MedSurg Notes - Nurse's Clinical Pocket Guide (FA Davis, 2007)

Copyright © 2008 by F. A. Davis.Copyright © 2008 by F. A. Davis. 2nd Edition MedSurg Notes Nurse’s Clinical Pocket Guide Tracey Hopkins, BSN, RN Ehren Myers, RN Purchase additional copies of this book at your health science bookstore or directly from F A. Davis by shopping . online at www.fadavis.com or by calling 800-323-3555 (US) or 800-665-1148 (CAN) A Davis’s Notes Book Copyright © 2008 by F. A. Davis. F A. Davis Company . 1915 Arch Street Philadelphia, PA 19103 www.fadavis.com Copyright © 2008 by F A. Davis Company . All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Printed in China by Imago Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1 Publisher, Nursing: Robert G. Martone Director of Content Development: Darlene D. Pedersen Project Editor: Padraic J. Maroney Manager of Art & Design: Carolyn O’Brien: Consultants: Ellen Kliethermes, RN; Glynda Renee Sherrill, RN, MS; Fraces Swasey, RN, MN; Deborah Weaver, PhD, RN, MSN; Jessie Williams, BSN, MA; As new scientific information becomes available through basic and clinical research, recommended treatments and drug therapies undergo changes. The author(s) and publisher have done everything possible to make this book accurate, up to date, and in accord with accepted standards at the time of publication. The author(s), editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of the book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation. The reader is advised always to check product information (package inserts) for changes and new information regarding dose and contraindications before administering any drug. Caution is especially urged when using new or infrequently ordered drugs. Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by F A. Davis Company for users . registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the fee of $.10 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy license by CCC, a separate system of payment has been arranged. The fee code for users of the Transactional Reporting Service is: 80361868/08 0 $.10. Copyright © 2008 by F. A. Davis. Sticky Notes ✓ HIPAA Compliant ✓ OSHA Compliant Waterproof and Reusable Wipe-Free Pages Write directly onto any page of MedSurg Notes with a ballpoint pen. Wipe old entries off with an alcohol pad and reuse. Look for our other Davis’s Notes titles RNotes®: Nurse's Clinical Pocket Guide. 2nd Edition ISBN-10: 0-8036-1531-0 / ISBN-13: 978-0-8036-1531-1 MedSurg Notes: Nurse's Clinical Pocket Guide. 2nd Edition ISBN-10: 0-8036-1868-9 / ISBN-13: 978-0-8036-1868-8 Coding Notes: Medical Insurance Pocket Guide ISBN-10: 0-8036-1536-1 / ISBN-13: 978-0-8036-1536-6 Derm Notes: Dermatology Clinical Pocket Guide ISBN-10: 0-8036-1495-0 / ISBN-13: 978-0-8036-1495-6 ECG Notes: Interpretation and Management Guide ISBN-10: 0-8036-1347-4 / ISBN-13: 978-0-8036-1347-8 IV Therapy Notes: Nurse's Clinical Pocket Guide ISBN-10: 0-8036-1288-5 / ISBN-13: 978-0-8036-1288-4 LabNotes: Guide to Lab and Diagnostic Tests ISBN-10: 0-8036-1265-6 / ISBN-13: 978-0-8036-1265-5 NutriNotes: Nutrition & Diet Therapy Pocket Guide ISBN-10: 0-8036-1114-5 / ISBN-13: 978-0-8036-1114-6 OB Peds Women's Health Notes: Nurse's Clinical Pocket Guide ISBN-10: 0-8036-1466-7 / ISBN-13: 978-0-8036-1466-6 IV Med Notes: IV Administration Pocket Guide ISBN-10: 0-8036-1446-2 / ISBN-13: 978-0-8036-1466-8 Coming Soon! Assess Notes: Nursing Assessment and Diagnostic Reasoning for Clinical Practice ISBN-10: 0-8036-1749-6 / ISBN-13: 978-0-8036-1749-0 For a complete list of Davis’s Notes and other titles for health care providers.Copyright © 2008 by F. visit www. . 2nd Edition ISBN-10: 0-8036-1335-0 / ISBN-13: 978-0-8036-1335-5 LPN Notes: Nurse's Clinical Pocket Guide. 2nd Edition ISBN-10: 0-8036-1767-4 / ISBN-13: 978-0-8036-1767-4 NCLEX-RN® Notes: Core Review & Exam Prep ISBN-10: 0-8036-1570-1 / ISBN-13: 978-0-8036-1570-0 MedNotes: Nurse's Pharmacology Pocket Guide.com. A.fadavis. Davis. Urgent care situations. ■ Notify the physician as soon as you detect any change in the patient’s condition that indicates deterioration in status. and notify the physician. state. A. and nursing interventions and patient’s response. function under a broader scope of practice. in which the patient’s life may be lost or potential quality of life compromised. require even more vigilant attention to nursing standards of care and best practices. Nurses have a duty of care of careful and continuous monitoring of the patient’s status. particularly on an immediate/STAT basis when the patient’s status warrants. Davis. ■ Keep informed of local. Document assessment. Advanced practice nurses. ■ Evaluate family members’ concerns as soon as possible. time of call to physician. ■ Know your state’s nurse practice law. intake and output. ■ Monitor each patient’s vital signs. nursing care plan. get involved as a lobbyist in your state. and clinical nurse specialists. contact your state representatives regarding issues that affect nursing practice. Notify the nursing supervisor if the physician does not respond immediately.Copyright © 2008 by F. The nurse is usually the first team member to detect an urgent care situation and has an obligation to report any changes in patient condition to the medical staff for timely intervention. increase frequency of vital signs if indicated. ■ Know your state’s requirements for licensure. ■ Know if and how a nursing union could affect your practice. neurological status. Nurses have a duty to communicate the patient’s status to the medical staff. The nurse practice law of each state defines the scope of nursing practice for that state. 1 Legal Issues in MedSurg Care Legal issues affect all aspects of nursing care. contact your state board of nursing for a copy. and maintain your nursing license as required. and national nursing issues. such as nurse midwives. status per physician order. (Continued on the following page) BASICS . nurse anesthetists. hospital policy and procedure. the family often detects subtle changes in a patient’s status. ■ Use the hospital’s chain of command if the physician fails to respond within minutes. Nurses assess and directly intervene on patients more than any other healthcare professionals. or underlying organic disease. time physician was notified. ■ Report an unsafe staffing condition to the nursing supervisor as soon as it is apparent. This is akin to the nurse’s duty to advocate for the patient at all times. interventions taken. licensed practical nurses and student nurses cannot perform all the actions of the registered nurse. dosage. ■ Working beyond a 12-hour shift can create a substantial decline in performance. verbal abusiveness. and time.BASICS Copyright © 2008 by F. and at what time. ■ Document the five rights—which medication. Nurses have a duty to keep the patient safe from self-harm. in what dose. Any patient can experience a psychiatric crisis from a myriad of causes. expected therapeutic response. ■ Know the nurse practice limitations on nurses under your supervision. The nurse must be vigilant regarding any changes in the patient’s sensorium/ mental status. and all nursing interventions. ■ Nurses have a duty to know about all the drugs they administer: drug names. ■ Assess the patient’s mental status with each nursing intervention. drug categories. Procedural safeguards should be followed to prevent medication errors. Nurses have a duty to administer medications safely at all times. time physician notified. and time physician arrived. note subtle changes. to whom. The nurse-patient ratio in intensive care settings should not exceed 1:2. time symptoms were present. increased anxiety. The medical chart should be a factual record of the patient’s medical treatment. drug withdrawal. Davis. ■ The nurse must maintain accurate nursing notes. Nurses have a duty to maintain safe patient care conditions. and procedures to minimize the incidence or severity of adverse drug effects. and patient’s response. and agitation. on general floors. time and nature of the reaction. medical Kardexes. place. including hypoxia. flow sheets. vital signs. ■ Signs of impending psychiatric crisis include changes in orientation to person. ■ Give the right drug in the right dose to the right patient by the right route at the right time. 2 . drug reaction. ■ Document fully any suspected adverse drug reaction. timing. duration of drug use. Medication errors are the most common source of nursing negligence. ICU psychosis. technique of administration. A. and notify the physician. including urgent care situations. and nursing care plans that record the patient’s symptoms. 1:6. responses thereto. through which route. The “five rights” of medication administration are minimum practice standards. restlessness. the nurse must question an order he or she deems problematic. not simply completing the form with the patient’s signature. tapering of medication or oxygen at specified time intervals. Informed consent is the process of informing the patient. and for prevention of positional asphyxiation. ■ Question an order for a patient’s discharge from the hospital when the patient’s medical condition is not stable. e. ■ Contact the physician immediately for any order that is unclear. The physician must be notified immediately of the use of restraints. ■ Informed consent involves providing the patient with adequate medical information so that he or she can make a reasonable decision as to treatment based upon that information. contrary to standard drug dosage/route/frequency of administration. be particularly vigilant in carrying out an order that changes over time. or when the patient is going to a potentially unsafe environment. except in an emergency. Document all assessments and frequency of checks (no less frequent than every 15 minutes). Davis. and follow them at all times.Copyright © 2008 by F. ■ Follow written physician orders. ■ If restraints are applied. e. know your state’s informed consent law and the hospital’s policy and procedure for obtaining informed consent. ■ Know the hospital’s policy and procedure regarding use of restraints. hospital policy and procedure. A. restraints can be applied. as patient advocate. In urgent care situations it can be impossible to obtain a patient’s informed consent for an immediate intervention. for maintenance of adequate circulation. the patient must be monitored closely for changes in medical condition and mental status. ■ State laws differ regarding the informed consent standards. Document interaction with the physician and health-care team. an order for vital signs every shift for a postoperative patient recently transferred to a general surgical floor. Concurrently.. 3 ■ If a patient is at risk of self-harm and/or of harming others. Nurses have a duty to carry out physician orders as required by state law.g. when delay in treatment resulting from discharge could injure the patient. (Continued on the following page) BASICS .. ■ Most states require a written physician order before restraining the patient.g. and nursing practice standards. particularly when an urgent care situation is present or when one could arise from fulfillment of the order. or that does not address the acuity of the patient’s medical condition. or did you find the patient in distress? What were your immediate interventions? 4 . As nursing practice. Nurses are held to the standard of care of the profession. nursing journals. and what the outcomes were.BASICS Copyright © 2008 by F. the patient’s choice supersedes the opinion of the health-care provider. and what triggered the situation. a nurse who has the requisite experience and knowledge of the authoritative resources. It is crucial in any legal analysis of care. This is the basis of a lawsuit against the healthcare professional. Keep the following in mind as you document: ■ Always document your assessment findings. Davis. ■ Exceptions to informed consent include an emergency in which the patient is incompetent and cannot make an informed choice. did the patient call for help. your interventions. and nursing treatises that nurses generally regard as authoritative define the nursing standards of care. Know if the patient has a do not resuscitate order. along with medical technology. the standards of nursing care will likewise increase. continues to become more sophisticated and complex. there is not sufficient time to obtain an authorized person’s consent. It enhances decision making and helps anyone who reads it understand what happened. ■ Ensure that each patient’s advance directive or living will (patient’s advance legal permission to the physician to withhold or discontinue treatment) is complied with and well documented in the medical chart per state law and hospital policy and procedure. Documentation Guidelines for Urgent Situations Documentation is critical in urgent situations. called medical malpractice. When nursing care falls below the standard of care.” This is implicit in the standard of care defined by what nursing professionals generally recognize on a national level as correct patient care. ■ Each nurse owes every patient the duty of “reasonable care. ■ If a patient is competent and refuses medical care. even when the condition is life-threatening. Did you observe a problem. ■ Whether a nurse’s care of a patient met the applicable standards of nursing care in a medical malpractice case is determined by a nursing expert. how it was handled. ■ Nationally recognized nursing textbooks. the care could be deemed to be negligent or deficient if that care (or lack of care) causes the patient some type of injury. and ensure that it is well documented. and the patient’s medical condition is life-threatening. A. Time. call your administrative superior (nurse manager). just note that you called the supervisor to report the patient’s condition. ■ If you do not get the response from the physician or nurse practitioner you think is required for the patient’s best interests. Do not blame or complain about someone. whether there was a response or not. The nurse retains accountability for the delegation. date.Copyright © 2008 by F. ■ Always note at what time. by what route. Check your state’s nurse practice act for details about which ” nursing activities cannot be delegated. A. The same applies to any non-drug intervention. determine the following: ■ The complexity of the task and the potential for harm posed by the task (what psychomotor skills are required? what harm can occur if the procedure is done incorrectly?) ■ The predictability or unpredictability of the outcome (is this procedure new to the patient. Document your call and the supervisor’s response. or has the patient tolerated this procedure well before?) (Continued on the following page) BASICS . and how much medication you or another member of the team has administered. ■ If you fail to document something. and give the time and date of the first note. Always record response to the medication and the time the response(s) occurred or the time you observed for a response. It establishes a timeline for the incident as well as conveying the interventions and outcomes accurately. 5 ■ Document as you go. and sign every individual entry. write another entry called “Addendum” to the note above. Delegation Guidelines The National Council of State Boards of Nursing defines delegation as “transferring to a competent individual the authority to perform a selected nursing task in a selected situation. creating the nursing plan of care Administration of medications by direct IV bolus (IV push) Administration of blood products Programming a PCA pump Changing a tracheotomy tube Before delegating. Davis. and report the problems. Sample of nursing tasks that cannot be delegated: ■ ■ ■ ■ ■ ■ Initial assessment or assessments of change in patient condition Formulating the nursing diagnosis. ■ Always note the time you called the physician or nurse practitioner and his or her response. Recognize differences and similarities. may require the more in-depth knowledge and problem-solving skills only the RN can supply) Remember the Five Rights of Delegation: ■ Right Task—is the task within the caregiver’s scope of practice? ■ Right Person—does the assigned caregiver have the knowledge and skill required? ■ Right Circumstances—is the setting appropriate. ■ Perform a focused physical examination. maintaining your availability to assist. ■ Listen and observe. or notify the physician/NP . A. ■ Right Supervision—monitoring performance. ■ The problem-solving or critical thinking abilities required (problem-prone activities such as changing a new colostomy appliance. seek information. Specialized nursing skills and nursing judgment cannot be delegated. subjective.BASICS Copyright © 2008 by F. ■ Have you noticed or has the patient complained of something unexpected? ■ Follow up with questions any new complaint or unusual finding. for example. if not. It may be as obvious as crushing chest pain or as subtle as a complaint of thirst. Know recent trends in the patient’s status. Assessing ■ Once a problem is identified. read recent entries in the chart. are the right resources available? what is the current health status of the patient? ■ Right Direction—clear description of the activity to be performed. The triggering event is something unexpected. limits. Davis. and expectations. understand normal and abnormal findings. Critical Thinking Guidelines Identifying ■ The first thing the nurse must do is identify that a problem exists. 6 . ■ If you have any doubts. obtain relevant laboratory and diagnostic reports. do not ignore tiny red flags. ask a nurse who is senior to you. Big red flags are easy to see. determine how important it is. Remember: The RN delegates a task but retains responsibility and accountability. providing feedback. do not ignore them. ■ Order problems in importance. and current data. relevant patient conditions. receiving feedback about the procedure and patient’s tolerance. historical. determine if the problem is urgent. gather objective. Davis. Diagnosing ■ The end result of analysis is a conclusion. ■ Urgent problems require that you immediately summon a physician or nurse practitioner. Do the data suggest something is worsening? Link the data to the patient’s physical status. A.Copyright © 2008 by F. ■ Ask yourself what other information is needed. what the problem is related to. Do the data “fit”? ■ Ask yourself if you are making the data fit and if you have overlooked another cause. this conclusion is a nursing diagnosis or a definition of the problem. urinary output. Do you need to assess another body system? Have you asked the patient about all recent related events? Should you check the medication record? ■ Other types of problems may require a different set of information (What other supplies are needed? Does the patient require referral to a religious leader? Does the family need to see a social worker?). and what data support this conclusion. Ask yourself if the data can be interpreted another way. Ask if the laboratory values or tests suggest a cause. State the desired outcomes as well and in what time frame you expect them to be achieved. Ask yourself what other issues or conditions could cause similar signs and symptoms. Is the problem hypotension? Think about the factors that influence blood pressure: What is the hemoglobin level. double-check that you are not making erroneous assumptions. ■ Consider if the data fit any of the known complications of the patient’s condition. 7 Analyzing ■ Analysis involves breaking the whole into parts and discovering the relationships of the part to the whole. (Continued on the following page) BASICS . ■ Implement the plan. Ask yourself again: Is it urgent? Does it have the potential to cause a sudden and rapid deterioration in the patient’s health status? Is it imperative that you act immediately? Do you need help? Planning ■ Consider which intervention(s) will be most effective. ■ While you analyze. document all problems and interventions. ■ Determine the significance of this problem. predict the consequences of the intervention and if it will produce the desired outcome. recent blood loss? Can you assess cardiac output? Is the patient on medications that affect blood pressure? ■ Think about what you have discovered through assessment. ■ State the problem clearly. For nurses who are thinking critically about a problem. ■ Work in other fields to gain experience. Learn from them. Use prevention strategies. ■ Be alert in your observations and assessments. Patients in chronic pain may not exhibit signs of being in pain. respiratory or physical therapy. wound care. Read journals and other literature. Principles of Pain Management ■ Differentiate between acute and chronic pain. Challenge yourself. Enhance Your Clinical Reasoning Abilities ■ The link between a problem and a positive outcome is sound professional judgment. surgery. ■ Assess any changes in pain pattern to ensure that new causes are not overlooked. ■ Try the least invasive route first in patients with cancer or chronic pain. evaluate if the interventions are effective. especially for constipation when opiods are used. 8 . Ask yourself what else might be responsible for the signs and symptoms. and weaknesses. ■ Monitor side effects. skills. ■ Assess the status of the problem at appropriate intervals. ■ Learn about other specialty areas such as oncologic nursing. A. and related fields. Ask others. and create an individualized treatment plan ■ Reassure patients in pain or who expect to have pain that pain can be relieved. Davis. Pose new questions to yourself every day. Keep dosage schedules simple. nursing. Correct weaknesses. ■ Ask questions of other experts in medicine.BASICS Copyright © 2008 by F. ■ Know your real strengths. Find out the answers. ■ Determine if further intervention is required. All practioners fundamentally are teachers. Look for ways to better manage pain. ■ Assess each patient’s pain. Realize that everybody makes assumptions and that assumptions can be wrong. Evaluating ■ Evaluation is the step that lets you know if the plan is working. ■ Keep current. ■ Do not assume that the patient’s pain is exaggerated because he or she asks for pain medicine frequently. consult the literature. Ask yourself why a certain complication occurs or why a medication helps. ■ Teach or arrange for instruction in biofeedback. ■ Include family in pain control plan. and hypnosis. 1259.) BASICS . A. ■ Do not avoid opioids because of fear the patient will become addicted. Mosby.Copyright © 2008 by F. 2005. or other route. Winkelstein ML: Wong’s Essentials of Pediatric Nursing. Wilson D. IM. relaxation exercises. Pain Management Numeric Scale 0 No pain 1 2 Mild pain 3 4 5 Moderate pain 6 7 Severe pain 8 9 Very severe pain 10 Worst possible pain Visual Analog Scale Text/image rights not available. Used with permission. Copyright. 9 ■ Be careful switching from oral to IV. Louis. Use for children over 3 years. Dosages change. ■ Encourage patients to request pain medication before pain becomes severe. 0 NO HURT 2 HURTS LITTLE BIT 4 HURTS LITTLE MORE 6 HURTS EVEN MORE 8 HURTS WHOLE LOT 10 HURTS WORST Wong-Baker FACES Pain Rating Scale. (From Hockenberry MJ. ed. ■ Suggest administering medication on an around-the-clock schedule to maintain therapeutic blood levels. St. 7. IT. ■ All can reduce pain and stress and give a greater sense of control. Davis. ■ Suggest time-released pain medications to avoid peaks and valleys in pain control. and different drugs may not provide as much pain relief. Use an equianalgesic dosing table for guidance. p. ■ Consult with a pain management clinical specialist. if available. Explain the 10/10 pain scale and have patient rate pain.... New onset pain. or if it is typical and expected. needs to be evaluated by the physician or nurse practitioner as soon as possible. spontaneous onset..... Tailor questions accordingly.. using a scale of 0–10.... etc... achy. if it is consistent with the patient’s diagnosis... diaphoresis. ■ For patients who cannot use the numerical scale. movement)? S (severity/s/s) .... use the Wong-Baker FACES Pain Rating Scale. Davis.When did it start? Is it constant or intermittent? How long does it last? Sudden or gradual onset? Does it start after you have eaten? Frequency? 10 ..... ■ Contact a pain care nurse. pressing.? Is it similar to pain you have had before? R (radiation/relief) .. abnormal vital signs. surface. postprandial.. dizziness..... deep.)? What makes it better (position. ” ■ Ask how distressing the pain is. PQRST P (provokes/point) . etc. Always find out if the pain is new and different.. ■ Some patients report a lower numerical value but are very distressed by the pain and may need medication or other intervention.. etc...) Point to where the pain is..... if available... ■ Some patients report a moderate to high numerical score (5 or above) but are not distressed and do not want medication.BASICS Copyright © 2008 by F...Is it dull. Are there any signs or symptoms associated with this pain (n/v.. stress. sharp.. or surgery.. back. dyspnea. Mnemonics for Thorough Pain Assessment (PQRST and COLDERRA) Perform pain assessment quickly but thoroughly prior to medicating. tell me what level of pain you are feeling now.. ■ Always ask the patient directly if he or she would like medication. stabbing.. with zero meaning no pain and ten meaning the worst pain possible..)? T (time/onset) ..Does it travel anywhere (to the jaw........... procedure.. etc.. A.What provokes the pain (exertion. ■ Say: “On a scale of zero to ten. procedure.. or pain that is unusual for the diagnosis.. Using Pain Scales ■ Most patients can use the numerical scale. arms.... being still)? What makes it worse (deep inspiration. Q (quality) ...... pallor....... or surgery. SOB.. Chest pain requires immediate assessment (see Chest Pain in CV tab)...... ..................... Painful.........................................offering reassurance Relieve anxiety and fears ............ achy...................... Must use concentrated medications.................................. takes longer to act.......... heat and cold therapy Decrease irritating stimulation ........... guided imagery Provide cutaneous stimulation ........ sharp.....................bright lights.....................Nausea..positioning.What provides relief? Associated s/s ..................................................................................................................... anxiety..............Does it travel to another part of the body? Relief.......... pressure? Onset ...............................Copyright © 2008 by F..................When did it start? Location . autonomic responses? Nursing Interventions for Pain Management Provide comfort .. changing sites usually easy............................................... Davis............ A.... stabbing........... (Continued on the following page) IM Quicker onset of action than oral route No need for IV access..................rhythmic breathing...... rest and relaxation Validate patient’s response to pain ........What makes it worse? Radiation..............Dull................................... least invasive.....massage.. difficulty finding sites in undernourished patients Only small volumes of fluid can be injected each hour...................... potential nerve injury.........setting aside time with patient Teach relaxation techniques .. which increases risk for drug error........................ temp Comparison of Routes of Analgesic Administration Route Oral Advantages Easiest.................... consider oral first while taking into account patient status Disadvantages Metabolized in the liver before reaching bloodstream—less drug available (40% to 60%) than with other routes.. 11 COLDERRA Characteristics............................... Cannot be used if patient has difficulty taking oral medications..........Where does it hurt? Duration . 80% of drug available Subcutaneous BASICS ..........................How long does it last? Frequency? Exacerbation ............ noise..................... fewer side effects Easy to use. Drug remains active for 14–25 hours after removal. Good for patients who cannot tolerate PO medications Sublingual Cultural Sensitivity It is not possible for nurses to know intimately all other cultures different from his or her own. Used primarily for break-through pain for cancer patients. It is possible. Too often people make assumptions based on the 12 . IT Epidural Transdermal Much lower doses. May not be appropriate for confused patient. Davis. which presents problems if patient overdosed. Usually used for patients with cancer pain. Better absorption.BASICS Copyright © 2008 by F. Slow buildup of drug. to acknowledge that significant cultural variations exist and to adopt an attitude of sensitivity that includes a desire to learn about and respect the culture of the patients for whom you care. Inform family also. Potential for infection or other complication Not suitable for acute pain. however. A. NOTE: Never administer a dose for the patient—can lead to respiratory depression and death. quicker onset than oral route. Comparison of Routes of Analgesic Administration (continued) Route IV PCA Advantages Immediate effect. can have a continuous rate and a bolus Disadvantages IV sites are portal for infection. Potential for Stereotyping Books that list cultural characteristics of various groups have some value but can lead to stereotyping. fewer side effects. Do not automatically use a family member. Sensitive information may be embarrassing for the two people to discuss. Show respect for that person’s role. and more. personal space. how the patient handles being ill or in pain are powerful cultural beliefs. As always. ask politely and respectfully. Observe each patient. BASICS . Always ask if the patient is willing to use the interpreter. Discuss issues such as organ donation. and follow his or her lead. communicate through the oldest family member present. Maintain a respectful and open attitude as you learn about each patient. 13 color of someone’s skin or other overt characteristics. ■ Health beliefs—What causes illness. special care of the body. Ask the patient or family members about these issues and integrate the information into your plan of care. so to speak. In an emergency. Suggest meeting with the family if the patient approves of you sharing or receiving information about personal preferences. If you are not sure. ■ Food preferences—providing the patient’s preferred food can be instrumental in rate of recovery. ■ Family relationships—families may have a hierarchy that includes a spokesperson. do not reveal confidential information about a person’s health without the express consent of the patient. ■ Birth and death rituals—End-of-life beliefs can vary significantly within any culture. Common domains of importance related to health care include: ■ Communication styles—eye contact. Cultural Assessment Cultural assessment covers many factors. too numerous for this book. ■ Language—it is very important to use competent interpreters when obtaining and receiving health information. ■ Religion—you may ask how important religion is to the patient in daily life and if he or she consults with another member of that religion in healthcare matters. and what the family will want to do in the immediate time after death. autopsy if applicable to the case. Ask about any natural remedies the patient has or is using. A. tone of voice. how care is provided. Keep in mind that cultural variation is frequently expressed within domains applicable to any culture.Copyright © 2008 by F. Davis. The challenge for nurses is to learn whether a person considers himself or herself to be a member of a group and to recognize that significant variation exists within groups. Try to get someone of about the same age and gender as the patient. Many do not feel competent to do so or that it is none of their business. You can always ask the patient how he or she feels spiritually.BASICS Copyright © 2008 by F. Davis. Follow the patient’s lead. The answer will be very revealing in terms of willingness to discuss the topic. Often. and never impose your own beliefs. 14 . Some nurses may be too intimidated to address this issue. A. Spiritual Care Providing spiritual care means different things to different people. the best spiritual intervention is to ask open-ended questions and then listen. ■ Palpate the anterior chest: ■ Locate apical beat. varicose veins. blood pressure. ■ Assess for thrills—a palpable murmur. ■ Assess current symptoms: ■ RED FLAG symptoms require immediate attention and intervention. ulcers. which is the point of maximum impulse (PMI). Palpitations possibly with chest pain and dizziness. or pulse changes in extremities. ■ Vital signs: ■ Blood pressure. ■ Mental status. vomiting. restlessness. possibly with neck. fatigue (especially in women). 15 Focused Assessment of the CV System ■ A focused assessment of CV status includes: ■ The core cardiovascular system—the heart. A. respiratory rate. ■ The peripheral vascular system—the extremities. ■ The lungs—adventitious sounds. color. Pain. particularly the lower extremities. circumoral cyanosis. ■ Auscultate the heart and lungs: ■ Obtain rate and rhythm. jugular venous distention. ■ Mental status—level of alertness. temperature. use a Doppler sonogram. confusion. ↓ LOC. its rate and rhythm. Sweating. color of conjunctiva. Syncope possibly with palpitations and shortness of breath. If pulses are not palpable. and other hemodynamic measures. ■ Listen for carotid abdominal and femoral bruits. or nailbeds. ■ Assess for heaves—a very forceful PMI. or left arm pain. Shortness of breath. feels like a cat purring. ■ Edema of lower extremities (check sacrum if client is bedridden). head and neck: ■ Look for restlessness. Davis. ■ Capillary refill time in hands and feet. coolness. ■ Inspect the anterior chest: ■ Look for visible pulsations of the chest wall. O2 saturation. then the bell. and oxygenation status. CARDIAC . pallor. heart rate. jaw. or stupor.Copyright © 2008 by F. ■ Assess extremities: Check for: ■ Cyanosis. nausea. ■ Changes in foot color. irritability. and amount of moisture. ■ Listen for normal heart sounds and possible murmurs. Chest pain. ■ Presence and equality of pedal pulses. assess for rhythm abnormalities. ■ Use the diaphragm of stethoscope first. the carotid arteries. cough. fingers. Cyanosis of lips. usually on the shin (pretibial edema) or dorsum of foot (pedal edema): 0–1/4 inch. disappears 2 min Possible Causes of Shortness of Breath Source Cardiac Potential Causes Coronary artery disease. heart failure. neuromuscular disorders. pulmonary embolus (PE). chronic pulmonary emboli. disappears in 1–2 min 1 inch. pulmonary edema COPD with comorbid cardiac disorder. angina. cardiomyopathy. dysrhythmias COPD. pericarditis.CARDIAC Copyright © 2008 by F. disappears in 5 sec 1 2 3 4 1/4–1/2 inch. asthma. trauma Metabolic acidosis. MI. hyperventilation Pulmonary Combined cardiopulmonary Other 16 . A. anxiety. panic. left ventricular hypertrophy. pneumothorax. pain. valve disease. upper airway disorders. disappears in 10–15 sec 1/2–1 inch. deconditioning. Davis. Assessment Guides Circulation Scale Capillary Refill Normal Delayed 3 sec 3 sec Pulse Scale Pulse Strength Absent Weak Normal Full Bounding 0 1 2 3 4 Edema Scale Press thumb carefully into edematous area. ■ Place patient in a supine position with affected limb extended. IMMEDIATE INTERVENTIONS ■ Notify physician or NP . ■ Hematoma. CARDIAC . A.Copyright © 2008 by F. using folded sterile gauze dressings. until bleeding has been controlled. possibly pulsatile. ■ Continue to apply pressure for 10 minutes or more. 17 Cardiac auscultation sites. ■ Don sterile gloves and. around arterial puncture site. apply firm pressure 2 cm above puncture site. Arterial Hematoma CLINICAL PICTURE The patient may have: ■ Pressure dressing to radial/brachial/femoral artery insertion site that is saturated with blood. ■ Cannulated artery that has been inadvertently decannulated and is hemorrhaging. using the first three fingers of one hand. Davis. and convey to physician or NP . clotting factors. and sensation in affected extremity. FOCUSED ASSESSMENT ■ Monitor distal pulses. or coolness in affected extremity. thrombolytic therapy. Monitor circulation. ■ Loss of sensation in the extremity. ■ Document patient’s status. Frequently assess site for rebleeding. STABILIZING AND MONITORING ■ ■ ■ ■ ■ ■ Instruct patient to maintain supine position a minimum of 6 hours. and sensation of affected limb. tingling. von Willebrand’s disease. Assess for history of preexisting conditions such as clotting abnormalities or blood dyscrasias or for recent/current administration of antiplatelet or anticoagulant medications. Arterial Occlusion CLINICAL PICTURE The patient may have: ■ Numbness. neutral position. 18 . Reassess for pain. ■ Assess LOC and patient’s ability to maintain extremity in immobile. ■ Once bleeding is controlled. Depending on institution protocol. apply sterile gauze dressing overlayed with a pressure dressing (Elastoplast). POSSIBLE ETIOLOGIES ■ Hemophilia. NP response. ■ Obtain IV access for the administration of blood. use a sandbag or other pressure device over the pressure dressing for added pressure. ■ Assess for pain. Davis. Frequently monitor VS for changes in BP and HR.CARDIAC Copyright © 2008 by F. skin color. severe burning pain. DIC. phone call to physician or NP and physician or . ■ Assess VS. thrombocytopenia. BE PREPARED TO ■ Assist physician or NP with cannulation of an alternate arterial site. temperature. or anticoagulant reversal agents such as protamine sulfate. ■ Chart patient status. antiplatelet therapy. anticoagulant therapy. A. noting decrease in BP or increase in HR. vascular trauma or iatrogenic arterial injury. mobility. POSSIBLE ETIOLOGIES ■ Compartment syndrome. major vascular injury. STABILIZING AND MONITORING ■ Continue to monitor condition of extremity. ■ Edematous. pain level) of affected extremity. ■ Assess pulses with Doppler amplification. Compare with those in contralateral extremity. movement (flexion. shock. cyanotic. ■ Notify physician or NP . or NP response. ■ Initiate large-bore IV access. hypotension.g. paresthesias. CARDIAC . FOCUSED ASSESSMENT ■ Assess for pallor. rotation).. IMMEDIATE INTERVENTIONS ■ Check all arterial pulses in the affected extremity. tight. ■ Document patient’s status. and sensation (response to pinprick or light touch. Davis. ruptured aortic aneurysm. shiny skin over affected extremity. local or regional block anesthesia. ■ Remove or do not use ice on the extremity. hypothermia. and pulselessness (5 Ps) by assessing circulation (skin color. dehydration. A. arteriogram puncture site or A-line insertion site) for swelling or hematoma. pulses). ■ Assess VS. ■ Capillary refill 3 sec or absent. BE PREPARED TO ■ Remove any external fixtures (casts) on the extremity. compare with that of contralateral extremity. mottled. capillary refill. or assist the physician or NP with fasciotomy for immediate relief of pressure. thrombus. phone call to physician or NP and physician . extension. ■ Assess mobility of affected extremity. or ashen extremity. ■ Keep extremity at heart level to promote arterial flow without diminishing venous return. ■ Control and manage pain.Copyright © 2008 by F. ■ Assess any sites of arterial puncture (e. paralysis. ■ Assess bandages or cast proximal to diminished pulses. fracture. lymphedema. pain. 19 ■ Pale. cord injury. ■ Prepare the patient for surgery. and temperature. Titrate O2 to SaO2 90%. Obtain IV access if none available. ■ Signs of unstable bradycardia: ■ Altered LOC. and/or cyanosis. and monitor rate and rhythm. moistness. phone call to physician or NP and physician . Bradycardia CLINICAL PICTURE The patient may have: ■ HR 60 bpm. Assess for associated symptoms (chest pain. shortness of breath (SOB). BE PREPARED TO Administer oral or IV medications as ordered. Obtain a 12-lead ECG. Assess skin for color. Chart patient status. Davis. hypotension). Assess BP . FOCUSED ASSESSMENT ■ ■ ■ ■ Assess LOC and orientation. Assess recent laboratory results. ■ Nausea and vomiting. Administer supplemental O2. assess SaO2 if readily available. Assess respirations for rate and effort. Check for patent IV access. ■ If patient on telemetry or cardiac monitor. SOB. Set up cardiac monitoring. STABILIZING AND MONITORING ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Monitor VS. Notify physician or NP . dizziness or lightheadedness. Obtain or order laboratory tests. or NP response. A. pulmonary congestion. Assess BP and HR. and convey to physician or NP . IMMEDIATE INTERVENTIONS ■ ■ ■ ■ ■ ■ ■ Have patient sit or lie down in bed. ■ Chest pain.CARDIAC Copyright © 2008 by F. ■ Hypotension. assess ECG. 20 . Assist with external pacing. Document patient’s status. Transfer patient to ICU or telemetry unit. STABILIZING AND MONITORING ■ Administer medications STAT for cardiac symptoms. temperature. ■ Marked anxiety. Assess SaO2 with pulse oximetry. fatigue. expression of “impending doom. or tightness. shock. jaw. ■ Document patient’s status. if ordered: NTG 0. ■ Notify physician or NP .4 mg SL (hold for BP 90 mm Hg). Auscultate lung fields. hypothyroidism. excellent physical condition (athletes). ■ SOB. myocardial infarction. and/or arm. FOCUSED ASSESSMENT ■ ■ ■ ■ ■ Assess HR. Chest Pain CLINICAL PICTURE The patient may have (see table below on Possible Causes of Chest Pain): ■ Substernal or epigastric sensations of fullness. ■ Dizziness.4 mg q 5 min 3 doses maximum (hold for BP 90 mm Hg) and one 325 mg nonenteric-coated aspirin. ” IMMEDIATE INTERVENTIONS ■ Elevate head of bed (HOB) to facilitate breathing. ■ Nausea. hypothermia. morphine (MS) 2 mg IV (hold for RR 8. aspirin (ASA) 162–325 mg PO. ■ Check for standing orders of nitrogylcerine (NTG) sublingual 0. A. CARDIAC . sepsis. vomiting. hyperkalemia. ■ Check for IV access. and effort. hypothermia. ■ Assess VS. hypoglycemia. Administer STAT. or NP response. Prepare to initiate saline lock IV access. rhythm. character and quality of pain (PQRST). phone call to physician or NP and physician . fainting. BP respiratory rate (RR). 21 POSSIBLE ETIOLOGIES ■ Medication toxicity.Copyright © 2008 by F. and moistness. tachypnea. and/or diaphoretic skin. . ■ Administer high-flow O2 by nonrebreather mask (10–15 L/min) or by nasal cannula (4–6 L/min). Inspect skin for color. skin color. pain may radiate to left neck. back. Assess rhythm strip. vasovagal response. ■ Cool. BP 90 mm Hg). pale. Davis. severe infection. pressure. indigestion. Call a code. Davis. chest trauma. Identify underlying rhythm. pulmonary edema. PTT. and convey to physician or NP . bronchitis. cardiac markers). ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Assess response to medications. pericarditis. Set up or change the O2 delivery system. gastroesophageal reflux disorder. Administer oral or IV medications. Obtain laboratory tests (electrolytes.CARDIAC Copyright © 2008 by F. endocarditis. Transfer patient to ICU. pleurisy. POSSIBLE ETIOLOGIES ■ Angina. A. Obtain cardiac enzymes/troponin levels. Set up cardiac monitoring. Call for a STAT 12-lead ECG. BE PREPARED TO Assess need and eligibility for thrombolytic therapy. perform CPR. pulmonary embolism. MI. anxiety. 22 . PT. Chart patient status. A. aching but may also have sharp pain. tightness. None. Anterior chest. large. Gradual or sudden onset. Variable. extreme exertion. No relief. arm. shoulder. . Mild to moderate. jaw. mild. Moderate. Sudden onset. lasting 2 min. lasting hours. Rest or sl NTG provides relief Ache with sharp. Sudden onset.Copyright © 2008 by F. Provoked by exertion. heavy meal. stabbing pain. → to left neck. No relief. PE (Continued on the following page) CARDIAC Dull. back Same as MI Severity and Time (Duration) Severe. or fright. squeezing. lasting longer than 20 min. Location and Radiation Substernal anterior chest or epigastrium. No provocation. Sudden. or moderate of variable duration. Pneumonia No provocation or coughing. stress. Davis. Quality and Relief Pressure. neck. Possible Causes of Chest Pain Etiology MI Provocation and Onset No provocation. No relief. Angina 23 Pressure. deep breathing. burning when patient in upright position. throat. lasting minutes to hours. antacids provide relief. possible sharp pain. lasting minutes or hours. LUQ. Chest. back. A. Davis. CARDIAC 24 Moderate. Severity and Time (Duration) Moderate to severe. coughing. Quality and Relief Sharp. back. Dull ache. abdomen. RUQ. . Arm. Musculoskeletal disorders Gradual or sudden. Location and Radiation Substernal anterior chest. endures for hours to days.Copyright © 2008 by F. shoulder. Mild to moderate. Possible Causes of Chest Pain (continued) Etiology Pericarditis Provocation and Onset No provocation. Gradual or sudden onset. Epigastric disorders Sharp. Rest and mild analgesics or NSAIDs provide relief. ribs. neck. sternum. Gradual or sudden. Elevate HOB. and electrolytes as ordered. ■ Closely monitor I&O. NTG. and lower legs if possible. CBC. Notify physician or NP . increased CVP positive fluid balance. Davis. morphine. Assess LOC and orientation. physical. weakness. ■ Change in mental status anxiety. systemic infection. confusion. Assess SaO2 via pulse oximetry. FOCUSED ASSESSMENT Assess airway. ■ Order a chest x-ray and ECG. septic shock. ■ SOB. Administer supplemental O2 (100% nonrebreather mask). Administer oral or IV diuretics. anxiety. pulmonary embolism.Copyright © 2008 by F. . adventitious breath sounds (rales or crackles). dyspnea. STABILIZING AND MONITORING ■ Restrict fluids. ■ Order or obtain laboratory tests (BUN. orthopnea. 25 Heart Failure CLINICAL PICTURE The patient may have: ■ Fatigue. note if hypotensive. Restrict fluids. ■ Edema. restlessness. creatinine. electrolytes). cyanosis. wheezes). ■ ■ ■ ■ BE PREPARED TO Titrate O2 to keep SaO2 90%. . ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ IMMEDIATE INTERVENTIONS Assess VS. Auscultate lung fields for pulmonary congestion (crackles. Assess cardiac rhythm. and administer diuretics as ordered. BP and HR. and emotional excesses. ■ Assess for improvement of LOC and oxygenation status. environmental. marked bradycardia. jugular vein distention. RR and effort. ■ Transfer patient to ICU or telemetry unit. POSSIBLE ETIOLOGIES ■ Atrial fibrillation. A. Set up cardiac monitoring. Obtain IV access. Assess for patent IV. CARDIAC . carcinoid syndrome. ■ Thirst. and have IVF ready to hang. obesity.CARDIAC Copyright © 2008 by F. cardiac infection and inflammation. ■ Peri-incisional swelling and hematoma. maintain patent airway. reinforce with additional dressing and pressure. Davis. stress. hypertension. anxiety. Monitor VS frequently. coronary artery disease. restlessness. Instead. ■ Slightly elevated RR to severe tachypnea. ■ Hypotension. coma (later CNS signs). Administer supplemental O2. Discontinue thrombolytics or anticoagulants. ischemic myocardial disease. MI. acute mitral or aortic regurgitation. irritability. or cyanotic skin. lethargy. A. diminished peripheral pulses ( l2). IMMEDIATE INTERVENTIONS ■ ■ ■ ■ Get help. polycythemia vera. ■ Subtle changes in LOC. ■ Delayed capillary refill ( 3 sec). ■ Excessive amounts of blood in wound drainage system. phone call to physician or NP and physician . glomerulonephritis. excessive intake of water and/or sodium administration of cardiac depressants or drugs cause salt retention. and notify surgeon. Hemorrhage/Wound Hemorrhage CLINICAL PICTURE The patient may have: ■ Saturated postoperative dressings. cardiomyopathy. anemia. If IV not in place. Document patient’s status. or NP response. pregnancy. decreased alertness (early CNS signs of blood loss). Control external bleeding with direct pressure. hyperthyroidism. ■ ■ ■ ■ ■ 26 . infective endocarditis with acute valve incompetence. ■ Narrowing of pulse pressure. mottled. ■ Confusion. cool extremities and pale. ■ Bruising around umbilicus or retroperitoneally in flank areas (internal bleeding). cor pulmonale. obtain large gauge (#18) IV access. ■ Increased HR to severe tachycardia. severe aortic stenosis. combativeness. as this may also remove any clot formation. Do not remove saturated dressings. ■ Insert Foley catheter. Davis. postsurgical. cancer. bradycardia. ■ Assess skin for color. ■ Prepare the patient for surgery. and VS (HR. tachycardia. call blood bank to see if any blood available. chest pain. ■ Assess SaO2 via pulse oximetry if available (Note: may be unreliable due to decreased peripheral perfusion). visual disturbances. vomiting. ■ Assess for orthostatic hypotension if possible. BP). A. ■ Check laboratory values. ■ Provide emotional support to patient/family. ■ Dyspnea. blood type and crossmatch). confusion. ABGs. and urinary catheter. ruptured aneurysm. BE PREPARED TO ■ Assist with insertion of a central line. 27 ■ Assess LOC. CARDIAC . dizziness. ■ Administer colloidal infusions. capillary refill. thrombolytic therapy. Hypertensive Urgency/Emergency Hypertensive urgency: systolic BP 200 mm Hg or a diastolic BP 120 mm Hg. internal bleeding: blunt trauma. GI perforation. ■ Administer blood. Hypertensive emergency: diastolic BP 140 mm Hg with evidence of acute end-organ damage. RR. ■ Lightheadedness. temperature. restlessness. pedal edema. CLINICAL PICTURE The patient may have: ■ Fatigue. ■ Obtain laboratory tests STAT (Hgb/Hct. POSSIBLE ETIOLOGIES ■ External bleeding: wounds (postsurgical and traumatic). moistness.Copyright © 2008 by F. ■ If patient previously typed and cross-matched. turgor. orientation. ■ Monitor output from Hemovac. NGT. headache. ■ Mechanically ventilate. electrolytes. FOCUSED ASSESSMENT STABILIZING AND MONITORING ■ Monitor VS and oxygenation status. ■ Chart patient status. ■ Nausea. JP drains. and convey to physician or NP . seizure. Transfer patient to ICU. ■ Altered LOC or orientation. cocaine. ■ ■ ■ ■ ■ ■ FOCUSED ASSESSMENT STABILIZING AND MONITORING ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ BE PREPARED TO POSSIBLE ETIOLOGIES ■ Atherosclerosis. hematuria. IMMEDIATE INTERVENTIONS ■ ■ ■ ■ ■ Assess BP in both arms. ■ Cool. anxiety. Assist with arterial line placement. cardiac or renal disease. Assess for associated symptoms: visual disturbances. A. and convey to physician or NP . BP). Elevate HOB to 30 –45 . Titrate O2 to SaO2 90%. Administer ordered antihypertensive medications (oral or IV). toxemia of pregnancy. Hypotension CLINICAL PICTURE The patient may have: ■ A systolic BP of 90 mm Hg or systolic BP 40 mm Hg less than baseline. Assess respiratory status. diabetes. phone call to physician or NP and physician . medication. Monitor I&O. oral contraceptives). Obtain a saline lock IV access. Assess for changes in cardiac rhythm if patient is on a monitor. Chart patient status. Assess baseline VS (temperature. RR. Davis. diaphoretic skin. slurred speech). if available. Assess SaO2 via pulse oximetry. Assess LOC and orientation. Obtain or order laboratory tests (BUN. pale. creatinine. UA). or NP response. peripheral edema. 28 . Notify physician or NP . electrolytes.CARDIAC Copyright © 2008 by F. HR. Administer supplemental O2. drugs (amphetamine. corticosteroids. stroke. Document patient’s status. Maintain continuous monitoring of BP and HR. chest pain. anger. ashen. Assess for neurological deficits (hemiparesis. stress. primary hypertension. cyanotic. Order specific laboratory tests to be drawn STAT. IMMEDIATE INTERVENTIONS FOCUSED ASSESSMENT ■ Assess LOC. BUN. RR. Transfer patient to a critical care unit. Continue to monitor VS. and convey to physician or NP . administer high-flow O2 via mask (10–15 L/min). Decreased urine output ( 30 mL/hr). electrolytes). ■ Assess for associated symptoms (chest pain. Tachycardia or bradycardia. ■ Place patient in a supine position with legs elevated above heart level to increase circulation to vital organs. Hypotension could be due to cardiac compromise. and pulse quality and rhythm. NP response. or urinary symptoms (burning. hematuria). turgor. Chart patient status. ■ Assess skin for color. moistness. Check MAR for possible medication-induced hypotension. ■ Document patient’s status. ask patient about recent history of vomiting. ■ Notify physician or NP . ■ Assess respiratory effort and airway patency. frequency. phone call to physician or NP and physician or . with direct pressure. BE PREPARED TO CARDIAC . HR. dyspnea. ■ Assess I&O. ■ Control bleeding. ■ Check for patent IV access. cyanosis. Review laboratory data (Hgb/Hct. flank pain. diarrhea. Obtain IV access. A. ■ If respiratory effort inadequate (RR 8. Titrate O2 to SaO2 of 90%. STABILIZING AND MONITORING ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Assess for cause. if any. baseline VS (temperature. ■ Assess MAR for medications that can affect blood pressure. nausea). place patient in supine or low Fowler’s position (HOB slightly elevated). Administer ordered vasoactive medications. SaO2 90%). Davis. dyspnea. in which case fluids might be contraindicated. Note: IVF is not routinely administered until reason for hypotension is determined. and administer ordered IVF . temperature. BP). or manually assist ventilations with an Ambu bag (mask-valve device). to maintain airway patency. urine specific gravity. and capillary refill. Evaluate previous 24-hr I&O.Copyright © 2008 by F. 29 ■ ■ ■ ■ SOB. Note: This position is contraindicated if the airway is compromised. Nausea and vomiting. orientation. ■ Tachycardia. ■ Cold and clammy skin. Hg. ■ Check for patent IV access. ■ Document assessment thoroughly. Assess breath sounds. GI bleed or other internal bleeding. ■ Take BP and assess apical HR and rhythm. adrenal crisis. hypotensive (drop in BP 20 mm Hg from baseline). ■ Continue to monitor VS and O2 saturation. Obtain and assess laboratory data such as ABG. O2 saturation Assess peripheral pulses. hemorrhage. phone call to physician or NP and physician . cardiac enzymes. or NP response. and provide reassurance. bradycardia. aneurysm..CARDIAC Copyright © 2008 by F. or dizziness. myxedema. hypoglycemia. Obtain rhythm strip to document event. Davis. rate as one measure of perfusion. anxiety. completed stroke. cardiac dyrsrhythmias. electrolytes. skin temperature and color. obtain and analyze rhythm strip every 4 hours and when rate or rhythm changes. peripheral pulses. FOCUSED ASSESSMENT ■ ■ ■ ■ ■ ■ Assess LOC. Assess precipitating event. IMMEDIATE INTERVENTIONS ■ Place patient supine in bed. congestive heart failure. nausea. STABILIZING AND MONITORING ■ Continue to monitor rhythm. Hct. ■ Stay with patient. ■ Quickly assess perfusion by assessing mental status. ■ Notify physician or NP . ■ SOB. dehydration. irregular rate. and pulse quality and rhythm. 30 . VS. heart racing. ■ Observe cardiac monitor if patient is being monitored. if appropriate. e. Compare apical rate to radial . Assess trends in pertinent laboratory data. hyperventilation. edema. A.g. pain level. dyspnea. sepsis. vasovagal response to anxiety. POSSIBLE ETIOLOGIES ■ Medication. Palpitations CLINICAL PICTURE The patient may have or be: ■ Sensation of fluttering in chest. Apply O2 if available at bedside. ■ Document patient’s status. shock. alcohol. salmeterol). liver and cardiac enzymes. VT. stroke. phenothiazine. PAC. hypoglycemia. pericarditis. Possible Causes of Palpitations Source Cardiac Conditions Sinus tachycardia or bradycardia. administer ordered IVF and medications. stress. quinidine. fever. adrenal crisis. cardiomyopathy. other chemistries. Pacemaker malfunction. PVC. antiarrhythmics. SVT. Theophylline. Transient ischemic attack. Heart failure.. thyrotoxicosis. and infuse IVF . and convey to physician or NP . digoxin. Vasovagal or postural hypotension.or 15-lead ECG ■ Administer antiarrhythmic medication (e. anemia. tobacco. Congenital heart disease. blood glucose. hemorrhage. Bradycardia/tachycardia syndrome (sick sinus syndrome). Wolff-Parkinson-White syndrome. BUN and creatinine. mitral valve prolapse.Copyright © 2008 by F. amiodarone). albuterol. Vasodilators. ■ Transfer patient to a unit with cardiac monitoring. ■ Assist with placement of temporary transvenous or external pacemaker or cardioversion. caffeine. A. ■ Review laboratory data such as Hgb/Hct.: procainamide. 31 ■ Keep IV line patent. ■ Chart patient status. PJC. electrolytes. BE PREPARED TO ■ Obtain a 12.g. dehydration. terbutaline. ■ Check MAR for possible drug side effect or interactions. Cocaine. hypoxia. Atrial fibrillation or flutter. Davis. POSSIBLE ETIOLOGIES ■ Premature atrial or ventricular contractions (PACs or PVCs) or other cardiac dyrsrhythmia. Beta2 agonists (e.g. Drugs Vascular Other CARDIAC . ■ Obtain IV access. hyperthyroidism. Hyperventilation. heart failure. hypoglycemia. medications. anxiety. and quality. rhythm. If patient is hypotensive. ■ Continue to assess VS as frequently as indicated. and moistness.CARDIAC Copyright © 2008 by F. ■ Notify physician or NP . and standing positions. which suggests hypovolemia or dehydration. ■ Palpitations. STABILIZING AND MONITORING ■ Assess orthostatic VS: take HR and BP in supine. ■ Ask if patient feels nauseated or is experiencing chest pain. ■ Check if new medications have been administered. Assess BP . Assess rate. ■ Nausea. ■ Assess for associated neurological signs (slurred speech. temperature. determine if patient had a sensation of spinning or movement. ■ Review I&O records from preceding days. using pillows. Syncope CLINICAL PICTURE The patient may have or be: ■ Lightheadedness. ■ Tachypnea. ■ Assess LOC and mental status. Assess HR. each 2 min apart. ■ Cool. vomiting. phone call to physician or NP and physician . Note if pulse increases by 20 or more bpm and the systolic BP drops by 20 mm Hg or more. pale. FOCUSED ASSESSMENT ■ Assess patency of airway and patient’s breathing. ■ Assess skin for color. ■ Review history and all current medications. or floor (if necessary). or NP response. ■ Document patient’s status. diaphoretic skin. ■ Check recent chemistry and hematology laboratory results. A. Davis. feeling faint. hyperventilation. weakness). and elevate lower legs above heart level. ■ ■ ■ ■ ■ ■ IMMEDIATE INTERVENTIONS Assist patient to chair or bed. numbness. Administer supplemental O2 via nasal cannula. sitting. 32 . ■ Assess mucous membranes and skin turgor for signs of dehydration. turgor. ease of breathing. keep supine. ■ Chest discomfort. ■ Anxiety. POSSIBLE ETIOLOGIES ■ Dysrhythmias. Administer 50% dextrose IV. Vasovagal or postural hypotension. stroke. dizziness or lightheadedness. Hyperventilation. BE PREPARED TO ■ ■ ■ ■ ■ Obtain IV access. electrolyte imbalance. hypoxia. ■ Palpitations. 33 ■ Test stool for occult blood. concussion. Order specific laboratory tests to be drawn STAT. head trauma. Seizure. Tachycardia (HR 100 bpm). hypertension. orthostatic/postural hypotension. SOB. HR 150 bpm (supraventricular tachycardia).Copyright © 2008 by F. Transient ischemic attack. A. Possible Causes of Syncope Source Cardiac Conditions Bradycardia (HR 60 bpm). Pulmonary hypertension. CARDIAC . Obtain a chemstick blood sugar level. vasovagal response. stress/anxiety/fear. Davis. hypoxia. hyperglycemia. ■ Chart patient status and convey to physician or NP . Aortic or pulmonic stenosis. Neurological Vascular Other Tachycardia CLINICAL PICTURE The patient may have: ■ HR 100–150 bpm (sinus tachycardia—may be asymptomatic). restlessness. hemorrhage. anemia. Decreased cardiac output. Administer IVF or a fluid challenge. cardiac insufficiency. hypoglycemia. medication reaction. hypovolemia/dehydration. ■ Chest pain. moistness. GI pain or nausea. and convey to physician or NP . BP). dehydration). ■ Assess recent history of emotional upset. ■ Hypotension. ■ Assess MAR for medications with potential to cause tachycardia. Assess heart rhythm. A. Assess for associated symptoms (body pain. vomiting. Notify physician or NP . assess rhythm strip. melanotic stool. STABILIZING AND MONITORING ■ Set up cardiac monitoring. and temperature. ■ Pulmonary congestion and/or cyanosis. IMMEDIATE INTERVENTIONS ■ ■ ■ ■ ■ ■ Have patient sit or lie in bed. chest pain. ■ Assess blood glucose level. Assess blood pressure and respirations. ■ ■ ■ ■ ■ FOCUSED ASSESSMENT Assess LOC. hypotension. Davis. infectious disease. SOB. turgor. Reduce or eliminate environmental stressors. blood loss from menses. ■ Signs of unstable tachycardia: ■ Altered LOC. ■ Assess HR. ■ Assess 12-lead ECG (see ECG in Tools tab). ■ Assess recent I&O. RR. orientation. order 12-lead ECG. Document patient’s status. diarrhea. physician or NP response. HR. . Administer supplemental O2. ■ Titrate O2 to keep SaO2 90%.CARDIAC Copyright © 2008 by F. if available. BE PREPARED TO 34 . Assess SaO2 via pulse oximetry. ■ Chart patient status. BP and SaO2. Assess skin for color. medication use. fever. ■ Obtain IV access. and VS (temperature. ■ If patient on telemetry or cardiac monitor. phone call to physician or NP and . exercise. Davis. anxiety. A. 35 ■ ■ ■ ■ Administer oral or IV medications as ordered. hemorrhage. fever. atrial fibrillation. pain. Order laboratory tests to be drawn STAT. hypovolemia. CARDIAC . A & P Snapshot Left common carotid artery Left subclavian artery Aortic arch Left pulmonary artery Left atrium Left pulmonary veins Mitral valve Left ventricle Aortic semilunar valve Interventricular septum Apex Right ventricle Papillary muscles Brachiocephalic artery Superior vena cava Right pulmonary artery Right pulmonary veins Pulmonary semilunar valve Right atrium Tricuspid valve Inferior vena cava Chordae tendinea Cardiac structure and blood flow. medications. Assist with cardioversion.Copyright © 2008 by F. hypoglycemia. dehydration. POSSIBLE ETIOLOGIES ■ Hypoxia. caffeine. stress. electrolyte imbalance. Transfer patient to the cardiac care or telemetry unit. infection. Davis.CARDIAC Copyright © 2008 by F. A. Occipital Internal carotid Vertebral Brachiocephalic Aortic arch Celiac Left gastric Hepatic Splenic Superior mesenteric Abdominal aorta Right common iliac Internal iliac External iliac Deep femoral Femoral Maxillary Facial External carotid Common carotid Subclavian Axillary Pulmonary Intercostal Brachial Renal Gonadal Inferior mesenteric Radial Ulnar Deep palmar arch Superficial palmar arch Popliteal Anterior tibial Posterior tibial Arterial circulation. 36 . or stupor ■ Ease of breathing and respiratory rate: ■ Ask the patient how his breathing is. restlessness. Always look at the whole picture.g. if applicable ■ Mental status level of alertness. ■ Note if the patient is wearing the O2 all the time and if the device is correctly applied. ■ Lung sounds: ■ Listen to lung sounds in all fields. Also. most adults have a respiratory rate in the lower end of the range. A. It also tells how well the lungs and kidneys are compensating or responding to treatments. 37 Focused Respiratory System Assessment ■ A focused assessment of respiratory status includes: ■ Ease of breathing and respiratory rate ■ Lung sounds ■ Use of O2 and oxygenation ■ ABGs ■ Ventilator assessment. not just a single reading. both of which indicate respiratory distress.Copyright © 2008 by F. RESP . Davis. A rate 26 is cause for alarm. pulse oximetry can be inaccurate in the presence of peripheral vascular disease. however. confusion. Ask if SOB is triggered by activity and if rest relieves the feeling. unless it’s the patient’s baseline. Rates 20 respirations/min should be investigated. Ask the patient to breathe deeply with his mouth open. areas where air movement is not heard. ■ Check pulse oximetry to assess percentage of oxygen saturation (SaO2): 97% to 99% is normal. although 93% to 97% may be normal for some patients. or areas where breath sounds are diminished. ■ Note adventitious sounds.. use his subjective terminology when documenting. irritability. ■ Assess rate—normal rate is 12–20. ventilation. and oxygenation. ■ Assess use of accessory muscles or nasal flaring. Ask about energy levels and if the patient can eat and talk comfortably. Reading of 90% or less indicates possible need for ventilation support. ■ Analyze ABG results: ■ ABG allows for assessment of acid-base balance. ■ Use of O2 and oxygenation: ■ Note the amount of O2 ordered and the method of delivery (e. 3 L/min via nasal cannula). Compare trends in O2 saturation to determine if oxygen therapy is effective. ■ Chest pain (pleuritic). ■ Notify physician or NP . ■ Altered mental status. decreased breath sounds. dyspnea. ■ Document patient status. PaCO2. ■ Normal values (memorize): pH: 7. Suction oropharynx. help patient to expectorate. A. and HCO3 tell about acid-base balance.45 PaO2: 80–100 mm Hg PaCO2: 35–45 mm Hg O2 saturation: 95%–100% HCO3: 21–28 mEq/L Base excess: 2 to 2 mEq/L See detailed explanation of how to interpret ABGs on page 51 in this tab. If there is evidence of foreign body obstruction see Choking in the Emergency tab. ■ Crackles and rhonchi (usually on the right. cyanosis. Encourage coughing. ■ Fever. FOCUSED ASSESSMENT ■ Assess patient’s ability to clear airway and effort to breathe. or NP response. ■ PaO2 and SaO2 indicate oxygenation status. ■ pH. Davis. Provide supplemental oxygen.RESP Copyright © 2008 by F. Aspiration CLINICAL PICTURE The patient may have: ■ Sudden onset of coughing and shortness of breath (SOB) associated with eating. but may be on the left or bilaterally). phone call to physician or NP and physician . ■ Assess airway for secretions or foreign objects. bradycardia. IMMEDIATE INTERVENTIONS ■ ■ ■ ■ ■ Elevate head of bed (HOB) to upright position. 38 .35–7. ■ Tachypnea. ■ Tachycardia. or regurgitation. drinking. but do not tape dressing in order to allow air to escape from chest cavity. SaO2. disorders that affect normal swallowing and gag reflex (depression of the laryngeal reflexes. 39 ■ Assess effectiveness of measures taken to clear airway. ■ Visible chest tube drain pores. use of sedative drugs. tracheotomy. decreased LOC. ■ Maintain constant pressure. and work of . gastroesophageal reflux). foreign body aspiration. and effort). if indicated. ■ Whistling sound as air enters or exits wound site or chest tube. stroke). disorders of the esophagus (esophageal stricture. IMMEDIATE INTERVENTIONS ■ Immediately cover chest tube insertion site with sterile petroleum gauze (occlusive dressing) covered with several 4 4 pads. breathing. ■ Assess oxygenation status: level of consciousness (LOC). ■ Assess HR. epiglottitis. Chest Tube Dislodgement CLINICAL PICTURE The patient may have: ■ Signs of respiratory distress: rapid. ■ Consider a speech pathology consultation to assess patient’s level of airway control and/or gag reflexes. restlessness. A. tracheitis. POSSIBLE ETIOLOGIES ■ Emesis. rhythm. anesthesia. presence of circumoral and nailbed cyanosis. ■ Partially or completely dislodged chest tube. and SaO2. or increased work of breathing. coma. cricothyrotomy. BP respirations (rate.Copyright © 2008 by F. and assess patient for evidence of dysphagia. excessive alcohol consumption. RESP . shallow. ■ Call a code. STABILIZING AND MONITORING ■ Continue to monitor airway and respiratory function. ■ Monitor patient during oral intake. or bronchoscopy. or anxiety. Davis. BE PREPARED TO ■ Set up and assist with intubation. cyanosis. ■ Auscultate lung fields. RESP Copyright © 2008 by F. ■ Cyanotic. ■ Assist patient with movement and repositioning. petroleum gauze. ■ Auscultate lung fields. and work of breathing. A. ■ Administer supplemental O2. BE PREPARED TO ■ Set up and assist with reinsertion of chest tube. improper transfer technique. 4 4 pads. ■ Document patient status. patient confused). ■ Maintain drainage system in upright position below heart. and diaphoretic. ■ Notify physician or NP and respiratory therapist STAT. and compare ventilation left to right. ■ Place emergency equipment in patient’s room (sterile NS. ■ Continue to evaluate lung sounds and quality of oxygenation. SaO2. phone call to physician or NP and physician or . skin color. Davis. POSSIBLE ETIOLOGIES ■ Excessive torque or tension on chest tube due to multiple possible causes (chest tubes not hanging freely during movement. 40 . ■ Make sure all chest tube connections are secure and that tubing is not tangled or encumbered. inability to take a deep breath. ■ Administer supplemental O2. ■ Order portable CXR. FOCUSED ASSESSMENT ■ Assess respirations and quality of oxygenation including LOC. NP response. ■ Assure that extra drainage collection system is readily available on the unit. tape and nontoothed padded clamps). ■ Difficulty breathing. Dyspnea/SOB CLINICAL PICTURE The patient may have or be: ■ Mild sensation of discomfort to feeling of suffocation. ■ Assess drainage system for proper functioning. ■ Assess vital signs (VS) and pain level. STABILIZING AND MONITORING ■ Assure chest x-ray (CXR) is obtained after reinsertion. ashen or pale. crackles. ■ Assess oxygenation status by evaluating for changes in mental status. ■ Assess for underlying respiratory conditions. circumoral and nailbed cyanosis. NP response. ■ Assess for chest pain. FOCUSED ASSESSMENT STABILIZING AND MONITORING ■ Continue to monitor respiratory status as detailed in Assessment. ■ Ask patient about previous episodes of SOB. and moistness. and orthopnea. noting diminished breath sounds. ■ Note tracheal alignment. other cardiovascular symptoms.Copyright © 2008 by F. and support effort to breathe. friction rubs or stridor. wheezing. symmetry of chest expansion. 41 ■ Tachypneic. if SOB is made worse by lying flat. phone call to physician or NP and physician or . Place on pulse oximetry and cardiac monitor if readily available. Assess cough. confused. RESP . if onset was sudden or gradual. ■ Assess skin for color. ■ Maintaining an upright position to facilitate breathing. Administer supplemental O2 if no history of COPD. use of accessory muscles. If patient is hyperventilating. noting evidence of chest pain or tightness. Notify physician or NP and respiratory therapy. fearful. A. assess O2 saturation and cardiac rhythm. retraction of subclavicular and intercostal spaces. anxious. bulging interspaces. ■ Assess work of breathing as evidenced by flared nostrils. measuring SaO2. Auscultate lung fields for adventitious sounds and quality of air movement. leg vein tenderness. agitated. wheezing. and presence of JVD. Document patient’s status. ■ Assess VS and respiratory status. Davis. ■ Auscultate lung fields. ■ Assess medication administration record for possible medication/anaphylactic reactions. what provoked it. use of accessory muscles. Assess VS. ■ ■ ■ ■ ■ ■ ■ ■ ■ IMMEDIATE INTERVENTIONS Place patient in a position that facilitates breathing. deeper breathing or. reassuring demeanor. ■ Restless. maintain calm. have the patient perform pursed-lipped breathing. Stay with patient. encourage slower. poor air movement. if indicated. nausea. and evaluating cardiac rhythm. Davis. Transfer to ICU. chronic pulmonary emboli. pulmonary edema. POSSIBLE ETIOLOGIES ■ Allergic reaction. airway obstruction. Administer medication. and convey to physician or NP . A. cardiomyopathy. left ventricular hypertrophy. pulmonary edema COPD with comorbid cardiac disorder. MI. asthma. neuromuscular disorders. ■ Administer medications as ordered. Suction the oropharynx/trachea. Obtain ABGs.RESP Copyright © 2008 by F. Assist with intubation or chest tube placement. ■ ■ ■ ■ ■ ■ ■ ■ ■ BE PREPARED TO Obtain IV access. angina. emphysema. upper airway disorders. pulmonary embolus (PE). pericarditis. Place a nasal or oral airway. pneumothorax. hyperventilation Pulmonary Combined cardiopulmonary Other 42 . asthma. trauma Metabolic acidosis. pneumonia. heart failure. pain. Possible Causes of Shortness of Breath Source Cardiac Potential Causes Coronary artery disease. aspiration. deconditioning. ■ Chart patient status. cardiac ischemia. Change or set up an O2 delivery system. Assist with diagnostic testing. valve disease. cardiac dysrhythmias or tamponade. heart failure. pulmonary embolism. anxiety. pleural effusion/pleuritis. pneumothorax. ■ Continue to assess patient for contributing factors and underlying cause. dysrhythmias COPD. anxiety/panic attack. panic. IMMEDIATE INTERVENTIONS ■ ■ ■ ■ ■ Attempt to arouse patient with physical stimulation to enhance breathing. Assess skin color and moistness. depth. Continue to monitor breathing and oxygenation closely. ■ Transfer to ICU. administer Romazicon 0. Assess airway for obstruction. Assess VS. 43 Hypoventilation/Ineffective Breathing Pattern CLINICAL PICTURE The patient may have or be: ■ Dyspnea at rest or on exertion. noting RR. Administer bronchodilators. obtunded. or pale.2 mg IV. For narcotic/opioid OD. ■ Obtain IV access. ■ Hypoxic and appear cyanotic. ■ Lethargic. Insert oral or nasal airway. ■ Administer medication as ordered. ABGs. ■ Get help. periods of apnea as in CheyneStokes (neurological). other laboratory tests. ■ Signs of right-sided heart failure (JVD. peripheral edema. ■ Rapid and shallow breathing pattern. and convey to physician or NP . ■ Obtain CXR. and hepatomegaly). FOCUSED ASSESSMENT ■ ■ ■ ■ STABILIZING AND MONITORING ■ ■ ■ ■ ■ ■ BE PREPARED TO ■ Assist with setup and application of various O2 delivery systems (mask. and quality. and call physician or NP . or NP response. phone call to physician or NP and physician .4 mg IV. Manually ventilate patient with a BVM device if RR 8 or O2 saturation 90%. . . administer Narcan 0. Davis. RESP . Chart patient status. ashen. notify RT. Perform orotracheal suctioning to clear secretions. For IM benzodiazepine OD. A. stuporous. Assess LOC and orientation. Auscultate lung fields for adventitious sounds and equality of breath sounds. Administer supplemental O2.Copyright © 2008 by F. CPAP BiPAP intubation/ventilator). or unconscious. or notably slow (narcotic) breathing. ■ Document patient status. if necessary. primary alveolar hypoventilation.RESP Copyright © 2008 by F. obesity hypoventilation syndrome. diaphoresis. Notify physician or NP . Assess VS. immobilization. trauma. fibrothorax. chest wall deformities. phone call to physician or NP and physician . diaphragm paralysis. Place on pulse oximetry and cardiac monitor. muscular dystrophy. ■ Assess for chest pain. amyotrophic lateral sclerosis. ■ Syncope. if available. Have second practitioner independently calculate dilutions and infusion pump programming. IMMEDIATE INTERVENTIONS ■ ■ ■ ■ ■ ■ Administer supplemental O2. STABILIZING AND MONITORING ■ Continue to assess VS. pleuritic chest pain. FOCUSED ASSESSMENT ■ Auscultate lung fields for adventitious sounds and quality of air movement. Document patient’s status. central respiratory drive depression. ■ Initiate anticoagulant therapy (heparin) as ordered. A. benzodiazepines. respiratory status. neuromuscular disorders. hypotension. thoracoplasty. and convey to physician or NP . neurological disorders: encephalitis. kyphoscoliosis. ■ Wheezing. recent DVT. Assess respiratory rate and work of breathing. malignancy. LOC. leg vein tenderness. ■ Signs and symptoms of thrombophlebitis. Guillain-Barré syndrome. barbiturates. chronic bronchitis. Pulmonary Embolism CLINICAL PICTURE The patient may have or be: ■ Dyspnea. ■ Assess O2 saturation. ■ Chart patient status. emphysema. ■ Assess for history of recent surgery. Davis. myasthenia gravis. ■ Anxiety. POSSIBLE ETIOLOGIES ■ COPD. ■ Lower extremity edema. brainstem disease. tachycardia. 44 . or NP response. drugs: narcotics. VS. cardiac rhythm. Change or set up an O2 delivery system. surgery and trauma. ■ Obtain serial PTTs. ■ Cyanosis of skin and mucous membranes. pregnancy. spiral CT scan. Administer medications or fluids to maintain blood pressure. POSSIBLE ETIOLOGIES ■ Embolization of thrombi from deep veins of the femur. evaluate in context of patient baseline—some patients with COPD may never have SaO2 greater than 88% but are stable. and titrate heparin infusion. ■ Tachycardia and dysrhythmias (due to hypoxemia and acidosis). malignancy. characterized by a PaO2 60 mm Hg and a normal or low PaCO2. and severe airway disorders such as asthma or emphysema. ■ Transfer to ICU for high acuity care or thrombolytic therapy. restlessness. is most common and is caused by any acute disease of the lung (pulmonary edema. 45 ■ ■ ■ ■ BE PREPARED TO Obtain IV access. hypercoagulable states. ■ Anxiety. ■ Decreased O2 saturation (SaO2 90% is considered abnormal. neuromuscular disease. Hypercapnic respiratory failure. excessive work of breathing. characterized by a PaCO2 50 mm Hg. IMMEDIATE INTERVENTIONS ■ Notify physician or NP and respiratory therapist of decline in respiratory function. pulmonary angiogram). pelvis. or somnolence. ■ Obtain ABGs. ■ Elevate HOB. RESP . ■ Abnormal ABG results: Hypoxemic respiratory failure. position patient to facilitate breathing. oral contraceptive and estrogen replacement therapy. and lower extremities from multiple causes including venous stasis. Respiratory Distress/Failure CLINICAL PICTURE The patient may have: ■ Dyspnea.Copyright © 2008 by F. Davis. however. Assist with obtaining diagnostic studies (CXR. is associated with drug overdose. pneumonia). chest wall abnormalities. A. confusion. V/Q scan. and levels below this can represent unstable respiratory status that requires immediate intervention. ■ Seizures (may occur with severe hypoxemia). Administer medications to treat underlying cause. POSSIBLE ETIOLOGIES ■ Hypoxemic respiratory failure: chronic bronchitis and emphysema (COPD). ■ ■ ■ ■ BE PREPARED TO ■ Call a code. ABGs. 46 . drug overdose. fat embolism syndrome. pulmonary embolism. ■ Assess VS. obesity hypoventilation syndrome. pulmonary edema. (Use O2 cautiously in patients with severe COPD and chronic CO2 retention. ■ Assist with diagnostic and laboratory studies (portable CXR. adult respiratory distress syndrome. primary alveolar hypoventilation. ■ Insert nasal or oral airway. If hypoxemia is severe. LOC. STABILIZING AND MONITORING Assess cardiac monitor. other diagnostic tests.) ■ Document patient’s status. myxedema. and rest respiratory muscles may be required. Continue to assess temperature. and work of breathing. poisonings. primary muscle disorders. and suction if patient unable to clear secretions. ■ Hypercapnic respiratory failure: COPD. myasthenia gravis. bronchiectasis. ■ Insert IV access. ECG. pneumoconiosis. ■ Assist with intubation. pulmonary fibrosis. FOCUSED ASSESSMENT ■ Assess oxygenation. pulmonary arterial hypertension. . orientation. ■ Apply supplemental oxygen via nasal prongs or face mask to correct hypoxemia and keep oxygen saturation above 90%.RESP Copyright © 2008 by F. assess for circumoral or nailbed cyanosis. poliomyelitis. ■ Transfer to ICU. asthma. Davis. polyneuropathy. A. BP pulse oximetry. LOC. granulomatous lung diseases. orientation. head and cervical cord injury. intubation and mechanical ventilation to increase PaO2. phone call to physician or NP and physician . respiratory rate. lower PaCO2. pneumonia. bronchoscopy). and ABG results. adult respiratory distress syndrome. ■ Assess if the airway is patent and if patient is alert enough to manage secretions and to protect airway. sputum culture. pulmonary edema. lung sounds. ■ Assess for underlying cause of respiratory distress. severe asthma. pneumothorax. or NP response. yet also allows the patient to initiate breaths. If apnea occurs. While you manually ventilate the patient. synchronizes with the patient’s own respiratory efforts. ■ Airway protection. ■ SIMV (synchronized intermittent mandatory ventilation)—ventilator is triggered only by a patient-activated demand valve and. the respiratory therapist should assess the ventilator per manufacturer’s guidelines. severe repiratory distress ■ Unhook the ventilator from the endotracheal (ET) tube. the ventilator is the probable source of the problem.Copyright © 2008 by F. ■ CMV (continuous mandatory ventilation)—ventilator delivers a set tidal volume at a set rate regardless of patient’s own attempts to breathe. A. ■ Inadequate ventilation—hypoventilation (high pCO2. Common Settings ■ AC (assist control)—patient triggers ventilator to deliver a breath. Davis. ineffective breathing pattern. a minimum rate and volume will be delivered to the patient. ■ PSV (pressure support ventilation)—for patients with spontaneous breathing. RESP . ■ CPAP (continuous positive airway pressure)—continuous. ■ Increased work of breathing. Notify respiratory therapy (RT). The ventilator may need to be changed if the problem cannot be found. ■ Inadequate oxygenation—O2 saturation (90% on hi-flow oxygen via nonrebreather mask). ■ PEEP (positive end-expiratory pressure)—maintains a preset positive airway pressure at the end of each expiration. Ventilator delivers a preset positive pressure for the duration of inspiration when the patient initiates a breath. ■ IMV (intermittent mandatory ventilation)—ventilator delivers a set tidal volume at a set rate. ■ BiPAP (bilevel positive airway pressure)—same as CPAP but with two preset pressure settings: one for inspiration and one for expiration. therefore. 47 Ventilators/Mechanical Ventilation Indications ■ Airway obstruction. pH acidosis). Expect patient to require sedation. ■ If patient is easy to ventilate manually and is no longer in distress. Get help after unhooking patient from ventilator. Troubleshooting Ventilator Problems Patient in sudden. and manually ventilate patient with 100% oxygen using an Ambu bag. nonstop positive pressure is applied throughout entire respiratory cycle. PEEP is used to treat a PaO2 of 60 mm Hg on FiO2 of 50%. and assist with reintubation. Suction the oropharynx to clear secretions. Interventions ■ Reconnect patient to ventilator. and assess for equal. remove and manually ventilate patient with 100% oxygen using Ambu bag and face mask. If unsuccessful. immediately disconnect patient from vent. if available. ■ Evaluate cuff. If there is unequal chest wall movement and/or decreased air entry on one side. check the patient first. 48 .RESP Copyright © 2008 by F. ■ Evaluate connections. and reinflate if needed (if ruptured. Notify physician and RT. consider sedating the patient. and assist with reintubation. If patient is in no apparent distress. atelectasis. and tighten or replace as needed. Notify RT. Ventilator Alarms: Implications and Interventions When the ventilator alarms. ■ If ineffective ventilation continues. Notify RT/physician STAT. bilateral breath sounds). inspect and auscultate the patient’s chest for equal and adequate air entry. Notify RT/physician STAT. and check cuff pressure with a manometer. ET tube will need to be replaced). ■ Assess for air leak. ■ If ineffective ventilation continues and no physical or mechanical cause can be found. or a tension pneumothorax. If tube is dislodged. try to calm the patient. Davis. extubate and manually ventilate with 100% oxygen using an Ambu bag and face mask. and manually ventilate with 100% oxygen using an Ambu bag and call for help. If unable to clear obstruction or pass suction catheter. Suction oropharynx to clear secretions. A. Listen for air around the cuff. ■ Assist with reintubation if needed or replacement of ventilator or ventilator components. check vent to determine source of problem. Alarm Low-Pressure Alarm Usually caused by system disconnections or leaks. If patient is showing signs of distress (“fighting the vent”). ■ Check ET tube placement (auscultate lung fields. ■ Assess for dislodgement. ■ If patient is difficult to ventilate manually: suction the ET tube to clear secretions. it may be related to a malpositioned tube. Notify RT for possible reintubation if air leak cannot be fixed. STAT intervention is required as the tract can collapse suddenly. ■ Suction patient. inadequate seal Interventions ■ Suction patient if secretions are suspected. or reposition tube. ■ Evaluate/reinflate cuff. pain). A. ■ Look for source of anxiety (e. tighten or replace as needed. RESP . Only trained personnel should replace a new tracheostomy tube. ■ Insert bite block to prevent patient from biting ET tube. ■ Reposition patient’s head and neck. ■ Sedation may be required to prevent a patient from fighting the vent.Copyright © 2008 by F. reconnect to ventilator.g. ■ Evaluate oxygenation. ■ If on a ventilator. copious secretions. low pressure alarms may sound. Page respiratory therapist and physician or NP STAT. High Respiratory Rate Can be caused by anxiety or pain. if ruptured. ■ Evaluate connections. check ET tube placement. IMMEDIATE INTERVENTIONS ■ If the tracheostomy is less than 4 days old. Tracheostomy Dislodgement CLINICAL PICTURE The patient: ■ Coughs out tracheostomy tube. ET tube must be replaced. hypoxia Low Exhaled Volume Usually caused by ET tubing disconnection. secretions in ET tube/airway. 49 Alarm High-Pressure Alarm Usually caused by resistance within the system. or plugged tube. but only after careful assessment excludes a physical or mechanical cause. Can be kink or water in ET tubing. Davis.. patient biting the tube. phone call to physician or NP and physician or . listen. ■ Document patient’s status. ■ If the tracheostomy is older than 4 days. ventilate with bag-valve mask. NP response. 50 . mucus. and prevent the edges of the tracheostomy from collapsing. suction catheter. ■ Chart patient status. ■ Auscultate lungs.RESP Copyright © 2008 by F. etc. the tract will be well formed and will not close quickly. ■ Notify physician or NP and respiratory therapist that tube needs to be replaced. ■ Stay with patient. or trauma. and assess patient’s ability to cough effectively and clear airway. ■ Perform tracheostomy care. ■ Assess oxygenation status by monitoring LOC and SaO2. swelling. ■ Obtain sterile hemostat. and replacement tracheostomy tube to be kept at bedside. FOCUSED ASSESSMENT ■ Assess patient’s ability to breathe through stoma. and report to physician or NP . ■ Obtain replacement tube. call a code. ■ Administer humidified supplemental O2. You should be able to easily insert 1 finger under the ties. have another nurse hold tube in place while ties are changed. ■ For future tracheostomy care. check that ties are secure but not excessively tight. if not already at the bedside. ■ Assist with the insertion of a new tracheostomy tube. Look. Davis. ■ Assess tracheostomy site for secretions (blood. ■ If you cannot be sure that someone clinically prepared to reinsert the tracheostomy tube will arrive within 1 minute. and prepare for insertion of new tube. and feel for signs of air movement through stoma. sterile obturator. STABILIZING AND MONITORING ■ After tube is reinserted and tracheostomy dressing is in place. or sterile gloved finger to maintain airway patency. ■ If patient cannot breathe.). A. BE PREPARED TO ■ Call a code. ■ Open the tracheostomy with a sterile hemostat. patient movement. so they are consistent. PaCO2 28. For example: if the ABG results are pH 7. the pH level is high: alkalosis. trending to acidic. A. ■ Evaluate HCO3. The range of 7. PaCO2. It can be called carbon dioxide or carbonic acid. a metabolic buffer. Carbon dioxide is an acid. accidental self-extubation. Basic ABG Interpretation Commonly Used Terms ■ SaO2 is the oxygen saturation. RESP . Is the problem primarily respiratory or metabolic? ■ Evaluate Paco2. This is the respiratory component.41 and 7. is normal. ■ If the pH is between 7. if it is too low. which is called respiratory alkalosis.40 it is considered normal. frequently called O-2-”sats” ■ PaO2 is the partial pressure of oxygen in the blood and is referred to as P-O-2 ■ PaCO2 is the partial pressure of carbon dioxide. compare the pH with both the respiratory and the metabolic components. Determine the source of the imbalance. ■ Putting it together: to determine if the imbalance is primarily respir tory or metabolic. therefore. alkaline. This means the respiratory system is causing the alkalosis.45 is very precise. This is the metabolic component. 1. or normal? ■ Evaluate pH. is low. HCO3. usually called “bicarb” Step-by-Step Interpretation Determine the acid base balance: is it acidic. it means metabolic acidosis. an elevated CO2 respiratory acidosis. and HCO3 23. Whichever of the two is consistent with the pH result (acidosis or alkalosis) is the system that is dominating. but people generally call it C-O-2 ■ HCO3 is bicarbonate. therefore.45 is considered normal. trending to alkalotic. Low acidity is another way of saying alkalosis.35 and 7. High bicarbonate metabolic alkalosis. 51 POSSIBLE ETIOLOGIES ■ Coughing. deflated tracheostomy cuff.Copyright © 2008 by F.50. a pH between 7. A decreased CO2 respiratory alkalosis. Davis. which is a respiratory acid. excessive torque or tension on a tracheostomy tube attached to a ventilator or other O2 administration device. Bicarbonate is a base. neither acidosis or alkalosis.35–7. poorly secured tracheostomy tube. Determine how well the lungs are oygenating. A. The extent of correction is referred to as compensation. ■ PaO2 is a measure of the amount of oxygen dissolved in the blood. ■ If pH is not normal. the nurse must look at the whole picture and not just an isolated number. ■ Abnormal pH with both the PaCO2 and the HCO3 abnormal indicates no compensation. ■ SaO2 reflects to what degree oxygen is carried by hemoglobin. it means the lungs are not performing well. Normal PaO2 80 mm Hg. PaO2 is the partial pressure of oxygen in the arteries. 52 . Hemoglobin has four oxygen-carrying sites. ■ Partially compensated: Abnormal pH with either the PaCO2 or the HCO3 abnormal indicates partial compensation. 3. ■ Compensated: Look at the pH. Some patients may have lower levels and not be in distress. It reflects how well the lungs are getting oxygen into the bloodstream from the atmosphere. ■ You will sometimes see a PaO2 and a PaO2. When all four sites have a molecule of oxygen attached. ■ The two basic measures of oxygen in the blood are SaO2 and PaO2. SaO2 less than 90% requires rapid intervention. 2. although there may be others (hemoglobin and O2CT). PaO2 is the partial pressure of oxygen in the alveoli. Normal ” SaO2 is 95%–100%. then the body has fully compensated. whereas the lungs try to correct metabolic disturbances. the hemoglobin is “saturated. If it is normal. which indicates how well the lungs are getting oxygen from the air into the pulmonary circulation. determine if problem is partially compensated or uncompensated. unless it is within the patient’s baseline range. Davis. These are different measures. Determine the body’s response. ■ PaO2 60–80 mm Hg mild hypoxemia ■ PaO2 40–60 mm Hg moderate hypoxemia ■ PaO2 40 mm Hg severe hypoxemia ■ Decreased PaO2 levels are associated with ■ anemia ■ hypoventilation ■ heart failure ■ COPD and other restrictive pulmonary diseases.RESP Copyright © 2008 by F. but the carbon dioxide or bicarbonate level is off. Both are used to calculate the A-a gradient. Is it compensated or not? ■ The kidneys attempt to compensate for respiratory abnormalities. If the A-a gradient is elevated. ■ Lateral perforations permit exhalation of CO2. ■ Allows patient to eat. A. (one-way valves) Exhalation port Inhalation port Bag-mask (nonrebreather). smallpercentage oxygen therapy is desired. ■ Flow rate of 1–6 L/min delivers 24%–44% oxygen.Copyright © 2008 by F. Simple Mask ■ Indicated when desired FiO2 to be delivered is 40%–60%. Davis. ■ Flow rate of up to 15 L/min delivers up to 100% oxygen. resulting in a high concentration of delivered oxygen and minimal to no CO2 rebreathed by the patient. ■ One-way flaps open and close with respiration. use with humidifier. ■ Extended use can dry the nose and nasopharynx. ■ Permits humidification. ■ Flow rate of 6–10 L/min delivers 35%–60% oxygen. RESP . drink. Bag-Mask (nonrebreather) ■ Indicated when high concentrations of O2 are desired. Exhalation ports Elastic strap To oxygen source Simple mask. 53 Oxygen Delivery Systems Cannula (nasal prongs) ■ Indicated when low-flow. Cannula (nasal prongs). and talk. and grasp underneath the ridge of the jaw with remaining three fingers (see picture). ■ Accurate delivery of O2 is accomplished with a graduated dial that is set to the desired percentage of oxygen to be delivered. Bag-Valve-Mask ■ Indicated for resuscitation or to manually ventilate a patient during transport or ventilator failure or interruption. ■ Setup may vary among brands. 