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Brunner & Suddarths

Textbook of
Medical-Surgical
Nursing

Edition

13

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Brunner & Suddarths

Textbook of
Medical-Surgical
Nursing
Janice L. Hinkle, PhD, RN, CNRN
Associate Professor
The Catholic University of America
Washington, DC

Kerry H. Cheever, PhD, RN


Professor and Chairperson
Department of Nursing
Moravian College
Bethlehem, Pennsylvania

Edition

13

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Vice President, Publishing: Julie K. Stegman


Supervisor, Product Development: Betsy Gentzler
Editorial Assistant: Dan Reilly
Design Coordinator: Joan Wendt
Art Director, Illustration: Jennifer Clements
Illustrator, 13th edition: Wendy Beth Jackelow
Production Project Manager: Cynthia Rudy
Manufacturing Coordinator: Karin Duffield
Prepress Vendor: Aptara, Inc.
13th Edition
Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins.
Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins. Copyright 2008 by Lippincott Williams
& Wilkins, a Wolters Kluwer business. Copyright 2004, 2000 by Lippincott Williams & Wilkins. Copyright 1996 by
Lippincott-Raven Publishers. Copyright 1992, 1988, 1984, 1980, 1975, 1970, 1964 by J. B. Lippincott Company. All rights
reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any
means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and
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9 8 7 6 5 4 3 2 1
Printed in China.
Library of Congress Cataloging-in-Publication Data
Hinkle, Janice L., author.
Brunner & Suddarths textbook of medical-surgical nursing / Janice L. Hinkle, Kerry
H. Cheever. Thirteenth edition.
p. ; cm.
Brunner and Suddarths textbook of medical-surgical nursing
Textbook of medical-surgical nursing
Preceded by Brunner & Suddarths textbook of medical-surgical nursing / Suzanne C.
Smeltzer ... [et al.]. 12th ed. c2010.
Includes bibliographical references and index.
ISBN 978-1-4511-3060-7 (v. 1 American edition : hardback : alk. paper) ISBN
978-1-4511-4666-0 (v. 2 American edition : hardback : alk. paper)
I. Cheever, Kerry H., author. II. Title. III. Title: Brunner and Suddarths textbook
of medical-surgical nursing. IV. Title: Textbook of medical-surgical nursing.
[DNLM: 1. Nursing Care. 2. Perioperative Nursing. WY 150]
RT41
617.0231dc23

2013028429
Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However,
the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the
information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy
of the contents of the publication. Application of this information in a particular situation remains the professional responsibility of the practitioner; the clinical treatments described and recommended may not be considered absolute and universal
recommendations.
The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are
in accordance with the current recommendations and practice at the time of publication. However, in view of ongoing research,
changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader
is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug.
Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for
limited use in restricted research settings. It is the responsibility of the health care provider to ascertain the FDA status of each
drug or device planned for use in his or her clinical practice.
LWW.com

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Contributors
Christina M. Amidei, PhD, RN, CNRN, CCRN, FAAN
Research Scientist
Neuro-Oncology Research
University of Chicago
Chicago, Illinois

Patricia E. Casey, MSN, RN, CPHQ


Associate Director
NCDR Training and Orientation
American College of Cardiology
Washington, DC

Chapter 65: Assessment of Neurologic Function


Chapter 70: Management of Patients With Oncologic or
Degenerative Neurologic Disorders

Chapter 26: Management of Patients With Dysrhythmias and


Conduction Problems

Janice M. Beitz, PhD, RN, CS, CNOR, CWOCN, CRNP


Professor
School of Nursing
Rutgers University
Camden, New Jersey
Chapter 48: Management of Patients With Intestinal and
Rectal Disorders

Elizabeth Blunt, PhD, RN, FNP-BC


Assistant Professor
Coordinator Nurse Practitioner Programs
College of Nursing
Villanova University
Villanova, Pennsylvania
Chapter 38: Assessment and Management of Patients With
Allergic Disorders

Lisa Bowman, MSN, RN, CRNP, CNRN


Nurse Practitioner
Division of Cerebrovascular Disease and Neurological
Critical Care
Thomas Jefferson University Hospital
Philadelphia, Pennsylvania
Chapter 67: Management of Patients With Cerebrovascular Disorders

Jo Ann Brooks, PhD, RN, FAAN, FCCP


Adjunct Assistant Professor
Indiana University
Indianapolis, Indiana
Chapter 23: Management of Patients With Chest and Lower
Respiratory Tract Disorders
Chapter 24: Management of Patients With Chronic
Pulmonary Disease

Kim Cantwell-Gab, MN, ARNP, CVN, RVT, RDMS


Acute Care Advanced Registered Nurse Practitioner
Southwest Medical Center Thoracic and Vascular Surgery
Vancouver, Washington
Chapter 30: Assessment and Management of Patients With Vascular
Disorders and Problems of Peripheral Circulation

Jill Cash, MSN, RN, APN


Family Nurse Practitioner
Southern Illinois Rheumatology
Herrin, Illinois
Chapter 64: Assessment and Management of Patients With Hearing
and Balance Disorders

Odette Y. Comeau, MS, RN


Clinical Nurse Specialist
Adult Critical Care
University of Texas Medical Branch
Galveston, Texas
Chapter 62: Management of Patients With Burn Injury

Linda Carman Copel, PhD, RN, PMHCNS, BC, CNE,


NCC, FAPA

Professor
College of Nursing
Villanova University
Villanova, Pennsylvania
Chapter 4: Health Education and Promotion
Chapter 6: Individual and Family Homeostasis, Stress,
and Adaptation
Chapter 59: Assessment and Management of Problems Related to
Male Reproductive Processes

Carolyn Cosentino, RN, ANP-BC


Memorial Sloan-Kettering Cancer Center
New York, New York
Chapter 58: Assessment and Management of Patients With
Breast Disorders

Susanna Garner Cunningham, PhD, BSN, MA, FAAN


Professor
Biobehavioral Nursing and Health Systems
University of Washington
Seattle, Washington
Chapter 31: Assessment and Management of Patients
With Hypertension

Nancy Donegan, MPH, RN


Director, Infection Control
MedStar Washington Hospital
Washington, DC
Chapter 71: Management of Patients With Infectious Diseases

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vi

Contributors

Diane K. Dressler, MSN, RN, CNRN, CCNS


Clinical Assistant Professor
College of Nursing
Marquette University
Milwaukee, Wisconsin

Jamie Moore Heffernan, BSN, RN, CCRN


Manager
Blocker Burn Unit
The University of Texas Medical Branch
Galveston, Texas

Chapter 27: Management of Patients With Coronary


Vascular Disorders
Chapter 29: Management of Patients With Complications From
Heart Disease

Chapter 62: Management of Patients With Burn Injury

Phyllis Dubendorf, MSN, RN


Clinical Nurse Specialist
Hospital of the University of Pennsylvania
Philadelphia, Pennsylvania
Chapter 66: Management of Patients With Neurologic Dysfunction

Susan M. Fallone, MS, RN, CNN


Clinical Nurse Specialist Adult and Pediatric Dialysis
Albany Medical Center Hospital
Albany, New York
Chapter 53: Assessment of Kidney and Urinary Function

Eleanor Fitzpatrick, MSN, RN, CCRN


ClinicalNurse Specialist
Surgical Intensive Care Unit and Intermediate Surgical
Intensive Care Unit
Thomas Jefferson University Hospital
Philadelphia, Pennsylvania
Chapter 49: Assessment and Management of Patients With
Hepatic Disorders
Chapter 50: Assessment and Management of Patients With
Biliary Disorders

Kathleen Kelleher Furniss, MSN, RNC, WHNP-BC, DMH


Coordinator
Womens Health and Womens Health NP
Montclair, New Jersey
Chapter 57: Management of Patients With Female
Reproductive Disorders

Catherine Glynn-Milley, RN, CPHQ, CRNO


Ophthalmology Clinical/Research Coordinator
VA Palo Alto Health Care System
Palo Alto, California
Chapter 63: Assessment and Management of Patients With Eye and
Vision Disorders

Dawn M. Goodolf, PhD, RN


RN to BS Program Coordinator, Assistant Professor
Department of Nursing
Moravian College
Bethlehem, Pennsylvania
Chapter 40: Assessment of Musculoskeletal Function

Theresa Green, PhD, RN


Assistant Professor
Faculty of Nursing
University of Calgary
Calgary, Alberta, Canada

Melissa Hladek, MSN, RN, FNP-BC


Family Nurse Practitioner Program Coordinator
Assistant Clinical Professor
The Catholic University of America
Washington, DC
Chapter 39: Assessment and Management of Patients With
Rheumatic Disorders

Joyce Young Johnson, PhD, MSN, RN


Dean and Professor
College of Sciences and Health Professions
Albany State University
Albany, Georgia
Chapter 1: Health Care Delivery and Evidence-Based
Nursing Practice
Chapter 2: Community-Based Nursing Practice
Chapter 3: Critical Thinking, Ethical Decision Making, and the
Nursing Process
Chapter 7: Overview of Transcultural Nursing

Tamara M. Kear, PhD, RN, CNN


Assistant Professor of Nursing
College of Nursing
Villanova University
Villanova, Pennsylvania
Chapter 54: Management of Patients With Kidney Disorders
Chapter 55: Management of Patients With Urinary Disorders

Elizabeth K. Keech, PhD, RN


Assistant Professor
College of Nursing
Villanova University
Villanova, Pennsylvania
Chapter 11: Health Care of the Older Adult

Lynne Kennedy, PhD, MSN, RN, CNOR, CHPN


Program Coordinator
Minimally Invasive Gynecologic Surgery and Palliative Care
Inova Fair Oaks Hospital
Fairfax, Virginia
Chapter 17: Preoperative Nursing Management
Chapter 18: Intraoperative Nursing Management
Chapter 19: Postoperative Nursing Management

Mary Theresa Lau, MS, APN, CNSN, CRNI


Nutrition Support/PICC Clinical Nurse Specialist
Edward Hines Jr. VA Hospital
Hines, Illinois
Chapter 45: Digestive and Gastrointestinal Treatment Modalities

Chapter 10: Principles and Practices of Rehabilitation

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Contributors

Dale Halsey Lea, MPH, RN, CGC, FAAN


Consultant
Maine Genetics Program
Cumberland Foreside, Maine

Donna M. Molyneaux, PhD, RN


Associate Professor of Nursing
Gwynedd-Mercy College
Gwynedd Valley, Pennsylvania

Chapter 8: Overview of Genetics and Genomics in Nursing Genetics


in Nursing Practice Charts

Chapter 22: Management of Patients With Upper Respiratory


Tract Disorders

Linda M. Lord, MS, RN, CNSC, NP


Nurse Practitioner
Ambulatory Nursing-Nutrition Support Clinic
University of Rochester Medical Center
Rochester, New York

Barbara Moran, PhD, CNM, RNC, FACCE


Assistant Clinical Professor
The Catholic University of America
Washington, DC

Chapter 45: Digestive and Gastrointestinal Treatment Modalities

Chapter 56: Assessment and Management of Female


Physiologic Processes

Mary Beth Flynn Makic, PhD, RN, CNS


Associate Professor
College of Nursing
University of Colorado Medical Campus
Research Nurse Scientist, Critical Care
University of Colorado Hospital
Aurora, Colorado

Susan Snight Moreland, DNP, CRNP


Nurse Practitioner
The Center for Breast Health
Bethesda, Maryland

Chapter 14: Shock and Multiple Organ Dysfunction Syndrome

Martha A. Mulvey, MSN


Adult Nurse Practitioner
Department of Neurosciences
University of Medicine and Dentistry of
New JerseyUniversity Hospital
Newark, New Jersey

Elizabeth Petit de Mange, PhD, MSN, RN


Assistant Professor
College of Nursing
Villanova University
Villanova, Pennsylvania
Chapter 52: Assessment and Management of Patients With
Endocrine Disorders

Barbara J. Maschak-Carey, MSN, RN, CDE


Diabetes Clinical Nurse Specialist
Department of Psychiatry, Center for Weight and
Eating Disorders
University of Pennsylvania
Philadelphia, Pennsylvania
Chapter 51: Assessment and Management of Patients With Diabetes

Agnes Masny, BS, MPH, MSN, RN, ANP-BC


Nurse Practitioner
Department of Clinical Genetics
Fox Chase Cancer Center
Philadelphia, Pennsylvania
Chapter 8: Overview of Genetics and Genomics in Nursing

Phyllis J. Mason, MS, RN, ANP


Faculty
Acute and Chronic Care
Johns Hopkins University School of Nursing
Baltimore, Maryland
Chapter 44: Assessment of Digestive and Gastrointestinal Function
Chapter 47: Management of Patients With Gastric and
Duodenal Disorders

Jennifer D. McPherson, DNP, CRNA


Clinical Instructor
Uniformed Services University of Health Sciences
Bethesda, Maryland

vii

Chapter 35: Assessment of Immune Function


Chapter 36: Management of Patients With Immunodeficiency Disorders

Chapter 13: Fluid and Electrolytes: Balance and Disturbance

Donna A. Nayduch, MSN, RN, ACNP, CAIS


Trauma Consultant
K-Force
Evans, Colorado
Chapter 72: Emergency Nursing
Chapter 73: Terrorism, Mass Casualty, and Disaster Nursing

Kathleen M. Nokes, PhD, RN, FAAN


Professor and Director of Graduate Program
City University of New York, Hunter College of Nursing
Hunter College
New York, New York
Chapter 37: Management of Patients With HIV Infection and AIDS

Kristen J. Overbaugh, MSN, RN, ACNS-BC


Clinical Assistant Professor
Health Restoration and Care Systems Management
University of Texas at San Antonio Health Science Center
San Antonio, Texas
Chapter 20: Assessment of Respiratory Function

Janet A. Parkosewich, DNSc, RN, FAHA


Nurse Researcher
Patient Services
Yale-New Haven Hospital
New Haven, Connecticut
Chapter 25: Assessment of Cardiovascular Function

Chapter 21: Respiratory Care Modalities

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viii

Contributors

Chris Pasero, MS, RN-BC, FAAN


Pain Management Educator and Clinical Consultant
El Dorado Hills, California
Chapter 12: Pain Management

Mae Ann Pasquale, PhD, RN


Assistant Professor of Nursing
Cedar Crest College
Allentown, Pennsylvania
Chapter 41: Musculoskeletal Care Modalities

Sue Baron Pugh, MSN, RN, CNS-BC, CRRN, CNRN, CBIS, FAHA
Clinical Nurse Specialist
Brain and Spine Institute
Sinai Hospital of Baltimore
Baltimore, Maryland
Chapter 69: Management of Patients With Neurologic Infections,
Autoimmune Disorders, and Neuropathies

Kimberly L. Quinn, BSN, MSN, RN, CRNP, ANP, ACNP, CCRN


Nurse Practitioner
Thoracic Surgery
Union Memorial Hospital
Baltimore, Maryland
Chapter 46: Management of Patients With Oral and
Esophageal Disorders

JoAnne Reifsnyder, PhD, APRN, BC-PCM


Research Assistant Professor
Division Director, Health Policy and Health Services
Research
Department of Health Policy
Thomas Jefferson University
Philadelphia, Pennsylvania
Chapter 16: End-of-Life Care

Marylou V. Robinson, PhD, FNP-C


Assistant Professor
College of Nursing
University of Colorado
Aurora, Colorado
Chapter 42: Management of Patients With Musculoskeletal Disorders

Linda Schakenbach, MSN, RN, CNS, CCRN, CWCN, ACNS-BC


Clinical Nurse Specialist
Cardiac Critical Care Services
Inova Fairfax Hospital
Falls Church, Virginia
Chapter 28: Management of Patients With Structural, Infectious, and
Inflammatory Cardiac Disorders

Suzanne C. Smeltzer, EdD, RN, FAAN


Professor and Director
Center for Nursing Research
Villanova University College of Nursing
Villanova, Pennsylvania
Chapter 9: Chronic Illness and Disability

LWBK1234-FM_pi-xl.indd 8

Anthelyn Jean Smith-Temple, DNS, MSN, BSN


Former Assistant Dean and Associate Professor
College of Nursing
Valdosta State University
Valdosta, Georgia
Chapter 1: Health Care Delivery and Evidence-Based Nursing
Practice
Chapter 2: Community-Based Nursing Practice
Chapter 3: Critical Thinking, Ethical Decision Making, and the
Nursing Process
Chapter 7: Overview of Transcultural Nursing

Jennifer A. Specht, PhD, RN


Assistant Professor
Department of Nursing
Moravian College
Bethlehem, Pennsylvania
Chapter 5: Adult Health and Nutritional Assessment

Karen A. Steffen-Albert, MSN, RN


Clinical Nurse Specialist
Performance Improvement
Thomas Jefferson University Hospital
Philadelphia, Pennsylvania
Chapter 68: Management of Patients With Neurologic Trauma

Cindy L. Stern, MSN, RN, CCRP


Cancer Network Administrator
Abramson Cancer Center
University of Pennsylvania
Philadelphia, Pennsylvania
Chapter 15: Oncology: Nursing Management in Cancer Care

Candice Jean Sullivan, MSN, RNC, LCCE


Education Coordinator
Inova Learning Network
Inova Health System
Falls Church, Virginia
Chapter 56: Assessment and Management of Female Physiologic
Processes

Mary Laudon Thomas, MS, RN


Associate Clinical Professor
Physiological Nursing
University of California
San Francisco, California
Chapter 32: Assessment of Hematologic Function and
Treatment Modalities
Chapter 33: Management of Patients With Nonmalignant
Hematologic Disorders
Chapter 34: Management of Patients With Hematologic Neoplasms

Lauren M. Weaver, MS, RN, CNS, ACNP, CCRN, CCNS


Advanced Heart Failure Nurse Practitioner
MedStar Washington Hospital Center
Washington, DC
Chapter 28: Management of Patients With Structural, Infectious, and
Inflammatory Cardiac Disorders

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Contributors

Kristin Weitmann, MSN, RN, ACNP


Acute Care Nurse Practitioner
Cardiovascular Surgery
Aurora St. Lukes Medical Center
Milwaukee, Wisconsin

Iris Woodard, BSN, RN-CS, ANP


Nurse Practitioner
Department of Dermatology
Kaiser Permanente Mid-Atlantic States
Rockville, Maryland

Chapter 27: Management of Patients With Coronary Vascular Disorders


Chapter 29: Management of Patients With Complications From
Heart Disease

Chapter 60: Assessment of Integumentary Function


Chapter 61: Management of Patients With Dermatologic Problems

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Reviewers
Joyette L. Aiken, MScN, RN, ORN, RM
Lecturer
University of the West Indies, Mona
Kingston, Jamaica, West Indies

Karen Elick
Ivy Tech Community College,
Bloomington
Bloomington, Indiana

Anna Gryczman, DNP, RN, AHN-BC


Nurse Educator
Century College
White Bear Lake, Minnesota

Terra Baughman, MSN, RN


Assistant Professor of Nursing
Ivy Tech Community College,
Greencastle
Greencastle, Indiana

Lorraine Emeghebo, EdD, RN


Molloy College
Rockville Centre, New York

Wade Hagan, PhD


Capella University
Minneapolis, Minnesota

Susan R. Evancho, DNP, RN


Nursing Faculty
Bridgeport Hospital School of Nursing
Bridgeport, Connecticut

Katherine C. Hall, MSN, RN-BC


Assistant Professor of Nursing
Northeast State Community College
Kingsport, Tennessee

Diane M. Evans-Prior, MSN, RN


Nursing Program Director
Central New Mexico Community
College
Albuquerque, New Mexico

Tamara L. Hall, BSN, MSN, RN


Assistant Professor, Nursing Faculty
Ivy Tech Community College,
Madison Campus
Madison, Indiana

Lisa Foertsch, MSN, RN


Instructor
University of Pittsburgh School of
Nursing
Pittsburgh, Pennsylvania

Anissa Harris-Smith, MSN, RN


Assistant Professor
Broward College, Central Campus
Davie, Florida

Jane Benedict, MSN, RN, CNE


Associate Professor of Nursing
Pennsylvania College of Technology
Williamsport, Pennsylvania
Jean S. Bernard, MSN, RN
Associate Professor, Fort Sanders
Nursing Department
Tennessee Wesleyan College
Knoxville, Tennessee
Joyel Brule, PhD, MSN, RN, ACNS-BC
Nurse Educator
Bay de Noc Community College
Escanaba, Michigan
Milagros Cartagena, BS, MSN
Associate Professor, Nursing
Tompkins Cortland Community
College
Dryden, New York
Erin M. Cattoor, MSN, RN
Clinical Assistant Professor of
Nursing
Maryville University
Saint Louis, Missouri
Julie C. Chew, PhD, MS, RN
Faculty
Mohave Community College
Colorado City, Arizona
Sandra Croasdell, BBA, BSN,
MSNE, MSN

Deborah Gielowski, BS, MS


Professor of Nursing
Buffalo, New York
Tammy Greathouse, MSN, RN
Faculty, Health Science Institute
Metropolitan Community
CollegePenn Valley
Kansas City, Missouri
Anne D. Green, MSN, RN
Nursing Instructor
Keiser University
Melbourne, Florida
Sue Greenfield, PhD, MS, CRNA
Associate Professor
Columbia University
New York, New York

