiratory rate will start to drop. \
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0 0 0 0
0000000000 0000000000 0
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Chapter 29 \\ MC D \ A patient in the acute care unit has developed neutropenia. A nurse would identify which history as a possible etiology of this condition? \ The patient had symptoms of an untreated bacterial infection for a week prior to admission. \ The patient’s blood sugar was 120 mg/dL on admission. \ The patient’s lab work reveals a vitamin C deficiency. \ The patient has been receiving chemotherapy treatment for lung cancer. \ \ Untreated bacterial infections are not implicated in the development of neutropenia. Hyperglycemia is not associated with the development of neutropenia. Neutropenia can occur with a vitamin B12 deficiency, but is not found with vitamin C deficiency. Neutropenia caused by decreased production of neutrophils can occur as a result of bone marrow suppression after chemotherapy. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ A patient with neutropenia develops a fever. Which nursing action is most important? \ Discuss the finding with the primary care provider.
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\ Encourage oral fluids. \ Review the medical record for trending. \ Document this expected finding. \ \ Febrile neutropenia is a potentially life-threatening event and must be treated rapidly. This occurrence should be discussed with the primary care provider with the expectation of prescriptions for antibiotics or other treatments. Encouraging oral fluids is not a sufficient nursing action in this situation. The nurse should take action beyond review of the medical record. Fever is not an expected finding and is an especially troubling complication in a patient with neutropenia. 183. a.Allow the medication to warm to room temperature for no longer than 6 hours., e.Give the medication at least 24 hours following cytotoxic chemotherapy. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B+E \ A patient is prescribed filgrastim (Neupogen). Which nursing intervention is indicated? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Prepare the medication for intramuscular injection. \ Allow the medication to warm to room temperature for no longer than 6 hours. \
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Withdraw prescribed amount and return remaining medication to refrigerator for later use. \ Discard vial if left at room temperature for longer than 4 hours. \ Give the medication at least 24 hours following cytotoxic chemotherapy. \ • The medication is administered either through subcutaneous injection or through an intravenous access line. • The medication must be used within 6 hours if left at room temperature. • Each vial is a one-time use, therefore any unused medication in a vial is not to be saved or returned to the refrigerator for later use. • Medication should be discarded after 6 hours if left at room temperature. • Cytotoxic chemotherapy could inactivate this medication. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ A patient receiving a blood transfusion begins gasping for breath 10 minutes into the transfusion. The nurse realizes the patient is experiencing which type of hypersensitivity response? \ Type I \ Type III \ Type IV \ Type II \ \
3
A type I hypersensitivity response occurs after repeated exposure to an allergen which causes an allergen– antigen response. A type III hypersensitivity response is also an allergen–antigen response, however the complexes are found in tissues. Organ rejection is an example of this type of response. A type IV hypersensitivity response is a delayed response seen after an insect bite or with poison ivy. A transfusion reaction is a major example of a type II hypersensitivity response. The reaction will occur within minutes of beginning the transfusion and is an emergency. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ A patient, recovering from skin grafts to the arm because of burn injuries, is demonstrating an increase of drainage, bleeding, and edema. The nurse prepares to treat which complication? \ Arthus reaction \ Serum sickness \ Type I hypersensitivity reaction \ Type IV hypersensitivity reaction \ \
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The Arthus reaction is a localized skin reaction in which antigen-antibody complexes form in vessel walls, triggering an inflammatory response in the vessels. The reaction onset is relatively rapid, usually within 1 hour of exposure, and peaks within 6 to 12 hours. The clinical manifestations are those caused by the inflammatory response and include leaking of fluid causing edema and hemorrhage. Serum sickness is a systemic type III hypersensitivity response. A type I hypersensitivity reaction occurs after repeated exposure to an allergen which causes an allergen– antigen response. A type IV hypersensitivity reaction is a delayed response seen after an insect bite or with poison ivy. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ A patient tells the nurse that he had a tuberculin test several months ago and the site of injection became very red and inflamed. How should the nurse interpret this information? \ This Arthus reaction is common with tuberculin tests. \ This type IV hypersensitivity response indicates the tuberculin test was positive. \ Since this type II hypersensitivity response occurred, the patient should never have another tuberculin test. \ The patient will require chest x-ray confirmation of this type I hypersensitivity response. \ \ An Arthus reaction is a localized skin reaction in which antigen–antibody complexes form in vessel walls, triggering an inflammatory response in the vessels. Tuberculin testing does not result in Arthus reaction. A type IV hypersensitivity response is seen in the induration of a positive tuberculin test. This is not a type II hypersensitivity response. This is not a type I hypersensitivity response.
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\ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ A patient with an autoimmune disorder says, “I don’t know why this happened to me. I try to exercise and eat well.” How should the nurse respond? \ “These disorders are usually associated with a vitamin deficiency.” \ “These problems happen when your body misinterprets normal cells as being foreign and attempts to destroy them.” \ “It happened because you were exposed to something repeatedly and then the body decided it needed to destroy it.” \ “Chronic illnesses are the cause of autoimmune disorders.” \ \ Autoimmune disorders are not specifically linked to vitamin deficiencies. One theory about autoimmunity is that of molecular mimicry. This is when the body will react appropriately to an allergen but then incorrectly identifies normal body tissue as being the same allergen and begins to destroy normal tissue. Autoimmune disorders do not occur in response to repeated exposure to an allergen. Autoimmune disorders are not linked specifically to chronic illnesses. \ 0 0 0
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0
0000000000 0000000000 0 \\ MC A \ The blood sample from a patient's bone marrow biopsy included Auer rods. The nurse would prepare to provide care for which disorder? \ Acute myelogenous leukemia \ Chronic myelogenous leukemia \ Acute lymphocytic leukemia \ Chronic lymphocytic leukemia \ \ An examination of peripheral blood and the bone marrow in a patient with acute myelogenous leukemia might include Auer rods which are abnormally large granule-containing needle-like rods in the cytoplasm. These rods are most commonly found in blast cells taken from the bone marrow and blood from patients with acute myelogenous leukemia. Auer rods are not associated with chronic myelogenous leukemia. Auer rods are not associated with acute lymphocytic leukemia. Auer rods are not associated with chronic lymphocytic leukemia. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC B \ A patient with leukemia begins to have seizures. The nurse realizes that the onset of seizure activity is most likely associated with which occurrence? \ The patient’s hemodynamic instability has decreased cerebral perfusion. \ Malignant cells have infiltrated into the central nervous system. \ Pancytopenia is occurring. \ Expansion of malignant cells has started. \ \ This is not the most likely reason for this seizure activity. Signs and symptoms of infiltration into the central nervous system include headache, nausea, vomiting, seizures, and coma. Signs and symptoms of pancytopenia include frequent infections, fevers, bleeding gums, and fatigue. Signs and symptoms of malignant cell expansion include bone tenderness or pain and impaired circulation. \ 0 0 0 0
0000000000 0000000000 0 \\ MC
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C \ A patient with acute myelogenous leukemia is scheduled for a hematopoietic stem-cell transplant (HSCT). How would the nurse categorize this patient’s treatment goal? \ Remission from the disease for at least 5 years \ Prolongation of the chronic phase of the disease for at least 10 years \ To affect cure \ To shorten the acute phase of the disease \ \ Limited remission is not the goal of HSCT. Acute myelogenous leukemia does not have a chronic stage. For some disorders such as acute myelogenous leukemia, hematopoietic stem-cell transplant is the only potential curative option. Cure is the goal of HSCT. Acute myelogenous leukemia does not have an acute stage. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A female patient is concerned after learning that a person with whom she had a casual sexual encounter has been diagnosed as being HIV positive. Which other patient statement would the nurse evaluate as significant? \ “I have not felt bad since the possible exposure.” \ “We were only together for about a week and had sex 3 or 4 times.”
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\ “I did have a cold and sore throat last week, but it has cleared up without problems.” \ “I had a normal period just a few days after we broke up.” \ \ There is a clinical latency period or asymptomatic stage that is generally present at the beginning of infection. The fact that the patient has not been symptomatic is not significant. The number of exposures is not significant in that infection can occur with one exposure. Within about 3 to 6 weeks after exposure to the virus, a transient flu-like or mononucleosis-like disease may occur. The presence of normal menses does not decrease the risk of infection. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B+D+E \ A patient infected with HIV is being monitored for the development of AIDS. Which characteristics would the nurse monitor? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ White blood count \ CD4+T cell count \ Presence of recurrent E. coli urinary tract infection \ Presence of Pneumocystis jiroveci (PJP) infection
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\ Presence of cytomegalovirus (CMV) \ • White blood count does not indicate whether or not AIDS has developed. • An HIV seropositive patient’s CD4+T count is monitored. If this count is less than 200 cells/mL, a diagnosis of AIDS is made. • E. coli urinary tract infections are not associated with AIDS. • PJP is an “AIDS-defining” illness. • CMV is an “AIDS-defining” illness. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A 55-year-old patient tells the nurse that he seems to be getting “more colds” as he gets older. Which possible explanation would the nurse have for this observation? \ Aging causes the immune system to have difficulty determining self from non-self cells. \ With aging, the body has increased difficulty recognizing mutated cells. \ The thymus gland shrinks with aging, reducing the maturation and differentiation of T cells needed to fight infections. \ The thyroid gland begins to malfunction after the 4th decade of life. \ \
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The ability of the immune system to discriminate between antigens that are “self” from those that are “non-self” would explain the increased incidence of autoimmune diseases in middle age and older patients, but not increase in infectious diseases. The body's immune system becoming less efficient at recognizing and destroying mutated cells can explain the increased incidence of cancer in the older adult, not increase in infectious diseases. The function of the immune system declines with age. The thymus gland, where T lymphocytes mature and differentiate, begins to atrophy early in life and continues to shrink until a person reaches middle age. Although T lymphocytes continue to be produced, their maturation and differentiation into the various functional T cells decreases. This places the older patient at higher risk for increased frequency and severity of infections accompanied by a decreased ability to resolve the infection. The thyroid gland plays no significant role in immunity. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ An elderly patient admitted with malnutrition begins to demonstrate signs of pneumonia. The nurse would explain which possible etiology of this pneumonia? \ There is a lack of nutrients to support immune function. \ Insufficient fluid intake has allowed bacteria to grow. \ The patient’s malnutrition resulted from poor living conditions making infection more likely. \ Poor nutrition has resulted in a deficiency of vitamin C. \ \
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Malnutrition affects the immune system because calories and protein are needed to form and maintain the T cells and immunoglobulins. An insufficient fluid intake could exacerbate the symptoms of pneumonia but not cause the illness. There is no evidence to support the presence of poor living conditions. Vitamin C deficiency is not implicated in the development of pneumonia. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ A patient tells the nurse that it seems like the only time she gets a cold is when she is under higher than normal stress. What information should the nurse provide? \ “You probably don’t eat as well when you are under stress.” \ “You probably don’t rest and sleep as well when your stress is high.” \ “Stress causes your body to have an autoimmune response.” \ “Stress increases cortisol which suppresses your immune system.” \ \ This is an assumption on the nurse’s part. There is no evidence that a change in nutrient intake exists. This is an assumption on the nurse’s part. There is no evidence that lack of sleep and rest exist. Colds are not a result of an autoimmune response. Cortisol has a direct suppressing effect on the immune system by inhibiting the production of interleukins which stimulate T and B cell production and response. \ 0
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0 0 0
0000000000 0000000000 0 \\ MC A+E \ The nurse is assessing a patient for altered immunocompetence. Which findings would indicate that the patient is at risk for developing an immunocompetence-associated illness? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Slow wound healing and easy bruising \ Bursitis and muscle cramps \ Heart palpitations \ Heartburn and increased flatus \ Mouth sores and oral patches \ • Assessment data that could indicate an immunocompetence-associated illness includes slow wound healing and easy bruising. • Bursitis and muscle cramps have little association with altered immunocompetence. • Heart palpitations have little association with altered immunocompetence. • Heartburn and increased flatus are not associated with altered immunocompetence. • Mouth sores and oral patches are related to immunocompetence. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC C \ The nurse is instructing a patient with a compromised immune status on the signs and symptoms of infections. What should be included in these instructions? \ Increased sputum production \ Cloudy urine \ Irritated oral mucosa \ Purulent wound drainage \ \ The immunocompromised patient will not demonstrate a normal immune response so clinical findings will be different. These patients will not be able to form pus so common infection findings such as increased sputum production will not occur. Cloudy urine occurs because of pus. The immunocompromised patient will not demonstrate a normal immune response and may not be able to produce pus. Monitoring for infection should focus on the mucous membranes, skin, and lungs, which are the most common sites of infection in this patient population. The nurse should instruct the patient to suspect irritated oral mucosa as a sign of infection. Purulent wound drainage is due to the production of pus. The immunocompromised patient may not be able to mount an immune response that will produce pus. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC A+B+C \ A patient hospitalized for treatment of a mediastinal malignancy is at risk for developing superior vena cava (SVC) syndrome. The nurse would monitor for the development of which signs of this disorder? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Headache \ Distended neck veins \ Flushed face \ Decreased pedal pulses \ Pain in the lower back \ • SVC syndrome causes decreased venous drainage in the upper body. Headache is a finding associated with this syndrome. • SVC syndrome results in decreased venous drainage in the upper trunk. The nurse should monitor for distention of neck veins. • HeartSVC syndrome results in decreased venous drainage in the upper trunk. Flushing of the face is a symptom. • SVC syndrome involves the upper trunk and is not associated with the lower extremities. • SVC syndrome is not associated with back pain. Spinal cord compression is an oncologic emergency that causes back pain. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC A+C+D \ A patient receiving treatment for lymphoma suddenly becomes critically ill and is diagnosed with tumor lysis syndrome. The nurse would review laboratory results for which expected levels? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ High serum phosphate \ Low serum potassium \ Low serum calcium \ High uric acid \ Hyponatremia \ • SVC syndrome causes decreased venous drainage in the upper body. Headache is a finding associated with this syndrome. • Potassium levels will be elevated due to the release of potassium as cells lyse. • One of the effects of tumor lysis syndrome is a decrease in serum calcium. • Hyperuricemia is a finding associated with tumor lysis syndrome due to rapid death of tumor cells • Hyponatremia is not associated with tumor lysis syndrome. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC C \ A patient being treated with isoniazid for tuberculosis develops symptoms of systemic lupus erythematosus (SLE). The patient says, “I can’t believe that I am so sick. First I get TB and now this. What is going to happen to me?” What nursing response is indicated? \ “You will have to learn to manage both the TB and the SLE.” \ “Once your TB is cured, we can help you fight the SLE.” \ “Often the SLE symptoms go away after the TB medication is changed.” \ “Your immune system must be under a great deal of stress for both of these diseases to develop.” \ \ This is not a therapeutic response and should not be used with this patient. There is no indication that SLE treatment must be delayed until the TB is cured. Drug-induced SLE often resolves upon discontinuation of the drug. Immunity is not associated with the development of this patient’s SLE. \ 0 0 0 0
0000000000 0000000000 0
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Chapter 30 \\ MC B \ The nurse notices that a patient in the intensive care unit has lost muscle mass and tone in his arms and legs. The nurse would attribute this loss to changes in which process? \ Energy \ Catabolism \ Adenosine triphosphate \ Anabolism \ \ Energy is the ability of the body to do work and is measured in calories. It is not directly associated with the loss of muscle mass in this patient. Catabolism is the process by which complex nutrients and body tissues are broken down into more basic elements such as glucose, fatty acids, and amino acids for the purpose of liberating energy necessary to maintain bodily functions. The patient in the intensive care unit has lost muscle tone which is evidence of catabolism of body tissues. Adenosine triphosphate is a source of energy in the body. It is not directly associated with the loss of muscle mass in this patient. Anabolism is the process of cell synthesis which builds body tissues. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A
1
\ A patient who is being mechanically ventilated is demonstrating respiratory acidosis. The nurse suspects that which metabolic process is malfunctioning? \ Anaerobic metabolism \ Catabolism \ Aerobic metabolism \ Anabolism \ \ Anaerobic metabolism occurs in the absence of oxygen; however, the patient is being mechanically ventilated so oxygen should be present. Catabolism is the process by which complex nutrients and body tissues are broken down into more basic elements such as glucose, fatty acids, and amino acids for the purpose of liberating energy necessary to maintain bodily functions. It is not associated with development of respiratory acidosis in this patient. Aerobic metabolism forms adenosine triphosphate through the Krebs cycle. The byproducts of this metabolism are carbon dioxide and water. Carbon dioxide and water normally are harmless and easily excreted from the body; however, excess retention of either of these substances can result in acid–base and fluid excess problems. Anabolism is the process of cell synthesis which builds body tissues and would not result in respiratory acidosis in this patient. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A patient's blood oxygen level is measured to be 78%. The nurse implements interventions to improve this level to avoid development of which situation?
