Additional Information
Book Details
Abstract
The compact, yet comprehensive, Manual of Critical Care Nursing: Nursing Interventions and Collaborative Management, 7th Edition is your students’a go-to reference forto help you provide safe, high-quality nursing care in the clinicalcritical care settings. Written in an abbreviated outline format, this easy-to-use Manual presents essential information on more than 75 disorders and conditions, as well as concepts relevant to caring for all critically ill patients and functioning in the critical care environment. Award-winning clinical nurse specialist Marianne Baird separates the content first by body system and then by disorder, with each disorder including a brief description of pathophysiology, assessment, diagnostic testing, collaborative management, nursing diagnoses, desired outcomes, nursing interventions, and patient teaching and rehabilitation. With the latest NANDA-I nursing diagnoses and new sections on Bariatric Considerations and Caring for the Elderly, this practical manual is designed to help critical care nurses and nursing students better care for any critically ill patient.
- Coverage of more than 75 disorders most commonly seen in critical care units.
- Consistent, easy-to-use format facilitates quick reference so you can find information exactly where you expect it to be.
- Portable size makes it ideal for use in the unit or bedside, and is also easy to carry on campus.
- Research Briefs boxes present abstracts of selected research studies and emphasize the use of evidence to guide care recommendations.
- NANDA-approved diagnoses are marked with an icon to familiarize you with NANDA terminology.
- Chapters mirror a practicing nurse’s approach to patient care, making it quicker and easier to find information.
- Diagnostic Tests tables highlight the definition, purpose, and abnormal findings for each test.
- Collaborative Management tables concisely summarize relevant performance measures while incorporating the best available patient care guidelines.
- Safety Alert! and High Alert! icons call attention to issues important to a patient’s safety.
- Chapter outlines display major heads, care plans, and their respective page numbers - and provide easy access to disorders.
- NEW! Bariatric Considerations section added to assessment sections to help you assess, and prevent complications and improve care in, overweight and obese patients.
- NEW! Section on Caring for the Elderly added to assessment sections to provide you with tips and guidelines unique to elderly patients, including recognizing differences in measuring pain, providing appropriate nutritional support, improving communication, and preventing infection.
- NEW! Updated content throughout keeps you current in the field of critical care nursing.
- NEW! Geriatric icon highlights considerations relating to the care of older adults.
- NEW! The latest NANDA-I nursing diagnoses ensure you stay up-to-date.
Table of Contents
| Section Title | Page | Action | Price |
|---|---|---|---|
| Front cover | Cover | ||
| Manual of critical care nursing | iii | ||
| Copyright page | iv | ||
| Contributors | v | ||
| Reviewers | viii | ||
| Preface | xi | ||
| Who will benefit from this book? | xi | ||
| Why is this book important? | xi | ||
| Benefits of using this book | xi | ||
| How to use this book | xi | ||
| New to this edition | xii | ||
| Acknowledgments | xii | ||