54 . bag-valve-mask. ■ Can deliver up to 100% oxygen. and attach mask or cannula to humidifier. Reservoir Bag O2 supply One-way valve Mask Ambu bag. Humidified Systems ■ Indicated for patients requiring longterm oxygen therapy to prevent drying of mucous membranes. Davis. To oxygen source To patient Maximum fill line Sterile water in reservoir Minimum water level line Humidified systems.RESP Copyright © 2008 by F. Ambu Bag. ■ Adjust flow rate. ■ To create seal. A. attach to oxygen source. Venturi Mask (Ventimask) ■ Indicated for precision titration of oxygen. Fill canister with sterile water to recommended level. Venturi mask (Ventimask). both to create a good seal and to prevent injury. ■ Flow rate of 4–8 L/min delivers 24%–40% oxygen. hold mask with thumb and pointer finger (thumb toward nose). ■ Appropriate size and fit are essential. OROPHARYNGEAL AIRWAY TRACHEA TONGUE ESOPHAGUS OROPHARYNGEAL AIRWAY PHARYNX Oropharyngeal airway. Chain necklace Tract Transtracheal catheter (connect to oxygen) Trachea Transtracheal oxygenation. PHARYNX TRACHEA NASOPHARYNGEAL AIRWAY ESOPHAGUS Nasopharyngeal airway. ■ Assess skin for signs of irritation. ■ Assess for and clear secretions as needed. 55 Transtracheal Oxygenation ■ Indicated for patients with a tracheostomy who require longterm oxygen therapy and/or intermittent. Davis. comatose with spontaneous respirations. ■ Rotate airway 180 while inserting into oropharynx.Copyright © 2008 by F. Nasopharyngeal Airway ■ Indicated for patients with a gag reflex. A. ■ Measure from the tip of the patient’s nose to the earlobe. tracheal tube). RESP . ■ Ensure proper placement (over stoma. Artificial Airways Oropharyngeal Airway ■ Indicated for unconscious patients who do not have a gag reflex. lockjaw. transtracheal aerosol treatment. ■ Measure either from the corner of the mouth to the earlobe or from the center of the mouth to the angle of the jaw. ■ The diameter should match that of the patient’s pinkie. ■ NEVER insert in the presence of facial trauma. respiratory failure. risk of aspiration. airway obstruction. ■ Can be inserted through the mouth or nose. Endotracheal tube. 56 . or when goal of therapy is hyperventilation. ■ Inflated cuff protects patient from aspiration. combative patient (protect from further injury).RESP Copyright © 2008 by F. Endotracheal Tube ■ Indicated for apnea. A. Davis. 57 A & P Snapshot Frontal sinuses Sphenoidal sinuses Nasal cavity Nasopharynx Soft palate Epiglottis Larynx and vocal folds Trachea Superior lobe Right lung Right primary bronchus Middle lobe Arteriole Pulmonary capillaries Alveolar duct Alveolus B Venule Left lung Left primary bronchus Superior lobe Bronchioles Inferior lobe Inferior lobe Mediastinum Cardiac notch Diaphragm A Respiratory system. Pleural membranes Pleural space RESP . A.Copyright © 2008 by F. Davis. 58 s . Davis. e Alv ir ra ola sp ac e Pulmonary capillary O2 pickup O2 Hb Hb O2 O2 O2 Systemic capillary O2 delivery Plasma Hb O2 Red blood cells Hb O2 O2 e iph per A in su lls tis Ce ral e O2 Oxygen pickup and delivery.RESP Copyright © 2008 by F. A. A. Davis. RESP s Hb e .Copyright © 2008 by F. 59 sp ac Pulmonary capillary CO2 delivery e Alv ir ra ola CO2 e CO2 H2CO3 CO2 Hb H 2O Systemic capillary Hb CO2 CO2 pickup Hb CO 2 H2CO3 H 2O CO2 iph per CO2 in su lls tis Ce ral e B CO2 delivery and pickup. instruct patient to distinguish between sharp and dull sensations. Sensation. Balance and Coordination ■ Gait/balance ■ Observe gait patterns while instructing patient to walk away from you and then back again. ■ Have patient stand from a sitting position. Neurological Assessment Mental Status ■ See Mini Mental Status Examination. but not against added resistance 4 Movement against resistance. with patient’s eyes closed. ■ Assess speech for clarity and coherence. Motion. place. but less than normal 5 Normal strength ■ Assess reflexes using a reflex hammer Tendon Reflex Grading Scale 0 Absent 1 Hypoactive 2 Normal 3 Hyperactive without clonus 4 Hyperactive with clonus 60 . Cranial Nerves ■ See Cranial Nerve Assessment in this tab. Compare left side of body with right. Continually change the position of your finger during the test. Davis. time. ■ Coordination ■ Instruct patient to tap the tip of the thumb with the tip of the index finger as fast as possible. grooming. Strength. ■ Assess motor strength of all four extremities. stuporous.NEURO Copyright © 2008 by F. but no movement at the joint 2 Movement at the joint. ■ Assess orientation—person. lethargic. Muscle Strength Grading Scale 0 No muscle movement 1 Visible muscle movement. obtunded. ■ Using your finger and a toothpick. ■ Assess LOC—alert. mood. A. but not against gravity 3 Movement against gravity. Reflexes ■ Ask about altered sensations such as numbness and tingling. ■ Have patient hop in place on each foot. ■ Assess affect. ■ Instruct patient to touch nose and your index finger alternately several times. appearance. Copyright © 2008 by F. ” NEURO . Davis. V 3. Best Eye Response (E) Spontaneously 4 On command 3 To pain 2 No response 1 Score:_______ Best Verbal Response (V) Alert and oriented Confused Inappropriate Incomprehensible No response Score:_________ Best Motor Response (M) Follows direction Localizes pain Withdraws from pain Abnormal flexion Abnormal extension No response Score:________ 5 4 3 2 1 6 5 4 3 2 1 Score may range from 3 (lowest neurological function) to 15 (highest function). A. However. Glasgow Coma Scale (GCS) The GCS is an LOC assessment tool. eye opening score 2. Normal response is flexion (withdrawal) of the toes. and motor response will give the same score. motor response score 4. 61 ■ Assess plantar (Babinski’s) reflex by stroking the lateral aspect of the sole of each foot with the reflex hammer. verbal response. M 4) This is read as “Glasgow Coma Score 9 out of a possible 15. To provide a clearer picture of the patient’s neurological functioning. a number of combinations of eye opening. record the score in the following manner: GCS 9/15 (E 2. verbal response score 3. coffee.g. peppermint). NEURO Cranial Nerve Assessment Nerve I II Name Olfactory Optic Function Smell Visual acuity Visual field Test Identify familiar odors (e. Assess pupils for equality and reactivity to light. Have patient smile. Patient shrugs or turns head against resistance.. Have patient hold mouth open. Feet together. Patient follows finger without moving head. puff cheeks. Touch face. Patient differentiates between sweet and salty taste. arms at side.Copyright © 2008 by F. Snap fingers close to patient’s ears. Assess visual acuity using eye chart. Patient follows finger without moving head. wrinkle face. Assess peripheral vision. Patient sticks out tongue and moves it from side to side. eyes closed for 5 sec. III IV V Oculomotor Trochlear Trigeminal Pupillary reaction Eye movement Facial sensation Motor function VI VII Abducens Facial Motor function Motor function Sensory VIII Acoustic Hearing Balance IX X XI XII Glossopharyngeal Vagus Spinal accessory Hypoglossal Swallowing and voice Gag reflex Neck motion Tongue movement 62 . A. Have patient swallow and then say “Ah. Davis. ” Use tongue depressor or swab to elicit gag reflex. and assess for sharp and dull sensation. Scoring 1 point each for year. 1 point for each correct answer. Ask patient to say “No ifs. Recall three objects 1 point for each item remembered correctly. and floor or room. ” Serial 7s 1 point for each correct answer (or letter). building. Point to your watch and ask patient “What is this?” Repeat with a pencil. season. town. 1 point for each item repeated correctly. “Where are you?” Ask for omitted items. Davis. A. 63 Mini Mental Status Examination Task Date orientation Instructions “Tell me the date. Ask patient to count backward from 100 by 7.Copyright © 2008 by F. county. Ask patient to repeat them. Stop after five answers (or ask patient to spell “world” backwards). or buts. and month. date. Ask patient to recall the objects mentioned above. day of week. ” Ask for omitted items. (Continued on the following page) NEURO . ands. 1 point each for state. Score Place orientation Register three objects Name three objects slowly and clearly. Naming Repeating a phrase 1 point if successful on first try. obtunded.Copyright © 2008 by F. fold it in half. Score of 24 or above is considered normal. A. “Close your eyes” printed on it. 64 . or comatose (see following table for definitions). obey commands. ■ Confused. stuporous. 2 intersecting lines. 1 point if sentence has a subject and a verb and makes sense. Ask patient to write a sentence. and put it on the floor. ■ Difficulty or inability to respond to verbal stimuli. ” Show patient a piece 1 point if patient of paper with closes eyes. say “Take this paper in your right hand. Written commands Writing Drawing Ask patient to copy a 1 point if the pair of intersecting figure has pentagons onto a 10 corners and piece of paper. ■ Inability to speak. Scoring Total possible score: 30. Davis. Altered Level of Consciousness CLINICAL PICTURE The patient may have or be: ■ Change in usual state of full consciousness. or open eyes in response to verbal or painful stimuli. NEURO Mini Mental Status Examination (continued) Task Verbal commands Instructions Scoring Score Give patient a plain 1 point for each piece of paper and correct action. lethargic. ■ Continue to monitor neurological status. ■ Notify physician or NP .. and oxygenation closely. IMMEDIATE INTERVENTIONS FOCUSED ASSESSMENT ■ ■ ■ ■ Assess airway for patency and secretions/obstructions. Assess HR for rate and regularity. grasping the pectoralis muscle)? Is the motor response to stimuli purposeful (removing or withdrawing from stimuli or posturing)? ■ Assess for associated neurological deficits such as weakness or numbness on one side of the body. Davis. and orientation. BE PREPARED TO ■ ■ ■ ■ ■ Assist with airway management or intubation if needed. or ventilate if patient is not breathing adequately (RR 8 and/or cyanosis).g. or NP response. pupil reactivity and size. ■ Assess responsiveness to verbal or painful stimuli. Assess breathing and oxygenation.Copyright © 2008 by F. Start an IV. ■ Administer supplemental O2. breathing. and pupillary reaction. NEURO . Order laboratory tests. ■ Suction the oropharynx. STABILIZING AND MONITORING ■ Collaborate with health-care team to treat underlying causes (such as drug overdose). 65 ■ Assess and protect airway. best motor response. does patient respond to gentle stimuli (shaking the arm) or only to painful stimuli (e. Assess LOC (see GCS in this tab). if applicable. O2 saturation. Note: Does patient respond to verbal stimuli? If not. ■ Assess medication administration record (MAR) for drugs capable of causing altered LOC. and clear secretions as needed. A. ■ Assess VS. Give medications. ■ Continue to monitor VS. ■ Document patient’s status. phone call to physician or NP and physician . Transfer patient to ICU. Copyright © 2008 by F. A. Davis. NEURO POSSIBLE ETIOLOGIES ■ Brain lesions/interruptions in blood flow, metabolic disorders (hypoglycemia, hypoxia), psychiatric disorder, toxic medication levels/drug overdose, increasing intracranial pressure (ICP), dysrhythmia. Levels of Consciousness LOC Full consciousness Characteristics Awake, alert, and oriented. Understands written and spoken language, and responds reliably. Disoriented first to time, then place, then person. Memory deficits, difficulty following commands, restless, agitated. Oriented to time, person, and place, but demonstrates slow mental processes, sluggish speech. Sleeps frequently, but wakens to spoken word or gentle shake. Maintains wakefulness with sufficient stimulation. Extreme drowsiness, responds with one or two words, follows very simple commands, requires more vigorous stimulation to waken, and stays awake for only a few minutes at a time. Minimal movement, responds unintelligibly, and wakens briefly only to repeated vigorous stimulation. Does not respond to verbal stimuli, does not speak. May have appropriate motor response (e.g., withdraws from noxious stimuli), nonpurposeful response, or no response. Confusion Lethargy Obtundation Stupor Coma 66 Copyright © 2008 by F. A. Davis. 67 Change in Mental Status/Delirium CLINICAL PICTURE The patient may have or be: ■ Confused, restless, agitated, disoriented to time and place. ■ Easily distracted, delusional, hallucinating. ■ Disturbed general appearance, motor activity, dress, and facial expression. ■ Agitated or obtunded with fluctuating LOC. ■ Rambling, disorganized speech. ■ Impaired cognitive function. ■ Reversal of sleep-wake cycle. ■ ■ ■ ■ ■ ■ IMMEDIATE INTERVENTIONS Assist patient to safe area or back to bed. If LOC is diminished, position to maintain patent airway. Provide supplemental O2 if saturation in room air is 93%. Check MAR for recently given medications. Stay with patient, and notify physician or NP . Document patient status, phone call to physician or NP and physician or , NP response. FOCUSED ASSESSMENT ■ Assess VS, oxygenation, and neurological status. ■ Assess mental status with Mini Mental Status Examination (see table in this tab). ■ Assess for associated neurological deficits, such as weakness or numbness on one side of the body or changes in consciousness. ■ Assess for history of alcohol abuse, medication use, psychiatric illness. ■ Assess for possible source of infection. STABILIZING AND MONITORING ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Assess neurological status, motor function, and respiratory function. Auscultate lungs for adventitious sounds. Reorient as needed. Place calendar, clock, and family photos in room. Provide stable, quiet, and well-lighted environment. Keep staff consistent, if possible. Explain procedures before beginning care. Have patient wear eyeglasses and hearing aids, if applicable. Enhance safety of environment. Stay with patient, and offer support and reassurance. Avoid use of restraints. NEURO Copyright © 2008 by F. A. Davis. NEURO ■ ■ ■ ■ ■ ■ Assess nutritional status and ability to take foods and fluids. Monitor I&O/fluid status. Monitor laboratory results. Provide support. Collaborate with health-care team to treat identified cause(s). Document patient status, and communicate to physician. BE PREPARED TO ■ ■ ■ ■ ■ Start a peripheral IV. Obtain laboratory work; prepare patient for diagnostic studies. Obtain blood, sputum, and urine cultures. Administer appropriate medications as ordered. Arrange for one-on-one care. POSSIBLE ETIOLOGIES ■ Hypoglycemia, hypoxia, low blood pressure, compromise of cerebral blood supply (stroke), elevated ammonia levels (end-stage liver failure), toxic medication levels, drug-induced psychosis, urosepsis (especially in the elderly), structural lesions, metabolic disorders, psychiatric disorders, renal disease, compromise of cerebral blood flow. Dizziness CLINICAL PICTURE The patient may have or be: ■ Sensation of spinning (vertigo), disequilibrium, or faintness. ■ Weakness, nausea. ■ Chest pain, tightness, squeezing, or pressure. ■ Shortness of breath, palpitations. ■ Tingling, pins-and-needles, weakness of extremities. IMMEDIATE INTERVENTIONS ■ ■ ■ ■ ■ ■ Assist patient to safe place to sit or lie down. Administer supplemental O2. Assess VS. Encourage slow deep breaths. Stay with patient, and provide reassurance. Document patient’s status, phone call to physician or NP and physician , or NP response. 68 Copyright © 2008 by F. A. Davis. 69 FOCUSED ASSESSMENT ■ Assess VS and respiratory status. ■ Assess cardiac rhythm and rate; assess for orthostasis (take blood pressure supine, sitting, and standing; note changes in systolic BP and HR). ■ Assess for circumoral cyanosis, skin temperature, and moistness. ■ Assess MAR for recently taken medications that can cause dizziness. ■ Assess history of similar episodes. ■ Assess for history of inner ear disease or migraine. ■ Assess recent laboratory values for electrolyte abnormality. ■ If patient is diabetic, obtain blood glucose level by fingerstick. STABILIZING AND MONITORING ■ ■ ■ ■ ■ Administer medications for dizziness as ordered. Assess VS and subjective feeling of dizziness. Help patient with ambulation and self-care until dizziness resolves. Monitor I&O. Monitor laboratory values. BE PREPARED TO ■ Start an IV. ■ Assist with diagnostic testing. POSSIBLE ETIOLOGIES ■ Hypertension, hypotension, stroke, hypoglycemia, cardiac dysrhythmias, myocardial infarction, neuropathy, deconditioning, dehydration, arteriosclerosis, Ménière’s disease, medications, migraine, hyperventilation. Head Trauma CLINICAL PICTURE The patient may have: ■ Scalp lacerations, hematoma, bilateral orbital ecchymosis. ■ Battle’s sign (bruising behind the ear at the mastoid process). ■ Altered mental status of LOC: agitated, semiconscious, consciousness or unconscious; may have seizures. ■ CSF leakage from ear or nose. ■ Signs of ICP: ■ Decreasing LOC, deterioration in GCS. ■ Cushing’s response (bradycardia, hypertension, bradypnea). NEURO ■ Call for assistance. 70 . ■ If patient conscious. administer IVF and medications as ordered. and monitor oxygen saturation. STABILIZING AND MONITORING ■ Continue to assess for impaired consciousness. foreign bodies. ■ With proper assistance and C-spine aligned or in collar. nausea and vomiting. circulation. NP response. deterioration in LOC. phone call to physician or NP and physician or . and notify physician or NP . Assess cause and underlying conditions. ■ Assist with diagnostic procedures (x-ray or CT scan). ■ Immobilize cervical spine with collar or by holding head and neck in neutral alignment with body. irritability or altered behavior. or secretions. Davis. unequal pupils/decrease in reactivity. Clear blood. vomitus. Assess for distal deficits such as numbness or paralysis in the arms or legs. Assist with diagnostic testing. breathing. assess VS. Insert a nasogastric tube once skull fracture has been ruled out. severe tachycardia or bradycardia— report changes in condition immediately. swelling. Inspect mouth for blood. transfer patient to bed or stretcher. ■ Document patient status. NEURO IMMEDIATE INTERVENTIONS ■ Assess airway. Inspect pupils for equality and reactivity. Inspect ears and nose for leakage of clear fluid (CSF) suggestive of skull fracture. Administer O2. ■ ■ ■ ■ ■ ■ ■ ■ BE PREPARED TO Set up and assist with intubation. FOCUSED ASSESSMENT ■ ■ ■ ■ ■ ■ ■ ■ Examine for lacerations. if available. Assist with immobilization of neck and back. Assess for history of seizures. Monitor cardiac rhythm and VS. and inspect. ■ Treat bleeding lacerations.Copyright © 2008 by F. Insert an indwelling urinary catheter. A. ■ Assess for severe and persistent headache. depressions. and vomitus. Assess recent laboratory values. open airway. Battle’s sign. Start an IV. sensitivity to light. ■ Decreased motor function. A. Minimize environmental stimuli. STABILIZING AND MONITORING ■ Monitor neurological status and VS. coma. bradycardia. trauma. NP response. Assess VS. nausea and vomiting. cardiac rhythm. drowsiness. FOCUSED ASSESSMENT ■ Assess neurological status (see Neurological Assessment in this tab and GCS in this tab). desaturation. 71 POSSIBLE ETIOLOGIES ■ Patient fall. Increasing Intracranial Pressure (ICP) CLINICAL PICTURE The patient may have or be: ■ Subtle to dramatic changes in LOC.Copyright © 2008 by F. Avoid flexion of the neck or hips. Provide high-flow O2 with a non-rebreather mask. Document patient’s status. ■ Double or blurred vision. Notify physician or NP of findings. Davis. stupor. Elevate head of bed to 15 –30 . IMMEDIATE INTERVENTIONS ■ ■ ■ ■ ■ ■ ■ ■ ■ Assess airway patency and breathing. ■ Asses oxygen saturation. phone call to physician or NP and physician or . and increased respiratory rate). Keep head in neutral alignment. ■ Assess for signs of decreased oxygenation (LOC. ■ Keep systolic blood pressure between 100 and 160 mm Hg (check with physician for parameters). headache. ■ Assess cranial nerves as condition allows (see Cranial Nerve Assessment in this tab). NEURO . restlessness. confusion. cyanosis. increase in respiratory rate). ■ Late findings: changes in VS (widening pulse pressure. anticonvulsants). cerebral hypoxia. ■ Extreme muscle rigidity. Perform skin assessment. ■ LOC or disorientation. ■ Maintain and assess I&O. ■ If necessary. intracranial bleed. ■ Insert nasogastric tube or urinary catheter.. suction for fewer than 10 seconds in duration. playing with buttons). obtain consult if needed. ■ Maintain quiet environment. ■ Urinary or fecal incontinence. osmotic diuretics. hydrocephalus. BE PREPARED TO ■ Assist with intubation if needed. ■ Obtain or perform chest physiotherapy as needed. ■ Cyanosis or apnea. cranial abcess.g. protect patient from injury. ■ Tongue or eye deviation. ■ Transfer to ICU. Seizure CLINICAL PICTURE The patient may have: ■ Repetitive. hypertension. limit to two passes. and give medications (sedatives. ■ Maintain SaO2 at 100%. corticosteroids. POSSIBLE ETIOLOGIES ■ Tumor. ■ Establish IV access. NEURO ■ Limit suctioning (increases ICP). ■ Provide education/reassurance/comfort measures. 72 . electrolytes. ■ Aura (warning or recognition that seizure may occur). A. insert an oral or nasal airway. Davis.Copyright © 2008 by F. jerking movements of the upper and lower extremities. ■ Monitor ABGs. Assess nutritional status. ■ Document all findings. head trauma. ■ Blinking or repetitive behaviors (e. and administer 100% O2 beforehand. ■ Difficulty in arousing from stuporous state (postictal). and communicate to physician or NP . and document findings. electrolytes. duration. progression. ■ Stay with patient. orientation. and call for help. respiratory status. A. pupils. Turn head/body to side. metabolic disorders (severe electrolyte disorders. ■ Protect patient from injury—clear immediate area of potentially harmful objects. body parts involved) of seizure activity. lumbar puncture. low blood glucose level. if patient is OOB. and location (i. and responsiveness during seizure. STABILIZING AND MONITORING ■ Suction the oropharynx. ■ Assess pupil size. and administer antiseizure medications. airway patency. arteriovenous malformation. Mg level. tumor. trauma. and any precipitating factors. ■ Do not insert objects into patient’s mouth. glucose level. including CT scan. ■ Raise siderails. during. ■ Provide reassurance and education. onset.e. and clear secretions as needed. BUN. hypoxia). LOC before. ■ Note tongue/eye deviation. body part in which seizure started. shape. ■ Note LOC. and reactivity to light. BE PREPARED TO ■ Start an IV. and creatinine levels. Include seizure description: aura. FOCUSED ASSESSMENT ■ Assess VS. and progression of seizure activity. renal failure. ■ Reorient patient if necessary. if able. 73 IMMEDIATE INTERVENTIONS ■ Ascertain that airway is not compromised by secretions or emesis. and respiratory status. Check blood levels of antiseizure medications. NEURO . ■ Note length. drug or alcohol withdrawal. POSSIBLE ETIOLOGIES ■ Inadequate blood levels of a prescribed anticonvulsant. ■ Remove dentures. Ca level. CBC. ■ Once seizure subsides (postictal phase). guide to floor. Davis. ■ Assess for incontinence. ■ Prepare patient with new onset seizures for extensive evaluation.Copyright © 2008 by F. Suction if necessary. e. and after seizure.. ■ Allow patient to sleep.. duration. overbed table or glasses. onset. complete assessment. stroke. EEG. infection.g. breathing.Copyright © 2008 by F. IMMEDIATE INTERVENTIONS ■ Immobilize cervical-spine (with light traction. numbness. O2 saturation. ■ Loss of sensation. bladder spasms. ■ Assess airway. legs and torso must be secured prior to securing head to board. abnormal sweating and thermoregulation (injuries to cervical or high thoracic cord). ■ Assess LOC. mental status. ■ Assess VS. ■ Constipation. ■ Altered sensation. ■ If immobilizing entire body on a backboard. ■ Arm and/or leg weakness. ■ Assess sensation by asking patient about numbness and altered sensation and by touching patient lightly. 74 . ■ Rapid blood pressure fluctuations. squeeze your hand. Davis. and move toes and turn feet (see Neurological Assessment in this tab). circulatory status. hematoma. reflexes. temperature. swelling. ■ Breathing difficulties. ■ Assess VS. and mobility below level of injury. hold head and neck in neutral alignment with body). incontinence. paralysis. ■ Spasticity (increased muscle tone). ■ Assess mobility by asking patient to open and close fist. deformity. beginning at shoulder and working down arms and legs of both sides. FOCUSED ASSESSMENT ■ Examine spine for lacerations. ■ Nausea and vomiting. STABILIZING AND MONITORING ■ Frequently assess motor or sensory function—call physician or NP immediately if condition changes. pain. NEURO Spinal Cord Trauma/Syndrome CLINICAL PICTURE The patient may have: ■ History of recent back trauma with varying amounts of weakness and sensory loss at and below the injury. A. pattern depends on whether cord injury is complete or partial (incomplete). ■ Loss of bowel and bladder control. Use a spine board with restraints or other items. A. skin breakdown. CT. ■ Tachycardia/bradycardia/hypertension. Insert an indwelling urinary catheter.Copyright © 2008 by F. Sudden Neurological Deficit (Stroke/ Transient Ischemic Attack) CLINICAL PICTURE The patient may have: ■ Weakness or numbness of one side of the face or body. NEURO . auto versus pedestrian. Monitor cardiac rhythm and VS. severe headache. to maintain position. ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ BE PREPARED TO Administer O2. MRI).g. ■ Slurred speech. Assist with placing patient in spinal traction. autonomic hyperreflexia. ■ Difficulty swallowing. POSSIBLE ETIOLOGIES ■ Blunt or penetrating trauma. ■ Ataxia. ■ Document findings. respiratory compromise. and delayed gastric emptying). constipation. urinary retention.. difficulty finding words. ■ Assist with diagnostic studies (spine x-rays. Start an IV. nutritional decline. ■ Maintain spinal stabilization and immobilization. Move the patient very carefully using logroll technique. Administer IVF and medications (e. spinal shock (urinary and bowel retention leading to abdominal distention. and communicate with physician or NP . spinal lesion or abcess. Assist with diagnostic testing. 75 ■ Assess for potential complications: neurogenic shock (hypothermia and hypotension without tachycardia). Set up and assist with intubation. ■ Problems with respiratory function/gag reflex. ■ Double vision. Assist with immobilization of neck and back. aphasia. motor vehicle accident. Davis. methylprednisone). ileus. such as head blocks and pillows. and monitor O2 saturation. clumsiness. Insert a nasogastric tube. ■ Begin discharge/rehabilitation planning if stroke is confirmed. ■ Reassess airway. and provide safe environment. and facial symmetry. STABILIZING AND MONITORING ■ Continue to maintain patent airway. breathing pattern. ■ Call physician or NP . elevate head of bed 30 . ■ Assist with diagnostic testing (CT scan. ■ Stay with patient.Copyright © 2008 by F. ability to clear secretions. ■ Monitor laboratory values. heart rate and rhythm. assess level of orientation. IMMEDIATE INTERVENTIONS ■ Maintain patent airway. ■ Do not give anything by mouth. ■ Assess motor strength and control (see Neurological Examination in Tools tab). ■ Support patient. ■ Stay with patient for continued monitoring and support. A. ■ Assess pupillary response. ■ Suction the oropharynx as needed to clear secretions. breathing pattern. oxygenation status. ■ If patient is conscious. MRI. ■ Perform skin assessment. 76 . ■ Assess speech. oxygenation status. ■ Document patient status. and blood pressure every 15 minutes. ■ Assess LOC (see GCS in this tab). vision. NEURO ■ ■ ■ ■ Changes in affect/memory/judgment. Davis. phone call to physician or NP and physician or . ■ Assess VS. heart rate and rhythm. ■ If in bed. and position head to one side to prevent aspiration of secretions (if no signs of shock present). NP response. ability to clear secretions. ■ Obtain nutrition assessment. ■ Administer supplemental O2. agitation. I&O. ■ Initiate seizure precautions. Nausea/vomiting. FOCUSED ASSESSMENT ■ Assess airway. ■ Administer medications as ordered. and blood pressure. confusion. Seizures. ECG). initiate pressure ulcer prevention strategies. Altered LOC. A. Assess if patient meets thrombolytic criteria. Transfer patient to a higher level of care. POSSIBLE ETIOLOGIES ■ Embolic. Prepare patient for thrombolytic or anticoagulant therapy. or hemorrhagic stroke. A & P Snapshot Motor area Premotor area Frontal lobe General sensory area Sensory association area Parietal lobe Occipital lobe Visual association area Visual area Motor speech area Auditory association area Auditory area Temporal lobe Functional areas of the brain. Accompany the patient to CT scan. thrombotic. 77 ■ ■ ■ ■ ■ ■ ■ ■ BE PREPARED TO Aggressively manage airway. Start an IV.Copyright © 2008 by F. Draw laboratory tests. TIA. Administer O2. Davis. NEURO . 78 . NEURO OLFACTORY 1 OCULOMOTOR 3 TROCHLEAR 4 ABDUCENS 6 OPTIC 2 TRIGEMINAL 5 FACIAL 7 GLOSSOPHARYNGEAL 9 VESTIBULOCOCHLEAR 8 HYPOGLOSSAL 12 VAGUS 10 1 ACCESSORY 1 Cranial nerves. A. Davis.Copyright © 2008 by F. 79 Interneuron Synapse Dorsal root Dorsal root ganglion Cell body of sensor neuron Dendrite of sensory neuron Central canal Dorsal column Corticospinal tract Rubrospinal tract Receptor Ventral root Axon of motor neuron Synaptic knobs Spinothalamic tract White matter Gray matter Effector muscle Cell body of motor neuron Cross section of the spinal cord. A. NEURO . Davis.Copyright © 2008 by F. blood levels rise). and creatinine clearance is preferred among the three blood tests.6–1. electrolytes.5–1. Therefore. It is generally produced at a constant rate by the body and then is excreted by the kidney. ABGs. Female: 0. urinalysis to screen for urinary system dysfunction.1 mg/dL ■ Critical level: 4 mg/dL 80 . therefore. A. ■ Normal values: Adult: Male: 0. (Many more urine tests are available and are used to assess for diseases of systemic or other body systems diseases.2 mg/dL.. It is used to estimate glomerular filtration rate. hematocrit level.Copyright © 2008 by F. urine C&S to assess for infection.g. A rise in BUN without a rise in creatinine is most likely not related to a decline in renal functioning. creatinine is a better measure of renal function. ■ Blood work: ■ BUN is a by-product of protein metabolism and is excreted by the kidneys. hemoglobin. ■ Creatinine is a breakdown product of creatine phosphate in muscle. RENAL/F&E Focused Renal/GU Systems Assessment ■ A focused nursing assessment of renal function includes: ■ Assessing blood work: blood urea nitrogen (BUN) and creatinine values including BUN to creatinine ratio. dehydration. assess hydration status. urine osmolality. upper GI bleed) and can remain within normal range even when kidney function is markedly impaired. ■ Normal value: Adults: 5–20 mg/dL ■ Critical Level: 40 mg/dL (not dehydrated/no history of renal disease) ■ Critical Level: 100 mg/dL (patient with history of renal disease) ■ Critical Level: 20 mg/dL increase in 24 hr (indicates acute renal failure) Call physician or NP immediately with critical results. ■ Assessing urine laboratory tests: specific gravity. other chemistries. A rise in serum creatinine reflects a decrease in glomerular filtration rate (kidneys are less able to filter and excrete the creatinine. creatinine clearance for renal function. palpate for flank and CVA (costovertebral angle) tenderness. Davis.) ■ Physical examination: vital signs. A rise in BUN reflects a decrease in kidney function (kidneys are less able to filter and excrete the urea). This tab cites only the urine tests used specifically to assess the urinary system. BUN is affected by other variables (e. Normal values: Male: 107–139 mL/min. which is the difference between . ■ Focused assessment of the lower urinary tract includes: ■ Voiding patterns. ■ Assess urine for cloudiness. Briefly. ■ Other urine tests include urinalysis for screening.Copyright © 2008 by F. or overflow incontinence and difficulties initiating stream. A. the sodium bicarbonate value represents the metabolic componet of the ABG and is controlled by the kidneys. the kidneys regulate acid-base balance. blood volume. ■ Hydration status: Assess I&O. Urine creatinine is based on a 24-hour urine collection. CrCl is usually estimated by using a formula based on age. urge. Davis. High pulse pressure ( 40 mm Hg) is a risk factor for cardiac events. The kidneys maintain BP through the renin-angiotensin system (RAS) and regulate hydration status by retaining sodium in response to aldosterone secretion. specific gravity. CrCl of 10–20 mL/min is indicative of renal failure and the need for dialysis. and urine culture and sensitivity for assessing urinary tract infection (UTI). the systolic and diastolic pressures. Therefore. electrolyte concentrations. daily weights. kidney disorders may be reflected in changes in BP fluids and electrolytes. 81 Call physician or NP immediately with critical results. Female: 85–105 mL/min. ■ Prostate examination in males. assessing BP calculate the pulse pressure. hypothalamus. ■ Residual urine volume (amount of urine left in the bladder after voiding). mucous membranes. ■ Creatinine clearance (CrCl) compares the level of creatinine in urine with the serum creatinine level. mass. ■ Vital signs and ABGs: In coordination with other organs (lungs. RENAL/F&E . When . and BP . urine osmolality and specific gravity for assessing renal concentrating ability. CrCl is used to determine safe dosing of nephrotoxic drugs. ■ CVA tenderness: The angle created where the lowest ribs connect with the vertebral column. blood for serum creatinine is collected at the end of the 24-hour period. BUN to creatinine ratio. and serum creatinine. including stress. endocrine system). adrenal glands. and volume. urine osmolality. sodium levels. color. and acid-base balance. CVA pain and tenderness with other UTI symptoms suggests a kidney infection. However. See Tab 3 for ABG interpretation. See p. RENAL/F&E Electrolyte Imbalances Electrolyte imbalances are encountered frequently in patients with all types of conditions. ECG changes. if available. or assess pulse for irregular beats. 89 for hyponatremia Hypocalcemia: Ca S&S Abdominal and muscle cramps. lethargy. Do not infuse too rapidly—is cardiotoxic and can cause ↓ BP . shortening of QT interval ↑ BP . 86 for hyperkalemia. Never given IM or subcutaneously—causes severe sloughing of tissue. polyuria. 10. *Do not confuse with calcium chloride. provide ↑ fiber diet and stool softeners. A. and p. seizure. furosemide 20–80 mg IV over 2 min to bring Ca down with diuresis. 8.2 mg/dL Nursing Monitor electrolyte levels. severe thirst. Treatment D5NS at 250–500 mL/hr. Encourage fluid intake. 82 .4 mg/dL Nursing Given by physician or NP on general care units and by RNs in ICU. Treatment Calcium gluconate 10%*: 1 g in 50–100 mL of D5W over 1 hr. Monitor ECG. Check calcium and magnesium levels. ↑ BP .Copyright © 2008 by F. Potentiate digoxin toxicity. Antidote: IV magnesium sulfate. Davis. 87 for hypernatremia. assess as indicated. tetany. p. p. Hypercalcemia: Ca S&S Dehydration. renal stones. constipation. confusion. then infusion of 1–2 mg/kg/hr. 88 for hypokalemia. rhabdomyolysis.Copyright © 2008 by F. 2. especially in patients with renal failure. Treatment Potassium or sodium phosphate 2 mg/kg IV over 6 hr if PO4 level is 1–5 mg/dL. Hypermagnesemia Mg S&S Nausea. . ↓ calcium. 1. Oral replacement with KPhos or Neutra-Phos if depletion is less severe. ↓ BP weakness.5 mEq/L Nursing Check other electrolyte levels.5 mg/dL Nursing Too rapid IV administration can cause severe hypocalcemia. confusion. hemolysis. PVCs. Treatment 2 g magnesium sulfate in D5W over 10–20 min. Hypophosphatemia PO4 S&S Anorexia. Hold medications containing magnesium. 2. Treatment Calcium gluconate 10%*: 1–10 mL in 50–100 mL of D5W over 10–20 minutes. *Do not confuse with calcium chloride. respiratory failure. cardiac and respiratory failure. 83 Hypomagnesemia Mg S&S Weakness. hyperreflexia. can have ↓ potassium. tachycardia. muscle twitching. weakness. vomiting. vertigo. then 1 g/hr for 3–4 hr.1 mEq/L Nursing Assess for changes in LOC. coma. tetany. A. assess for tetany. drowsiness. Davis. ↓ phosphate. RENAL/F&E . ↓ HR. seizures. Assess reflexes. muscle pain. Assess reflexes and monitor Mg levels. possible tetany if calcium is low. Assess for patent IV access. fainting. possibly acetazolamide. Notify physician. ■ Confusion. ■ Weakness.5 mg/dL Nursing Teach patient about avoiding foods and OTC medications high in phosphorus Treatment Phosphate binders. creatinine. check BP lying. moistness. RENAL/F&E Hyperphosphatemia PO4 S&S Limited symptoms. sitting. 84 . Assess electrolytes. STABILIZING AND MONITORING Administer oral or IVF . temperature. integrity. low-phosphate diet Dehydration CLINICAL PICTURE The patient may have: ■ Increased thirst. Document patient’s status. seizure. and standing. A. phone call to physician or NP and physician . BUN. dizziness. hypotension. which is a result of hyperphosphatemia. IMMEDIATE INTERVENTIONS ■ ■ ■ ■ ■ Assess VS. Assess current urine output and recent intake and output (I&O). Davis. ■ Tachycardia. FOCUSED ASSESSMENT ■ ■ ■ ■ ■ ■ ■ ■ ■ Assess VS including temperature.Copyright © 2008 by F. Assess LOC and orientation. 4. note changes. Assess mucous membranes. Make sure patient is comfortable and safe. dry mouth. palpitations. or NP response. and swollen tongue (see table below of Signs and Symptoms of Progressive Dehydration). ■ Decreased urine output. Closely monitor I&O. Assess skin for color. sluggishness. Monitor urine output for adequate hourly rate. burns. ■ Insert urinary catheter with a urometer to monitor hourly output.Copyright © 2008 by F. A. BE PREPARED TO ■ Obtain IV access. but orthostasis Thready Slow Oliguria Severe Dehydration Obtunded Greater than 4 sec. ■ Chart patient status and convey to physician or NP . stomatitis. diabetic ketoacidosis. GI obstruction. 85 ■ Maintain safe environment. RENAL/F&E . ■ Obtain a nutritional/dietary assessment. ■ Provide oral care. Signs and Symptoms of Progressive Dehydration Symptom/ Sign LOC Capillary refill Mucous membranes HR RR BP Pulse Skin turgor Urine output Mild Dehydration Alert 2 sec Normal Slight increase Normal Normal Normal Normal Decreased Moderate Dehydration Lethargic 2–4 sec Dry Increased Increased Normal. Davis. heat stroke. pharyngitis. thyrotoxicosis. diabetes insipidus. cracked Very increased Increased and hyperpnea Decreased Faint or impalpable Tenting Oliguria/anuria POSSIBLE ETIOLOGIES ■ Gastroenteritis. febrile illness. cool limbs Parched. ■ Transfer to telemetry unit. IMMEDIATE INTERVENTIONS ■ ■ ■ ■ ■ ■ Assess VS. ■ Administer IV calcium. note cardiac rate and rhythm. serial potassium levels. electrolytes). Davis. or NP response. ■ Administer potassium-binding resins (Kay-exalate) orally or rectally. I&O. ■ Nausea. Notify physician or NP . Assess recent laboratory results (BUN. Assess musculoskeletal function.Copyright © 2008 by F. Assess LOC and orientation. A. creatinine. sodium bicarbonate. and assess cardiac rhythm if available. phone call to physician or NP and physician . STABILIZING AND MONITORING ■ Obtain IV access. Administer oxygen. ■ Order a 12-lead ECG. BE PREPARED TO ■ Set up cardiac monitoring. Document patient’s status. peaked T waves). FOCUSED ASSESSMENT ■ ■ ■ ■ Monitor VS. ■ Order or obtain laboratory tests. ■ Monitor cardiac rhythm. Assess for patent IV access. ■ Chart patient status and convey to physician or NP . and other laboratory tests. ■ Cardiac dysrhythmias. RENAL/F&E Hyperkalemia CLINICAL PICTURE The patient may have: ■ Muscular weakness. ■ ECG abnormalities (tall. insulin and glucose. or furosemide per order. Assess previous 2 days’ I&O. 86 . disorientation. A. tachycardia IMMEDIATE INTERVENTIONS ■ Assess recent lab values. ■ Notify physician or NP and document findings and discussion with . ■ Provide mouth care and measures to protect skin integrity. digitalis poisoning. ■ Administer parenteral fluids as ordered using a volume control infusion device. lethargy. if necessary. excessive use of salt substitutes. hypoaldosteronism trauma. metabolic acidosis. irritability. doing so in the presence of elevated sodium levels causes fluid shifts that can result in cerebral edema and brain damage. physician or NP in the chart. insulin deficiency. move patient to a room near the nurse’s station or ask if a family member can stay with the patient. RENAL/F&E . coma (if imbalance is severe) ■ Restlessness. ■ Assess skin and mucous membranes. hemolysis. obtain orthostatic BP if possible.Copyright © 2008 by F. make sure fluids do not infuse too quickly. seizures. chemotherapy. 87 POSSIBLE ETIOLOGIES ■ Medication. Davis. ■ Continue assessment outlined above as treatment progresses. Hypernatremia CLINICAL PICTURE The patient may have: ■ Sodium level 144 mEq/L ■ Confusion. ■ Assess mental status (see Mini Mental Status Examination in Tab 4) ■ Assess for intact IV site. uncontrolled hyperglycemia. ■ Assess vital signs. acute or chronic renal failure. acidosis. FOCUSED ASSESSMENT ■ Assess total intake and output over previous several days. note dry cracked skin. STABILIZING AND MONITORING ■ Insert IV. sticky oral membranes. burns. ■ If patient is disoriented. peripheral edema ■ Postural hypotension. hallucinations ■ Thirst (many older adults have an impaired sense of thirst and may not express thirst) of flushed skin. Assess LOC and muscle strength. constipation. ■ Hypoventilation. creatinine. weakness. muscle cramps. respiratory distress. ■ Palpitations. STABILIZING AND MONITORING ■ Obtain IV access. Hypokalemia CLINICAL PICTURE The patient may have: ■ Serum potassium 3. Assess recent laboratory results (BUN. diabetes insipidus. depending on changes in patient’s status ■ Monitor changes in mental status. VS POSSIBLE ETIOLOGIES ■ Poor water intake due to inability to express thirst or insensible water loss. fatigue. ileus. Assess cardiac rhythm if patient on telemetry. RENAL/F&E BE PREPARED TO ■ Change IVF as soon as a different concentration is ordered. electrolytes. if indicated. phone call to physician or NP and physician . bradycardia or tachycardia.Copyright © 2008 by F. ■ Assess medication history. ■ Assess for patent IV access. 88 . A. hypotension. IMMEDIATE INTERVENTIONS ■ ■ ■ ■ ■ Assess BP sitting and standing. or NP response. Document patient’s status.5 mEq/L. ventricular dysrhythmias. magnesium level). near-drowning in salt water. Notify physician or NP . ■ Malaise. Assess for digitalis toxicity. use of diuretics or laxatives. note orthostasis. vomiting. Davis. note rhythm. Assess HR. laboratory values. ■ Nausea. excess salt intake. FOCUSED ASSESSMENT ■ ■ ■ ■ Assess recent I&O. chronic respiratory acidosis. seizures. A gradual drop in serum sodium may be tolerated because of neuronal adaptation. diarrhea. laxative abuse. Davis. LOC. ■ Monitor potassium and other electrolyte levels. ■ Moderate: Na 110–120 mEq/L: hallucinations. vomiting. ■ Neurological symptoms usually reflect severe. gait disturbance. BE PREPARED TO ■ Place patient on telemetry. 89 ■ Administer oral and/or IV potassium supplement. POSSIBLE ETIOLOGIES ■ Deficient potassium intake. ■ Maintain safety precautions due to muscle weakness. ■ Severe: Na 110 mEq/L: coma. ■ Order or obtain laboratory tests. Patient should be on telemetry if receiving treatment level amounts of potassium. aldosteronism. RENAL/F&E . feelings of weakness. weakness. ■ Monitor HR and rhythm. Hyponatremia CLINICAL PICTURE The patient may have: ■ Mild: Na 120 mEq/L: headache.5 mEq/L). hyperventilation. which causes intracerebral osmotic fluid shifts and cerebral edema.Copyright © 2008 by F. excess adrenocortical secretion.0–2. A. ECG. Make sure patient is comfortable and safe. muscle cramps. Oral supplementation is much safer. especially if taking diuretics. urine sample for potassium. metabolic alkalosis. IV rate should not exceed 200–400 mEq/24 hr (based on serum potassium level of 2. fistulas. and convey to physician or NP . phone call to physician or NP and physician . sudden drop in serum sodium level. bizarre behavior. nausea. Check if blood for laboratory was drawn above a running IV site. Notify physician or NP . IMMEDIATE INTERVENTIONS ■ ■ ■ ■ ■ Assess VS. never give as a bolus: may precipitate cardiac arrest. or NP response. hypertension. respiratory arrest. Document patient’s status. ■ Nutrition/dietary education. renal tubule disease. dilated pupils. diuretic therapy. vomiting. ■ Chart patient status. cyclophosphamide. ■ Assess recent I&O. desmopressin. creatinine. GI fistulas or drainage tubes. opiates. Too rapid correction can cause permanent neurological impairment. chlorpropamide. administration of hypotonic IV or irrigation fluids in the immediate postoperative period. or tolbutamide). use of the recreational drug MDMA (ecstasy). ■ Obtain IV access. ■ Assess for recent infusion of hypotonic IVF (common cause of ↓ Na in hospitalized patients) or use of continuous bladder irrigation (CBI). Treatment for Mild or Moderate Hyponatremia). A. congestive heart failure. ■ Assess fluid status: examine mucous membranes and skin turgor. vincristine. Caution: Must be administered slowly via an infusion pump. clofibrate. and administer diuretics or IVF as ordered. diarrhea. check for peripheral edema. pancreatitis. note changes in BP and HR. urine sodium concentration). and standing (if possible). 