Lead Faculty for Advanced Medical


Surgical Nursing
Bay de Noc Community College
Escanaba, Michigan

Laura Greep, MS, RN


Faculty
Maricopa Community Colleges
Scottsdale, Arizona

Jane F. deLeon, PhD, RN


Assistant Professor
San Francisco State University
San Francisco, California

Annette L. Griffin, MSN, MBA, RN


Assistant Professor of Nursing
Rhode Island College
Providence, Rhode Island

Melissa Hladek, APRN, FNP-BC


Family Nurse Practitioner
Unity Health Care, Inc.
Washington, DC
Marie J. Hunter, BSN, MSN
Faculty, Nursing Department
Utah Valley University
Orem, Utah
Catherine Jamaris-Stauts, MSN, RN
Associate Professor
Community College of Baltimore County
Catonsville, Maryland
Janice Jones, PhD, RN, CS
Clinical Professor
University at Buffalo, School of Nursing
Buffalo, New York
Barbara Kennedy, MS, AAS, BS
Assistant Professor
Nassau Community College
Garden City, New York
Jonni K. Pielin Kircher, MSN,RN, CSN
Assistant Professor of Nursing
Westmoreland County Community
College
Youngwood, Pennsylvania

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xii

Reviewers

Angie Koller, MSN, RN


School Dean, Nursing
Ivy Tech Community College
Indianapolis, Indiana
Heather Lashley, BSN, MSN
Nursing Instructor
Helene Fuld College of Nursing
New York, New York
Karen D. Lipford, EdD, MSN, ARNP
Professor of Nursing
Chipola College
Marianna, Florida
Tamella Livengood, MSN, FNP-BC
Nursing Faculty
Northwestern Michigan College
Traverse City, Michigan
June Mair
Professor of Nursing
Valencia Community College
Orlando, Florida
Patricia Martin, MSN, APRN-BC, CNE
Associate Professor in Nursing
West Kentucky Community and
Technical College
Paducah, Kentucky
Kim McCarron, MS, RN, CRNP
Associate Professor
Towson University
Towson, Maryland
Rene Menkens, MS, RN, CNE
Assistant Professor
Southwestern Oregon Community
College
Coos Bay, Oregon
Sandra Moser
Associate Professor
Tompkins Cortland Community
College
Dryden, New York
Robert J. Muster, PhD, MS, RN
Dean of Nursing and Allied Health
Minneapolis Community and
Technical College
Minneapolis, Minnesota

LWBK1234-FM_pi-xl.indd 12

Sandra L. Nash, PhD, RN


Assistant Professor, School of
Nursing
Western Illinois University
Macomb, Illinois
Anthony W. Pennington, MBA,
MSN, RN-BC

Assistant Dean and Assistant


Professor
Remington College of Nursing
Lake Mary, Florida
Linda Lee Phelps, MSN, RN
Assistant Professor
Ivy Tech Community College
Indianapolis, Indiana
Kathleen Pirtle
Instructor, Department of
Baccalaureate Nursing
Indiana State University
Terre Haute, Indiana
Rowland Ramdass, DNP, ANP, RN
Assistant Professor
Farmingdale State College
Farmingdale, New York
Janet Reagor, PhD, RN
Assistant Professor
Avila University
Kansas City, Missouri
Patricia Reuther, MS, RN
Innovative Practice Center
Coordinator
Binghamton University Decker School
of Nursing
Binghamton, New York
Lisa Richwine, MSN, RN,
ANP-C, CLNC

ASN Program Chair


Ivy Tech Community College
New Castle, Indiana
Robin Schaeffer, MSN, RN, CNE
Nursing Faculty
Mesa Community College
Mesa, Arizona

Patricia A. Sharpnack, DNP,


MSN, CNE

Director of Strategic Planning and


Assistant Professor
Ursuline CollegeThe Breen School of
Nursing
Pepper Pike, Ohio
Barbara C. Sinacori, MSN, RN, CNRN
Nursing Instructor
Muhlenberg Harold B. & Dorothy A.
Snyder School of Nursing
Plainfield, New Jersey
Mary J. Stedman
Associate Chair, Professor
Farmingdale State College
Farmingdale, New York
Linda L. Steeg, MS, RN, ANP-BC
Clinical Assistant Professor
University at Buffalo, State University
of New York
Buffalo, New York
Julio E. Torres, MSN, RN-BC, CRRN
Associate Professor
Phillips Beth Israel School of Nursing
New York, New York
Joan Ulloth, PhD, MSN, BS
Kettering College of Medical Arts
Kettering, Ohio
Diane Vangsness, BA, MA, RN, PHN
Nursing Instructor
Minnesota West Community and
Technical College
Worthington, Minnesota
Cynthia L. Williams, MS, RN, CMSRN
Professor of Nursing
Oklahoma City Community College
Oklahoma City, Oklahoma
Connie S. Wilson, EdD, RN, CNE
Professor
University of Indianapolis
Indianapolis, Indiana
Ellen Zimmerman, BS, MSN, RN
Associate Professor
Phillips Beth Israel School of Nursing
New York, New York

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Preface

The 1st edition of Brunner & Suddarths Textbook of MedicalSurgical Nursing was published in 1964 under the leadership

of Lillian Sholtis Brunner and Doris Smith Suddarth. Lillian


and Doris pioneered a medical-surgical nursing textbook that
has become a trusted learning resource. Lillian and Doris
groomed Suzanne Smeltzer and Brenda Bare as their successors. For several decades, Suzanne and Brenda continued the
legacy of medical-surgical nursing excellence established by
Lillian and Doris, meticulously supervising all updates and
revisions for subsequent editions of this textbook. Suzanne
and Brenda, in turn, served as our mentors for the past several editions of this textbook and have passed that legacy of
excellence on to us. The result of the seamless and meticulous
succession planning for editorship of this textbook is this new
13th edition.
Medical-surgical nursing has significantly advanced since
1964 but continues to be strongly influenced by the expansion of a host of other disciplines and new developments
in technology, as well as myriad social, cultural, economic,
and environmental changes throughout the world. In todays
environment, nurses must be particularly skilled in critical
thinking and clinical decision making, as well as in consulting and collaborating with other members of the multidisciplinary health care team.
Along with the challenges that todays nurses confront,
there are many opportunities to provide skilled, compassionate nursing care in a variety of health care settings, for patients
in the various stages of illness, and for patients across the age
continuum. At the same time, there are significant opportunities for fostering health promotion activities for individuals
and groups; this is an integral part of providing nursing care.
Continuing the tradition of the first 12 editions, this 13th
edition of Brunner & Suddarths Textbook of Medical-Surgical
Nursing has evolved to prepare nurses to think critically and
practice collaboratively within todays challenging and complex health care delivery system. The textbook focuses on
physiologic, pathophysiologic, and psychosocial concepts as
they relate to nursing care, and emphasis is placed on integrating a variety of concepts from other disciplines such as
nutrition, pharmacology, and gerontology. Content relative to
health care needs of people with disabilities, nursing research
findings, ethical considerations, evidence-based practice, bariatrics, and prioritization has been expanded to provide opportunities for the nurse to refine clinical decision making skills.

Organization
Brunner & Suddarths Textbook of Medical-Surgical Nursing,
13th edition, is organized into 17 units. These units mirror those found in previous editions with the incorporation
of some changes. Content was streamlined throughout all
units, with cross-references to specific chapters included as
appropriate. Units 1 through 4 cover core concepts related to

medical-surgical nursing practice. Units 5 through 17 discuss


adult health conditions that are treated medically or surgically.
The sequential ordering of some of these units was changed
so that they dovetailed more logically with each other. For
instance, the musculoskeletal unit (Unit 9) follows the immunologic unit (Unit 8) so that coverage of rheumatic disorders
precedes coverage of orthopedic disorders. Hematologic disorders are now no longer presented in a chapter within the cardiovascular unit but have been expanded into a separate unit
with three chapters organized consistently with other units
focused on adult health conditions. Each of these units is structured in the following way to better facilitate comprehension:
The first chapter in the unit covers assessment and
includes a review of normal anatomy and physiology of
the body system being discussed.
Subsequent chapters in the unit cover management
of specific disorders. Pathophysiology, clinical manifestations, assessment and diagnostic findings, medical
management, and nursing management are presented.
Nursing Process sections, provided for selected conditions, clarify and expand on the nurses role in caring
for patients with these conditions.

Special Features
When caring for patients, nurses assume many different roles,
including practitioner, educator, advocate, and researcher.
Many of the features in this textbook have been developed to
help nurses fulfill these varied roles. Key updates to practiceoriented features in the 13th edition include new unit-opening
Case Studies and QSEN Competency Focusa feature that
highlights a competency from the Quality and Safety Education for Nurses (QSEN) Institute that is applicable to the case
study and poses questions for students to consider about relevant knowledge, skills, and attitudes (KSAs). New Obesity
Considerations icons identify content related to obesity or to
the nursing care of obese patients. In addition, Quality and
Safety Nursing Alerts, Genetics in Nursing Practice charts, and
Ethical Dilemma charts offer updated formats and information.
The text also provides pedagogical features developed to
help readers engage and learn critical content. New to this
edition are Concept Mastery Alerts, which clarify fundamental nursing concepts to improve the readers understanding of
potentially confusing topics, as identified by Misconception
Alerts in Lippincotts Adaptive Learning Powered by PrepU.
Data from hundreds of actual students using this program in
medical-surgical courses across the United States identified
common misconceptions for the authors to clarify in this new
feature. In addition, prioritization questions have also been
added to chapter-ending Critical Thinking Exercises. An
enhanced suite of online, interactive multimedia resources is
also highlighted with icons placed in text near relevant topics.
Read the Users Guide that follows the Preface for a full
explanation and visual representation of all special features.

xiii

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xiv

Preface

A Comprehensive Package for


Teaching and Learning
To further facilitate teaching and learning, a carefully
designed ancillary package has been developed to assist faculty and students.

Instructor Resources
Tools to assist you with teaching your course are available
upon adoption of this text on
at http://thePoint.lww.
com/Brunner13e.
A thoroughly revised and augmented Test Generator
contains more than 2,900 NCLEX-style questions
mapped to chapter learning objectives.
An extensive collection of materials is provided for
each book chapter:
Lesson Plans outline learning objectives and identify relevant resources from the robust instructor and
student resource packages to help you prepare for
your class.
Pre-Lecture Quizzes (and answers) allow you to
check students reading.
PowerPoint Presentations provide an easy way to
integrate the textbook with your students classroom
experience; multiple-choice and true/false questions
are included to promote class participation.
Guided Lecture Notes are organized by objective
and provide corresponding PowerPoint slide numbers to simplify preparation for lecture.
Discussion Topics (and suggested answers) can be
used in the classroom or in online discussion boards
to facilitate interaction with your students.
Assignments (and suggested answers) include group,
written, clinical, and Web assignments to engage
students in varied activities and assess their learning.
Case Studies with related questions (and suggested
answers) give students an opportunity to apply their
knowledge to a client case similar to one they might
encounter in practice.
Sample Syllabi are provided for one- and two-semester
courses.
A QSEN Competency Map identifies content and special features in the book related to competencies identified by the QSEN Institute.
An Image Bank lets you use the photographs and illustrations from this textbook in your course materials.
Strategies for Effective Teaching provides general tips
for instructors related to preparing course materials and
meeting student needs.
Access to all Student Resources is provided so that you
can understand the student experience and use these
resources in your course as well.

Student Resources
An exciting set of free learning resources is available on
to help students review and apply vital concepts
in medical-surgical nursing. For the 13th edition, multimedia engines have been optimized so that students can access
many of these resources on mobile devices. Students can
activate the codes printed in the front of their textbooks at
http://thePoint.lww.com/activate to access these resources:

LWBK1234-FM_pi-xl.indd 14

NCLEX-Style Review Questions for each chapter,


totaling more than 1,800 questions, help students
review important concepts and practice for NCLEX.
Interactive learning resources appeal to a variety of
learning styles. Icons in the text direct readers to relevant resources:

Concepts in Action Animations bring physiologic and pathophysiologic concepts to life.

Interactive Tutorials review key information
for common or complex medical-surgical conditions. Tutorials include graphics and animations
and provide interactive review exercises as well as
case-based questions.

Practice & Learn Case Studies present case scenarios and offer interactive exercises and questions to help students apply what they have learned.

Watch & Learn Video Clips reinforce skills
from the textbook and appeal to visual and
auditory learners. With the 13th edition, all content
from Lippincotts Video Series for Brunner & Suddarths
Textbook of Medical-Surgical Nursing is included!
A SpanishEnglish Audio Glossary provides helpful
terms and phrases for communicating with patients
who speak Spanish.
Journal Articles offer access to current articles relevant
to each chapter and available in Lippincott Williams
& Wilkins journals to familiarize students with nursing
literature.

Study Guide
A comprehensive study aid for reviewing key concepts, Study
Guide for Brunner & Suddarths Textbook of MedicalSurgical Nursing, 13th edition, has been thoroughly revised
and presents a variety of exercises, including case studies and
practice NCLEX-style questions, to reinforce textbook content and enhance learning.

Quick Reference Tools


Clinical Handbook for Brunner & Suddarths Textbook of
Medical-Surgical Nursing, 13th edition, presents need-toknow information on nearly 200 commonly encountered disorders in an easy-to-use, alphabetized outline format that is
perfect for quick access to vital information in the clinical
setting. Brunner & Suddarths Handbook of Laboratory and
Diagnostic Tests, 2nd edition, includes a review of specimen
collection procedures, followed by a concise, alphabetical
presentation of tests and their implications. Information for
each test includes reference values or normal findings, abnormal findings and related nursing implications, critical values,
purpose, description, interfering factors, precautions, and
nursing considerations.
Both quick references are available in print or e-book
format. An enhanced e-book format is available to facilitate
mobile use for on-the-go reference. For more information on
these two quick references and available formats, please visit
, http://thePoint.lww.com.

Adaptive Learning Powered by PrepU


Updated to accompany the 13th edition, Lippincotts Adaptive Learning Powered by PrepU helps every student learn

8/1/13 10:01 PM

more, while giving instructors the data they need to monitor


each students progress, strengths, and weaknesses. The adaptive, formative quizzing program allows instructors to assign
quizzes or students to take quizzes on their own that adapt
to each students individual mastery level. Visit
at
http://thePoint.lww.com/PrepU to learn more.

Computer-Based Simulations
Lippincott | Laerdal Computer-Based Simulations for MedicalSurgical Nursing offers innovative scenario-based learning
modules consisting of Web-based virtual simulations, course
learning materials, and curriculum tools designed to develop
critical thinking and promote clinical confidence and competence. The medical-surgical module includes 10 virtual
simulations based on the National League for Nursing Volume I Complex scenarios. In addition, students can progress
through suggested readings, pre- and post-simulation assessments, documentation assignments, and guided reflection
and debriefing questions, as well as receive an individualized
feedback log from the simulation. Throughout the learning
experience, the product offers remediation back to trusted
Lippincott resources, including Brunner & Suddarths Textbook
of Medical-Surgical Nursing as well as Lippincotts Nursing
Advisor and Lippincotts Nursing Procedures and Skillstwo
online, evidence-based, clinical information solutions used
in health care facilities throughout the United States. This
innovative product provides a comprehensive solution for
learning and integrating simulation into the classroom.
Contact your Lippincott Williams & Wilkins sales representative or visit
, http://thePoint.lww.com, for
bundling options that can bring all resources together in
money-saving packages for students.

A Comprehensive, Integrated
Course Solution
Lippincotts CoursePoint is the only integrated digital course
solution for nursing education, combining the power of
enhanced eBook, interactive resources, Adaptive Learning
Powered by PrepU, and Computer-Based Simulation. Pulling these resources together into one solution, the integrated
product offers a seamless experience for learning, studying,
applying, and remediating.

Preface

xv

Users get seamless access to an enhanced eBook for this


textbook and the incredible learning resources that accompany it, providing the content and tools that students need to
study more effectively, score higher on exams, and prepare for
clinical practice. In the enhanced eBook, learning resources
are embedded in context within the textbook, allowing students with varied learning styles to interact with different
media types to review and apply information at the point of
learning. Students will find everything they need to succeed
in classanimations, interactive case studies, videos, journal
articles, and more.
Lippincotts CoursePoint brings Adaptive Learning Powered by PrepU and Computer-Based Simulations (described
earlier) together on the same platform to provide all of the
resources that students need to study more effectively, score
higher on exams, and prepare for clinical practice. The
SmartSense Links feature included throughout CoursePoint
makes additional learning resources only a click away. In
Adaptive Learning Powered by PrepU, this means that when
students take a quiz and receive feedback on their performance, they can link directly to their eBook or other learning resources at the moment they confirm they do not understand a concept. Similarly, in Computer-Based Simulations,
students receive feedback with remediation to the eBook and
other trusted Lippincott resources. With Lippincotts CoursePoint, these resources are one click away. Whether learning
content, preparing for a test, or engaging in a simulation,
students using Lippincotts CoursePoint have access to the
specific information or resource they need from Lippincott
Williams & Wilkins library of respected educational and
clinical content. This unique offering creates an unparalleled
learning experience for students.
Contact your Lippincott Williams & Wilkins sales representative or visit
, http://thePoint.lww.com, for more
information about the Lippincotts CoursePoint solution.
It is with pleasure that we introduce these resourcesthe
textbook, ancillary resources, and additional supplements and
learning toolsto you. One of our primary goals in creating
these resources has been to help nurses and nursing students
provide quality care to patients and families across health care
settings and in the home. We hope that we have succeeded in
that goal, and we welcome feedback from our readers.
Janice L. Hinkle, PhD, RN, CNRN
Kerry H. Cheever, PhD, RN

Nursing diagnoses in text are from Herdman, T. H. (Ed.). Nursing Diagnoses: Definitions and Classification 20122014. Copyright 2012, 19942012 by NANDA International. Used by arrangement with John Wiley & Sons Limited. In order to make
safe and effective judgments using NANDA-I nursing diagnoses, it is essential that
nurses refer to the definitions and defining characteristics of the diagnoses listed in
this work.

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Users Guide

runner & Suddarths Textbook of Medical-Surgical Nursing, 13th edition, has been revised
and updated to reflect the complex nature of nursing practice today. This textbook includes
many features to help you gain and apply the knowledge that you need to pass NCLEX and successfully meet the challenges and opportunities of clinical practice. In addition, features have
been developed specifically to help you fulfill the varied roles that nurses assume in practice.

Opening Features That Start With the End in Mind


Unit opening features put the patient first and highlight competent nursing as well as application of the nursing process.
New! A Case Study with QSEN Competency Focus opens each unit and provides
discussion points focusing on one competency from the QSEN Institute: patient-centered
care, interdisciplinary teamwork and collaboration, evidence-based practice, quality
improvement, safety, and informatics. This feature helps you consider the KSAs required
for the delivery of safe, quality patient care.
Applying Concepts from NANDA-I, NIC, and NOC offers additional online case
study content on nursing classifications and languages (NANDA-I, NIC, and NOC) as
well as concept maps illustrating the nursing process.

Unit

and
6 Cardiovascular
Circulatory Function

Case Study

Q s e n C o m p e t e n c y F o c u s : Evidence-Based Practice
The complexities inherent in todays health care system challenge nurses to demonstrate integration of specific interdisciplinary core competencies. These competencies are aimed at ensuring the delivery of safe, quality patient care (Institute
of Medicine, 2003). The concepts from the Quality and Safety Education for Nurses (QSEN) Institute (2012) provide a
framework for the knowledge, skills, and attitudes (KSAs) required for nurses to demonstrate competency in these key
areas, which include patient-centered care, interdisciplinary teamwork and collaboration, evidence-based practice, quality
improvement, safety, and informatics.

A PAtient Who hAs intermittent ClAudiCAtion


And ulCerAtion

Evidence-Based Practice Definition: Integrate best current evidence with clinical expertise and patient/family
preferences and values for delivery of optimal health care.

r. Black, age 63 years, has a history of peripheral arterial occlusive disease


(2 years), hypertension, hypercholesterolemia, type 2 diabetes, and smoking.
He eats low-fat foods and has cut back on smoking to half a pack of
cigarettes a day. His home-monitored blood glucose levels range from
180 to 215 mg/dL. Because he has severe calf pain after walking,
he now walks only two blocks a dayone block from home
and one block back. He now receives medical treatment for
a nonhealing ulcer on the plantar aspect of his left foot. He
questions why he is told that he should walk when it causes
pain and wonders how it may affect the healing of his ulcer.

RElEvant PRE-licEnsuRE Ksas

aPPlication anD REflEction


Knowledge

Discriminate between valid and invalid reasons for


modifying evidence-based clinical practice based on
clinical expertise or patient/family preferences.

What is the strength of the evidence that suggests that


walking is therapeutic for patients with peripheral
arterial occlusive disease? Is the pain that Mr. Black
is experiencing a reason for him to stop walking?
Identify the pathophysiologic relationships between his
multiple comorbidities, the pain he experiences, and
the presence of his nonhealing ulcer. How might his
continued smoking, albeit less than it had been, also
affect his disease processes?
skills

Consult with clinical experts before deciding to deviate


from evidence-based protocols.

Identify members of the health care team you would


consult with to help you craft the most appropriate,
individualized plan of care for Mr. Black.

attitudes
Acknowledge own limitations in knowledge and clinical
expertise before determining when to deviate from
evidence-based best practices.

Reflect on the complexity of the interrelationships between


Mr. Blacks many comorbid conditions. Think about
your own desire to relieve a patients pain. How might
your desire to make Mr. Black comfortable potentially
hamper his odds of achieving his best outcomes?