| Table of contents | xiii | ||
| 1 General concepts in caring for the critically ill | 1 | ||
| Acid- base imbalances | 1 | ||
| Pathophysiology of acid-base regulation | 1 | ||
| Example of compensation (pH regulation) | 2 | ||
| Understanding the arterial blood gas (ABG) | 4 | ||
| Arterial blood gas values | 4 | ||
| Step-by-step guide to arterial blood gas analysis | 7 | ||
| Step 1: Check the pH: Determine if pH is perfect (7.40) | 7 | ||
| Step 2: Check the Paco₂ | 8 | ||
| Step 3: Check for base (deficit or excess) | 8 | ||
| Step 4: Evaluate both Paco₂ and HCO₃− | 8 | ||
| Step 5: Check Pao₂ and Sao₂ | 8 | ||
| Respiratory acidosis | 8 | ||
| Pathophysiology | 8 | ||
| Evaluation of an abnormal arterial blood gas resulting in a decreased ph attributable to hypoventilation | 8 | ||
| Step 1: pH is 7.28, not perfect or neutral (7.40) and outside the normal range of 7.35 to 7.45 | 9 | ||
| Step 2: Paco₂ is 55 mm Hg, not perfect (40 mm Hg) and above the normal range of 35 to 45 mm Hg, indicating an excess of ... | 9 | ||
| 2 Managing the critical care environment | 199 | ||
| Bioterrorism | 199 | ||
| Bioterrorism assessment: Surveillance | 199 | ||
| Goal of surveillance | 199 | ||
| Key signs | 199 | ||
| Monitor | 200 | ||
| Report | 200 | ||
| Contain (prevent the spread of the disease) | 200 | ||
| Labwork | 201 | ||
| Anthrax | 201 | ||
| Pathophysiology | 201 | ||
| Transmission | 201 | ||
| Assessment | 201 | ||
| Diagnostic tests | 201 | ||
| Collaborative management | 201 | ||
| Care priorities | 201 | ||
| 1. Antibiotics | 201 | ||
| 2. Intubation and mechanical ventilation (inhalation) | 202 | ||
| 3. Intravenous fluids (inhalation and gastrointestinal) | 202 | ||
| 4. Prevention after exposure | 202 | ||
| 5. Treatment after infection | 202 | ||
| 6. Vaccination | 202 | ||
| Care plans: Anthrax | 202 | ||
| Botulism | 203 | ||
| Pathophysiology | 203 | ||
| Transmission | 203 | ||
| Assessment | 203 | ||
| Diagnostic tests | 203 | ||
| Collaborative management | 204 | ||
| Care priorities | 204 | ||
| 1. Antitoxin | 204 | ||
| 2. Antibiotic | 204 | ||
| 3. Supportive care | 204 | ||
| Care plans: Botulism | 204 | ||
| Hemorrhagic fever viruses | 204 | ||
| Pathophysiology | 204 | ||
| Transmission | 205 | ||
| Isolation | 205 | ||
| Assessment | 205 | ||
| Diagnostic tests | 205 | ||
| Collaborative management | 205 | ||
| Care priorities | 205 | ||
| 1. Supportive care | 205 | ||
| 2. Antivirals | 205 | ||
| 3. Ribavirin | 205 | ||
| 4. Control risk for bleeding | 205 | ||
| 5. Vaccine | 205 | ||
| Plague | 206 | ||
| Pathophysiology | 206 | ||
| Transmission | 206 | ||
| Assessment | 206 | ||
| Diagnostic tests | 206 | ||
| Collaborative management | 206 | ||
| Care priorities | 206 | ||
| 1. Antibiotics | 206 | ||
| 2. Vaccine | 206 | ||
| 3. Supportive care | 206 | ||
| Smallpox (variola) | 207 | ||
| Pathophysiology | 207 | ||
| Transmission | 207 | ||
| Assessment | 207 | ||
| Diagnostic tests | 207 | ||
| Laboratory criteria for confirmation of smallpox | 208 | ||
| Collaborative management | 208 | ||
| Care priorities | 208 | ||
| 1. Vaccine | 208 | ||
| 2. Isolation | 208 | ||
| 3. Supportive management | 208 | ||
| Care plans: Smallpox | 208 | ||
| Tularemia | 209 | ||
| Pathophysiology | 209 | ||
| Transmission | 209 | ||
| Assessment | 209 | ||
| Diagnostic tests | 209 | ||
| Collaborative management | 209 | ||
| Care priorities | 209 | ||
| 1. Antibiotics | 209 | ||