91.Copyright © 2008 by F. ■ Administer oral or IV diuretics. medications (thiazide diuretics. Davis. carbamazepine. oxcarbazepine. SIADH. selective serotonin reuptake inhibitors. uncorrected hypothyroidism. ■ Monitor neurological status. trazodone. urine and serum osmolality. STABILIZING AND MONITORING ■ Treament depends on patient’s volume status. ■ Chart patient status and convey to physician or NP . BUN. nephrotic syndrome. assess lung sounds. POSSIBLE ETIOLOGIES ■ Vomiting. ■ Review medication and dietary history (salt and water intake). burns. RENAL/F&E FOCUSED ASSESSMENT ■ Assess HR and BP lying. duration and magnitude of hyponatremia. hepatic cirrhosis. ■ Restrict fluids. excessive sweating. acute or chronic renal insufficiency. 90 . prolonged exercise in a hot environment. I&O. ■ Administer hypertonic saline solution IV if CNS symptoms present. BE PREPARED TO ■ Order or obtain laboratory tests (electrolyes. cortisol deficiency. and severity of symptoms (see Table on p. oxytocin. laboratory values. VS. sitting. carbamazepine. Most common cause of hyponatremia in surgical patients is infusion of hypotonic fluids. ↑ in total body water and sodium with paradoxical ↓ in circulating volume. trauma. major surgery. Also called dilutional hyponatremia. haloperidol. Possible diuretics. Intervention Infuse 0. Restrict free water. stress. hypervolemic. and euvolemic.9% NS IV. amitriptyline. RENAL/F&E . cyclophosphamide. vinblastine. Associated with SIADH arising from many clinical conditions including CNS disturbances. Increase in serum ADH further impairs free water excretion. A. ↑ sodium absorption and resultant impairment of renal free water excretion. chlorpropamide. Davis.Copyright © 2008 by F. ↓ renal perfusion due to intravascular volume depletion leading to ↑ renin and angiotensin excretion. infection.. Stimulates the same pathophysiological mechanism of impaired water excretion as is found in hypovolemic hypotonic hyponatremia. 91 Hypotonic Hyponatremia Inability of the kidneys to excrete free water adequately. Treatment for Mild or Moderate Hyponatremia Type Hypovolemic hyponatremia Cause ↑ sympathetic tone. SSRI. and certain medications (e.g. and MAOI). vincristine. Euvolemic hyponatremia Treat underlying cause. Categorized according to the associated intravascular volume: hypovolemic. pulmonary tumors. Hypervolemic hyponatremia Restrict free water. abdominal pain. Obtain urine samples for analysis. assess for fluid overload. hypotension. mental status. nausea. drugs (aminoglycosides. radiocontrast medium). renal arterial . vomiting. A. Insert urinary catheter. RENAL/F&E Oliguria (Low Urine Output/Acute Renal Failure) CLINICAL PICTURE The patient may have: ■ Urine output 500 mL in 24 hr. and monitor urine output hourly. . LOC. Assess for bladder distention. ■ Electrolyte imbalance. and convey to physician or NP . chemistries. ureteral. dry mucous membranes. Administer diuretics. ■ Orthostatic hypotension (if volume depleted). blood loss). Davis. Monitor BP HR. disease. acute glomerulonephritis. capillary refill time. mucosal membrane moisture. pulmonary crackles. CBC. phone call to physician or NP and physician or . STABILIZING AND MONITORING ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Insert IV access. ■ Peripheral edema. culture. Chart patient status. or urethral obstruction. IMMEDIATE INTERVENTIONS ■ ■ ■ ■ ■ Assess vital signs. Document patient status. Notify physician or NP of low urine output. neck vein distention. Obtain or order laboratory tests including BUN/creatinine. Monitor I&O. 92 . FOCUSED ASSESSMENT ■ Assess recent laboratory chemistry tests. ■ Fatigue. tubular. and hang fluids to reverse hypovolemia. BE PREPARED TO POSSIBLE ETIOLOGIES ■ Renal hypoperfusion (hypovolemia. NP response. and tissue turgor. ■ Assess for orthostatic hypotension. Transfer patient to ICU if invasive monitoring is required.Copyright © 2008 by F. CHF sepsis. Administer IVF challenge. Assess for patent IV access. other studies. especially BUN/creatinine. recent I&O. Educate patient and family about dialysis. acute tubular necrosis. ■ Implement triggers to help initiate stream (Credé’s maneuver. ■ If ordered. bladder distention and spasm. pouring warm water over perineum). ■ Palpate bladder to assess distention and tenderness. ■ Inability to void. if available. medications. catheterize patient. Remove catheter. call physician or NP and relate findings. urethral stricture. ■ If patient does not have a straight catheter order or if residual volume is excessive ( 500 mL). and convey to physician or NP . check for PRN order to catheterize patient. running water. ■ Assist patient to assume natural voiding position if possible (stand male patients. . Inspect and palpate for distention or tenderness of the lower abdomen. ■ Evaluate subsequent attempts to void and PVR. history of BPH. recent urological procedure or procedure requiring anesthesia. assist females to commode or raise HOB when using bedpan). feeling of not emptying bladder. A. 100 mL. IMMEDIATE INTERVENTIONS FOCUSED ASSESSMENT ■ ■ ■ ■ Assess urine volume with a bladder scanner.Copyright © 2008 by F. phone call to physician or NP and physician or . ■ Lower abdominal pain. RENAL/F&E . Assess temperature. BE PREPARED TO ■ ■ ■ ■ ■ Collect sterile urine sample. ■ Document patient status. ■ Chart patient status. Note: Do not catheterize patient if suspected pelvic trauma or blood at meatus. Teach self-intermittent catheterization. recent WBC count. note amount and characteristics of urine. Assess voiding patterns. STABILIZING AND MONITORING ■ Monitor I&O. history of incontinence. Instruct patient about urodynamic testing. ■ If patient still unable to empty bladder. 93 Urinary Retention CLINICAL PICTURE The patient may have: ■ Difficulty initiating stream. ■ Voiding in frequent small amounts. NP response. Initiate timed voiding and obtain postvoid residual (PVR) until PVR Place indwelling urinary catheter. if available. Davis. kidney stones. and provide privacy. male: legs flat. Don sterile gloves. benign prostatic hyperplasia (BPH). 6. 7. 2. using sterile technique. using a different swab each time.Copyright © 2008 by F. 3. With nondominant hand and using forceps to hold cotton balls: female— hold labia apart. 4. spinal anesthesia. 8. Check for leaks and proper inflation. 94 . Gently insert catheter (about 2–3 inches for females and 6–9 inches for males) until return of urine is noted. Open and set up catheter kit using sterile technique. RENAL/F&E POSSIBLE ETIOLOGIES ■ Obstruction in the bladder or urethra. They have a third lumen for irrigation. Place patient in supine position (female: knees up. Attach catheter to drainage bag. male—retract foreskin. Davis. Indwelling catheters have two lumens. Secure catheter to patient’s leg according to hospital policy. Hang drainage bag on bed frame below level of bladder. Three-way Foley catheters are used for continuous or intermittent bladder irrigation. anticholinergics. urinary tract infection (UTI). Prepare patient: explain procedure. test patency of balloon by filling balloon with 5 mL sterile water. medications— antihypertensives. Straight catheters have ” only a single lumen and do not have a balloon near the tip. swab from front to back. Procedure 1. and inflate balloon. sedatives. Indwelling Catheter Also called Foley or retention catheter. saturate cotton balls with cleansing solution. 9. and set up sterile field. Use one swab per swipe (total of five). If placing indwelling catheter. 10. Indwelling: insert an additional inch. legs apart. long period of inactivity or bedrest. 11. neurogenic bladder (secondary to CVA. A. Lubricate end of catheter. Remove water. Straight: collect specimen or drain bladder. swab in a circular motion from the meatus outward. 5. Straight catheters are inserted for only as much time as required to drain the bladder or obtain a urine specimen. starting with the outer labia and working inward toward the meatus. MS. low fluid intake. surgery. antihistamines (can be over-the-counter). Urinary Catheterization Straight Catheter Also called red rubber catheter or “straight cath. 12. neuropathy). Repeat at least three times. slightly apart). spinal trauma/tumor. and remove catheter. Collect appropriate equipment. one for urine drainage and one for inflation of the balloon near the tip. ■ Cloudy. ■ Check frequently to be sure there are no kinks or loops in tubing and that patient is not lying on tubing. or foul odor. ■ Fever. cloudiness. ■ Catheter should withdraw easily. ■ Provide bedpan. ■ Wash around catheter entry site with soap and water twice each day and after each bowel movement. ■ Do not pull or tug on catheter. swelling. Removal ■ Don gloves. redness. foul-smelling. RENAL/F&E . ■ Offer fluids frequently (if not contraindicated by health status). urinal. hesitancy. and odor. note color. urgency. A. Palpate bladder to ascertain it is empty. frequency.Copyright © 2008 by F. If balloon appears to be deflated and catheter cannot be removed gently. or drainage. especially water or cranberry juice. ■ Hold a clean 4 4 pad at meatus in the nondominant hand. ■ Irritation or leaking around catheter entry site. 95 Patient Care ■ Wash hands with soap and water before and after handling catheter. Measure spontaneous void amount. ■ Keep bag below level of patient’s bladder at all times. ■ Empty collection bag each shift. or bloody urine. ■ Do not use powder around catheter entry site. If you meet resistance. Urinary Tract Infection (UTI) CLINICAL PICTURE The patient may have: ■ Lower UTI S&S (cystitis): ■ Dysuria. ■ Decreased urine output ( 30 mL/hr). Davis. tube. or bag. ■ Periodically check skin around catheter entry site for signs of irritation. or assist patient to toilet. ■ Note time catheter discontinued. gently pull catheter. abdominal or flank pain. clarity. ■ Record urine output according to physician orders. ■ Notify physician for any of the following: ■ Blood. tenderness. stop and reassess if balloon is completely deflated. Wrap tip in clean 4 4 pad as it is withdrawn to prevent leakage of urine. notify physician or nursing supervisor for assistance. With dominant hand. ■ Use a 10-mL syringe to withdraw all water from balloon. 96 . Change or discontinue indwelling urinary catheter. lack of adequate fluids. immobility or decreased mobility. ■ Fever 101 F chills. prostatitis. Offer acetaminophen (if ordered) and heating pad or hot water bottle to relieve suprapubic pain. and urethral strictures. Monitor temperature. coli). Notify physician or NP of symptoms. IMMEDIATE INTERVENTIONS ■ ■ ■ ■ Assess VS. A. incontinence. vomiting. ■ Assess for flank pain. ■ Upper UTI S&S (pyelonephritis): ■ Fever 101 F shaking chills. cloudiness). ■ Nausea. onset of upper UTI symptoms). Encourage fluids. anorexia. factors that increase risk: incomplete emptying of bladder secondary to benign prostatic hyperplasia. flank pain. Administer IVF . Monitor for relief of symptoms or complications (urosepsis. color. Obtain catheterized urine sample. BE PREPARED TO ■ ■ ■ ■ Insert saline lock for IV antibiotics for upper UTI. ■ Assess urine characteristics (odor. bowel incontinence. and malaise. ■ Document patient status. FOCUSED ASSESSMENT ■ Assess history of UTI and usual voiding patterns. volume. neurogenic bladder. or asymptomatic. ■ Encourage patient to drink fluids to flush urinary system. . Obtain clean catheter urine specimen. ■ Elderly: altered mental status. delerium. Administer phenazopyridine PRN for dysuria. abdominal pain. . phone call to physician or NP and physician . RENAL/F&E ■ Suprapubic pain. or NP response. POSSIBLE ETIOLOGIES ■ Bacterial invasion of urinary tract (usually E. Davis. STABILIZING AND MONITORING ■ ■ ■ ■ Administer antibiotics promptly and on schedule.Copyright © 2008 by F. indwelling urinary catheters. Diaphragm Lumbar vertebra Pelvis Sacrum Urinary bladder Urethra RENAL/F&E . Davis.Copyright © 2008 by F. 97 A & P Snapshot Ribs Aorta Inferior vena cava Left adrenal gland Superior mesenteric artery Left renal artery and vein Left kidney Right kidney Left ureter Left common iliac artery and vein Psoas major muscle lliacus muscle Right ureter Opening of ureter Trigone of bladder Symphysis pubis Urinary system. A. Copyright © 2008 by F. (A) Female. 98 . RENAL/F&E Parietal peritoneum Detrusor muscle Openings of ureters Ureter Rugae Trigone Ureter B Prostate gland Prostatic urethra Trigone A Internal urethral sphincter External urethral sphincter Urethra Urethral orifice Membranous urethra Cavernous (spongy) urethra Cavernous (erectile) tissue of penis Bladder and urethra. A. Davis. (B) Male. and vomiting. mark the abdomen. ■ Bowel sounds provide supporting information to the clinical picture for the patient with an evolving GI problem. ■ When bowel sounds return. ■ Use a hemeoccult slide to test for blood in the emesis. the abnormal accumulation of fluid in the peritoneal cavity. can cause massive distention. ■ Bowel sounds are absent after abdominal surgery and may take a few days to return. ■ Absence of bowel sounds can indicate an inflammatory process such as peritonitis or a bowel obstruction. intake. A. although there is considerable variability that is still considered normal. excessive abdominal gas. Davis. ■ Fecal material in the emesis is rare but is an emergency if found.Copyright © 2008 by F. ■ Ascites. and consider any recent procedures or new medication. or infection. most clinicians think that it is difficult to pinpoint the origin of bowel sounds because they can be heard even when ausculatating the lungs. it indicates that the intestinal tract is beginning to function again. ■ Appetite. and tolerance of foods and fluids. severe bowel dysfunction. Patients are not fed when bowel sounds are absent. which is usually accompanied with passing flatus. and measure girth at the same level each day to assess if ascites is decreasing or increasing. frequent. ■ Normal bowel sounds are small gurgles heard every few seconds. ■ Assess bowel sounds: ■ Assess bowel sounds before palpating the abdomen. ■ Frequency and character of bowel sounds. Use the PQRST guideline in the Basics tab. however. ■ Assess abdominal distention: ■ The abdomen can be distended in many bowel problems. ■ Amount of abdominal distention ■ Frequency and character of bowel movements (constipation or diarrhea). nausea. nausea. The abdomen can be distended from constipation. Listen in all four quadrants. swallowing. GI . and vomiting: ■ Ask the patient about the nature of the abdominal pain. ■ High-pitched. tinkling bowel sounds can be heard in the initial stages of a bowel obstruction. assess quantity and characteristics of emesis. ■ Ask about nausea. 99 Focused GI Assessment ■ A focused nursing assessment of the GI system includes: ■ Investigation of abdominal pain. obstruction. such distention is frequently associated with abnormal or absent bowel sounds. For patients with ascites. ■ If the patient has vomited. ■ Abdominal pain. ■ Palpate or precuss the abdomen after listening to bowel sounds. Davis. hyperactive. ■ Assess for black. assess dentition. especially when accompanied by vomiting. and tolerance of foods and fluids: ■ Any impairment in swallowing is serious and should be evaluated by a speech pathologist. and ask the patient if he or she feels constipated. COPD. measurement as described above is not done routinely. ■ Appetite. 100 . Both skills take practice to be helpful in an assessment. vomiting or weight loss? ■ If general food intake is low. ■ If the patient is constipated. NPO status. decline in acuity of taste buds. or absent bowel sounds. ■ If the patient has diarrhea. is there early satiety (feeling full after eating small quantities). ■ High-pitched. why not? Ask about allergies.Copyright © 2008 by F. If constipation is chronic. or other possible causes. flank pain. Abdominal Pain and/or Distention CLINICAL PICTURE The patient may have: ■ Abdominal pain. ■ Abdominal distention or rigidity. ■ Does the patient tolerate the foods and fluids offered? If not. intake. especially when the distention is of acute onset as in a postoperative complication. tarry stools (melena). Ask about normal bowel habits. Diarrhea. is there nausea. look to the recent history (procedures). ascertain the frequency and amount of stool. GI ■ Bowel distention is usually observed. and others and promptly needs to be evaluated. ■ Frequency and character of bowel movements (constipation or diarrhea): ■ Monitor bowel movements. A. Test the stool for blood when GI bleeding is suspected. tenderness. ■ Nausea/vomiting/diarrhea. medications that affect peristalsis (narcotics and many others). can quickly cause electrolyte imbalances and dehydration. Suggest a consultation to the physician or NP . hypoactive. Measurements only become meaningful once a baseline is established. especially in older adults. such as cancer. find out more about the problem. How long has it been. swallowing. ■ If the patient complains of loss of appetite. Refer to an assessment textbook for more information. and ascertain if foods have lost their taste to the patient. esophageal problems. discuss eating habits. ■ Decreased appetite is a symptom of many conditions. reconnect NGT to suction—note amount of immediate NGT drainage. ■ Monitor nutritional status. Test emesis for occult blood. Document findings and phone call. ulcers. and test for occult blood. Insert indwelling urinary catheter. Palpate abdomen for pulsations. GI . tenderness. Inspect abdomen.9% NS (with order). Monitor VS as frequently as indicated. liver disease. recent laxative or enema use. Assess output from NGT (if placed). auscultate bowel sounds. Administer pain medication. Order or obtain laboratory tests. and rigidity. Insert an IV and hang 0. or set up suction. appendicitis. malignancy. ■ Assess vital signs (VS). Assess recent bowel habits. A. antiemetics. Davis. endoscopy. Assess hydration status and urine output (UO) by reviewing I&O record for previous 2 days. if ordered. peritonitis. Assess from area of least tenderness to area of most tenderness. POSSIBLE ETIOLOGIES ■ Bowel obstruction. FOCUSED ASSESSMENT ■ ■ ■ ■ ■ ■ ■ ■ Ask patient to describe pain. ■ Obtain stool/emesis sample. ileus. Facilitate diagnostic tests such as abdominal x-ray. irritable bowel syndrome (IBS). STABILIZING AND MONITORING ■ ■ ■ ■ ■ Administer antiemetic and pain medication. CT. cholecystitis. and diagnostic imaging. including temperature. Clarify with physician or NP on alternative route for administration of PO medications. BE PREPARED TO ■ ■ ■ ■ ■ ■ Hang IVF . Check all recent laboratory values including WBC count.Copyright © 2008 by F. 101 IMMEDIATE INTERVENTIONS ■ Place patient in position of comfort. gastroenteritis. ultrasound. use the PQRST guidelines in the Basics tab. Notify physician or NP of assessment findings. ascites. pancreatitis. Insert an NGT. antibiotics. ■ If patient has a nasogastric tube (NGT) but is unattached to suction. Instruct patient to take small sips of water during insertion to help facilitate passing of the tube. Secure tube to patient’s nose using tape. 4. Position patient upright in high Fowler’s position. GI NGT Insertion Indications ■ Aspirate blood or fluids and gas from stomach. This helps to prevent accidental insertion into the trachea. ■ Attach a connector to the end of tube. ■ Control nausea and vomiting. and reattempt. 8. Typically. Be careful not to block the nostril. ■ Pull back on plunger of a 20-mL syringe to aspirate stomach contents. A reading of 1–3 suggests placement in the stomach. Explain procedure to the patient. ■ An alternate. Assemble suction canister. 6. 7. 102 . Never use petroleum-based jelly. Procedure 1. 5. Then pin tape to patient’s gown. Hearing a loud gurgle of air suggest placement in the stomach. gastric aspirates are cloudy and green. remove tube. bloody. or tan. Mark this point on the tube with a piece of tape. ■ Checking the pH of aspirate is the preferred method for checking placement. ■ Attach the extension tubing that comes with the suction canister to the connector. 2. Lubricate tube by applying water-soluble lubricant to tube. 3. Davis. have ready at bedside. off-white.Copyright © 2008 by F. or brown in some cases. Instruct patient to keep chin-to-chest posture during insertion. Confirm proper location of tube. Measure tube from tip of the nose to the ear lobe. ■ An inability to speak also suggests intubation of trachea instead of stomach. If using portable suction. but less reliable. Withdraw tube immediately if patient becomes cyanotic or develops breathing problems. Withdraw tube immediately if patient becomes cyanotic or develops breathing problems. allowing slack for movement. is to inject 20 mL of air into tube while auscultating the abdomen. Gastric aspirate can look like respiratory secretions. method. ■ Dip litmus paper into gastric aspirate. Insert tube through nostril until the previously marked point on the tube is reached. If no bubbling is heard. and attachment for wall suction. then down to xyphoid. Tape tube 12–18 inches below insertion line. liner. A. Copyright © 2008 by F. A. Davis. 103 ■ Connect the other end of the tubing to suction canister where indicated. ■ Set suction as ordered. Patient Care ■ Reassess placement of tube. ■ Assess amount and character of drainage. ■ Replace collection liner before it is full (full or nearly full liner prevents thorough suction of GI material). ■ Flush tube with water after each feeding and after each medication. ■ Assess skin around nose for irritation and breakdown, and replace tape as needed. Change at least every other day. ■ Gently wash around the nose with soap and water, and dry before replacing tape. ■ Provide mouth care every 2 hours and PRN. ■ Mouthwash, water, toothettes: clean tongue, teeth, gums, cheeks, and mucous membranes. ■ If patient is performing oral hygiene, remind him or her not to swallow any water. Removal 1. Explain procedure to patient. Don gloves. 2. Remove tape from nose and face. Offer patient some tissues as he or she may gag slightly as the tube is withdrawn. 3. Clamp or plug tube (prevents fluid from entering lungs), and remove tube in one gentle, swift motion. 4. Assess for signs of aspiration. Constipation CLINICAL PICTURE The patient may have: ■ Complaints of constipation. ■ Infrequent stools accompanied by discomfort, bloating, flatulence. IMMEDIATE INTERVENTIONS/FOCUSED ASSESSMENT ■ Assess abdomen for bowel sounds. Bowel sounds may be infrequent; listen for a full minute before concluding that bowel sounds are absent. If no bowel sounds are heard, do not administer laxatives or PRN enemas; notify physician or nurse practitioner with findings. ■ Assess for abdominal distention and pain. ■ Ask about last bowel movement and recent dietary intake. ■ Check MAR for medications that can cause constipation; check MAR for PRN orders for laxatives and daily stool softener order. GI Copyright © 2008 by F. A. Davis. GI ■ If the patient has bowel sounds, is on a solid diet, and has a PRN order for a laxative, check how soon the laxative is designed to work, and administer it at the appropriate time (e.g., some magnesium-containing laxatives work very quickly; some are designed to work over 8 hrs). ■ If there is an order for a small-volume enema that can be selfadministered or an oral laxative, ask the patient which he or she would prefer. Explain how to use the enema if the patient chooses that option. STABILIZING AND MONITORING ■ Assess effectiveness of laxative and return of usual bowel function. ■ Review diet and medications for possible changes that can prevent or treat constipation. ■ Assess need for daily stool softener or bulk-forming laxative. Stimulant laxatives should be used infrequently. BE PREPARED TO Check for impaction; administer saline enemas. POSSIBLE ETIOLOGIES Medications such as diuretics, loperamide, opioids, antidepressants, and medications containing iron, calcium, or aluminum; insufficient intake of dietary fiber; dehydration; hypothyroidism; hypokalemia; injury to the anal sphincter; diminished or absent peristalsis related to surgery, cancer, diverticula, irritable bowel syndrome, functional incapacity. Diarrhea CLINICAL PICTURE The patient may have: ■ Frequent loose, watery, bowel movements. ■ Loose stools containing blood, pus, or mucus. ■ Abdominal pain, cramps, flatulence. ■ Nausea, vomiting, dehydration. ■ Fatigue, temperature elevation. IMMEDIATE INTERVENTIONS ■ ■ ■ ■ Assess VS and mental status. Provide comfort measures and perineal care. Obtain stool samples. Assess for patent IV access. 104 Copyright © 2008 by F. A. Davis. 105 ■ Notify physician or NP of symptoms. ■ Document patient status, phone call to physician or NP and physician or , NP response. FOCUSED ASSESSMENT ■ Assess hydration status (orthostasis, hypotension, and tachycardia; tissue turgor, mucous membrane moisture, mentation, UO). ■ Assess recent GI history (onset, frequency and nature of stools, presence or absence of blood and mucus, vomiting, cramps, and fever). ■ Assess recent antibiotic use, use of stool softeners and opiates (all associated with increased risk of psuedomembranous colitis [PMC] caused by Clostridium difficile). ■ Ask about recently eaten meals (raw eggs, contaminated food, raw seafood) and travel history. ■ Assess recent blood chemistries (electrolyte levels). STABILIZING AND MONITORING ■ Insert IV, and administer IVF (D5 1/2 NS with KCl) if dehydrated or unable to tolerate oral fluids (with order). ■ Encourage fluids if able to tolerate. ■ Monitor I&O. ■ Administer appropriate antibiotic/anti-infective agent promptly and on schedule. ■ Avoid use of antimotility drugs (diphenoxalate, loperamide) or opiates if infectious diarrhea suspected. ■ Monitor for relief of symptoms or complications (toxic megacolon if PMC, dehydration, electrolyte imbalance, skin breakdown). ■ Document patient’s status in medical record, and communicate to physician or NP . BE PREPARED TO ■ Insert IV access and administer IVF . ■ Obtain specimens. ■ Implement enteric precautions. POSSIBLE ETIOLOGIES ■ Viral, bacterial, or parasitic gastroenteritis; food-borne diarrhea; ulcerative colitis; Crohn’s disease; AIDS; pseudomembranous colitis; drug side effect; inflammatory bowel disease. GI Copyright © 2008 by F. A. Davis. GI Feeding Tube Complications CLINICAL PICTURE The patient may have: ■ Occluded tube. ■ Tube displacement. ■ Extubation. ■ Stomal infection. ■ Stomal leak. IMMEDIATE INTERVENTIONS ■ Assess site for leak. ■ Assess for signs and symptoms of infection (elevated temperature, pain, redness, warmth, purulent discharge). ■ Assess for proper placement (is tube too far in tract, too far out, or completely out?). ■ If tube is occluded, attempt to dislodge using method described in table below. ■ Elevate HOB to minimize risk of aspiration. ■ For other complications or if attempt to dislodge tube is ineffective, notify physician or NP . ■ Document patient status, phone call to physician or NP and physician or , NP response. FOCUSED ASSESSMENT ■ Assess for signs and symptoms of aspiration (temperature, RR, lung sounds). ■ Assess LOC/mental status. ■ Assess hydration status. STABILIZING AND MONITORING ■ ■ ■ ■ ■ See table below for guide to ongoing interventions. Monitor nutritional status. Provide stomal care. Obtain nutrition consult if indicated. Chart patient status, and convey to physician or NP . BE PREPARED TO ■ Obtain replacement tube, and assist with bedside reinsertion. ■ Obtain portable chest x-ray for placement if nasoenteric tube is inserted. ■ Resume tube feedings. POSSIBLE ETIOLOGIES ■ Varies according to complication; see following table. 106 ■ Elevate patient’s head 30 –45 during feeding and for 1 hr after meal. Inadequate stomal care. A. ■ Reposition tube. Tube migration. ■ Check residuals before feeding. ■ Stabilize tube with gauze pads. ■ Document length in nursing record. and call physician or NP . ■ Correct cause of leakage. suture. or attachment device is secure. Feeding tubes must be replaced within a few hours. use plain water or change type of soap used. ■ Carefully clean and protect stoma per facility protocol. ■ Consider continuous feeds or smaller. ■ If stoma site is irritated. Stomal infection: Leakage around tube. adjust crosspiece. ■ Check that disc. Allergic reaction to soap. Gastroesophageal reflux/ large residuals: Delayed gastric emptying. ■ Keep skin around stoma clean and dry. Stomal erosion or widening. Davis. to promote gastric emptying. ■ Use gastric stimulant. if ordered. bumper. use protective ointments and gauze. and measure each shift. Hold feeding if greater than 100 mL. ■ Note length of tube outside of body. using either the external marks on the tube or a tape measure. or disc falls out. GI . Extubation: Internal balloon deflates or suture. 107 Feeding Tubes: Preventing and Managing Complications Complication/Cause Leakage of gastric secretions: Improper positioning of patient. or disc falls out. Interventions ■ Position patient upright for feeding. ■ Tract can close within a few hours. more frequent boluses (Continued on the following page) Tube migration: Internal balloon deflates or external tube suture. bumper.Copyright © 2008 by F. ■ Check residuals before bolus feeding or every 4 hr for continuous feeding. ■ Reduce rate of administration. tube migration from stomach to small intestine Feeding Tubes: Preventing and Managing Occlusions Prevention ■ Flush with 30 mL of water every 4–6 hr and before and after administering tube feedings. ■ Add fiber. Davis. feeding too cold. ■ Dilute liquid medications with 20–30 mL of water. A. Interventions ■ Change to a low-fat formula. lactose intolerance. ■ Administer feeding at room temperature. and replace per facility policy. ■ Hang only 4-hr amount of formula at a time. Hold feeding if greater than 125 mL. GI Feeding Tubes: Preventing and Managing Complications (continued) Complication/Cause Nausea. vomiting. ■ Retract tube to reposition against stomach wall. 108 . call physician or NP . ■ Use a feeding pump with an automatic water flush feature. contamination of food or feeding bag.Copyright © 2008 by F. ■ Do not add medication to formula. checking for residuals and administering medications. lactose intolerance. fat malabsorption. or use a formula with fiber. ■ Clean tops of formula cans before opening. too rapid administration. ■ Refrigerate open cans of formula. Diarrhea: Too rapid increase in amount of feeding. and keep only as long as manufacturer suggests. ■ Reduce rate of administration. ■ Administer feeding at room temperature. ■ Clean feeding sets well. cramps. bloating: Too rapid administration of feeding. GI . temperature. 109 ■ Obtain all medications in liquid form. position patient to facilitate an open airway (upright or turned to one side). a physician or NP usually must perform the procedure. and withdraw syringe plunger to remove obstruction. or use a syringe smaller than 30 mL. ■ Anxiety. rigid. and gently pull back on the plunger to dislodge the occluding plug. do not use force to unclog. place flushing syringe (30 mL) into the tube end. ■ To prevent tube damage. Management ■ Check the feeding tube for kinks. If unsuccessful. ■ Assess BP HR. ■ Distended. IMMEDIATE INTERVENTIONS ■ To prevent aspiration of blood and subsequent respiratory compromise. SOB. clamp tube for 10–15 min. Hematemesis/Upper GI Bleed CLINICAL PICTURE The patient may have: ■ Bright red or dark coffee ground–appearing emesis. and/or tender abdomen. instill warm water into the tube. check with pharmacist to see if medication can be crushed. ■ Nausea. ■ If no obvious kink is found. and try again. particularly in patients who have inadequate gag reflexes or altered LOC. ■ Commercial products that use thin plastic devices for clearing feeding tubes or products that use a catheter and chemical declogging powder are available. ■ Dizziness. . ■ Do not instill meat tenderizer—can cause metabolic complications and allergic reactions. ■ Inject a small amount of air into tube. If liquid form is not available. hypotension. ■ If tube still blocked. A. however.Copyright © 2008 by F. Gently depress. black stools. Davis. ■ Administer each medication separately. leave instilled warm water in tube. ■ Provide emesis basin. ■ Milk the tube with fingers from the insertion site out. weakness. ■ Do not mix medications with feeding formula. and flush with 5–10 mL of water between each medication. RR. ■ Change patient’s position. ■ Tachycardia. ■ Check if patient has been previously typed and cross-matched and if any blood products are available in the blood bank. ■ Provide oral hygiene and other comfort measures after episodes of vomiting. and administer IVF per order. or NP response. ■ ■ ■ ■ ■ ■ ■ BE PREPARED TO Start an IV (two large-bore IVs if vomiting copious amounts of blood). PT/PTT/INR. Prepare for ICU transfer if hemodynamically unstable. laboratory and diagnositic studies (x-ray. Administer H2 blockers. FOCUSED ASSESSMENT ■ Assess BP HR. ■ Hematest emesis. ■ Monitor VS frequently (every 5 min if unstable). Davis. Assist with central line placement. type and cross-match). endoscopy). Check blood pressure supine and standing (if . and perform room temperature saline lavage. Obtain ECG. and rigidity. ■ Place an NG tube (per level of practice and physician’s order). STABILIZING AND MONITORING ■ Insert a large-bore IV. and convey to physician or NP . ■ Monitor laboratory studies (CBC. and document difference. GI ■ Differentiate that patient has vomited. capillary refill. ■ Chart patient status. Assess LOC. ABGs. peristalsis. ■ Assess skin color and temperature. not expectorated. A. guarding. BUN. 110 .Copyright © 2008 by F. ■ Assess for patent IV. blood. ■ Suction oropharynx if patient vomiting copious amounts of blood and cannot clear vomitus/secretions. and RR. ■ Assess for use of anticoagulants. ■ Document patient status. Connect to low intermittent suction. ■ Assess abdomen for distention. electrolytes. phone call to physician or NP and physician . ■ Check oxygen saturation via pulse oximetry. or steroids. ■ Assess respiratory status and lung sounds. and monitor I&O. ■ Call physician or NP . NSAIDs. ■ Insert a urinary catheter. tenderness. Give IVF or blood products. feasible). ■ Monitor serial Hgb/Hct. assess amount and characteristics. Set up gastric suction. blood dyscrasias. Insert large-bore IV access. tenderness. assess oxygen saturation. ■ Assess for patent IV access. NSAIDs. hemodynamic status. and UO. BP RR. oliguria. uremia. carcinoma. Administer supplemental oxygen. fatigue. ■ Abdominal cramping. pallor. Assess skin color. A. gastric erosions. esophageal varices. salicylates. duodenal ulcer. . assess capillary refill. cold clammy extremities. Mallory-Weiss syndrome. ■ Check recent CBC. moistness. Chart patient status. use of NSAIDs. Lower GI Bleed/Melena CLINICAL PICTURE The patient may have: ■ Frankly bloody or melanotic stool or stool tests positive for occult blood. chest pain (chronic bleed). IMMEDIATE INTERVENTIONS ■ ■ ■ ■ ■ Assist patient to bed. Davis. associated symptoms). GI . and convey to physician or NP . Obtain detailed GI history (history of tarry stools. ■ Anemia. dizziness. Record frequency and character of stools. hemorrhagic gastritis. and temperature). esophagitis. and temperature. Assess LOC and orientation. SBP 100 mm Hg. or NP response. ■ Signs and symptoms of hypovolemic shock (acute bleed): hr 110 beats/min. peptic ulcer. leukemia. FOCUSED ASSESSMENT ■ ■ ■ ■ ■ Assess VS (HR. Assess abdomen (distention. pain.Copyright © 2008 by F. ■ Check if patient has been previously typed and cross-matched and if any blood products are available in blood bank. mental status changes. STABILIZING AND MONITORING ■ ■ ■ ■ Monitor VS. corticosteroids. check for orthostasis. polyps. Document patient status. Assess VS. Notify physician or NP . bowel sounds). orthostatic drop in systolic BP of 16 mm. 111 POSSIBLE ETIOLOGIES ■ Gastric ulcer. phone call to physician or NP and physician . PT. IMMEDIATE INTERVENTIONS ■ Elevate HOB to high Fowler’s position. ■ Assess hydration status (orthostatic hypotension. skin pallor. visual disturbances. ■ Insert a urinary catheter. and monitor UO. INR). SOB. medication. ■ Offer a cool compress to the forehead or nape of neck. skin turgor. ■ Abdominal pain. confused. ulcerative colitis. anal fissures. 112 . POSSIBLE ETIOLOGIES ■ Diverticulitis. ischemic colitis. ■ Tachycardia. activity). provide emesis basin. Assess for chest pain. eating. type and cross-match. ■ Assess for patent IV access. BUN. serial Hb and Hct. Nausea CLINICAL PICTURE The patient may have: ■ Sensation/urge to vomit. or debilitated patient in a side-lying position to reduce risk of aspiration. ■ Prepare patient for or assist with anoscopy or colonoscopy. mucous membranes. ■ Keep NPO. creatinine. recent I&O). bradycardia. electrolytes. ■ Place weak. upper GI bleed. remove if negative.. GI polyps. GI BE PREPARED TO ■ Obtain or order laboratory tests including coagulation studies (platelet count. and administer IVF or blood products. FOCUSED ASSESSMENT ■ ■ ■ ■ Assess patient’s ability to protect airway. ■ Insert NGT.g. hemorrhoids. ■ Decreased or high-pitched bowel sounds. and check aspirate for blood. ■ Start an IV.Copyright © 2008 by F. Assess VS. Davis. PTT. Assess onset of symptoms and associated events (e. ■ Diaphoresis. A. Crohn’s disease. headache. diaphoresis. IMMEDIATE INTERVENTIONS ■ Elevate HOB to high Fowler’s position. ■ Monitor and record I&O. decreased or high-pitched bowel sounds. or NP response. bradycardia. chemotherapy). head injury. Vomiting CLINICAL PICTURE The patient may have: ■ Small or large amounts of emesis. notify physician or NP . ■ Tachycardia. motion sickness. fast. ■ Place weak. pain. meningitis. stress. phone call to physician or NP and physician . slow. chemotherapy. ■ If nausea is not expected given the patient’s clinical problem.Copyright © 2008 by F. provide emesis basin. pregnancy. and give IVF for hydration. Facilitate diagnostic studies. ■ Keep NPO. ■ Abdominal pain. ■ Offer a cool compress to the forehead or nape of neck. and UO. BE PREPARED TO ■ ■ ■ ■ ■ ■ Administer antinausea medication as ordered. other GI disorder. Start an IV. ■ Clarify with physician or NP whether to withhold PO medication or give by alternate route. A. SOB. Monitor serial electrolytes. or irregular HR. other neurological cause. ■ Check MAR for as-needed antiemetic. or debilitated patient in a side-lying position to reduce risk of aspiration. administer if clinically indicated. ■ Document patient status. Insert NGT if bowel obstruction is present. GI . 113 STABILIZING AND MONITORING ■ Determine if nausea is an anticipated side effect of treatment (anesthesia. confused. appendicitis. infection. vascular headache. bowel obstruction. skin pallor. drug side effect. nutritional status. Davis. POSSIBLE ETIOLOGIES ■ Gastroenteritis. Call for an ECG if associated with chest pain. ■ Clarify with physician or NP whether to withhold PO medication or give by alternate route. ■ Assess for patent IV access. SOB. Call for an ECG if associated with chest pain. slow. ■ Assess onset of symptoms and associated events (e. pain. appendicitis. BE PREPARED TO ■ ■ ■ ■ ■ ■ Start an IV. abdominal pain. ■ Note if vomiting is projectile.g. Administer antinausea medication as ordered. head injury. chemotherapy.. Insert NGT if bowel obstructed or vomiting continues. ■ Assess VS. Monitor serial electrolytes. ■ Administer IVF if ordered. phone call to physician or NP and physician or NP response. motion sickness. GI FOCUSED ASSESSMENT ■ Assess patient’s ability to protect airway. activity). and UO. response to treatment. Facilitate diagnostic studies. ■ Monitor and record I&O. mucous membranes. and contents. other GI disorders. or irregular heart rate. Davis.Copyright © 2008 by F. fast. ■ Monitor laboratory tests for electrolyte imbalances (from loss of fluid) or metabolic alkalosis (from loss of gastric acid). 114 . infection. STABILIZING AND MONITORING ■ Determine if vomiting is an anticipated side effect of treatment (anesthesia. other neurological cause. notify physician or NP . odor. vascular headache. ■ Inspect emesis for color. ■ Assess hydration status (orthostatic hypotension. dizziness. POSSIBLE ETIOLOGIES ■ Gastroenteritis. pregnancy. medication. ■ Check MAR for as-needed antiemetic. meningitis. A. tissue turgor. bowel obstruction. amount. eating. recent I&O). drug side effect. ■ If vomiting is not expected given the patient’s clinical problem. SOB or other symptoms (headache. chemotherapy). ■ Document patient status. administer if clinically indicated. . stress. diarrhea). ■ Assess abdomen for distention and tenderness. and give IVF for hydration. nutritional status. ■ Assess for chest pain. 115 A & P Snapshot Tongue Teeth Parotid gland Pharynx Sublingual gland Submandibular gland Esophagus Liver Left lobe Stomach (cut) Spleen Right lobe Gall bladder Bile duct Transverse colon (cut) Ascending colon Cecum Vermiform appendix Duodenum Pancreas Descending colon Small intestine Rectum Anal canal Digestive system. A. Davis.Copyright © 2008 by F. GI . triiodothyronine (T3). Diagnostic testing is the cornerstone of endocrine assessment. mineralocorticoids (aldosterone). insomnia. and signs and symptoms can be vague or attributable to other causes. follicle-stimulating hormone (FSH). and other tests. Davis. hypertension or hypotension ■ Kidney stones. A. tetany. confusion Laboratory and diagnostic tests consist of radioimmunoassay of hormone levels. glucagon. Diabetic Ketoacidosis (DKA) CLINICAL PICTURE The patient may have: ■ Rapid onset excessive thirst. blood glucose levels. and skin ■ Increased or decreased energy. pathological fractures. polydipsia. muscle weakness. ENDO Focused Endocrine Assessment The endocrine system comprises hormone-secreting glands. muscle aches ■ Tachycardia. somatostatin ■ Ovaries or testes: sex hormones Physical assessment of the endocrine system is difficult in that the thyroid gland is the only palpable gland. nails. growth hormone (GH). excessive urination) ■ Anorexia. N&V 116 . luteinizing hormone (LH). agitation.Copyright © 2008 by F. hypothermia or fever ■ Tremors. constipation. memory loss ■ Polyuria. 24-hour urine studies. dehydration ■ Change in thought processes. ■ Abdominal pain. weight gain or loss. fatigue ■ Heat or cold intolerance. oxytocin. and calcitonin ■ Parathyroids: parathyroid hormone (PH) ■ Adrenals: medulla: epinephrine and norepinephrine. nearly constant urination. The glands and the hormones they secrete include: ■ Hypothalamus and pituitary: antidiuretic hormone (ADH). cortex: glucocorticoids (cortisol). and radiological scans. adrenocorticotropic hormone (ACTH). Some physical signs and symptoms that may be the result of endocrine malfunction include: ■ Change in appearance of hair. polyphagia (excessive eating and drinking. thyroid-stimulating hormone (TSH). and prolactin (PRL) ■ Thyroid: thyroxine (T4). These hormones are instrumental in all aspects of homeostasis. and adrenal androgens ■ Endocrine pancreas: insulin. phone call to physician or NP and the response. Assess ABG results. Transfer patient to ICU. and other findings. ■ Assess for patent IV access.3. peripheral neuropathy. ■ Hyperventilation (Kussmaul’s respirations). Abnormal ABGs indicating metabolic acidosis (pH 7. underlying medical illness. IMMEDIATE INTERVENTIONS ■ Assess VS. ■ Stay with patient. decreased LOC. 117 ■ ■ ■ ■ Lethargy progressing to coma (in later stages). ■ Notify physician or NP of elevated glucose. Blood glucose level of 250–800 mg/dL. and osmolality. and ability to protect airway. skin infections. and ability to protect airway. ENDO .Copyright © 2008 by F. ■ Monitor I&O. new onset of diabetes. Hang IVF . Dehydration leading to hypotension and shock. ■ Document findings. poor circulation to feet and toes). with order). bicarbonate 15 mEq/L). including high potassium levels. STABILIZING AND MONITORING ■ Ongoing assessment of VS. ketones. LOC. .g. A. if present.. administer medications (regular insulin) as ordered. Continue to assess LOC and VS—hypotension can be severe. Administer IV insulin. POSSIBLE ETIOLOGIES ■ An infection in an otherwise well-controlled diabetic patient. ■ Insert IV and hang IVF (NS. Davis. FOCUSED ASSESSMENT ■ ■ ■ ■ Assess electrolyte values. too little insulin or failure to take any insulin. ■ Multiple electrolyte abnormalities. Assess for other complications of diabetes (e. ■ Monitor blood glucose and electrolytes. BE PREPARED TO ■ ■ ■ ■ Obtain blood work. and fruity-smelling breath (somewhat like nail polish remover). LOC. notify physician or NP . Davis. not diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic nonketotic coma (HHNC). generalized weakness. based on sliding scale. and if there has been a recent change in diabetic management. usual level of glucose control. ■ Blurred vision. increased urination. and dizziness. BE PREPARED TO ■ Administer insulin as ordered. ■ Assess for signs of dehydration (dry mucous membranes. dry skin. ■ Fruity breath odor (like acetone). Assess patient’s understanding of disease process and treatment. Check MAR for regular insulin sliding scale based on blood glucose level. ■ Usually there are few or no symptoms or signs other than blood glucose level ■ Can have: ■ Flushed. assess LOC if indicated. 