Cronenwett, L., Sherwood, G., Barnsteiner, J., et al. (2007). Quality and safety education for nurses. Nursing Outlook, 55(3), 122131.
Institute of Medicine. (2003). Health professions education: A bridge to quality. Washington, DC: National Academies Press.
QSEN Institute. (2012). Competencies: Prelicensure KSAs. Available at: qsen.org/competencies/pre-licensure-ksas

Read More About This Case


More information about this case study and the relationships between nursing
diagnoses, interventions, and expected outcomes is available online. Visit
for Applying Concepts from NANDA-I, NIC, and NOC.

653

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xvii

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xviii

Users Guide

Chapter opening pedagogical features help organize learning.


Learning Objectives give an overview of each chapter and identify learning goals to help focus reading and
studying.

27

Chapter

A Glossary provides a list of key terms and definitions


at the beginning of each chapter, providing a review of
vocabulary words before reading the material and a useful
reference and study tool.

29
Management of Patients
With Complications From
Heart Disease

Learning Objectives
On completion of this chapter, the learner will be able to:
1 Describe the management of patients with heart failure.
2 Use the nursing process as a framework for care of
patients with heart failure.
3 Develop an education plan for patients with heart failure.

4 Describe the medical and nursing management of patients


with pulmonary edema.
5 Describe the medical and nursing management of patients
with thromboembolism, pericardial effusion, and cardiac
arrest.

Glossary
acute decompensated heart failure: acute exacerbation
of heart failure, with signs and symptoms of severe
respiratory distress and poor systemic perfusion
anuria: urine output of less than 50 mL/24 h
ascites: an accumulation of serous fluid in the peritoneal
cavity
cardiac resynchronization therapy (CRT): a treatment for
heart failure in which a device paces both ventricles to
synchronize contractions
congestive heart failure (CHF): a fluid overload condition
(congestion) associated with heart failure
diastolic heart failure: the inability of the heart to pump
sufficiently because of an alteration in the ability of the
heart to fill; term used to describe a type of heart failure
ejection fraction (EF): percentage of blood volume in the
ventricles at the end of diastole that is ejected during
systole; a measurement of contractility
heart failure (HF): a clinical syndrome resulting from
structural or functional cardiac disorders that impair the
ability of a ventricle to fill or eject blood
left-sided heart failure (left ventricular failure): inability
of the left ventricle to fill or eject sufficient blood into the
systemic circulation

oliguria: diminished urine output; less than 0.5 mL/kg/hr


orthopnea: shortness of breath when laying flat
paroxysmal nocturnal dyspnea (PND): shortness of breath
that occurs suddenly during sleep
pericardiocentesis: procedure that involves aspiration of
fluid from the pericardial sac
pericardiotomy: surgically created opening of the
pericardium
pulmonary edema: abnormal accumulation of fluid in the
interstitial spaces and alveoli of the lungs
pulseless electrical activity (PEA): condition in which
electrical activity is present on an electrocardiogram, but
there is not an adequate pulse or blood pressure
pulsus paradoxus: systolic blood pressure that is more than
10 mm Hg lower during inhalation than during exhalation;
difference is normally less than 10 mm Hg
right-sided heart failure (right ventricular failure):
inability of the right ventricle to fill or eject sufficient blood
into the pulmonary circulation
systolic heart failure: inability of the heart to pump
sufficiently because of an alteration in the ability of the
heart to contract; term used to describe a type of heart
failure
Chapter 29

Tliveoday
it is possible to help the patient with heart disease
longer and achieve a high quality of life. Advances in

Management of Patients With Complic

Heart Failure N U R S I N G P R O C E S S

diagnostic
treatments,
Heart failure (HF) is a clinical
syndrome
resulting
The Patient
With
Heartfrom
Failure
Features
toprocedures,
Develop
thetechnologies,
Nurseand
aspharPractitioner
macotherapies allow earlier and more accurate diagnoses and
structural or functional cardiac disorders that impair the

Despite
advances
treatment
thatroles
can begin
well nurse
before significant
debilitation
ventricles to fill
or eject
blood.inIntreatment
the past,of HF, morbidity and mortality
One of the
central
of the
is to provide
holisticability
care of
to the
patients
remain high.
a major impact on outcomes for
occurs. However, heart disease remains a chronic and often
HF was often referred to as congestive
heartNurses
failurehave
(CHF),
and their
families,
both
independently
and
through
collaboration
with
patients
with HF, especially
in the areas of patient education
progressive condition that is associated with serious complibecause many patients experience
pulmonary
or peripheral
other health
Special
features
chapters
and monitoring.
cations.care
This professionals.
chapter presents the
complications
mostthroughout
often
congestion
with are
edema. Currently,
HF is recognized as a
heart with
disorders
and thepractice.
collaborative treatclinical syndrome characterized by signs and symptoms of
designedassociated
to assistwith
readers
clinical

ment options for these complications.

Assessment
fluid overload or inadequate tissue
perfusion. Fluid overload
Nursing assessment for the patient with HF focuses on observing for effectiveness of therapy and for the patients ability to
understand and implement 795
self-management strategies. Signs
and symptoms of increasing HF are analyzed and reported to
the patients provider so that therapy can be adjusted. The
nurse also explores the patients emotional response to the
diagnosis of HF, because it is a chronic and often progressive
condition that is commonly associated with depression and
other psychosocial issues (Pressler,
Perkins,
18/06/13 Subramanian,
9:58 AM
et al., 2011; Sherwood, Blumenthal, Hinderliter, et al., 2011).

Nursing Process sections are organized according to the nursing


process frameworkthe basis for all nursing practiceand help clarify
the nurses responsibilities in caring for patients with selected disorders.

LWBK1234-C29_p795-818.indd 795

LWBK1234-FM_pi-xl.indd 18

Health History
The health history focuses on the signs and symptoms
of HF, such as dyspnea, fatigue, and edema. Sleep disturbances, particularly sleep suddenly interrupted by shortness of breath, may be reported. Patients are asked about
the number of pillows needed for sleep, edema, abdominal
symptoms, altered mental status, activities of daily living, and the activities that cause fatigue. Nurses need to
be aware of the variety of clinical manifestations that may

Physical Examination
The patient is observed for
suggest hypoxia from pulm
level of consciousness is als
CO can decrease the flow o
The rate and depth of r
the effort required for bre
to detect crackles and whe
sudden opening of edemato
may be heard at the end o
with coughing (Bickley &
also be heard in some patie
with pulmonary congestion
The blood pressure is
patients may present wit
Patients may be assessed f
cially if they report lighth
The heart is auscultated fo
early sign that increased bl
each beat. Heart rate and
patients are often placed o
the hospital setting. When
the SV decreases and poten
JVD is assessed with t
angle; distention greater th
considered abnormal and i
ure. This is an estimate, n
central venous pressure (Bi
The nurse assesses perip
8/1/13 10:01 PM
on a scale from 0 (not palp

Users Guide

xix

Plans of Nursing Care, provided for selected disorders, illustrate how the nursing process isUnit
applied
to meet the patients health care and nursing needs.
748
6 Cardiovascular and Circulatory Function
Chart

27-11

PlaN oF NuRsiNg caRe

Care of the Patient With an Uncomplicated Myocardial Infarction

nUrSInG DIAGnOSIS: Ineffective cardiac tissue perfusion related to reduced coronary blood flow
GOAL: Relief of chest pain/discomfort
nursing Interventions
1. Initially assess, document, and report to
the physician the following:

rationale

Expected Outcomes

Chapter 27 Management of Patients With Coronary Vascular Disorders

731

1. These data assist in determining the


Reports beginning relief of chest discause and effect of the chest discomfort
comfort and symptoms
and provide a baseline with which post Appears comfortable and is free of pain
Aortic valve
Right
pulmonary
veins
Superior
therapy symptoms can be compared.
and other
signs
or symptoms
a. The patients description of chest dis- Aortic
a. arch
There are many conditions associ Respiratory rate, cardiac rate, and blood
vena cava
Left pressure
pulmonary
veins
comfort, including location, intensity,
ated with chest discomfort. There
return
to prediscomfort level
radiation, duration, and factors that
are characteristic clinical findings of
Skin warm and dry
Coronary
sinusoutput as evidenced
affect it; other symptoms such as
ischemic pain and symptoms.
Adequate
cardiac
Superior
nausea, diaphoresis, or complaints of
by:
Right
vena
atrium
unusual fatigue
Left
Stable/improving
electrocardiogram
atrium
cava
b. The effect of coronary ischemia on
b. Myocardial infarction (MI) decreases
(ECG)
branch
perfusion to the heart (e.g., change
myocardial contractility and ventricuCircumflex
Heart rate and
rhythm
in blood pressure, heart rhythm), to
lar compliance and may produce dysof
Blood
pressure
left coronary
Right
the brain (e.g., changes in level of
rhythmias. Cardiac output is reduced,
artery
Mentation
atrium
consciousness), to the kidneys (e.g.,
resulting in reduced blood pressure
Urine output
Inferior
decrease in urine output), and to the
and decreased organ perfusion.
Serum
blood urea nitrogen (BUN) and
Anterior
skin (e.g., color, temperature)
creatinine
vena
descending
2. Obtain a 12-lead ECG recording during
2.Right
An ECG during symptoms may be use Skin color and temperature
cava
branch of
symptomatic events, as prescribed, to
ful in the diagnosis of ongoing ischemia.
No adverse effects from medications
coronary
left coronary
assess for ongoing ischemia.
Right
artery
3. Administer oxygen as prescribed.
3.artery
Oxygen therapy increases the oxygen
ventricle
supply to the myocardium.
Right
Left circumflex
FigUre
27-2
The coronary
4. Administer
medication
therapy as
4. Medication
therapy (nitroglycerin, morventricle
arteries
supplyand
theevaluate
heart muscle
branch
prescribed,
the patients
phine, beta-blocker, aspirin) is the first
Posterior descending
continuously.
line of defense in preserving myocardial
withresponse
oxygenated
blood, adjusting
branch of right
Left
ventricle
tissue.
the flow according to metabolic
coronary artery
5. Ensure
head
5. Physical rest reduces myocardial
needs.
A. physical
Anteriorrest:
view
of of
thebed
elevated
to promote
comfort;
diet as
oxygenA
consumption. Fear and anxiety
B
heart.
B. Posterior
view
of heart.
tolerated; the use of bedside commode;
precipitate the stress response; this
the use of stool softener to prevent
results in increased levels of endogstraining at stool. Provide a restful envienous catecholamines, which increase
ronment, and allay fears and anxiety by
myocardial oxygen consumption.
is a tool commonly used to estimate the risk for having a
support
needs for
blood. A decrease in blood supply
being the
calmbodys
and supportive.
Individualize
on patient
response.
cardiac event within the next 10 years (Arsenault, Pibarot,
fromvisitation,
CAD based
may even
cause
the heart to abruptly stop beating

& Despres, 2009). This tool is designed for adults 20 years


(sudden
cardiac death).
nUrSInG DIAGnOSIS: Risk for impaired gas exchange related to left ventricular failure
and older. The calculation is performed using the individuals
The
most
common
manifestation
of
myocardial
ischemia
GOAL: Absence of respiratory distress
risk factor data, including age, gender, total cholesterol, HDL
is the onset of chest pain. However, the classic epidemiologic
nursing
rationale
Expected
Outcomes

Assessment
charts
focus on data
that should showed
be col Risk
Factors
charts
factorspressure,
that can
cholesterol,
smoking
status, outline
systolic blood
andimpair
need
study
of Interventions
the people
in Framingham,
Massachusetts,
as
part
of
assessment
theChapter
nursing
process.
1.of
These
data
are useful
in Management
diagnos- forhealth.
No shortness
breath, dyspneaFrom
on Heart Disease
1.lected
Initially,
every
4 hours,
and
with women
chest step
29
of Patients
With of
Complications
799
antihypertensive
medication.
that
nearly
15%
of the
men
and
who
had
coronary
events,
ing left ventricular failure. Diastolic
exertion, orthopnea, or paroxysmal nocdiscomfort or symptoms, assess, docuwhich
included
unstable
angina,
MIs,
or
sudden
cardiac
death
filling sounds (S3 and S4) result from
turnal dyspnea
ment, and report to the physician abnorevents,
weresounds
totally
to the coronary
event
and S4 gallop or prior decreased
left ventricular
compliance
RespiratoryRrate
mal heart
(S3 asymptomatic
i s <20
k breaths/min
Fsufficient
a c t o with
Roxygen,
s
CHART
A
S
S
e
S
S
m
e
n
T
Chartdioxide.
carbon
Without
the patient expeCHART
new murmur),
abnormal
breath
sounds
associated
with may
MI. Papillary
physical activity
and 16
breaths/min
with
Chart
(Kannel,
1986).
Patients
with
myocardial
ischemia
pres- muscle
27-4
27-1
(particularly
crackles),
decreased
oxydysfunction
(from
infarction
of
the
papilrest
Coronary
Artery sleeping.
Disease
riences dyspnea and
has difficulty
27-4
Heart
Failure (ED) or clinic with a variety
29-1
ent
to
an
emergency
department
genation, and activity intolerance.
lary muscle) can result in mitral regurgiSkin color and temperature normal
The cough
associated with left ventricular failure is iniof symptoms other than chest pain. Some
of inepitation complain
and a reduction
stroke volume.
SpO2, PaO2, and PaCO2 within normal
A
nonmodifiable
risk factor is a circumstance
overpatients
which a comtially
dry
and
nonproductive.
Most often,
Be alert
for the and
following
symptoms:
limits
presence
of crackles
(usually at the
gastric
distress
painsigns
that and
radiates
toThethe
jaw or
left arm.
person
no
control.
A modifiable
risk
factorbe
is one
over
has
Heart
rate
<100 bpm
and
>60 bpm,
with
lung bases) may indicate pulmonary
plain
of
a
dry
hacking
cough
that
may
mislabeled
as
Patients who are older or have a history
of diabetes
or heartleft heart
blood
pressure
within
patients
normal
congestion
from
increased
which
a
person
may
exercise
control,
such
as
by
changing
a
Congestion
asthma
or
chronic
obstructive
pulmonary
disease
(COPD).
failure
may report shortness of breath.pressures.
Many The
women
have
association of symptoms
lifestyle limits
or personal habit or by using medication. A risk factor
cough
may
over time. Large quantities
Dyspnea
Chest
x-raybecome
unchangedmoist
and activity can
be used as a guideThe
been
found to have atypical symptoms, including
indigestion,
may operate
independently
or in tandem with other risk factors.

Orthopnea
Appears
comfortable
and
rested
for activity prescription and a basisof
forfrothy
sputum,
which
is
sometimes
pinktheorlikelihood
tan (blood
nausea, palpitations, and numbness (Overbaugh,
2009). ProThe more risk factors a person has, the greater
patient education.
Paroxysmal nocturnal dyspnea
tinged),
may
be
produced,
indicating
acute
decompensated
of coronary artery disease (CAD). Those at risk are advised to
dromal symptoms may occur (i.e., angina a few hours to days
Cough (recumbent or exertional)
HF
with
pulmonary
edema.
seek
regular
medical examinations
and to engage in heartbefore
the acute
episode),
or not
a major
event may be the
Pulmonary
crackles
that do
clearcardiac
with cough
Adventitious
sounds
may
heard
variousand
areas
healthy
behavior breath
(a deliberate
effort
to be
reduce
theinnumber
first
indication
of
coronary
atherosclerosis.
Weight gain (rapid)
extent
of risks).
of
the
lungs.
Usually,
bibasilar
crackles
that
do
not
clear
with
Dependent edema
Risk
Factors
coughing
are
detected
in
the
early
phase
of
left
ventricular
Abdominal bloating or discomfort
Nonmodifiable
Riskworsens
Factors
failure.
As the failure
and pulmonary congestion
Ascites
Epidemiologic
studies point to several factors that increase
increases,
crackles
may
be
auscultated
the lung
Jugular venous distention
Family history of CAD (first-degree
relative throughout
with cardiovascuthe
probability that a person will develop heart disease. Major
Sleep disturbance (anxiety or air hunger)
lar At
disease
55 years
of age
or younger
for decrease.
men and at
fields.
this at
point,
oxygen
saturation
may
risk
factors are listed in Chart 27-1. Although many people
Fatigue
65 addition
years of age
younger formanifestations,
women)
In
to or
pulmonary
the amount of
with CAD have one or more risk factors, some do not have
Increasing
age
(more
than
45
years
for men;
more than
years
blood ejected from the left ventricle
decreases
and 55
can
lead
classic
factors. Elevated
low-density
lipoprotein (LDL)
Poor risk
Perfusion/Low
Cardiac
Output
for women)
to
inadequate
tissue
perfusion.
The
diminished
CO
has
wideLWBK1234-C27_p729-768.indd
748
6/14/13
3:53
PM
Gender (men develop CAD at an earlier age than women)
cholesterol,
known
as bad cholesterol, is a well-known
Decreasedalso
exercise
tolerance
spread
manifestations because not enough blood reaches all
Race (higher incidence of heart disease in African Americans
risk
factor wasting
and theor
primary
target of cholesterol-lowering ther Muscle
weakness
of the
tissues
and organs (low perfusion) to provide the necthan in Caucasians)
Anorexia
apy.
People or
at nausea
highest risk for having a cardiac event are those
essary
oxygen.
The decrease in stroke volume (SV) can also
Unexplained
weight
with
known CAD
or loss
those with diabetes, peripheral arterial
stimulate
the sympathetic
nervous system to release catecholModifiable
Risk Factors

Lightheadedness
or
dizziness
disease, abdominal aortic aneurysm, or carotid artery disease.
amines, which further impedes perfusion to many organs,
Unexplained confusion or altered mental status
Hyperlipidemia
The latter diseases are referred to as CAD risk equivalents,
including
kidneys.
Resting tachycardia
Cigarette the
smoking,
tobacco use
because
patients
with
these
diseases
have
the
same
risk
for
a
LWBK1234-FM_pi-xl.indd
19 oliguria with recumbent nocturia
Daytime
As reduced CO and catecholamines decrease blood flow 8/1/13
Hypertension

10:01 PM

xx

Users Guide

Guidelines charts review key nursing interventions and


rationales
for specific
patient care
situations.
Chapter
20 Assessment
of Respiratory
Function
489
GuiDeLiNeS

Chart

20-11

Assisting the Patient Undergoing Thoracentesis

Equipment
Thoracentesis tray (should include standard supplies needed to
perform procedure)
Sterile gloves

Antiseptic solution
Local anesthetic
Sterile collection bottles, laboratory requisition forms, and labels

Implementation
Action

Rationale

1. Ascertain in advance that a chest x-ray or ultrasound has


been ordered and completed and the consent form has been
signed.
2. Verify patients identity using at least two identifiers, not
including the patients room number. Verify purpose of procedure and procedure site; assess patient for allergies to latex,
antiseptic, or local anesthetic; and review coagulation status
(prothrombin time/INR [international normalized ratio] and
platelet count).
3. Inform the patient about the nature of the procedure as well
as:
a. The importance of remaining immobile
b. Pressure sensations to be experienced
c. That minimal discomfort is anticipated after the procedure
4. Obtain baseline vital signs, oxygen saturation, pain level, and
respiratory status. Administer sedation if prescribed.
5. Position the patient comfortably with adequate supports. If
possible, place the patient upright or in one of the following
positions:
a. Sitting on the edge of the bed with the feet supported and
arms on a padded over-the-bed table
b. Straddling a chair with arms and head resting on the back
of the chair
c. Lying on the unaffected side with the head of the bed
elevated 30 to 45 degrees if unable to assume a sitting
position

1. Chest x-ray films are used to localize fluid and air in the
pleural cavity and to aid in determining the puncture site.
When fluid is loculated (isolated in a pocket of pleural fluid),
ultrasound scans are performed to help select the best site for
needle aspiration.
2. Verification maintains patient safety and prevents potential
complications such as allergic reactions and bleeding.

3. An explanation helps to orient the patient to the procedure,


assists the patient to mobilize resources, and provides an
opportunity to ask questions and verbalize anxiety.
4. Provides preprocedure assessment data to guide sedation
administration and postprocedure assessment. Sedation
enables the patient to cooperate with the procedure and
promotes relaxation.
5. The upright position facilitates the removal of fluid that usually
localizes at the base of the thorax. It expands the ribs and
widens the intercostal space to aid needle insertion A position
of comfort helps the patient to relax and prevents patient
movement that could contribute to potential complications.