| Emerging infections | 209 | ||
| Infection prevention and infection control | 209 | ||
| Multidrug-resistant organisms | 210 | ||
| Methicillin-resistant staphylococcus aureus (MRSA) | 211 | ||
| Vancomycin-resistant enterococcus (VRE) | 211 | ||
| Carbapenem-resistant enterobacteriaceae (CRE) | 211 | ||
| Ebola virus disease | 211 | ||
| Transmission | 212 | ||
| Case definitions | 212 | ||
| Signs and symptoms | 212 | ||
| Prevention and infection control | 212 | ||
| Diagnosis | 213 | ||
| Treatment | 213 | ||
| Severe acute respiratory syndrome | 214 | ||
| Pathophysiology | 214 | ||
| Transmission | 214 | ||
| Assessment | 214 | ||
| Goal of assessment | 214 | ||
| History and risk factors | 214 | ||
| Evaluation of sars-CoV disease among persons presenting with community-acquired illness | 214 | ||
| Signs and symptoms | 215 | ||
| Early illness | 215 | ||
| Mild-to-moderate respiratory illness | 215 | ||
| Severe respiratory illness | 215 | ||
| Screening labwork | 215 | ||
| 3 Trauma | 260 | ||
| Major trauma | 260 | ||
| Pathophysiology | 260 | ||
| Psychological response | 261 | ||
| Major trauma assessment: Primary | 261 | ||
| Goal of system assessment | 261 | ||
| Airway assessment | 261 | ||
| Breathing assessment | 262 | ||
| Circulatory assessment | 262 | ||
| Disability assessment | 262 | ||
| Exposure | 262 | ||
| Major trauma assessment: Secondary | 262 | ||
| Goal of system assessment | 262 | ||
| Vital signs | 262 | ||
| History | 262 | ||
| Head-to-toe assessment | 263 | ||
| Head and neck | 263 | ||
| Chest | 263 | ||
| Abdomen and pelvis | 263 | ||
| Extremities | 263 | ||
| Posterior surface | 263 | ||
| Laboratory work | 263 | ||
| Collaborative management | 265 | ||
| Care priorities | 265 | ||
| 1. Secure a patent airway | 265 | ||
| 2. Support ventilation | 265 | ||
| 3. Manage hemorrhage and hypovolemia | 266 | ||
| 4. Identify, prevent, and/or manage hypothermia | 267 | ||
| 5. Provide gastric decompression | 267 | ||
| 6. Ensure urinary drainage | 267 | ||
| 7. Prevent infection with antibiotics | 267 | ||
| 8. Control pain and anxiety with analgesics and anxiolytics | 267 | ||
| 9. Provide tetanus prophylaxis | 267 | ||
| 10. Initiate nutrition support therapy | 268 | ||
| 11. Facilitate evaluation for surgery | 268 | ||
| Care plans: Major trauma | 268 | ||
| Additional nursing diagnoses | 271 | ||
| Abdominal trauma | 271 | ||
| Pathophysiology | 271 | ||
| Blunt trauma | 271 | ||
| Mechanisms of action with penetrating injury | 271 | ||
| Intrathoracic abdomen | 271 | ||
| Pelvic abdomen | 272 | ||
| Retroperitoneal abdomen | 272 | ||
| True abdomen | 272 | ||
| Assessment: Abdominal trauma | 273 | ||
| Goal of system assessment | 273 | ||
| History and risk factors | 273 | ||
| Vital signs | 273 | ||
| Observation and subjective/objective symptoms | 274 | ||
| Inspection | 274 | ||
| Auscultation | 275 | ||
| Palpation | 275 | ||
| Percussion | 275 | ||
| Collaborative management | 277 | ||
| Care priorities | 277 | ||
| 1. Identify and manage hypothermia | 277 | ||
| 2. Provide oxygen therapy to manage hypoxia | 277 | ||
| 3. Manage hypovolemia and anemia | 277 | ||
| 4. Consider surgery for penetrating abdominal injuries | 278 | ||
| 5. Consider an appropriate surgical intervention based on type of injury | 278 | ||
| 6. Considerations regarding closure of the abdominal surgical incision | 279 | ||
| 7. Provide nutrition support | 279 | ||