2
\ Anabolism \ Catabolism \ Anaerobic metabolism \ Aerobic metabolism \ \ Anabolism is the process of cell synthesis which builds body tissues. Catabolism is the process by which complex nutrients and body tissues are broken down into more basic elements such as glucose, fatty acids, and amino acids for the purpose of liberating energy necessary to maintain bodily functions. Anaerobic metabolism is partially a compensatory mechanism that allows energy production to proceed whenever energy demands exceed the oxygen supply, such as during exercise. Anaerobic metabolism, however, is intended only to be temporary and cannot sustain life indefinitely. Aerobic metabolism occurs in the presence of oxygen and is the normal state. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ It has been calculated that a patient in the intensive care unit needs 1800 calories each day to sustain normal metabolic functioning. The nurse calculates that which number of calories is needed to sustain central nervous system functioning? \ 1440 calories \ 360 calories
3
\ 900 calories \ 720 calories \ \ The central nervous system will not require this many calories. Central nervous system functions require about 20 percent of the energy expenditure. The patient's daily needs are 1800 calories. Twenty percent of this number of calories is 360 calories. The central nervous system will not require this number of calories for normal function. The central nervous system will not require this number of calories for normal function. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ A patient in the intensive care unit is surprised to learn that he has an elevated blood glucose level since he has not been diagnosed with diabetes. How should the nurse explain this elevation? \ Many people are not diagnosed with diabetes until they are admitted to an intensive care unit. \ Increasing blood glucose is the body's way of making sure there is enough energy for brain functioning. \ Many people have diabetes but are not aware of it. \ When stressed, the body releases more glucose into the blood, raising the blood glucose level. \ \
4
This patient’s blood glucose elevation is not likely associated with undiagnosed diabetes. This statement is not correct and should not be given to the patient. This is a true statement, but it probably does not address this patient’s situation. Stored glycogen is released into the bloodstream in response to increased levels of epinephrine, norepinephrine, vasopressin, and angiotensin II. These are hormones that are released rapidly during physiologic stress, leading to hyperglycemia as a metabolic stress response. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ A patient is admitted with poor wound healing and malnutrition. To best address issues of wound healing the nurse designs interventions to support intake of which nutrient? \ Protein \ Minerals \ Carbohydrates \ Lipids \ \ In the high-acuity patient, inadequate protein intake can quickly lead to malnutrition, prolonged wound healing, diminished resistance to infection, and even death. Mineral intake is important, but cannot reverse poor wound healing in the absence of another critical nutrient. Adequate carbohydrate intake is important, but absence of a different nutrient is more implicated in poor healing. Lipids are an energy source and cannot contribute to wound healing without a different essential nutrient. \
5
0 0 0 0
0000000000 0000000000 0 \\ MC B \ A patient with poorly controlled diabetes has elevated lipid levels in spite of her attempts to decrease fat and carbohydrate intake. How should the nurse explain this finding? \ “You are not eating enough and your proteins are breaking down.” \ “Your body is using your high glucose levels to produce lipids.” \ “You are not eating enough carbohydrates.” \ “Most persons with diabetes are not able to efficiently metabolize fats.” \ \ An elevated lipid level in the presence of an elevated glucose level does not mean that there is a breakdown of protein. The liver can produce lipids from glucose through a process called lipogenesis. This occurs when there are more carbohydrates present than required for energy or for glycogen storage in the liver. Insufficient intake of carbohydrates will not result in high lipid levels. There is no truth to this statement. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC B \ A male patient is 6 feet 2 inches tall with a body weight of 145 lbs. The nurse would calculate this patient's BMI to be in which category? \ Underweight \ Normal \ Overweight \ Obese \ \ This patient’s BMI is too high to fall in the underweight range. This patient’s BMI is 18.69 which falls into the normal range. This patient’s BMI does not fall in the overweight range. This patient’s BMI does not put him in the obese range. \ 0 0 0 0
0000000000 0000000000 0
7
\\ MC A \ A patient has been in the intensive care unit for 10 days after a traumatic injury requiring intubation and multiple blood transfusions. The patient now has assessment findings consistent with protein malnutrition. Which laboratory result would the nurse evaluate as supporting this diagnosis? \ Prealbumin level 15 mg/dL \ Transferrin level 325 mcg/dL \ BUN level 10 mg/dL \ Albumin level 4.0 g/Dl \ \ A prealbumin level of less than 17 mg/dL indicates protein-energy malnutrition. Since the half-life of prealbumin is 2–3 days, this laboratory test assists in monitoring acute changes in nutritional status. Transferrin’s use as an indicator of nutrition in the high-acuity patient may be limited because of other bloodrelated factors, such as blood loss anemia or blood transfusions. This is a normal transferrin level. Urine urea nitrogen (UUN) is more significant in assessing nutritional status than is blood urea nitrogen (BUN). This is a normal BUN. Albumin is not a good indicator of acute changes in nutritional status. This is a normal albumin level. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \
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The nurse is explaining the mechanics of collecting a 24 hour urine urea nitrogen test to the patient. The nurse would also explain which purpose of this test? \ Fluid status \ Kidney function \ Blood volume \ Nitrogen balance \ \ A 24 hour urine collection for urine urea will not provide information about fluid status. Blood urea nitrogen or BUN will reveal information about kidney function. Collection of a 24 hour urine test will not reveal information regarding blood volume. In the high-acuity patient, nitrogen balance may be evaluated as an indicator of protein status. Nitrogen balance is the difference between nitrogen output and nitrogen intake, and is measured by a test called the urine urea nitrogen test. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A patient who is hemodynamically stable has been receiving protein replacement therapy for several days. The nurse realizes that which laboratory test would be the best to determine the patient's current nutritional status? \ Total lymphocyte count \ Albumin \
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Transferrin \ Vitamin assay \ \ Total lymphocyte count should be interpreted with caution in the high-acuity patient experiencing hypermetabolism or infections. Albumin should not be used as an indicator to detect early malnutrition or effectiveness of nutrition support. Transferrin is a plasma protein that binds with and transports iron to cells and may be more useful than albumin for tracking responses to nutritional therapies because its half-life is 8 to 10 days. Use of transferrin as an indicator of adequacy of nutrition in the high-acuity patient may be limited because of other blood-related factors, such as blood loss anemia or blood transfusions, however the patient is hemodynamically stable and therefore transferrin is the best way to determine the patient's nutritional status at this time. Vitamin assays should be assessed if the patient has a digestive or absorptive disorder, but that information is not provided in this question. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ A patient, diagnosed with malnutrition and who has known exposure to Candida was given an intradermal Candida test dose 3 days ago. The site is currently showing no signs of induration. How would the nurse evaluate this finding? \ There is lack of anergy. \ There is no current infection with Candida. \ The immune system has been impaired, possibly by malnutrition. \
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The test should be repeated in 48 hours. \ \ Lack of induration reveals positive anergy. This test is not being done to test for current infection with Candida. Cell-mediated immunity is one of the body's defense mechanisms that is most affected by malnutrition. Skin testing is a simple method for evaluating cell-mediated immunity status. A test dose of a known antigen, such as Candida, is administered intradermally. The patient's ability to respond to this immunologic challenge is evaluated 24 and 48 hours after administration. If cellular immunity is intact, an induration of 2 to 5 mm should be observed at the injection site. If no skin reaction occurs, the patient is considered to be anergic, which means that cellular immunity may have been negatively affected by malnutrition. There is no indication that the test should be repeated. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C+D \ A patient in the intensive care unit is at risk for developing malnutrition. Indirect calorimetry is planned to estimate the patient’s caloric needs. Which information would the nurse provide to this patient? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ “You will be taken to a special chamber where you can be isolated.” \ “You will be required to exercise on a treadmill for this testing.” \ “You can expect this test to take about 15–20 minutes.” \ “In order for results to be accurate, I will need to measure your height.”
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\ “We will not be able to do this test until you are off the mechanical ventilator.” \ • Isolation in a special chamber is required for direct calorimetry. • Treadmill exercise is not a part of this testing. • Indirect calorimetry is done at the bedside in about 15–20 minutes. • Height is a parameter used in this determination. • Patients on mechanical ventilators can have this testing. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B+E \ A patient's respiratory quotient is measured to be 1.1. How would the nurse interpret this information? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ A vitamin deficiency is present. \ The patient has the potential to retain carbon dioxide. \ Malnutrition is present. \ The patient has fluid overload. \ The patient is receiving too much carbohydrate. \ • Respiratory quotient is not associated with vitamin deficiency.
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• • • •
A respiratory quotient above 1.0 indicates that the patient is receiving too much carbohydrate. Because glucose breaks down to carbon dioxide, excess carbohydrate intake can potentially result in carbon dioxide retention. Respiratory quotient does not measure malnutrition. Respiratory quotient does not measure fluid balance. A respiratory quotient above 1.0 indicates the patient is receiving too much carbohydrate.
\ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ The nurse is monitoring a patient's metabolic status with a thermodilution catheter to determine oxygen saturation of venous blood. How would the nurse report the findings of this test? \ As oxygen extraction \ Using the Fick equation \ As indirect calorimetry \ As direct calorimetry \ \ Oxygen extraction is measured with the use of a special thermodilution catheter at the bedside. The Fick equation requires blood gas analysis of arterial and venous blood. An indirect calorimetry is done with the use of a portable unit called a metabolic cart. A direct calorimetry is done with the use of a special room. \ 0
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0 0 0
0000000000 0000000000 0 \\ MC A+B \ The nurse is going to calculate a patient's metabolic needs by using the Harris-Benedict equation. Which information should the nurse collect for this calculation? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Height in centimeters \ Weight in kilograms \ Age in months \ Body mass index \ Body temperature \ • Height in centimeters is used in the Harris-Benedict calculation. • Weight in kilograms is used in the Harris-Benedict calculation. • Age in years is used in the Harris-Benedict calculation. • Body mass index is not used in the Harris-Benedict calculation. • Body temperature is not used in the Harris-Benedict calculation. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC A \ A patient has a pituitary adenoma that has increased secretion of thyroid-stimulating hormone. Which nutritional effect, if any, will the nurse note in this patient? \ Metabolism will be increased. \ The patient’s appetite will be suppressed. \ No changes will be noted. \ The patient will crave salt. \ \ The primary function of the thyroid gland is to increase metabolism. Increase in thyroid-stimulating hormone will increase thyroid hormone and will increase metabolism. It is more likely that the patient’s appetite will be increased. Thyroid hormone does affect nutrition. There is no indication that increase in thyroid action will cause the patient to crave salt. \ 0 0 0 0
0000000000
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0000000000 0 \\ MC A+B+E \ The patient was admitted to the emergency department after being injured in a drive-by shooting. Despite very serious injuries, the patient is awake and alert and cries continuously that “someone tried to kill me.” The nurse tries to calm the patient because of which catecholamine affects? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Increased heart rate \ Increased blood pressure \ Constriction of coronary vessels \ Constriction of blood vessels in skeletal muscles \ Increase in blood glucose \ • Catecholamines increase heart rate. • Catecholamines increase blood pressure. • Catecholamines dilate coronary vessels. • Catecholamines dilate blood vessels in skeletal muscles. • Catecholamines increase blood glucose. \ 0 0 0 0
0000000000 0000000000 0 \\
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MC A+B \ The nurse is reviewing laboratory results and the dietician’s analysis of a hospitalized patient’s normal home diet. The nurse would plan to support additional amounts of nutrients based on which percentages? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Carbohydrates 35% \ Fat 7% \ Protein 45% \ Thiamine 18 ng/mL \ Magnesium 2.2 mEq/L \ • A normal carbohydrate intake for an adult is between 40–60% of daily diet. This patient’s intake should be supported with additional carbohydrates. • Fats are required for absorption of fat soluble vitamins. This patient is not consuming enough fat. • This protein intake is excessive so increasing intake is not appropriate. • This is a normal thiamine level so supplementation is not necessary. • This is a normal magnesium level so supplementation is not indicated. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \
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It is necessary to measure a patient’s height, but the patient’s legs are suspended in traction. Which nursing action is indicated? \ Measure from the patient’s head to the iliac crest and use a standard table to estimate height. \ Remove the traction weights long enough to quickly measure length of one leg. \ Measure the patient’s arm span. \ Estimate the patient’s height from his stated weight. \ \ No such standard table exists. Traction weights should not be removed. Arm span correlates with height at maturity. There is no reliable method of estimating height from stated weight. \ 0 0 0 0
0000000000 0000000000 0
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Chapter 31 \\ MC A+C+D \ A nurse is providing care to a patient diagnosed with urinary sepsis. Which symptoms would the nurse evaluate as indicating the patient has entered the flow stage of metabolic response to this physiologic stress? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ The patient’s heart rate has increased to 125 bpm. \ The patient’s respiratory rate has dropped from 24 to 18. \ The patient’s cardiac output has increased. \ The patient’s temperature is 101.6°F. \ The patient’s blood pressure has been stable for 24 hours. \ • The onset of tachycardia is a typical symptom of the flow phase. • The nurse would expect a patient in flow phase to have tachypnea. • An increased cardiac output indicates movement to the flow phase. • Fever is an indicator of movement to the flow phase. • Stability of blood pressure is not indicative of movement to the flow stage. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+C+D+E
1
\ A patient has been tentatively diagnosed with adrenal insufficiency. Which findings would the nurse evaluate as supporting this diagnosis? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ The patient’s low blood pressure is not responding to fluid infusion. \ The patient’s heart rate is consistently lower than 60 bpm. \ The patient has had a fever for a week. \ Arterial blood gas results reveal acidosis. \ The patient reports abdominal pain. \ • Hypotension that is refractory to volume administration is a manifestation of adrenal insufficiency. • Tachycardia is a manifestation of adrenal insufficiency. • Fever is a manifestation of adrenal insufficiency. • Acidosis is a manifestation of adrenal insufficiency. • Abdominal pain is a manifestation of adrenal insufficiency. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ A patient is being tested for adrenal insufficiency with the rapid ACTH stimulation test. How will the nurse explain this test to the patient? \
2
You will drink about a cup of a salty-tasting fluid during this test. \ It will take several hours to complete this test. \ We have to do this test first thing in the morning, just after you awaken. \ A series of blood samples will be drawn during this test. \ \ There is no need for the patient to drink anything during this test. The test will take less than 2 hours to complete. The rapid ACTH test is not affected by diurnal variations and can be done at any time of the day or night. A baseline arterial blood sample is drawn, followed by administration of synthetic ACTH, followed by a second blood sample for plasma cortisol level. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ A critically ill patient’s plasma cortisol level is 2.6 mcg/dL. Which intervention does the nurse expect? \ Treatment for adrenal insufficiency \ Treatment for adrenal excess \ Continued diagnostic testing of adrenal function. \ Emergency dialysis \ \
3
Very low baseline cortisol level (less than 3 mcg/dL) in a critically ill patient indicates therapy for adrenal insufficiency is indicated. This plasma cortisol level does not indicate adrenal excess. This plasma cortisol level is diagnostic in this patient situation, so additional testing is not needed. Emergency dialysis is not indicated by this lab result. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+B+C+E \ The nurse is advised that a patient diagnosed with hyperthyroid crisis will be admitted from the emergency department. The nurse prepares to care for a patient with which possible conditions? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Atrial fibrillation \ High fever \ Congestive heart failure \ Constipation \ Agitation \ • Atrial fibrillation is common in patients with hyperthyroid crisis. • The metabolic effects of hyperthyroidism include high fever. • Development of congestive heart failure is a common cardiovascular effect of hyperthyroid crisis. • Diarrhea is a common effect of hyperthyroid crisis.
4
•
Agitation is caused by the neurological effects of hyperthyroidism.
\ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A patient diagnosed with hyperthyroid crisis is receiving propylthiouracil (PTU). The nurse will increase monitoring for which adverse reaction? \ Tremors \ Emotional outbursts \ Elevation of WBC \ Widening of pulse pressure \ \ Tremors are more likely to occur due to hyperthyroidism. Emotional lability is more likely to occur due to hyperthyroidism. Elevation of WBC is an adverse effect of PTU. Widening of pulse pressure is associated with hyperthyroidism. \ 0 0 0 0
5
0000000000 0000000000 0 \\ MC A \ A critically ill patient requires IV insulin for persistent hyperglycemia. Current finger stick blood glucose is 68 mg/dL. According to international critical care guidelines, which nursing intervention is indicated? \ Call for a laboratory glucose test. \ Increase the rate of the insulin drip by 2 units per hour. \ Administer 10 mL of D5W by bolus injection. \ Administer 0.5 g sugar dissolved in orange juice by mouth. \ \ According to guidelines from the Society of Critical Care Medicine and the Surviving Sepsis Campaign, full blood or plasma testing is indicated. This blood glucose reading is low, so additional insulin is not indicated. Treating this patient for hypoglycemia is premature. Treating this patient for hypoglycemia is premature. \ 0 0 0 0
0000000000 0000000000
6
0 \\ MC B \ A patient who has required an insulin drip is being transitioned to subcutaneous insulin. Which intervention would the nurse anticipate? \ Administering NPH insulin subcutaneously every two hours according to finger stick blood sugar. \ Administering the prescribed dose of NPH insulin two hours before discontinuing the insulin drip. \ Tapering the insulin drip administration rate over the next several days. \ Plan to administer twice the number of units of NPH insulin that the patient has been receiving per hour in regular insulin. \ \ The insulin administered according to finger stick blood sugar should be regular insulin. In order to maintain blood glucose levels, the nurse should plan to administer the ordered NPH insulin two hours before the rapidly acting regular insulin being administered by IV is discontinued. Transition to NPH insulin is generally done by discontinuing the regular insulin drip without tapering. The total daily dose of NPH insulin will be half the total regular insulin dose administered over the last 24 hours. This NPH insulin will be administered in two divided doses. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+B+D \
7
A patient is diagnosed with hyperglycemic hyperosmolar state (HHS). Which interventions would the nurse anticipate? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Potassium supplementation \ Testing for sources of infection \ Increasing amount of NPH insulin administered \ Increasing IV fluid administration \ Monitoring arterial blood gases \ • HHS can cause either potassium deficit or excess. Potassium supplementation may be necessary. • Infection can cause HHS. Identification and management of causative factors is important. • HHS management requires administration of IV insulin. • HHS results in dehydration that is managed with IV fluids. • Monitoring patient’s level of consciousness \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ The patient whose lower extremities were crushed in a motor vehicle accident is likely experiencing “fight-orflight.” Which finding would the nurse attribute to that neuroendocrine response? \ Heart rate is 78.