Chapter 29

Chart

29-2

Management of Patients With Com

PhARmACology

Administering and Monitoring


Diuretic Therapy

Pharmacology charts and tables display important considerations


When nursing care involves diuretic therapy for conditions
Chapter
29 Management
of Patients With Complications
Heart
Disease
related to administering medications and
monitoring
drug therapy.
such as heartFrom
failure,
the nurse
needs to 801
administer the

medication and monitor the patients response carefully, as


follows:

Pleural effusion

Table 29-3
Medication

Therapeutic Effects

Angiotensin-Converting Enzyme Inhibitors


Lisinopril (Prinivil)
BP and afterload
Enalapril (Vasotec)
Relieves signs and symptoms of HF
Prevents progression of HF
Angiotensin Receptor Blockers
Valsartan (Diovan)
Losartan (Cozaar)
Hydralazine and Isosorbide
Dinitrate (Dilatrate)

BP and afterload
Relieves signs and symptoms of HF
Prevents progression of HF
Dilates blood vessels
BP and afterload

Beta-Adrenergic Blocking Agents (Beta-Blockers)


Metoprolol (Lopressor)
Dilates blood vessels and afterload
Carvedilol (Coreg)
Signs and symptoms of HF
Improves exercise capacity
Diuretics
LWBK1234-C20_p461-492.indd
489
Loop diuretic:
Furosemide (Lasix)
Thiazide diuretics:
Metolazone (Zaroxolyn)
Hydrochlorothiazide (HCTZ)
Aldosterone antagonist:
Spironolactone (Aldactone)
Digitalis
Digoxin (Lanoxin)
LWBK1234-FM_pi-xl.indd 20

Prior to administration of the diuretic, check laboratory results


for electrolyte depletion, especially potassium, sodium, and
magnesium.
Key Nursing Considerations
Prior to administration of the diuretic, check for signs and
symptoms of volume depletion, such as postural hypotension, lightheadedness, and dizziness.
+
, cough, to the patients
Observe for symptomatic hypotension,
Administer theincreased
diuretic atserum
a timeKconducive
and worsening renal function.
lifestylefor example, early in the day to avoid nocturia.
Monitor urine output during the hours after administration,
and analyze intake, output, and daily weights to assess
response.
Continue to monitor serum electrolytes
for depletion. Replace
Observe for symptomatic hypotension,
increased
serum
K+, and
potassium with
increased
oral intake
of food rich in potas(continues
on
page
worsening renal function.
sium or potassium supplements. Replace490)
magnesium as
needed.
Monitor for hyperkalemia in patients receiving potassiumObserve for symptomatic hypotension.
sparing diuretics.
Continue to assess for signs of volume depletion.
Monitor creatinine for increased levels indicative of renal
dysfunction.
Monitor for elevated uric acid level and signs and symptoms
Observe for decreased heart
rate, symptomatic hypotension,
of gout.
dizziness, and fatigue. Assess lungs sounds and edema to evaluate response to
therapy.
Monitor for adverse reactions such as gastrointestinal
distress and dysrhythmias.
9:31 AM
Encourage supine position after dose is given27/05/13
to facilitate
Observe for electrolyte abnormalities,
dysfunction, diuretic
effects of therenal
diuretic.
resistance, and decreased
BP. Carefully
andfrequency
daily
Assist
patients tomonitor
manageI&O
urinary
and urgency
weight (see Chart 29-2).
associated with diuretic therapy.

Common Medications used to treat Heart Failure

Fluid volume overload


Signs and symptoms of HF

Improves HF symptoms in advanced HF

Improves cardiac contractility


Signs and symptoms of HF

usually require admissio


and may also have hem
nary artery catheter or
25). Hemodynamic data
volume status and to gu
tors, and diuretics (Urd

Milrinone. Milrinone i
delays the release of cal
prevents the uptake of e
promotes vasodilation,
afterload and reduced c
istered IV to patients w
are waiting for heart tra
vasodilation, the patien
to administration; if th
pressure could drop quic
tension and increased v
sure and ECG are mon
infusions of milrinone.

Dobutamine. Dobutam
istered to patients with
tion and hypoperfusion
ulates the beta-1 adren
increase cardiac contrac
urine output. However
can precipitate ectopic
et al., 2011).

the symptoms of systolic HF and may help prevent hospi-

Medications for Dias


Patients with predomin
ventricular EF are tre
systolic HF. Contributi
ischemic heart disease
patients do not tolera
allow time for ventric
used to control tachyca
causes (ICSI, 2011).

older patients should receive smaller doses of digoxin, as it is


excreted through the kidneys.
A key
concern
associated with digoxin therapy is digitalis
Observe for bradycardia and
digitalis
toxicity.
toxicity. Clinical manifestations of toxicity include anorexia,
nausea, visual disturbances, confusion, and bradycardia.

Other Medications fo
Anticoagulants may be
has a history of atrial fib
(Lindenfeld et al., 2010)
darone
ma
8/1/13
10:02(Cordarone)
PM

Observe for hyperkalemia,


hyponatremia.
talization
(ICSI, 2011). Patients with renal dysfunction and

at vascular access site


mass, bruit
d urine output
BUN, serum creatinine

blood urea nitrogen.

Vessel trauma during the


procedure
Nephrotoxic contrast agent

Notify physician.
Anticipate intervention.
Monitor urine output, BUN, creatinine,
electrolytes.
Provide adequate hydration.
Administer renal protective agents (acetylcysteine) before and after procedure as
prescribed.
chapter 25 Assessment of Cardiovascular Function
677

Users Guide

xxi

Interpret and store alarms


hysiologic alterations in Updated!
Quality
Safety
Alerts
Gerontologic Considerations, identified with an icon
eghhospital
few diagdays.
Some patients
withand
unstable
lesionsNursing
and at high
risk foroffer

it does for
notahelp
tips
forTrend data over time
best
clinical
practice
and red-flag
safety
warnings
to
applied to headings, charts, and tables, highlight informaV
heparin
or
a
thrombin
abrupt
vessel
closure
are
restarted
on
heparin
after
sheath
Print a copy of rhythms from one or more specific ECG
nose some complications
help
avoid
common
mistakes.
tion that pertains specifically to the care of the older adult
max])
and
are
monitored
removal,
or
they
receive
an
IV
infusion
of
a
GP
IIb/IIIa
inhibleads over a set time (called a rhythm strip)
cemakers and pulmonary
e
&
Rao,
2009).
Patients
itor.
These
patients
are
monitored
closely
and
may
have
a
patient. In the United States, older adults comprise the
y chest x-ray.
Chapter 14 Shock and Multiple O
nt
(e.g., eptifibatide)
for
delayed
recovery
period. Nursing Alert
fastest-growing segment of the population.
g technique
that allows
and Safety
664
unit Quality
6 Cardiovascular
and Circulatory Function
prevent
platelet
aggregaAfter
hemostasis
is
achieved,
a
pressure
dressing
is
applied
en. It shows cardiac and
on resume
continuous
ECG and
monitoring
must
be
ediac
coronary
artery.
toPatients
the site.placed
Patients
self-care
ambulate
unassisted
contours.
ThisHemotechis 70% (Ramos & Azeved
Chart
informed
of its
purpose
and
cautioned
thatduration
it does not
aths
may
be
removed
at
within
a
few
hours
of
the
procedure.
The
of
immo(continued)
TAble
25-2
assessing
chest
Pain
which makes it a useful aid
mately 25% of the oxygen
14-1
Recognizing Shock in Older Patients
detect
shortness
of
breath,
chest
pain,
or
other
ACS
a vascularand
closure
device
bilization depends on the size of the sheath inserted, the type
Precipitating Events
Alleviating
electrodes
for guiding
metabolism. During stress
symptoms.
Thus,
patients
are
instructed
to
report
new
or
Duration
and Aggravating Factors
Factors
The physiologic
changes associated with aging, coupled with
evice
that sutures
ves- Location
of anticoagulant administered,Character
the method of hemostasis,
s catheters
during the
cardiac
gen is consumed and the S
worsening
symptoms
and
val
may also be achieved Anxiety
the
condition,immediately.
and the
preference.
andpatients
Panic Disorders
Painphysicians
described as stabbing
to
PeaksOn
in
Can occur at any timepathologic
Removal
of chronic disease states, place older people at
ocedures.
that the tissues are consum
increased
risk for developing a state of shock and possibly
dull ache
10 min
including during sleep
stimulus,
nical compression device
the day after the procedure, the
site is inspected and the
Interventions focus on
Associated with diaphoresis,
Can be associated with
a
relaxation,
multiple
organ
dysfunction syndrome. Older adults can recover
matic compression device
dressing removed. The patient ispalpitations,
instructed
to ofmonitor the
shortness
specific trigger
medications
ments
and increasing perf
from
shock
if
it
is
detected
and
treated
early
with
aggressive
Hardwire
Cardiac
Monitoring
tingling ofconsiderations
hands or
to treat
Critical
Care icons
identifybreath,
site for bleeding
or development
ofnursing
a hard
mass
indicative of for
and supportive
tissues. For instance, sed
mouth, feeling of unreality,
anxiety ortherapies. Nurses play an essential role in
ion of the electrical curHardwire
cardiac
monitoring
is
used
to
continuously
observe
or fear of losing control
underlying
sing by
unit
withdisposable
the large the
hematoma.
critically ill patient.
assessing
and interpreting subtle changes in older patients
to lower metabolic dema
ned
placing
disorder
the heart for dysrhythmias and conduction disorders using
n place.
The
are
responses to illness.
treated with IV opioid age
the
skin of
thesheaths
chest wall
one or two ECG leads. A real-time ECG is displayed on
activated
clotting
Medications such as beta-blocking agents (metoprolol
for oxygen. Supplementa
or(e.g.,
electrode
placement).
a
bedside
monitor
and
at
a
central
monitoring
station.
In
surgical
Procedures:
Coronary
[Lopressor]) used to treat hypertension may mask
no
and two
the
tion may be required to
nt longer
flowingactive
between
critical care
units, revascularization
additional components can be added to
tachycardia, a primary compensatory mechanism to increase
eor
range.
This usually
takes
artery
the blood. Administration
displayed
on a monicardiac output, during hypovolemic states.
the bedside monitor to continuously monitor hemodynamic
heparin by
given
durports BP and cardiac out
nunt
beofobtained
using
a
The aging immune system may not mount a truly febrile
parameters
(noninvasive
BP,
arterial
pressures,
pulmonary
st remain
in bed
and Musculoskeletal
Advances
in diagnostics,
medical
management,
and surgical
red blood cells enhances
alled
leads.flat
Simply
stated,
Sharp
or
stabbing
pain
Hours
to
Most
often
follows
Rest,
ice,
or
Disorders
(costochondritis)
response
(temperature
greater
than
38C
[100.4F]);
however,
artery
pressures),techniques,
respiratory parameters
rate, oxythe activity
sheaths ofare
removed
and anesthesia
as well
as (respiratory
the
care
provided
localized
in
anterior
chest
days in
respiratory tract
heata febrile response (temperature less than 37C
sue oxygen consumption w
ical
heart.
The
a
lack
of
gen
saturation),
ST segments
foroften
myocardial
ischemia.
Most
unilateral
infection with
Analgesic
to or
maintain
hemostasis.
critical
care andand
surgical
units, home
care,
and rehabilitation
measure to more accurate
or an increasing trend in body temperature should
ads
12 different
views,
Can radiate across chest to
significant coughing, [98.6F])
or antiay
discomfort, treatprograms, have continued to make
surgery
an effective treatepigastrium
or back
vigorous exercise, or be addressed.
inflammatory
The patient may also report increased fatigue
compensatory stage of sh
Telemetry
or cause
18 leads.
posttrauma
medications
and malaise
in the absence of a febrile response.
edation.
Sheath removal
ment option for patients with CAD. CAD has been treated
detect altered tissue perfu
gnose
dysrhythmias,
conSome
cases
are
idiopathic.
In addition to hardwire cardiac monitoring, the ECG can
Exacerbated by deep The heart does not function well in hypoxemic states, and
theenlargement,
vessel insertion
site
by myocardial revascularization since the 1960s, and the most
& Azevedo, 2010).
ber
as well
be continuously observed by telemetrythe transmission of
inspiration, coughing,the aging heart may respond to decreased myocardial
the bloodItpressure
to
common
CABG
have been
performed
more
Newer technologies a
rndinfarction.
can also
sneezing, and
radio
waves
from atechniques
battery-operated
transmitter
to afor
central
oxygenation with dysrhythmias that may be misinterpreted as
movement of upper
ose
of IV atropine
is usuthan
40
years.
Coronary
artery
bypass
graft
(CABG)
is
a
in
tissue
perfusion before
te disturbances
(high
or
bank of monitors. The primary benefit of using telemetry is
a normal part of the aging process.
torso or arms
surgical
procedure
in which
a blood
is grafted
to an
rate, and urine output) i
and the effects of antiar There is a progressive decline in respiratory muscle strength,
that
the system
is wireless,
which
allowsvessel
patients
to ambulate
Sublingual capnometry, a
CG adds three additional
maximal ventilation, and response to hypoxia. Older patients
while one or two ECG leads are monitored. The patient has
information about the d
have
a
decreased
respiratory
reserve
and
decompensate
ium and is used for early
electrodes placed on the chest with a lead cable that connects
more quickly.
ACS,Genetics
acute coronary syndrome;
myocardial infarction.
the sublingual partial pre
in MI,17
Nursing
Practice
charts
summarize
andWilliams & Wilkins; DeVon,
eft posterior (ventricular)
the
transmitter.
The
transmitter
can
be
placed
in aPhiladelphia:
disposChapter
Preoperative
Nursing
Management
405Lippincott
Adaptedto
from
Bickley,
L. S. (2009).
Bates
guide to
physical examination
and history
taking (9th ed.).
H. A., Ryan, C. J.,
Changes in mentation may be inappropriately misinterpreted
probe is placed under the
hree posterior leads to the Rankin,
S. H.,pouch
et al. (2010).
Classifying
subgroups
of patients
with
symptoms
of simply
acute
coronary
syndrome: A
cluster
analysis. Research in Nursing and Health, 33, 386397; and
highlight
nursing
assessments
and
management
issues
able
and
worn
around
the
neck,
or
secured
to
as dementia. Older people with a sudden change in mentation
S. L., Froelicher, E. S., Motzer, S. A., et al. (2009). Cardiac nursing (6th ed.). Philadelphia: Lippincott Williams & Wilkins.
are derived from the bloo
y detection of myocardial Woods,
the patients
transmitter
batteries
are changed
related
to theclothing.
role ofMost
genetics
in selected
disorders.
should be aggressively assessed for acute delirium and
During shock, an elevate
terpretation
of
the
ECG,
every 24 to 48 hours.
y Based on urgency
treated for the presence of infection and organ hypoperfusion.
sion. Near-infrared spectr
t, weight, symptoms, and
6/14/13 3:53 PM
G E n E t i CExamples
S in nurSinG PrACtiCE
Indications
for Chart
Surgery
Lead Systems
invasive technology, uses
d antiarrhythmic
agents)
25-1
Cardiovascular Disorders
etal muscle oxygenation a
See
Chapter 26
for a more
The number of electrodes
needed for hardwire cardiac moniof decreased stroke volume, is illustrated in the following
te attention;
Without
delay
Severe bleeding
Several
cardiovascular
disorders
associated
with
genetic
Assessin
whether
genetic testing has
probe is applied to the th
toring and telemetry
isaredictated
by
the
lead system used
the DNA mutation or otherexample:
Bladder
or intestinal
obstruction
abnormalities. Some examples are:
performed on an affected family member.
Fractured need
skull to be securely and been
palm of the hand near th
clinical
setting.
Electrodes
accurately
Familial hypercholesterolemia
phic Monitoring
Systolic BP - Diastolic BP = Pulse pressure
Gunshot
stab wounds
gen saturation of tissue by
Patient Assessment
placed on
the chest
wall. or
Chart
25-4 provides helpful
hints
Hypertrophic
cardiomyopathy
Extensive burns
he standard of care for Long
Assess
for signs
(xantholight absorption. Low val
syndrome
onQThow
to apply these electrodes. There are three-,
four-,
or and symptoms of hyperlipidemias
Normal
pulse
pressure:
mas, corneal arcus, abdominal pain of unexplained origin).
ention
Acute gallbladder infection
hemochromatosis
dysrhythmias.Within
This 2430
formh Hereditary
than 80%) indicate severi
five-lead
systems available
for ECG monitoring. The
type
of
Assess
for muscular
weakness.798 unit 6 Cardiovascular and Circulatory Function
Elevated homocysteine levels
Kidney or ureteral stones
120 mm Hg - 80 mm Hg = 40 mm Hg
normalities in heart rate
more severe the tissue hyp
lead system used determines the number of lead options for
gery
withinfor
a fewNursing
weeks orAssessments
months
Prostatic hyperplasia without bladder obstruction
e capacity to Plan
monitor
Although treatments a
Management
Issues Specific toNarrowing
Genetics of pulse pressure:
monitoring. For example,
the
five-lead
system
provides
up
to
Thyroid disorders
Physiology
Pathophysiology
used to identify the pres- Family
physician, the nurse usua
History
Assessment
If indicated,
refer for further genetic counseling and evaluation
seven
different
leadCataracts
selections. Unlike the other two
systems,
mm Hg - 70 mm Hg = 20 mm Hg
so that
the family can discuss inheritance, risk to other 90
family
patients with
cardiovascular
symptoms
for corory (see Chapter
27). Two Assess
troubleshoots equipment
thenotall
five-lead
system
can ofmonitor
the
activity of the
anterior
y
Failure to have surgery
Repair
members, and availability of genetic testing, as well as genearterycatastrophic
disease (CAD), regardless
ofscars
age (early-onset CAD
ng techniques are used in nary
patients status during trea
wall of the left ventricle.
Figure 25-9 presents diagrams
of
Simple hernia
based interventions.
Elevation of the diastolic BP with release of catecholamines
occurs).
iac monitoring, found in Assess
Vaginal
Offer appropriate genetic information and resources (e.g.,
effects of treatment. In add
family history
of sudden
deathrepair
in people who may or
electrode
placement.
and
attempts
to
increase
venous
return
through
vasoconGenetic Alliance Web site, American Heart Association).
have been diagnosed
with CADsurgery
(especially of early
and telemof the patient and family t
tive care units;Personal
preferencemay not
The
two ECG Cosmetic
leads
most
often selected for continuous
striction
is an early compensatory mechanism in response to
Provide support to families newly diagnosed
with geneticsonset).
nits or outpatient cardiac AskECG
leads asymptomatic
II and V1.child,
Lead II provides
the
related cardiovascular
disease.
about monitoring
sudden death in are
a previously
decreased
stroke volume, BP, and overall cardiac output.

Reducing Anxiety

or adult.
cardiac monitoring and adolescent,
best visualization
of atrial depolarization (represented by the

about other family members with biochemical or neuation; however, most sys- Ask
Genetics
Resources
Patients and their familie
P wave).
Lead V
records ventricular
1 best
romuscular
conditions
(e.g.,
hemochromatosis
or muscular depolarization and
If these are not present, dystrophy).
anesthesia
and surgical
care, and (3)formeticulous
andChapter
compecommon:
hensive when they face a
See
8, Chart 8-6 for genetics resources. Quality and Safety Nursing Alert
is most helpful
when monitoring
certain dysrhythmias
ropriate treatment begins
tent
and postanesthesia
management.
Nurses
lead simultaneously
being and are the focus of
(e.g.,postoperative
premature ventricular
contractions,
tachycardias,
bunBy the time BP drops, damage has already been occurmust
educate
patients
appropriate
pain management
segment depression is a
viders. Providing brief exp
dle branch
blocks)
(see about
Chapter
26).
ring at the cellular and tissue levels. Therefore, the patient
and encourage
pain
communication to obtain
postopObesity
Considerations
iconsgreater
identify
content
ia; ST-segment elevation New!
treatment procedures, su
at
risk
for
shock
must
be
assessed
and
monitored
closely
derations
Ambulatory
Electrocardiography
erative
pain
relief.
Older
adults
may need
explanaing
MI)
procedures, and providing
related
to
obesity
or
to the
nursing
caremultiple
of patients
who are
before the BP falls.

tions
to understand
and retain what
is communicated
(see
ible alarms (based on priAmbulatory
electrocardiography
is a form
of continuous ECG
are usually effective in re
lts
are proportional to the obese.
Providing
Education
section).
est grade ofand
alarm)
monitoringPatient
used for
diagnostic
purposes in the outpatient
promoting the patients
morbidities
the nature
_
Continuous central venous oximetry (Scv O ) monitoring
Speaking in a calm, reass
dure. The underlying prin2
Bariatric Patients
also help ease the patient
may be used to evaluate
mixed
venous blood oxygen satuessment, surgical care,
and
LWBK1234-C25_p652-691.indd
664
6/5/13 12:46
PM

vide comfort for criticall


ration and severity
of tissue hypoperfusion states. A central

t patients have less physi


Bariatrics has to do with patients who are obese. Like age,
Figure
29-1 (SVC),
The pathophysiology
Lensky, & Brassel, 2011).
catheter is introduced into the superior vena
cava
organ to return to normal
of heart failure. A decrease in cardiac
obesity increases the risk and severity of complications assooutput activates multiple neurohormobers have certain needs du
and a sensor on the catheter measures the oxygen
saturation
m) than younger patients
nal mechanisms that ultimately result
ciated with surgery. During surgery, fatty tissues are especially
in the signs and symptoms of heart
ing the need for honest,
of the blood in the SVC as blood returns to
the _heart and
l., 2011). Respiratory and
failure.
susceptible to infection. Wound infections are more common
nication with health care
pulmonary system for re-oxygenation. A normal Scv O2 value
ding causes of postoperain the obese patient (Haupt & Reed, 2010). Obesity also 6/5/13 12:46 PMsubstances promote vasodilation and diuresis. However, their causes a further decrease in CO. All of these
compensatory
er adults (Tabloski, 2009).
mechanisms of HF have been referred to as the vicious cycle
effect is usually not strong enough to overcome the negative
increases technical and mechanical problems related to surof HF because low CO leads to multiple mechanisms that
effects of the other mechanisms.