| 8. Prevent infection with antibiotics | 279 | ||
| 9. Manage pain using analgesics | 279 | ||
| Care plans: Abdominal trauma | 280 | ||
| Additional nursing diagnoses | 283 | ||
| Acute cardiac tamponade | 284 | ||
| Pathophysiology | 284 | ||
| Assessment: Acute cardiac tamponade | 285 | ||
| Goal of system assessment | 285 | ||
| Observation | 285 | ||
| Vital signs | 285 | ||
| Auscultation | 285 | ||
| Percussion | 286 | ||
| Hemodynamic monitoring | 286 | ||
| Screening diagnostic tests | 286 | ||
| Collaborative management | 289 | ||
| Care priorities | 289 | ||
| 1. Stabilize ventilation with oxygen, intubation, and mechanical ventilation | 289 | ||
| 2. Facilitate providing pericardiocentesis | 289 | ||
| 3. Anticipate the need to provide a surgical procedure | 290 | ||
| 4. Provide fluid resuscitation | 290 | ||
| 5. Administer vasoconstrictors | 290 | ||
| 6. Administer inotropic agents | 290 | ||
| 7. Stabilize BP with ongoing titration of medications and fluids | 290 | ||
| Care plans: Acute cardiac tamponade | 290 | ||
| Additional nursing diagnoses | 291 | ||
| Acute spinal cord injury | 291 | ||
| Pathophysiology | 291 | ||
| Fractures involving the vertebral bodies | 292 | ||
| Spinal shock | 292 | ||
| Neurogenic shock | 292 | ||
| Spinal shock with neurogenic shock | 293 | ||
| Septic shock | 293 | ||
| Acute phase assessment | 294 | ||
| Goal of assessment | 294 | ||
| Clinical assessment | 294 | ||
| Interpretation of physical assessment findings | 294 | ||
| Types of injury | 294 | ||
| Levels of injury | 294 | ||
| Cord syndromes | 295 | ||
| Diagnostic tests | 297 | ||
| Spinal radiograph | 298 | ||
| CT scans | 298 | ||
| Spinal MRI scans | 298 | ||
| Collaborative management | 298 | ||
| Care priorities | 298 | ||
| 1. Immobilize the injured site | 298 | ||
| Cervical spine injury | 298 | ||
| 2. Prevent secondary injury | 299 | ||
| 3. Maintain hemodynamic stability | 299 | ||
| 4. Manage vasodilation-induced hypovolemia | 300 | ||
| 5. Support ventilation | 300 | ||
| 6. Provide aggressive pulmonary care | 300 | ||
| 7. Prevent aspiration using gastric decompression | 300 | ||
| 8. Gastric ulcer prevention | 300 | ||
| 9. Relieve pain and anxiety | 301 | ||
| 10. Prevent deep venous thrombosis and thromboembolism | 301 | ||
| 11. Nutrition support | 301 | ||
| 12. Skin care | 301 | ||
| 13. Bladder program | 301 | ||
| 14. Bowel management | 302 | ||
| 15. Prevent infections | 302 | ||
| Care plans: Acute spinal cord injury | 302 | ||
| Additional nursing diagnoses | 310 | ||
| Burns | 310 | ||
| Pathophysiology | 310 | ||
| Injury severity assessment | 312 | ||
| History and risk factors for a major burn | 312 | ||
| Initial assessment | 313 | ||
| Initial system assessment | 313 | ||
| Airway/breathing | 313 | ||
| Heart rate, heart rhythm, BP to evaluate co and perfusion | 314 | ||
| Burn wound extent (calculation of tbsa burn) | 314 | ||
| Palpation | 315 | ||
| Auscultation | 316 | ||
| Respiratory system | 316 | ||
| Cardiovascular system | 317 | ||
| Gastrointestinal system | 317 | ||
| Renal system | 317 | ||
| Integumentary system | 318 | ||
| Wound infection | 318 | ||
| Systemic inflammatory response syndrome/septic shock | 318 | ||
| Diagnostic tests | 321 | ||
| Bronchoscopy | 321 | ||
| Fluorescein examination | 321 | ||
| Culture and sensitivity studies | 321 | ||
| Urine collections | 322 | ||
| Hematology | 322 | ||
| Electrolyte panel | 322 | ||
| ECG | 322 | ||