118 . STABILIZING AND MONITORING ■ ■ ■ ■ ■ Continue to assess LOC and orientation. Discuss diabetic management with health-care team. Reassess blood glusose level at appropriate intervals. BP RR. Administer appropriate dose of regular insulin. ■ N&V. *This is a discussion of uncomplicated. and dry mucous membranes. If patient is symptomatic. educate as needed. or if blood glucose level exceeds parameters of sliding scale. ■ Dipstick urine for ketones. ■ Obtain serial blood glucose levels. Consider nutrition consult. A. ■ Assess if infusing IVF contains dextrose (if applicable). if MAR does not contain a sliding scale. IMMEDIATE INTERVENTIONS ■ ■ ■ ■ Obtain a blood glucose level if not already done. . ■ Ask patient about recent health changes. poor skin turgor. poor skin turgor. moderately elevated blood glucose. and dry scaly skin). cramping. FOCUSED ASSESSMENT ■ Assess HR.Copyright © 2008 by F. and convey to physician or NP . ENDO Hyperglycemia* CLINICAL PICTURE The patient may have: ■ Blood glucose level 180–300 mg/dL on routine fingerstick. ■ Chart patient status. ↑ BUN. gather needed supplies for IV insertion. ■ Visual changes. that triggered HHNC. excessive thirst. lethargy to coma. tachycardia. which can resemble signs of stroke. ■ Hypotension. Note shallow. weight loss. 119 POSSIBLE ETIOLOGIES ■ New-onset DM. possibly infection. ■ Assess for history of type 2 diabetes (HHNC occurs almost exclusively in this group). possibly every 15 min. infection. ■ Check electrolytes for hypokalemia. including aphasia and hemiparesis. ■ Assess HR apically or with ECG monitoring. Assess LOC at the same time. ■ Hang IVF as ordered. tachycardia. ENDO .Copyright © 2008 by F. A. IMMEDIATE INTERVENTIONS ■ Call physician or NP as soon as the serum glucose level is known or if the patient’s LOC has changed. delirium. If patient’s LOC is declining from drowsiness to stupor or coma (which can happen rather quickly). ■ Assess for focal neurological changes. assess ability to protect airway. rapid respirations. Assess for orthostasis (drop in systolic BP 10 mm Hg when position changes from lying to standing or lying to sitting upright if standing is not possible). ■ Confusion. if available. if none. ■ Monitor BP. ■ Assess for underlying illness. Note dysrhythmias. Hyperosmolar Hyperglycemic Nonketotic Coma (HHNC) CLINICAL PICTURE The patient may have: ■ Hyperglycemia ( 600 mg/dL) ■ Polyuria. illness. Take NS to keep the vein open (with order) until treatment-level IV orders are written. stress. shock can develop quickly. ■ Dehydration—dry mucous membranes. Davis. certain medications such as cortisone. noncompliance with insulin and diet regimen. trauma. STABILIZING AND MONITORING ■ Continue all assessments as outlined above. FOCUSED ASSESSMENT ■ Check ABGs as frequently as indicated. ■ Check for a patent IV access. dry skin. ↑ serum osmolality ( 350 mOsm/L). ). POSSIBLE ETIOLOGIES ■ Preceding or concomitant illness that triggers dehydration (pneumonia and urinary tract infection are common triggers). This predisposes the patient to thrombosis. and replace electrolytes as ordered. ■ Assess for signs or symptoms of venous thrombosis (due to dehydration. Facilitate blood tests and other diagnostic tests. IMMEDIATE INTERVENTIONS ■ Obtain a blood glucose level by fingerstick. such as adult respiratory distress syndrome (ARDS) and multiorgan dysfunction syndrome (MODS). Transfer to ICU. ■ Assess for other serious complications. and monitor glucose levels. or cause dehydration. and diaphoretic skin. ■ Headache. BE PREPARED TO ■ ■ ■ ■ ■ ■ ■ Obtain ABGs. A. stress response to illness that raises glucose levels. ■ Notify physician or NP . ■ ↓ LOC progressing to coma and/or seizures if not treated. blank stare. meaning the blood is very thick. ■ Monitor serum chemistries. blood becomes hyperosmolic. Davis. drugs that raise glucose levels. position patient to protect airway.Copyright © 2008 by F. hunger. Assist with insertion of a central venous catheter. inhibit insulin. Insert a nasogastric tube. rapidly absorbed carbohydrates (orange juice) if alert and no risk of aspiration. ■ Assess coagulation studies for signs of disseminated intravascular coagulation (DIC). a complication of HHNC. ■ Agitation. Assist with intubation. disorientation. palpitations/tachycardia. ■ Assess VS and LOC. pale. ■ If patient has ↓ LOC. trembling. slurred speech. ■ Give oral. ENDO ■ Begin insulin drip. Teach patient about process of HHNC to avoid recurrence. Hypoglycemia CLINICAL PICTURE The patient may have: ■ Cool. 120 . give 1 amp (25 g in 50 mL) of 50% dextrose IV push (with order). FOCUSED ASSESSMENT ■ ■ ■ ■ ■ Assess time the insulin or oral hypoglycemic agent was taken and amount. milk. Assess other medications for potential to affect glucose control. excessive alcohol consumption. ■ Consult dietitian/nutrition support. alcohol. Ascertain that dose/type of insulin/oral hypoglycemic given was accurate. increased activity. NP response. Administer glucagon or other medications if necessary. ■ Edema.g. emotional stress. crackers). Obtain serial blood glucose levels. too little food intake. phone call to physician or NP and physician or .. drugs. provide more slowly absorbed carbohydrates (e. ENDO . Assess if patient has eaten. Assist with airway management and intubation if needed. 121 ■ If patient has ↓ LOC. Davis. ■ Chart patient status. and reevaluate patient as needed. Myxedema Coma CLINICAL PICTURE The patient may have: ■ Low body temperature. ■ Document patient status. Manage seizure activity if needed.Copyright © 2008 by F. ■ Hypoventilation. depression. ■ Weakness. nondiabetic patients: liver disease. ■ Once symptoms improve. BE PREPARED TO ■ ■ ■ ■ ■ Start a peripheral IV. POSSIBLE ETIOLOGIES ■ Diabetic patients: overdose of insulin or oral hypoglycemic agent. ■ Monitor for hypokalemia. cold intolerance. ■ Reassess insulin dosages with team. and convey to physician or NP . Assess response to oral or IV administration of glucose. STABILIZING AND MONITORING ■ Repeat serum glucose test. ■ Confusion. A. infections. drug reaction (beta-adrenergic blockers and sulfonylureas are most common). opioids. Thyroid Storm CLINICAL PICTURE The patient may have: ■ Tachycardia. ■ Bradycardia. ■ Generalized facial swelling. Davis. ■ Assess patent IV access. inserting and hanging IVF . GI bleed. beta blockers. low calcium. abdominal distention. ■ Provide blankets. medications such as diuretics. sparse hair. ■ Elevated diastolic BP in early stages. ■ Assess respiratory pattern and ABGs. hypotension later. psychosis. trauma. cortisol. BE PREPARED TO ■ Assist with obtaining laboratory studies. A. cool. myxedema megacolon (late). ENDO IMMEDIATE INTERVENTIONS ■ Assess LOC. Will have high T4 and low TSH. high CPK and high creatinine. VS. ■ Provide blankets (not a warming blanket—can cause vasodilation and lower BP even further). ■ Decreased GI motility. widened pulse pressure. and ability to protect airway. tranquilizers. may have ↓ pH. coarse. ■ Transfer patient to ICU. surgery. low glucose. such as apathy. periorbital edema. with ↑ carbon dioxide (respiratory acidosis). administering medications as appropriate to the unit. stroke. ■ Dry. ↓ oxygen saturation. and others in a hypothyroid patient. or coma. ■ Assess laboratory values—may have low sodium. palpitations. POSSIBLE ETIOLOGIES ■ New infection in an otherwise well-controlled hypothyroid patient.Copyright © 2008 by F. ■ Call physician or NP. FOCUSED ASSESSMENT STABILIZING AND MONITORING ■ Continued assessment of cardiac and respiratory status. ■ Alopecia. ■ Assess for other signs and symptoms of hypothyroidism: ■ Altered mentation. ■ Administer IV thyroid hormone replacement. skin. 122 . atrial fibrillation. document phone call and response. ptosis. confusion. or electrolytes as ordered. ■ Low temperature. and/or tepid baths if needed. POSSIBLE ETIOLOGIES ■ Lung infections. thyroid surgery in patients with overactive thyroid gland. ■ Reduce fever with acetaminophen. propylthiouracil (PTU) or methimazole (MMI) to control T4 production. 123 ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Anxiety. Insert IV if no access. ENDO . ◆ Pretibial myxedema—itchy lesions on the legs and feet (not to be confused with myxedema as seen in hypothyroidism). Assess patent IV access. ■ Transfer patient to ICU. Warm.Copyright © 2008 by F. chest pain. increased sweating. Assess VS. and neurological status. hang IVF . Elevated free thyroxin level (T4). Call physician or NP with findings. excessive dose of thyroid replacement medications. Assess for signs and symptoms consistent with hyperthyroidism: ■ Edematous legs and feet. IMMEDIATE INTERVENTIONS FOCUSED ASSESSMENT STABILIZING AND MONITORING Continue frequent assessments. ■ Labile mood. Assess electrolyte levels. Continued assessment of cardiac. and propranolol to control signs and symptoms. ■ Intolerance to heat. obtain other laboratory values. ◆ Exophthalmia (bulging eyeballs). Check oxygen saturation by pulse oximetry. irritability. high fever (105 –106 F). LOC. ■ ■ ■ ■ BE PREPARED TO ■ Assess glucose level. cardiac rhythm. discontinuing hyperthyroid medications. cooling blanket. respiratory. Assess for signs and symptoms of heart failure. low TSH. Document phone call and response. Administer electrolytes as ordered. and ability to protect airway. ◆ Weakness. restlessness to unresponsiveness. A. possible psychosis. Davis. Administer medications as ordered. if recent ones are available. SOB. flushed skin. hydrocortisone. Prolactin Posterior: ADH. Oxytocin HYPOTHALAMUS Releasing hormones for anterior pituitary PINEAL GLAND Melatonin THYROID GLAND Thyroxine and T3 Calcitonin THYMUS GLAND Immune hormones PARATHYROID GLANDS PTH PANCREAS Insulin Glucagon ADRENAL (SUPRARENAL) GLANDS Cortex: Aldosterone Cortisol Sex hormones Medulla: Epinephrine Norepinephrine OVARIES Estrogen Progesterone Inhibin TESTES Testosterone Inhibin The endocrine system. TSH.Copyright © 2008 by F. LH. ACTH FSH. Davis. 124 . ENDO A & P Snapshot PITUITARY (HYPOPHYSIS) GLAND Anterior: GH. A. If the patient uses an assistive device.. sensation). A. 125 Focused Assessment of Musculoskeletal System ■ Assess the musculoskeletal system on all patients with an orthopedic problem or recent trauma. Sensation) ■ Palpate peripheral pulse and check capillary refill. ■ Ask about paresthesias (numbness and tingling. elbows. but initially compare with the contralateral arm. Motion. an assessment of circulatory compromise and/or nerve damage.g. ■ Do not push a joint past its range. ■ Gait ■ Assess patient’s ability to ambulate independently. Davis. hips. or foot. asses if he or she is using it safely. hand. ■ Fall risk. ■ Assess strength by having patient push or pull against resistance. ■ Note skin color of extremity. ■ Joint range of motion (ROM) ■ Ask patient to put shoulders. ■ Neurovascular status (CMS: Circulation. and patients with neurological (e. ■ Assessment of musculoskeletal status includes: ■ Gait. motion. even if limited. odd sensations). leg. wrists and fingers.Copyright © 2008 by F. joint ROM evaluation may be necessary only with initial assessment. ■ Pain. and ankles through full range of joint motion as indicated. ■ Joint mobility. compare with that of opposite extremity. lightly trace your finger over different surfaces of the at-risk area MSKEL/ INTEG . ■ As a nursing assessment. ■ Do not push the joint if the patient has pain. Neck and back can be included if appropriate. ■ If the patient is not able to move or participate. ■ Clinicians usually assess the peripheral nervous system simultaneously. ■ Have patient move hands and fingers. knees. ■ Neurovascular status (CMS: circulation. Focus on the extremity of interest. stroke) or neuromuscular disease. ■ Assess need for assistive devices. passively move the joints to assess ROM. If the patient is receiving physical therapy to increase that joint’s ROM. flex and extend feet. then the physical therapist will assess the extent to which the joint can move. Assessment includes evaluation of dressings and wound drainage systems. patients with arthritis or who have been on bedrest. casts. assess for bleeding or drainage on dressings. wound dressings. Assess the tightness of these dressings. ■ Casts and circular dressings can abrade skin and impair circulation. the tape causes a shear injury by pulling the skin. MSKEL/ INTEG to assess sensation. intactness of dressings. especially in the older person who has fragile skin. moist. Have the patient close his or her eyes while you do this. tape covering a postoperative dressing can cause skin maceration and blistering. abraded. ■ Ask about pain. but as the skin stretches with swelling. and drainage systems. as circulation to lower extremities is decreased. assess for intactness of sutures or staples. or wounds. ■ Bandages. 126 . or signs of infection. For example. ■ Bandages. swelling. ■ Pressure ulcers. ■ Assessment of skin integrity includes: ■ Skin condition. and other disruptions in skin integrity such as surgical incisions. pressure ulcers. (See Pain Assessment in Basics tab.) Focused Assessment of Skin Integrity ■ Assess skin integrity each shift for patients at risk for skin breakdown and patients with incisions. This sometimes occurs in the total hip replacement dressing. ■ Surgical or traumatic wounds. A. ■ Assess for skin tears. ■ Pressure points. Be extra vigilant if the patient is diabetic. ■ Skin condition ■ Note if skin is dry. which can become irritating and quite injurious. drainage.Copyright © 2008 by F. ■ Assess for skin problems related to bandaging. casts. ■ Surgical or traumatic wounds ■ If dressings are not to be removed. which are common in older patients. and any tubes or drains exiting from the periwound area. or fragile. wound dressings. Davis. ■ When changing the dressing. The tape is secured to the surface of the skin. and drainage systems ■ Assess for signs of skin breakdown or pressure points from casts. ■ Diminished capillary refill time ( 3 seconds). and preventive mattresses to alleviate pressure. arteries. ■ Assess healing. for example. Davis. MSKEL/ INTEG . swelling of the muscles in the fascial compartment causes increased pressure because the fascia cannot expand with the swelling. with a description of signs of healing (granulation tissue. do not massage reddened areas.” ■ Severe Pain not relieved by opioid analgesics and unusual for the injury. but is possible at other sites of injury such as the abdomen. This pain is the first symptom to appear. Compartment Syndrome ■ Muscle groups are contained within a tough. and tissue damage is probable. ■ Pallor—paleness of the involved extremity. ■ After injury or surgery. Once the other Ps are evident. ” decreased circumference). arterioles and. ■ Use position changes.Copyright © 2008 by F. and arteries. The correct term. ■ Pressure ulcers ■ Perform and document a thorough wound assessment and staging (see pressure ulcer later in this tab). The increased pressure closes off capillaries. causing ischemia that will progress to necrosis if not treated. inelastic tissue called fascia. 127 ■ Pressure points ■ Assess pressure points. This discussion is focused on the arm or leg. nerves. eventually. veins. CLINICAL PICTURE ■ The patient may have or complain of the “5 Ps. This envelope of tissue creates a compartment that contains muscles. ■ Compartment syndrome is more common in the extremities. particularly the anterior or posterior compartments of the lower leg. the process is well established. ■ Pulselessness—loss of pulses or markedly diminished pulses of the affected extremity. The pain worsens with stretching of the involved muscles. is “healing stage 3 ulcer. ■ Paralysis—loss of ability to move the extremity. Note that ulcers may progress to a later stage but do not “regress” as they heal. ■ Paresthesia—numbness and tingling. A. pillows. ■ Get the patient ready for an emergency fasciotomy in the OR: draw blood. ■ Stay with the patient. Blanch the skin. ■ Elevate the extremity to the level of the heart to prevent further swelling and increase venous return. ■ Although pain medication should not be delayed or withheld. etc. ■ Remain with patient until the physician or NP arrives. 128 . A. When pain is more severe than expected. Pain indicates ischemia. burns. tissue necrosis and permanent damage will occur. immediately consider compartment syndrome. and perform a focused assessment. Loss of pulses and/or the extreme pain that accompanies compartment syndrome constitutes a surgical emergency. BE PREPARED TO ■ Assist with pressure measurements of the affected compartment. fractures. Note skin color and if pallor is present. Assess nerves in the affected extremity. and check capillary refill time. POSSIBLE ETIOLOGIES ■ Severe muscle injury. Is there altered sensation or impaired mobility? STABILIZING AND MONITORING ■ Continue to monitor vascular status. The physician or NP must rapidly determine the treatment plan and if immediate surgery is necessary. MSKEL/ INTEG IMMEDIATE INTERVENTIONS ■ The extreme pain is the first warning sign. ■ Document phone call to physician or NP and physician or NP response. Use a Doppler if not palpable. start an IV. Davis. do not simply medicate and return later to see if the medication is working. ■ Do not put ice bags on the extremity. and notify physician or NP .Copyright © 2008 by F. FOCUSED ASSESSMENT ■ ■ ■ ■ Palpate pulses. Make sure the time of the patient’s last meal or fluids is documented and easy to find. but if pallor or pulselessness develops. knee. ■ Assess VS. if patient has fallen. perform a primary survey and stabilize ABCs. mental status changes. assess for patent IV access. and orientation. clammy skin. and observe for signs and symptoms of shock such as cool. ■ Insert a urinary catheter. MSKEL/ INTEG . ■ Assess vital signs (VS). allow patient to maintain position of comfort. ■ Do not assess ROM unless x-ray is negative. ■ Inability to bear weight on affected extremity. ■ Inspect and palpate for deformity. ■ Inability to move affected leg. to lift patient into bed. A. ■ Call 4–6 staff members to help transfer patient from stretcher to bed or. Davis. ONGOING CARE AND ASSESSMENT ■ Administer pain medication (determine that there is no associated head injury first). and ability to move toes. and decreased urine output (blood loss from hip fracture can be as much as 1500 mL). ■ Call physician or NP . level of consciousness (LOC). ■ Avoid PO medications because patient may need surgery. ■ Monitor patient’s response to pain management.Copyright © 2008 by F. ■ Inspect affected leg for shortening and rotation as compared with the opposite leg. ■ Shortened and externally rotated leg. ■ Assess VS. laceration. hematoma. FOCUSED ASSESSMENT ■ If patient has experienced trauma. and monitor urinary output. 129 Hip Fracture CLINICAL PICTURE The patient may have: ■ Groin. ■ Assess distal circulation. or hip pain. IMMEDIATE INTERVENTIONS ■ Do not move leg. sensation. Then perform a secondary survey to detect associated injuries. and asymmetry. blistered tissue with foul-smelling. ■ Circle the affected area on the dressing. . phone call to physician or NP and physician or . ■ Document your findings. IMMEDIATE INTERVENTIONS ■ Take the patient’s vital signs. CLINICAL PICTURE The patient may have or be: ■ Minor skin disruption. POSSIBLE ETIOLOGIES ■ Osteoporosis. ■ Cellulitis-like appearance of affected area. ■ Assess for changes in skin such as a grayish color beneath the skin. and ↓ hemoglobin are characteristic of dehydration. blackened areas (necrotic tissue). which is hot and painful to the touch. at least every half hour. and ↑ bilirubin level are common with NF . purple blisters. MSKEL/ INTEG BE PREPARED TO ■ Start an IV. ■ Assess area for rapid progression of swelling and erythema and crepitance. 130 . NP response. or major disruption (e. purplish. foul drainage. Very high mortality rate. ■ High fever with flu-like symptoms. FOCUSED ASSESSMENT ■ Assess and document VS frequently. ↓ sodium.. x-rays. no disruption at all. requiring immediate intervention. possible CT or MRI. ↑ BUN and hematocrit level. ■ Swollen. surgical incision). ■ Call physician or NP describe the affected area and patient’s condition. ■ Assist with set-up and application of traction. Davis. if present. trauma. ■ Obtain laboratory work. ↑ WBCs. which gets progressively worse. Necrotizing Fasciitis (NF) A very rapidly progressing infection by Streptococcus pyogenes of the deeper layers of skin and tissue. and circle the area so that rapid spreading can be ascertained. or apply a dressing. ■ Dehydrated and hypotensive. ■ Assess laboratory values.Copyright © 2008 by F.g. ↓ albumin. ■ Severe or worse than expected pain at site. watery discharge. A. aureus. S. A. Audible crack may be heard. BE PREPARED TO ■ ■ ■ ■ Assist with bedside débridement. ■ Abnormal or limited motion of extremity. edema over bone or joint. NP response. or S. ■ Facilitate assessment of laboratory values. MSKEL/ INTEG . or ambulating. ■ Document patient’s status. Obtain x-rays or CT. ■ Change dressings as ordered. infection with Clostridium. POSSIBLE ETIOLOGIES ■ Infection with Group A beta-hemolytic streptococcus alone or in combination with S aureus. IMMEDIATE INTERVENTIONS ■ Immobilize extremity in its position. or get the patient ready for the OR. Pseudomonas. ■ Unexplained ecchymosis. Transfer the patient to ICU. ■ Notify physician or NP . coli. Davis. and hang ordered IV fluids. ■ Administer antibiotics immediately. 131 STABILIZING AND MONITORING ■ Obtain wound cultures immediately so that antibiotics (penicillin and clindamycin) can be given. E. Do not attempt to realign bone. delay in administration of the correct antibiotics is associated with a higher mortality rate. ■ Back pain (with spinal compression fracture). ■ Administer pain medication. ■ Insitute contact isolation or precautions. pyogrenes.Copyright © 2008 by F. Pathological Fracture CLINICAL PICTURE The patient may have: ■ Sudden pain in leg/hip/back/shoulder/arm while moving in bed. S. ■ Insert an IV. Peptococcus. ■ Obvious deformity of extremity. phone call to physician or NP and physician or . marcescens. transferring to wheelchair or stretcher. Start a heparin drip (to decrease risk of vasculitis and thrombosis). ■ Assess extremity for swelling or hematoma. ■ Prepare patient for surgery. ■ Initiate rehabilitation consultation. ■ Assist with diagnostic procedures (x-ray or bone scan). BE PREPARED TO ■ ■ ■ ■ ■ Initiate pressure ulcer prevention strategies. Davis. ■ Assist with casting or immobilization with splint or traction. Initiate discharge planning and collaborate with home care nurse for follow-up care and prevention. unexplained abrasions. and cough and deep-breathing exercises. or reported falling. Paget’s disease.Copyright © 2008 by F. primary bone tumors. Obtain assistive devices for ambulation or self-care activities. ■ Assess mobility and sensation of arms and legs if spinal fracture suspected. ■ Assess sensation and mobility of fingers or toes distal to injury if extremity fracture is suspected. ■ Initiate care to prevent complications of restricted mobility. Monitor for signs of respiratory depression or excessive sedation. ■ Assess history of falls or fractures. POSSIBLE ETIOLOGIES ■ Osteoporosis. Patient Fall CLINICAL PICTURE The patient may have or be: ■ Found on floor. if applicable. metastatic bone lesions. Manage pain so that patient is comfortable but not sedated. 132 . MSKEL/ INTEG FOCUSED ASSESSMENT ■ Assess VS. such as foot and ankle exercises to decrease risk of deep venous thrombosis. A. STABILIZING AND MONITORING ■ Medicate for pain as indicated. early mobilization. ■ Monitor foot or hand of affected extremity for peripheral neurovascular dysfunction. Protect patient from additional injury. osteomalacia. medication use. which can suggest brain injury. especially changes in mental status. MSKEL/ INTEG . assist to bed or chair with help from another staff member. transient ischemic attack. get help. ■ Monitor patient closely for changes in condition. have patient lie still while you call for help. swelling. ■ Assess distal circulation. sensory. ■ If unconscious. Assess for orthostasis. Assess medication administration record for polypharmacy or medication that may have contributed to fall. Davis. phone call to physician or NP and physician or . Assess for acute underlying condition. ■ Document patient’s status. Assess ability to move all extremities. and previous falls. Assess alignment and symmetry of extremities. NP response. hypotension. Review records for preexisting conditions. ■ Notify physician or NP . and recent changes in functional status. deformity. A. immobilize cervical spine (with light traction.Copyright © 2008 by F. problems with gait. FOCUSED ASSESSMENT ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Assess LOC and orientation. or has a deformity of an extremity (obvious fracture. changes in mental status. Assess soft tissue and skin for abrasions. Assess VS and pain level. urinary tract infection. assess ABCs. Assess environment for potential cause of fall and safety hazards. ■ Assess history of falls. ■ If the patient is alert with no obvious injuries. or cardiac dysrhythmia. such as infection. Ask if patient felt dizzy or lightheaded before falling. internal rotation of hip or knee). ■ If conscious. hold head and neck in neutral alignment with body). complains of severe pain. ■ Assess for injuries. apply ice to contusions or areas of swelling. 133 IMMEDIATE INTERVENTIONS ■ Do not move patient if he or she is unconscious. and motor function of injured extremities. STABILIZING AND MONITORING ■ Treat minor injuries—clean and dress abrasions. MSKEL/ INTEG BE PREPARED TO ■ ■ ■ ■ ■ ■ Assist with x-rays or other diagnostic test. A. Eliminate medications if possible. debilitation. poor lighting Start physical therapy for strengthening exercises. Make sure path from bed to bathroom is well lit and that objects the patient can use for support (cane. Tell patient to consciously look around and evaluate the walking surface. improper use of restraints. callbell malfunction or not left within easy reach. Specific medications: benzodiazepines. dysrhythmias. spill on the floor. reduce dosages if possible. POSSIBLE ETIOLOGIES ■ Sedation. altered proprioception. change in proprioception Uneven surfaces. drug reaction. Modify environment to eliminate hazards. unfamiliar surroundings. antidepressants Deconditioning Postural hypotension. Limit number of PRN medications. Order laboratory tests.Copyright © 2008 by F. side rails left down. Arrange for one-on-one care if patient is confused. balance training. Complete an incident report. altered LOC. hypnotics. Tell patient to get out of bed or up from a chair slowly. antipsychotics. walker) are within reach 134 . Assess drug interactions for additive CNS effects Avoid medications known to cause adverse events in older patients. avoid turning on heels quickly. Davis. Make sure to be aware of where one surface changes to another and the potential for thresholds in doorways. Administer oxygen. Fall Risk Factor and Nursing Interventions Risk Factor Polypharmacy Nursing Intervention Review medications with physician or NP . sedatives. depth. ■ Obtain special wound care products. and amount]. blistered. ■ Do NOT massage the area. ■ Assess patient for other areas of pressure and skin breakdown. granulation tissue. ■ Assess for pressure ulcer risk. color of skin surrounding wound. ■ Assess patient’s pain level. Davis. type and amount of necrotic tissue [color. See Wound Assessment Guide in this tab. infection). immobility. and physician or NP response. ■ Obtain specialized support surface for bed or wheelchair. pack the wound. A. consult dietitian. induration. ■ Assess nutritional status.) ■ Turn and reposition patient at least every 2 hours. open skin over pressure point such as sacrum. VS. POSSIBLE ETIOLOGIES ■ Pressure or shearing forces. consistency adherence. phone call to physician or NP. dress. edges. ■ Assess wound (size. coccyx. trochanter. ■ Assess wound using Wound Assessment Guidelines and/or Pressure Ulcer Stage chart in this tab. or heel. IMMEDIATE INTERVENTIONS ■ Relieve the pressure by turning patient or supporting extremity with pillows. ■ Keep wound free of contamination from urine and stool. massage can cause tissue damage under the skin. 135 Pressure Ulcer CLINICAL PICTURE The patient may have: ■ Reddened. ■ History of immobility. scapula. BE PREPARED TO ■ Clean. undermining. (See Wound Care Products for Pressure Ulcers in this tab. these items impede circulation. ■ Document patient status. STABILIZING AND MONITORING ■ Perform dressing changes as ordered. incontinence. ■ Notify physician or NP. decreased sensorium. peripheral tissue edema. exudate type and amount.Copyright © 2008 by F. MSKEL/ INTEG . characteristics of wound. FOCUSED ASSESSMENT ■ Assess temperature. ■ Do NOT use doughnut-shaped or ring-shaped cushions or sock-like heel booties. The total possible score is 23. document findings. There are other scales as well. nondrying cleansing solution. ■ Teach the patient to shift his or her weight every 15 minutes while in a chair. ■ Prevent contractures. ■ Effectively manage urinary and fecal incontinence. A. using a mild. Clean skin promptly. 136 . ■ Provide adequate nutrition and hydration. ■ Position patient to alleviate pressure and shearing forces. MSKEL/ INTEG Pressure Ulcer Assessment and Intervention Guides Braden Scale Risk Assessment The Braden Scale assesses six domains or risk factors: ■ Activity—Amount of physical activity. Pressure Ulcer Prevention Strategies ■ Inspect skin daily. Avoid friction during cleansing. ■ Moisture—Extent to which skin is exposed to moisture. nonirritating. ■ Use positioning devices and foam padding. find out which pressure risk assessment tool is used in your facility.Copyright © 2008 by F. ■ Friction and Shear—Extent to which skin is subject to friction and shear forces. The lower the score. Davis. ■ Sensory perception—Ability to respond meaningfully to pressure-related discomfort. ■ Avoid placing the patient on his or her trochanters or directly on a wound. depending on amount of impairment. the greater the risk. ■ Maintain the lowest head elevation possible to prevent sacral pressure. ■ Use lifting devices such as draw sheets or a trapeze. ■ Use topical moisture barriers and moisture absorbing pad for incontinent patients. The patient is assigned a score of 1–4 (1–3 for Friction and Shear). Do not use doughnut-shaped devices. ■ Mobility—Ability to change or control body position. ■ Nutrition—Usual food intake pattern. ■ Do not massage reddened areas over bony prominences. ■ Reposition patient every 2 hours when in bed and every hour when in a chair. Assess by gently pinching the tissue distal to wound edge. Using a felt-tipped pen. hard black. ■ Assess for granulation tissue: Granulation tissue is present in the healing wound. Davis. ■ Describe exudate type: ■ Bloody. Poorly vascularized tissue supply appears pale pink. ■ Firmly adherent.Copyright © 2008 by F. ■ Purulent.e. It is the regrowth of small blood vessels and connective tissue. ■ Assess and describe skin color surrounding wound: Assess tissues within 4 cm of wound edge. For light-skinned persons. ■ Describe exudate amount: ■ None—wound tissues dry. Notify physician immediately if wound is crepitant: may indicate gas gangrene. fibrotic).. ■ Stage the pressure ulcer: (see the following table). ■ Loosely adherent yellow slough. drainage involves 75% of dressing. ■ Large—wound tissues bathed in fluid. or dusky red. ■ Serosanguineous. ■ Assess for undermining: Insert a cotton-tipped applicator under the wound edge. dull. ■ Assess wound edge for tissue edema: Note if edema is pitting or nonpitting and if wound is crepitant (crackly noises when tissue is palpated). Healthy granulation tissue is bright. MSKEL/ INTEG . For dark-skinned persons. ■ Foul purulent. attached. and granular. drainage involved 25%–75% of dressing. ■ Nonadherent yellow slough. not attached. and depth using a centimeter ruler. ■ Describe necrotic tissue type: ■ White/gray. soft black eschar. ■ Small—wound tissues wet. drainage involved 25% of dressing. ■ Assess amount of induration: Induration is abnormal firmness of tissues with margins. shiny. ■ Assess characteristics of wound edges (i. note if skin is reddened or darker or purplish around wound edges. ■ Serous. note if skin is reddened. Continue around the wound. ■ Moderate—wound tissues saturated. 137 Wound Assessment and Documentation Guide ■ Measure length. A. gently advance it until resistence is met. ■ Scant—wound tissues moist. ■ Adherent. width. no measurable exudates. beefy red. mark the skin where applicator is felt. if indurated. you will be unable to pinch a fold of skin. Prevent continued injury from pressure or shearing forces. and warmth over a bony prominence. Nonblanchable erythema of intact skin. dermis. Davis. Extensive destruction and necrosis or damage to muscle. or supporting structures. Undermining and sinus tracts present. edema. erythema. Full-thickness skin loss involving damage or necrosis of subcutaneous tissue. Fullthickness skin loss. Same as stage II treatment plus débride eschar and necrotic tissue. The ulcer looks like a deep crater with or without undermining of adjacent tissue. and remove the skin “roof. Same as stages II and III plus remove all dead tissue. 138 . Partial-thickness skin loss involving epidermis. Ulcer is superficial and looks like an abrasion. bone. (Heel ulcers with dry eschar and no edema. Interventions No dressing. IV Extensive tissue damage. For patients with darker skin: discoloration. or both. water jets. Monitor frequently. Keep surrounding intact skin dry. A. May extend down to fascia. Do not use topical antiseptics. Eschar and necrosis. then resume moist dressings. Fill wound dead space with loosely packed dressing material to absorb excess drainage and maintain a moist environment. II Use a dressing that will keep ulcer bed continuously moist. or shallow crater. or drainage may not need to be débrided. explore undermined areas. Clean wound base.) Débridement may be done surgically with enzymatic agents or mechanically with wet-to-dry dressings. blister. III Copyright © 2008 by F. or whirlpool. Use clean.MSKEL/ INTEG Pressure Ulcer Stages and Treatment Stage I Ulcer Characteristics Intact skin. dry dressings for ” 8–24 hours after sharp débridement to control bleeding. redness. ■ Change once daily. Easy to wounds. ■ Permeable to oxygen and water vapor. A. and skin tears. ■ Occlusive and adhesive wafer dressings. ■ Provides moist wound environment. III. Indications Nursing Considerations Hydrogels ■ Hypergel ■ CarraSorb ■ Nu-gel ■ Curafil Copyright © 2008 by F. Helps clean and débride by supplying liquid to dry. sing over alginates or gels. ■ Waterproof. ■ Transparency allows visual inspection of wound. do not confuse with infectious process. ■ Facilitate rehydration and autolytic débridement of dry. Davis. ■ Changed up to three times/ week. and IV soothing effect. apply and remove. or sheet dressings. sloughy. ■ Dressing change up to three times per week. sloughy wounds. ■ Water. blisters. ■ Reduce pain and promote ■ Stage II. epithelizing wounds ■ Breakdown of product may with low to moderate produce residue and foul amounts of exudate. or hydrocolloid powders and pastes. ■ Work best on ■ Can be a secondary dressuperficial wounds. help reduce ■ Granulating and pain at wound site. odor. ■ Do not absorb large amounts of exudate due to large water content. ■ Conformable for easy application. or necrotic wounds.or glycerin-based gels. Do not absorb exudates. ■ Provide moist healing environment and prevent bacterial contamination. change when fluid collects underneath. (Continued on the following page) 139 MSKEL/ INTEG Wound Care Products for Pressure Ulcers . ■ Stage II and III wounds. impregnated gauzes. Hydrocolloid dressings ■ Tegasorb ■ Comfeel ■ DuoDERM ■ Restore ■ Stage I and II wounds. ■ Require secondary dressing.Product Transparent Films ■ Tegaderm ■ CarraFilm ■ OpSite ■ BIOCLUSIVE Characteristics ■ Semipermeable membrane. hydrophilic ■ Heavily exudating polyurethane foam. ■ Require prescription. Enzymatic débriding agents ■ Panafil ■ Santyl ■ Accuzyme ■ Soft nonwoven fibers ■ Stage III and IV derived from seaweed. ■ Usually changed up to three times/week. moderate to heavy or ribbons. ■ Deep cavity wounds and weeping ulcers such as venous stasis ulcers. ■ Require secondary dressing. ■ Can be left undisturbed for 3–4 days. or dry wound beds. A. ■ Highly absorbent foam may allow less frequent dressing changes. Copyright © 2008 by F.MSKEL/ INTEG Wound Care Products for Pressure Ulcers (continued) Product Alginates ■ CURASORB ■ AlgiDERM ■ Sorbsan ■ Algosteril Foam dressings ■ Flexzan ■ CURAFOAM ■ Mepilex Characteristics Indications Nursing Considerations ■ Highly absorbent. but not ■ Can absorb up to 20 wounds with eschar times their weight. 140 . especially ■ Some have adhesive during inflammatory borders. ■ Usually changed once daily. ■ Agents selective in ■ Stage III and IV removing necrotic wounds. ■ Surgical débridement may be avoided in some cases with use of enzymatic débriding agents. Comfortable and conformable. Davis. ■ Decrease maceration of surrounding tissue. (may remove debris in areas that cannot be visualized). ropes. wounds. phase following débridement and desloughing. exudate. ■ Highly absorbent ■ Stage III and IV dressings made from wounds. wounds with ■ Available in pads. tissues from wound ■ Tunneling wounds bed. therefore good for packing exudating wounds. IMMEDIATE INTERVENTIONS FOCUSED ASSESSMENT ■ Assess temperature. VS. place the patient in semi-Fowler’s position. dehiscence—partial or complete separation of deep wound layers. induration. ■ Abdominal wound: If there is evidence of dehiscence or evisceration. infection. Stay with patient and offer support and reassurance. painful wound. Do not manipulate viscera or attempt to replace. Notify physician or NP. and amount). tender.Copyright © 2008 by F. Saturate a sterile dressing with normal saline. ■ Separation of wound edges with serous-sanguineous or purulent drainage from wound. ■ Examine wound for evisceration—total separation of deep wound layers (fascia and muscle) with protrusion of internal organs and viscera. Davis. exudate type and amount. granulation tissue. depth. Place a large sterile dressing over top. ■ For superficial wound separation. 141 Surgical Site Infection/Complication CLINICAL PICTURE The patient may have: ■ Warm. MSKEL/ INTEG . ■ Purulent discharge from wound drain. ■ Assess for patent IV access. phone call to physician or NP. ■ If evidence of infection. ■ Exposure or protrusion of abdominal contents through open wound. and physician or NP response. undermining. peripheral tissue edema. type and amount of necrotic tissue (color. swollen. edges. Keep patient NPO and NOTIFY PHYSICIAN OR NP STAT. ■ Assess patient’s pain level. (See Wound Assessment Guide in this tab). and medicate per order. ■ Assess pain level. or superficial wound separation—separation of skin and subcutaneous tissue. ■ Low-grade fever. color of skin surrounding wound. A. Place a large sterile dressing over top. and cover the open wound. reddened. then saturate a sterile dressing with normal saline. ■ Feeling of wound tearing or opening. ■ For dehiscence of wounds elsewhere on the body. with knees bent to decrease tension on abdominal wall. consistency adherence. ■ Assess wound: determine or describe size. and cover the open wound. obtain wound culture. position patient to alleviate tension on suture line. cover wound with a sterile normal saline wet-to-dry dressing. ■ Document patient’s status. Notify physician or NP immediately. Copyright © 2008 by F. A. Davis. MSKEL/ INTEG STABILIZING AND MONITORING ■ ■ ■ ■ Perform dressing changes as ordered. Administer antibiotics. Assess nutritional status; consult dietitian. Document assessment findings. BE PREPARED TO ■ Prepare the patient for surgery. ■ Clean, dress, pack the wound. ■ Start an IV. POSSIBLE ETIOLOGIES ■ Infection, excessive tension on suture line (vomiting or coughing), dehydration, long surgery time, hematoma, abdominal distention, obesity, poor nutritional status, diabetes, insufficient suturing, stretching or pulling at suture site (trauma), higher risk in geriatric patients. Wound Vacuums Vacuum-assisted closure (VAC) units are negative pressure devices that help promote wound healing by removing exudate and other fluids with continuous and/or intermittent subatmospheric pressure; in other words, by suction. The suction, in conjunction with the system, also helps pull the wound edges together, stimulates granulation tissue, and improves blood flow to the wound bed. Setting up the wound VAC: ■ Wash your hands, don gloves, and clean the wound using aseptic technique. ■ Apply skin preparation to peri-wound area to help secure the dressing. ■ Cut foam to fit wound, and place in the wound; do not push it in, just place it on the wound. ■ Apply Tegaderm-like plastic sheet over foam and onto healthy skin; put it on in patches, if necessary. ■ Cut a small hole in the plastic sheet over the foam. This is essential for suction to reach wound bed. ■ Apply suction disc over the hole in the plastic dressing. ■ Connect suction tubing, remove kinks, and set suction as ordered. ■ Remove gloves, discard old dressing properly, wash hands. 142 Copyright © 2008 by F. A. Davis. 143 Dressing before suction is turned on. Dressing appearance after suction is applied. MSKEL/ INTEG Copyright © 2008 by F. A. Davis. MSKEL/ INTEG A & P Snapshot Zygomatic arch Maxilla Mandible Sternum Humerus Skull (cranium) Cervical vertebrae Thoracic vertebrae Clavicle Scapula Ribs Lumbar vertebrae Radius Ulna Carpals Metacarpals Phalanges Pubis Ischium Femur Ilium Sacrum Coccyx Patella Tibia Fibula Tarsals Metatarsals Phalanges Skeletal system. 144 Copyright © 2008 by F. A. Davis. 145 Receptor for touch (encapsulated) Pore Stratum germinativum Stratum corneum Epidermis Papillary layer with capillaries Dermis Pilomotor muscle Sebaceous gland Hair follicle Receptor for pressure (encapsulated) Nerve Arteriole Venule Fascia of muscle Adipose tissue Subcutaneous Eccrine tissue sweat gland Free nerve ending Skin structure. MSKEL/ INTEG body fluids. mucous membrane.Copyright © 2008 by F. ■ After touching blood. droplet. Davis. Wash hands immediately. Gloves: ■ Wear clean. or airborne precautions. 146 . ■ Change gloves between procedures on the same patient after contact with contaminated material. ■ Remove gloves promptly after use and before touching noncontaminated items and environmental surfaces. ■ Before touching mucous membranes and nonintact skin. ■ Between patient contacts. secretions. and contaminated items. ■ Between tasks and procedures on the same patient to prevent cross contamination of different body sites. depending on the mode of transmission. INFECT Standard Precautions Use standard precautions for the care of all patients. nonsterile gloves: ■ When touching blood. Patient-Care Equipment: ■ Prevent skin. and contaminated items. nonsterile gown when patient-care activities are likely to generate splashes or sprays of blood. A. body fluids. ■ Do not use reusable equipment for another patient until cleaned appropriately. and clothing exposure to contaminated linen. body fluids. Add contact. Face Shield: ■ Wear mask and eye protection or face shield when patient-care activities are likely to generate splashes or sprays of blood. or excretions. ■ Immediately after gloves are removed. Eye Protection. ■ To avoid transfer of microorganisms to other patients or environments. Handwashing: ■ Wash hands. Linen: ■ Prevent skin. body fluids. ■ Discard single-use items properly. or excretions. excretions. mucous membrane. secretions. secretions. and clothing exposure to contaminated equipment. secretions. excretions. Mask. Gown: ■ Wear a clean. ■ Wear a mask when working within 3 ft of patient. do not bend. Airborne Precautions For patients who are or may be infected with microorganisms transmitted by airborne droplet nuclei. and other sharp items in appropriate puncture-resistant containers. ■ Door may be open. A. INFECT . Droplet Precautions For patients who are or may be infected with microorganisms transmitted by large-particle droplets that occur with coughing. ■ Place mask on patient when leaving the room. or manipulate used needles by hand. ■ Do not remove used needles from disposable syringes by hand. ■ Monitored high-efficiency filtration of room air. sneezing. ■ Private room or in room with patient who has active infection with same microorganism but no other infection. talking. ■ 6 to 12 air changes per hour. ■ Keep patient in room. ■ Door closed. ■ Do not direct needle point toward self. 147 Preventing Needle and Sharps Injuries Never recap used needles or manipulate them using both hands. ■ Place used disposable syringes and needles. ■ If private room not possible. Davis. ■ Use one-handed “scoop” technique. maintain at least 3 ft of space between infected patient and other patients and visitors. break. scalpel blades.Copyright © 2008 by F. if possible. ■ Private room with: ■ Monitored negative air pressure in relation to the surrounding area. Clostridium-Associated Diarrhea (CDAD. ■ Remove gloves before leaving patient room. and discontinuation of the antibiotic is part of the treatment. and immediately wash hands with antimicrobial or waterless antiseptic agent. has diarrhea. ■ Document findings. reassess as needed. Psuedomembranous Colitis) CLINICAL PICTURE The patient may have: ■ Frequent. nausea. ■ Remove the gown before leaving room. 148 . if patient is still on antibiotics. IMMEDIATE INTERVENTIONS ■ Assess hydration status. possibly with blood. electrolyte balance. ■ Abdominal cramping. ■ Move patient to a private room. INFECT Contact Precautions For patients who are or may be infected or colonized with microorganisms transmitted by direct contact with the patient or indirect contact with environmental surfaces or patient-care items. and recent I&O records (to assess hydration). ■ Fever. or wound drainage not contained by a dressing. ■ Assess for recent antibiotic use. ■ Wear clean. A. an ileostomy. Davis. nonsterile gown when entering room if clothing will have contact with patient. and tenderness. ■ Call physician or NP about the character and frequency of the stool. and physician or NP response. ■ Private room or in room with patient who has active infection with same microorganism but with no other infection. nonsterile gloves when entering the room. phone call. withhold until you speak with the physician or NP Clostridium difficile . pain.Copyright © 2008 by F. watery diarrhea. a colostomy. infection is usually caused by antibiotic-induced derangement of normal intestinal flora. ■ Wear clean. ■ Do not touch potentially contaminated surfaces once gloves are removed and hands washed. or items in the room or if patient is incontinent. ■ Obtain stool sample for laboratory testing. ■ Loss of appetite. ■ Note trends in recent VS assessment. and initiate contact precautions. surfaces. BE PREPARED TO ■ Transfer patient to high-acuity unit if infection is severe with complications. ■ Administer oral metronidazole or Vancomycin as ordered. ■ Provide incontinence care. high-grade 101 F). and hang IV fluids. ■ Insert an IV. IMMEDIATE INTERVENTIONS ■ Assess VS. and monitor perianal skin for breakdown. dry skin.Copyright © 2008 by F. which can occur with severe infection. difficile. toxic megacolon. weakness. ■ Assess stool for blood or pus. and palpate abdomen for tenderness. ■ Monitor hydration status and food intake ■ Monitor electrolytes. POSSIBLE ETIOLOGIES ■ C. inflammation of colonic tissues. and wash their hands with soap and water each time before they leave the room. WBC count. dehydration. ■ Collect stools for testing as ordered—usually three stools from three separate bowel movements on consecutive days. ■ Auscultate bowel sounds. 