Physiology/Pathophysiology
figures
include
nd hepatic functions are
make the heart
work harder, worsening
the HF. illustraAs
the hearts workload increases, contractility of the
gery, such as dehiscence (wound separation). It may be more
myocardial muscle fibers decreases. Decreased contractilty is likely to be reduced.
tions
and inalgorithms
describing
normal physiologic and
ity results
in an increase
end-diastolic blood volume
in
Clinical Manifestations
challenging to provide care for the patient who is obese owing
the ventricle, stretching the myocardial muscle fibers and
malnutrition may occur
Many clinical manifestations are associated with HF (Chart
pathophysiologic
processes.
to the excessive weight and possible restrictions in moveincreasing
the size of the ventricle (ventricular
dilation).
29-1). These signs and symptoms are related to congestion
One way the heart compensates for the increased workload
s, such as impaired vision
and poor perfusion. The signs and symptoms of HF can also be
ment. The estimation of about 25 additional miles of blood
is to increase the thickness of the heart muscle (ventricurelated to the ventricle that is most affected. Left-sided heart
tivity, frequently interact
lar hypertrophy). However, hypertrophy results in abnormal
vessels needed for every 30 pounds of excess weight results
failure (left ventricular failure) causes different manifestachanges in structure and function of myocardial cells, a protions than right-sided heart failure (right ventricular failnt, so falls are more likely
cess
known
as
ventricular
remodeling.
Under
the
influence
LWBK1234-C14_p285-309.indd
289
in increased cardiac demand (Alvarex, Brodsky, Lemmens,
ure). In chronic HF, patients may have signs and symptoms of
of neurohormones (e.g., angiotensin II), enlarged myocardial
ning a safe environment
both left and right ventricular failure.
cells become dysfunctional and die early (a process called
et al., 2010). The patient tends to have shallow respirations
apoptosis), leaving the other normal myocardial cells strugand planning. Arthritis
Left-Sided Heart Failure
gling to maintain CO.
when supine, increasing the risk of hypoventilation and postAs cardiac cells die and the heart muscle becomes fibrotic,
Pulmonary congestion occurs when the left ventricle cannot
er patients, and it affects
operative pulmonary complications.
diastolic HF can develop, leading to further dysfunction. A
effectively pump blood out of the ventricle into the aorta
g from one side to the
stiff ventricle resists filling, and less blood in the ventricles
and the systemic circulation. The increased left ventricular
The acquired physical characteristics of short thick necks,
mfort. Protective
measures
LWBK1234-FM_pi-xl.indd
8/1/13 10:02 PM
large21
tongues, recessed chins, and redundant pharyngeal tisr bony prominences and
Myocardial dysfunction
Ischemic heart disease
Hyperthyroidism
Myocardial infarction
Valve disease
Alcohol, cocaine abuse
Hypertension

Cardiac output
Systemic blood pressure
Perfusion to kidneys

Activation of reninangiotensin
aldosterone system

Activation of
baroreceptors
Left ventricle
Aortic arch
Carotid sinus

Stimulation of
vasomotor regulatory
centers in medulla

Angiotensinogen

Angiotensin I

Activation of sympathetic
nervous system

Lungs

Renin

Aldosterone released
by adrenal cortex

Catecholamines
(epinephrine and
norepinephrine)

Vasoconstriction

Aldosterone

Angiotensin II

Sodium and water retention


Arginine vasopressin
Endothelin
Cytokines
(tumor necrosis factor-)

Remodeled

Normal

Vasoconstriction
Afterload
Blood pressure
Heart rate

Ventricular
remodeling

Hypertrophy and
dilation of ventricle
Large cells
Impaired contractility

to determine the efficacy of routine intervals for BP and HR


measurement for identification of bleeding complications in
patients post PCI.

Design

xxii

This descriptive study was conducted in a university hospital. It


was comprised of 1,292 participants who were predominately
men (71.9%) and had a mean age of 61.4 years. Almost
two thirds of the sample (62.8%) underwent a cardiac
catheterization, and the remaining (37.2%) had a percutaneous
transluminal coronary angioplasty. The femoral artery was
cannulated in the majority of these patients (92.8%). Vital signs
and assessment for bleeding were initiated upon arrival to the
postprocedure recovery unit and continued for the first hour
after ambulation.

Users Guide

Features to Develop the Nurse as Educator

versus no bleeding (152 [11.8%] vs. 43 [3.3%]). After adjusting


for age, gender, and history of hypertension, the differences
between BP and HR values taken at various time points were
not predictive of bleeding complications.

Nursing Implications
Nursing practice needs to be evidence based. Results of
this study found that frequent monitoring of BP and HR
every 15 minutes for the first hour after PCI may not be
an effective method for detecting bleeding complications
in this population. Nurses time may be better served by
individualizing the frequency of vital signs based on each
patients condition, which will give nurses more opportunities
to assess the catheter insertion site and affected extremity for
bleeding.

Health education is a primary responsibility of the nursing profession. Nursing care is directed toward promoting, maintaining,
the catheter access site and for orthostatic hypotension,
For patients being discharged from the hospital on the
and restoring health; preventing illness; and
helping patients and families adapt to the
residual effects of illness. Patient educaindicated by complaints of dizziness or lightheadedness
same day as the procedure, additional instructions are protion and health promotion are central to (Wiegand,
all of these
activities.
2011; nursing
Woods et al.,
2009).
vided (Chart 25-6).
806

unit 6 Cardiovascular and Circulatory Function

Patient Education charts


P A t iWith
E nComplications
t E D u C A From
t i oHeart
n Disease
Management of Patients
809
help the nurse prepare the Chapter 29Chart
25-6
Self-Management After Cardiac Catheterization
and back
are also assessed for edema. The upper extremities
and exercise tolerance. Prolonged inactivity, which may be
patient and family
for proce Call your primary provider if any of the following occur:
After discharge
from the
hospital for cardiac
catheterization,
diagnosis of HF can bemay
successfully
managed
with lifestyle
(Pressler,
Gradus-Pizlo,
Chubinski,
et al.,
2009). An effecalsounderstandbecome
edematous
in some
patients.
Edema
isfortypiself-imposed,
should
be bruising
avoided
because
of procedure
its deconditionswelling, new
or pain
from your
puncture
patients
should
theseplan
guidelines
self-care:
dures,
themrecurrences
in
changes
andassist
medications,
of acute HF lessen,
tive follow
treatment
incorporates
both the patients goals and
cally
rated
on
a
scale
from
0
(no
edema)
to
4+
(pitting
edema).
ing
effects
and
such ofas101F
pressure
site,risks,
temperature
or more.ulcers (especially in
If the artery
in your
armhealth
or wristcare
artery
was used:The
For nurse
the must consider
unnecessary
hospitalizations
decrease,
and
life
expectancy
those
of
the
providers.
ing the patients The
condition,
and

If
test
results
show
that
you
have
coronary
artery
disease,
next 48for
hours,
avoid
lifting and
anything
heavier
than 5 pounds
is examined
tenderness
andadapt
hepatoedematous
patients) and venous thromboembolism. An
increases. The Joint Commissionabdomen
and other agencies
have
cultural
factors
the education
plan accordingly.
talk with your primary provider about options for treatment,
and avoidPatients
repetitiveand
movement
ofneed
yourto
affected
hand
and
explain
to them
howtoThe
totheprovide
established
standards
pertaining
education
patients
families
be aware
of
treatment
choices
megaly.
presenceof of
firmness,
distention,
and
possible
acute
illness
that
exacerbates
HF symptoms
oryour
requires
hosincluding
cardiac rehabilitation
programs in
community.
wrist.
with
HF. Nurses play aascites
key roleisinnoted.
instructing
patients
and
and
the
possible
outcomes
of
specific
therapies.
They
need
self-care.

Talk
providerfor
about
lifestyle changes
The liver
be inassessed
pitalization
may with
be your
an primary
indication
temporary
bedto reduce
rest.
Ifmay
the artery
your groinfor
was hepatojuguused: For the next 24 hours,
do

their families about medication management, a low-sodium


to understand that effective HF management is influenced
your risk for further or future heart problems, such as quitting
bendto
at the
waist, strain,
or lift heavy
objects. Otherwise, some
reflux. The
patient
is not
asked
breathe
normally
while
of physical activity every day should
diet, moderate alcohollar
consumption,
activity
and exercise
by choices
about
options
their abilitysmoking,
to type
lowering your cholesterol level, initiating dietary
Do not submerge
themade
puncture
sitetreatment
in water. Avoid
tuband
baths,
manual
pressure
applied
over
the
right
upper
quadrant
be
encouraged.
Exercise
training
has program,
many favorable
effects
recommendations, smoking
cessation,
how toisrecognize
the
follow
the
treatment
plan.
They
also
need
to
be
informed
that
changes,
beginning
an exercise
or losing weight.
but shower as desired.
signs and symptoms of of
worsening
HF, and when
health
care
providers
are distenavailable
tomay
assist
them
reaching
Your primary
provider increased
may prescribefunctional
one or more new
the abdomen
for to30contact
to Talk
60a with
seconds.
If neck
vein
for
thetoin
HF
patient,
including
capacity,
your primary
provider
about
when you
return
medications depending on your risk factors (medications to
health care provider (ICSI,
Although
nonadherence
their
health
care
drive,
or resume
strenuous
activities.
tion 2011).
increases
more
than work,
1 cm,
the
finding
isgoals.
positive
for
decreased dyspnea,
and improved quality of life (Downing &
lower your blood pressure or cholesterol; aspirin or clopidogrel
continues be a challenge in this patient population, interIf bleeding occurs, sit (arm or wrist approach) or lie down (groin
increased
venous
pressure.
Balady,
2011).
exercise
regimen
should
includeas5 mintoThe
prevent
blood clots).
Take all of
your medications
and apply firm
pressure
to the puncture
site forof HF requires
ventions that promote adherence include educating approach)
the
Continuing
Care.
Successful
management
instructed.
If you feel
that any of
are causing
side effects,
10 minutes.
Notify
your
primary
provider
as soon
as utes
possible
If the patient
is hospitalized,
the
nurse
urinary
warm-up
activities
followed
bythem
about
30 minutes
of
patient and family about effectively
managing
HF. A basic
adherence
tomeasures
a complex
medical
regimen
thatof
includes
mulcall your primary provider immediately. Do not stop taking any
followtiple
instructions.
there is a
amount
of bleeding,
home education plan output
for the patient
with HF is it
presented
lifestyle Ifchanges
forlarge
most
patients.
Assistance
may
beprescribed intensity level. A typical program
and evaluates
in and
terms
of
diuretic
use.
Intake
and
exercise
at
the
medications before talking to your primary provider.
call
911.
Do
not
drive
to
the
hospital.
in Chart 29-6. The patient should receive a written copy of
provided through a number of options that optimize evioutput records are rigorously maintained
and analyzed. It for
is effective
for amanagement
patient with
HF might include a daily walking regithe instructions.
of American Journal of Nursing, 112(1), 4956; and Woods, S. L.,
Adapted fromdence-based
Durham, K. A. recommendations
(2012). Cardiac catheterization
through the radial artery.
important
to track
whether
the
patient
has excreted
excessive
men,
with
the
duration
increased
over a 6-week period. The
The patients readiness
to learn and
potential
barriers
to
HF.
options
home
health
care
tranFroelicher, E.
S.,These
Motzer,
S. A., et include
al. (2009).
Cardiac
nursing
(6th services,
ed.).
Philadelphia:
Lippincott
Williams & Wilkins.
learning are assessed. volume
Patients with
may have
tempocare programs,
HF clinics,
(i.e.,HF
negative
fluid
balancesitional
is generally
the goal).
The and tele-health
physician,managenurse, and patient collaborate to develop a schedrary or ongoing cognitive
impairment
due to their
illness
or
ment
programs.
Transitional
care programs
by promotes
advanced pacing and prioritization of activities. The
intake
and output
is then
compared
with
changes
in weight.
ule led
that
other factors, increasing the need to rely on family members
practice nurses significantly reduce readmission rates for HF

Although diuresis is expected, the HF patient must also be


monitored for oliguria (diminished urine output, less than
0.5
hom
e mL/kg/hr)
C A R e C h eor
C kanuria
l i S T (urine output less than 50 mL/24 h)
Chart
29-6
The Patient
With
Failure
because
of Heart
the risk
of renal dysfunction.
LWBK1234-C25_p652-691.indd 685
The patient is weighed daily in the hospital or at home,
At the completion of home care education, the patient or caregiver will be able to:
at the same time of day, with the same type of clothing, and
Identify heart failure ason
a chronic
diseasescale.
that canIfbethere
managed
medications and
specific in
self-management
the same
is with
a significant
change
weight
behaviors.
(i.e., 2- to 3-lb increase in a day or 5-lb increase in a week),
Take or administer medications daily, exactly as prescribed.
the primary provider is notified and medications are adjusted
Monitor effects of medication such as changes in breathing and edema.
(e.g., the diuretic dose is increased).

Know signs and symptoms of orthostatic hypotension and how to prevent it.
Weigh self daily at theDiagnosis
same time with same clothes.
Restrict sodium intakeNursing
to no more than
2 g/day: Adapt diet by examining nutrition labels to check sodium
Diagnoses
content per serving, avoiding canned or processed foods, eating fresh or frozen foods, consulting the written
Based
on
the
assessment
data,salt
major
nursing
mayand
diet plan and the list of permitted and restricted
foods, avoiding
use, and
avoiding diagnoses
excesses in eating
drinking.
include the following:

Participate in prescribed activity


program.
Activity intolerance related to decreased CO
Participate in a daily exercise program.
Excess fluid volume related to the HF syndrome
Increase walking and other activities gradually, provided they do not cause unusual fatigue or dyspnea.
Anxiety-related symptoms related to complexity of the
Conserve energy by balancing
activity with rest periods.
Avoid activity in extremes oftherapeutic
heat and cold, which
increase the work of the heart.
regimen
Recognize that air-conditioning may be essential in a hot, humid environment.

Powerlessness related to chronic illness and hospitaliza-

Develop methods to manage and prevent stress.


tions
Avoid tobacco.
Avoid alcohol.
Ineffective family therapeutic regimen management
Engage in social and diversional activities.

Collaborative
Keep regular appointments
with physician Problems/Potential
or clinic.

Complications
Potential complications may include the following:
Be alert for symptoms that may indicate recurring heart failure.
Know how to contact primary
provider.
Hypotension,
poor perfusion, and cardiogenic shock
(seeprovider
Chapter
14)any of the following:
Report immediately to the primary
or clinic
Gain in weight of 23 lb (0.91.4
kg) in 1 day, or 5 lb (2.3 kg) in 1 week
Dysrhythmias (see Chapter 26)
Unusual shortness of breath with activity or at rest
Thromboembolism (see Chapter 30)
Increased swelling of ankles,
feet, or abdomen
Persistent cough
Pericardial effusion and cardiac tamponade
Loss of appetite
Development of restless sleep; increase in number of pillows needed to sleep
Planning and Goals
Profound fatigue

LWBK1234-C29_p795-818.indd 809

Major goals for the patient may include promoting activity and reducing fatigue, relieving fluid overload symptoms,
decreasing anxiety or increasing the patients ability to manage anxiety, encouraging the patient to verbalize his or her
ability to make decisions and influence outcomes, and educating the patient and family about management of the therapeutic regimen (Doenges, Moorhouse, & Murr, 2010).

Nursing Interventions
Promoting
Activityreview
Tolerance
Health Promotion
charts
important points that the
Reduced physical activity caused by HF symptoms leads to
nurse should discuss with the patient to prevent common health
physical deconditioning that worsens the patients symptoms

problems from developing.

LWBK1234-C29_p795-818.indd 806

LWBK1234-FM_pi-xl.indd 22

schedule should alternate activities with periods of rest and


avoid having two significant energy-consuming activities
Home Care Checklists review
occur on the same day or in immediate succession. Before
points that
should should
be covered
as
undertaking physical activity,
the patient
be given
part ofnoted
home
education
prior
guidelines similar to those
in care
Chart
29-4. Because
patient
caregiver
to discharge
from they
the health
care
some patients may be severely
debilitated,
may need
to
4
4
limit
physical
activitiesfacility.
to only 3 to 5 minutes at a time, one
to four times per day. The patient should increase the dura4
tion
of the4activity, then the frequency, before increasing the
4
4
intensity
of
the activity.
4 Barriers
4to performing activities are identified, and meth4 of adjusting an activity are discussed. For example, vegeods
4
tables
can4be chopped or peeled while sitting at the kitchen
table rather than standing at the kitchen counter. Small,
frequent meals decrease the amount of energy needed for
digestion
while providing adequate nutrition. The nurse
4
helps the patient identify peak and low periods of energy,

Chart

29-4

6/5/13 12:46 PM

heAlTh PRomoTion

An Exercise Program for Patients


With Heart Failure

Before undertaking physical activity, the patient should be given


4
the following
guidelines:
4
4
Talk with your primary provider for specific exercise program
recommendations.
4
4
Begin with
low-impact activities such as walking, cycling, or
water exercises.
Start with warm-up activity followed by sessions that
gradually build up to about 30 minutes.
Follow your exercise period with cool-down activities.
Avoid performing physical activities outside in extreme hot,
cold, or humid weather.
Wait 2 hours after eating a meal before performing the
physical activity.
Ensure that you are able to talk during the physical activity;
if you cannot do so, decrease the intensity of activity.
Stop the activity if severe shortness of breath, pain, or
dizziness develops.
4

18/06/13 9:58 AM

Adapted from Andreuzzi, R. (2010). Does aerobic exercise have a role


in the treatment plan of a patient with heart failure. Internet Journal of
American Physician Assistants, 7(2), 129; and Flynn, K. E., Pia,
I. L., Whellan, D. J., et al. (2009). Effects of exercise training on health
status in patients with chronic heart failure: HF-ACTION randomized
controlled trial. Journal of the American Medical Association, 301(14),
14511459.

18/06/13 9:58 AM

8/1/13 10:02 PM

Chapter 27 Management of Patients With Coronary Vascular Disorders

767

Users Guide
xxiii
resume normal activities. The patient and family are reasMI is made. If a diagnosis of STEMI is made, which treatsured that the difficulty is almost always temporary and will
ment options may be considered?
subside, usually in 6 to 8 weeks. In the meantime, instructions
Features
to
Develop
the
Nurse
as
Patient
Advocate
are given to the patient at a slower pace than normal, and
3 A 60-year-old woman has just returned to your unit
a family
member
making
that the right to health care) and assisting patients and their famiNurses
advocate
forassumes
patientsresponsibility
by protectingfor
their
rightssure
(including
following a heart catheterization and PCI. She appears
766
Unit 6 Cardiovascular and Circulatory Function
theinprescribed
regimen decisions
is followed.
lies
making informed
about health care.
restless Chapter
and uncomfortable.
What
should
be included
in
27 Management of Patients
With Coronary
Vascular
Disorders
745
Continuing Care. Arrangements arepatients
madecore
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syndrome
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patient
must
gradually
nurse
Updated!
Ethical Dilemma
when appropriate.
Because the warmed
hospital
is relatively
other
postoperative
complications (e.g.,
incisional
to astay
normal
temperature.
parIdentify
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mcated?
ma
Chart
charts
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patients
own
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Should
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Be and
Recommended
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Adults Withembolus,
Acute Coronary
Syndrome?
27-9
watch
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PCI.
monia, atelectasis). Treatment depends on the severity of the
the assistance of heated air blanket systems. While the
discussion
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Describe
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this case
(Nipride)
may be necessary.
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principles
related
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drome
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resultant
increase
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oxygen demands
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patient
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interventions to manage symptoms (Parry
etmeasures
al., 2010).
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them left
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and other
are usedThey
to lower body temperature.
including
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Discussion
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ventricular
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also have a higher risk of depression Common
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What resources are available to help you facilitate this discusMany patients
present and
with ACS
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lungs, urinary
tract, who
incisions,
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catheters.
et al.,sion
2009).
with the patient and her sons?
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cardiac
often
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Meticulous
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the sites
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Ionescu,
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et al.that
(2010)
cardiac
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PCI
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process. Lifestyle changes for risk factor
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not capable
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tial, and medications taken before surgery
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of Invasive
22(10),
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more, than
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NCLEX-Style
Questions
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physical
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family set
realistic, achievlems such as blood pressure and hyperlipidemia
will
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be
Resources
(Ionescu, Amuchastegui, Ionescu, et al., 2010).
encouraging the patient to breathe deeply and
cough. Pre- , able
goals. An education plan that meets the patients indion
http://thePoint.lww.com/Brunner13e
necessary.
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3-6
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ethics
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vention of aspiration is another important factor in prevenvidual needs is developed with the patient and family. Specific
postoperative
Harbert,Guide
2011)
instructions are provided about incision care; signs and sympThe nurse encourages the patienttion
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surgeon,(Starks&Study
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the thrombus,
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ated heparin
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LMWH may
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undergoplatelet-inhibiting
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characterized
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Some
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The patient
may
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research
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research
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catheterization
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immediate
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hospital.PCI (if a cardiac with these difficulties often become frustrated when they try
benefit from supportive programs, such
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nursing
2012b). Thisresearch.
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catheterization laboratory is on site).*Asterisk
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27-14
Aspiration
Prevention Protocol: Decreasing Postoperative
Pneumonia
in Heart
Surgery
Patientscardiac
Following PCI
or thrombolytic
therapy,
continuous
comes have been reported with the use
of PCI when compared
Books
applicationsabout
of nursing
research
information
resuming
work, driving,
and
sexual
activis indicated,
preferablysurgery
in a cardiac
intensive
Starks,to
B.,thrombolytic
& Harbert, C.(also
(2011).
Aspiration
prevention
called
fibrinolytic)
agentsprotocol:
(ICSI, 2012b; adultmonitoring
patients who
had cardiothoracic
from April
2008 care
unitOctober
(ICU).S.Continuing
pharmacologic
management
includes
findings
for evidence-based
Decreasing
postoperative
pneumonia
in heart
surgery patients.
2008
were enrolled
the study.
Historical(4th
con-ed.).
see
the
Thrombolytics
(Fibrinolytics)
section).
Early PCI
Aschenbrenner,
D.has
S.,through
& Venable,
J. (2012).
Drug intherapy
in nursing
ity;
assistance
with tobacco use cessation;
and
support
groups
a beta-blocker,
enzyme
Criticalbeen
Care shown
Nurse, 31(5),
trolsaspirin,
were used
to compare and
ratesan
of angiotensin-converting
pneumonia.
to be 3845.
effective in patients Philadelphia:
of all ages, including
Lippincott
Williams
&
Wilkins.
nursing
practice.
for patients and families. Support groups, those
sucholder
as than
the75AHA(ACE) inhibitor. ACE inhibitors prevent the conversion of
years (Chart 27-9). The procedure treats
McCance,
K.
L.,
Huether,
S.
E.,
Brashers,
V.
L.,
et
al.
(2010).
Pathophysiology.
angiotensin I to angiotensin II. In the absence of angiotensin
Purpose
the underlying
atherosclerotic
Because the duration Findings
sponsored Mended Hearts, provide information
as well
as an lesion. The
II, theinblood
decreases(6th
and the
kidneys
excreteHeights,
sodium
biologic
basis forThe
disease
adultspressure
and children
ed.).
Maryland
of oxygen
deprivation
determines
the number
of myocardial
Postoperative
pulmonary
dysfunction
(including
atelectasis
and
interdisciplinary team of nurses, physicians, administrators,
opportunity for families to share experiences.
fluid (diuresis), decreasing the oxygen demand of the heart.
cells that
die, thecause
time of
from
the patients
arrival
ED and and
MO:
Mosby
Elsevier.
pneumonia)
is a frequent
morbidity
and
mortality
inin the
speech therapists who developed and implemented this pro to

of ACE
inhibitors
patients
after MI
decreases
mortowho
the have
time open
PCI isheart
performed
be less of
than
60
minutes. Essentials
patients
surgery.should
The purpose
study
tocolThe
set use
a goal
that no
patients in
who
participated
in this
protocol
Porth,
C.this
M.
(2011).
of pathophysiology (3rd ed.). Philadelphia:
tality
rates postoperative
and prevents remodeling
myocardial
is frequently
referred toofasandoor-to-balloon
time. A car- would
was to This
determine
if implementation
aspiration prevention
develop
pneumonia.of
This
goal was cells
met; that is
Lippincott
Williams
&
Wilkins.
associated
with the
of heart failure.
Blood pressure,
diac
catheterization
laboratory
andwould
staff must
be available
if an no study
protocol
in patients
after cardiac
surgery
decrease
the
participants
(n onset
= 79) developed
pneumonia.
However,urine
output,
and
serum
sodium,
potassium,
andsupport
creatinine
levels need
Sinz,this
E.,short
& Navarro,
(2011).
Advanced
cardiovascular
life
provider
emergent
PCI is to be
performed within
time. TheK.
incidence
of postoperative
pneumonia.
11%
of historical
controls
(n = 65)
developed
postoperative
to
be
monitored
closely.
If
an
ACE
inhibitor
is
not suitable,
pneumonia.
nursing care related to PCI is presented manual.
later in this
chapter.
Dallas:
American Heart Association.