8
\ Bowel sounds are diminished. \ Very little bleeding from the injury \ Decreased level of consciousness \ \ The fight-or-flight response increases heart rate. Part of the fight-or-flight response is the decrease of blood flow to abdominal organs. Decreased bowel sounds are expected. Fight-or-flight increased blood flow to skeletal muscles, so increased bleeding would be possible. Fight-or-flight causes increased blood flow to the brain. Decrease in level of conscious specifically related to fight-or-flight is not expected. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ A patient was severely injured when a building exploded. The patient’s pain level report does not seem to reflect the severity of these injuries. How would the nurse evaluate this response? \ The patient is in shock and cannot respond to painful stimuli. \ Someone at the scene must have given the patient pain medication. \ The patient has increased endogenous opioids. \ The patient does not understand the severity of the injuries. \
9
\ Patients in shock do report experiencing pain. There is no reason to assume that this patient was given pain medication based upon this response. During stress the pituitary gland increases endogenous opioids which provide some analgesia. Perception of pain is not related to having a clear understanding of the severity of injuries. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ Because a patient is experiencing the fight-or-flight stage of the stress response, the nurse would be least concerned about which laboratory finding? \ Serum glucose 80 mg/L \ Serum potassium 3.3 mEq/L \ Serum sodium 148 mEq/L \ Total bilirubin 2.4 mg/Dl \ \ Serum glucose would be expected to increase during this response. A low glucose may indicate severe hypoglycemia. Hypokalemia is not an expected effect of the stress response. The stress response results in an increased serum sodium level as the body attempts to support cardiac output. Total bilirubin of 2.4 mg/dL is high and should be further assessed. Total bilirubin is not affected by the stress response. \
10
0 0 0 0
0000000000 0000000000 0 \\ MC A \ A patient is still hypermetabolic two weeks after his injury. What finding would the nurse expect? \ Muscle wasting \ Low serum BUN levels \ Hypoglycemia \ Decreased level of consciousness \ \ The hypermetabolic state results in the breakdown of body proteins. Muscle wasting is a finding associated with this breakdown. BUN levels would be likely to risk as proteins are broken down. Since stress is continuing, glucose levels are likely to be elevated. Changes in level of consciousness are not related to hypercatabolism. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC A \ A patient who is being mechanically ventilated has been prescribed hydrocortisone for treatment of adrenal insufficiency. Which nursing intervention should be implemented? \ Range of motion exercising \ Expect urine to be cloudy \ Increase monitoring for thrombus development \ Mix all IV medications in D5W for administration \ \ Hydrocortisone increases risk of myopathy. Early activity and physical therapy are indicated. Range of motion exercising is an appropriate level of exercise for a patient being mechanically ventilated. Cloudy urine is not an expected effect of hydrocortisone therapy. Thrombocytopenia is a severe adverse effect of hydrocortisone therapy. Hydrocortisone therapy places the patient at risk for hypoglycemia. Carbohydrates should be limited. \ 0 0 0 0
0000000000 0000000000 0 \\ MC
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A \ A patient who is receiving taper doses of hydrocortisone has been taking oral medication for 3 days. This morning the patient has assessment findings of recurrent adrenal insufficiency. What nursing action, if any, is indicated? \ These symptoms may come and go for several days, so no action is necessary. \ Discuss this assessment with the primary health care provider. \ Give a dose of methylprednisolone instead of hydrocortisone. \ Give the next hydrocortisone by IV. \ \ The return of symptoms is not expected. It may be necessary to return this patient to full-dose therapy. The nurse should discuss this assessment with the provider. Methylprednisolone and hydrocortisone are interchangeable, so in effect, the nurse is making no therapy changes. Giving the next dose by IV is not a sufficient intervention. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+C+D+E \ The nurse has established the nursing diagnosis of Risk for Decreased Cardiac Output for a patient who has hyperthyroidism. Which interventions are indicated to address this diagnosis? (Select all that apply.)
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Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Monitor for development of peripheral edema. \ Keep room warm. \ Provide medications to manage pain. \ Frequently reassure and calm the patient. \ Monitor activity tolerance. \ • Development of peripheral edema can be related to cardiac output changes. • The patient with hyperthyroidism may have a fever. A cool ambient temperature is advised. • Pain increases stress, which exacerbates the effects of hyperthyroidism. • Increased stress exacerbates the effects of hyperthyroidism. The nurse should try to keep the patient calm and relaxed. • Inability to tolerate activity may be an indication of poor cardiac output. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ A patient is receiving radiation treatment for laryngeal cancer. Which ECG change would the nurse evaluate as indicating need to assess this patient for hypothyroidism? \ Inverted T wave \ Shortened PR interval \
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P wave inversion \ Atrial fibrillation \ \ Inversion of the T wave may occur with hypothyroidism. PR interval prolongation may occur with hypothyroidism. P wave inversion is not a typical ECG change in hypothyroidism. Ventricular arrhythmias are more common in hypothyroidism. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ Which nursing interventions are indicated to support the outcome of “maintain normal body temperature” for a patient with hyperthyroidism? \ Keep room door closed. \ Provide an additional blanket. \ Consider a cooling blanket if fever is greater than 102°F. \ Place a scarflike covering over the patient’s head. \ \ Keeping the room door closed may trap heat in the room, which is not desired. Light bedclothes should be used for this patient. This patient is at risk for very high temperatures. A cooling blanket should be used if fever exceeds 102°F. The head is a source of heat loss. For this patient, the head should be left uncovered.
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\ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ A nurse is reviewing laboratory results for a patient just admitted to the intensive care unit. The patient is not known to have diabetes, but initial non-fasting blood sugar is 140 mg/dL. At which point would the nurse expect insulin therapy to begin? \ When fasting blood sugar exceeds 110 mg/dL \ When the patient shows assessment findings associated with hyperglycemia \ If another random blood glucose is in the same range as this initial reading \ When fasting blood glucose levels reach 180 mg/dL \ \ This blood glucose level would not require insulin administration. Insulin administration need is determined by blood glucose levels. Hyperglycemia shares assessment findings with many other conditions. It is not necessary to treat this blood glucose level with insulin even if it is persistent. Insulin therapy should be initiated for persistent hyperglycemia, defined as a blood glucose level of 180 mg/dL. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC C \ The nurse realizes that increased interventions to prevent infection are necessary when the patient is under stress. Which effect of cortisol complicates this risk? \ Increased release of histamines \ Increased production of eosinophils \ Causing a shift to the left \ Increasing serum sodium levels \ \ Cortisol suppresses the immune system by decreasing release of histamines, which reduces inflammatory response. The production of eosinphils decreases decreasing the inflammatory response. Cortisol results in release of immature neutrophils or a “shift to the left.” Cortisol does increase serum sodium levels, but this has little effect on immune status. \ 0 0 0 0
0000000000
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0000000000 0
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Chapter 32 \\ MC D \ A patient tells the nurse that there is a history of diabetes in the family and even though she has always tried to keep her blood glucose level on the "low side" she still developed diabetes. What information should the nurse provide? \ Body weight is a big contributor to the development of all types of diabetes. \ There is no way to stop the development of diabetes. \ Diabetes can be caused by taking some medications. \ It is thought that genetics is involved with the development of both type 1 and type 2 diabetes. \ \ Obesity in the presence of hereditary tendencies is a major risk factor for developing type 2 diabetes. Type I diabetes is not associated with obesity. Some risk factors for the development of diabetes can be controlled. Diabetes is not caused by medications. Type 1 diabetes seems to have a strong genetic component and is also a factor in development of type 2 diabetes. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \
1
A patient with acute pancreatitis asks the nurse why everyone is concerned about his blood glucose level. Which nursing response is appropriate? \ Pancreatitis can injure the cells that produce insulin. \ Since you are not eating, there is concern you won’t have enough glucose in your system. \ Nearly everyone with pancreatitis develops diabetes. \ Pancreatitis requires treatment with high amounts of intravenous fluids that can increase blood glucose. \ \ Insulin is a polypeptide produced by the beta cells of the islets of Langerhans in the pancreas whose role is to lower the blood glucose level. An injury to the pancreas can injure these cells. This is not the reason for concern regarding this patient’s blood glucose. This is not a true statement. This is not the reason for monitoring this patient’s glucose. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ A patient receiving an insulin injection for the first time asks the nurse how it works to reduce the blood glucose. Which of the following would be the best response for the nurse to make to the patient? \ Insulin makes sure that fat is used as the body's main energy source. \ Insulin helps prevent fluid overload in the cells. \ Insulin helps break down protein.
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\ Insulin helps with cellular uptake of glucose. \ \ Insulin spares fat as the main energy source and makes sure that fat is not used as the main energy source. Lack of insulin results in intracellular dehydration. Insulin decreases the breakdown of protein and does not help the breakdown of protein. Under the influence of insulin, glucose is moved into cells for immediate use or stored for later use. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ A patient with type 2 diabetes mellitus experiences a hypoglycemic reaction. The capillary blood glucose level is 60 mg/dL and the patient is given 4 ounces of orange juice. What should the nurse do next? \ Recheck the patient's blood glucose in 15 minutes. \ Mark the medication administration record to hold the next scheduled dose of insulin. \ Recheck the blood glucose before the next meal. \ Give the patient another 4 ounces of orange juice in 30 minutes. \ \ Blood glucose levels should be tested 15 to 20 minutes after treatment has been initiated. It is unknown if the next insulin dose should be held. It may be necessary to check the blood glucose before the next meal, but it is not a good idea to wait for that check. It is not known if another administration of orange juice is indicated.
3
\ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ The nurse is preparing to administer an intravenous insulin drip to a patient admitted with diabetic ketoacidosis. Which laboratory is of most concern to the nurse? \ Phosphorus level of 2.8 mEq/L \ Bicarbonate level of 16 mEq/L \ Sodium level of 130 mEq/L \ Potassium level of 3.2 mEq/L \ \ The phosphorus level is within normal limits. The bicarbonate level is low, which is expected with acidosis, but it often corrects itself with insulin and IV fluid replacement. The sodium level is low but is not as critical as another option. Insulin treatment when potassium is below 3.3 mEq/L increases the risk for cardiac dysrhythmia or cardiac arrest. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC B \ The nurse is planning the care for a patient admitted with diabetic ketoacidosis. How does the nurse anticipate this condition will be medically managed? \ BID dosing of NPH insulin and PRN coverage with regular insulin \ A continuous low-dose intravenous infusion of regular insulin \ Once-per-evening dose of Lantus insulin with daytime coverage with regular insulin \ sliding scale coverage with regular insulin \ \ Twice a day dosing of NPH insulin and as needed coverage with regular insulin is frequently used to regulate patients with type 1 diabetes experiencing blood sugar fluctuations secondary to physiological stressors. A low-dose continuous source of insulin provides for stricter regulation and control of the blood sugar because dosing can be regulated hourly. Once-per-evening dose of Lantus insulin with daytime coverage of regular insulin is frequently used to regulate patients with type 1 diabetes experiencing blood sugar fluctuations secondary to physiological stressors. Sliding scale coverage with regular insulin is frequently used to regulate blood sugars in a patient with type 2 diabetes who does need a daily insulin dose but is experiencing elevated blood sugars. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC B \ A patient with type 1 diabetes mellitus is admitted with hyperglycemia and dehydration, and is being evaluated for diabetic ketoacidosis. The nurse recognizes that which laboratory finding would support this diagnosis? \ Potassium of 4.5 mEq/L \ Anion gap of 20 mEq/L \ Sodium of 140 mEq/L \ Bicarbonate level of 36 mmol/L \ \ Potassium level is within normal limits. An anion gap of greater than 17 mEq/L indicates an accumulation of unmeasured anions and would be indicative of acidosis. The sodium level is normal. A bicarbonate level of 36 is elevated, indicating metabolic alkalosis. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D
6
\ The nurse is preparing to administer an intravenous infusion containing regular insulin for a patient diagnosed with diabetic ketoacidosis. Which nursing intervention added to the patient’s plan of care has the highest priority? \ Check urine for ketone bodies every shift \ Check blood glucose levels every 2 hours \ Monitor serum calcium levels closely \ Adjust infusion rate according to glucose readings. \ \ The presence of ketones in the urine is significant, but is not an accurate method of evaluating the effectiveness of this treatment. Blood glucose levels need to be checked hourly. Serum calcium levels are important but are not the most important intervention. The most important intervention is to adjust insulin administration in response to glucose readings. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ A patient with type 2 diabetes mellitus, lethargy, and a blood glucose level of 650 mg/dL has been diagnosed with hyperglycemic hyperosmolar syndrome. The nurse monitors this patient for the development of which complication? \ Hyperkalemia \
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Seizures \ Metabolic acidosis \ Fluid volume overload \ \ HHS results in a substantial loss of electrolytes. HHS is associated with severe neurological changes secondary to profound dehydration. Acidosis is usually not seen with this type of diabetes because sufficient insulin is produced to prevent lipolysis and ketogenesis. HHS results is osmotic diuresis and resultant dehydration. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ The nurse is caring for a patient with a history of type 2 diabetes who has recently experienced a myocardial infarction. The nurse would increase monitoring for findings of diabetic ketoacidosis when which medication is added to the patient’s drug regimen? \ Warfarin sodium \ Hydrochlorothiazide diuretic \ Aspirin \ Calcium channel blocker \ \
8
Warfarin sodium will not have any significant effect on blood glucose level. Thiazide diuretics along with the stress of the myocardial infarction may increase insulin deficit sufficiently to precipitate a hyperglycemic crisis such as DKA. Aspirin therapy should not have a significant effect on blood glucose level. Calcium channel blockers do not have any significant effects on the blood glucose level. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+C \ Just after being admitted to the emergency department for symptoms of influenza the patient loses consciousness. His wife reports that he is diabetic but has not taken his oral medications for a “couple of days.” Which nursing interventions are indicated? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Check the patient’s blood glucose using a finger stick monitor. \ Place 1.5 tubes of 40% glucose gel under the patient’s tongue. \ Obtain intravenous access. \ Administer 50% dextrose subcutaneously. \ Administer regular insulin subcutaneously. \ • There are a number of reasons this patient may have lost consciousness including hypoglycemia. Checking the patient’s glucose is indicated. • This patient is not conscious, so this is not an acceptable intervention.
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• • •
Since this patient is not conscious, it is important to secure intravenous access for administration of medications. 50% dextrose injected subcutaneously would severely damage tissues. 50% dextrose is given by intravenous infusion. This patient is more likely to have hypoglycemia due to illness even though he has not been taking his medications. Additional insulin is not indicated.
\ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ A patient with type 2 diabetes reports that she can always tell when her blood sugar is low because “my fingers tingle.” How should the nurse interpret this information? \ This is a central nervous system effect of hypoglycemia. \ The patient is experiencing increased blood glucose rather than decreased blood glucose. \ This patient is developing hypoglycemia unawareness. \ This is a common catecholamine effect of hypoglycemia. \ \ This symptom is not a nervous system effect of hypoglycemia. There is no indication that the patient is experiencing hyperglycemia. The patient is aware of how her body responds to hypoglycemia. This is not hypoglycemia unawareness. Tingling fingers is a finding caused by increased levels of catecholamines. \ 0
10
0 0 0
0000000000 0000000000 0 \\ MC A+B+E \ A patient with long-standing type 2 diabetes may be developing diabetic ketoacidosis. Which assessment findings would the nurse evaluate as supporting that diagnosis? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ A sweet smell to the breath \ Ketonuria \ Blood pH of 7.48 \ WBC of 28,000 \ Potassium of 3.4 mEq/L \ • Acetone is excreted through the lungs due to production of acidic ketone bodies. This causes “ketone breath.” • Presence of ketones in the urine, or “ketonuria,” is associated with diabetic ketoacidosis. • Blood pH of 7.48 would indicate the patient is alkalotic, not acidotic. • A WBC this high indicates infection, but this level would also occur with DKA. DKA is often caused by infection. • Low potassium occurs in DKA. \ 0 0 0
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0
0000000000 0000000000 0 \\ MC A+B+E \ A patient is brought to the emergency department by her son who reports that she was recently diagnosed with diabetes and “is not acting like herself” today. Which additional findings would the nurse consider as suggesting hyperglycemic hyperosmolar state? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ The son reports his mother’s diabetes is type 2. \ The patient’s plasma glucose reading is 638 mg/dL. \ The patient’s bicarbonate level is 14. \ The patient’s blood pH is 7.28. \ The patient is 60 years of age. \ • HHS is more common in patients with type 2 diabetes. • Very high serum glucose levels are associated with HHS. • Low bicarbonate levels are associated with DKA. • Acidosis in often not present in HHS. • HHS is seen in older patients, while DKA typically occurs in those younger than 44. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC B+D \ A patient diagnosed with hyperglycemic hyperosmotic syndrome (HHS) will be started on rehydration fluids. How will the nurse anticipate managing this treatment? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Initial treatment will be with rapidly infused lactated Ringer’s solution. \ Once the patient’s blood glucose has decreased to around 200 mg/dL a glucose containing solution will be used for the remaining hydration. \ The patient will be encouraged to drink as much fluid as possible. \ The nurse will monitor the patient’s lungs for signs of overload. \ The fluid used for resuscitation will contain insulin. \ • Lactated Ringer’s solution will not be used for this patient’s fluid resuscitation. • In order to prevent hypoglycemia as the blood glucose approaches “normal,” the original fluid used for resuscitation is changed to a fluid containing glucose. • The patient will be held NPO until the crisis state is resolved. • This rapid fluid resuscitation places the patient at risk for fluid overload. The nurse should conduct careful assessment for this complication. • The patient will receive intravenous insulin by infusion, but this fluid will not be used for fluid resuscitation. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC C \ Despite the inherent risks, the patient with diabetic ketoacidosis will be given sodium bicarbonate to reverse severe metabolic acidosis. How does the nurse expect to administer this medication? \ In enema form \ As a 50 mL bolus injection intravenously \ Along with potassium chloride \ Over at least an 8-hour period \ \ Sodium bicarbonate is not administered by enema. Sodium bicarbonate is not given as a bolus in this application. This sodium bicarbonate will be given in a water solution along with 20 mEq of potassium chloride. It is recommended that the standard dose of 100 mmol be given over a 2-hour period. \ 0 0 0 0
0000000000 0000000000 0
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\\ MC C \ A patient will receive insulin as treatment for diabetic ketoacidosis. The patient weighs 225 pounds and has a pretreatment serum glucose of 288 mg/dL. Which prescription would the nurse be comfortable administering? \ Administer regular insulin 102 units/hr by intravenous infusion. \ Administer NPH insulin 20 units twice daily. \ Administer regular insulin intravenously at 10 units/hr. \ Administer regular insulin 100 units in 1000 mL NS at 28.8 mL/hr. \ \ This patient weighs approximately 102 kg. An infusion at 100 unit/hr is too high. NPH insulin is a slowly acting insulin and would not be used for this treatment. The recommended insulin dose is 0.1 unit/kg/hr. This patient weighs 102 kg. 102 × 0.1 unit = 10.2. The nurse would be comfortable administering a dose within 0.2 units of recommended. The patient’s pretreatment blood glucose is not used as a component of the recommended dose of insulin. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B+C \ The nurse comes to the cardiac patient’s room to administer subcutaneous insulin. The patient says, “I have always taken pills for my diabetes. Am I getting worse?” What should the nurse consider when formulating a response to this question? (Select all that apply.)