| Collaborative management | 322 | ||
| Care priorities | 322 | ||
| 1. Manage hypoxemia and protect the upper airways by using humidified oxygen therapy | 322 | ||
| 2. Support ventilation by providing intubation and mechanical ventilation: | 323 | ||
| 3. Thin secretions with bronchodilators and mucolytic agents | 323 | ||
| 4. Relieve constriction of circumferential burns with escharotomy | 323 | ||
| 5. Hydrate using large-bore IV access | 323 | ||
| 6. Fluid resuscitation | 324 | ||
| 7. Maintain an accurate record of the fluid balance | 324 | ||
| 8. Facilitate core body temperature regulation | 324 | ||
| 9. Prevent aspiration of gastric contents by ng intubation | 324 | ||
| 10. Provide proper patient positioning to decrease the potential for further injury | 324 | ||
| 11. Provide aggressive nutrition support | 325 | ||
| 12. Perform wound care | 325 | ||
| 13. Prepare for surgery as needed | 326 | ||
| Pharmacotherapy | 326 | ||
| 1. Provide tetanus prophylaxis | 326 | ||
| 2. Manage pain with IV analgesics and anxiolytics | 326 | ||
| 3. Consider gastric acid suppression therapy | 326 | ||
| 4. Administer antibiotics for known infections | 326 | ||
| 5. Provide DVT prophylaxis | 326 | ||
| Care plans: Burns | 326 | ||
| Additional nursing diagnoses | 333 | ||
| Compartment syndrome/ischemic myositis | 334 | ||
| Pathophysiology | 334 | ||
| Compartment syndrome assessment | 335 | ||
| Goal of assessment | 335 | ||
| History and risk factors | 335 | ||
| Vital signs | 336 | ||
| Observation and subjective symptoms | 336 | ||
| Early indicators | 336 | ||
| Late-onset syndrome indicators | 336 | ||
| Late findings | 336 | ||
| Palpation | 336 | ||
| Compartmental pressure monitoring | 338 | ||
| Early indicators | 338 | ||
| Collaborative management | 338 | ||
| Care priorities | 338 | ||
| 1. Eliminate external pressure on the affected compartment | 338 | ||
| 2. Manage pain | 338 | ||
| 3. Reduce internal compartmental pressure | 338 | ||
| 4. Provide surgical intervention | 338 | ||
| 5. Provide vascular surgical intervention if blood vessel injury caused the compartment syndrome | 339 | ||
| 6. Renal protection | 339 | ||
| Care plans: Compartment syndrome | 339 | ||
| Drowning | 341 | ||
| Incidence | 341 | ||
| Pathophysiology | 341 | ||
| Wet versus dry drowning | 342 | ||
| Freshwater versus saltwater drowning | 342 | ||
| Assessment: Drowning | 342 | ||
| Goal of system assessment | 342 | ||
| History and risk factors | 342 | ||
| Vital signs | 342 | ||
| Observation | 343 | ||
| Palpation | 343 | ||
| Auscultation | 343 | ||
| Collaborative management | 344 | ||
| Care priorities | 344 | ||
| 1. Provide oxygen therapy | 344 | ||
| 2. Correct hypothermia with rewarming | 344 | ||
| 3. Manage ventilation and acid-base balance | 344 | ||
| 4. Assess for need for endotracheal intubation and mechanical ventilation | 344 | ||
| 5. Initiate positive end-expiratory pressure | 344 | ||
| 6. Consider bronchoscopy | 345 | ||
| 7. Assess for the need of extracorporeal membrane oxygenation | 345 | ||
| 8. Promote neurologic/brain recovery | 345 | ||
| 9. Manage fluid and electrolyte imbalance | 345 | ||
| 10. Prevent and/or control infection | 345 | ||
| 11. Identify and manage the event that precipitated the drowning | 345 | ||
| Care plans: Drowning | 345 | ||
| Additional nursing diagnoses | 347 | ||
| Pelvic fractures | 347 | ||
| Pathophysiology | 347 | ||