Critical Thinking Exercises


Design

an angiotensin receptor blocker (ARB) should be prescribed

M.,
& Lough, M.
E. (2010). Critical care nursing (6th
Thrombolytics
(Fibrinolytics) Urden, L. D., Stacy, K.Nursing
(ICSI, 2011c).
Nicotine replacement therapy and smoking cesImplications
1
A 67-year-old patient hasAnjust
been diagnosed
aspiration prevention protocol was developed
andSt.
impleed.).
Louis: Mosby Elsevier.
sation counseling should also be initiated for smokers.
Thrombolytic
therapy
is
initiated
when
primary
PCI
is
not
availThe Plan-Do-Study-Act Model encourages team collaboration
mented in a 24-bed
intensive
care unit using the Plan-Do-Studywith metabolic syndrome with hypertension,
obesity,
dysablefor
or the
transport
time to advocated
a PCI-capable
hospital
is too
nurses Rehabilitation
and their interdisciplinary colleagues and results
Act Model
quality
improvement
by the
Institute
for long. between
Cardiac
Journals
and
Electronic
Documents
lipidemia, and insulin resistance. She
isThese
asking
more
agents for
are administered
IV according
to a extendspecific
proin rapid cycle improvement. These rapid cycle improvements
Healthcare
Improvement
(IHI).
The protocol
incorporated
tocol
(Chart
27-10).
The thrombolytic
agentsfrom
used2most
Afterquality
the patient
is free
of symptoms,
an The
active
patientwith
outcomes
and
ensure
patient safety.
ing thewhat
time that
patients
received
nothing by mouth
hoursoften enhance
information about this syndrome and
she
can
doand
Alberti,
K. G.,
Eckel, R. H.,
Grundy,
S. M.,
etanal.MI
(2009).
Harmonizing
the
are 6alteplase
(Activase) and
reteplase
(r-PA)aand
tenecteplase development
rehabilitation
program is initiated.
Cardiac rehabilitation
is
and implementation
of this aspiration
prevention
to at least
hours preoperatively
incorporating
postoperasyndrome.
Circulation,
120(16),
16401645.
expeditiously
met an
ambitious
aimfor
to reduce
rateCAD
tive bedside
swallowing
evaluation
by a speechmetabolic
After
about it. How will you define metabolic
syndrome
for
this
(TNKase).
The purpose
of thrombolytics
istherapist.
to dissolve
(i.e., lyse) protocol
an important
continuing
care
program
patientsthe
with
of postoperative
pneumonia
in patients
who had
swallow evaluation was completed, nurses
implemented
Arsenault,
B. aJ., Pibarot,
P., & Despres,
J. (2009).
The quest
forcardiothoracic
the optimal
patient? What does this diagnosis the
mean
for
her protocol.
futureA convenience
to nil.
progressive
oral intake
sample of 79of globalsurgery
assessment
cardiovascular
risk: Are traditional risk factors and
health and health care needs? Knowing that multiple lifemetabolic syndrome partners in crime? Cardiology, 113(1), 3549.
style changes are recommended, what is your first priority
Bhatty, S., Cooke, R., Shettey, R., et al. (2011). Femoral vascular access-site
complications in the cardiac catheterization laboratory: Diagnosis and
for patient education?
LWBK1234-C27_p729-768.indd 745

2
You are caring for an 88-year-old man who is
766 ambulating
hospitalized with a diagnosisLWBK1234-C27_p729-768.indd
of syncope. After
in the hall, he tells you that he is having some chest pain
and mild shortness of breath. Based on your knowledge
of evidence-based guidelines, identify the initial interventions and diagnostic testing that are indicated for patients
with these symptoms. Describe how the diagnosis of acute

LWBK1234-C27_p729-768.indd 767

LWBK1234-FM_pi-xl.indd 23

management. Interventional Cardiology, 3(4), 503514.


6/14/13 3:53 PM
Bukkapatnam, R. N., Yeo, K. K., Li, Z., et al. (2010). Operative mortality
in women and men undergoing coronary artery bypass grafting (from the
6/14/13 3:53 PM
Coronary ArteryPractice
Bypass Grafting
Outcomes Reporting
California
Evidence-Based
questions,
includedProgram).
in
American Journal of Cardiology, 105(3), 339342.
the Critical Thinking Exercises sections, encourage you
Cadwallader, R. A., Walsh, S. R., Cooper, D. G., et al. (2009). Great sapheto think
about the
evidencereview
baseand
formeta-analysis
specific nursing
nous
vein harvesting:
A systematic
of open versus
interventions.
endoscopic
techniques. Vascular and Endovascular Surgery, 43(6), 561566.
Chang, B. H., Aggie, C., Dusek, J. A., et al. (2010). Relaxation response and
spirituality: Pathways to improve psychological outcomes in cardiac rehabilitation. Journal of Psychosomatic Research, 69(2), 93100.

6/14/13 3:53 PM

8/1/13 10:02 PM

ability to function (secondary liver dysfunction). As hepatic


dysfunction progresses, increased pressure within the portal
vessels may force fluid into the abdominal cavity, causing
ascites. Ascites may increase pressure on the stomach and
intestines and cause gastrointestinal distress. Hepatomegaly
may also increase pressure on the diaphragm, causing respiratory distress.
xxiv Users Guidew
Anorexia (loss of appetite), nausea, or abdominal pain
may result from the venous engorgement and venous stasis
within
the abdominal organs. The generalized weakness that
chapter 25 Assessment of Cardiovascular Function
659
Features to Facilitate Learning
accompanies right-sided HF results from reduced CO and
In addition to practice-oriented features, special features have been
developed
to help readers learn key information.
impaired
circulation.
refractory
period.
During
the
effective
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the
open,
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blood is ejected into the pulmonary artery and
New! Concept Mastery Alerts highlight and clarify
cell
is
completely
unresponsive
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any
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aorta,
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The exit of blood is at first rapid; then,
fundamental nursing concepts to improve understanding
Concept
Mastery
Alertand its corresponding artery
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depolarization.
The
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tive
refractory
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phase
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the
flow
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Left-sided HF refers to failure gradually
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ventricle; itAt the end
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0adaptive
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of
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right
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leftHF,
ventricles
results in pulmonary congestion. Right-sided
failure ofrapplatform. Data from hundreds of actual
Chapter 27 Management of Patients With Coronary Vascular Disorders
767
relative
refractory
period
corresponds
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the
short
time
idly
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result,
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right
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in
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students using this program in medical-surgical courses
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end
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3.
During
the
relative
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period,
sures
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semilunar
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These
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viscera.
across the United
States identified
common
misconceptostimulus
resume normal
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The patient
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if
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electrical
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to clarify
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the difficulty
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may depolarizesured
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Earlyis almost
depolarizations
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repeated.
ment options may be considered?
subside, usually in 6 to 8 weeks. In the meantime, instructions
atrium or ventricle
cause
premature
contractions,
placing
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pressures can be measured with the use of speare given to the patient at a slower pace than normal, and
3monitoring
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woman
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returned to your
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Interactive
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to resume normal activities. The patient and family are reasMI isL.made.
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ventricle.
following a heart catheterization
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Arsenault, B. J., Pibarot, P., & Despres, J. (2009). The quest for the optimal
patient? What
this diagnosis
mean for
for aher
future
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home
care
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American
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105(3), 339342.
ily.inAdditional
may
dressing
changes,
88/60
mmHg;
2 mm
Hg. Which other assessment
Cadwallader,
R. A.,
Walsh, S. R., Cooper,
D. G., et al. (2009). Great sapheandsystole
mild shortness
of
Basedtoonpropagation
your knowledge
rate of
discharge,
transmitting
to the cerebral
point, ventricular
begins
inbreath.
response
diet
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use cessation
strategies.
Women their
parameters
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What type impulses
of postoperative
nous vein harvesting: A systematic review and meta-analysis of open versus
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Vascular
and Endovascular
Surgery, 43(6), 561566.
tions and diagnostic
testing
that are
indicated
patients
interventions
to manage
symptoms
(Parry
et al., for
2010).
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H., Aggie, C., Dusek,response,
J. A., et al. (2010).
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response
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heart
rate and
milliseconds earlier.
with
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how the
diagnosis
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have
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of depression
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during hypotension (low BP).
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lems such as blood pressure and hyperlipidemia will still be
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increased
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References

Reduction o
status
Stabilizatio
risk of hosp
Delay of th
expectancy
Promotion
Treatment op
patients conditio
(IV) medications
gen, implantation
including cardiac
Managing the
comprehensive e
family. The patie
of HF and the im
ment regimen. L
tion of dietary so
sive smoke; avoid
weight reduction

6/14/13 3:53 PM

8/1/13 10:02 PM

3
Your patient is a 65-year-old man who had a colon
resection 3 days ago. At about 2 am, he complains of shortness of breath and pain on inspiration. Describe how you
will assess the patient. What are your priority interventions? What diagnostic tests would you expect the medical
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References

xxv

References cited are listed at the end of each chapter and include updated, current sources.

Resources lists at the end of each chapter include sources of additional information, Web sites,
agencies, and patient education materials.

References

817

Resources

Brunner Suite Resources highlighted at the end of


each chapter identify additional resources available for further review, application, and clinical reference.
Brunner Suite Resources

on
, http://thePoint.lww.com/Brunner13e
Study Guide
PrepU
Clinical Handbook
Handbook of Laboratory and Diagnostic Tests

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Books
Aschenbrenner, D. S., & Venable, S. J. (2012). Drug therapy in nursing (4th
ed.). Philadelphia: Wolters Kluwer.
Bickley, L. S., & Szilagyi, P. G. (2009). Bates guide to physical examination and
history taking (10th ed.). Philadelphia: Lippincott Williams & Wilkins.
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2010). Nursing care plans.
Guidelines for individualizing client care across the life span (8th ed.). Philadelphia: F. A. Davis.
McCance, K. L., Huether, S. E., Brashers, V. L., et al. (2010). Pathophysiology.
The biologic basis for disease in adults and children (6th ed.). Maryland Heights,
MO: Mosby Elsevier.
Porth, C. M. (2011). Essentials of pathophysiology (3rd ed.). Philadelphia:
Wolters Kluwer.
Sinz, E., & Navarro, K. (2011). Advanced cardiovascular life support provider
manual. Dallas: American Heart Association.
Urden, L. D., Stacy, K. M., & Lough, M. E. (2010). Critical care nursing (6th
ed.). St. Louis: Mosby Elsevier.

Journals and Electronic Documents


*Albert, N., Trochelman, K., Li, J., et al. (2010). Signs and symptoms of heart
failure: Are you asking the right questions? American Journal of Critical Care,
19(5), 443453.
Colucci, W. S. (2011). Treatment of acute decompensated heart failure: Components of therapy. Available at: www.uptodate.com/contents/treatment-ofacute-decompensated-heart-failure-components-of-therapy?source=search_
result&search=acute+decompensated+heart+failure&selectedTitle=1
%7E150
Damman, K., Voors, A. A., Navis, G., et al. (2011). The cardiorenal syndrome
in heart failure. Progress in Cardiovascular Diseases, 54(3), 144153.
Downing, J., & Balady, G. J. (2011). The role of exercise training in heart
failure. Journal of the American College of Cardiology, 58(6), 561569.
Fiaccadori, E., Regolisti, G., Maggiore, U., et al. (2011). Ultrafiltration in
heart failure. American Heart Journal, 161(3), 439449.
Field, J. M., Hazinski, M. F., Sayre, M. R., et al. (2010). Executive sumLWBK1234-C29_p795-818.indd 818
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failure
Jessup, M., Abraham, W. T., Casey, D. E., et al. (2009). 2009 focused update:
ACCF/AHA guidelines for the diagnosis and management of heart failure
in adults: A report of the American College of Cardiology Foundation/
American Heart Association Task Force on Practice Guidelines. Circulation,
119(14), 19772016.
Klersy, C., De Silvestri, A., Gabutti, G., et al. (2011).
Economic impact of
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a meta-analysis of randomized controlled trials in heart failure. European
Journal of Heart Failure, 13(4), 450459.
Koehler, F., Winkler, S., Schieber, M., et al. (2011). Impact of remote
telemedical management on mortality and hospitalizations in ambulatory patients with chronic heart failure. Circulation, 123(17),
18731880.
Lindenfeld, J., Albert, N. M., Boehmer, J. P., et al. (2010). Evaluation and
management of patients with acute decompensated heart failure: HFSA
2010 comprehensive heart failure practice guidelines. Journal of Cardiac
Failure, 16(6), e134e156. Available at: www.guidelines.gov/content.aspx?id
=23908&search=heart+failure
Logan, A., Sangkachand, P., & Funk, M. (2011). Optimal management of
shivering during therapeutic hypothermia after cardiac arrest. Critical Care
Nurse, 31(6), e18e30. Available at: http://ccn.aacnjournals.org/
content/31/6/e18.full
Metra, M., Bettari, L., Carubelli, V., et al. (2011). Old and new intravenous
inotropic agents in the treatment of advanced heart failure. Progress in
Cardiovascular Diseases, 54(2), 97106.
Norton, C., Georgiopoulou, V. V., Kalogeropoulos, A. P., et al. (2011).
Epidemiology and cost of advanced heart failure. Progress in Cardiovascular
Diseases, 54(2), 7885.
*Pressler, S. J., Gradus-Pizlo, I., Chubinski, S. D., et al. (2009). Family
caregiver outcomes in heart failure. American Journal of Critical Care, 18(2),
149159.
*Pressler, S. J., Subramanian, U., Perkins, S. M., et al. (2011). Measuring depressive symptoms in heart failure: Validity and reliability of the
patient health questionnaire-8. American Journal of Critical Care, 20(2),
146152.
Qaseen, A., Chou, R., Humphrey, L. L., et al. (2011). Venous thromboembolism prophylaxis in hospitalized patients: A clinical practice guideline from
the American College of Physicians. Available at: guideline.gov/content.
aspx?id=34969
Riegel, B., Dickson, V. V., Cameron, J., et al. (2011). Symptom recognition
is older adults with heart failure. Journal of Nursing Scholarship, 42(1),
92100.
Roger, V. L., Go, A. S., Lloyd-Jones, D. M., et al. (2012). Heart disease and
stroke statistics2012 update: A report from the American Heart Association. Available at: circ.ahajournals.org/content/early/2011/12/15/
CIR.0b013e31823ac046.citation/

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Contents
Unit

Basic Concepts in Nursing 2

1 Health Care Delivery and Evidence-Based Nursing


Practice 4
The Nursing Profession and the Health Care Industry 5
Health, Wellness, and Health Promotion 6
Influences on Health Care Delivery 8
Quality, Safety, and Evidence-Based Practice 9
Professional Nursing Practice 10

2 Community-Based Nursing Practice 15


Key Components of Community-Based Care 16
Home Health Care 17
Other Community-Based Health Care 20

3 Critical Thinking, Ethical Decision Making, and


the Nursing Process 24
Critical Thinking 24
Ethical Nursing Care 26
The Nursing Process 31

4 Health Education and Health Promotion 43


Purpose of Health Education 43
The Nature of Teaching and Learning 45
The Nursing Process in Patient Education 47
Health Promotion 49
Health Promotion Strategies Throughout the Lifespan 52
Nursing Implications of Health Promotion 53

5 Adult Health and Nutritional Assessment 56


Considerations for Conducting a Health
Assessment 56
Health History 57
Physical Assessment 65
Nutritional Assessment 68

Unit

Biophysical and Psychosocial


Concepts in Nursing Practice 75

6 Individual and Family Homeostasis, Stress,


and Adaptation 77

Nursing Management 88
The Role of Stress in Health Patterns 92

7 Overview of Transcultural Nursing 95


Cultural Concepts 95
Transcultural Nursing 97
Culturally Mediated Characteristics 99
Causes of Illness 102
Folk Healers 103
Cultural Nursing Assessment 103
Additional Cultural Considerations: Know Thyself 103
The Future of Transcultural Nursing Care 105

8 Overview of Genetics and Genomics


in Nursing 107
Genomic Framework for Nursing Practice 108
Integrating Genetic and Genomic Knowledge 109
Genetic and Genomic Technologies in Practice 115
Personalized Genomic Treatments 120
Applications of Genetics and Genomics in Nursing
Practice 121
Ethical Issues 128
Genetics and Genomics Tomorrow 128

9 Chronic Illness and Disability 131


Overview of Chronicity 132
Nursing Care of Patients With Chronic
Conditions 136
Overview of Disability 140
Right of Access to Health Care 144
Nursing Care of Patients With Disabilities 147

10 Principles and Practices of Rehabilitation 153


The Rehabilitation Team 154
Areas of Specialty Rehabilitation 155
Substance Abuse Issues in Rehabilitation 155
Assessment of Functional Ability 156
Nursing Process:The Patient With Self-Care Deficits
in Activities of Daily Living 156
Nursing Process:The Patient With Impaired Physical
Mobility 159
Nursing Process:The Patient With Impaired Skin
Integrity 167
Nursing Process:The Patient With Altered Elimination
Patterns 175
Promoting Home and Community-Based Care 178

Fundamental Concepts 78
Overview of Stress 78
Stress at the Cellular Level 84

xxvii

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xxviii

Contents

11 Health Care of the Older Adult 182


Overview of Aging 183
Age-Related Changes 184
Mental Health Problems in the Older Adult 196
Geriatric Syndromes 203
Other Aspects of Health Care of the Older Adult 205
Ethical and Legal Issues Affecting the Older
Adult 207

Unit

Concepts and Challenges in Patient


Management 210

12 Pain Management 212


Fundamental Concepts 213
Pain Assessment 218
Pain Management 221

13 Fluid and Electrolytes: Balance and


Disturbance 237
Fundamental Concepts 238
Fluid Volume Disturbances 245

Hypovolemia 245
Hypervolemia 249

Electrolyte Imbalances 251

Sodium Imbalances 251

Sodium Deficit (Hyponatremia) 251


Sodium Excess (Hypernatremia) 253

Potassium Imbalances 254

Potassium Deficit (Hypokalemia) 255


Potassium Excess (Hyperkalemia) 256

Calcium Imbalances 258

Calcium Deficit (Hypocalcemia) 259


Calcium Excess (Hypercalcemia) 260

Magnesium Imbalances 262

Magnesium Deficit (Hypomagnesemia) 262


Magnesium Excess (Hypermagnesemia) 263

Phosphorus Imbalances 264

Phosphorus Deficit (Hypophosphatemia) 264


Phosphorus Excess (Hyperphosphatemia) 265

Chloride Imbalances 266

Chloride Deficit (Hypochloremia) 266


Chloride Excess (Hyperchloremia) 267
AcidBase Disturbances 267

Acute and Chronic Metabolic Acidosis


(Base Bicarbonate Deficit) 268
Acute and Chronic Metabolic Alkalosis
(Base Bicarbonate Excess) 269
Acute and Chronic Respiratory Acidosis
(Carbonic Acid Excess) 269
Acute and Chronic Respiratory Alkalosis
(Carbonic Acid Deficit) 270
Mixed AcidBase Disorders 271