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Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Some cardiac diseases cause oral antidiabetic medications to be less effective. \ The stress of illness makes it difficult to control glucose with oral medications. \ The changes associated with hospitalization make it difficult to control glucose with oral medications. \ The patient will likely need to take insulin to control glucose even after release from the hospital. \ Once discharged the patient can use urine dipstick measurements to guide insulin therapy. \ • There is no truth to this statement. • Often patients with type 2 diabetes require insulin while acutely ill. • While hospitalized, the patient is under additional stress and may not eat or exercise as at home. These changes may make it necessary to use insulin for glucose control. • Generally once patients are discharged to home, they can control their glucose with oral medications. • It is recommended that blood glucose rather than urine glucose measurements be used to guide therapy. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A patient with diabetic retinopathy is admitted to the intensive care unit. Which nursing interventions are indicated? \ Keep the room light dimmed. \ Provide a braille board for communication.
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\ Offer frequent reorientation to the environment. \ Limit visitors to immediate family only. \ \ Dimming the room lights may make it more difficult for the patient to identify unfamiliar objects. The patient has difficulty seeing, but there is no indication that the patient cannot communicate. When patients cannot see, they may become confused in unfamiliar environments. Frequent reorientation is helpful. There is no reason to limit this patient’s visitors to immediate family only. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ The patient with diabetic neuropathy has been admitted to the intensive care unit after major abdominal surgery. Which nursing intervention is indicated because of this neuropathy? \ Keep the skin clean and dry. \ Place the arms and legs in the patient’s position of comfort. \ Instruct the patient to cough and take deep breaths every 2 hours. \ Place a warming blanket under the patient to prevent hypothermia. \ \
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The patient with neuropathy has high risk for skin breakdown. Keeping the skin clean and dry helps prevent breakdown. The position of comfort may not be the best position for the patient’s limbs. Coughing and deep breathing will help prevent pneumonia, but will not protect skin integrity. A patient with neuropathy or who is unable to move himself should not be in contact with a warming device. Burns may occur because the patient cannot feel the excessive heat or because the patient cannot move away from this heat. \ 0 0 0 0
0000000000 0000000000 0
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Chapter 33 \\ MC C \ The nurse assessing a patient with multiple injuries is concerned about the patient's ability to maintain adequate oxygenation. Which explanation would the nurse provide for this increased concern? \ The patient’s bowel sounds are hypoactive. \ The patient has a hemoglobin level of 14 mg/dL. \ The patient suffered a cervical neck injury and slight concussion. \ The patient had an arm injury from flying glass. \ \ Hypoactive bowel sounds would not necessarily indicate an injury that would impact the patient's ability to maintain adequate oxygenation. A hemoglobin level of 14 mg/dL would be sufficient for oxygenation to the tissues and would not cause the nurse concern. Since the respiratory system requires constant input from the nervous system, the assessment findings of a cervical neck injury and slight concussion would be the ones that concern the nurse about the patient's ability to maintain adequate oxygenation. An arm injury due to flying glass would likely have little impact on the patient’s ability to maintain oxygenation. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A
1
\ A patient has a hemoglobin level of 8.6 mg/dL. The nurse is concerned that which oxygenation component will be affected in this patient? \ Oxygen delivery \ Diffusion of oxygen \ Pulmonary gas exchange \ Oxygen consumption \ \ The concept of oxygenation involves three physiologic components for the intake, delivery, and use of oxygen for energy: pulmonary gas exchange, oxygen delivery, and oxygen consumption. Adequacy of oxygenation depends on the integration of these physiologic components. Oxygen delivery is the process of transportation of oxygen to cells and is dependent on cardiac output, hemoglobin saturation with oxygen, and the partial pressure of oxygen in arterial blood. Diffusion is part of pulmonary gas exchange. The actual process of diffusion will not be affected by low hemoglobin. The concept of oxygenation involves three physiologic components for the intake, delivery, and use of oxygen for energy: pulmonary gas exchange, oxygen delivery, and oxygen consumption. Adequacy of oxygenation depends on the integration of these physiologic components. Pulmonary gas exchange involves the intake of oxygen from the external environment into the internal environment. The concept of oxygenation involves three physiologic components for the intake, delivery, and use of oxygen for energy: pulmonary gas exchange, oxygen delivery, and oxygen consumption. Adequacy of oxygenation depends on the integration of these physiologic components. Oxygen consumption involves the use of oxygen at the cellular level to generate energy for cells to use to perform their specific functions. \ 0 0 0 0
0000000000 0000000000 0 \\
2
MC C \ A patient is being started on oxygen therapy for an oxygen saturation level of 84% on room air. The nurse expects that this therapy will be effective if oxygen enters the blood through which physiological process? \ Osmosis \ Fluid shift \ Diffusion \ Concentration gradient \ \ Osmosis is a passive exchange and is not the primary mechanism by which oxygen crosses the alveolar– capillary membrane. Fluid shifts are not involved in the physiologic process in which oxygen crosses the alveolar–capillary membrane. Oxygen crosses alveolar–capillary membranes by diffusion, combines with hemoglobin, and is transported via the pulmonary vein to the left side of the heart. After the heart pumps oxygenated blood into the vascular system where it is transported to cells, oxygenated blood then leaves the capillaries by diffusion and enters cells. Movement of oxygen across the alveolar–capillary membrane is not dependent upon a concentration gradient. It does depend upon the presence of a pressure gradient. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \
3
The nurse, caring for a patient with hypovolemic shock is primarily concerned that which change could occur in this patient's pulmonary gas exchange? \ Insufficient distribution of oxygen \ Buildup of electrolytes in the blood \ Over-oxygenation \ Oxygen delivery shift to osmosis \ \ Since adequate blood flow must exist to distribute the oxygenated blood to the left side of the heart and the systemic circulation, the patient with hypovolemic shock is not going to have sufficient blood flow, which can lead to an insufficient distribution of oxygen to the tissues. A buildup of electrolytes in the blood is not of primary concern in this patient’s oxygenation. Hypovolemic shock will not result in over-oxygenation. Oxygen delivery is through diffusion and not osmosis. Hypovolemic shock does not cause an alteration to a different process. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ The nurse is caring for a patient diagnosed with uncontrolled asthma. The nurse implements interventions to help control the effects of asthma on which element of the patient’s pulmonary gas exchange? \ Removal \ Diffusion
4
\ Ventilation \ Perfusion \ \ Removal is not an element of pulmonary gas exchange. Diffusion impairments are seen in pneumonia, lung cancer, and conditions that cause pulmonary edema. Restrictive pulmonary disorders, such as uncontrolled asthma, will impair ventilation, the actual movement of air between the atmosphere and lungs. Perfusion impairments are seen in anemia, carbon dioxide poisoning, hemorrhage, and pulmonary embolism. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ The nurse is caring for a patient with pneumonia that has impaired diffusion of oxygen. Assessment findings related to this impairment are similar to those the nurse would see in patients with which other disease states? \ Spinal cord injuries \ Flail chest \ Atelectasis \ Carbon monoxide poisoning \ \
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The underlying pathophysiology of respiratory system changes in spinal cord injuries is associated with inability to ventilate. The underlying pathophysiology of respiratory system changes in flail chest is associated with inability to ventilate. Atelectasis results in decreased lung surface area and decreased ability to diffuse oxygen. Carbon dioxide poisoning affects the affinity of oxygen to hemoglobin, therefore affecting perfusion. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ A nurse reviewing arterial blood gas results identifies the oxygen saturation level as low. The nurse interprets this information to reflect changes in which process? \ Ratio of oxygenated hemoglobin to total hemoglobin \ Percentage of cardiac output \ Content of oxygen in arterial blood \ Autoregulation \ \ The measurement of SaO2 or oxygen saturation by arterial blood gas analysis is a measurement of the ratio of oxygenated hemoglobin to total hemoglobin. Oxygen saturation level does not provide evidence about percentage of cardiac output. The measurement of SaO2 or oxygen saturation by arterial blood gas analysis is a measurement of the ratio of oxygenated hemoglobin to total hemoglobin. Oxygen saturation level within the arterial blood gas analysis is not evidence of autoregulation. \
6
0 0 0 0
0000000000 0000000000 0 \\ MC A \ A patient is diagnosed with iron deficiency anemia. The nurse plans interventions for a patient with which most likely complication? \ Impaired oxygen delivery \ Bleeding \ Multisystem organ failure \ Reduced lung function \ \ Oxygen delivery can be significantly reduced in a patient with a decrease in hemoglobin level, which would occur in a patient with iron deficiency anemia. Iron deficiency anemia should not increase the patient’s risk of bleeding. This patient has some risk for organ failure, but this is not the most likely complication. Anemia should not affect this patient’s ability to breath. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC C \ A patient tells the nurse that he feels more energetic when he wears oxygen. What would the nurse consider prior to responding to this statement? \ The patient’s ability to extract oxygen is increased by wearing oxygen. \ Increasing oxygen availability has shifted the oxyhemoglobin dissociation curve to the left. \ Increasing availability of oxygen has produced more adenosine triphosphate. \ Increased oxygen increases energy by breaking down carbohydrates. \ \ Oxygen extraction is the ability to take oxygen into the cells. The process of extraction is not improved by increased delivery. Shifting the oxyhemoglobin dissociation curve to the left will increase the body's hemoglobin carrying capacity of oxygen, but will also decrease the release of oxygen to the tissues. Oxygen consumption is the process by which cells use oxygen to generate energy. Oxygen enables the energy contained in food to be broken down into elements that are converted into energy in the form of adenosine triphosphate. The primary value of oxygen is its ability to develop adenosine triphosphate, which would explain why the patient feels more energetic when he wears oxygen. The breakdown of carbohydrates is done without oxygen. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC D \ A patient is diagnosed with diabetic ketoacidosis. The nurse plans to provide care to a patient whose energy is being produced through which process? \ Affinity \ Aerobic metabolism \ Extraction \ Anaerobic metabolism \ \ Affinity refers to the hemoglobin's ability to release oxygen to the tissues. Aerobic metabolism would not cause diabetic ketoacidosis. Extraction refers to the body cell's ability to extract oxygen from hemoglobin. Carbohydrates are the only food substrates that can be broken down to generate adenosine triphosphate without the use of oxygen. Anaerobic metabolism produces the by-products pyruvate and lactate, causes lactate to accumulate in the body, and leads to lactic acidosis. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C
9
\ The nurse is planning essential activities for a critically ill patient. In order to provide the least impact on oxygen consumption, the nurse would be certain the patient rests before and after which activity? \ Abdominal wound dressing change \ Bed bath \ Daily weight using bed sling scale \ Turning and repositioning \ \ Changing the abdominal wound dressing will increase the patient's oxygen consumption by 10%. This is not the activity with the greatest impact on oxygen status. A bed bath will increase the patient's oxygen consumption by 20%. This is not the activity with the greatest impact on oxygen status. A daily weight with a bed sling scale will increase a patient's oxygen consumption by 40% and is the activity that the nurse should do separately and then permit the patient to rest. Turning and repositioning will increase the patient's oxygen consumption by 30%. This is not the activity with the greatest impact on oxygen status. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A patient's PaO2 level is 48 mm Hg. The nurse would plan care to prevent development of which condition? \ Hypoxemia \
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Intrapulmonary shunt \ Hypoxia \ Hyperventilation \ \ Hypoxemia, an inadequate amount of oxygen in the blood, is frequently quantified as a PaO2 of less than 60 mm Hg. This condition already exists. There is not enough information to identify whether the current condition is related to intrapulmonary shunt. If this condition is allowed to progress, hypoxia may result. The nurse’s interventions are directed at reversing this progression. There is not enough information to determine if the patient is hyperventilating. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ A patient is going to be assessed for oxygen consumption level. Which parameter will the nurse identify for this assessment? \ Serum potassium level \ Hemoglobin level \ Creatinine level \ Serum lactate level \ \
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Serum potassium is not used in determining oxygen consumption. Hemoglobin is not used in determining oxygen consumption. Creatinine is not used in determining oxygen consumption. Current methods of assessing oxygen consumption are limited to indirect measurement techniques including measurement of serum lactate levels, base deficit, and mixed venous oxygen saturation monitoring; therefore, the serum lactate level will be used to assess the patient's oxygen consumption level. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ A patient's mixed venous oxygen saturation level is 56%. What evaluation would the nurse make of this reading? \ The cells are taking more oxygen to meet needs. \ The cells are not receiving enough oxygen. \ The cells are releasing more carbon dioxide. \ There isn't enough oxyhemoglobin to meet the patient's needs. \ \
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The level of 56% does not mean that the cells are taking more oxygen to meet needs. Venous blood from all body systems is considered "mixed" when it has reached the pulmonary artery. Normal mixed venous oxygen saturation is 60%–80%. If the oxygen delivery to tissues is adequate for tissue demands, oxygen saturation of the blood in the pulmonary artery will be 60%–80%. A low mixed venous oxygen saturation level means that less oxygen is returning to the right heart and the cells are not getting enough oxygen to meet their needs. The level of 56% does not mean that the cells are releasing more carbon dioxide. There is not enough information to determine the cause of this reading. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A patient with COPD says, “I have to rest a lot. It just wears me out trying to breath.” The nurse interprets this statement to mean the patient has difficulty with which respiratory process? \ Perfusion \ Diffusion \ Ventilation \ Consumption \ \
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There is nothing in this statement that indicates the patient is not perfusing the lungs adequately. Oxygen is moved across the alveoli and into pulmonary capillaries by diffusion. This process does not require work on the part of the patient. Ventilation is movement of air between the atmosphere and the lungs. It involves the actual work of breathing. In a patient with COPD the movement of air into and out of the lungs is impaired. Oxygen consumption involves the use of oxygen at the cellular level and does not require work on the patient’s part. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+D+E \ A patient injured in an explosion has a flail chest and crushing injuries to his left arm and leg. He is unconscious and is losing blood rapidly. Laboratory testing reveals impaired oxygenation. Nursing interventions should be implemented to improve which components of oxygenation disrupted by this injury? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Ventilation \ Thickness of the alveolar–capillary membrane \ Oxygen affinity \ Hemoglobin concentration \ Blood flow to the lungs \
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• • • • •
Since the patient has a flail chest, ventilation, or the movement of air between the atmosphere and the lungs, will be impaired. These injuries should not have a significant initial impact on thickness of the alveolar–capillary membrane. Should the flail chest result in pneumothorax or hemothorax, the effective surface area of the lungs will be decreased, but the thickness of the membrane will not be affected initially. Nothing in this scenario will affect hemoglobin affinity for oxygen. As the patient continues to bleed, the amount of available hemoglobin will continue to reduce. Since the patient has massive blood loss, the body has shunted blood to core organs in an attempt to maintain blood flow. This compensation is short lived as bleeding continues.
\ 0 0 0 0
0000000000 0000000000 0 \\ MC A+B+D+E \ A nurse is preparing a patient for pulmonary functioning testing (PFT). Which nursing statements will help to reinforce teaching about the purposes of these tests? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ These tests can help in the diagnosis of any pulmonary diseases you may have. \ We can monitor how well therapies are working by comparing the results of your tests. \ Insurance companies require these tests be done before you can be discharged from the hospital. \ By testing you frequently we can identify changes occurring in your pulmonary health before they become severe. \ The tests give us numbers so we can make accurate assessments of your pulmonary health.
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\
• • • • •
PFT are helpful in diagnosing pulmonary diseases. These tests are often used for monitoring the effects of therapies. The results of the tests may be used to satisfy discharge screens but saying they are required by insurance companies is not accurate. Identifying changes in pulmonary status is a valid rationale for these tests. Because the results of these tests are reported in numbers, the trending of results is easy and useful.
\ 0 0 0 0
0000000000 0000000000 0 \\ MC A+C \ A patient who is receiving chemotherapy is anemic and has low CaO2 levels. Which nursing interventions offer the best support for this patient? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Monitor the administration of blood products. \ Administer diuretics as ordered. \ Keep the patient’s oxygen cannula in place. \ Keep the patient on bedrest \ Monitor the patient’s pulmonary artery wedge pressure (PAWP). \ • One of the methods for increasing the amount of oxygen in arterial blood is to increase the amount of hemoglobin in the blood. If the patient is severely anemic, blood transfusion is an option.
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• • • •
Diuretics will not increase CaO2 but might increase hematocrit. Supplementing oxygen to increase SaO2 and PaO2 will help increase CaO2. Keeping the patient on bedrest would decrease the effects of low CaO2 by decreasing metabolic demand, but will not increase CaO2. Monitoring the PAWP will not improve oxygenation of arterial blood.
\ 0 0 0 0
0000000000 0000000000 0 \\ MC A+C \ Arterial blood gases were drawn when a patient was discovered in cardiopulmonary arrest. Which results would the nurse evaluate as indicating global lactic acidosis? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ pH 7.21 \ HCO324 mEq/L \ Base excess –12 mmol/L \ PaO282 mm Hg \ PaCO237 mmHg \ • The patient in global lactic acidosis will have an acidotic pH (less than 7.35). • HCO3 of 24 mEq/L is normal. In global lactic acidosis the HCO3 would be low. • A base deficit will be seen in global lactic acidosis.
17
• •
This is a normal PaO2 and is not an expected finding in the global hypoxia that results in global lactic acidosis. This is a normal PaCO2.