| Assessment: Pelvic fractures | 347 | ||
| Goal of system assessment | 347 | ||
| History and risk factors | 347 | ||
| Stable pelvic fracture | 347 | ||
| Unstable pelvic fracture | 348 | ||
| Vital signs | 348 | ||
| Observation | 349 | ||
| Palpation | 349 | ||
| Collaborative management | 350 | ||
| Care priorities | 350 | ||
| 1. Stabilize the pelvis | 350 | ||
| 2. Initiate surgical exploration | 350 | ||
| 3. Replace blood loss with massive transfusion | 351 | ||
| 4. Initiate pharmacotherapy for the following | 351 | ||
| Care plans: Pelvic fractures | 351 | ||
| Renal and lower urinary tract trauma | 352 | ||
| Pathophysiology | 352 | ||
| Renal and lower urinary tract assessment | 354 | ||
| Goal of system assessment | 354 | ||
| History and risk factors | 354 | ||
| Observation and subjective symptoms | 355 | ||
| Vital signs | 355 | ||
| Palpation | 355 | ||
| Inspection | 355 | ||
| Collaborative management | 358 | ||
| Care priorities | 358 | ||
| 1. Identify and manage bleeding complications, including hypovolemic or hemorrhagic shock | 358 | ||
| 2. Manage pain | 358 | ||
| 3. Prevent and/or manage infection | 358 | ||
| 4. Support renal function | 358 | ||
| 5. Manage urinary elimination without causing further injury | 359 | ||
| Catheterization | 359 | ||
| 6. facilitate a timely surgical intervention | 359 | ||
| Care plans: Renal and lower urinary tract trauma | 360 | ||
| Thoracic trauma | 361 | ||
| Pathophysiology | 361 | ||
| Assessment: Thoracic trauma | 362 | ||
| Goal of system assessment | 362 | ||
| History and risk factors | 362 | ||
| Vital signs | 362 | ||
| Observation | 362 | ||
| Percussion | 363 | ||
| Palpation | 363 | ||
| Auscultation | 363 | ||
| Assessment | 363 | ||
| Pneumothorax/tension pneumothorax | 363 | ||
| Hemothorax | 363 | ||
| Flail chest | 363 | ||
| Pulmonary contusion | 363 | ||
| Blunt cardiac injury | 363 | ||
| Aortic trauma | 363 | ||
| Collaborative management | 365 | ||
| Care priorities | 365 | ||
| 1. Ensure patent airway | 365 | ||
| 2. Restore intrathoracic negative pressure | 365 | ||
| 3. Enhance oxygenation and ventilation | 366 | ||
| 4. Restore perfusion and oxygen-carrying capacity | 366 | ||
| 5. Support cardiac function | 366 | ||
| Care plans: Thoracic trauma | 367 | ||
| Additional nursing diagnoses | 368 | ||
| Traumatic brain injury | 368 | ||
| Pathophysiology | 368 | ||
| Changes in intracranial pressure dynamics | 368 | ||
| Primary brain injuries | 368 | ||
| Secondary brain injuries | 369 | ||
| Associated skull fractures | 369 | ||
| Vascular injuries | 370 | ||
| Neurologic complications | 370 | ||
| Herniation syndromes | 370 | ||
| Assessment: Traumatic brain injury | 370 | ||
| Epidural hematoma/linear skull fracture | 372 | ||
| Basilar skull fracture | 372 | ||
| Compound depressed skull fracture | 372 | ||
| Concussion | 372 | ||
| Contusion | 372 | ||
| Diffuse axonal injury | 372 | ||
| Subdural hematoma | 373 | ||
| Subarachnoid hemorrhage | 373 | ||
| Intracranial hematoma | 373 | ||
| Collaborative management | 374 | ||
| Care priorities | 374 | ||
| 1. Surgical intervention | 374 | ||
| 2. Preoperative and postoperative management of coagulopathies | 374 | ||
| 3. Management of ICP dynamics | 375 | ||
| 4. Reduction of ICP by CSF drainage | 375 | ||
| 5. Hyperventilation via mechanical ventilation | 375 | ||
| 6. Monitoring jugular venous oxygen saturation (SjO₂) | 376 | ||
| 7. Monitoring brain tissue oxygenation (PbTO₂) | 377 | ||