101 F. STABILIZING AND MONITORING ■ Make sure all visitors wear gloves when touching the patient. ■ Offer cool compress for forehead. ■ Assess for complications of severe infection including anasarca. Davis. Fever CLINICAL PICTURE The patient may have: ■ Temperature elevation (low-grade fever: T ■ Fatigue. A. 149 FOCUSED ASSESSMENT ■ Assess for IV access as rehydration may be necessary. ■ Flushed. if needed. which produces two toxins that cause tissue damage. INFECT . albumin. and colonic perforation. Copyright © 2008 by F. A. Davis. INFECT ■ Auscultate lungs for diminshed breath sounds, crackles, rhonchi. ■ Assess for stiff neck, headache, photophobia, irritability, confusion. ■ Assess IV sites, surgical incisions for redness, warmth, tenderness, swelling. ■ Assess legs for swelling, warmth, pain (do not massage calves). ■ Assess for urinary symptoms. ■ Assess for GI symptoms. ■ Evaluate medications for possible drug fever; note any rashes. ■ Assess mucous membranes, I&O. ■ Ask about prosthetic implants (heart valve, artificial joint). ■ Check recent laboratory test for ↑WBC count. ■ Notify physician or NP . ■ Document patient’s status, phone call to physician or NP and physician or , NP response. FOCUSED ASSESSMENT STABILIZING AND MONITORING ■ Encourage patient to cough, breathe deeply, and use incentive spirometer. ■ Encourage fluids (unless contraindicated by renal or cardiac disease). ■ Check medication administration record for order for PRN antipyretic. Administer if patient feels uncomfortable. ■ Obtain cooling blanket, or give tepid bath, if ordered. BE PREPARED TO ■ Obtain sputum, blood, or urine sample for Gram stain, culture, and sensitivity. ■ Obtain or change IV access. ■ Order a chest x-ray. ■ Order or obtain laboratory tests. POSSIBLE ETIOLOGIES ■ Numerous potential causes include bacterial, viral, or fungal infection; deep venous thrombosis; medications; tumor; neutropenia. Fever With SIRS/Sepsis Terms: ■ Infection: Inflammatory response to microorganisms, or the invasion of normally sterile host tissue by those organisms. 150 Copyright © 2008 by F. A. Davis. 151 ■ Systemic Inflammatory Response Syndrome (SIRS): Systemic inflammatory response to severe clinical insults, including infection, pancreatitis, trauma, and burns. This response is manifested by two or more of the following conditions: ■ Core temperature 38 C (100.4 F) or 36 C (96.8 F). ■ HR 90 beats/min. ■ RR 20 breaths/min or PaCO2 32 mm Hg. ■ WBC count 12,000/mm3, 4000/mm3, or the presence of 10% immature neutrophils. ■ Sepsis: A systemic inflammatory response to infection that initiates a cascade of biochemical events resulting in hypotension, coagulopathy, suppression of fibrinolysis, and multisystem organ dysfunction. Sepsis is diagnosed when there is a documented infection with at least two of the four systemic inflammatory response criteria. ■ Severe sepsis: Sepsis with dysfunction of one or more organ systems, hypoperfusion, or hypotension. ■ Septic shock: Sepsis with hypotension (systolic BP 90 mm Hg or a reduction of 40 mm Hg from baseline) despite adequate fluid resuscitation and with perfusion abnormalities that include lactic acidosis, oliguria, or change in mental status. ■ Multiple organ dysfunction syndrome: Altered organ function in an acutely ill patient such that homeostasis cannot be maintained without intervention. CLINICAL PICTURE The patient may have: ■ Temperature 38 C (100.4 F) or 36 C (96.8 F). ■ Chills, sweating. ■ Tachypnea, respiratory alkalosis. ■ Tachycardia. ■ Elevated or depressed WBC count. ■ Change in mental status. ■ Abdominal or flank pain. ■ Rash; warm, dry, flushed skin. Progressive Indications: ■ Restlessness, confusion, altered LOC. ■ Hypotension, widening pulse pressure. ■ Oliguria. ■ Rapid thready pulse, delayed capillary refill. ■ Decreased urinary output. INFECT Copyright © 2008 by F. A. Davis. INFECT ■ Hypoactive bowel sounds. ■ Rapid shallow breathing. ■ Cold, clammy, mottled skin. ■ ■ ■ ■ ■ ■ ■ ■ ■ IMMEDIATE INTERVENTIONS Assess HR, BP RR, and temperature (rectally). , Administer supplemental oxygen. Assess for patent IV access. Obtain SaO2 via pulse oximetry. Review recent WBC count if available. Notify physician or NP . Obtain large-bore IV access if needed. Obtain IV fluids (NS) for administration. Document patient’s status, phone call to physician or NP and physician , or NP response. ■ ■ ■ ■ ■ FOCUSED ASSESSMENT Assess airway status, LOC, and VS (HR, RR, BP) frequently. Assess SaO2 via pulse oximetry. Assess VS and capillary refill. Assess onset, recent history of fever. Assess for possible source of infection. STABILIZING AND MONITORING ■ Obtain and administer prescribed antibiotic STAT. ■ Administer isotonic IV fluids to correct hypovolemia (due to vasodilation and capillary leak) and restore blood pressure and tissue perfusion. ■ Monitor for signs of volume overload: dyspnea, pulmonary crackles, jugular vein distention. ■ Monitor mental status, HR, BP capillary refill, and urinary output. , ■ Monitor coagulation studies, BUN, and creatinine. BE PREPARED TO ■ ■ ■ ■ ■ ■ ■ Obtain urine, blood, wound, and sputum samples for culture. Assist with line placement. Assist with central line placement. Order or obtain laboratory tests. Facilitate diagnostic testing such as x-rays or CT scan. Insert indwelling urinary catheter. Administer vasoactive drugs to treat hypotension. 152 Copyright © 2008 by F. A. Davis. 153 ■ Assist with intubation and airway management. ■ Call a code. ■ Transfer patient to ICU or monitored unit. POSSIBLE ETIOLOGIES ■ Head and neck infections; chest and pulmonary infections; GI infections; pelvic/genitourinary infections; bone, soft-tissue, and skin infections. Hepatitis Inflammation of liver cells that results in necrosis and obstruction of bile. There are many forms of hepatitis, including viral, bacterial, alcoholic, and drug-induced hepatitis. The various forms of viral hepatitis are named with a letter of the alphabet, using A through G. CLINICAL PICTURE The patient may have: ■ Fever, loss of appetite, nausea, and vomiting ■ Fatigue, headache. ■ Tea-colored urine, clay-colored stools, jaundice. ■ Right upper quadrant abdominal pain. IMMEDIATE INTERVENTIONS/FOCUSED ASSESSMENT ■ ■ ■ ■ ■ Assess laboratory values for positive hepatitis test. Institute contact precautions if needed (see following table). Assess pain, activity tolerance, appetite. Assess for jaundice. Observe urine for characteristic tea color and stools for the absence of bile, which renders them clay-colored. ■ Document findings. STABILIZING AND MONITORING ■ Continue ongoing assessment. ■ Implement energy-conserving routines for self-care. ■ Teach patient about self-care during recovery and how to prevent transmission to others. POSSIBLE ETIOLOGIES ■ Viral infection. INFECT Not spread by casual contact or through food or water. blood splashes to open skin or mucous membranes. Davis. People may get hepatitis C by sharing needles to inject drugs or through exposure to blood in the workplace. tears. spread under poor sanitary conditions and poor personal hygiene. sweat. thus disease can be spread by a bite. or eating fruits and vegetables contaminated during handling. Feces. Standard precautions. Spread by sharing needles and through unprotected sexual contact. or indirectly when dried blood on a surface or instrument gets transferred to open skin or mucous membranes. sputum. Standard precautions. A. See Hepatitis A. drinking contaminated water. Not transmitted by casual contact. See Hepatitis B. Standard precautions. Found in feces. Spread by blood-to-blood contact or exposure of contaminated blood to open skin or mucous membranes. Spread by blood-to blood contact via punctures of the skin with bloodcontaminated needles or scalpels. Saliva can contain very low concentrations of hepatitis B virus.Copyright © 2008 by F. HBV Parenteral: bloodto-blood contact HCV Parenteral: blood-to-blood contact HDV HEV Parenteral: bloodto-blood contact Fecal-oral: possible person-toperson contact 154 . and emesis do not spread hepatitis B unless visibly contaminated with blood. Can be sexually transmitted. urine. eating raw shellfish taken from contaminated water. Can also be transmitted through oral and anal sexual activity. Standard precautions plus contact precautions. nasal secretions. exposure to contaminated food or water Precautions Standard precautions plus contact precautions. INFECT Precautions for Major Types of Viral Hepatitis Type HAV Route of Transmission Fecal-oral route. STABILIZING AND MONITORING ■ Record I&O. ■ Monitor patient’s vital signs and neurological status and record. ■ Neck stiffness. Davis. leukemia. protein. headache. viral. which is caused by bacteria. ■ Send patient for CT scan or MRI. nausea and vomiting. ■ Institute droplet precautions for meningococcal meningitis. and observe patient for signs of dehydration. Bacterial meningitis is much more severe than viral meningitis and will be fatal if not treated promptly. LOC. SaO2. A. ■ Assess for Brudzinski’s sign (hip and knee flexion in response to forced flexion of the neck). maintain until 48 hours after antibiotics are started. or TB infection. 155 Meningitis Inflammation of the meninges. ■ Confusion. ■ Initiate seizure precautions. rash. ■ Administer IV fluids and medications. blood cultures. ■ Document findings. ■ Photophobia. as ordered by the physician. ■ Assess for Kernig’s sign (inability to completely extend the legs). neonatal. or aseptic. CLINICAL PICTURE The patient may have: ■ Fever. which is viral or secondary to a lymphoma. lethargy. sore throat. ■ Start antibiotics immediately. ■ Obtain blood for CBC. nerve palsy). IMMEDIATE INTERVENTIONS FOCUSED ASSESSMENT ■ Assess cranial nerves for possible complication (hearing loss. weakness. delirium. Use Glasgow Coma Scale in this tab for accuracy and consistency.Copyright © 2008 by F. which cover the brain and spinal cord. or a brain abscess. POSSIBLE ETIOLOGIES ■ Bacterial. May be septic meningitis. amoebic. ■ Assess VS. seizure. INFECT . See cranial nerve assessment in Neurological tab. visual impairment. ■ Discuss diagnosis with physician or NP for information about causative organism. BE PREPARED TO ■ Assist with lumbar puncture. fungal. blood cultures. ■ Obtain chest x-ray STAT. LOC and orientation. Provide diet high in protein. Assess for complications such as empyema. for patent IV line. ■ Assist with thoracentesis. muscle aches. STABILIZING AND MONITORING ■ ■ ■ ■ ■ Administer antibiotics as soon as they are available. tachycardia. note if patient is short of breath or struggling to breathe. hemoptysis. ■ Document phone call and physician or NP response. Keep patient well hydrated. fatigue. INFECT Pneumonia Acute infection of the lungs. BE PREPARED TO ■ Obtain sputum culture and sensitivity. or other laboratory work. Alveoli become inflamed and fluid-filled. ■ Loss of appetite. and determine if patient has SOB. ■ Notify physician or NP of assessment findings. oxygen saturation by pulse oximetry. respiratory distress. ■ Listen to lung sounds. ■ Assess HR and RR. tachypnea. Maintain O2. ABGs. and monitor for complications (pneumothorax). FOCUSED ASSESSMENT ■ ■ ■ ■ ■ ■ ■ Assess Assess Assess Assess Assess Assess Assess sputum quantity and character. ■ Apply O2 if already ordered. 156 . A. for cyanosis. cyanosis. The patient may have: ■ Cough. assist with bronchoscopy. chills. chest pain. for pleuritic chest pain. or superinfection (worsening signs and symptoms despite treatment). and check oxygen saturation frequently. assess use of accessory muscles. fever. ■ Joint pain.Copyright © 2008 by F. ■ Shortness of breath. ■ Suction the patient. Davis. appetite. IMMEDIATE INTERVENTIONS ■ Assess VS. chills. chest pain. ■ Document phone call and physician or NP response. ■ Painful skin abscesses. MRSA can be fatal. IMMEDIATE INTERVENTIONS ■ Using gloves. dressing. FOCUSED ASSESSMENT ■ Assess for signs and symptoms of internal infection: auscultate lungs for adventitious sounds. A. cardiac valves. which means the bacterium lives on the skin and nares but does not cause infection. ■ Ask patient about general aches and pains. fungal. cover the wound(s). ■ Assess VS. headache. aureus is resistant to the broad-spectrum antibiotics commonly used to treat it. upper respiratory tract disorder. assess urine for cloudiness. joints. A patient or health-care worker can be colonized with MRSA. abscesses. and listen for murmurs. INFECT . muscle aches. feeling unwell (malaise). who may develop the hard-to-treat infection. mechanical ventilation. or bumps with a clean. which are often found in hospitals. 157 POSSIBLE ETIOLOGIES ■ Viral. Davis. aureus bacteria. TB. take apical pulse. lungs. SOB. ■ Notify physician or NP of possible staph infection. swelling. dry. incisions. The danger with colonization is that the patient or health-care worker can transmit the bacteria to others. blood. ■ Erythema. prolonged bedrest. wash hands thoroughly. check BUN and creatinine for signs of renal impairment. however. CLINICAL PICTURE The patient may have: ■ Small red pimple-like bumps that may look like boils or spider bites. aspiration.Copyright © 2008 by F. purulent drainage. malnutrition. bacterial infection. smoking. ■ Infection of bone. MRSA and Vancomycin-Resistant Staph Infection Methicillin-resistant Staphylococcus aureus (MRSA) infection is caused by S. ■ Fever. CA-MRSA is community-acquired MRSA. S. and warmth around bumps. vancomycin-resistant staph has begun to emerge. Vancomycin is one of the few antibiotics that effectively treat MRSA. 158 . SOB. Davis. calcification (indicates healed disease). are negative for MRSA. If urinary tract infection is suspected. worse in the morning. Move patient to private room. IMMEDIATE INTERVENTIONS/FOCUSED ASSESSMENT ■ Institute airborne precautions (see Airborne Precautions in this tab). ■ Assist with incision and drainage of skin abscesses. BE PREPARED TO ■ Transfer patient to ICU if septic.Copyright © 2008 by F. Wear a mask if patient has a productive cough. Tuberculosis CLINICAL PICTURE The patient may have: ■ Productive cough. ■ Chest pain. Do not discontinue contact precautions until two sets of cultures. aureus colonization or infection. ■ Assess findings of chest x-ray: cavitation. night sweats. ■ Assess sputum production and patient’s ability to clear airway. ■ Hemoptysis. Obtain blood cultures. bronchial breathing. coarse crackles. ■ Auscultate lungs for possible diminished breath sounds. taken 24 hours apart and 48 hours after all antibiotics are discontinued. STABILIZING AND MONITORING Initiate contact precautions (See Contact Precautions in this tab). If pneumonia is suspected. INFECT ■ ■ ■ ■ ■ ■ ■ ■ ■ Obtain culture of wound and drainage. Start antibiotics promptly. ■ Extreme weight loss if disease is advanced. POSSIBLE ETIOLOGIES ■ S. ■ Fever. obtain sputum culture. ■ Teach family about preventing spread of MRSA. and nodes in the upper lobes suggest pulmonary TB. obtain urine culture. A. empyema). POSSIBLE ETIOLOGIES ■ Mycobacterium tuberculosis. ■ Assess for signs and symptoms of tuberculosis outside the lungs (meningitis. and teach patient that it is critical that he or she take medications as prescribed for the duration of therapy (6 to 18 months). ■ Ethambutol (EMB). renal or bone involvement. INFECT . Davis. 159 ■ Obtain early morning sputum specimens for 3 consecutive days for culture and acid-fast bacilli (AFB). STABILIZING AND MONITORING BE PREPARED TO ■ Assist with bronchoscopy. ■ Assist with chest tube placement (ruptured TB granuloma. Obtain proper medium for AFB specimen. ■ Vitamin B6 for neuropathy of hands/feet. A combination of the following drugs is standard treatment: ■ Isoniazid (INH). A. peritonitis.Copyright © 2008 by F. ■ Administer standard therapy. pericarditis). ■ Rifampin (RM). ■ Pyrazinamide (PZA). and support circulation. circulation)—take precedent in any emergency situation. whether in the ED. pulse oximetry. rapid (less than 5 minutes) assessment. you can forget about C. teeth. If there is no answer. all attention is directed to the problem. A: Airway Assessment (with cervical spine immobilized): ■ Ask “are you all right?” Can the patient speak? If so. ICU. EMERG Assessment in an Emergency This assessment guideline was developed for the multiple trauma patient brought into the emergency department (ED). proceed to D (disability) and E (expose) and then to the seconday survey. rapidly begin more in-depth airway and breathing assessment. Breathing. The primary survey should be accomplished within the first few minutes. etc. the basic primary survey—the ABCs (airway. ■ Assessed multiple times by cardiac monitoring. ■ Ensure that needed staff is available. and its efficacy is assessed before proceeding. This should be done only in the OR. 160 . vomitus.Copyright © 2008 by F. Primary Survey: Airway. Davis. Circulation The primary survey is a crucial. ■ Check that needed equipment is readily available. A. ■ Look in the oropharynx for foreign objects. Once ABC is established. breathing. catastrophic bleeding or additional injury can occur. the team ALWAYS reassesses ABCs—if problems arise in ABCs. and BP measurement ■ Penetrating objects are NOT removed. The highest priorities are to establish an airway. ). These are the ABCs and must always be addressed first in any situation in which a patient’s status is deteriorating. an intervention to correct or improve the problem is initiated immediately. Throughout. supplement breathing or provide ventilation. blood. ■ During the primary survey all patients are ■ Given high-flow O2. The order of assessment is critical (a blunt clinical saying: “If you do not have A and B. ■ Put on gloves and face mask with visor. or general care floor. If the team encounters a problem with the ” ABCs. However. You may hear abnormal sounds such as wheezing or stridor. Otherwise. ABC is functional to some extent. thrashing about. ■ Is the patient restless. extremely anxious? You will see this in an emergency unless the patient has had a head injury and is unconscious. ■ If patient is not breathing or the airway cannot be cleared. Do not use an oral airway in a conscious patient as it may induce vomiting and aspiration.Copyright © 2008 by F. ■ Assess rate and ease of breathing. 161 Interventions: ■ Immobilize cervical spine. or tension). Remove any obstructing material by sweeping with a gloved finger. ■ If the patient is breathing and you hear any noises with breathing. EMERG . or other highly skilled individual will assess the airway. ■ Establish patent airway with: ■ Jaw thrust/chin lift maneuver. B: Breathing Assessment: ■ Some patients are not breathing in an emergency (see CPR Quick Reference in this tab). manually ventilate if necessary. ■ Rib fractures. A. endotracheal intubation will be attempted. a tracheotomy will be performed. ■ Hemo-pneumothorax. ■ Flail chest. Check nailbed and circumoral area for cyanosis. ■ Evaluate ABG results. and an anesthesiologist. open. Davis. ■ If the patient cannot be intubated. Interventions: ■ Provide high-flow supplemental O2. and inspect the airway. This will help: ■ Protect airway and ensure patency. examine the chest. ■ Suction fluid from oropharynx. open the mouth. ■ Correct hypoxemia. and auscultate lungs. the code team will take over. ■ Identify and treat major thoracic injuries: ■ Pneumothorax (simple. In a hospital. ■ Consider a nasal airway. ■ Feel trachea. respiratory therapist. ■ Provide access for some medications. Head and Face ■ Inspect and palpate head and face for lacerations. and type and crossmatch. Interventions: ■ Control external bleeding. ■ Infuse a warmed crystalloid. . ■ Mouth. hemorrhage. hemorrhage. and altered function. contact lens.Copyright © 2008 by F. ■ Includes AMPLE history (allergies. 162 . or other injury. Secondary Survey ■ Follows primary survey and resuscitation. ■ Cover patient to reduce heat loss. D: Disability Assessment: ■ Initial neurological assessment is limited to checking pupils and assessing LOC (responsiveness) using the AVPU scale: ■ A Alert ■ V responds to Voice ■ P responds to Pain ■ U Unresponsive ■ Any change in AVPU requires reassessment of ABC. last meal eaten. ■ Includes continuous reassessment of primary survey. ■ Cranial nerves. E: Exposure ■ Remove clothing (expose). ■ Ears and nose for CSF. ■ Insert two large-bore IV accesses. altered perfusion. events prior). medications. ■ Involves head-to-toe systematic assessment to detect injuries. EMERG C: Circulation Assessment: ■ Check cardiac rate and rhythm and BP Recheck every few minutes. penetrating injury. abrasion. ■ Check peripheral perfusion. and inspect for obvious injuries. fractures. ■ Provides for assessment of each body area for signs of deformity. contusions. contusion. past medical history. Davis. ■ Eyes (injury. A. ■ Send blood for laboratory tests. dislocation of lens). paresis. Fractures ■ Assess for bone/joint deformity. abnormal movement. ■ Determine GCS. ■ Evaluate for paralysis. Auscultate lungs. swelling. tenderness. sphincter tone. Back ■ Inspect for injuries. Abdomen Inspect for distention. soft or rigid. crepitation. ■ Check all pulses. A. Davis. and injury. deformity. use of accessory muscles. Neurological ■ Reevaluate pupils and LOC. skin condition. Chest ■ ■ ■ ■ ■ ■ ■ ■ Inspect for injury. Auscultate for bowel sounds. tender or nontender? Extremities ■ Inspect for signs of injury or deformity.Copyright © 2008 by F. ■ Assess for loss of function. ■ Assess for bleeding or other injury to genitalia. Percuss. ■ Palpate for tenderness. ■ Palpate for sensation. EMERG . tracheal deviation. and compare left with right. crepitation. Palpate entire chest for tenderness. Perineum ■ Inspect for rectal blood. subcutaneous emphysema. ■ Assess for flank pain. Percuss. hematoma. swelling. 163 Cervical Spine and Neck ■ Inspect for signs of injury. motor and sensory responses of extremities. Palpate. ■ Auscultate for carotid bruits. EMERG Diagnostic Studies ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Type and crossmatch for blood. and religion in end-of-life questions. all patients ” should have advance directives in the medical record indicating whether they wish to be resuscitated and to what extent resuscitative efforts should be carried out. ■ Always treat the patient as an individual. ■ Help patients and families address end-of-life care issues. However. Glucose. sometimes this is not possible. Head CT. Urinalysis. Therefore. and other signs precede a full-blown code. ■ Keep in mind the role of culture. Hemoglobin and hematocrit levels. changes in mentation. breathing difficulties. Cardiac and liver enzymes. WBC count. ethnicity. Abdominal CT. ■ Suggest discussing with a religious leader of their faith. Davis. ■ Tell patients that they will not be abandoned or given substandard care if they or their advance directive limit medical interventions. Ideally. Advance Directives and Do Not Resuscitate Orders First. Rapid Response Teams Patients typically go through several hours of subtle changes in condition before a respiratory or cardiac arrest. make sure this document is always available in the record.Copyright © 2008 by F. Cervical-spine radiographic series. and if there is any doubt as to the interpretation or whereabouts of a patient’s advance directives a code must be called and resuscitative efforts initiated. HR and BP changes. Arterial blood gas. Admission personnel often ask this of the patient when he or she is admitted. Chest x-ray. if the patient is unable to make decisions) regarding “heroic measures. make sure you know the patient’s wishes (or family’s. Intervening earlier in the downward spiral of events vastly increases the 164 . A. Amylase. The staff nurse is usually responsible for: ■ Calling the rapid response team. initiate ventilations. ■ Providing the recent history and background information. A. ■ If you have no help. notify the nurse manager or nursing supervisor. ■ Place the arrest board under the patient’s back. If one is not available. If your facility does not have a rapid response team. As you do this. pull the call bell out so that the light flashes continually. call the code before proceeding. . proceed until a second person arrives. if you have help. The nurse’s role is critical in getting the right help for the patient. preferably with a bag-valve-mask device. quickly apply a barrier. 165 patient’s chance of survival. ■ Note if the patient has a running IV or an IV access device. and pull the curtain if another patient is present. and give two breaths of 11/2–2 seconds each. clear airway by sweeping your fingers in the patient’s mouth or by suctioning. ask any visitors to wait outside the room. ■ Next. EMERG . ■ Providing other noncritical care. Davis. What to Do If Your Patient Codes If you are by yourself: ■ Establish unresponsiveness. The rapid response team may consist of: ■ Resident. NP or physician’s assistant. call for help. assess breathing for 5 seconds. If the patient is not breathing. ■ Calling the attending physician. ■ ICU nurse. even if you cannot say for sure what it is (“something’s different/wrong”). ■ Obtaining and administering medications. Many hospitals have rapid response teams that can be and should be called when the patient’s condition changes. If not. if possible. ■ Nurse anesthetist or respiratory therapist. ■ Continuing to assess the patient. who can help you get the resources needed.Copyright © 2008 by F. ■ Place the patient in a supine position in bed. and check ABC. using the head-tilt/chin-lift maneuver (see first figure below). ALWAYS consider the family’s needs first. Document after time the code ended. sensitively ask them if they would like you to do this first. Do not practice beyond your level of expertise. 166 . ■ Connecting the bag-valve-mask to oxygen tubing. ■ Once the code team arrives. EMERG ■ Check for a pulse. If an autopsy will be performed. administering medications. detail the events in your end-of-shift report. ■ Many other tasks may be required of you in a code situation. and give report to receiving unit. ■ If the patient does not survive. begin one-person CPR until another person or the code team arrives (see CPR Quick Reference in this tab). and resume CPR. If family members were present at the time the patient coded. ■ Once you are relieved: ■ Make sure one nurse is documenting and another nurse is retrieving medications and supplies as needed from the code cart.Copyright © 2008 by F. leave all tubes in place. ■ Setting up the flowmeter. ■ If the patient survives. If you work in an ICU and the patient is not being moved. If the patient has no pulse. and check with your supervisor to determine what can be removed. Davis. calling the attending physician. ■ Clean and cover the patient. write a transfer note. arranging for a bed in the ICU. suctioning the airway. Check that the code record is complete and on the chart. you will not remove anything. When another nurse arrives to help: ■ Bring the crash cart into the room. ■ Stay in the room to be available to the team. including obtaining laboratory tests and transporting them to the laboratory. someone will relieve you and begin other resuscitative interventions. It may be unbearable for them to wait. and document on the ICU flowsheet. ■ Switch to bag-valve-mask ventilations by: ■ Inserting an oral airway. inserting an IV or Foley catheter. ■ Offer support to any visitors who are present. A. etc. and straighten the room before the family views the body. ■ Turning on the oxygen to 12–15 L/min. ■ Get an IV of NS running. ■ Document all events up to and including time code was called. ■ Make sure the seal around the patient’s airway is tight. Davis. Heimlich maneuver: abdominal thrusts if unresponsive. Jaw thrust maneuver. Hand placement. Hemlich. and Recovery Positions Head—tilt. Recovery position. A. 167 Adult/Child CPR.Copyright © 2008 by F. EMERG . chin—lift. Heimlich maneuver. 168 . Davis. Heimlich maneuver: chest thrusts. support head. EMERG Infant CPR and Heimlich Positions Head—tilt. CPR hand placement. Heimlich maneuver: back blows. support head. chin—lift. A.Copyright © 2008 by F. Open airway ■ All ages: head—tilt. ■ Child or infant: Call 911 after 2 min (5 cycles) of CPR. chin—lift ■ If trauma suspected. Check without interrupting chest compressions. and reattempt to ventilate. Check for a pulse for 10 seconds ■ If pulse is present but patient is not breathing. EMERG . Infants. 169 CPR Quick Reference Determine unresponsiveness ■ Adult: Call 911: get help—obtain AED if available. ■ Adults: Do not use pediatric pads. CPR Parameters for Adults.Copyright © 2008 by F. ■ Child: Use after 2 min (5 cycles) of CPR (may use adult pads if pediatric pads are unavailable). and follow voice prompts (AED) ■ Perform 2 minutes of CPR between each shock. Note: Recheck pulse every 2 minutes and after each shock. Assess for breathing ■ If not breathing. give two slow breaths at 1 sec/breath. start chest compressions. begin rescue breathing (see table below). ■ If unsuccessful. ■ If no pulse after 10 seconds. A. reposition airway. Davis. refer to Choking Quick Reference below. If still unsuccessful. Children. and Neonates Adult Ventilations Pulse check location Compression rate Ratio of compressions to breaths Compression depth 10–12/min Carotid 100/min 30:2 (1 or 2 rescuers) 11/2–2 inches Child and Infant 12–20/min Child: Carotid Infant: Brachial 100/min 30:2 (15:2 if 2 rescuers) 1/2–1/3 Newborn 40–60/min Brachial Umbilicus 120/min 3:1 (1 or 2 rescuers) 1/3 the depth of the chest the depth of the chest If a defibrillator is available Power on. use jaw-thrust method. begin CPR (for all ages). Determine unresponsiveness ■ Adult: Get help or call 911 prior to any intervention. and reassess ABCs every minute. Repeat manuevers ■ Inspect. ■ Perform a finger sweep only to remove a visible foreign body. sweep. ■ Pregnant or obese patients: Chest thrusts until the obstruction is relieved or the patient becomes unresponsive (see step 3 below). ■ Perform CPR until obstruction relieved. 7. 170 . A. Assess for airway obstruction ■ Adult or child: Ask victim if he/she is choking. and reattempt ventilation. Davis. ■ If still unsuccessful. ■ If trauma suspected. use the jaw-thrust method. Unresponsive Patient 3. place into recovery position. 4. child. Attempt to relieve obstruction ■ Adult or child: Abdominal thrusts until the obstruction is relieved or victim becomes unresponsive (see step 3 below). 5. 2. and infant: Use a tongue-jaw lift while opening the airway during CPR. EMERG Choking Quick Reference Conscious Patient 1. Inspect mouth and remove obstruction ■ Adult. can he/she speak or make any sounds? ■ Infant: Cannot cry or ineffective cough. reposition airway. Open airway ■ Head—tilt.Copyright © 2008 by F. Note: If patient resumes breathing. ■ Child or infant: Get help or call 911 after 1 min. ventilate. chin—lift. Assess breathing and attempt to ventilate ■ If unsuccessful. ■ Infant: 5 back blows and 5 chest thrusts until the obstruction is relieved or victim becomes unresponsive (see step 3 below). 6. Rate: Set demand rate to approximately 80 bpm. Current: Output ranges 0–200 mA ■ Bradycardia: Increase mA from minimum setting until a consistent capture is achieved. stand clear. then increase by 2 mA. EMERG . and wait for instructions (do not make contact with patient while AED is analyzing rhythm). slowly decrease until capture is lost. and then instruct the operator to press the “shock” button if indicated. and follow voice prompts. Symptomatic bradycardia unresponsive to atropine.Copyright © 2008 by F. and plug pad cable into the AED unit if needed. ■ Analyze: Press the “Analyze” button. PACING MODES ■ Demand (synchronous) mode senses the patient’s heart rate and paces only when the HR falls below the clinician-set rate. and assure all cables are connected. ■ Semiautomatic units analyze rhythm. ■ Power: Turn on the AED. PROCEDURE ■ ■ ■ ■ Pads: Apply pacing electrodes to patient per package instructions. and assure that no one ” is in contact with the patient. ■ Shock: Announce “Shock indicated. A. then increase by 2 mA. ■ Adults ≥8 years: get help/AED immediately. Bradycardia with ventricular escape rhythms. Power: Turn on pacemaker. Davis. ■ Upper right sternal border and cardiac apex. ■ Attach pads: Stop CPR. Transcutaneous Pacing (TCP) INDICATIONS ■ ■ ■ ■ Symptomatic 2nd-degree AV block type II or 3rd-degree AV block. but rather paces at the rate set by the clinician. ■ Children 1–8 years: get help/AED after 2 min of CPR. attach appropriate-size pads to patient. ■ Perform CPR until AED arrives. 171 Automatic External Defibrillators (AEDs) ■ Assessment: Determine unresponsiveness and assess ABCs. Overdrive pacing of tachycardia refractory to drug therapy or electrical cardioversion (to be performed by physician only). ■ Fixed (asynchronous) mode does not sense the HR. ■ Fully automatic units analyze rhythm and shock if indicated. If capture occurs. ■ Asystole: Begin at full output. smoke inhalation ■ Epiglottitis or severe croup ■ Pneumothorax ■ Pulmonary embolism ■ Respiratory failure SHOCK ■ ■ ■ ■ ■ Anaphylaxis Cardiogenic shock Hypovolemic or hemorrhagic shock Neurogenic shock Septic shock METABOLIC Acute renal failure Addisonian crisis Dehydration. severe Hepatic encephalopathy Hypoglycemic coma UROLOGICAL. EMERG Emergency Conditions INJURY AND ILLNESS ■ Appendicitis (leading to peritonitis) ■ Chest pain or sudden severe abdominal pain ■ Cholecystitis ■ Compound fracture ■ Drug overdose or withdrawal ■ Gangrene ■ Head trauma ■ Hypothermia or hyperthermia ■ Intestinal obstruction ■ Malignant hyperthermia ■ Necrotizing faciitis ■ Pancreatitis ■ Peritonitis ■ Septicemia blood infection ■ Severe burn ■ Spreading wound infection ■ Spinal injury ■ Lactic acidosis ■ Thyroid storm NEUROLOGICAL ■ ■ ■ ■ Cerebrovascular accident (stroke) Meningitis Seizure Syncope (fainting) OPHTHALMOLOGICAL ■ Acute angle–closure glaucoma ■ Orbital perforation/penetration ■ Retinal detachment RESPIRATORY CARDIAC AND CIRCULATORY ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Air embolism Aortic aneurysm (ruptured) Aortic dissection Cardiac arrest Cardiac arrhythmia Cardiac tamponade Hemorrhage Hypertensive emergency Myocardial infarction Subarachnoid hemorrhage Subdural hematoma. GYNECOLOGICAL. A. drowning. choking. Davis. acute Ventricular fibrillation ■ Acute asthma ■ Agonal breathing ■ Asphyxia secondary to angioedema. AND OBSTETRIC ■ ■ ■ ■ ■ ■ ■ ■ Eclampsia Ectopic pregnancy Gynecological hemorrhage Obstetrical hemorrhage Paraphimosis Priapism Testicular torsion Urinary retention 172 . advanced Diabetic ketoacidosis Electrolyte disturbance.Copyright © 2008 by F. and communicate to physician. Get help. or manually assist ventilations with an Ambu-bag. restlessness. ■ Feelings of impending doom. contrast medium. ■ Assess SaO2 via pulse oximetry. ■ Bronchospasm. ■ Assess skin for color. Provide emotional support to family/patient. Administer high concentrations of supplemental O2. ■ Assess airway status. respiratory distress. Administer IV fluids and medications (vasopressors. BP) on a continuous basis. volume expanders). phone call to physician. ■ Hypotension. EMERG . Assist with intubation and airway management. IV fluids as ordered. moistness. insect sting. turgor. dysrhythmia. or more frequently. Call a code. ■ Document patient’s status. itching. POSSIBLE ETIOLOGIES ■ Exposure to antigen. and physician response. LOC. ■ Anticipate need for mechanical ventilation. FOCUSED ASSESSMENT STABILIZING AND MONITORING ■ ■ ■ ■ ■ ■ ■ ■ ■ Monitor VS every 5 min. hives. 173 Anaphylaxis CLINICAL PICTURE The patient may have: ■ Angioedema. and VS (HR. ■ Initiate continuous cardiac and VS monitoring. RR. ■ Transfer patient to ICU. steroids. Have someone bring code cart or emergency medications box to room. Davis. ■ Nausea. diphenhydramine. ■ Establish patent airway. Record patient’s status in chart.Copyright © 2008 by F. blood product. latex). Assist with obtaining central venous access. laryngeal edema. medication. anxiety. vomiting. IMMEDIATE INTERVENTIONS ■ Call physician and respiratory therapist or anesthesiologist STAT. ■ Obtain IV access. A. BE PREPARED TO Administer epinephrine subcutaneously. and capillary refill. temperature. ■ Assess recent exposure to allergen (food. diarrhea. Administer medications. ■ Flank. respiratory status. pruritus. temperature. assess rhythm strip. orientation. Continue to monitor VS. STABILIZING AND MONITORING ■ ■ ■ ■ Return unused portion of blood product to blood bank for analysis. ■ Recheck patient ID and blood labels for error. ■ Administer supplemental O2. and urine output. 174 . LOC. back. ■ Nausea. phone call to physician or NP and physician . and circulation. ■ Notify physician or NP . Get help. Document specific reaction. Run normal saline through the IV to maintain IV access. and VS (temperature. Assess skin for color. BE PREPARED TO ■ Administer epinephrine. ■ Hematuria. restlessness. BP). IMMEDIATE INTERVENTIONS ■ Stop the transfusion. turgor. and convey to physician or NP . or NP response. ■ Urticaria. EMERG Transfusion Reaction CLINICAL PICTURE The patient may have: ■ Fever. Assess SaO2 via pulse oximetry if available. tachycardia. Administer prescribed medications and O2. initiate CPR if necessary.Copyright © 2008 by F. ■ Chest pain. ■ Document patient’s status. ■ Burning at infusion site. chills. A. skin erythema. Notify blood bank of reaction. SOB. RR. If patient on telemetry or cardiac monitor. Davis. vomiting. ■ Assess airway. and temperature. moistness. ■ ■ ■ ■ FOCUSED ASSESSMENT Assess LOC. treat shock. HR. ■ Administer IV fluids. or joint pain. breathing. ■ Check VS. ■ Chart patient status. ■ Apprehension. hypotension. diarrhea. Infusion of bacteriacontaminated blood. ■ Acute hemolytic reaction: IV normal saline with diuretics to maintain urine output of 100 mL/hr. vasopressors. cardiac arrest. Sensitivity to foreign proteins. ■ Allergic response: corticosteroids such as Solu-Medrol. flushing. ■ Administer medications such as: ■ Antihistamine. Febrile nonhemolytic Sensitization to donor WBCs. headache. respiratory distress. or plasma proteins. wheezing. diarrhea. hypotension. vomiting. A. allergic response. flushing. cardiac dysrhythmias. Types of Reactions Type Acute hemolytic Cause ABO incompatibility reaction to RBC antigens. deep IM. low back pain. vascular collapse. chills. shock. Davis. ■ Kidney failure and shock: IV fluids and vasopressors. ■ Urticaria: diphenhydramine 25–50 mg IV. 175 ■ Insert indwelling catheter to monitor hourly urine output. Fever. cardiac arrest. tachycardia. Chills. antipyretic. hypotension. Allergic Hives. blood contamination. ■ Titrate O2 to keep SaO2 90%. Restlessness. chills.Copyright © 2008 by F. fever. ■ Septicemia: antibiotics. ■ Fever: acetaminophen. Signs and Symptoms Fever. Anaphylactic Administration of donor’s IgA proteins to recipient with anti-IgA antibodies. ■ Obtain or order STAT laboratory tests. urticaria. IV fluids. flushing. Bacteremia EMERG . and furosemide (Lasix) IV. septic shock. itching. ■ Obtain two large-bore IV accessories. platelets. POSSIBLE ETIOLOGIES ■ ABO incompatibility. urticaria. steroids. muscle aches. fever. IVF. and suction oropharynx if needed. 176 . ■ Assess SaO2 via pulse oximetry if available (may be unreliable due to decreased peripheral perfusion). ■ Assess skin for color. Obtain IV access. ■ Throat tightness. Establish patent airway. elevate lower limbs (if not contraindicated). Anticipate need for mechanical ventilation. ■ Evaluate previous 2-hour I&O.Copyright © 2008 by F. pale. to maintain airway patency. Set up cardiac monitoring. and VS (HR. ■ Manage various types of shock accordingly: ■ Hypovolemic: O2. and/or blood. Administer high-flow O2 via nonrebreather mask (10–15 L/min). or manually assist ventilations with an Ambu-bag (mask-valve device). temperature. plasma volume expanders. stridor. flushing. orientation. EMERG Shock CLINICAL PICTURE The patient may have: ■ Anxiety (early). turgor. or cyanotic skin (hypovolemic shock). Davis. FOCUSED ASSESSMENT STABILIZING AND MONITORING ■ Monitor VS every 5 minutes or more frequently. ■ Delayed capillary refill ( 3 sec). 2). place patient in supine or low Fowler’s position (HOB slightly elevated). IMMEDIATE INTERVENTIONS ■ ■ ■ ■ Call physician or NP STAT. ■ ■ ■ ■ ■ ■ ■ Assess LOC. phone call to physician or NP and physician . Note: This position is contraindicated if the airway is compromised. Document patient’s status. RR. urticaria (anaphylactic shock). and capillary refill. Place patient in a supine position with legs elevated above heart level to increase circulation to vital organs. Get help from other staff. ■ Tachycardia (bradycardia in neurogenic shock). ■ Decreased urine ouput. A. ■ Hypotension. diminished peripheral pulses ( ■ Cool. mottled. or NP response. moistness. ■ Diaphoresis. arterial line placement. lethargy and coma (later). control bleeding. ■ Tachypnea. Insert nasal or oral airway. volume replacement with crystalloids. BP). Control bleeding with direct pressure if patient hemorrhaging. colloids. BE PREPARED TO ■ ■ ■ ■ ■ Call a code. spinal stabilization. rash. insert Foley’s catheter. (Continued on the following page) EMERG . arterial line placement. ↓ BP. Assist with obtaining central venous access. possible seizure activity. airway management. Assist with intubation and airway management. bronchospasm. vasopressors. arterial line placement. exposure to antigen (anaphylactic). IVF. fluid shifts out of intravascular space. A. vasopressors. volume replacement. IV fliuds. dehydration (hypovolemic shock). ■ Anaphylactic: O2. arterial line placement and hemodynamic monitoring. epinephrine. cardiotonics. Interventions O2. blood products.e. ■ Record patient’s status in chart. UA). Signs and Symptoms Respiratory distress (stridor). hives. antihistamines. steroids. Hct. cool. IVF. antibiotics. infection. pharmacological overdose. pump failure (cardiogenic shock). steroids. vasopressors. ■ Transfer to ICU. IVF. tight chest. peripheral and laryngeal edema. ↓ tissue perfusion. ■ Septic: O2. correct dysrhythmias. POSSIBLE ETIOLOGIES ■ Blood loss. pale skin. electrolytes. intubation and airway management. antidysrhythmics (i. anesthesia (neurogenic shock). vomiting. MI. dopamine. profound brady/tachycardia. Pathophysiology Massive vasodilation. Davis.. epinephrine. cardiac markers. antipyretics. lidocaine). lifethreatening allergic reaction to a specific antigen. Comparison of Different Types of Shock States Type Anaphylactic: Acute. 177 ■ Cardiogenic: O2. ■ Provide emotional support to family/patient. ■ Neurogenic: O2. antihistamines (Benadryl/Atarax).Copyright © 2008 by F. WBC. Administer fluids. ABG. edema. and communicate to physician or NP . Order or obtain specific laboratory tests to be drawn STAT (Hgb. spinal cord injury. arterial line placement. intubation and airway management. and medications as ordered. endo/ exotoxin release (septic shock). IVF. dobutamine. IV fliuds. burns. a BP. clammy. moist to diaphoretic skin. bounding pulse. weak pulse. Pathophysiology Signs and Symptoms Hypotension. third spacing decreased of fluids. Interventions O2. vasopressors. altered LOC. altered LOC. IV fluids. heart failure. Hypotension. warm. 178 . tachycardia. decreased tissue perfusion. aneurysm. spinal stabilization. capillary leak syndrome. IV fluids. colloids. dysrhythmias. tachycardia. sputum C&S antibiotics. or tachycardia. cardiotonics. EMERG Comparison of Different Types of Shock States (continued) Type Cardiogenic: Pump failure due to MI. cyanosis. vascular resistance sufficient to sustain BP. decreased tissue perfusion. Septic: Septicemia Circulatory secondary to failure due to endo/exotoxin systemic release. ↓ urine output. volume expanders. possible flaccid paralysis and absent reflexes. tachypnea. bradycardia. Fever or low temperature. O2. pale skin. Neurogenic: Profound vasodiSpinal shock lation that secondary to results in lack spinal cord injury. blood cultures. fluid replacement with crystalloids. increased HR/RR. tissue perfusion. Hypotension. blood. O2. weak pulse. cool. of peripheral anesthesia. control bleeding. O2. dysrhythmias. flushed. airway management. most inflammatory commonly Gramresponse. possible vasopressors. antidysrhythmics. ↓ capillary refill. vasopressors. UA. negative bacteria. clammy skin. Hypovolemic: ↓ Decrease in intracirculating volume vascular due to hemorvolume with rhage. PE. cardiac tamponade. which to create dehydration.Copyright © 2008 by F. Davis. A. Inadequate cardiac output due to lack of contractile force to create BP. decreased tissue perfusion. EMERG . 