\ 0 0 0 0
0000000000 0000000000 0 \\ MC A+B+C+D \ A nurse is monitoring trends of a patient’s SvO2 as a measure of oxygen delivery to tissues. The nurse would be concerned about the accuracy of this trending if which patient condition develops? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ The patient’s heart rate drops. \ The patient develops a high fever. \ The patient develops gastrointestinal bleeding. \ The patient’s SaO2 improves with antibiotic therapy. \ The patient is receiving multivitamins in intravenous infusions. \ • Dropping heart rate would change cardiac output. SvO2 is influenced by cardiac output. • High fever will increase oxygen consumption, which affects SvO2. • If the patients hemoglobin level changes it will change SvO2. • Improvement of SaO2 will change SvO2. • The presence of vitamins in intravenous infusions will not change SvO2. \
18
0 0 0 0
0000000000 0000000000 0
19
Chapter 34 \\ MC A \ Which consideration will the nurse apply to the assessment of a patient who sustained penetrating trauma? \ The extent of injury is related to the amount of energy transferred to the body tissues. \ The amount of trauma sustained is related to the patient's nutritional status before the injury. \ If the patient was well hydrated at the time of injury, the extent will be diminished. \ The primary determinant of injury is the arc traveled by the penetrating object. \ \ Penetrating trauma refers to injury sustained by the transmission of energy to body tissues from a moving object that interrupts skin integrity. Penetrating trauma produces actual tissue penetration and may also cause surrounding tissue deformation based on the energy transferred by the penetrating object. Pre-injury nutritional status is not a major factor in the amount of injury sustained. The patient’s fluid volume status has little to do with the amount of injury sustained. The physics of injury does include arc, direction of travel, diameter of the object, and other components, but these measures all relate to a more specific concept. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \
1
A 14-year-old white male is brought into the emergency room of an urban hospital with a penetrating wound caused by the accidental discharge of a gun. Which risk factor for this injury pattern would the nurse rank as the most influential? \ Living in an urban area \ Being white \ Age \ Gender \ \ Risk for unintentional injury is higher in rural areas. Rate for intentional injury is higher in urban areas. Native Americans have the highest death rates from unintentional injury. The risk of injury is highest for those 15 through 24. The risk for males is 2.5 times that of females, possibly because of male involvement in hazardous activities. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A patient was injured when the car he was driving hit a telephone pole. The patient is 6 feet tall and weighs 200 pounds. The car was traveling at approximately 25 miles per hour when it hit the 36 inch diameter wooden pole. The nurse would calculate which pounds per square inch of impact for this patient? \ 833.3 \ 30,000 \
2
5000 \ 12,245 \ \ This is an incorrect measurement of this impact. This is an incorrect measurement of this impact. To calculate pounds per square inch of impact, the nurse would multiply the patient's weight by the speed the car was traveling. For this situation, the calculation would be 200 lb × 25 miles per hour, which means the patient sustained 5000 lb per square inch of impact. This is an incorrect measurement of this impact. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A patient brought into the emergency department with injuries sustained from a motor vehicle accident (MVA) is complaining of abdominal pain and begins to vomit. The nurse suspects injury from which most likely source? \ Shearing \ Deceleration \ Compression \ Acceleration \ \
3
Shearing occurs when two parts of the same structure move in opposite direction causing a tear. Shearing forces are common in MVAs, but this is not the most specific injury pattern for this patient. Deceleration is a decrease in the speed of velocity of a moving object. Deceleration injury is common in MVAs but is not the most specific injury in this situation. Compression is the process of being pressed or squeezed together with a resulting reduction in volume or size. The small bowel may be compressed between the vertebral column and the lower part of the steering wheel or an improperly placed seat belt. The bowel may rupture. Because the patient complained of abdominal pain and started to vomit, the nurse should suspect that the patient sustained a compression force injury. Acceleration is the increase in the rate of velocity or speed of a moving object and frequently occurs in MVAs. It is not the most specific injury pattern suggested by this scenario. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A teenage patient comes into the emergency department with an arrow lodged in his right lower thoracic region. Which nursing intervention is indicated? \ Have the patient assume a left side lying position and pull on the arrow to remove it. \ Slowly move the arrow to the left and right to attempt to dislodge it. \ Stabilize the arrow by padding around the wound with gauze rolls. \ Slowly rotate the arrow to attempt to dislodge it. \ \
4
The nurse should not pull on the arrow to attempt to remove it. The nurse should not move the arrow to the left and right since impaled objects may actually be controlling a hemorrhage from damaged structures and removal may precipitate exsanguination. If the offending weapon is impaled in the body, it is critical that the object be left in place and protected from further movement until definitive surgical intervention is available. Protective padding can be placed around the object, such as gauze rolls or abdominal pads. The nurse should stabilize the arrow by padding around the wound with gauze rolls. The nurse should not rotate the arrow since impaled objects may actually be controlling a hemorrhage from damaged structures and removal may precipitate exsanguination. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ A patient with a gunshot wound to the knee is complaining of groin and hip pain. The nurse realizes that this patient's pain might be because of which effect? \ Cavitation \ Tumble \ Yaw \ Blast effect \ \
5
Cavitation is the formation of a cavity caused by the force of the missile. It would be unlikely that cavitation would extend from the knee to the groin. Tumble is the action of forward rotation around the center of the missile or somersaulting. It would be unlikely that tumble alone would cause the groin pain. Yaw is the deviation of the missile either above or below the axis and may cause additional damage in the immediate are of the penetration. Tissue surrounding the missile tract is exposed to stretching, compressing, and shearing forces, which produce damage outside the direct path of the missile. Vessels, nerves, and other structures that are not directly damaged by the missile may be affected. The phenomenon of structure injury outside the direct missile path is referred to as "blast effect." \ 0 0 0 0
0000000000 0000000000 0 \\ MC C+E \ The nurse is preparing to assess a motor vehicle accident victim who was lap and shoulder harness restrained. Due to the mechanism of injury the nurse will look for which most common injuries? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Lumbar spine fractures \ Fractured patella \ Pulmonary contusion \ Flexion fracture of the cervical spine \ Contusion of the small bowel
6
\
• • • • •
Lumbar spine fractures are more commonly seen in lap belt only restrained drivers. Fractured patella is more commonly seen in unrestrained front seat passengers and fall injuries. Since the patient was restrained with a lap and shoulder harness, the nurse will most likely assess contusions underlying the location of the harness. Pulmonary contusions are an example of this injury. Flexion fracture of the cervical spine is most likely seen with an unrestrained driver. Since the patient was restrained with a lap and shoulder harness, the nurse will most likely assess contusions underlying the location of the harness. Small bowel contusions are an example of this injury.
\ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ A patient is brought into the emergency department after a car accident. Injuries include fractured left femur, tibia, and fibula with a mild contralateral head injury. The nurse would identify this injury pattern as consistent with which situation?\ Unrestrained front seat passenger of a motor vehicle \ Adult pedestrian hit by an automobile \ Unrestrained driver of a motor vehicle \ Child pedestrian hit by an automobile \ \
7
An unrestrained front seat passenger of a motor vehicle would have facial and lower extremity injuries.. The injuries of a fractured femur, tibia, and fibula on the same side with a contralateral head injury is an expected injury pattern for an adult pedestrian hit by a motor vehicle. An unrestrained driver of a motor vehicle would have extensive injuries to the head, neck, thorax, abdomen, and lower extremities. A child pedestrian would have a chest injury in addition to the limb and head injury. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ A pregnant patient in her third trimester has been involved in a motor vehicle accident. Which intervention should the nurse implement to treat the patient's symptoms of hypotension? \ Turn the patient to the right lateral position. \ Turn the patient to the left lateral position. \ Place the patient in Trendelenburg's position. \ Place the patient in the supine position. \ \ The right lateral position would allow compromise of the inferior vena cava. Placing the patient in the left lateral position shifts the uterus to the left, thus, preventing the heavy uterus from compressing the inferior vena cava against the spinal column and decreasing venous return and preload. Placing the patient in Trendelenburg’s position would compress the inferior vena cava and may compromise the patient’s ability to breath. Supine positioning can result in development of inferior vena cava syndrome, making it difficult to treat hypotension.
8
\ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ A 78-year-old patient with a history of hypertension being treated with daily doses of metoprolol (Lopressor) was involved in a motor vehicle accident. The nurse would provide care based on absence of which compensation for hypovolemic shock? \ A drop in blood pressure \ A drop in urine output \ A decrease in level of consciousness \ Tachycardia \ \ A drop in blood pressure would likely occur. The patient is likely to manifest a drop in urine output if hypovolemic shock occurs. Treatment with metoprolol will not prevent decrease in LOC if hypovolemic shock occurs. Tachycardia usually associated with hypovolemic shock is prevented by the medication, a beta blocker, which the patient is taking daily. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC B+C+E \ The nurse is assessing a patient injured in a fall from a tree. During the assessment the patient suddenly loses consciousness. Which interventions should the nurse use to protect this patient’s airway? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Hyperextend the neck. \ Suction the patient. \ Stabilize the neck. \ Remove the tape the paramedics used to tape the patient’s head to the backboard. \ Pull up on the patient’s lower jaw. \ • The nurse should avoid hyperextension of the neck in patients who may have sustained a cervical spine injury. Falling from a tree is a mechanism of injury that suggests cervical spine injury may be possible. • Suctioning the patient to clear the airway is a standard resuscitation intervention. • The nurse must attend to neck stabilization at all times even when opening the airway. • This tape is used for stabilization and should not be removed until the cervical spine is cleared of injury. • Using the jaw thrust maneuver or pulling up on the lower jaw will help open the airway without moving the head on the neck. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC A \ The nurse has adequately managed a patient’s airway, breathing, and circulation. What is the next nursing action? \ Assess level of consciousness. \ Administer prophylactic tetanus toxoid as prescribed. \ Auscultate heart sounds. \ Assess the chest for paradoxical movements. \ \ The nurse should assess the patient's neurological status or level of consciousness as the next step. Administering prophylactic tetanus toxoid and transferring the patient should happen after the assessment is complete. Auscultation of heart sounds is part of the secondary survey, which is done after the primary survey. Assessment for paradoxical movement of the chest is part of the secondary survey, which occurs after the primary survey. The primary survey is not yet completed. \ 0 0 0 0
0000000000 0000000000
11
0 \\ MC D \ While conducting the secondary survey of a patient admitted with multiple traumas, the nurse assesses paralysis of the patient's left lower leg. Which nursing intervention is indicated? \ Move the patient to a semi-sitting position. \ Support limb by placing it on a pillows. \ Turn the patient to assess the back. \ Immediately immobilize the patient. \ \ Moving the patient is not indicated. The nurse should not move the limb in order to place it on pillows. Turning the patient is not indicated at this time. If during the complete neurological examination the nurse assesses any evidence of paralysis or paresis, prompt immediate immobilization of the entire patient should occur if not already done. The nurse should remember that during the secondary survey, the patient may manifest findings requiring return to interventions recognized as part of the primary survey. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \
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A patient who sustained a chest injury has developed tracheal deviation to the left side. The nurse would provide which equipment for immediate treatment of this complication? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ A venous cut down tray \ A chest tube \ Intubation equipment \ 14 gauge needle \ \ • Suctioning will not manage this complication. Suctioning may be necessary after the management procedure is completed. • Accessing a vein with a venous cut down tray will not resolve this complication. • Tracheal deviation indicates development of a tension pneumothorax. The treatment for this complication includes decompression with a chest tube. A nurse should anticipate this and prepare a chest tube insertion tray. • Intubation will not resolve this complication but may be required after the treatment procedure is completed. • Development of tracheal deviation indicates pneumothorax and is an emergent situation. Immediate decompression of the thorax is indicated and can be achieved by insertion of a 14 gauge needle. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+B \
13
The nurse is providing care to a farmworker who was pinned against a steel gate by a horse. Deformation of the patient’s pelvis and femurs is obvious, but little blood is present on the patient’s clothing. Initial blood pressure is 110/68 mm Hg. What nursing interventions are indicated? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Initiate intravenous access with a 16 gauge catheter. \ Start fluid resuscitation with normal saline. \ Prepare to administer vasopressor medication. \ Turn the patient to assess for injuries to the back. \ Prepare to insert a chest tube. \ • This patient’s mechanism of injury and assessment indicates potential for femur and pelvic fractures, which can result in massive blood loss. The “normal” blood pressure may be related to pain and adrenaline release. Venous access with large gauge catheters is essential. • This patient may be bleeding internally. Fluid resuscitation is indicated. • Vasopressor medications are not useful until fluid volume is restored. • This patient should not be moved until further assessment is conducted. • Nothing in the patient’s assessment indicates need for a chest tube at this point. The nurse should continue to assess airway and breathing. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B+C+D \
14
A 24-year-old woman was critically injured when hit by a car while she was walking to work. Emergency department staff has been working for one hour to stabilize her. Which parameters would the nurse evaluate as indicating the patient is adequately fluid resuscitated? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Her core temperature is 98.2°F. \ Her mean arterial pressure has been in the 70s for the last 30 minutes. \ She is no longer tachycardic. \ Her last lactate level was 2.0 mMol/L. \ Her last sublingual capnography reading was 74. \ • Temperature is not evaluated as an end point of trauma resuscitation. • MAP above 70 is an end point for trauma resuscitation. • HR less than 100 bpm is an end point for trauma resuscitation. • Lactate levels less than 2.2 mMol/L is an end point for trauma resuscitation. • Sublingual capnography level should be less than 70. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ A patient being treated for hypovolemia because of traumatic injuries has a blood pressure of 110/60 mmHg. What should the nurse do to validate this clinical finding? \
15
Assess neck veins and urine output. \ Measure oxygen saturation with oximetry. \ Check serum potassium and sodium levels. \ Check for pupillary constriction. \ \ Peripheral vasoconstriction, a compensatory mechanism, may artificially elevate blood pressure readings even though central arterial pressures are low in the patient being treated for hypovolemia because of traumatic injuries. To prevent misdiagnosis by focusing on one symptom while ignoring others, the nurse should monitor the trauma patient's blood pressure and at the same time assess neck veins, level of consciousness, and urine output. The oxygen saturation measurement through oximetry will not provide information about the patient's fluid status. Electrolyte levels will not provide adequate information about the patient’s fluid volume status. Pupillary constriction is not a good indicator of fluid volume and may have been affected by medications administered during resuscitation. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ It is suspected that a patient who sustained multiple traumas is developing cardiac tamponade. Which nursing assessment finding would help to support this tentative diagnosis? \ Flat neck veins despite fluid resuscitation \ Persistent hypotension
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\ Atrial fibrillation per cardiac monitor \ Bilateral basilar crackles \ \ Cardiac tamponade causes neck vein distention. Hypotension is part of Beck s triad, which indicates development of cardiac tamponade. Atrial fibrillation is not an indicator of cardiac tamponade. Crackles in the lungs are not indicative of cardiac tamponade. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ The nurse is caring for a patient who sustained a lacerated spleen from a motorcycle accident. Which complication is this patient most prone to experience because of the trauma? \ Acute renal failure \ Sepsis \ Deep vein thrombosis \ ARDS \ \
17
Abdominal trauma, specifically a lacerated spleen, makes the patient prone to developing the complication of acute renal failure, abdominal compartment syndrome, or disseminating intravascular coagulation. Sepsis is associated with an open pneumothorax and perforated intestine. Deep vein thrombosis is not associated with any particular organ system and can occur at any time with any health problem that restricts mobility or increases blood coagulation. ARDS is seen more often with thoracic traumatic injuries. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A patient is in the intensive care unit with a pulmonary contusion sustained from a motor vehicle accident. Which post-traumatic complication should the nurse focus on when providing care to this patient? \ Abdominal compartment syndrome \ Sepsis \ ARDS \ Acute renal failure \ \ Abdominal compartment syndrome is more common in patients with abdominal trauma. Sepsis is more common in patients with abdominal trauma or open wounds. The patient with a thoracic injury is prone to developing the post-traumatic complications of ARDS and DIC. Acute renal failure can occur with any massive trauma that involves blood loss, but is more common if injuries to the abdomen exist. \
18
0 0 0 0
0000000000 0000000000 0
19
Chapter 35 \\ MC C \ Victims of a house fire are being admitted through the emergency department. Of the patients, the nurse realizes that which will have the greatest general risk for mortality from the burn injuries? \ 25-year-old pregnant female \ 49-year-old male who smokes \ 75-year-old female with arthritis \ 50-year-old male with coronary artery disease \ \ Pregnancy is not a factor in increasing mortality from burn injury. This patient does not have the greatest risk of mortality from this burn injury. People of advancing age have thinner skin, with decreased microcirculation and an increased susceptibility to infection. All of these factors not only put them at a greater risk for burn injuries, but also lead to a greater morbidity and mortality. Coronary artery disease does not make this patient at higher risk than another patient also injured in this fire. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ The nurse is caring for a patient admitted with thermal burns. The nurse will plan to monitor the patient closely over the next 2 to 3 days for development of which most serious complication?
1
\ Pain \ Burn shock \ Continuation of the burn process below the level of obvious injury \ Hypervolemia \ \ Thermal burns are painful, but this is not the most serious complication listed. Thermal burns produce microvascular and inflammatory responses within minutes of the injury; however, the effects from these two responses can last from 2 to 3 days. Substances released by damaged cells increase vascular permeability, causing fluid, electrolytes, and proteins to leak into the interstitial space. The fluid shift from intravascular to interstitial spaces may cause a hypovolemic shock state, which is frequently referred to as burn shock. Continuation of the burn process below the level of obvious injury is a characteristic of an alkaline burn not a thermal burn. It would be more likely that the patient would develop hypovolemia. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ A civilian patient admitted with frostbite burns to his feet is receiving pain medication, fluid replacement, and is being monitored for any signs of organ dysfunction. What rationale would the nurse provide for this conservative management? \ Frostbite injuries are not as serious as thermal or chemical burns. \
2
The extent of the injury is not obvious. \ Little is known about other methods to treat frostbite. \ Aggressive frostbite management is only done in specialty military hospitals. \ \ Frostbite injuries can be devastating. Since it may take weeks before there is a clear demarcation between viable and nonviable tissue with frostbite injuries, patients are treated conservatively, which includes fluid support, pain management, and ongoing assessment of organ functioning. This treatment approach is not related to lack of knowledge of other potential treatments. Hospitals of all descriptions generally approach frostbite care conservatively. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+C+E \ A patient is being admitted for treatment of deep partial-thickness burns. When doing this patient’s initial assessment, the nurse would expect which burn characteristics? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Sluggish capillary refill \ Leathery, white tissue \ Significant edema \
3
Blisters \ Erythema \ • The deep partial-thickness burn damages capillaries. Capillary refill may be sluggish or absent. • Leathery, white tissue is characteristic of full-thickness burns. • Deep partial-thickness burns result in a significant amount of edema. • No blisters are present in deep partial-thickness burns. • Erythema can be present with these burns, or the tissues may be pale. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ A patient comes into the emergency department with severe burns over the face, arms, legs, and back after spending the day boating with friends. The skin is dry and very red with brisk capillary refill. How would the nurse classify this patient's burn injuries? \ Superficial \ Deep partial thickness \ Superficial partial thickness \ Full thickness \ \
4
Superficial burns involve the epidermis only and are associated with burns from the sun. The burns are red and no blisters are present. Deep partial-thickness burns involve the epidermis and the deep layer of the dermis. They are caused by contact with flame, hot liquids, tar, or hot objects. Skin may be red or pale and capillary refill is sluggish or absent. Superficial partial-thickness burns involve the epidermis and papillary layer of the dermis and are caused by contact with hot objects, hot liquids, or flash flame. The skin is red with brisk capillary refill and blisters. Full-thickness burns involve the epidermis, dermis, and subcutaneous tissue. These are caused by contact with flame, electricity, or chemicals. The skin is dry and leathery or white with absent capillary refill. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ A patient has full-thickness burns of the right chest area, entire right arm, and deep partial-thickness burns of both upper anterior legs. Based on the rule of nines, which estimate of total body surface area burn would the nurse record? \ 36% \ 27% \ 45% \ 18% \ \
5
This estimate is incorrect. According to the rules of nines, the right chest area = 9%, entire right arm = 9%, and the upper anterior legs = 4.5% + 4.5%. The total = 9 + 9 + 9 = 27%. This estimate is incorrect. This estimate is incorrect. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+C+D \ A patient is admitted with partial-thickness burns over the entire left arm and neck. Superficial burns are present on the face and scalp. The anterior truck has patches of superficial burns. There are deep partial-thickness burns on the legs with full-thickness burns on both feet. The nurse using the Lund and Browder chart to estimate the total body surface area burned will include the burns on which body areas? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Left arm \ Face \ Legs \ Feet \ Trunk \ • Partial-thickness burns are included in this estimate. • Superficial burns are not included in this estimate.