| 8. Hyperosmolar therapy | 377 | ||
| 9. Maintenance of blood pressure to maintain cpp | 377 | ||
| 10. Reduction of metabolic demand | 377 | ||
| 11. Modifying nursing care activities that raise icp | 379 | ||
| 12. Nutrition support: Feeding should be initiated as early as possible to achieve full caloric replacement within 7 day ... | 380 | ||
| 13. Prevention of aspiration | 380 | ||
| 14. DVT prophylaxis | 380 | ||
| 15. Management of cardiac dysrhythmias | 381 | ||
| 16. Glucose management | 381 | ||
| 17. Glucocorticoid | 381 | ||
| 18. Rehabilitation | 381 | ||
| 19. Neuroprotective strategies | 382 | ||
| Care plans: Traumatic brain injury | 382 | ||
| Additional nursing diagnoses | 385 | ||
| Selected references | 385 | ||
| 4 Respiratory disorders | 390 | ||
| Respiratory assessment: General | 390 | ||
| Goal of system assessment | 390 | ||
| Vital sign assessment | 390 | ||
| Continuous pulse oximetry (spo2 monitoring) | 390 | ||
| Observation | 390 | ||
| Considerations for the bariatric patient | 390 | ||
| Auscultation | 391 | ||
| Screening labwork | 391 | ||
| Care plans: General approaches to respiratory disorders | 391 | ||
| Acute asthma exacerbation | 393 | ||
| Pathophysiology | 393 | ||
| Assessment | 393 | ||
| Goal of system assessment | 393 | ||
| History and risk factors | 393 | ||
| For asthma | 393 | ||
| For asthma exacerbation | 394 | ||
| Spirometry or peak expiratory flow | 394 | ||
| Vital signs (severe to life-threatening asthma exacerbation) | 394 | ||
| Observation | 394 | ||
| Auscultation | 395 | ||
| Palpation | 395 | ||
| Percussion | 395 | ||
| Screening labwork | 395 | ||
| Collaborative management | 397 | ||
| Care priorities | 397 | ||
| 1. Determine severity of asthma exacerbation | 397 | ||
| 2. Oxygen therapy | 397 | ||
| 3. Heliox therapy | 398 | ||
| 4. Intubation and mechanical ventilation | 398 | ||
| 5. Pharmacotherapy to manage acute asthma exacerbation | 400 | ||
| 6. Fluid replacement | 400 | ||
| 7. Chest physiotherapy | 400 | ||
| Care plans: Acute asthma exacerbation | 400 | ||
| Additional nursing diagnoses | 404 | ||
| Acute respiratory distress syndrome | 404 | ||
| Pathophysiology | 404 | ||
| match | 406 | ||
| Components of an abnormal ratio | 406 | ||
| Carbon dioxide production | 406 | ||
| Assessment | 406 | ||
| Goal of system assessment | 406 | ||
| History and risk factors | 406 | ||
| Vital signs | 407 | ||
| Observation: Oxygenation failure | 407 | ||
| Hypoxemic hypoxia in mild ards | 407 | ||
| Hypoxemic hypoxia in moderate to severe ards | 407 | ||
| Auscultation | 408 | ||
| Palpation | 408 | ||
| Percussion | 408 | ||
| Screening labwork | 408 | ||
| A-a gradient/a-ado2/p(a-a)o2 | 408 | ||
| Diagnostic tests | 409 | ||
| Collaborative management | 410 | ||
| Care priorities | 410 | ||
| 1. Augment oxygen content with oxygen therapy | 410 | ||
| 2. Facilitate ventilation and gas exchange | 410 | ||
| 3. Maintain adequate cardiac output with fluid therapy | 412 | ||
| 4. Reduce anxiety | 412 | ||
| 5. Provide nutrition support | 412 | ||
| Additional nursing diagnoses | 414 | ||
| Acute pneumonia | 414 | ||
| Pathophysiology | 414 | ||
| Community-acquired pneumonia | 414 | ||
| Nosocomial pneumonia | 414 | ||
| Aspiration pneumonia | 415 | ||
| Ventilator-associated pneumonia | 415 | ||
| Ventilator-associated events | 415 | ||
| Assessment | 416 | ||
| Goal of system assessment | 416 | ||