179 Cardiogenic Shock Ineffective Pump Ventricular Emptying End-diastolic Volume Stroke Volume Cardiac Output Filling Pressures Tissue Perfusion Cardiogenic shock. Hypovolemic Shock Volume Venous Return Filling Pressures Stroke Volume Cardiac Output Tissue Perfusion Hypovolemic shock. A. Davis.Copyright © 2008 by F. 180 . Davis. EMERG Neurogenic Shock Massive Vasodilation Venodilation Venous Return Filling Pressures Stroke Volume Arteriolar Dilation Peripheral Resistance Cardiac Output Blood Pressure Tissue Perfusion Neurogenic shock.Copyright © 2008 by F. A. opiates and narcotics. metoprolol). and/or route of administration. MEDS/LABS . ■ Have a colleague double-check dosage calculations and infusion pump programming. warfarin. dosage. ■ High-concentration dextrose (greater than 10% dextrose). ■ IV potassium (phosphate and chloride). ■ Chemotherapeutic agents. A. ■ Hypoglycemic agents (oral). 9% concentration). ■ Use the Five Rights (right drug. ■ Colchicine injection. ■ IV digoxin. ■ Opiates (opioids). epinephrine. Many of these drugs are used commonly in the general population or are used frequently in urgent clinical situations. norepinephrine). right time) as a guide.g. 181 High-Alert Medications High-alert medications are those medications that have a high risk of causing injury or death when improperly handled or administered. isoproterenol. ■ Lidocaine/benzocaine. IV anticoagulants (heparin). ■ Midazolam. esmolol. ■ IV adrenergic antagonists (propranolol. Exercise extreme caution when administering these medications: ■ Adrenergic agonists (e. heparin. ■ Chloral hydrate (in pediatric patients).. other topical anesthetics. right dose. ■ Thrombolytics. injectable potassium chloride (or phosphate) concentrate. ■ Insulin. ■ IV calcium. and sodium chloride solutions above 0. right patient. right route.9%.Copyright © 2008 by F. ■ Cardioplegic solutions. ■ Hypertonic sodium chloride injection ( 0. The Joint Commission monitors the five most often prescribed high-alert medications: insulin. Safe Medication Administration ■ Carefully read product packaging to note strength of solution. ■ IV magnesium sulfate. ■ Double-check with a pharmacist about dose range. ■ Neuromuscular blocking agents. Davis. affect the patient as well as the health-care providers. ■ Use an interpreter if provider and patient speak different languages. is confusing or hard to read. Patient education also enhances compliance. ■ Suspect a missed decimal point. 182 . ■ Have the patient repeat the information you provide. ■ Improper drug selection. ■ Adherence with prescribed medication therapy. ■ Overdose/subtherapeutic dose (consider age. ■ All patients need clear written and verbal instruction for all medications.g. Davis. ■ Efficacy. It also can prevent adverse drug reactions or early or improper discontinuation of a medication. ■ Medication duplication. ■ Appropriate duration of therapy. hearing Cerebyx for Celebrex. ■ Include family members. contains abbreviations. unfamiliarity with a drug. or fifty for fifteen).Copyright © 2008 by F. Patient Education and Medication Use Educating patients about their medications is a critical nursing function that promotes proper medication use and improved outcomes. ask prescriber to spell out the drug name and dosage to avoid sound-alike confusion (e. Many issues related to medication errors. renal/hepatic impairment). A. ■ Review each patient’s medications for: ■ Medication use without an indication. ■ Potential drug or food interactions. which is a factor in proper medication use. or raises a question. thereby emphasizing the need for careful education. ■ If taking a verbal order. ■ Read back the order to the prescriber after you have written it in the chart. such as ambiguous directions. MEDS/LABS ■ Clarify any order that is incomplete. ■ Contraindications. ■ Do not rush. ■ Do not borrow medications from other patients or begin new medications before the order has been received in the pharmacy. and confusing packaging. to do so circumvents the built-in checks that can detect a prescribing error.. and clarify any order if the dose requires more than 3 dosing units. ■ Adverse drug reactions/toxicity. ■ Weight changes requiring dosage adjustments. ■ Present information in a format the patient can understand. Davis. OU ■ BT ■ cc ■ D/C ■ IJ ■ IN ■ HS. SSI ■ 1/d ■ TIW. ■ What to do if a dose is missed. QD ■ q1d ■ q6PM. 183 ■ Make sure to tell the patient: ■ The brand and generic names of the medication. hs ■ IU ■ o. if any. ■ Signs and symptoms of adverse drug reactions. ■ Use commas for dosing units at or above 1. SQ.000. ■ The purpose of the medication. ■ SC. OS. should be avoided while on the medication. tiw ■ U. ■ What activities. AU ■ OD. ■ Place adequate space between a drug name. MEDS/LABS . ■ What medications or foods to avoid and why they should be avoided. A. u Symbols ■ (dram) ■ (minim) ■ @ (at) ■ & (and) ■ (hour) ■ / (slash) ■ (plus) ■ (minus) ■ (greater than) ■ (less than) ■ Apothecary symbols Drug Names ■ ARA A ■ AZT ■ CPZ ■ DPT ■ DTO ■ HCl ■ HCT ■ HCTZ ■ IV Vanc ■ MgSO4 ■ MTX ■ Nitro drip ■ Norflox ■ PCA ■ PTU ■ T3 ■ TAC ■ TNK ■ ZnSO4 General Tips ■ Avoid using a zero after a decimal point. etc. ■ The strength and dose and when to take the medication.. Error-Prone Abbreviations and Symbols Abbreviations ■ g ■ AD. AS. ■ Use a zero before a decimal point. dose.d.Copyright © 2008 by F. and the unit of measure. sub q ■ ss ■ SSRI..d. ■ Possible side effects and what to do if they occur. ■ How to store the medication. OD ■ OJ ■ per os ■ q. ■ How long to take the medication. Activated Charcoal (Absorbent) Indications: Overdose and poisoning. Indications: MI. heart failure without hypotension. Side Effects: Constipation. Always consult an authoritative. Precautions: Lower doses in renal failure. HA. A. Contraindications: Hypotension. preparation. Contraindications: Concurrent use with syrup of ipecac. 184 . ACE Inhibitors (Antihypertensive) Common Agents: Captopril. fatigue. Davis. It is not meant to be exhaustive. N&V. and route and rate of administration before administering medications. Lisinopril. Emergency Medications (62 Medications) Note: This list is a reference only. and infusion pump programming for high-alert medications. Side Effects: Dizziness. Dose: 25–100 g PO. especially IV medications. angioedema. Have a second licensed person independently check dose calculations. Enalapril.Copyright © 2008 by F. altered LOC. ST elevation. hypotension. diarrhea. Dose: See individual order and drug for route and dosage. MEDS/LABS IV Fluid Drip Rate Table (drops/min) Rate: mL/ hr → 10 gtt/ mL set 12 gtt/ mL set 15 gtt/ mL set 20 gtt/ mL set 60 gtt/ mL set TKO 5 6 8 10 30 50 8 10 13 17 50 75 13 15 19 25 75 100 17 20 25 33 100 125 21 25 31 42 125 150 175 25 30 37 50 150 29 35 44 58 175 200 33 40 50 67 200 250 42 50 62 83 250 Note: TKO is 30 mL/hr. current reference about dose. NG tube. dilution. interactions. original orders. pregnancy. Precautions: Ineffective in iron (heavy metals) OD. aortic dissection. A. N&V. Side Effects: Hypotension. Precautions: Tachydysrhythmias. Dose: Per order. cardiac disease. Davis. HA. lumbar puncture within 1 week. atrial flutter. asystole. MEDS/LABS . hyperglycemia. Dose: 6 mg IV. severe (uncontrolled) HTN. elderly. tightness. N&V. Albuterol (Ventolin®) (Bronchodilator) Indications: Reversible airway restriction due to acute bronchospasm. Dose: Per order. history of neurovascular event within 2 months. tachycardia. Precautions: Patients with severe renal or hepatic disease. tremor. reperfusion dysrhythmias. A third dose of 12 mg may be given in 1–2 min. Side Effects: Nervousness. Contraindications: Drug. Dose: 1. bleeding disorder. cardiac disease. HTN. Contraindications: Hypersensitivity to adrenergic amines. anaphylaxis. bradycardia. HA. major surgery or trauma within 2 weeks. Repeat with 12 mg IV in1–2 min if needed. pulmonary embolus. VF . Alupent (Metaproterenol®) (Adrenergic Agonist [Bronchodilator]) Indications: Reversible airway restriction due to asthma or COPD. Avoid in patients on dipyridamole or with a history of MI or cerebral hemorrhage. hypersensitivity. Side Effects: Nervousness. tachycardia. anxiety. heart failure. Precautions: Ineffective in treating atrial fibrillation. ventricular ectopy. asthma. Dose: 10–15 mg nebulized in 3-mL saline. restlessness. flushing. Max: 30 mg.25–5 mg nebulized in 3-mL saline. chest pain. Side Effects: Flushing.or poison-induced tachycardia. Alteplase (Activase®. diarrhea. HTN. diarrhea. urticaria. tremor.Copyright © 2008 by F. 185 Adenosine (Adenocard®) (Antidysrhythmic) Indications: Narrow complex PSVT. anxiety. HA. t-PA) (Thrombolytic. Aminophylline (Truphylline®) (Bronchodilator) Indications: Long-term control of reversible airway obstruction due to asthma or COPD. heart block. increased bleeding time. Fibrinolytic) Indications: Within 4–6 hr of acute MI and 3 hr from onset of symptoms in acute ischemic stroke. prolonged CPR. or VT. hypersensitivity. Precautions: Tachydysrhythmias. or COPD. hyperglycemia. restlessness. elderly. Contraindications: Active internal bleeding within 10 days (except menses). Contraindications: Hypersensitivity to adrenergic amines. deep or superficial hemorrhage. pulmonary impairment. Dose: 160–325 mg PO nonenteric-coated for antiplatelet effect. epigastric pain.5 mg/min). Sedative. . Dose: 150 mg over first 10 min (15 mg/min). 186 . tachycardia. Anxiolytic. drowsiness. CHF PSVT. anaphylaxis. 360 mg over next 6 hr (1 mg/ min). anxiety.05 mg)/kg. recent MI. nausea. maximum 4 mg each dose. acute coronary syndrome. Side Effects: Dizziness. Side Effects: Seizures. narrow-angle glaucoma. Amyl Nitrate (Antidote to Cyanide Poisoning) Indications: Cyanide poisoning. Side Effects: Hypotension. Analgesic) Indications: Analgesic. acute ETOH withdrawal. N&V. tremors. ARDS. Side Effects: HA. Davis. not to exceed 8 mg/12 hr or 2 mg/min IV infusion. N&V. renal. Contraindications: Sinus bradycardia. Precautions: Active ulcers and asthma. prolonged QT interval. multiple drug interactions. hypotension. blood dyscrasias. A. . hyperthyroidism. dysrhythmias. Precautions: Avoid concurrent use with procainamide. Dose: 50 g (0. patients with CHF or liver failure. head trauma. cardiac arrest. hypersensitivity to nitrates or nitrites. pregnancy. glaucoma. Hypnotic) Indications: Status epilepticus. lethargy. Aspirin (Acetylsalicylic Acid) (Antiplatelet. Amiodarone (Cordarone®) (Antidysrhythmic) Indications: Wide. VF and pulseless VT. hypotension. Contraindications: Known allergy to aspirin. Precautions: Increased hypotension with alcohol consumption. may be repeated after 10–15 min. MEDS/LABS Contraindications: Uncontrolled dysrhythmias. Atracurium (Tracrium®) (Neuromuscular Blocking Agent [Nondepolarizing]) Indications: Paralysis to facilitate endotracheal intubation. Dose: Inhale vapors from crushed ampules for 30 sec of every min continuously.or 3rddegree heart block. Precautions: Severe hepatic. obesity.and narrow-complex tachycardia. Ativan® (Lorazepam) (Anticonvulsant. diarrhea. N&V. Precautions: Geriatric patients. paradoxical excitation. Side Effects: Anorexia. apnea. Contraindications: Allergy to benzodiazepines.Copyright © 2008 by F. cardiogenic shock. Contraindications: Cerebral hemorrhage. 2nd. 540 mg over next 18 hr (0. Contraindications: Atrial fibrillation. Precautions: Ensure intubation and suction equipment available. hypersensitivity. atrial flutter. Labetalol. N&V. dilated pupils. extrapyramidal symptoms. multiple drug interactions. Metoprolol. drowsiness. hypotension. Beta Blockers (Antihypertensive) Common Agents: Atenolol. asystole. Atropine (Anticholinergic) Indications: Sinus bradycardia. Side Effects: Hypotension. Eaton-Lambert syndrome. flushed skin. Dose: Bradycardia: 0. antidote to cholinergic drug toxicity and mushroom poisoning. Precautions: Concurrent use with calcium channel blockers can cause hypotension. not to exceed 400 mg/24 hr. may repeat subsequent boluses of 0. Time Action Profile: Onset 2–2. glaucoma. HTN. tachycardia. Side Effects: Tachycardia. and in working order. hypotension. maximum 0. severe liver disease.04 mg/kg. SBP 100. Side Effects: Dry mouth. Precautions: Use caution in hypoxia.or 3rd-degree HB. use caution in patients with a history of bronchospasm. 2nd. multiple drug interactions. lactating. Benadryl® (Diphenhydramine) (Antihistamine) Indications: Anaphylactic reaction. narrow angle glaucoma. PSVT.5 min. duration 30–40 min. asthma. pregnant.1 g/kg q 15–20 min or an infusion of 5–9 g/kg/min.Copyright © 2008 by F. Indications: MI.4–0. pregnancy. organophosphate and neurotoxin (nerve gas) exposure. PEA with rate 60. atrial fibrillation. HA. bradycardia.5 mg/kg IV bolus. Dose: 10–50 mg IV or deep IM up to 100 mg. nerve gas and organophosphate exposure: 2–6 mg IV or IM depending on severity of symptoms. 187 Dose: 0. maximum 0. Propranolol. Dose: See individual order and drug for route and dosage. Precautions: Elderly.5–1 mg IV (may give via ET tube at double the dose) q 3–5 min. Avoid in hypothermic bradycardia and 2nd-degree (Mobitz) type-II HB. Contraindications: HR 50. dizziness. cardiac arrest: 1 mg q 3–5 min. A. severe electrolyte imbalances. left ventricular failure. may repeat in 2-mg increments q 3 min titrated to relief of symptoms. Side Effects: Bronchospasm. HA.04 mg/kg. VF/VT. dry mouth. unstable angina. urticaria. peak 1–2 min. MEDS/LABS . Contraindications: Myasthenia gravis. Contraindications: Asthma. atrial flutter. set up. Davis. dysrhythmias. hypocalcemic tetany. do not administer IM due to potential for tissue necrosis. Precautions: Digoxin toxicity. hypermagnesemia. Cardizem® (Diltiazem) (Calcium Channel Blocker) Indications: Atrial fibrillation. Side Effects: Cardiac arrest. Precautions: Incompatible with sodium bicarbonate. may repeat in 1–2 min. . Contraindications: Hypercalcemia. hypotension.5–9 mEq IV. antidote to calcium channel blockers and beta blockers. syncope. N&V. hypocalcemia. .Copyright © 2008 by F. VF . Side Effects: Hypotension. maintenance drip 1–2 mg/min. Side Effects: Bradycardia. PSVT refractory to adenosine. hypermagnesemia: 4. tingling. VF N&V. hyperkalemia with cardiac toxicity: 2. repeat until symptoms are controlled. severe pulmonary hypertension.3–9.25–14 mEq IV. Dose: Antidote to calcium channel blocker: 2–4 mg/kg IV. hypocalcemic tetany: 4. 188 . and titrate to HR. may be repeated as needed. hypocalcemia: 2. VT w/pulse 5–10 mg/kg in 50–100 mL over 10 min. and ECG. May repeat in 15 min at 20–25 mg IVP over 2 min (0. Calcium Chloride (Minerals/Electrolytes/Calcium Salt) Indications: Hyperkalemia.25–14 mEq. hypermagnesemia. additional dose administered.35 mg/kg). Dose: 15–20 mg IVP over 2 min (0. . A. maximum . maintenance drip: start at 5–15 mg/hr. atrial flutter. may repeat in 1–2 min. bradycardia. administered undiluted IVP .3 mEq as needed or 7–14 mEq if emergent need elevates Ca . phlebitis. Dose: Hypocalcemia: 7–14 mEq IV.25 mg/kg). asystole. renal failure. then observe for response before any . 30 mg/kg in 24 hr. hyperkalemia with cardiac toxicity. Davis.5–16 mEq IV. Calcium Gluconate (Minerals/Electrolytes/Calcium Salt) Indications: Hypocalcemia. CP bradycardia. VF digoxin toxicity. given prophylactically with calcium channel blockers to prevent hypotension. Contraindications: Hypercalcemia. given prophylactically prior to IV calcium channel blockers 8–16 mg/kg IV. Precautions: Monitor blood pressure. N&V. renal calculi. Contraindications: Severe aortic stenosis. MEDS/LABS Bretylium (Bretylol®) (Antidysrhythmic) Indications: Ventricular dysrhythmias. Dose: VF pulseless VT 5 mg/kg IVP repeat 10 mg/kg q 15 min. hypermagnesemia: 2–7 mEq slows IVP may be repeated in 10 min. hyperkalemia: 2. give amount sufficient to return ECG to normal. . pulse. 189 Contraindications: Drug or poison induced tachycardia. respiratory depression. otherwise. hyperglycemia. Precautions: Tissue necrosis with infiltration. Side Effects: Hypotension. ventricular extrasystoles. Precautions: Head trauma. MEDS/LABS . Davis. muscle weakness. maximum 10 mg/kg. One 40 mg vial binds to approximately 0. Demerol® (Meperidine) (Opioid-Narcotic Analgesic [Agonist]) Indications: Moderate to severe pain. Side Effects: Hyperglycemia.6 mg of digoxin. . Contraindications: Pregnancy. HA. do not withdraw abruptly. Contraindications: Concurrent or recent use of MAO inhibitors. Side Effects: Respiratory depression. alcohol intolerance. Precautions: Cardiac. Dose: 10 mg IVP . Side Effects: Drowsiness. WPW syndrome. shock. Precautions: Severe hypotension in patients on beta blockers. allergy to corn. Contraindications: CNS bleed. N&V. pulmonary. hypotension. wide-complex tachycardia of uncertain type. fluid overload. . Dose: Dependent on serum digoxin levels. Precautions: Tissue necrosis with infiltration. Dose: 25–100 mg IM or 15 to 35 mg/hr continuous IV infusion. confusion. spinal trauma. seizure. confusion. Digibind® (Digoxin Immune fab) (Antidote to Digoxin. sedation. Digitoxin) Indications: Symptomatic digoxin toxicity or acute ingestion of unknown amount of digoxin. Dose: 25 g slow IVP . Contraindications: Ulcer. pregnancy. HTN. or liver disease. Dose: 1–3 mg/kg IVP may repeat as needed. epilepsy or convulsive states. none known. Dextrose 50% (Caloric Agent) Indications: Hypoglycemic coma/altered LOC. cerebral edema. cardiogenic shock. Decadron® (Dexamethasone) (Glucocorticoid. A. N&V. Dantrolene (Dantrium®) (Skeletal Muscle Relaxant) Indications: Emergency treatment of malignant hyperthermia. elderly. Anti-inflammatory) Indications: Anaphylaxis.Copyright © 2008 by F. pulmonary edema. CNS toxicity. increased ICP asthma. Side Effects: Peptic ulceration. BBB. infection. Contraindications: Allergy only. dopamine. pediatric clients. May be used as an alternative treatment for PSVT. Ensure adequate hydration prior to infusion. Side Effects: Tachycardia. uncorrected tachycardia. Epinephrine (Adrenalin®) (Adrenergic Agonist) Indications: All cardiac arrest. blurred or yellow vision. VF and . and vasopressor shock. Ensure adequate hydration prior to infusion. HA. anaphylaxis. vasoconstriction. bronchospasm. hypokalemia. Dose: Loading dose of 10–15 g/kg.and hypertension. Precautions: Adjust dosage in elderly patients and in those with occlusive vascular disease. Inotropic) Indications: Cardiogenic shock d/t MI. acute asthma attack. atrial fibrillation. fatigue. angina. N&V. renal failure. Side Effects: Dysrhythmias. idiopathic hypertrophic subaortic stenosis (IHSS). open heart surgery. 190 . Extravasation may result in sloughing of tissue. hypersensitivity. and TCP. increased . palpitations. constrictive pericarditis. pregnancy. Dopamine (Intropin®) (Vasopressor. Precautions: Avoid electrical cardioversion of stable patients. CHF pulmonary edema.Copyright © 2008 by F. Contraindications: Uncontrolled atrial dysrhythmias. If unstable. hypersensitivity. Contraindications: Pheochromocytoma. MEDS/LABS Side Effects: Worsening of CHF atrial fibrillation. . Side Effects: Ventricular ectopy. Digoxin (Lanoxin®) (Inotropic. particularly VF AV block. dyspnea. use lower current settings such as 10–20 joules. and chronic cardiac decompensation. hypokalemia. Dose: Per order. N&V. Antidysrhythmic) Indications: Atrial fibrillation and atrial flutter. endotoxic septicemia. severe hypotension. A. Dose: Per order. AV block. Davis. elderly. trauma. Also used for symptomatic bradycardia refractory to atropine. serum digoxin levels. . Precautions: Safe use in acute MI not established. hypo. chest pain. bradycardia. Precautions: Patients with allergies to sheep proteins. Dobutamine (Dobutrex®) (Inotropic) Indications: Short-term treatment of cardiac decompensation in organic heart disease or cardiac surgical procedures. Contraindications: Idiopathic hypertrophic subaortic stenosis. VF nervousness. .1–1 mg SQ or IM of 1:1000 solution. anaphylaxis: 0. Precautions: Avoid use in children.3 mg SQ or IM of 1:10. Esmolol (Brevibloc) (Selective Beta Blocker.Copyright © 2008 by F.000 solution. hypoglycemia: 0. Glucagon (Hormone) Indications: Antidote to beta-blocker and calcium channel blocker overdose. 191 Dose: Cardiac arrest: 1 mg IV of 1:10. restlessness. suicidal/homicidal tendencies. cerebral or subarachnoid hemorrhage and aortic rupture. Contraindications: Hypersensitivity to adrenergic amines. elderly. Precautions: Use caution in patients with insulinoma or pheochromocytoma.5–1 mg IV. tachycardia. pregnancy. VT. adjunct to percutaneous coronary intervention in patients with high risk of abrupt closure of treated coronary vessel. Contraindications: Dosage has not been established in children. Tirofiban HCl (Aggrastat®). double the dose if administering via ET tube. pallor. HTN. Eptifibatide (Integrilin®). antidote to beta blocker: 50–150 g/kg IVP followed by a 1–5 mg/hr infusion. Dose: 80 mg over 30 sec followed by 150 g/kg/min. midscapular pain. multiple drug interactions. Side Effects: Flushing. Dose: Antidote to calcium channel blocker: 2 mg IV. urinary retention. SC. DM.1–0. Antidysrhythmic) Indications: SVT in those with atrial fibrillation or atrial flutter. MEDS/LABS . asthma: 0. burning and/or edema at site of infusion. Side Effects: Angina. tachycardia and HTN during induction or emergence from anesthesia. noncompensatory ST. tachydysrhythmias.000 solution q 3–5 min. A.000 solution in 500 mL of saline and start at 1–5 mL/min). tremors. hyperthyroidism. pallor. Contraindications: Known allergy to beef or pork protein. Indications: Acute coronary syndrome without ST-segment elevation. asthenia. Precautions: Use caution in HTN. Glycoprotein IIb and IIIa Inhibitors (Platelet Aggregation Inhibitor) Common Agents: Abciximab (ReoPro®). to decrease GI motility: 0. May repeat dose. glaucoma. refractory bradycardia and hypotension: 2–10 g/min (1 mg of 1:1. cardiac disease. used to decrease GI motility during GI procedures. IM. hypoglycemia when IV access unavailable and patient cannot protect airway (cannot take oral glucose). Side Effects: N&V. narrow-angle glaucoma. induration.25–1 mg slow IVP or up to 2 mg IM. Davis. Precautions: Increased chance of bleeding. nodal dysrhythmias. multiple herb interactions. famotidine (Pepcid®). Contraindications: Hypersensitivity. dizziness. constipation. and in the elderly. hypotension.01 mg/kg slow IVP over 10 min. site pain. may repeat same dose in 10 min. HA. Dose: Patients 60 kg: 1 mg slow IVP over 10 min. Precautions: Use with caution in menstruating women. procainamide. Indications: Duodenal and gastric ulcers. management of gastroesophageal reflux disease (GERD). N&V. impaired renal or hepatic function. post-partally. blood dyscrasias. amiodarone. may repeat in 10 min. subendocarditis. thrombocytopenia. Davis. Dose: See individual order and drug for route and dosages. Heparin (Anticoagulant) Indications: Acute pulmonary/peripheral embolism.Copyright © 2008 by F. PVCs. Side Effects: Increased bleeding and bruising. anaphylaxis. treatment of DIC. agitation. severe (uncontrolled) HTN. Side Effects: Confusion. MEDS/LABS Dose: See individual order and drug for route and dosages. known bleeding disorder. Side Effects: Severe ventricular dysrhythmias such as torsades de pointes. . Side Effects: Minor to major hemorrhage. multiple herb interactions. severe HTN. following CVA. bradycardia. ranitidine (Zantac®). Patients 60 kg: 0. shock. Contraindications: Known allergy. pregnancy. bundle branch block. 192 . Contraindications: Active bleeding. Contraindications: Active internal bleeding within 30 days. in patients with history of GI disease. suspected intracranial hemorrhage. Histamine Blockers (H2-Receptor Antagonists) Common Agents: Cimetidine (Tagament®). HA. A. bronchospasm. ulceration of the GI tract. Precautions: Assess elderly and severely ill patients for confusion routinely. liver disease. tachycardia. upper GI bleed. anaphylaxis. drowsiness. including atrial fibrillation and atrial flutter. use with caution in elderly. HTN. cardiac arrest. Ibutilide Fumarate (Corvert®) (Antidysrhythmic) Indications: SVT. Dose: Per order. or those receiving thrombolytics. hypersensitivity. within 6 weeks of a known GI or GU bleed. Precautions: CHF LV dysfunction. multiple drug interactions. history of neurovascular event within 1 month (within 2 years of surgery or trauma within 1 month) aortic dissection. concomitantly with other antidysrhythmics such as quinidine. GI irritation. nizatidine (Axid®). threatened abortion. thrombocytopenia. N&V. atrial fibrillation with emoblization. shock. TCA OD. 193 Inamrinone (Inocor®) (Inotropic) Indications: Short-term treatment of CHF unresponsive to traditional therapies. coughing or choking with emesis. Dose: 2–10 g/min titrated to desired heart rate. fecal impaction. Isuprel® (Isoproterenol) (Inotropic) Indications: Symptomatic bradycardia. sedation. MEDS/LABS . hypersensitivity. Dose: 15 g PO or 25–100 g rectally as a retention enema 1–4 times daily in water or sorbitol (if severe. hepatotoxicity. cardiac arrest. Contraindications: Life-threatening hyperkalemia. hypokalemia. CHF hypertension. N&V. ileus. A. tachyphylaxis. hypotension. consider Isuprel last. angina. high dosages (except in beta-blocker OD). bronchospasm. Precautions: Monitor ECG and electrolytes during therapy. hypocalcemia. . heart block caused by digitalis intoxication. Side Effects: Diarrhea. Side Effects: Dyspnea. dysrhythmias. Dose: 15–30 mL PO followed by 240 mL of water. calcium. or glucose/insulin infusion should be instituted). Contraindications: Hypersensitivity to bisulfates. renal impairment. seizures. . pulmonary edema. Side Effects: Hypotension. electrolyte imbalances. use cautiously in the elderly. ingestion of caustic substance. hypersensitivity to saccharin or parabens. Davis. HA. constipation. cautious use in persons with tuberculosis. gastric irritation. beta-blocker OD. diarrhea. Contraindications: Altered LOC. Precautions: Pregnancy. more immediate measures such as sodium bicarbonate IV. Dose: Per order. Contraindications: Cardiac arrest. N&V. VT. tachydysrhythmias. Kayexalate® (Sodium Polystyrene Sulfonate) (Cation Exchange Resin) Indications: Mild to moderate hyperkalemia. concurrent use with epinephrine. IHSS. atrial fibrillation. Side Effects: Constipation. sodium retention. VF tachycardia. Ipecac Syrup (Emetic) Indications: OD/poisoning of noncaustic substance. may repeat 15 mL in 30 min if ineffective. torsades de pointes refractory to magnesium. bradycardia in heart transplant patients. known alcohol intolerance. Precautions: Use cautiously in atrial fibrillation or atrial flutter. severe inebriation. abuse in bulemic or anorexic patients.Copyright © 2008 by F. and geriatric patients. dysrhythmias. Precautions: Increase cardiac ischemia. Magnesium Sulfate (Electrolyte. pulmonary edema. disease. Contraindications: Hypermagnesemia. Anesthetic) Indications: Pulseless VF/VT. Davis. anuria. Side Effects: Altered LOC. hypomagnesemia or hypothyroidism. hypotension. hepatic cirrhosis. cardiovascular collapse. Contraindications: 2nd. hypokalemia. digitalis toxicity.Copyright © 2008 by F. If conversion successful. toxemia of pregnancy: 1–4 g slow IVP (4–5 g IV followed by an infusion of 1–2 g/hr) continuous infusion not to exceed 40 g/24 hr. hypocalcemia. seizure. hypersensitivity to amide-type local anesthetics. A. dehydration. increased ICP nephrotic syndrome. flushed skin. may repeat once at 2 mg/kg slow IVP over 1–2 min. Distal Loop) Indications: CHF with acute pulmonary edema. then infuse 0. Anticonvulsant) Indications: Seizures associated with toxemia of pregnancy. malignant hyperthermia. altered LOC. Dose: Hypomagnesemia: 0. Lidocaine (Xylocaine®) (Antidysrhythmic.5–1 g/hr IV. azotemia. toxemia of pregnancy 2 hr prior to delivery. hypotension. hypocalcemia. may repeat q 5–10 min. slurred speech. VF refractory to lidocaine. hypotension.or 3rd-degree HB. dizziness. severe respiratory depression. start an infusion of 2–4 mg/min. severe . Precautions: Reduce infusion dose by 50% if 70 yr. hypokalemia. respiratory arrest. Dose: 1–1. Dose: 1. Contraindications: Never use with ethacrinic acid. hyponatremia. torsades de pointes. 194 . Side Effects: Hypotension. anuria. cardiac arrest 1–2 g IVP. Stokes-Adams and WPW syndromes. cardiac arrest following IV administration. maximum 3 mg/kg. vertigo.5–1 g /hr. heart block. marked hypoxia. digoxin-induced VT/VF . MEDS/LABS Lasix® (Furosemide) (Diuretic. hypertensive crisis. diaphoresis. intraocular pressure.5–2 g/kg IV over 30–60 min. cardiac arrest. Dose: 0. wide-complex tachycardia of uncertain type. Contraindications: Intracranial bleeding. Precautions: Monitor urine output and electrolytes during therapy and injection site for thrombophlebitis. Mannitol (Osmitrol®) (Diuretic [Osmotic]) Indications: Increased ICP the oliguric phase of acute renal failure. renal disease. Side Effects: Severe dehydration/hypovolemia. hepatic coma. diuresis of toxic substances. bradycardia. severe asthma. . CHF shock. torsades de pointes (noncardiac arrest): load with 1–2 g infused over 5–60 min.5 mg/kg IVP or ET tube (double dose if giving via ET tube). respiratory depression. hypotension. Precautions: Renal insufficiency. liver . hypersensitivity to sulfonamides.5–1 mg/kg slow IVP over 1–2 min. digoxin-induced VT/VF: 1–2 g IVP. hypochloremia. dehydration. half-life may not be as long as narcotic half-life. acute alcoholism. Davis. SC. Precautions: Reverse with Narcan. undiagnosed acute abdominal pain. MEDS/LABS . HA. A. Contraindications: Obstructive pulmonic or aortic valvular disease. Side Effects: Respiratory depression. multiple drug interactions. seizures. hypersensitivity.4–2 mg IV. hypokalemia. CHF and dyspnea associated with pulmonary edema. chest pain. Precautions: Elderly. SVT. seizures. altered LOC. HA. respiratory depression. Contraindications: Aortic coarctation or AV shunting. altered LOC. VF . Dose: Per order. angina. . . bradycardia. Side Effects: Acute withdrawal symptoms in addicted patients. ET (double the dose when administered via ET tube) q 2–3 min intervals. Dose: 4–15 mg IVP q 3–4 hr or as a loading dose titrated to respiratory status followed by an infusion of 0. Side Effects: VT. DTs. Dose: Per order. pregnancy. hypotension. acute CHF . VT. electrolyte imbalances. hypotension. Morphine Sulfate (Opioid-Narcotic Analgesic [Agonist]) Indications: Moderate to severe pain. Precautions: Use cautiously in patients with a history of dysrhythmias. Side Effects: Dizziness. HA. Milrinone (Primacor®) (Inotropic) Indications: Short-term treatment of CHF in patients receiving digoxin and diuretics. seizures. palpitations. Contraindications: Heart failure due to chronic lung disease. head injury. CHF seizures. N&V. tremors. Precautions: Avoid total narcotic reversal in addicted patients. hypotension. chest pain unrelieved with NTG. blurred vision.Copyright © 2008 by F. narcotic addicts. tachycardia. bradycardia. Dose: 0. cardiovascular and renal disease. 195 Side Effects: Altered LOC. restlessness. Narcan (Naloxone®) (Opioid-Narcotic Antagonist) Indications: Narcotic-induced respiratory depression. renal impairment.2–1 mg/mL. Contraindications: Known allergy to Narcan. hypotension or HTN. hypotension or hypertension. Nitropress®) (Vasodilator) Indications: Hypertensive crisis. nausea. N&V. increased ICP thiocyanate toxicity. flushing. tachycardia. maximum 10 mg. IM. Nipride® (Nitroprusside. abnormal digoxin levels. May cause severe HTN in hypertensive patient during labor. high output failure in endotoxic sepsis. Dose: 10 units IM or 10–40 units in 1000 mL saline. Precautions: Evaluate for multiple births. rapid atrial fibrillation in WPW. Contraindications: Known allergy. weakness. Dose: 20 mg/min. Precautions: Do not mix with other medications. CHF associated with acute MI. Dose: Hypokalemia ( 2.1 units/min (titrate to effect). MEDS/LABS Precautions: Use with caution in hypothyroidism. and infuse at 0. Nitrate) Indications: Angina. seizure. 196 .02–0. maximum 3 doses. hypersensitivity. untreated Addison’s disease. postpartum hemorrhage. maintenance of 1–4 mg/min. severe bradycardia. incomplete delivery. severe tachycardia. and tissue necrosis with extravasation. Hypokalemia ( 2) up to 400 mEq/day as an infusion (rate should generally not exceed 20 mEq/hr). dysrhythmias. Nitroglycerin (Nitrostat®) (Antianginal. titrate IV form to maintain SBP 90 mm Hg. torsades de pointes.or 3rd-degree HB. Pitocin® (Oxytocin) (Hormone) Indications: Postpartum hemorrhage. flushed skin.4 mg SL q 5 min. hypertensive crisis. paroxysmal atrial tachycardia. . stable wide-complex tachycardia of uncertain type. severe renal impairment. myasthenia gravis. respiratory paralysis. maintenance after conversion. uterine rupture. Severe pain . HA. HTN. A. severe tissue trauma. N&V. abdominal pain. lupus. Precautions: Monitor HR. Contraindications: SBP 90 mm Hg. Davis. Side Effects: Dysrhythmias including heart block. cardiac load-reducing agent. RV infarction. and ECG throughout infusion.Copyright © 2008 by F. Dose: 0. Contraindications: 2nd. or D5W. Side Effects: Hypotension with secondary tachycardia. LR. Side Effects: Anaphylaxis. Procainamide (Pronestyl®) (Antidysrhythmic) Indications: VT. Contraindications: Hyperkalemia. liver or renal impairment. Potassium Chloride (Mineral/Electrolyte) Indications: Hypokalemia. Use with caution in the elderly with cardiac or renal disease. diarrhea. restlessness. maximum 17 mg/kg.3–0. PSVT refractory to adenosine and vagal stimulation. irritation at IV site. Viagra® within 24 hr. increased ICP and the elderly. digoxin toxicity. BP RR. coma.5) up to 200 mEq/day as an infusion (not to exceed 20 mEq/hr or a concentration of 40 mEq/L via peripheral line) (up to 80 mEq/L has been used via central line [unlabeled]). hypotension. syncope. confusion. bradycardia. up to a maximum of 1 mg. upper GI bleed. HA. widening QT. flushed skin. known history of seizures.5 mg/kg. Precautions: Stop administration for hypotension or when QT interval begins to widen. . ventricular dysrhythmias.5 mg q min. labor and delivery. dizziness. rabeprazole (Aciphex®). MI. MEDS/LABS . followed with 0.2 mg if no patient response after 45 sec). Side Effects: Apnea. Contraindications: Hypersensitivity. allergy to benzodiazepine. A.3 mg in 30 sec. asystole. Buffer) Indications: Hyperkalemia. use associated with high risk of seizures in certain patients. drowsiness. Proton Pump Inhibitors Common Agents: Lansoprozole (Prevacid®). burning at the site. partial or complete HB. HTN. HA. Precautions: Assess elderly and severely ill patients for confusion routinely. site pain. seizure. dizziness. and in patients with liver or renal disease. maximum 3 mg/hr (0. flushed skin. N&V. or glycerol products. increased ICP cardiovascular . Sodium Bicarbonate (Alkalizing Agent. 197 Side Effects: Hypotension. Indications: Duodenal and gastric ulcers. Precautions: Lipid metabolism disorders. Davis. Use cautiously in patients with CHF cardiomyopathy. metabolic acidosis. disease. uncontrolled DM. Contraindications: TCA OD. cocaine or diphenhydramine or ASA OD. the elderly.2 mg given over 15 sec. or . followed by 0. hypotension or HTN. seizures. omprazole (Prilosec®). Romazicon® (Flumazenil) (Antagonist [Benzodiazepines]) Indication: Antidote to benzodiazepines. Dose: 0. May be repeated at 60-sec intervals. esomeprazole (Nexium®). Dose: See individual order and drug for route and dosages. management of GERD. anesthesia. shock. N&V. pantroprazole (Protonix®). shock associated with severe diarrhea. dizziness. CVA.2 mg IVP may repeat 0. use half the dose for elderly and debilitated patients. soy. HA. maintenance 100–200 g/kg/min or may be given in 25–50-mg increments. N&V. especially those with head injury or alcoholism. Multiple drug interactions. Precautions: Avoid using in multiple drug OD.Copyright © 2008 by F. Side Effects: Confusion. tricyclic antidepressant OD. dehydration. Propofol (Diprivan®) (Sedative. reduce dosage in impaired hepatic function. Dose: Initial dose 2–2. Contraindications: Allergy to egg. N&V. acute ischemic heart disease. Side Effects: Withdrawal symptoms. Anesthetic) Indication: Sedation. increased ICP . Use with caution in clients with CV. pulmonary. use half the dose for patients over 65 yr. Precautions: Ensure intubation and suction equipment available. A. Davis. prolonged CPR. bronchospasm.1 mg/kg IVP. acute narrow-angle glaucoma. urticaria. or metabolic disorders. Contraindications: Cannot use with lactated Ringer’s solution or in patients with a family history of malignant hyperthermia. anaphylaxis. 198 . Precautions: CHF renal disease. Toradol® (Ketorolac) (NSAID. flushing. renal failure. severe (uncontrolled) HTN. Contraindications: Allergy. Streptase® (Streptokinase) Indication: Acute MI 12 hr from onset of symptoms and acute ischemic stroke. lactation. concurrent use with glucocorticoids. Dose: Initial dose: 1–2 mg/kg IVP (0. peak 1–2 min. Patients with myasthenia gravis may show resistance. apnea. duration 4–10 min. Dose: 15–30 mg IV or 30–60 mg IM. history of neurovascular event within 3 months. Precautions: Patients with severe renal or hepatic disease. Side Effects: Hypotension. as an antidote to ingestion of strong mineral acid. pregnancy. seizures. Dose: See individual order and drug for route and dosages. or have renal impairment.Copyright © 2008 by F. Thrombolytics Common Agents: Activase® (Alteplase. set up. Succinylcholine chloride (Sucostrin®) (Neuromuscular Blocking Agent [Depolarizing]) Indications: Paralysis to facilitate endotracheal intubation. multiple drug interactions. HTN. . Side Effects: Hypotension. t-PA). aortic dissection.5–1 min. maintenance: 0. myopathies with elevated CPK. recombinant. convulsions. . Retavase® (Reteplase). tetany. 50 kg. hemorrhage. Contraindications: Metabolic or hypochloremic alkalosis. bleeding disorder.5–10 mg/min continuous infusion). malignant hyperthermia. Side Effects: Hypokalemia. Contraindications: Active internal bleeding within 21 days (except menses). LP within 1 week.3–1. major surgery or trauma within 2 weeks. hyperkalemia. and in working order. renal impairment. metabolic alkalosis. reperfusion arrhythmias. hypocalcemia. active peptic ulcer disease or GI bleeding. prior to and during surgery. Nonopioid Analgesic) Indication: Short-term management of moderate acute pain. known alcohol intolerance.5 mEq/kg q 10 min. MEDS/LABS Dose: 1 mEq/kg IVP may repeat 0. N&V. HA. bradycardia. increased bleeding time. Time Action Profile: Onset 0. severe persistent respiratory depression or apnea. hepatic. peak 3–5 min. Dose: Cardiac arrest: 40 units IVP one-time dose. may repeat 5–10 mg q 10 min. abdominal cramps. MI. Precautions: Monitor ECG throughout therapy. coma. CVA. neurogenic diabetes insipidus. VT. asthma. bronchoconstriction. atrial flutter. repeat every 12–15 min as needed or as a continuous infusion at 1 g/kg/min Contraindications: Cannot use with lactated Ringer’s solution. nausea.4 units/min. or CV disease. impaired hepatic or renal function. Precautions: GI bleed. flushed skin. renal. multiple drug interactions. Contraindications: Pregnancy. GI hemorrhage: 0. hypotension. chest pain. bradycardia. 199 Side Effects: Drowsiness. anaphylaxis. severe CHF . set up. anaphylaxis. Time Action Profile: Onset 1 min. bronchospasm. tachycardia. maximum 30 mg/min). A. MI. . epilepsy. Multiple drug interactions.Copyright © 2008 by F. Contraindications: Atrial fibrillation/flutter with WPW. AV heart block. exacerbation of CHF asystole. and in working order. Side Effects: Dizziness. sensitivity to bromides. heart failure. Isoptin®) (Calcium Channel Blocker) Indications: PSVT refractory to adenosine. migraine. increased bleeding time.1–0. convulsions. Verapamil (Calan®. allergy to beef or pork protein. IV diabetes insipidus: 5–10 units IM/SC. Precautions: Ensure intubation and suction equipment available. bradycardia. dyspnea.5–5 mg (5–10 mg slow IVP over 2 min. renal failure with BUN. Side Effects: Hypotension. GI hemorrhage. diarrhea. never give the tannate IV. MEDS/LABS . Dose: Initial dose: 80–100 g/kg. N&V. Side Effects: Hypotension. heartburn. Dose: 2. duration 15–25 min. Vecuronium (Norcuron®) (Neuromuscular Blocking Agent [Nondepolarizing]) Indications: Paralysis to facilitate endotracheal intubation. maintenance 10–15 g/kg 25–40 min after initial dose. HA. avoid use in patients with myasthenia gravis or EatonLambert syndrome. may give prophylactic calcium chloride (8–16 mg/kg IV) to counteract hypotension. Hormone) Indication: Cardiac arrest as an alternative to epinephrine. CAD. hypertrophic cardiomyopathy. atrial fibrillation. Davis. 2nd or 3rd degree heartburn. malignant hyperthermia. HA. Precautions: Patients on oral beta blockers. or wide-complex tachycardia of uncertain type. GI bleed or perforation. Vasopressin (Pitressin®) (Vasopressor. diaphoresis. urticaria. Davis. A. MEDS/LABS Medications Compatible With IV KCl acyclovir alatrovafloxacin aldesleukin allopurinol amifostine aminophylline amiodarone ampicillin amrinone atropine aztreonam betamethasone calcium gluconate chlordiazepoxide chlorpromazine cimetidine ciprofloxacin cisatracurium cladribine cyanocobalamin dexamethasone digoxin diltiazem diphenhydramine dobutamine docetaxel dopamine doxorubicin liposome droperidol droperidol/fentanyl edrophonium enalaprilat epinephrine esmolol conjugated estrogens ethacrynate sodium etoposide famotidine fentanyl filgrastim fludarabine fluorouracil furosemide gatifloxacin gemcitabine granisetron heparin hydralazine idarubicin potassium indomethacin insulin isoproterenol kanamycin labetalol lidocaine linezolid lorazepam magnesium sulfate melphalan menadiol meperidine methoxamine methylergonovine midazolam minocycline morphine neostigmine norepinephrine ondansetron oxacillin oxytocin paclitaxel penicillin G potassium pentazocine phytonadione piperacillin/tazobactam procainamide prochlorperazine edisylate propofol propranolol pyridostigmine ranitidine remifentanil sargramostim scopolamine sodium bicarbonate succinylcholine tacrolimus teniposide theophylline thiotepa tirofiban trimethaphan trimethobenzamide vinorelbine warfarin zidovudine Medications Incompatible With IV KCl adrenaline HCl amphotericin B cholesteryl sulfate complex atropine sulfate cephalothin sodium chloramphenicol sodium succinate chlorpromazine HCl diazepam ergotamine tartrate methicillin sodium phenytoin phenytoin sodium sulphadiazine sodium suxamethonium chloride thiopentone sodium 200 .Copyright © 2008 by F. 3 mg/dL 0.5–10.55 PaO2: 45 PaCO2: 20 or 60 HCO3: 15 or 40 Base Excess: 3 mEq/L Chemistries Test Albumin Alkaline phosphatase ALT AST BUN Bilirubin.25 or 7.5–1.98 kPa O2 sat 95%–100% HCO3 21–28 mmol/L Base Excess 2 to 2 mmol/L Critical Levels: pH: 7.Copyright © 2008 by F.9–5.9–8.66–5.0–0.19 mmol/L 20–29 mmol/L 70–120 mol/L 10–58 U/L 3. Davis.9 mg/dL 8.1–15.35–7.9 mmol/L 0–8 mol/L 0–20 mol/L 2.5 mmol/L 98–106 mmol/L 2–5.5 mEq/L or 8. System of Measurements) pH 7.45 PaO2 PaCO2 O2 sat 95%–100% HCO3 21–28 mEq/L Base Excess 2 to 2 mEq/L 80–100 35–45 mm Hg mm Hg Normal ABG Results (SI Units) pH 7. direct Bilirubin.45 PaO2 10.0 g/dL 44–147 units/L 6–59 units/L 10–34 units/L 7–20 mg/dL 0.6 kPa PaCO2 4.5 mmol/L (Continued on the following page) MEDS/LABS .5–1.2–1.15–2. 201 Reference Ranges for Common Laboratory Tests Arterial Blood Gases (ABGs) Normal ABG Results (U.9 mg/dL 101–111 mmol/L 100–240 mg/dL 20–29 mEq/L 0.8–1. total Calcium Chloride Cholesterol. A.S. total CO2 Creatinine Gamma-GT Glucose Lactic acid Conventional 3.4 mg/dL 0–51 units/L 64–128 mg/dL 0.6–12.3 mg/dL SI Units 35–50 g/L 40–120 U/L 20–65 U/L 15–45 U/L 2.3–11 mmol/L SI units: 0.35–7. 2 10–14 sec 21–37 sec 0.03 ng/mL 202 .8–7.3 mg/dL SI Units 300–600 mmol/L 0.2 ng/mL Cardiac troponin I: 0.5 mg/dL Female: 2.7–4. creatine kinase CK isoenzymes Troponins (TnI.Copyright © 2008 by F.9–1. serum Conventional 105–333 units/L 1. TnT) Conventional 85 U/mL 0–100 pg/mL Male: 55–170 U/L Female: 30–135 U/L CK-MB: 0%–3% Cardiac troponin T: 0.24–0. Davis.7–1.0–8.2 10–14 sec 21–37 sec 1.5–2 mEq/L 2.03 ng/mL SI Units 85 U/mL Ø–100 ng/L Male: 55–170 U/L Female: 30–135 U/L 0–0.43 mmol/L Coagulation Profile Test INR PT PTT/aPTT D-dimer FDP (fibrin degradation products) Fibrinogen Conventional 0.3–7. MEDS/LABS Chemistries (continued) Test LDH Magnesium Phosphorus Potassium Protein.51 mmol/L 0.5–5 mmol/L 60–80 g/L 136–144 mmol/L 0.1 mg/dL 3.5–5 mEq/L 6.03 Cardiac troponin T: 0.4 mmol/L 3.2 ng/mL Cardiac troponin I: 0.8–1.4–4.16–0.5 g/mL 5 g/mL 150–400 mg/dL SI Units 0. total Sodium Uric acid.9–1.9 g/dL 136–144 mEq/L Male: 4.1 g/L Cardiac Markers Test Albumin cobalt binding test B-type natriuretic peptide Creatinine phosphokinase.05 mmol/L 0. A. 04 0. females over 50 yr: 30 mm/ hr (Westergren method) MEDS/LABS .58 kat/L Hematology Test Blood volume Conventional SI Units 80–85 mL/kg 4.25–0.2 million/mm3 Red blood cell (RBC) Female: 4.2 mmol/L 7.Copyright © 2008 by F.000/mm3 Platelets Male: 1–13 mm/hr Erythrocyte sediFemale: 1–20 mm/hr mentation rate 150.300–10.9 1012/L 8.37–0. serum Lactate dehydrogenase (LD.20 0.01–0. females under 50 yr: 20 mm/ hr.9 million/mm3 Male: 13–18 g/100 mL Female: 12–16 g/100 mL Hemoglobin (Hgb) Male: 45%–52% Hematocrit (Hct) Female: 37%–48% 4.6–6. 203 Cardiac Markers (continued) Test Myoglobin.52 0.45–0.01 0.800/mm3 Leukocytes (WBC) 0%–5% ■ Bands 0%–1% ■ Basophils 1%–4% ■ Eosinophils 25%–40% ■ Lymphocytes 10%–20% ■ B lymphocytes 60%–80% ■ T lymphocytes 2%–8% ■ Monocytes 54%–75% ■ Neutrophils 150.2 1012/L 4. A.08 0.75 150–350 109/L 1–13 mm/hr 1–20 mm/hr 150–450 109/L 8.40 0.03–0.80 0.0% of body weight in kg Male: 4.2–5.2–5.8 109/L 0.000 mm3 Platelets Males under 50 yr: 15 mm/hr.000–350.9 mmol/L 0. LDH).48 4.4–9.60–0.54–0.000–450.10–0.5–9.08 0–0. LDH isoenzymes Aspartate aminotransferase Conventional 90 g/L 100–190 U/L 0–35 U/L SI Units 90 g/L 100–190 U/L 0-0.6–6. Sedimentation rate males over 50 yr: 20 mm/hr.3–10.1–11. Davis.02–0. A. 204 . Davis. MEDS/LABS A & P Snapshot IM injection sites.Copyright © 2008 by F. and variations. Davis. MEDS/LABS .Copyright © 2008 by F. A. 205 Two inches away from the umbilicus SC injection sites. technique. 