6
• • •
Deep partial-thickness burns are included in this estimation. Full-thickness burns are included in this estimation. Superficial burns are not included in this estimation.
\ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ The nurse is providing emergency care to patients injured in a house fire. Which patient would the nurse prepare for transfer to a burn center for additional care and treatment? \ 15-year-old child with 5% total body surface area burns to the left arm \ 10-year-old child with partial-thickness burns to the left hand \ 30-year-old female with superficial burns to the arms, face, and neck \ 35-year-old male with partial-thickness burn to a part of his back. \ \ The child with 5% total body surface burn to the left arm would not need to be transferred to the burn center since the total body surface area is less than 10%. The 10-year-old child would fulfill the burn center referral criteria for transfer to a burn center because the child has burns to the face and hands. Superficial burns can typically be addressed in a non-burn unit environment. Referral is considered when a partial-thickness burn occurs to more than 10% of TBSA. \ 0 0
7
0 0
0000000000 0000000000 0 \\ MC A \ The nurse is caring for a 154-pound patient with 50 percent total body surface area burns. If using the Parkland formula, the nurse will calculate which amount of intravenous solution to provide this patient in the first 24 hours of care? \ 14,000 mL \ 42,000 mL \ 3,500 mL \ 7,000 mL \ \ Based on the Parkland formula, the total amount of fluids required in the first 24 hours = 4 mL of Ringer's lactate × TBSA of burns × patient's weight in kgs. For this patient, 4 mL × 50 × 70 kg = 14,000 mL; 7, 000 mL should be given in the first 8 hours; 3,500 mL in the second 8 hours; and 3,500 mL in the last 8 hours. This is an inaccurate calculation based on this patient’s weight and TBSA. This patient will require 3,500 mL in the last 8-hour period of the next 24 hours, not for the entire 24 hours. This patient will require 7, 000 mL of fluid in the first 8 hours of the next 24 hours. \ 0 0 0 0
8
0000000000 0000000000 0 \\ MC D \ A patient, recovering from being struck by lightning 36 hours prior to admission, is demonstrating an acute onset of confusion and muscle weakness. Which rationale would the nurse provide for this assessment? \ The patient has is suffering a stroke unrelated to the injury. \ The patient likely has an electrolyte imbalance. \ The patient has developed a seizure disorder from the injury. \ The patient is having delayed onset of neurological symptoms, which are common after a lightning injury. \ \ There is not enough information for the nurse to determine that the patient is suffering a stroke. Without more information the nurse cannot attribute this finding to an electrolyte imbalance. This assessment does not support the diagnosis of a seizure disorder. Neurological effects are common with electrical and lightning injuries. The onset of clinical manifestations may be acute or delayed. Patients may experience confusion, exhibit a flat affect, lose the ability to concentrate, or have short-term memory problems. Seizures, headaches, peripheral nerve damage, and loss of muscle strength may also be observed. \ 0 0 0 0
0000000000 0000000000
9
0 \\ MC C \ A patient with severe deep partial-thickness burns is scheduled for hydrotherapy at 10:00 a.m. every day. The patient has an order for Percocet (oxycodone and acetaminophen) two tablets by mouth every 4 to 6 hours PRN for pain. When developing the nursing care plan, the nurse should include which nursing order? \ Administer two tablets of Percocet at 11:00 a.m. every day right after hydrotherapy. \ Administer two tablets of Percocet at 10:00 a.m. every day prior to hydrotherapy. \ Administer two tablets of Percocet at 9:00 a.m. every day prior to hydrotherapy. \ Administer two tablets of Percocet at 9:45 a.m. every day prior to hydrotherapy. \ \ Giving Percocet after the procedure may decrease its effectiveness because it is easier to control pain before it becomes severe. Administering pain medication at the beginning of a painful procedure will not effectively manage the pain from the treatment. The nurse should plan to administer the pain medication prior to a painful procedure. Because it takes about 45 to 60 minutes for an oral medication to be absorbed, the nurse should plan to give Percocet at 9:00 a.m. every day, one hour prior to hydrotherapy. More time is needed in order for the Percocet to be effective. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C
10
\ A patient, being treated for burns over 40% of the total body surface area, is experiencing a hypermetabolic state. The nurse anticipates the addition of which type of medication to help reduce muscle wasting and accelerate healing time? \ Antibiotics \ Cardiac glycosides \ Insulin \ Calcium channel blockers \ \ Antibiotics are not the primary choice for this therapeutic effect. Cardiac glycosides may be indicated for this patient, but are not the drug class of choice for this therapeutic effect. Administration of insulin in severely burned patients has been shown to improve muscle protein synthesis, accelerate healing time, attenuate loss of lean body mass and decrease the acute phase response. Calcium channel blockers are not the drug class of choice for this therapeutic effect. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+E \ The nurse assesses a burn patient's urine to be reddish-brown in color. Which interventions would the nurse anticipate? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected.
11
\ Interventions to raise the urine pH to an alkaline level \ Discontinuing orders for sodium bicarbonate \ Irrigating the patient's bladder with a sodium bicarbonate solution \ Management of intravenous fluids to achieve a urine output of 75 mL per hour \ Monitor for hypocalcemia. \ • If a patient has experienced muscle damage from exposure to an electrical current or a crush-type injury, the urine may be a red to reddish-brown color. This discoloration results from myoglobin in the urine. The solubility of myoglobin increases in an alkaline environment, so maintaining alkaline urine will increase the rate of myoglobin clearance. • The nurse would anticipate adding sodium bicarbonate to this patient’s treatment plan. • Irrigating the patient's bladder with sodium bicarbonate will not raise the urine pH. • Adequate urine output of 75 to 100 mL per hour will help to increase the rate of myoglobin clearance. • Treatment of myoglobinuria may result in hypocalcemia. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ The nurse caring for a patient who sustained burns of 30% of the total body surface area seven days ago is assessing the status of the patient's wounds. Which phase of wound healing would the nurse expect to be occurring? \ Contraction \
12
Inflammatory \ Maturation \ Proliferative \ \ Contraction is not a phase of wound healing The inflammatory phase lasts approximately 2 weeks. The maturation phase of wound healing can last 6 to 18 months or longer depending on the wound. The proliferative phase begins after about two weeks and may last up to 1 month. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+D \ A patient has been treated in the burn unit for 3 months. What characteristics of wound healing would the nurse evaluate as normal? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Organization of collagen layers \ Reepithelialization \ Revascularization \ Strengthening of the scar \
13
Keloid production \ • The patient should be in the maturation stage of wound healing, which is characterized by the organization of collagen layers. • Reepithelialization occurs in the proliferative stage. This stage should be completed. • Revascularization occurs in the proliferative stage. • Strengthening of the scar occurs during the maturation phase, which should be happening at this point after injury. • Keloids may occur during this stage, but this is not a normal finding. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ The nurse caring for a patient admitted for burns over his torso and upper arms has clothing adhered to the skin. Which nursing action is indicated? \ Leave the clothing in place and flush the areas with cooled water \ Flush the clothing with hydrogen peroxide to clean the skin underneath \ Cover the areas with gauze \ Apply a topical antiseptic over the clothing areas \ \
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Clothing, jewelry, belts, or anything containing heat is removed from the patient however adhered clothing or tar is left in place and cooled with water because removing it will cause further damage to the skin. The nurse should not use hydrogen peroxide on this wound. Simply covering the areas with gauze is an insufficient intervention. Applying a topical antiseptic over the clothing is an insufficient intervention. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C+D+E \ The nurse is planning the care of a patient who has burns to the face, neck, upper chest, and both upper arms. To prevent contracture development, the nurse should include which interventions in the patient's plan of care? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Use a bed cradle over the burned areas. \ Have patient assume the position of comfort while sleeping. \ Administer analgesics prior to physical therapy. \ Instruct the patient to avoid using pillows under the head. \ Get the patient out of bed as soon as medically feasible. \ • Using bed cradles is effective in preventing infection and irritation of burn wounds, but it has no direct effect on preventing contractures. • The position of comfort is most often flexion, which should be avoided at all times.
15
• • •
Physical therapy can be painful for patients with burns. Reducing the pain can help the patient be more participative in therapy sessions. Using pillows under the head leads to hyperflexion of the neck and burned surfaces will be touching each other. This may lead to developing contractures of the neck. Getting the patient out of bed and using the joints is the best way to prevent development of contracture. Total body mobilization is also beneficial to cardiopulmonary functioning.
\ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ The nurse is preparing to ambulate a patient who sustained burns over 20% of his lower extremities. Which intervention is most important to facilitate the success of the patient's ambulation? \ Transfer the patient to a chair before ambulating. \ Apply compression wraps to the lower extremities before getting out of bed. \ Be certain the patient is well-hydrated before ambulation. \ Have the patient perform incentive spirometry. \ \
16
Transferring the patient to a chair before ambulating may or may not be necessary. It is important to apply compression wraps on lower extremities before getting the patient out of bed in order to prevent venous stasis. If extremities are not wrapped, the patient is at risk for capillary bed bleeding, which could cause autograft failure or delay donor-site healing. Venous pooling coupled with prolonged immobility also predisposes the patient to deep-vein thrombosis. Wrapping the extremities continues until all wounds are healed and pressure garments are applied. The patient should always be well-hydrated, but hydration status is not the most important aspect of preparing a patient for ambulation. Use of incentive spirometry may help prevent development of pneumonia, but is not necessary in preparation for ambulation. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ A patient is rehabilitating after a severe burn 6 months ago that left her with scars across her chest and abdomen. She says, “I don’t care what people think, I am going to the beach in a bikini next week.” What most important information should the nurse provide? \ “This may be difficult since you are still supposed to be wearing your compression garment.” \ “You need to avoid sun exposure to your scars for at least one year.” \ “You should prepare yourself for how others will react to your scars.” \ “Remember that you are prone to getting too hot easily.” \ \
17
The patient probably is still supposed to be wearing her compression garment, but this is not the most important consideration. Scars should be protected from sun exposure for one year or until the scar turns silvery white. Otherwise the scar will “tan” and remain permanently pigmented, leaving a less than satisfactory cosmetic result. This is an important consideration but is not the most important information for the nurse to share. This may be the case, but it is not the most important information for the nurse to share. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ A female patient recovering from a burn to the left side of her face tells the nurse that she has no idea how she is going to return home and resume her regular life since she is so "ugly and disfigured." What nursing response is indicated? \ “It is good that your work does not include having to meet the public everyday.” \ “I don’t think your scars are so bad.” \ “I think you should see a plastic surgeon before you try to go back to work.” \ “Would you like a referral to the Phoenix Society?” \ \
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This statement reinforces that the patient needs to “hide” from others and is not appropriate. This statement devalues the patient’s concern and is not appropriate. Suggesting plastic surgery reinforces the idea that the patient should not be seen in public and is not appropriate. The Phoenix Society maintains a registry of professionals who specialize in scar therapy and camouflage makeup techniques. This offer of a referral addresses the patient’s concerns, but puts the patient in charge of her decision. \ 0 0 0 0
0000000000 0000000000 0
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Chapter 36 \\ MC B \ A patient is admitted to the emergency department with severe burn injuries. The nurse’s priority actions are to prevent development of which type of shock? \ Cardiogenic \ Hypovolemic \ Distributive \ Obstructive \ \ Cardiogenic shock may develop in this patient if injury stress results in myocardial infarction. However, immediate actions are focused on a different type of shock. Hypovolemic shock states are a result of a decrease in vascular volume, which leads to a decrease in cardiac output. Severe burns will cause loss of intravascular fluids from the skin and may lead to this shock state. This is a critical issue in the emergent care of the patient with burn injury and is the priority. Distributive shock, particularly septic shock, is a potential complication for patients with burn injury and the nurse will take measures to prevent wound contamination. However, this is not the highest priority in emergent burn care. Depending upon other injuries the patient with burns may develop obstructive shock, but this is not the nurse’s highest priority in emergent care. \ 0 0 0 0
0000000000 0000000000 0 \\ MC
1
B \ A nurse is providing care to a patient with progressive shock. Which nursing diagnosis is priority in guiding the selection of interventions for this patient? \ Ineffective Airway Clearance \ Ineffective Tissue Perfusion \ Stress Overload \ Impaired Skin Integrity \ \ Without additional assessment findings, it is not possible to determine if this patient has ineffective airway clearance. Shock occurs when oxygen delivery does not support tissue oxygen demands. This is a state of ineffective tissue perfusion and is the priority nursing diagnosis for all patients in shock. Undoubtedly this patient is experiencing stress, but this is not the highest priority nursing diagnosis. This patient may have impaired skin integrity, but not enough assessment data is provided to make that determination. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A patient was admitted to the emergency department for treatment of a severe infection. Which subjective assessment would raise the nurse’s concern that this patient may be developing shock? \ Hot, dry skin
2
\ Respiratory rate 11 \ Pulse rate 118 and weak \ Anxiety \ \ Hot, dry skin is the expected assessment when a patient is febrile, which may be the case with severe infection. Typically rapid breathing occurs in the presence of shock. This response is an attempt to add oxygen to the system. Rapid pulse occurs in an attempt to increase blood flow, thereby increasing oxygenation to tissues. Weak pulses occur as the contractility of the heart decreases. Anxiety can occur for a variety of reasons and would not immediately be associated with a shock state. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+B+D \ A patient was admitted to the emergency room for treatment of severe infection. Which objective parameters would increase the nurse’s concern that shock is developing? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Serum lactate level is 5.4 mmol/L. \ Base deficit is -12 mmol/L. \ SvO2 is 68%.
3
\ pHi is 6.9. \ Arterial pH of 7.38. \ • Lactate is the metabolic byproduct of pyruvate, which is formed as the result of anaerobic metabolism. Elevated levels mean that the body is depending, at least to some part, on anaerobic metabolism rather than the normal aerobic metabolism. • This is a moderate base deficit and indicates buildup of lactic acidosis resulting from impaired tissue oxygenation. • Normally, when oxygen supply and demand are in balance, hemoglobin is about 60% to 80% saturated after leaving the tissues. • Low mucosal pH indicates development of acidosis. • Headaches should be investigated further as they may indicate bleeding disorders. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ A patient in shock has been sedated using a propofol (Diprivan) drip. How will the nurse assess this patient’s mental status? \ Temporarily discontinue the drip and assess mental status within a few minutes. \ Temporarily discontinue the drug and plan to assess mental status in an hour. \ Use “train of four” testing while the medication is still infusing. \ This assessment will have to wait until the sedating drug is no longer needed. \
4
\ Propofol has a very short half-life, so assessment of mental status can occur within a few minutes of the drugs discontinuation. Benzodiazepines used for sedation require discontinuation of the drug for a longer time in order for mental status assessment to be valid. “Train of four” testing is used when the patient is receiving neuromuscular blocking agents. Mental status should be assessed frequently and cannot be safely deferred until sedation is no longer needed. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A patient is being treated with acetaminophen and a cooling blanket for persistent hyperthermia. Which assessment finding would the nurse evaluate as indicating therapy has been too aggressive? \ The patient complains of a severe headache. \ The patient’s urine output has dropped. \ The patient begins to shiver. \ The patient develops a cough. \ \ Development of a severe headache should be evaluated, but is not associated with treatment for hyperthermia. Decreased urine output is not associated with treatment for hyperthermia. Shivering increases metabolism and oxygen consumption and should be avoided. It may indicate that efforts at decreasing hyperthermia have been too aggressive and should be modified. Development of a cough is not associated with treatment for hyperthermia. \
5
0 0 0 0
0000000000 0000000000 0 \\ MC B \ The nurse is assessing a patient being treated for neurogenic shock after a spinal cord injury. Which assessment would the nurse evaluate as patient improvement? \ Temperature of 97.8°F \ Heart rate of 70 bmp \ Resistance to ventilator-assisted breaths. \ Pink skin tone \ \ Hypothermia is one of the triad of expected signs of neurogenic shock. This patient remains hypothermic. Bradycardia is one of the triad of expected signs of neurogenic shock. Return to a normal heart rate is a sign of improvement. Respiratory rate is not one of the triad of expected findings associated with neurogenic shock. The patient may be mechanically ventilated, but a change in acceptance of this assistance is not indicative of an improved shock status. Peripheral vasodilation produces a pink skin tone so this finding does not indicate improvement. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC C \ An adult patient is demonstrating anaphylaxis from an insect sting. What is the nurse’s priority intervention? \ Benadryl (diphenhydramine) 50 mg intravenously \ Oxygen at 3 liters via nasal cannula \ Epinephrine 1:1000 0.5 mg sq \ Normal saline at 150 mL/hr \ \ Administration of diphenhydramine is appropriate but is not the initial therapy. Oxygen should be administered, but is not the priority intervention. The patient in anaphylaxis experiences bronchial spasm and constriction. The administration of epinephrine is necessary to reverse this process and facilitate an open airway. This is the priority intervention. After experiencing anaphylaxis the patient will likely be hospitalized and given IV fluids. This is not the immediate priority. \ 0 0 0 0
0000000000
7
0000000000 0 \\ MC D \ A patient who has been receiving norepinephrine (Levophed) at a rate of 10 mcg/min will have the drug discontinued. How should the nurse plan to manage this intervention? \ Stop the infusion, but leave normal saline infusing at a rate to keep the vein open. \ Stop the infusion and place an intermittent infusion cap on the IV access device. \ Decrease the rate to 5 mcg/min for 30 minutes before discontinuing the infusion. \ Decrease the rate by 1 mcg/min every 30 minutes while monitoring the patient’s response \ \ Abrupt withdrawal of this medication is not indicated. Abrupt withdrawal of this drug is not indicated. The infusion rate should not be abruptly lowered. The nurse should decrease the infusion slowly, while monitoring the patient’s response. This is the only response that does not result in abrupt withdrawal of the medication. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B+C+D+E \ A patient in shock has just been started on IV Dopamine at 5 mcg/kg/min. Which findings would the nurse evaluate as indication of a possible adverse effect of this therapy?