Parenteral Fluid Therapy 272

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14 Shock and Multiple Organ Dysfunction


Syndrome 285
Overview of Shock 285
Stages of Shock 287
Compensatory Stage 288
Progressive Stage 290
Irreversible Stage 292

General Management Strategies in Shock 292


Hypovolemic Shock 295
Cardiogenic Shock 298
Circulatory Shock 300
Septic Shock 301
Neurogenic Shock 304
Anaphylactic Shock 306

Multiple Organ Dysfunction Syndrome 306


Promoting Home and Community-Based Care 307

15 Oncology: Nursing Management in Cancer


Care 310
Epidemiology of Cancer 311
Pathophysiology of the Malignant Process 312
Detection and Prevention of Cancer 318
Diagnosis of Cancer 320
Management of Cancer 321
Surgery 321
Radiation Therapy 324
Chemotherapy 328
Hematopoietic Stem Cell Transplantation 336
Hyperthermia 338
Targeted Therapies 339
Complementary and Alternative Medicine 343

Nursing Care of Patients With Cancer 343


Cancer Survivorship 365

16 End-of-Life Care 373


Nursing and End-of-Life Care 374
Settings for End-of-Life Care 376
Nursing Care of Terminally Ill Patients 380
Nursing Care of Patients Who Are Close to
Death 392
Coping With Death and Dying: Professional Caregiver
Issues 397

Unit

Perioperative Concepts and Nursing


Management 400

17 Preoperative Nursing Management 402


Perioperative Nursing 403
Technology and Anesthesia 403
Surgical Classifications 403
Preadmission Testing 403
Special Considerations During the Perioperative
Period 403
Informed Consent 406

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Contents

Preoperative Assessment 407


Preoperative Nursing Interventions 413
Immediate Preoperative Nursing Interventions 416
Expected Patient Outcomes 418

18 Intraoperative Nursing Management 420


The Surgical Team 421
The Surgical Environment 424
The Surgical Experience 427
Potential Intraoperative Complications 433
Anesthesia Awareness 433
Nausea and Vomiting 434
Anaphylaxis 434
Hypoxia and Other Respiratory Complications 434
Hypothermia 434
Malignant Hyperthermia 435

Nursing Process:The Patient During Surgery 435

19 Postoperative Nursing Management 440


Care of the Patient in the Postanesthesia Care
Unit 440
Care of the Hospitalized Postoperative Patient 446
Nursing Process:The Hospitalized Patient Recovering
From Surgery 447

Unit

Gas Exchange and Respiratory


Function 461

20 Assessment of Respiratory Function 463


Anatomic and Physiologic Overview 463
Assessment 472
Diagnostic Evaluation 484

21 Respiratory Care Modalities 493


NONINVASIVE RESPIRATORY THERAPIES 494

Oxygen Therapy 494


Incentive Spirometry (Sustained Maximal
Inspiration) 498
Small-Volume Nebulizer (Mini-Nebulizer)
Therapy 499
Chest Physiotherapy 500

Postural Drainage (Segmented Bronchial Drainage) 500


Chest Percussion and Vibration 502
Breathing Retraining 503
Airway Management 504

Emergency Management of Upper Airway


Obstruction 504
Endotracheal Intubation 504
Tracheostomy 506
Mechanical Ventilation 509
Nursing Process:The Patient Receiving Mechanical
Ventilation 514

The Patient Undergoing Thoracic


Surgery 521

Preoperative Management 521


Postoperative Management 523

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xxix

22 Management of Patients With Upper


Respiratory Tract Disorders 538
Upper Airway Infections 538

Rhinitis 539
Viral Rhinitis (Common Cold) 541
Rhinosinusitis 542
Acute Rhinosinusitis 542
Chronic Rhinosinusitis and Recurrent Acute
Rhinosinusitis 544

Pharyngitis 546

Acute Pharyngitis 546


Chronic Pharyngitis 548

Tonsillitis and Adenoiditis 548


Peritonsillar Abscess 550
Laryngitis 551
Nursing Process:The Patient With Upper Airway
Infection 551
Obstruction and Trauma of the Upper
Respiratory Airway 553

Obstruction During Sleep 553


Epistaxis (Nosebleed) 554
Nasal Obstruction 555
Fractures of the Nose 556
Laryngeal Obstruction 557
Cancer of the Larynx 557
Nursing Process:The Patient Undergoing
Laryngectomy 561

23 Management of Patients With Chest and


Lower Respiratory Tract Disorders 569
Atelectasis 570
Respiratory Infections 573

Acute Tracheobronchitis 573


Pneumonia 573
Nursing Process:The Patient With Pneumonia 582
Aspiration 584
Severe Acute Respiratory Syndrome 586
Pulmonary Tuberculosis 586
Lung Abscess 591

Pleural Conditions 592

Pleurisy 592
Pleural Effusion 593
Empyema 594
Pulmonary Edema (Noncardiogenic) 595
Acute Respiratory Failure 595
Acute Respiratory Distress Syndrome 596
Pulmonary Hypertension 598
Pulmonary Embolism 600
Sarcoidosis 604

Occupational Lung Diseases:


Pneumoconioses 605
Chest Tumors 605

Lung Cancer (Bronchogenic Carcinoma) 605


Tumors of the Mediastinum 610

Chest Trauma 610

Blunt Trauma 610

Sternal and Rib Fractures 611


Flail Chest 611
Pulmonary Contusion 612

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xxx

Contents

Penetrating Trauma 613


Pneumothorax 613
Cardiac Tamponade 615
Subcutaneous Emphysema 616

24 Management of Patients With Chronic


Pulmonary Disease 618
Chronic Obstructive Pulmonary Disease 618
Bronchiectasis 631
Asthma 637
Status Asthmaticus 646
Cystic Fibrosis 648

Unit

Cardiovascular and Circulatory


Function 652

25 Assessment of Cardiovascular Function 654


Anatomic and Physiologic Overview 655
Assessment of the Cardiovascular System 661
Diagnostic Evaluation 674

26 Management of Patients With Dysrhythmias


and Conduction Problems 692
Dysrhythmias 693

Normal Electrical Conduction 693


Influences on Heart Rate and Contractility 693
The Electrocardiogram 694
Analyzing the Electrocardiogram Rhythm Strip 697
Nursing Process:The Patient With a
Dysrhythmia 713

Adjunctive Modalities and


Management 714

Cardioversion and Defibrillation 715


Pacemaker Therapy 717
Implantable Cardioverter Defibrillator 721
Electrophysiology Studies 724
Cardiac Conduction Surgery 726

27 Management of Patients With Coronary


Vascular Disorders 729
Coronary Artery Disease 729

Coronary Atherosclerosis 730


Angina Pectoris 736
Nursing Process:The Patient With Angina Pectoris 739
Acute Coronary Syndrome and Myocardial
Infarction 741
Nursing Process:The Patient With Acute Coronary
Syndrome 746

Invasive Coronary Artery


Procedures 750

Percutaneous Coronary Interventions 750


Surgical Procedures: Coronary Artery
Revascularization 752

LWBK1234-FM_pi-xl.indd 30

28 Management of Patients With Structural,


Infectious, and Inflammatory Cardiac
Disorders 769
Valvular Disorders 769

Mitral Valve Prolapse 770


Mitral Regurgitation 771
Mitral Stenosis 772
Aortic Regurgitation 773
Aortic Stenosis 773
Nursing Management: Valvular Heart Disorders 774

Surgical Management: Valve Repair and


Replacement Procedures 774

Valvuloplasty 774
Valve Replacement 777
Nursing Management: Valvuloplasty and Valve
Replacement 778
Cardiomyopathy 779
Nursing Process:The Patient With Cardiomyopathy 784

Infectious Diseases of the Heart 786

Rheumatic Endocarditis 786


Infective Endocarditis 787
Myocarditis 789
Pericarditis 790
Nursing Process:The Patient With Pericarditis 792

29 Management of Patients With Complications


From Heart Disease 795
Heart Failure 795

Chronic Heart Failure 796


Nursing Process:The Patient With Heart Failure 805
Pulmonary Edema 810

Other Complications 812

Cardiogenic Shock 812


Thromboembolism 813
Pericardial Effusion and Cardiac Tamponade 813
Cardiac Arrest 814

30 Assessment and Management of Patients With


Vascular Disorders and Problems of Peripheral
Circulation 819
Anatomic and Physiologic Overview 819
Assessment of the Vascular System 823
Diagnostic Evaluation 824
Arterial Disorders 828

Arteriosclerosis and Atherosclerosis 828


Peripheral Arterial Occlusive Disease 835
Upper Extremity Arterial Occlusive Disease 838
Aortoiliac Disease 839
Aneurysms 839
Thoracic Aortic Aneurysm 839
Abdominal Aortic Aneurysm 841
Other Aneurysms 842

Dissecting Aorta 842


Arterial Embolism and Arterial Thrombosis 843
Raynauds Phenomenon and Other
Acrosyndromes 845

8/1/13 10:02 PM

Contents

Venous Disorders 845

Venous Thromboembolism 845


Chronic Venous Insufficiency/Postthrombotic
Syndrome 851
Leg Ulcers 852
Nursing Process:The Patient With Leg Ulcers 854
Varicose Veins 855

Lymphatic Disorders 857

Lymphangitis and Lymphadenitis 857


Lymphedema and Elephantiasis 857

Cellulitis 858

31 Assessment and Management of Patients


With Hypertension 861
Hypertension 862
Nursing Process:The Patient With Hypertension 866
Hypertensive Crises 873

Unit

Hematologic Function 875

32 Assessment of Hematologic Function


and Treatment Modalities 877
Anatomic and Physiologic Overview 878
Structure and Function of the Hematologic System 878

Assessment 884
Diagnostic Evaluation 884
Therapeutic Approaches to Hematologic
Disorders 888
Procuring Blood and Blood Products 889
Transfusion 892

Immune Thrombocytopenic Purpura 923


Platelet Defects 924
Hemophilia 926
Von Willebrand Disease 928
Acquired Coagulation Disorders 929

Liver Disease 929


Vitamin K Deficiency 929
Complications of AnticoagulantTherapy 929
Disseminated Intravascular Coagulation 929
Thrombotic Disorders 932
Hyperhomocysteinemia 932
Antithrombin Deficiency 935
Protein C Deficiency 935
Protein S Deficiency 935
Activated Protein C Resistance andFactor V Leiden
Mutation 935
Acquired Thrombophilia 935

34 Management of Patients With Hematologic


Neoplasms 941
Clonal Stem Cell Disorders 942
Leukemia 942

Acute Myeloid Leukemia 942


Chronic Myeloid Leukemia 945
Acute Lymphocytic Leukemia 946
Chronic Lymphocytic Leukemia 947
Nursing Process:The Patient With Acute Leukemia 948

Myelodysplastic Syndromes 951


Myeloproliferative Neoplasms 953

Polycythemia Vera 953


Essential Thrombocythemia 954
Primary Myelofibrosis 955

Lymphoma 956

Hodgkin Lymphoma 956


Non-Hodgkin Lymphomas 959

33 Management of Patients With Nonmalignant


Hematologic Disorders 899

Multiple Myeloma 960

Anemia 900

Unit

Nursing Process:The Patient With Anemia 902


Hypoproliferative Anemias 904
Iron Deficiency Anemia 904
Anemias in Renal Disease 905
Anemia of Chronic Disease 906
Aplastic Anemia 906
Megaloblastic Anemias 907

Hemolytic Anemias 909


Sickle Cell Anemia 909

Nursing Process:The Patient With Sickle Cell


Crisis 913
Thalassemia 915
Glucose-6-Phosphate DehydrogenaseDeficiency 915
Immune Hemolytic Anemia 916
Hereditary Hemochromatosis 917
Polycythemia 918

Secondary Polycythemia 918

Neutropenia 918
Lymphopenia 920
Bleeding Disorders 920

Secondary Thrombocytosis 921


Thrombocytopenia 921

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xxxi

Immunologic Function 967

35 Assessment of Immune Function 969


Anatomic and Physiologic Overview 970
Advances in Immunology 978
Assessment of the Immune System 978
Diagnostic Evaluation 984

36 Management of Patients With


Immunodeficiency Disorders 986
Primary Immunodeficiencies 986

Phagocytic Dysfunction 988


B-Cell Deficiencies 988
T-Cell Deficiencies 990
Combined B-Cell and T-Cell Deficiencies 992
Deficiencies of the ComplementSystem 993

Secondary Immunodeficiencies 994


Nursing Management of Patients With
Immunodeficiencies 994

8/1/13 10:02 PM

xxxii

Contents

37 Management of Patients With HIV Infection


and AIDS 998
HIV Infection and AIDS 999
Nursing Process:The Patient With HIV/AIDS 1016
Emotional and Ethical Concerns 1025

38 Assessment and Management of Patients


With Allergic Disorders 1029
Allergic Assessment 1030

Physiologic Overview 1030


Assessment 1033
Diagnostic Evaluation 1033

Allergic Disorders 1036

Anaphylaxis 1036
Allergic Rhinitis 1038
Nursing Process:The Patient With Allergic
Rhinitis 1043
Contact Dermatitis 1046
Atopic Dermatitis 1046
Dermatitis Medicamentosa (Drug Reactions) 1047
Urticaria and Angioneurotic Edema 1047
Hereditary Angioedema 1048
Cold Urticaria 1048
Food Allergy 1048
Latex Allergy 1049

39 Assessment and Management of Patients


With Rheumatic Disorders 1054
Rheumatic Diseases 1054
Diffuse Connective Tissue Diseases 1062
Rheumatoid Arthritis 1062
Systemic Lupus Erythematosus 1069
Sjgrens Syndrome 1072
Scleroderma 1073
Polymyositis 1074
Polymyalgia Rheumatica and GiantCellArteritis 1074

Osteoarthritis (Degenerative Joint Disease) 1075


Spondyloarthropathies 1077
Ankylosing Spondylitis 1077
Reactive Arthritis (Reiters Syndrome) 1078
Psoriatic Arthritis 1078

Metabolic and Endocrine Diseases Associated With


Rheumatic Disorders 1078
Gout 1078

Fibromyalgia 1080
Miscellaneous Disorders 1081

Unit

Musculoskeletal Function 1085

40 Assessment of Musculoskeletal
Function 1087
Anatomic and Physiologic Overview 1088
Assessment 1094
Diagnostic Evaluation 1098

41 Musculoskeletal Care Modalities 1103


The Patient in a Cast, Splint, or Brace 1103
The Patient With an External Fixator 1110
The Patient in Traction 1111
Principles of Effective Traction 1112
Types of Traction 1112

The Patient Undergoing OrthopedicSurgery 1116


Joint Replacement 1117

Nursing Process:Postoperative Care of the Patient


Undergoing Orthopedic Surgery 1127

42 Management of Patients With Musculoskeletal


Disorders 1132
Low Back Pain 1132
Common Upper Extremity Problems 1135
Bursitis and Tendonitis 1136
Loose Bodies 1136
Impingement Syndrome 1136
Carpal Tunnel Syndrome 1136
Ganglion 1137
Dupuytrens Disease 1137
Nursing Management of the Patient Undergoing Surgery of
the Hand or Wrist 1137

Common Foot Problems 1138

Plantar Fasciitis 1139


Corn 1139
Callus 1139
Ingrown Toenail 1139
Hammer Toe 1139
Hallux Valgus 1140
Pes Cavus 1140
Mortons Neuroma 1140
Pes Planus 1140
Nursing Management of the Patient Undergoing Foot
Surgery 1140

Metabolic Bone Disorders 1141


Osteoporosis 1141

Nursing Process:The Patient With a Spontaneous


Vertebral Fracture Related to Osteoporosis 1145
Osteomalacia 1146
Pagets Disease of the Bone 1146

Musculoskeletal Infections 1147


Osteomyelitis 1147

Nursing Process:The Patient With Osteomyelitis 1149


Septic (Infectious) Arthritis 1150

Bone Tumors 1151

43 Management of Patients With Musculoskeletal


Trauma 1156
Contusions, Strains, and Sprains 1156
Joint Dislocations 1157
Injuries to the Tendons, Ligaments, and Menisci 1158
Rotator Cuff Tears 1158
Epicondylitis 1158
Lateral and Medial Collateral Ligament Injury 1158
Cruciate Ligament Injury 1159
Meniscal Injuries 1159
Rupture of the Achilles Tendon 1160

Fractures 1160

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Contents

Fractures of Specific Sites 1168


Clavicle 1168
Humeral Neck 1169
Humeral Shaft 1170
Elbow 1170
Radial Head 1171
Radial and Ulnar Shafts 1171
Wrist 1171
Hand 1171
Pelvis 1172
Hip 1173
Femoral Shaft 1176
Tibia and Fibula 1182
Rib 1182
Thoracolumbar Spine 1183

Sports-Related Injuries 1183


Occupation-Related Musculoskeletal Disorders 1185
Amputation 1185
Nursing Process:The Patient Undergoing an
Amputation 1187

Unit

10

Digestive and Gastrointestinal


Function 1194

44 Assessment of Digestive and Gastrointestinal


Function 1196
Anatomic and Physiologic Overview 1197
Assessment of the Gastrointestinal System 1200
Diagnostic Evaluation 1203

45 Digestive and Gastrointestinal Treatment


Modalities 1214
Gastrointestinal Intubation 1215
Gastrostomy and Jejunostomy 1224
Nursing Process:The Patient With a Gastrostomy
or Jejunostomy 1225
Parenteral Nutrition 1228
Nursing Process:The Patient Receiving Parenteral
Nutrition 1230

46 Management of Patients With Oral


and Esophageal Disorders 1236
Disorders of the Oral Cavity 1236

Dental Plaque and Caries 1237


Dentoalveolar Abscess or Periapical Abscess 1240

Disorders of the Jaw 1240

Temporomandibular Disorders 1240


Jaw Disorders Requiring SurgicalManagement 1241

Disorders of the Salivary Glands 1241

Parotitis 1241
Sialadenitis 1241
Salivary Calculus (Sialolithiasis) 1242
Neoplasms 1242

Cancer of the Oral Cavity andPharynx 1242

Nursing Management of the Patient With Conditions


of the Oral Cavity 1243

LWBK1234-FM_pi-xl.indd 33

xxxiii

Neck Dissection 1245

Nursing Process:The Patient Undergoing a Neck


Dissection 1246
Disorders of the Esophagus 1250

Achalasia 1250
Diffuse Esophageal Spasm (Nutcracker Esophagus) 1250
Hiatal Hernia 1251
Diverticulum 1252
Perforation 1252
Foreign Bodies 1253
Chemical Burns 1253
Gastroesophageal Reflux Disease 1253
Barretts Esophagus 1254
Benign Tumors of the Esophagus 1254
Nursing Process:The Patient With a Noncancerous
Condition of the Esophagus 1254
Cancer of the Esophagus 1256

47 Management of Patients With Gastric and


Duodenal Disorders 1261
Gastritis 1262
Peptic Ulcer Disease 1265
Nursing Process:The Patient With Peptic Ulcer
Disease 1268
Obesity 1272
Nursing Process:The Patient Undergoing Bariatric
Surgery 1274
Gastric Cancer 1278
Nursing Process:The Patient With Gastric Cancer 1279
Gastric Surgery 1281
Tumors of the Small Intestine 1281

48 Management of Patients With Intestinal and


Rectal Disorders 1285
Abnormalities of FecalElimination 1286

Constipation 1286
Diarrhea 1289
Fecal Incontinence 1290
Irritable Bowel Syndrome 1292
Conditions of Malabsorption 1293

Acute Inflammatory Intestinal


Disorders 1294

Appendicitis 1295
Diverticular Disease 1296
Nursing Process:The Patient With Diverticulitis 1299
Peritonitis 1299

Inflammatory Bowel Disease 1301

Crohns Disease (Regional Enteritis) 1301


Ulcerative Colitis 1303
Nursing Process:Management of the Patient With
Chronic Inflammatory Bowel Disease 1305

Intestinal Obstruction 1316

Small Bowel Obstruction 1316


Large Bowel Obstruction 1317
Colorectal Cancer 1318
Nursing Process:The Patient With Colorectal Cancer 1321
Polyps of the Colon and Rectum 1327

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xxxiv

Contents

Diseases of the Anorectum 1328

Anorectal Abscess 1328


Anal Fistula 1328
Anal Fissure 1328
Hemorrhoids 1329
Sexually Transmitted AnorectalDiseases 1329
Pilonidal Sinus or Cyst 1330

Unit

11

Metabolic and
EndocrineFunction 1334

49 Assessment and Management of Patients With


Hepatic Disorders 1336
Assessment of the Liver 1336

Anatomic and Physiologic Overview 1336


Assessment 1339
Diagnostic Evaluation 1340

Manifestations of Hepatic Dysfunction 1342

Jaundice 1342
Portal Hypertension 1344
Ascites 1344
Esophageal Varices 1349
Hepatic Encephalopathy and Coma 1354
Other Manifestations of Hepatic
Dysfunction 1357

Viral Hepatitis 1358

Hepatitis A Virus 1358


Hepatitis B Virus 1360
Hepatitis C Virus 1364
Hepatitis D Virus 1364
Hepatitis E Virus 1365
Hepatitis G Virus and GB Virus-C 1365