20 sec Q-T interval . . inherent . Standard Placement: Lead-II & 7-Channel White's on the right (negative) G and. . TOOLS/ INDEX Electrical Conduction of the Heart SA node Intra-atrial pathways AV Node Bundle of His Right bundle branch Left bundle branch Purkinje fibers Electrical conduction of the heart. . . . . . . . . . . . . . . . .Between 0.40 sec Atrial rate. . . . . . . . . . . . . . Normal Cardiac Rhythm Parameters NSR . . . . . . . . . . . . inherent .Between 60 and 100 bpm SB . . . . . . . . . . . . . . . . . . .Fewer than 60 bpm ST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Davis. . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . .40–60 bpm Ventricular rate. A. .20–40 bpm 206 .Copyright © 2008 by F. . . . . . . . . . . . . . . . . . Smoke (Ground) Over Fire Chest lead and Right leg lead Included for seven channel monitoring (positive) + Standard placement: Lead II and 7-channel. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .0. . . . . . . . . . . . . . .Over 100 bpm QRS width . . . . .60–100 bpm Junctional rate. . . . . . . . . .Between 0. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30–0. . . . . . . . . . . inherent . . . . . . . .12 sec P-R interval . . . . . . . . . . . . . .12 and 0. . .08 and 0. . . . . . . . . . . . . . . . . . . . . TOOLS/ INDEX . A. Davis.Copyright © 2008 by F. 207 Lead Placement and Normal Deflection of PQRST Waves Midclavicular line Anterior axillary line Midaxillary line V6 V5 V 1 V2 V3 V4 Right lung Left lung V6 V5 V4 V1 V2 V3 Lead placement and normal deflection of PQRST waves. 208 . TOOLS/ INDEX ECG Waveform of the Cardiac Cycle R P PR T Q S Atrial Ventricular Ventricular depolarization depolarization repolarization ECG waveform of the cardiac cycle.Copyright © 2008 by F. Davis. A. Davis. A. TOOLS/ INDEX . 209 Heart Sounds QRS P T P QRS T S1 S2 S1 S2 Aortic valve Pulmonic valve S2 S2 S1 Mitral valve S1 Tricuspid valve Heart sounds.Copyright © 2008 by F. and so forth..... Remember the number sequence below and find an R wave that falls on a heavy line....... TOOLS/ INDEX Figuring Rate and Measurement To figure out rate (regular rhythms only)......... 150... Davis. 100......... 210 ....... Divide the number of large boxes between two R waves into 300.. you can do one of the following: Count the number of QRS complexes (regular rhythms only) in a 6-sec strip and multiply by 10... A..04 sec and is 1 mm2. Starting from the next heavy line. 20–40 bpm One big box represents 0... Irregular rhythms should be counted for an entire minute. Inherent rates of different cardiac regions: SA Node .. count 300......... One small box represents 0... 40–60 bpm Ventricles. 60–100 bpm AV Node ..... 1st R wave 300 150 100 75 60 50 43 Next R wave here would be 150 bpm... and whatever line the next R wave falls on is the heart rate (see below for example).Copyright © 2008 by F.20 sec and is 5 mm2.... Next R wave here would be 60 bpm... . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12–0. . P-R <0. . . . . . . . . . . . . . . . . . . . . .Normal QRS . . . . . . . . . . . . . . . . . . . . . . . . . . . .Present P-R . . . . . . . . . . . . . . . . . . . .08–0. Davis. . . . .Between 60–100 Rhythm . . . . . . . . . 211 Normal Cardiac Cycle and Measurements QRS T R P P Q P-R interval Normal Rate 60–100 bpm Normal Rate → 60–100 bpm Normal P-R → 0. . . . . .12–0. . . . . . . . . . . . . . . .04 sec 0. . . . . . . T wave → ventricular repolarization S 0. . . . . QRS → ventricular depolarization. . . .08–0. . . . . . . . .Copyright © 2008 by F. . . . .12 sec P wave → atrial depolarization. . . . . . . . . . .12 sec) TOOLS/ INDEX . . . . . . . . . . . . . . . . . . . . . .20 sec Normal Sinus Rhythms P waves before every QRS. . .Normal (0. .Regular P waves . .20 Rate . . . . . . . . . . . . . . . . . A. . . .20 sec Normal P-R 0. . . . . . . . . . .20 sec Normal QRS → 0. . . . . . . . . . . . . . . . . . 20 sec (5 small boxes). it remains consistent in length from PRI to PRI: consider 1 AV block.08 and 0. Determine QRS duration and shape. Is P wave shape consistent? 6. Determine ventricular rate.12 sec (3 small boxes): consider junctional rhythm. however. 3. A. Davis. This is considered a normal PRI. 2:1).20 sec (3–5 small boxes). “wide and bizarre”: consider ventricular ectopy..12 and 0. there are additional P waves that do not precede a QRS complex: consider 2 AV block.12 sec. 4. 3:1.12 (2–3 small boxes): consider normal. nor is there any correlation between the P wave and the QRS: consider 3 AV block (CHB). TOOLS/ INDEX Analyzing the P-R Interval (PRI) ■ PRI is consistent and between 0. type I. and determine if a P wave precedes every QRS complex. ■ PRI is longer than 0.12 sec (3 small boxes). 7. ■ QRS 0. Determine P-R intervals and if they are consistent. with notched or “rabbit ears” appearance: consider BBB. Analyzing the QRS Complex ■ QRS between 0. determine ratio of P waves to QRS complex (ex. ■ QRS 0. ■ QRS preceded by 1–2 very narrow “spikes”: think pacemaker. type II. 5. ■ PRI undergoes progressive lengthening until a QRS is dropped: consider 2 AV block. If more than 1 P wave precedes a QRS complex.Copyright © 2008 by F. 212 . 4:1. 2. Identify P waves. ■ PRI is 0. Basic ECG Assessment 1. ■ PRI is consistent. ■ PRI is not consistent. Determine atrial rate and rhythm. . . . . . . . . . .08–0. . . . . . .Present P-R . . . . . . . .12 sec) Sinus Bradycardia Rate . . . . . . . . . . . . . . . . . . . .Present P-R . . . . . . . . . . . . . . . . . . . . . . . . .Normal QRS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Regular P waves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Normal QRS .Narrow (0. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Copyright © 2008 by F. . . . . . . . . . . . . . .Narrow (0. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Regular P waves . . . . . . . .Fast ( 100 bpm) Rhythm . . . . . . . . . . . . . . . . . . . . . .08–0. . . . . . . 213 Sinus Tachycardia Rate . . . . .Slow ( 60 bpm) Rhythm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Davis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A. . .12 sec) TOOLS/ INDEX . . . . . .None (nondiscernible) P-R.Narrow (0....... ventricular → 125–175 bpm Rhythm .................................................................12 sec) Atrial Flutter Flutter waves Rate ...................................................................Irregularly-irregular P waves .......................................................................... Davis....................Usually regular P waves ..Nondiscernible QRS....................................... TOOLS/ INDEX Atrial Fibrillation Rate...................08–0........Nondiscernible QRS........................................................................................................................................................................................................................................................................ A................................................................................................Copyright © 2008 by F.....................................12 sec) 214 ............Atrial → 250–350 bpm.................................................Variable Rhythm ...............................Flutter waves → sawtooth pattern P-R..........08–0...............................Narrow (0...... ....Not present P-R ..................................................................Wide and bizarre ( 0....................................................................................................................................... buried in the QRS P-R............................................................ retrograde......Not present QRS ................. A..............................12 sec) TOOLS/ INDEX ...............................................................................Regular P waves ........Normal junctional rate is 40–60 bpm Rhythm ....................100–220 bpm Rhythm ... Davis.................Copyright © 2008 by F.............................................................12 QRS.......................Usually regular P waves........................................................................................If present: inverted............................................... 215 Junctional Rhythm No P waves Rate .................................................................................................Narrow Ventricular Tachycardia (Fast and Wide) Rate................................................................... it will be 0.........If present.............................. ...............................................................................................................................No rhythm P waves..................None P-R ..........................................................Completely chaotic and disorganized P waves.............................................................................................................................................................................................................................................................................................None Asystole Rate......Copyright © 2008 by F.......................None P-R .............................VF rate is 350–450 (no Ps or QRSs) Rhythm.............................................N/A QRS ................. A........................................................................................................No rate Rhythm ........... Davis...................................................... TOOLS/ INDEX Ventricular Fibrillation Rate .............................................................................................................................................Not present QRS......................None (occasional agonal beats) 216 ................. ........................................................................................................................12 sec) TOOLS/ INDEX ..........................................Regular P waves ..........................................20 sec QRS................................................Remains 0.................Gets progressively longer until a QRS is dropped QRS..................... 217 1 AV Block Prolonged P-R interval Rate ........................................................................................................................16 0....20 Dropped QRS Rate .........Narrow (0..........................................................Present.................................................Regular P waves ......Narrow (0.....................................Usually between 60–100 bpm Rhythm ....................Present P-R......................................................32 0............ A.................................08–0............................ one P for every QRS P-R ........12 sec) 2 AV Block (Mobitz I—Wenckebach) 0...................................................................Copyright © 2008 by F....................Slow ( 100) Rhythm .................................................08–0....... Davis. ..............................................................Atrial: 60–100 bpm............................ Davis................................................................................................................Regular P waves.......................................Both ventricular and atrial are usually regular P waves..........Inconsistent QRS .......................................................12 sec 218 ... but may also be wide 3 AV Block (Complete Heart Block) No correlation between atria and ventricles P P P P Rate ....... no correlation P-R ........................................................................................ ventricular: 20–40 bpm Rhythm ..................................................Usually wider than 0.................More Ps than QRSs..Narrow..........................Unblocked Ps usually have a normal P-R QRS...................................................................................................Usually slow Rhythm ............................................. TOOLS/ INDEX 2 AV Block (Mobitz II) Blocked P waves Rate ........................................................Copyright © 2008 by F.....More Ps than QRSs P-R......................... A.......................... ..........Normal TOOLS/ INDEX ....................................................................................................Premature Rhythm..........................................................Premature P waves .................................................................................................................................................................................N/A Rhythm.............................................................................. A..Copyright © 2008 by F...None P-R ............................................................................Not present in the PJC QRS ............................................................................... Davis..Temporary delay caused by compensatory pause P waves......N/A QRS ..............................................................................................................................................................Present in PAC.......... but may be hidden in the T wave P-R ....12 sec) Premature Atrial and Junctional Complex P PAC No P PJC Rate...................................................................................................... 219 PVC (Premature Ventricular Complex) Compensatory Pause Rate ....Wide and bizarre ( 0.......................... Release the tourniquet. hang IV solution with primed tubing close by. gloves. answer any questions. Locate vein: palpate with finger tips. 2 2 or other dressing open. Peripheral and Central Line Care General Care for All Vascular lines ■ Always use aseptic technique when caring for IV sites. have patient make a fist. Lower catheter almost parallel to the skin. gently tap. Apply tourniquet: proximal to intended insertion site. avoid touching site once it has been prepared. A. Advance the catheter: thread catheter into vein while maintaining skin traction and pulling back on needle. and observe for “flash back” in flash chamber. cleanse in a circular motion. Organize supplies: tear tape. and insert the needle 1–2 additional mL to ensure catheter has also entered the vein. tape. Position needle: bevel side up. ■ Assess for signs of infection every shift. to further enhance dilation. catheter. IV catheter of appropriate size. or wet dressings immediately. and give reassurance. ■ Call physician if IV access appears infected. Connect IV tubing. and apply sterile dressing per hospital policy/procedure. ■ Change loose. Remove needle. Insert needle. Secure catheter. Put on gloves: while waiting for cleansed area to dry. TOOLS/ INDEX Starting an IV Prepare the patient: explain procedure. and discard into approved sharps container. don gloves. Apply traction (opposite the direction of the catheter). 15 –30 Note: hold the needle with the thumb and pointer finger in a way that allows for visualization of the flash chamber. soiled. and document per hospital policy/procedure. antiseptic swabs. 220 . open clamp. and apply digital pressure just above the end of the catheter tip while gently stabilizing the hub of the catheter.Copyright © 2008 by F. Gather equipment: IV bag with primed tubing. tourniquet. and observe for free flow of IV fluid. Clean up. sharps container. or dangle arm below heart. Cleanse site: using moderate friction. Davis. ■ Remove peripheral line if site appears infected or phlebitic. apply heat/warm soak. sharps container within easy reach. moving outward from intended site. either mid-forearm or above the elbow. dressing. or leaks are seen. dextrose. CVC: External Access Port(s) (Groshong) ■ Avoid touching the exit site with fingers. ■ Clean with alcohol. Crystalloids contain water. change and clean the exit site dressing once a week. ■ Change the end cap(s) every 7 days or sooner if any blood.9% NaCl. swelling. cracks. site cool to touch) or phlebitis (vein feels firm and appears red. Never use iodine! Tunneled CVC: External Access Ports (Hickman. discontinue IV. ■ Change the dressing. Davis. tenderness. cracks. A. and clean the exit site every 2 days. burning with infusion. sodium chloride. and tenderness). Broviac. and clean the exit site every day. If using an opsite. 221 Peripheral Access IV Lines ■ Change site every 72 hours. blanching of skin. they remain in intravascular space longer and are used for volume expansion. redness. If recently inserted. provide aseptic incision care until healed. ■ Change the end cap(s) every 7 days or sooner if any blood. ■ Change the dressing. ■ Assess for signs of infiltration (swelling. 0. or leaks are seen. Leonard. change and clean the exit site dressing once a week. IV Solutions: Crystalloids and Colloids IV solutions can be divided into two basic categories: crystalloids and colloids (volume expanders). 3% and 5% saline Components Na and Cl Indications ■ Alkalosis ■ Fluid loss ■ Sodium depletion (Continued on the following page) TOOLS/ INDEX . ■ If using a transparent film. Comparison of Crystalloids Type of Solution Saline solutions NS. saline. decreased or no infusion rate. or Ventra Catheters) ■ Keep tubes clamped when not being used. and restart in a new site. and/or electrolytes and are commonly used to treat different fluid and electrolyte imbalances. warmth.Copyright © 2008 by F. Implanted Port Catheters: Groshong ■ Wash skin around area of port daily with soap and water. Colloids (also referred to as plasma expanders or volume expanders) have an increased osmotic pressure in comparison with crystalloids. D10W Components Dextrose in water ■ ■ ■ ■ ■ ■ ■ ■ Indications Replace calories as carbohydrates Prevent dehydration Maintain water balance Promote sodium diuresis Promote diuresis Correct moderate fluid loss Prevent alkalosis Provide calories and sodium chloride Dextrose and saline mixtures D5NS. dextran. Davis. 222 . and commercial plasmas (e. K.. Colloids are protein solutions such as albumin. D51/2NS.g. synthetic sugar. plasma. and lactate ■ Replaces fluid lost due to vomiting or GI suctioning ■ Treats dehydration ■ Restores normal fluid balance Volume Expanders (Colloids) Volume expanders include colloids.Copyright © 2008 by F. Ca. Hetastarch is a synthetic colloid that works similarly to Dextran. Because Dextran is slowly metabolized. and hetastarch. Ringer’s lactate Dextrose in saline Combination of Na. it does not stay in the vascular space as long as a colloid. A. Plasmanate). D10NS Multielectrolyte solutions Lactated Ringer’s. Dextran is a complex. Cl. TOOLS/ INDEX Comparison of Crystalloids (continued) Type of Solution Dextrose solutions D5W. Comparison of Volume Expanders (Colloids) Type of Solution Albumin 5% and 25% Components Human plasma protein Indications 5%: Rapid volume expansion and mobilize interstitial edema 25%: Hypoproteinemia To increase serum colloid osmotic pressure Plasma plasmanate Contains human Plasma protein plasma proteins fraction in NS Dextran 40% and 70% Hetastarch: Hespan Volume expansion Synthetic colloid made of glucose Mobilize interstitial edema polysaccharides Synthetic colloid made from corn Volume expansion Mobilize interstitial edema Blood products: any of the components found in whole blood. To replace clotting factors after multiple transfusions ( 6 PRBCs). Plasma and clotting factors. platelets. 1 unit may increase pools of 6–10 units. No clotting factors or Acute and chronic anemia. A. may be given to an exsanguinating patient. Indications Rarely used. plasma removed. Davis. It is not without risk—stored blood may still become contaminated. ■ Used to prevent transmission of disease from donor blood. coaguUsually given in lopathies.Copyright © 2008 by F. ■ Salvage of blood normally lost during a surgical procedure. Coumadin intoxication. platelet count by 6000 units. TOOLS/ INDEX . Low platelet counts. DIC Fresh frozen plasma Cryoprecipitate Clotting factors Autologous Blood Donation/Transfusion ■ A procedure for collecting and storing a patient’s own blood several weeks before its anticipated need by the patient. 223 Comparison of Blood Products Blood Product Whole blood Packed red blood cells (PRBCs) Platelets Components Contains all blood products. 80% blood loss. fibrinogen deficiency. replace clotting factors Hemophilia. 224 .Reusable Assessment Flowsheet Patient Time ↓ BP HR DX/S/P Vital Signs RR O2 sats on on on on Temp Notes TOOLS/ INDEX on on on on Copyright © 2008 by F. Davis. A. Davis. A.Labs/Diagnostics Time ↓ Na Cl K Ca Mg General Chemistry Glu BUN Creat. Coagulation ACT PT INR PTT Thrombin time pH PO2 Blood Gases PCO2 HCO3 BE CO2 SaO2 TOOLS/ INDEX . Hematology Hct Hgb RBC WBC Platelets Troponin-I Cardiac Enzymes Troponin-T CPK-MB SGOT LDH Myoglobin 225 Copyright © 2008 by F. Davis. A.Copyright © 2008 by F. TOOLS/ INDEX Intake and Output Record Intake IVF Amount In Urine Output Amount Out IVPB NG drainage/emesis Blood/colloid Oral intake Liquid stool Other Total In Total Out 226 . Page 9 from Hockenberry MJ. pages 55–56 from Taber’s Cyclopedic Medical Dictionary. FA Davis. FA Davis. 167–168. Gallimore D. TOOLS/ INDEX . 2005. Philadelphia. 36. Management of acute decompensated heart failure. 2001. Building a rapid response team. Wilson D. Neurologic assessment skills for the acute medical surgical nurse. pages 35. Tube feeding in the demented elderly with severe disabilities. 227 Selected References Crimlisk JT. 124. p.62(5):1223–27. 49–67. Philadelphia. 144–145 from Scanlon VC and Sanders T: Essentials of Anatomy and Physiology. 206 from Myers E: RNotes: Nurse’s Clinical Pocket Guide. Isr Med Assoc J 2006 Dec. A consensus statement on critical thinking in nursing. M. 10. Used with permission. Deglin JH.Copyright © 2008 by F. J Psych Res 12:196–198 (1975) *Reference ranges vary according to brand of laboratory assay materials used. Philadelphia. Offner PJ. Hyperosmolar hyperglycemic. Fundamentals of Nursing. Grande MM. ed. Part 2: Nursing care to prevent complications. Critical thinking models and their application. Jackson. Copyright. ed. FA Davis. Vallerand AH: Davis’s Drug Guide for Nurses. Garner JS. Pohl Publishing. 2005. Philadelphia. Varughese S. Illustration Credits Pages 17. Hospital infection control practices advisory committee: Guideline for isolation precautions in hospitals. 2007 Apr-Jun. 57. nonketotic coma http://www.emedicine. Halvorsan L. Caring for patients after mechanical ventilation. 55 from Williams L and Hopper P: Understanding Medical Surgical Nursing. Sole ML. FA Davis. 2003. Davis.103(11):28–29. Conversations in Critical Thinking and Clinical Judgment. Van Leuven K. Winkelstein ML: Wong’s Essentials of Pediatric Nursing. Caring for patients after mechanical ventilation. 2001. Elsevier Saunders. Adv Crit Care Nurse 2007 AprJun. Philadelphia. 23(1):3–9. Jaul E. Sagarin M. 1259. Taber CW (eds): Taber’s Cyclopedic Medical Dictionary. 24:24–52. discussion 1227–28. 2004. 97–98. Review. pages 53. ed 2. 2003. Heit J. Gallimore D. Singer P. Philadelphia. Thomas CL. et al. FA Davis. J Trauma 2007 May. Pensacola. Mini Mental State. 115. Crit Care Nurs Q. Wilkinson JM. B Case (eds. Louis. Scheffer BK. Implementation of a rapid response team decreases cardiac arrest outside of the intensive care unit. Philadelphia. 2003. Am J Infect Control 1996. Nurs Times 2007 Mar 13–19. A. 2006. Introduction to Critical Care Nursing. St. ed 4.8(12):870–74. ed 19. Calderon-Margalit R. 2007.htm. Venes D. Adapted from Folstein et al.com/emerg/topic264. 77–79. FL.). Accessed March 2007. et al. Philadelphia. 7. check normal reference ranges from your facility’s laboratory when evaluating results. ed. McAfee A. pp. Orthop Nurs 2004 Jan-Feb. 59.18(2):129–40. 19. Rubenfeld MG. J Nurs Educ 2000 39(8):352–59. FA Davis. Mosby. Roberts R. Part 1: Physical and psychological effects. FA Davis.30(2):94–103.103(12):28–29. DD Ignatavicius. Nurs Times 2007 Mar 20–26. In M Jackson. 186 Amyl nitrate. 186 Acidosis. 186 Assist-control (AC) ventilation. 167f Advance directives. 214f Atrioventricular (AV) block. 36f Blood gas values. for pressure ulcer. 157–158 Antidysrhythmics. 228 . 194. 223 Automated external defibrillators (AEDs). 54f Balance. in Heimlich maneuver. 191. 171 Airborne precautions. 35f. 169. 54. in emergency. artificial. reference range for. 47 Bilirubin. 109–112 wound. 201 assessment of. 217f–218f B Back. 184 Acute hemolytic reaction. 55–56. 47 Bleeding/hemorrhage. assessment of. 190. 185–186 Amiodarone (Cordarone). A. 188. of oxygen. 51–52 AC (assist-control) ventilation. 196 Antihypertensives. 37–38. 168f Bacteremia. 184. 167f. 100–101 thrusts to. 37–38. 185 Alupent (metaproterenol). 54. 18–19 Artificial airways. 187. in emergency. 186–187 Atrial fibrillation. 191 Bilevel positive airway pressure (BiPAP). Davis. 11–12 Anaphylaxis. in emergency. 48–49 Albumin. 175 ALT. assessment of. to transfusion. 38–39 Aspirin (acetylsalicylic acid). 175 Bag delivery. diabetic. to transfusion. assessment of. 185 Adrenalin (epinephrine). 189. transfusion and. 92 Adenosine (Adenocard). 26–27 gastrointestinal. in infection prevention. 201 Allergic reaction. 214f Atrial flutter. 51–52 Blood loss. 17–18 Arterial occlusion. 147 Airway(s). 192. 168f. 169. 23 Angiotensin-converting enzyme (ACE) inhibitors. 37–38. ventilator. reference range for. 167f ABG (arterial blood gas) values. 167f. in patient with feeding tube. 195. 216f Ativan (lorazepam). 140 Alkaline phosphatase. 185. 47 AST. 190–191 Adrenergic agonists. 201 BiPAP (bilevel positive airway pressure). 185. 54f Aminophylline (Truphylline). 187 Autologous blood transfusion. 47 ACE (angiotensin-converting enzyme) inhibitors. 170 Alarms. 100–101 pain in. 26–27 Bloating. A Abdomen. 175 Acute renal failure. 198 routes for administration of. choking in. 36f Arterial hematoma. reference range for. t-PA). 186. 164 AEDs (automated external defibrillators). 51–52 Arterial circulation. 184 Antibiotic-resistant staphylococcal infections. 201 Asystole. 163 distention of. 187 Arterial blood gas (ABG) values. 170 CPR in. reference range for. oxygen delivery via.Copyright © 2008 by F. See Bleeding/hemorrhage. 201 assessment of. 217f–218f Atropine. in Heimlich maneuver. 169 Heimlich maneuver in. TOOLS/ INDEX Index Note: Page numbers followed by f refer to figures (illustrations). reference range for. 201 Albumin solution. 186 Analgesics. 186 Atracurium (Tracrium). 187 Beta blockers. 60 Benadryl (diphenhydramine). 175 Angina. 116–117 Activase (alteplase. 184 Acetylsalicylic acid (aspirin). 201 Alteplase (Activase. t-PA). 222 Albuterol (Ventolin). 55f–56f assessment of. 177 in reaction to transfusion. 55–56. 171 AV (atrioventricular) block. 169. 185 Activated charcoal. 53. 108 Blood flow. 173. 53f. 55f–56f Aspiration. 160 methods of opening. 163 blows to. 185 Alginates. 185 Ambu bag. 190 Adult. 186. 201 assessment of. 186 Corvert (ibutilide fumarate). 61 hyperosmolar hyperglycemic nonketotic. 16 in emergency. 208f studies of. 127–128 Complete heart block. in Heimlich maneuver. 206.Copyright © 2008 by F. 213f Brain. 47 CPR (cardiopulmonary resuscitation). 53. in emergency. 223 adverse reactions to. 119–120 myxedema. 220–221 Cervical spine. of patient’s status. 148–149 Colloids. 66 assessment scale for. 169. reference range for. 169 Cardiovascular system. 36f assessment of. 40–44. 188 Calcium imbalance. 188 Calcium gluconate. 80 Braden scale. 6–8 Cryoprecipitate. assessment of. 184 Chemistries. assessment of. 167f. management of. 148 Continuous mandatory ventilation (CMV). 21–24 thrusts to. 168f Chin lift. to open airway. 170 Cholesterol. delivery and pickup of. 82 Cannula delivery. 206f–219f. 45–46 rescue. 188–189 CDAD (Clostridium difficile–associated diarrhea). 168f. 167f. 170 CPR in. functional areas of. 161. 188. and sudden neurological deficit. 80 C Calan (Isoptin. 169 pain in. 199 Calcium chloride. 11 Colitis. in nursing. 121–122 Communication. 218f Compressions (chest compressions). in nursing. reference ranges for. 169 Heimlich maneuver in. 169 Bretylium (Bretylol). 47 Coagulation tests. A. 148–149 Central lines. 39–40 Child/infant. 167f. 136 Bradycardia. 62 Creatinine values. 165–166 COLDERRA mnemonic. choking in. 168f. head tilt and. 47 Continuous positive airway pressure (CPAP). 20–21 sinus. 170 compromised. 201 assessment of. Davis. in pain assessment. activated. reference range for. 221–222 Cultural sensitivity. 103–104 Contact precautions. 168f. 201 Cardiac cycle. 78f assessment of. delayed. 201 assessment of. See also Heart and Cardioentries. 201–202 Chest. 201 assessment of. 199 Calcium. of oxygen. 1–2 Compartment syndrome. 53f Capillary refill. 185 BUN (blood urea nitrogen) values. 178. 202–203 Cardiogenic shock. 191 Bronchodilators. 186 TOOLS/ INDEX . dislodgement of. 174–175 Blood urea nitrogen (BUN) values. 203 Blood transfusion. 170 Chloride. in CPR. 12–13 Cyanide poisoning. 212 Cardiac markers. 108 Cranial nerves. 167f. 37 in emergency. 60 Cordarone (amiodarone). 169 Cramps. 75–77 Breathing. reference range for. in emergency. in CPR. 169 Clostridium difficile–associated diarrhea (CDAD). 66 Consciousness level. 168f. 80–81 Critical thinking. 167f. assessment of. 16 Carbon dioxide. 3–4 Constipation. in infection prevention. in patient with feeding tube. 163 Charcoal. 201 Choking. 202 Code responses. 201 Calcium channel blockers. verapamil). care of. 163 compressions of. pseudomembranous. 223 Crystalloids. 15–16 Cardizem (diltiazem). 168f Chest tube. 229 Blood tests. 77f vascular lesions of. normal vs. arterial. waveform of. 188 Brevibloc (esmolol). 210. 192 CPAP (continuous positive airway pressure). 201 Circulation. altered. 148–149 CMV (continuous mandatory ventilation). 169 Confusion. informed. 16. 64–66 Consent. for pressure ulcer risk. 162. 222 Coma. antidote to. 59f reference range for. reference ranges for. 47 Coordination. 169. assessment of. assessment of. in CPR. 179f Cardiopulmonary resuscitation (CPR). 140 Decadron (dexamethasone). assessment for. 16. 16 Education. 222 Embolism. 99–100 bleeding from. 188. 139 First-degree AV block. medications for. 171 Extremities. regarding medications. 131–132 Fresh frozen plasma. 23 Emergency(ies). 109–112 Digoxin (Lanoxin). 130–131 Feeding tube(s). 223 Furosemide (Lasix). 188–189 Diphenhydramine (Benadryl). pulmonary. 139–140 Droplet precautions. 190 Dorsogluteal site. automated external. in infection prevention. 116 disorders of. for pressure ulcers. for IM injection. 56. A. 206f–219f. 171 Dehydration. 163 hip. 137 Do Not Resuscitate orders. 210. in emergency. 15 in emergency. 216f Film dressings. assessment of. for IM injection. 190. e. atrial. 40–42 Dysrhythmias. in infection prevention. 82–91 Electrolyte solutions. 189–190 Diltiazem (Cardizem). 190 Documentation. 169. 116–123 Endotracheal tube. 194 G Gait. 217f ′′Five P’s. E ECG (electrocardiography). 162 Distention. 124f assessment of. in emergency situations. 164 Dopamine (Intropin). 100–101 Diuretics. 4–5 hypertensive. 189 Dexamethasone (Decadron). 162 Face shield. 91 External defibrillators. 151 Fibrillation. 212 Electrolyte imbalances. 186.′′ in compartment syndrome. 129–130 pathological. and chest pain. 125 D Dantrolene (Dantrium). 172 assessment in cases of. 163 Eye protection. necrotizing. 116–117 Dobutamine (Dobutrex). 149–152 nonhemolytic transfusion reaction and. 175 sepsis and. for pressure ulcer. for pressure ulcer. 184–199 response to. 185. for pressure ulcer. 182–183 230 . 84–85 Delegation. 187 Diprivan (propofol). 189 Dextran solution. 160–164 documentation in cases of. 132–134 Fasciitis. 27–28 medications used in. in emergency. 165–166 Endocrine system. 214f ventricular. 189 Data sheets. 164 Diarrhea. 212 Edema. 146 F Face and head assessment. 190–191 Esmolol (Brevibloc). 192. 204f Dressings. 4–5 in management of pressure ulcer. 127 Flumazenil (Romazicon). 56f Enzymatic débriding agents. in infection prevention. TOOLS/ INDEX Electrocardiography (ECG). assessment for. 189 Defibrillators. 151 SIRS and. 106–109 Fever. 206f–219f. 191 Euvolemic hyponatremia. for pressure ulcer. 214f Foam dressings. 194 Dizziness. assessment of. 146 Fall(s). 210. abdominal. 204f Demerol (meperidine). 140 Fracture(s). 148–149 in patient with feeding tube. when patient codes. 189. 44–45 chest pain from. 197 Disability. 67–68 Deltoid site. Davis. 140 Epigastric disorders. 5–6 Delirium. 206. in nursing. 147 Dyspnea. 196 types of. 104–105 Clostridium difficile–associated. 222 Diabetic ketoacidosis (DKA). 68–69 DKA (diabetic ketoacidosis).g. 190 Digoxin immune fab (Digibind). Tachycardia.Copyright © 2008 by F. 224f–226f Débriding agents. problems with. 206. of patients. 116–117 Diagnostic studies. 222 Dextrose solutions. 108 Digestive tract. assessment of. 191. See specific problems. atrial.. 169. 194. 197 Flutter. 24 Epinephrine (Adrenalin). 115f assessment of. 80–82 Glasgow coma scale. and chest pain. 82 Hyperglycemia. in infection prevention. 190. 99–100 bleeding from. 146 Head. 47 Intracranial pressure (ICP). 178. 83 Hyponatremia. assessment of. 168f tilting of. 115f assessment of. 201 Glucose imbalance. 181 High-pressure alarm.entries. 118 Hyperglycemic nonketotic coma. 162 support of. 71–72 Intramuscular (IM) injection sites. 47 Inamrinone (Inocor). 168f Hematemesis. anatomy of. 109–112 Genitourinary system. in infection prevention. 193 Intermittent mandatory ventilation (IMV).Copyright © 2008 by F. 151 Informed consent. 206. 170 trauma to. to open airway. 119–120 Hyperphosphatemia. to transfusion. in Heimlich maneuver. increased. 25–26 Heart sounds. 187 Hypervolemic hyponatremia. chin lift and. in patient with feeding tube. 168f Infarction. 26–27 Heparin. 168f. 43–44 Infant/child. as emergency. 169. 17–18 Hemolytic reaction. 120–121 Hypokalemia. 147 H Hand placement. 212 Heart block. 167f. 184. 87–88 Hyperosmolar hyperglycemic nonketotic coma (HHNC). 167f. fracture of. arterial. 118–121 Glycoprotein IIb/IIIa inhibitors. 71–72 IM (intramuscular) injection sites. 169 Heimlich maneuver in. 139 Hydrogels. 201 Gastric secretions. 192 Humidified systems. 83 Hypernatremia. 193 Inotropics. for pressure ulcer. 69–70 Heart. 217f–218f Heart failure. 49 Hip. 54. 84 Hypertension. 222 HHNC (hyperosmolar hyperglycemic nonketotic coma). 97f–98f assessment of. 23 Infection prevention. 168f Hand washing. reference range for. 91 Hypovolemic shock. 175 Hemorrhage/bleeding. choking in. 168f. 119–120 High-alert medications. 24 electrical conduction in. 204f TOOLS/ INDEX . of oxygen delivery. 170 CPR in. 35f conditions compromising. 191–192 Gowns. 146–148 Inflammatory response syndrome. 109–112 wound. 26–27 gastrointestinal. 107 Gastroesophageal reflux. A. 28–30 Hypotonic hyponatremia. 167f. in patient with feeding tube. 27–28 medications for. 204f IMV (intermittent mandatory ventilation). 179f I Ibutilide fumarate (Corvert). 193 Ineffective breathing. 91 Hypocalcemia. 119–120 Hyperkalemia. hyperosmolar. 167f. 192 Hepatitis. increased. systemic. 49 High respiratory rate alarm. 43–44 Hypovolemic hyponatremia. 15 in emergency. 206f studies of. 89–91 Hypophosphatemia. Davis. 83 Hypotension. 209f sites for assessment of. 146 Glucagon. 109–111 Hematological tests. 204f. 3–4 Injection sites. 139 Hypercalcemia. and chest pain. in CPR. 205f Inocor (inamrinone). leakage of. reference range for. for pressure ulcer. 191 Glucose. 82 Hypoglycemia. 107 Gastrointestinal tract. 86–87 Hypermagnesemia. 231 Gamma-GT. reference ranges for. 54f Hydrocolloid dressings. 23. in infection prevention. 192 ICP (intracranial pressure). 203 Hematoma. 91 Hypoventilation. 17f Heimlich maneuver. 61 Gloves. 88–89 Hypomagnesemia. 206f–219f. 210. 167f. myocardial. 153–154 Hetastarch solution. 129–130 Histamine blockers. See also Cardiac and Cardio. 195 Narcan (naloxone). 54f Mechanical ventilation. 112–113 in patient with feeding tube. of patient. 199 IV infusion. 53. reference ranges for. 185 Methicillin-resistant Staphylococcus aureus (MRSA) infection. (in)compatibility of IV potassium chloride in. 23 infection of. chest pain from. A. 169. 54. 63–64 Mnemonic aids. 170 Junctional rhythm. 83 232 . 189 Metaproterenol (Alupent). 194 LDH. diabetic. 206f. 186 Lower gastrointestinal tract. in electrocardiography. 195 Mini–Mental Status Examination. Medications. 53f Nasogastric tube (NGT). 66 Level of consciousness. to pain assessment. assessment of. 222 Multiple organ dysfunction syndrome. 116–117 Ketorolac (Toradol). 53f. embolism in. 102–103 Nasopharyngeal airway. assessment of. administration of. 23 Lung sounds. Davis. 215f K Kayexalate (sodium polystyrene sulfonate). 53. altered. See Intravenous infusion. Urine. 92 L Laboratory tests. acute. 183 educating patients about. 15. 55f Nausea. 184–199 high-alert. 44–45 chest pain from. 157–158 Multielectrolyte solutions. 67–68 Meperidine (Demerol). 194–195 Mask(s). 193 Ischemic attack. 146 in oxygen delivery. 158–159 Myocardial infarction (MI). 1–4 Lethargy. 15 in emergency. 153 Lorazepam (Ativan). 174–175 KCl in. reference range for. 24 Mycobacterium tuberculosis infection.Copyright © 2008 by F. 223 adverse reactions to. 80–82 failure of. 220 blood products used in. of nursing. 198–199 Kidney(s). 193 Isoptin (Calan. transient. reference range for. oxygen delivery via. 181–182. 202 Magnesium imbalance. 163 Intravenous infusion. 194 Mannitol (Osmitrol). 200 sources of error in. viral infection of. 111–112 Meningitis. 151 Musculoskeletal system. 63–64 change in. 64–66 Lidocaine (Xylocaine). J Jaw thrust. in infection prevention. insertion of. 37 M Magnesium. assessment of. 217f–218f Monitoring. chest pain from. 195 Nasal prongs. 125–126 disorders of. See Nursing and see also Patient(s). 190 Ipecac syrup. 48 Lung(s). 60. 23 Milrinone (Primacor). 48–49 problems with. 2. 195 Motion. prevention of infection from. medications incompatible with. 60. 23 Myxedema coma. 55. 108 Neck. 121–122 N Naloxone (Narcan). 201 Lanoxin (digoxin). bleeding from. 200 solutions used in. 1 Morphine sulfate. 146 Liver. 181 Melena. assessment of. See also Intravenous infusion. to open airway. 207f Legal aspects. 47–48 Medical-surgical nursing. 155 Mental status. 202 Lead placement. 10–11 Mobitz-type AV block(s). assessment of. 182–183 emergency. 75–77 Isoproterenol (Isuprel). 158 chest pain from. 201–203 Lactic acid. 157–158 MI (myocardial infarction). 184. 111–112 Low exhaled volume alarm. 156. assessment of. 47 alarms used with. 167f. 49 Low-pressure alarm. 193 Ketoacidosis. reference range for. verapamil). 194 Linens. 221–222 Intropin (dopamine). 190 Lasix (furosemide). 125 MRSA (methicillin-resistant Staphylococcus aureus) infection. TOOLS/ INDEX Magnesium sulfate. and chest pain. See also Urinary tract. 9–11 mnemonics aiding. 196 IV. 151 Oropharyngeal airway. 30–31 Pathological fracture. 100–101 assessment of. 202 Physician orders. assessment of. 169 Q QRS complex. 44–45 chest pain from. 147 Neurogenic shock. analysis of. 66 Oliguria. analysis of. 2–3 medication administration and. 47 Pericarditis. 186. 195 P-R interval. spiritual care in. 92 Organ dysfunction syndrome. 202 Potassium chloride solutions. in transfusion. code responses for. 23 PEEP (positive end-expiratory pressure). 148–149 PSV (pressure support ventilation). 1–4 pain management in. 5–6 documentation in. See also Patient(s). 53f Norcuron (vecuronium). 47 Pulmonary embolism (PE). 219f Pressure support ventilation (PSV). prevention of injury from. 47 Pressure ulcer. medications incompatible with. chest pain from. 222. 146 falls by. 23 Pulmonary infection(s). 125–126 NF (necrotizing fasciitis). multiple. 178. 195 Nonhemolytic reaction. 196 Nitroprusside (Nipride. 207f Premature atrial complex. 9–10 chest. insertion of. 10 PQRST waves. 9 Nursing. 3 Pitocin (oxytocin). 132–134 monitoring of. Nitropress). 24 Perineum. 131–132 Patient(s). care of. 1 safety of. 158 chest pain from. 53f–55f Oxygen transport. 223 Platelets. 197 Pseudomembranous colitis. 16 in emergency. 83–84 Phosphorus. 196 Pitressin (vasopressin). 200 Potassium imbalance. 175 Nonketotic coma. 196 P Pacing. A. 196–197 Propofol (Diprivan). 4–5 legal aspects of. 163 Peripheral lines. in pain assessment. regarding medications. prevention of infection from. 197 Protein. 156 chest pain from. transfusion and. Davis. 233 Necrotizing fasciitis (NF). 199 Plasma infusions. 53. assessment of. normal deflection of. 23 Pulse. 102–103 Nitroglycerin (Nitrostat). 156. 12–13 delegation in. 55f Osmitrol (mannitol). 6–8 cultural sensitivity in. 135–140 Primacor (milrinone). in pain assessment. 223 Pain. 198 Neurovascular status. 44–45 chest pain from. 23 Positive end-expiratory pressure (PEEP). 181–182 PE (pulmonary embolism). See also Pain. febrile. 86. 8–12 abdominal. in emergency. 165–166 communication of status of. critical thinking in. 223 reference range for. 21–24 management of. 212 Procainamide (Pronestyl). 130–131 Needles/sharps. 1–14. 219f Premature ventricular complex. 88–89 PQRST mnemonic.Copyright © 2008 by F. sudden. 53–55. assessment of. hyperosmolar hyperglycemic. 119–120 Nonrebreather delivery. reference range for. 75–77 Neuromuscular blocking agents. 10–11 rating scales in. 60–61 in emergency. 212 TOOLS/ INDEX . 194–195 Oxygen delivery systems. 182–183 equipment used in care of. reference range for. reference range for. 163 Neurological deficit. 55. transcutaneous. 180f Neurological assessment. 220–221 Phosphate imbalance. 8–12 Palpitations. 199 Numeric rating scale. of oxygen. 1–2 education for. 58f Oxytocin (Pitocin). in respiratory system. 14 O Obtundation. 130–131 NGT (nasogastric tube). 219f Premature junctional complex. 47 Potassium. 203 Pneumonia. See also Nursing. 127. 8–12. 171 Packed red blood cells. 202 Proton pump inhibitors. 33–35 sinus. 185 Tracheostomy tube. 47 Sinus bradycardia. assessment of. 198–199 t-PA (Activase. 92 Rescue breathing. 87. 171 Tendon reflexes. grading of. 144f Skin. 193 Sore. 215f TCP (transcutaneous pacing). assessment of. 178. 202 Sodium bicarbonate. in patient with feeding tube. 158–159 R Rapid response teams. 65 management of choking victim based on. 213f Sinus rhythm. 75–77 Stupor. 164 Romazicon (flumazenil). 127. 1 Stomal infection. 180f septic. pressure. 178 Sharps/needles. 80–82 Renal failure. 170 Resuscitation. 126–127 structures of. 45–46 Respiratory system. 69–70 spinal cord. 37–38 oxygen and carbon dioxide transport in. 151 Septic shock. 72–73 Self-harm. 205f Second-degree AV block. 58f–59f Responsiveness. 74–75 Truphylline (aminophylline). 2–3 medication administration and. 186–187 Transcutaneous pacing (TCP). 201–203 Reflexes. 40–42 SIMV (synchronized intermittent mandatory ventilation). 168f. 151 T Tachycardia. 75–77 Transparent films. 178 Shortness of breath (SOB). 147 Shock. 32–33 Systemic inflammatory response syndrome (SIRS). 197 S Safety. 139 Transtracheal oxygenation. 145f SOB (shortness of breath). 163 Spiritual care. protection of patient from. 74–75 Spine. TOOLS/ INDEX Sodium imbalance. prevention of injury from. Davis. 211f Sinus tachycardia. assessment of. in CPR. 167f. 169 Respiratory distress/failure. 177 cardiogenic. 178. 218f Thrombolytics. 151 Skeletal system. 135–140 Spinal cord. 167f Reference ranges. reference range for. 179f hypovolemic. 141–142 Synchronized intermittent mandatory ventilation (SIMV). 60 Sepsis. cardiopulmonary. 55f Trauma. 221. 179f neurogenic. 171 Transfusion. 198 Sudden neurological deficit. 217f–218f Seizure(s). 185–186 Tuberculosis. 75–77 Surgical site. 89–91 Sodium polystyrene sulfonate (Kayexalate). 2–3 Sensation. 205f Succinylcholine chloride (Sucostrin). 4 Staphylococcal infection. for nurses. 197–198 234 . 60 Third-degree AV block. 57f assessment of. problems involving. assessment of. 174–175 Transient ischemic attack. for laboratory tests.Copyright © 2008 by F. 213f ventricular. 222 SC (subcutaneous) injection sites. 185. 40–42 Sodium. alteplase). 79f trauma to. in patient with feeding tube. 14 Standard infection-prevention precautions. assessment of. 169 orders against. 55. 107 Renal assessment. A. 16. 16. 49–51 Tracrium (atracurium). in emergency. 223 adverse reactions to. antibiotic-resistant. 157–158 State practice laws. acute. 179f–180f anaphylactic. 176–178. 146–147 Standard of care. 164–165 Recovery position. head. 151. in nursing. 181–182 Saline solutions. for pressure ulcer. 107 Strength. assessment of. 151. 66 Subcutaneous (SC) injection sites. 178. in nursing. of patient. 213f SIRS (systemic inflammatory response syndrome). 60–61 Reflux. 198 Thyroid disorders. 60 Stroke. 47 Syncope. 121–123 Toradol (ketorolac). dislodgement of. 169 Ventilator(s). 215f Ventrogluteal site. 199 Ventilation rate. 109–111 Urgent situations. for rating pain. 113–114 in patient with feeding tube. 95–96 Urine. Davis. 143f X Xylocaine (lidocaine). 217f Whole blood. 47–48 Ventolin (albuterol). for IM injection. 142. 135–140 vacuum-assisted closure units for. for transfusion. 9 Volume expanders. for IM injection. 47 alarms on. 135–140 Unresponsiveness. 216f Ventricular tachycardia. 194 TOOLS/ INDEX . 204f Vecuronium (Norcuron). 153–154 Visual analog scale. 127. 97f–98f assessment of. 108 W Wenckebach AV block. 223 Wound(s). 204f Venturi mask. 26–27 pressure-ulcer. 235 U Ulcer. A. 127. in CPR. 169 management of choking in presence of. hemorrhage from. 202 Urinary tract. 185 Ventricular fibrillation. 48–49 problems with. Isoptin). pressure. 80–82 catheterization of.Copyright © 2008 by F. 222 Vomiting. Uric acid. 199 Vastus lateralis site. 157–158 Vasopressin (Pitressin). oxygen delivery via. 170 Upper gastrointestinal tract. 142. See Emergency(ies). for wounds. 54f Verapamil (Calan. reference range for. 143f Vancomycin-resistant staphylococcal infection. 92 retention of. 54. 199 Viral hepatitis. 95–96 V Vacuum-assisted closure (VAC) units. 94–95 infection of. low output of. 93–94 UTI (urinary tract infection). assessment for. bleeding from. Copyright © 2008 by F. Davis. TOOLS/ INDEX Notes 236 . A. Davis. A.Copyright © 2008 by F. Notes .