8
(Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Persistent hypotension \ Heart rate 118 \ Development of a bundle branch block \ Drop in urine output \ Mottling of extremities \ • The rate of infusion of dopamine can be increased above that which is being given if hypotension is not resolved. This is not an adverse effect but may be a case of not getting enough drug. If the patient remains hypotensive at higher infusion rates (50 mcg/kg/min), an adverse effect may be occurring. • Tachycardia can be an adverse effect of dopamine. • Aberrant cardiac conduction may indicate an adverse drug effect is occurring. • Tissue ischemia is an adverse effect of dopamine. Decreased blood flow to the kidney will cause decrease in urine output. • Mottling of extremities indicates peripheral ischemia. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A patient with cardiac decompensation is started on dobutamine at 1 mcg/kg/min with an order to titrate to effect. After receiving this dose for several minutes the patient develops tachycardia and occasional premature ventricular contractions. What nursing intervention is indicated?
9
\ Increase the dose to 1.5 mcg/kg/min. \ Discontinue the infusion. \ Decrease the infusion to 0.5 mcg/kg/min. \ Contact the prescriber immediately. \ \ There is no indication to increase the dose. Discontinuing the infusion is not the first intervention. Decreasing the infusion rate may reverse these adverse cardiac effects. The order is given to titrate the drug to effect. There is no reason to contact the prescriber at this point. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+C+E \ The nurse is monitoring a patient at risk for development of left ventricular failure and cardiogenic shock. Which findings would the nurse immediately discuss with the primary health care provider? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Development of an S3 heart sound \ Sustained systolic hypertension \ Development of bilateral crackles
10
\ Decrease in PAWP \ Decrease in cardiac index \ • Development of third or fourth heart sounds may indicate development of left ventricular failure. • Sustained systolic hypotension would indicate development of left ventricular failure. • Increased pulmonary congestion, as manifested by development of bilateral crackles, may indicate that left ventricular failure is developing. • Left ventricular failure would be manifested by elevation of PAWP. • Low cardiac index can indicate development of left ventricular failure. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A patient who had a myocardial infarction this morning is now developing cardiogenic shock. Which nursing intervention is indicated? \ Increase IV fluids. \ Administer vasoconstricting drugs. \ Provide care in a calm, reassuring manner. \ Withhold oral fluids and nutrition. \ \
11
Increasing IV fluids is not indicated when the patient’s heart is already damaged. The physiological issue is not lack of fluid, but inability to pump fluid efficiently. It is more likely that vasodilating drugs like nitroglycerin will be administered. Providing care in a calm and quiet manner helps to decrease the patient’s anxiety, thereby reducing oxygen consumption. There is no reason to withhold oral fluids and nutrition that is evidenced by this scenario. If the patient appears to be deteriorating rapidly, withholding food may be indicated. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+C \ A patient has been admitted to the emergency department with bleeding from a traumatic amputation of the leg. Which findings would the nurse interpret as indicating this patient’s blood loss is severe? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Heart rate is 120. \ Blood has soaked the dressing applied by first responders. \ Blood pressure is 78/50. \ Mild anxiety is present. \ Heart rate is 50. \ • Marked tachycardia, greater than 110 bpm, indicates severe volume loss.
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• • • •
It is not possible to characterize blood loss by the appearance of a bandage. Blood may have been lost prior to the application of the bandage. Marked hypotension indicates severe blood loss. Presence of mild anxiety indicates moderate hypovolemia. As exsanguination occurs, heart rate will drop and the condition becomes life-threatening. This indicates massive blood loss.
\ 0 0 0 0
0000000000 0000000000 0 \\ MC A+C+E \ A patient who sustained a gunshot wound walks into the emergency department and collapses. Which priority directions should the nurse who assumes this patient’s care give to those coming to assist? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Check the airway. \ Bring a wheelchair. \ Put direct pressure on the leg wound. \ Check for identification. \ Check the pulse. \ • Airway patency is the most important intervention for this patient. • This patient will likely need to be transported by stretcher. • Controlling the source of the fluid loss is imperative.
13
• •
Checking for identification can wait until more pertinent interventions are performed. The patient may have collapsed due to cardiac arrest from hypovolemia. Checking the pulse is part of the immediate assessment.
\ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ A patient hospitalized for treatment of a severe urinary tract infection may be developing septic shock. The nurse would monitor for the development of which finding associated with early septic shock? \ Cold extremities \ Increase in serum lactate levels \ Decreased SCVO2 \ Widening of pulse pressure \ \ Cold and mottled extremities are associated with later stages of septic shock. Increased serum lactate levels indicate a later stage of shock. Decreased SCVO2 indicates a later stage of shock. Since the patient’s diastolic blood pressure decreases, the pulse pressure increases. This finding is associated with early stages of septic shock. \ 0 0 0
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0
0000000000 0000000000 0 \\ MC B \ A patient being evaluated for septic shock has a serum lactate level of 5 mmol/L. What intervention does the nurse anticipate? \ Decreasing the amount of oxygen being given \ Immediate initiation of fluid resuscitation \ Repeat of the testing in 4 hours \ Bedside fingerstick level of blood glucose \ \ An increased serum lactate calls for increased oxygenation. A lactate level of 4 mmol/L is suspicious of significant tissue hypoperfusion and requires immediate fluid resuscitation. There is no need to repeat this test before intervening. Measuring blood glucose is not indicated by this lab result. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC A \ A patient being treated for a severe infection has a temperature of 35.8°C. Which additional finding would indicate to the nurse that initiation of treatment for sepsis is likely? \ A shift to the left on the white blood cell differential \ Heart rate 88 \ Respiratory rate 10 \ Acute alteration in mental status \ \ Greater than 10% bands on the white blood cell differential, or a shift to the left, along with this temperature would indicate sepsis has developed. Heart rate over 90, along with this temperature, indicates sepsis is present. Respiratory rate greater than 20, along with this temperature, indicate sepsis is present. Acute alteration in mental status is related to development of septic shock. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \
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A patient admitted to the emergency department following chest trauma has tracheal deviation to the left. The nurse would prepare for which emergency medical intervention? \ Open thoracotomy \ Placement of a chest tube \ Open excision of the pericardial sac \ Immediate cardiopulmonary resuscitation \ \ Open thoracotomy is not indicated for this complication. Tracheal deviation can result from mediastinal shifting due to a tension pneumothorax. Treatment is placement of a chest tube or a needle thoracotomy. Excision of the pericardial sac may be indicated when cardiac tamponade exists. There is no indication that this complication has developed. There is no indication that cardiopulmonary resuscitation is needed at this point. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ Which finding would cause the nurse to be concerned that a patient who sustained chest trauma is experiencing cardiac tamponade? \ Distant heart sounds \ Decrease of right arterial pressure \
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Sudden development of hypertension \ Development of an S3 heart sound \ \ The presence of blood in the pericardial space makes the heart tones sound muffled or distant. Right arterial pressure increases with cardiac tamponade. Hypotension is associated with cardiac tamponade due to the heart’s inability to fill. S3 heart sounds are not associated with cardiac tamponade. \ 0 0 0 0
0000000000 0000000000 0
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Chapter 37 \\ MC C \ A patient admitted with an infected wound is demonstrating signs of improvement. The nurse would attribute this improvement to which physiologic process? \ Cortisol released from the adrenal glands \ Hypothalamus activating white blood cells \ Endothelial cells releasing mediators to contain the infection \ Mediators that decrease permeability of vessel walls \ \ The wound infection was not contained because of the release of cortisol by the adrenal glands. The hypothalamus does not activate white blood cells. Mediators, bioactive substances that stimulate physiologic changes in cells, are released from endothelial cells. It is these mediators that control inflammation, activate coagulation, deposit fibrin, and inhibit fibrinolysis to contain the inflammatory activity to the site of the infection. Permeability of the vessel walls is increased in order to contain infection. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ A patient tells the nurse that he is upset because his surgical wound is infected and everyone else that he knows who had the same surgery did not have the same problem. How should the nurse respond to this concern?
1
\ “There really is nothing that could be done to prevent it.” \ “You should talk to your surgeon about your concerns.” \ “At least you are in the hospital when the infection started and not at home.” \ “Developing an infection depends on many factors, even things like age and gender.” \ \ The nurse has no way of knowing if there was a way to prevent this patient’s infection. The nurse can offer some explanation about the development of infection instead of referring the patient to the surgeon. Commenting about being in the hospital instead of home when the infection developed does not address the patient’s concerns. How endothelial cells respond to alterations in the environment differ, according to the host genetics, age, gender, nature of the pathogen, and location of the vascular bed. The nurse should explain to the patient that the development of a wound infection depends upon these variables. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ A patient who underwent transurethral resection of the prostate 5 days ago returns to the emergency department. After assessing the patient and obtaining laboratory results the nurse notes a temperature of 96.8°F, a respiratory rate of 26, and a white blood cell (WBC) count of 3,000 mm3. The nurse anticipates additional treatment for which disorder? \ Systemic inflammatory response syndrome \
2
Homeostasis \ Localized inflammation \ Multiple organ dysfunction syndrome \ \ Systemic inflammatory response syndrome is correct because the clinical manifestations include a respiratory rate of greater than 20 breaths per minute and a white blood cell count below 4,000/mm 3. These findings meet the American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference criteria of sepsis. Homeostasis is incorrect because the clinical manifestations are not compatible with the state of equilibrium found in homeostasis. Localized inflammation may exist and contribute to the patient’s condition, but is not the specific problem of concern. There is no indication of the failure of organ systems. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ The nurse is admitting a patient into the intensive care unit and is planning preventative measures to avoid the onset of the systemic inflammatory response syndrome. Which assessment findings would increase the patient's risk of developing this syndrome? \ Age 36 \ Body mass index of 23 \ Asian ancestry
3
\ 15 pack-year smoking history \ \ Patient-related risk factors for developing systemic inflammatory response syndrome include older age. A normal body mass index does not increase risk for SIRS. There is no indication that those of Asian ancestry are at higher risk of developing SIRS. Smoking is a risk factor for developing SIRS. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ A patient involved in a motor vehicle accident was admitted to the intensive care unit with a closed head injury. Which clinical manifestation would warn the nurse that the patient's condition was progressing to multiple organ dysfunction syndrome? \ Urine output less than 400 mL/day \ Decreased PaO2 with an increase in FiO2 \ Alteration in level of consciousness \ Hypotension that responds to fluids \ \
4
Urine output less than 400 mL/day develops later in the course of multiple organ dysfunction syndrome. Decreased PaO2 with an increase in FiO2 is correct because the lungs are usually the first organs to show signs of dysfunction and is the main organ affected in multiple organ dysfunction syndrome. Alteration in level of consciousness is probably already present with the closed head injury, and it also can occur with hypoperfusion, microvascular coagulopathy, or cerebral ischemia and not necessarily progress to multiple organ dysfunction syndrome. The hypotension and dysrhythmias common in MODS do not respond to fluid therapy. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+B+C \ The nurse will calculate the pressure-adjusted heart rate for a patient with cardiovascular dysfunction associated with MODS. Which information must the nurse obtain before this measurement can be calculated? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Heart rate \ Central venous pressure \ Mean arterial pressure \ Temperature \ PaFiO2 \ • Heart rate is a part of this calculation. • Central venous pressure is used in this calculation.
5
• • •
Mean arterial pressure is used in this calculation. Temperature is not part of this calculation. PaFiO2 is not part of this calculation.
\ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A patient with a history of alcoholism and esophageal varices was admitted to the intensive care unit and developed multiple organ dysfunction syndrome. Which laboratory results would confirm the nurse's suspicion of hepatic involvement? \ Increased fibrinogen level \ Decreased blood urea nitrogen \ Increased serum bilirubin \ Increased serum albumin \ \ Abnormalities in the liver would be likely to result in decreased fibrinogen levels. Blood urea nitrogen changes for several reasons and would generally increase in metabolic disorders. Liver dysfunction typically manifests as high levels of serum bilirubin. An increased serum bilirubin level would confirm the suspicion of hepatic involvement. Low serum albumin levels would indicate liver involvement. \ 0 0
6
0 0
0000000000 0000000000 0 \\ MC A \ A patient diagnosed with sepsis and multiple organ dysfunction syndrome has developed acute renal failure. Which arterial blood gas (ABG) result would the nurse expect to find? \ pH = 7.30, PaCO2 = 38, HCO3 = 16, PaO2 = 60 \ pH = 7.50, PaCO2 = 30, HCO3 = 26, PaO2 = 90 \ pH = 7.35, PaCO2= 45, HCO3 = 24, PaO2 = 70 \ pH = 7.46, PaCO2 = 42, HCO3= 28, PaO2 = 80 \ \ The choice pH = 7.30, PaCO2 = 38, HCO3 = 16, and PaO2 = 60 metabolic acidosis is correct because of anaerobic metabolism due to hypoxia and an increase in lactic acid and the kidney's inability to excrete hydrogen ions. In acute renal failure metabolic acidosis can be caused by loss of bicarbonate. The choice pH = 7.50, PaCO2= 30, HCO3 = 26, PaO2 = 90 is incorrect because respiratory alkalosis can be found initially when a patient is hyperventilating or adjustments to the ventilator need to be made but not in an acute renal failure. The choice pH = 7.35, PaCO2 = 45, HCO3 = 24, PaO2 = 70 is incorrect; it is a normal ABG. The choice pH = 7.46, PaCO2 = 42, HCO3 = 28, PaO2 = 80 is incorrect because it is metabolic alkalosis and acute kidney failure would likely result in metabolic acidosis. \ 0 0 0 0
7
0000000000 0000000000 0 \\ MC C \ A patient is in the intensive care unit with multiple organ dysfunction syndrome. Which assessment finding would suggest to the nurse that the patient is experiencing failure of the gastrointestinal system? \ Increased flatus \ Abdominal cramps \ Absent bowel sounds \ Complaint of epigastric burning \ \ Increased flatus would indicate some degree of gastrointestinal functioning. Abdominal cramps would indicate some degree of gastrointestinal functioning. Because there is no objective measure of gastrointestinal function in the patient, the one assessment finding that could indicate dysfunction in this system would be the absence of normal bowel sounds. Complaint of epigastric burning is not specific to gastrointestinal dysfunction. \ 0 0 0 0
0000000000 0000000000
8
0 \\ MC A+B+D \ Which nursing interventions should be implemented to help prevent the development of multiple organ dysfunction in a critically ill patient who is being mechanically ventilated? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Enforcing hand washing before and after touching a patient \ Following an evidence-based ventilator bundle \ Using urinary catheters to prevent perineal skin breakdown \ Complying with turning and repositioning schedules \ Restricting visitors to immediate family only \ • Enforcing hand washing before and after touching a patient is correct because hand washing may prevent infections. • An evidence-based ventilator bundle should be implemented to help avoid ventilator-associated pneumonias. • Use of urinary catheters increases risk for infection and risk for multiple organ dysfunction. • Minimizing the risk for pressure ulcers by relieving pressure and shear points can help prevent development of MODS. • Restricting visitors is not necessary as long as universal precautions are followed. \ 0 0 0 0
0000000000 0000000000 0
9
\\ MC B \ A critically ill patient who is being mechanically ventilated has a temperature of 97.8°F. What nursing intervention is priority? \ Cover the patient with a warming blanket. \ Communicate with the provider. \ Increase frequency of turning and repositioning the patient. \ Increase the amount of humidification given via the ventilator. \ \ The patient may be more comfortable with a warming blanket, but this is not the priority intervention. Communicating a low temperature to the provider and discussing alteration in the plan of care is an essential intervention. This intervention may be indicated, but is not the priority. Increasing the amount of humidification may be indicated, but this is not the priority intervention. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ Which blood glucose reading would the nurse evaluate as supporting the outcome measure of maintaining glycemic control in a patient at risk for multiple organ dysfunction? \ 100 mg/dL
10
\ 120 mg/dL \ 156 mg/dL \ 184 mg/dL \ \ The normal fasting blood sugar level is not a goal for this patient and may result in hypoglycemia. A high normal level of blood glucose is not the goal for this patient and may result in hypoglycemia. The goal for glucose control in this patient is approximately 150 mg/dL. This blood glucose level indicates inadequate glycemic control. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B+C+D \ The nurse is caring for a patient with multiple organ dysfunction syndrome. Which interventions would help optimize tissue perfusion for this patient? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Assess pulse oximetry. \ Maintain patency of the endotracheal tube. \ Administer pain medications as scheduled. \ Keep the environment calm and quiet.