Nonviral Hepatitis 1365

Toxic Hepatitis 1365


Drug-Induced Hepatitis 1365

Fulminant Hepatic Failure 1366


Hepatic Cirrhosis 1366
Cancer of the Liver 1377

Primary Liver Tumors 1378


Liver Metastases 1378
Liver Transplantation 1380
Liver Abscesses 1386

50 Assessment and Management of Patients With


Biliary Disorders 1389
Anatomic and PhysiologicOverview 1389
Disorders of the Gallbladder 1391

Cholecystitis 1391
Cholelithiasis 1391
Nursing Process:The Patient Undergoing Surgery for
Gallbladder Disease 1399

Disorders of the Pancreas 1401

Acute Pancreatitis 1401


Chronic Pancreatitis 1405
Pancreatic Cysts 1409
Cancer of the Pancreas 1410

LWBK1234-FM_pi-xl.indd 34

Tumors of the Head of the Pancreas 1411


Pancreatic Islet Tumors 1413
Hyperinsulinism 1413
Ulcerogenic Tumors 1413

51 Assessment and Management of Patients With


Diabetes 1416
Diabetes 1417
Acute Complications of Diabetes 1441

Hypoglycemia (Insulin Reactions) 1441


Diabetic Ketoacidosis 1443
Hyperglycemic Hyperosmolar Syndrome 1445
Nursing Process:The Patient With Diabetic Ketoacidosis
or Hyperglycemic Hyperosmolar Syndrome 1446

Long-Term Complications of Diabetes 1448

Macrovascular Complications 1448


Microvascular Complications 1449
Diabetic Retinopathy 1449
Nephropathy 1451

Diabetic Neuropathies 1453


Peripheral Neuropathy 1453
Autonomic Neuropathies 1453

Foot and Leg Problems 1454

Special Issues in Diabetes Care 1456

Patients With Diabetes Who Are Undergoing


Surgery 1456
Management of Hospitalized Patients With
Diabetes 1456

52 Assessment and Management of Patients With


Endocrine Disorders 1462
Assessment of the Endocrine System 1463

Anatomic and Physiologic Overview 1463


Assessment 1464
Diagnostic Evaluation 1465

The Pituitary Gland 1466

Anatomic and Physiologic Overview 1466


Pathophysiology 1468
Pituitary Tumors 1468
Diabetes Insipidus 1469
Syndrome of Inappropriate Antidiuretic Hormone
Secretion 1470

The Thyroid Gland 1470

Anatomic and Physiologic Overview 1470


Pathophysiology 1471
Assessment 1471
Hypothyroidism 1474
Hyperthyroidism 1478
Nursing Process:The Patient With
Hyperthyroidism 1482
Thyroid Tumors 1484
Thyroid Cancer 1485

The Parathyroid Glands 1487

Anatomic and Physiologic Overview 1487


Pathophysiology 1487
Hyperparathyroidism 1487
Hypoparathyroidism 1489

The Adrenal Glands 1490

Anatomic and Physiologic Overview 1490


Pheochromocytoma 1492

8/1/13 10:02 PM

Contents

Adrenocortical Insufficiency (Addisons Disease) 1494


Cushing Syndrome 1496
Nursing Process:The Patient With Cushing
Syndrome 1498
Primary Aldosteronism 1500
Corticosteroid Therapy 1500

Unit

12

Neurogenic Bladder 1587


Catheterization 1587
Urolithiasis and Nephrolithiasis 1591

Nursing Process:The Patient With Kidney Stones 1595


Genitourinary Trauma 1596
Urinary Tract Cancers 1597

Cancer of the Bladder 1597

Urinary Diversions 1598

Kidney and Urinary Function 1505

53 Assessment of Kidney and Urinary


Function 1507
Anatomic and Physiologic Overview 1507
Assessment of the Kidney and UrinarySystems 1513
Diagnostic Evaluation 1518

54 Management of Patients With Kidney


Disorders 1526
Fluid and Electrolyte Imbalances in Kidney
Disorders 1527
Kidney Disorders 1528

Chronic Kidney Disease 1528


Nephrosclerosis 1529
Primary Glomerular Diseases 1529
Acute Nephritic Syndrome 1529
Chronic Glomerulonephritis 1531
Nephrotic Syndrome 1532

Polycystic Kidney Disease 1533


Renal Cancer 1533
Renal Failure 1535

Acute Kidney Injury 1535


End-Stage Kidney Disease or Chronic Renal
Failure 1540

Renal Replacement Therapies 1548

Dialysis 1548

Hemodialysis 1548
Continuous Renal ReplacementTherapies 1553
Peritoneal Dialysis 1554
Special Considerations: Nursing Management of the Patient
on Dialysis Who Is Hospitalized 1560
Kidney Surgery 1561

Management of Patients Undergoing Kidney


Surgery 1561
Kidney Transplantation 1566

Renal Trauma 1571

55 Management of Patients With Urinary


Disorders 1574
Infections of the Urinary Tract 1574

Lower Urinary Tract Infections 1575


Nursing Process:The Patient With a Lower Urinary
Tract Infection 1579
Upper Urinary Tract Infections 1581

Acute Pyelonephritis 1581


Chronic Pyelonephritis 1581
Adult Voiding Dysfunction 1582

Urinary Incontinence 1582


Urinary Retention 1586

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xxxv

Cutaneous Urinary Diversions 1599


Ileal Conduit 1599
Cutaneous Ureterostomy 1602

Continent Urinary Diversions 1602


Continent Ileal Urinary Reservoir (Indiana Pouch) 1602
Ureterosigmoidostomy 1603

Other Urinary Diversion Procedures 1603


Nursing Process:The Patient Undergoing Urinary
Diversion Surgery 1603

Unit

13

Reproductive Function 1609

56 Assessment and Management of Female


Physiologic Processes 1611
Role of Nurses in WomensHealth 1612
Assessment of the Female Reproductive
System 1612

Anatomic and Physiologic Overview 1612


Assessment 1615
Lesbians and Bisexual Women 1620
Diagnostic Evaluation 1623

Management of Female Physiologic


Processes 1626

Menstruation 1627
Menstrual Disorders 1627

Premenstrual Syndrome 1627


Dysmenorrhea 1628
Amenorrhea 1629
Abnormal Uterine Bleeding 1629

Dyspareunia 1629
Contraception 1630

Abstinence 1630
Sterilization 1630
Hormonal Contraception 1630
Intrauterine Device 1632
Mechanical Barriers 1632
Coitus Interruptus or Withdrawal 1634
Rhythm and Natural Methods 1634
Emergency Contraception 1634

Abortion 1635

Spontaneous Abortion 1635


Elective Abortion 1636

Infertility 1636
Preconception/Periconception Health Care 1639
Ectopic Pregnancy 1639
Nursing Process:The Patient With an Ectopic
Pregnancy 1640
Perimenopause 1641
Menopause 1642

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xxxvi

Contents

57 Management of Patients With Female


Reproductive Disorders 1647
Vulvovaginal Infections 1648

Candidiasis 1648
Bacterial Vaginosis 1649
Trichomoniasis 1650
Gerontologic Considerations 1650
Nursing Process:The Patient With a Vulvovaginal
Infection 1650
Human Papillomavirus 1652
Herpesvirus Type 2 Infection (Herpes Genitalis,
Herpes Simplex Virus) 1653
Nursing Process:The Patient With a Genital Herpes
Infection 1653
Endocervicitis and Cervicitis 1655
Pelvic Inflammatory Disease 1656
Human Immunodeficiency Virus Infection and
Acquired Immunodeficiency Syndrome 1657

Structural Disorders 1658

Fistulas of the Vagina 1658


Pelvic Organ Prolapse: Cystocele, Rectocele,
Enterocele 1658
Uterine Prolapse 1660

Benign Disorders 1662

Vulvitis and Vulvodynia 1662


Vulvar Cysts 1662
Vulvar Dystrophy 1662
Ovarian Cysts 1663
Benign Tumors of the Uterus: Fibroids (Leiomyomas,
Myomas) 1664
Endometriosis 1665
Chronic Pelvic Pain 1666
Adenomyosis 1666
Endometrial Hyperplasia 1666

Malignant Conditions 1666

Cancer of the Cervix 1667


Cancer of the Uterus (Endometrium) 1669
Cancer of the Vulva 1670
Cancer of the Vagina 1672
Cancer of the Fallopian Tubes 1672
Cancer of the Ovary 1673
Hysterectomy 1674
Nursing Process:The Patient Undergoing a
Hysterectomy 1675
Radiation Therapy 1677

58 Assessment and Management of Patients With


Breast Disorders 1680

Benign Conditions of the Breast 1690

Breast Pain 1690


Cysts 1690
Fibroadenomas 1690
Benign Proliferative Breast Disease 1690
Other Benign Conditions 1691

Malignant Conditions of the Breast 1691

Nursing Process:The Patient Undergoing Surgery for


Breast Cancer 1696
Reconstructive Breast Surgery 1710
Diseases of the Male Breast 1710

Gynecomastia 1710
Male Breast Cancer 1710

59 Assessment and Management of Problems


Related to Male Reproductive Processes 1713
Assessment of the Male Reproductive
System 1714

Anatomic and Physiologic Overview 1714


Assessment 1715
Diagnostic Evaluation 1716

Disorders of Male SexualFunction 1717

Erectile Dysfunction 1717


Disorders of Ejaculation 1721

Infections of the Male Genitourinary


Tract 1722
Prostatic Disorders 1722

Prostatitis 1722
Benign Prostatic Hyperplasia (Enlarged Prostate) 1723
Cancer of the Prostate 1725
The Patient Undergoing Prostate Surgery 1732
Nursing Process:Patient Undergoing
Prostatectomy 1735

Disorders Affecting the Testes and


Adjacent Structures 1740

Orchitis 1740
Epididymitis 1740
Testicular Torsion 1741
Testicular Cancer 1741
Hydrocele 1744
Varicocele 1744
Vasectomy 1744

Disorders Affecting the Penis 1745

Phimosis 1745
Cancer of the Penis 1745
Priapism 1746
Peyronies Disease 1747
Urethral Stricture 1747
Circumcision 1747

Breast Assessment 1681

Anatomic and Physiologic Overview 1681


Assessment 1682
Diagnostic Evaluation 1684

Conditions Affecting the Nipple 1689

Nipple Discharge 1689


Fissure 1689

Breast Infections 1690

Mastitis 1690
Lactational Abscess 1690

LWBK1234-FM_pi-xl.indd 36

Unit

14

Integumentary Function 1750

60 Assessment of Integumentary Function 1752


Anatomic and Physiologic Overview 1752
Assessment 1756
Diagnostic Evaluation 1765

8/1/13 10:02 PM

Contents

61 Management of Patients With Dermatologic


Problems 1767
Skin Care for Patients With Skin
Conditions 1767
Wound Care for Skin
Conditions 1768
Pruritus 1772

General Pruritus 1772


Perineal and Perianal Pruritus 1774

Secretory Disorders 1774

Hidradenitis Suppurativa 1774


Seborrheic Dermatoses 1774
Acne Vulgaris 1775

Infectious Dermatoses 1777

Bacterial Skin Infections 1777

Impetigo 1777
Folliculitis, Furuncles, and Carbuncles 1778

Viral Skin Infections 1779


Herpes Zoster 1779
Herpes Simplex 1780

Fungal (Mycotic) Skin Infections 1780


Parasitic Skin Infestations 1781
Pediculosis: Lice Infestation 1781
Scabies 1782
Noninfectious Inflammatory
Dermatoses 1783

Irritant Contact Dermatitis 1783


Psoriasis 1784
Generalized Exfoliative Dermatitis 1787

Blistering Diseases 1788

Pemphigus Vulgaris 1788


Bullous Pemphigoid 1788
Dermatitis Herpetiformis 1789
Nursing Process:Care of the Patient With Blistering
Diseases 1789
Toxic Epidermal Necrolysis and Stevens-Johnson
Syndrome 1790
Nursing Process:Care of the Patient With
Toxic Epidermal Necrolysis or Stevens-Johnson
Syndrome 1791

Skin Tumors 1793

Benign Skin Tumors 1793


Malignant Skin Tumors 1794
Basal Cell and Squamous Cell
Carcinoma 1795
Malignant Melanoma 1797

Nursing Process:Care of the Patient With Malignant


Melanoma 1798
Metastatic Skin Tumors 1800
Kaposis Sarcoma 1800
Plastic Reconstructive and Cosmetic
Procedures 1800

Wound Coverage: Grafts and


Flaps 1801
Cosmetic Procedures 1802
Laser Treatment of Cutaneous
Lesions 1803

xxxvii

62 Management of Patients With Burn


Injury 1805
Overview of Burn Injury 1805
Management of Burn Injury 1814
Emergent/Resuscitative Phase 1814
Acute/Intermediate Phase 1817
Rehabilitation Phase 1829

Nursing Process:Care of the Patient During the


Rehabilitation Phase 1831
Outpatient Burn Care 1834

Unit

15

Sensory Function 1837

63 Assessment and Management of Patients With


Eye and Vision Disorders 1839
Assessment of the Eye 1840

Anatomic and Physiologic Overview 1840


Assessment 1842
Diagnostic Evaluation 1844

Impaired Vision 1846

Refractive Errors 1846


Vision Impairment and Blindness 1846

Ocular Medication Administration 1850

Glaucoma 1852
Cataracts 1857

Corneal Disorders 1861

Corneal Dystrophies 1861


Corneal Surgeries 1861
Refractive Surgeries 1862

Retinal Disorders 1863

Retinal Detachment 1863


Retinal Vascular Disorders 1865
Age-Related Macular Degeneration 1866

Orbital and Ocular Trauma 1867

Orbital Trauma 1867


Ocular Trauma 1869

Infectious and Inflammatory


Conditions 1870

Dry Eye Disease 1870


Conjunctivitis 1871
Uveitis 1873
Orbital Cellulitis 1874

Orbital and Ocular Tumors 1874

Benign Tumors of the Orbit 1874


Benign Tumors of the Eyelids 1874
Benign Tumors of the Conjunctiva 1875
Malignant Tumors of the Orbit 1875
Malignant Tumors of the Eyelid 1875
Malignant Tumors of the Conjunctiva 1875
Malignant Tumors of the Globe 1875

Surgical Procedures and Enucleation 1876

Orbital Surgeries 1876


Enucleation 1876

Ocular Consequences of Systemic


Disease 1877

Diabetic Retinopathy 1877


Cytomegalovirus Retinitis 1877
Hypertension-Related Eye Changes 1878

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Contents

64 Assessment and Management of Patients With


Hearing and Balance Disorders 1880
Assessment of the Ear 1881

Anatomic and Physiologic Overview 1881


Function of the Ears 1883
Assessment 1883
Diagnostic Evaluation 1886

Hearing Loss 1887


Conditions of the External Ear 1890

Cerumen Impaction 1890


Foreign Bodies 1890
External Otitis (Otitis Externa) 1891
Malignant External Otitis 1891
Masses of the External Ear 1891

Conditions of the Middle Ear 1891

Tympanic Membrane Perforation 1891


Acute Otitis Media 1892
Serous Otitis Media 1893
Chronic Otitis Media 1893
Nursing Process:The Patient Undergoing Mastoid
Surgery 1894
Otosclerosis 1896
Middle Ear Masses 1896

Conditions of the Inner Ear 1897

Motion Sickness 1897


Mnires Disease 1897
Benign Paroxysmal Positional Vertigo 1898
Tinnitus 1901
Labyrinthitis 1901
Ototoxicity 1901
Acoustic Neuroma 1902

Aural Rehabilitation 1902

Unit

16

Neurologic Function 1907

65 Assessment of Neurologic Function 1909


Anatomic and Physiologic Overview 1909
Assessment of the Nervous System 1920
Diagnostic Evaluation 1928

66 Management of Patients With Neurologic


Dysfunction 1935
Altered Level of Consciousness 1936

Nursing Process:The Patient With an Altered Level


of Consciousness 1937
Increased Intracranial Pressure 1942

Nursing Process:The Patient With Increased


Intracranial Pressure 1947
Intracranial Surgery 1953

Supratentorial and Infratentorial Approaches 1954


Preoperative Management 1954
Postoperative Management 1954

Nursing Process:The Patient Who Has Undergone


Intracranial Surgery 1955

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Transsphenoidal Approach 1958


Preoperative Management 1958
Postoperative Management 1959
Seizure Disorders 1959

The Epilepsies 1961


Nursing Process:The Patient With Epilepsy 1964
Status Epilepticus 1966

Headache 1966

67 Management of Patients With Cerebrovascular


Disorders 1972
Ischemic Stroke 1972
Nursing Process:The Patient Recovering From an
Ischemic Stroke 1980
Hemorrhagic Stroke 1988
Nursing Process:The Patient With a Hemorrhagic
Stroke 1991

68 Management of Patients With Neurologic


Trauma 1995
Head Injuries 1995
Brain Injury 1997
Nursing Process:The Patient With a Traumatic Brain
Injury 2001
Spinal Cord Injury 2010
Nursing Process:The Patient With Acute Spinal Cord
Injury 2015
Nursing Process:The Patient With Tetraplegia or
Paraplegia 2020

69 Management of Patients With Neurologic


Infections, Autoimmune Disorders, and
Neuropathies 2026
Infectious Neurologic Disorders 2026

Meningitis 2026
Brain Abscess 2029
Herpes Simplex Virus Encephalitis 2030
Arthropod-Borne Virus Encephalitis 2031
Fungal Encephalitis 2032
Creutzfeldt-Jakob and Variant Creutzfeldt-Jakob
Disease 2032

Autoimmune Processes 2033

Multiple Sclerosis 2033


Nursing Process:The Patient With Multiple Sclerosis 2037
Myasthenia Gravis 2040
Guillain-Barr Syndrome 2043
Nursing Process:The Patient With Guillain-Barr
Syndrome 2044

Cranial Nerve Disorders 2046

Trigeminal Neuralgia (Tic Douloureux) 2048


Bells Palsy 2049

Disorders of the Peripheral Nervous


System 2050

Peripheral Neuropathies 2050


Mononeuropathy 2050

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Contents

70 Management of Patients With Oncologic or


Degenerative Neurologic Disorders 2052
Oncologic Disorders of the Brain and
Spinal Cord 2052

Brain Tumors 2052


Clinical Manifestations 2054
Cerebral Metastases 2058
Nursing Process:The Patient With Nervous System
Metastases or Primary Brain Tumor 2059
Spinal Cord Tumors 2061

Degenerative Disorders 2062

Parkinsons Disease 2063


Nursing Process:The Patient With Parkinsons
Disease 2066
Huntington Disease 2069
Amyotrophic Lateral Sclerosis 2070
Muscular Dystrophies 2072
Degenerative Disk Disease 2073
Herniation of a Cervical Intervertebral Disk 2074
Nursing Process:The Patient Undergoing a Cervical
Diskectomy 2075
Herniation of a Lumbar Disk 2077
Postpolio Syndrome 2079

Unit

17

xxxix

72 Emergency Nursing 2116


Issues in Emergency Nursing Care 2117
Emergency Nursing and the Continuum
of Care 2120
Principles of Emergency Care 2120
Airway Obstruction 2122
Hemorrhage 2125
Hypovolemic Shock 2126
Wounds 2126
Trauma 2127

Collection of Forensic Evidence 2127


Injury Prevention 2128
Multiple Trauma 2128
Intra-Abdominal Injuries 2128
Crush Injuries 2130
Fractures 2130

Environmental Emergencies 2131

Heat-Induced Illnesses 2131


Frostbite 2132
Hypothermia 2133
Nonfatal Drowning 2134
Decompression Sickness 2134
Animal and Human Bites 2135
Snakebites 2135
Spider Bites 2136
Tick Bites 2137

Poisoning 2137

Acute Community-Based
Challenges 2082

71 Management of Patients With Infectious


Diseases 2084
The Infectious Process 2085
Infection Control and Prevention 2089
Home-Based Care of the Patient With an Infectious
Disease 2095
Diarrheal Diseases 2098
Nursing Process:The Patient With Infectious
Diarrhea 2105
Sexually Transmitted Infections 2106
Syphilis 2107
Chlamydia trachomatis and Neisseria gonorrhoeae
Infections 2107

Nursing Process:The Patient With a Sexually


Transmitted Infection 2108
Emerging Infectious Diseases 2110
West Nile Virus 2110
Legionnaires Disease 2110
Pertussis 2111
Hantavirus Pulmonary Syndrome 2112
Viral Hemorrhagic Fevers 2112

Travel and Immigration 2113

Ingested (Swallowed) Poisons 2137


Carbon Monoxide Poisoning 2138
Skin Contamination Poisoning (Chemical Burns) 2139
Food Poisoning 2139

Substance Abuse 2139

Acute Alcohol Intoxication 2140


Alcohol Withdrawal Syndrome/Delirium
Tremens 2140

Violence, Abuse, and Neglect 2145

Family Violence, Abuse, and Neglect 2145


Sexual Assault 2146

Psychiatric Emergencies 2148

Overactive Patients 2148


Posttraumatic Stress Disorder 2149
Underactive or Depressed Patients 2149
Suicidal Patients 2149

73 Terrorism, Mass Casualty, and Disaster


Nursing 2152
Federal, State, and Local Responses to
Emergencies 2153
Hospital Emergency Preparedness Plans 2154
Preparedness and Response 2158
Natural Disasters 2160
Weapons of Terror 2160
Appendix A Diagnostic Studies and Interpretation 000

Available on
Index I-1

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