11
\ Maintain a darkened environment \ • Simply assessing pulse oximetry will not affect tissue perfusion but may provide information about gas exchange. • Maintaining the integrity of the endotracheal tube is part of managing the care of a patient being mechanically ventilated. Mechanical ventilation helps to provide oxygen for perfusion. • Managing pain helps to decrease oxygen consumption so that more oxygen is available for tissue perfusion. • A calm environment decreases oxygen consumption. • A darkened environment can be frightening and stressful for the patient which would increase oxygen consumption. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A patient develops systemic inflammatory response syndrome (SIRS) after acute pancreatitis. The patient’s wife says, “I thought he didn’t have any infection.” How should the nurse respond? \ He probably had an infection that we did not recognize. \ He developed SIRS after getting MODS. \ Infection isn’t necessary to develop SIRS, only a severe inflammation. \ Your husband’s body is working against itself. \ \
12
SIRS can occur in the absence of infection. Multiple organ dysfunction syndrome follows SIRS. Pancreatitis is a severe inflammatory illness. SIRS can develop without infection. The wife is not likely to understand this explanation. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B+E \ A patient with a foot infection says, “I can hardly walk on my foot because it is stiff and swollen.” What nursing response is indicated? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ “Infections in the foot always swell because of gravity.” \ “The swelling and pain help remind you not to overuse your foot.” \ “That is a sign of infection that would not have occurred if the area was only inflamed.” \ “Swelling indicates that your infection is getting worse.” \ “Inflammation often causes pain and tissue swelling.” \ • The swelling is a normal part of the inflammatory process. • Loss of function due to local swelling and pain is a physiologic change to help protect the site of injury. • Inflammation also results in localized swelling and pain. • Swelling may or may not indicate worsening of the infection. • Pain and swelling are normal parts of the inflammatory response.
13
\ 0 0 0 0
0000000000 0000000000 0 \\ MC B+D \ A hospitalized patient develops multiple organ dysfunction syndrome. Which assessment findings would be the best indication of oxygenation status? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Absence of central cyanosis \ Decreased bowel sounds \ Unlabored respirations \ Mental slowing \ Normal pulse amplitude \ • Patients with MODS may appear clinically to have adequate oxygenation. It is not possible to determine that the patient is oxygenating all tissues on the basis of absence of central cyanosis. • Regional tissue hypoxia, particularly in the intestinal tract, is a complication of MODS. Decreased bowel motility, evidenced by decrease in bowel sounds, is a result of that hypoxia. • The patient with MODS may appear clinically to have adequate oxygenation, so respiratory effort may also appear to be normal. • Regional tissue hypoxia occurs in MODS, particularly in the brain. Slowing of mental processes results from that hypoxia.
14
•
Increasing cardiac contractility is compensatory for decreased tissue perfusion. This change will result in normal pulse amplitude in many cases, so the presence of normal pulses does not rule out regional tissue hypoxia.
\ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ A patient has developed MODS. The nurse would monitor for development of which classic coagulation system findings? \ Large pulmonary emboli \ Deep vein thrombosis \ Clots in microcirculation \ Clot occlusion of coronary arteries \ \ Large pulmonary emboli are not the most common effect of coagulation changes in MODS. Development of deep vein thrombosis is not the most common effect of coagulation changes in MODS. MODS causes abnormal clotting in the small blood vessels (microcirculation) that results in microthrombosis that obstructs blood flow. This is not the most common result of coagulation changes in MODS. \ 0 0 0
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0000000000 0000000000 0 \\ MC D \ The health care team is working to prevent the development of MODS in a critically injured patient. The nurse would evaluate that these efforts have failed when which findings develop? \ SIRS is confirmed. \ Transfusion is required. \ Laboratory findings over the last 24 hours indicated renal failure. \ Respiratory distress and gastrointestinal bleeding have persisted for 36 hours. \ \ SIRS is a risk factor, but not all persons with SIRS develop MODS. Transfusion is a risk factor, but not all those who receive transfusions develop MODS. Failure of one organ system does not indicate MODS. MODS is the failure of two or more organ systems that persists beyond 24 hours. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC C \ Which information will the nurse gather to figure a patient’s Sequential Organ Failure Assessment (SOFA) score? \ Hemoglobin \ Blood glucose \ Platelets \ Urine pH \ \ Hemoglobin is not considered in this scoring. Blood glucose is not considered in this scoring. Platelet measurement is considered in SOFA scoring as an indicator or hematological function. Urine pH is not considered in SOFA scoring. \ 0 0 0 0
0000000000 0000000000 0 \\ MC B \ A patient has developed MODS. Which information should the nurse provide to the patient’s family? \
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Treatment will require intubation and placement on mechanical ventilation. \ Treatment will focus on supporting all organ systems. \ MODS can be corrected with antibiotic therapy and rest. \ MODS patients require dialysis. \ \ Not all MODS patients require this level of respiratory support. Treatment must focus on supporting those organ systems that are failing and protecting the organ systems that have not failed. There is no definitive treatment for MODS. Not all patients require this level of renal support. \ 0 0 0 0
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Chapter 38 \\ MC A \ A patient being prepared for a heart transplant is concerned that the transplanted organ will not be accepted in his body. What should the nurse consider when formulating a response to this concern? \ Heart transplants are very successful because of immunosuppressant medication. \ Today it is more common to do heart–lung transplants. \ Hearts were the first organs to be transplanted so the technique has been perfected. \ There are no guarantees since transplants are more successful between twins. \ \ Cardiac transplantation is highly successful today, in part because of tissue typing and improved immunosuppressant therapy. Both heart and heart–lung transplants are successful today. The first transplants were done in the 1950s and were kidney transplants. Heart transplants were first successful in the mid-to-late 1960s. Identical twin transplants are the most successful, but much success has also been demonstrated with non-twin transplants. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \
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A patient tells the nurse that chronic kidney disease is "in his family" and his father died within a few months after having a kidney transplant in the late 1940s. What information should the nurse provide? \ “Your chances of a successful transplant depend upon finding a healthy family member who is a match and will agree to provide an organ.” \ “The most successful transplants have always been the heart and lungs.” \ “Many of the earlier failures of kidney transplants had to do with suturing technique.” \ “Medications to prevent problems associated with organ transplantation are now widely available.” \ \ Many non-family transplants are performed and are successful. Transplanting the heart and lungs did not receive the focus of transplantable organs until the 1980s. There is no evidence that transplant of these organs is more successful than transplant of other organs. The major problem associated with transplant has always been rejection. Cyclosporine and other antirejection drugs are now available and have made transplant surgeries much more successful. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \ The older brother of a patient in renal failure has agreed to donate a kidney. Testing reveals that the brothers are a good match for this procedure. How would the nurse describe this treatment plan? \ Heterograft living donor \ Histograft living donor
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\ Allograft living donor \ Isograft living donor \ \ Heterograft is the transplantation of tissue between two different species. Histograft is not a term used to describe status of the donor. Histocompatible refers to the compatibility between donor and recipient. An allograft refers to tissue that is transplanted within the same species. A living donor is someone who agrees to have body parts transplanted into another person while alive. The patient's brother is an allograft living donor. Isograft refers to tissue transplanted between twins. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ A patient is scheduled to receive a liver for transplantation from a person who has died. The nurse anticipates that the donor has which characteristic? \ Died of natural causes \ Experienced cardiac death \ Died in an automobile accident \ Experienced brain death \ \
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It is not possible for the nurse to know if the donor died from natural causes. Cardiac death refers to death by cessation of cardiac and respiratory function. This type of death limits the kinds of tissues that can be donated and typically excludes organ donation. The method of death is not predictable. There are two types of cadaver donors. Organ donors from cadavers who have died from brain death comprise the largest number of implantable organs. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+E \ A patient, identified as a potential organ donor, has been diagnosed as brain dead and is being maintained on ventilator support. The nurse is reviewing the patient's hemodynamic parameters and is concerned about which findings? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Mean arterial pressure 50 mm Hg \ Central venous pressure 5 mm Hg \ Serum sodium 145 mEq/L \ Serum glucose 170 mg/dL \ Ejection fraction 30% \ • There are specific hemodynamic parameters that an adult potential organ donor must meet. The mean arterial pressure should be between 60 and 110 mm Hg.
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• • • •
Acceptable CVP ranges are 4–12 mm Hg. Acceptable serum sodiums are less than 155 mEq/L. Acceptable serum glucose readings are less than 180 mg/dL. The desirable range for ejection fraction is above 50%.
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0000000000 0000000000 0 \\ MC B \ A patient, identified as an organ donor, is diagnosed as being brain dead. The organ procurement organization (OPO) rules that the patient is not a candidate for transplant. The nurse would attribute this decision to which patient history? \ Experimented with intravenous heroin 20 years prior \ Being treated for hepatitis B \ Treated for prostate cancer one year ago \ Treated for shock \ \ Drug abuse many years ago would be considered, but is not the most likely reason this patient’s donor status was denied. Transplantation from a donor with active hepatitis B causes risk for transmission to the recipient. This is the most likely reason that this patient’s donor status was denied. History of cancer, particularly if the cancer is in remission, is localized, and if not bloodborne does not eliminate a person from being a donor. Treatment for shock may or may not result in the organs being unsuitable. The patient would likely be considered as a donor.
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0000000000 0000000000 0 \\ MC A \ The nurse is caring for a patient who will be an organ donor. Which nursing intervention is indicated to protect endocrine function? \ Provide bolus of levothyroxine, Solu-Medrol, insulin, and 50 percent dextrose followed by continuous levothyroxine intravenous infusion. \ Administer salt poor intravenous fluid. \ Administer blood transfusion. \ Provide intravenous dopamine. \ \ Management of the patient who is an identified organ donor includes maintaining endocrine stability. To do this, the thyroid protocol should be implemented which is to provide a bolus of levothyroxine, Solu-Medrol, insulin, and 50 percent dextrose followed by a continuous levothyroxine intravenous infusion. Salt poor intravenous fluids are used to manage the renal/fluid/electrolyte status. Blood transfusions are used to manage the hematopoietic status. Intravenous dopamine is used to manage the patient's hemodynamic status. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC A \ A patient awaiting a kidney transplant has O blood type. The nurse would explain that the patient’s kidney can come from someone with which blood type? \ Only O \ B or O \ A or O \ A, B, or O \ \ If an organ recipient's blood type is O, the only blood type of an organ donator that the recipient can receive must also be O. If the organ recipient has the blood type of B, organs from donors with B or O can be received. An organ recipient with the blood type A can receive an organ from a donor with the blood type of either A or O. If the recipient has the blood type of AB, organs from donors with A, B, or O can be received. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC B \ A patient who received a kidney transplant 2 years ago has been diagnosed with skin cancer. He tells the nurse that he cannot believe that he has cancer since he has already gone through "so much" with the kidney disease. How should the nurse respond to this patient’s statement? \ “It is unusual for malignancies to develop this long after transplant.” \ “Patients on long-term medications to prevent organ rejection are at risk for developing cancer.” \ “At least this cancer will not affect the transplanted kidney.” \ “Everyone can develop cancer at any time.” \ \ Cancers can develop as soon as 6 months after transplant surgery or may not develop for 10 to 15 years after surgery. Patients on long-term immunosuppressant therapy are at increased risk for development of some form of malignancy. It is unknown whether this cancer, which may be melanoma, will or will not affect the transplanted kidney. This is a true statement but does not address this patient’s concerns. \ 0 0 0 0
0000000000 0000000000 0 \\ MC
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B \ It has been determined that a patient who received hematopoietic stem cell transplantation is having poor functioning of the graft. The nurse would prepare the patient for which intervention? \ Administration of high dose corticosteroids \ A second stem cell infusion \ Administration of platelets \ Surgery to remove the graft \ \ Corticosteroids are included in the management of the patient experiencing graft versus host disease. If the initial graft fails a second stem cell infusion may be possible. The administration of platelets or red blood cells would be indicated in the management of the patient experiencing severe pancytopenia. Surgery to remove a stem cell graft is not possible. \ 0 0 0 0
0000000000 0000000000 0 \\ MC D \ A patient received allogeneic hematopoietic stem cell transplantation 2 days ago. Which information should the nurse provide? \ “Your body is accepting the transplanted cells so you should be feeling a lot better.” \ “Your body is making normal hematopoietic cells.”
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\ “You feel so bad because the transplanted cells are attacking your tissues, but that is normal and will pass.” \ “You may not feel well today and we need to protect you from exposure to any infections.” \ \ This is a period in which the patient will not feel “much better.” It can take up to 5 weeks for the body to make normal hematopoietic cells and not 2 days. If graft vs. host disease is occurring the patient will feel sick but GVHD does not “pass” nor is it normal. Within 2 to 3 days after the transplant, the patient's bone marrow function drops to its lowest level, placing the patient at significant risk for infection. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C+E \ During the post-transplantation period, a patient received tacrolimus (Prograf). The nurse would monitor this patient for the development of which adverse effects? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Congestive heart failure \ Nausea and vomiting \ Hyperglycemia \ Hair loss \
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Infection \ • Tacrolimus is not associated with the development of congestive heart failure. • Tacrolimus is not associated with the development of nausea and vomiting. • Tacrolimus, a macrolide antibody, has the development of hyperglycemia as a potential adverse reaction. • Tacrolimus is associated with hirsutism, not hair loss. • Tacrolimus increases risk for infection. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A+D+E \ A patient being conditioned for hematopoietic stem cell transplantation will receive muromonab-CD3 (Orthoclone OKT3). Which medications will the nurse anticipate administering before this medication is given? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Acetaminophen \ Vitamin C \ Penicillin \ Diphenhydramine \ Glucocorticoids \ • Acetaminophen is given prophylactically to prevent “first-dose effect.”
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• • • •
Vitamin C is not standardly administered before this drug. Penicillin is not standardly given before this drug. Diphenhydramine is given prophylactically to prevent “first-dose effect.” Glucocorticoids are administered prophylactically to prevent “first-dose effect.”
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0000000000 0000000000 0 \\ MC C \ A patient recovering from liver transplant surgery is being instructed on the long-term use of steroid medication. Which education should the nurse provide? \ Abdominal pain and nausea are side effects and are expected. \ There are no major side effects associated with this medication. \ This medication helps prevent organ rejection but you must report any vision changes and bone pain and be tested for diabetes regularly. \ This medication works for a few months and will be discontinued. \ \ Abdominal pain and nausea are not expected side effects of glucocorticoid therapy. There are major side effects of steroid medications. Steroid therapy is useful for prevention of rejection and is used in rescue therapy for organ rejection; however, long-term use is associated with severe bone disorders, diabetes mellitus, and cataracts. The patient should be instructed to report any vision changes and bone pain and should be tested regularly for the onset of diabetes. The patient will most likely be on this medication for a very long time, perhaps for life. \
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0000000000 0000000000 0 \\ MC D \ The nurse is caring for a patient recovering from a kidney transplant. Which information should the nurse provide to this patient? \ “You may have a graft site leak, so do not eat or drink anything until I talk to the surgeon.” \ “I am going to slow down your IV fluids to see if that brings your blood pressure down.” \ “It is probably going to be necessary to give you some fresh frozen plasma.” \ “Hypertension is a common problem after surgery, so I will be giving you the antihypertensive medication your surgeon ordered in case this occurred.” \ \ There is not enough information to support a graft site leak. Reducing IV fluids is not likely to be a sufficient intervention to control hypertension in this patient. Administration of fresh frozen plasma, which would expand the patient’s circulating blood volume, is not indicated. Hypertension is a common problem in the kidney transplant patient. This condition can be exacerbated during the postoperative recovery period because of fluid volume imbalances precipitated by the high volume of IV fluids used to maintain a high urine flow. Antihypertensive agents may be ordered preoperatively and postoperatively to maintain the blood pressure within an acceptable range for the patient. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC B+C \ The nurse is preparing for oculocephalic reflex testing of a patient who may be brain dead. Which equipment should the nurse gather? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Reflex hammer \ Cold water \ Syringe \ Hydrogen peroxide \ A tongue blade \ • A reflex hammer is not used in the determination of oculocephalic reflex. • The oculocephalic test requires instillation of cold water into the patient’s ear. • The oculocephalic test requires a syringe. • Hydrogen peroxide is not used to test the oculocephalic reflex. • A tongue blade is not used to test the oculocephalic reflex. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC A+B+E \ Apnea testing is being done on a patient that may be brain dead. During the test the patient develops ventricular tachycardia. What nursing action is indicated? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. \ Reconnect the patient to the ventilator. \ Draw an immediate arterial blood gas. \ No action is necessary unless ventricular fibrillation ensues. \ Allow the patient to die a natural death. \ Treat the dysrhythmia. \ • If the patient develops cardiac dysrhythmia during testing, the ventilator should be reestablished. • If a dysrhythmia develops during testing an immediate arterial blood gas should be drawn. • Action is necessary. • Actions besides allowing death to occur are indicated. • Treatment for this patient should occur just as if brain death was not expected. \ 0 0 0 0
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0000000000 0000000000 0 \\ MC A \ A patient declared brain dead after cardiac surgery has been accepted as a potential donor. The family has given consent for donation. The nurse providing care to this patient would expect directions from which provider? \ OPO coordinator \ Surgeon \ Cardiologist \ Hospitalist \ \ After consent is obtained the care of the donor is transferred to the OPO and the OPO coordinator directs care. At this point the surgeon no longer is associated with the patient’s care. At this point the cardiologist is no longer associated with this patient’s care. At this point the hospitalist is not associated with the patient’s care. \ 0 0 0 0
0000000000 0000000000 0 \\ MC C \
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After several months of testing a patient is placed on the United Network for Organ Sharing (UNOS) waiting list for a kidney transplant. The patient says, “How long do you think it will take for me to get a kidney?” Which nursing response is indicated? \ “Most people get a kidney within the first 6 months of being on the list.” \ “It depends upon how much you are willing to pay for a kidney.” \ “It is impossible to predict when your kidney will be available.” \ “Some people die waiting for a kidney.” \ \ Only about 17% of people receive a kidney in the first 6 months of being listed. The Uniform Anatomical Gift Act prohibits trafficking in organs for a profit. Waiting time is impossible to predict and is related to such variables as body size, blood type, and antibody levels. This is a true statement, but is not therapeutic. \ 0 0 0 0
0000000000 0000000000 0 \\ MC A \ The transplant team works to decrease the number of posttransplant infections due to iatrogenic causes. Which nursing intervention would support this goal? \ Maintaining strict sterile technique with all invasive procedures \ Teaching the patient to restrict the number of visitors the patients have after returning home \
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Identifying potential source of infection from patient history \ Assisting with careful screening of donors \ \ Iatrogenic infections are those acquired in the hospital following transplantation. Vigilance regarding hand hygiene and sterile technique for invasive procedures can help reduce these infections. Reduction of Risk Potential If a contagion is brought into the home by visitors it is still considered community acquired. Reduction of Risk Potential Infections can reactivate from a dormant state. The team should look for these potential infections during pretransplant evaluations. Reduction of Risk Potential Infections that occur because the donor organ or tissues were infected are called donor-derived infections. Reduction of Risk Potential \ 0 0 0 0
0000000000 0000000000 0
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