| History and risk factors | 416 | ||
| Cough | 416 | ||
| Chest radiograph | 416 | ||
| Vital signs | 416 | ||
| Observation | 416 | ||
| Auscultation | 416 | ||
| Palpation | 417 | ||
| Percussion | 417 | ||
| Screening labwork | 417 | ||
| Collaborative management | 418 | ||
| Care priorities | 418 | ||
| 1. Relieve hypoxemia | 418 | ||
| 2. Determine severity of pneumonia | 419 | ||
| 3. Control infection | 419 | ||
| 4. Control cough | 419 | ||
| 5. Provide hydration | 420 | ||
| 6. Reduce fever | 420 | ||
| 7. Provide pain relief | 420 | ||
| 8. Support nutritional status | 420 | ||
| 9. Relieve congestion | 420 | ||
| Care plans for acute pneumonia | 421 | ||
| Additional nursing diagnoses | 422 | ||
| Acute respiratory failure | 423 | ||
| Pathophysiology | 423 | ||
| Ventilation and perfusion matching ( match) | 423 | ||
| Components of an abnormal ratio | 423 | ||
| Assessment | 424 | ||
| Goal of system assessment | 424 | ||
| History and risk factors | 424 | ||
| Vital signs | 424 | ||
| Vital signs | 425 | ||
| A-a gradient/a-ado2/p(a-a)o2 | 425 | ||
| Observation | 425 | ||
| Auscultation | 425 | ||
| Palpation | 425 | ||
| Percussion | 425 | ||
| Screening labwork | 425 | ||
| Collaborative management | 426 | ||
| Care priorities | 426 | ||
| 1. Correction of hypoxemia: First treatment priority | 426 | ||
| 2. Correction of respiratory acidosis (hypercapnia) | 427 | ||
| 3. Correction of acidotic ph as a result of hypercapnia (hypoventilation) | 427 | ||
| 4. Correction of alkalotic ph as a result of hypocapnia (hyperventilation) | 427 | ||
| 5. Provide nutrition support | 427 | ||
| Care plans for acute respiratory failure | 428 | ||
| Impaired gas exchange | 428 | ||
| Respiratory monitoring | 428 | ||
| Anxiety reduction | 428 | ||
| Oxygen therapy | 428 | ||
| Ventilation assistance | 429 | ||
| Additional nursing diagnosis | 429 | ||
| Pneumothorax | 429 | ||
| Pathophysiology | 429 | ||
| Spontaneous | 429 | ||
| Traumatic | 429 | ||
| Tension | 429 | ||
| Assessment | 430 | ||
| Goal of system assessment | 430 | ||
| History and risk factors | 430 | ||
| Chest radiograph | 430 | ||
| Vital signs | 430 | ||
| Observation/inspection | 430 | ||
| Spontaneous or traumatic pneumothorax | 430 | ||
| Tension pneumothorax | 430 | ||
| Palpation | 431 | ||
| 5 Cardiac and vascular disorders | 462 | ||
| Cardiovascular assessment: General | 462 | ||
| Care plans for generalized cardiovascular dysfunctions | 463 | ||
| Heart failure | 466 | ||
| Pathophysiology | 466 | ||
| Systolic and diastolic dysfunction | 466 | ||
| Left- versus right-sided heart failure | 466 | ||
| Heart failure progression | 466 | ||
| Cardiovascular assessment: Heart failure | 467 | ||
| Goal of system assessment | 467 | ||
| History and risk factors | 468 | ||
| Collaborative management | 472 | ||
| Care priorities | 472 | ||
| 1. Treat the underlying cause and precipitating factors | 472 | ||
| 2. Provide oxygen therapy and support ventilation | 472 | ||
| 3. Provide evidence-based pharmacotherapy to help improve long-term prognosis, relieve symptoms, and promote stabilizati ... | 472 | ||
| 4. Manage acute pulmonary edema; include the following immediate interventions | 474 | ||
| 5. Initiate a low-cholesterol and low-sodium diet | 474 | ||
| 6. Consider an implanted cardiac device | 474 | ||
| 7. Initiate advanced heart failure therapy | 475 | ||
| 8. Patient education and psychosocial support | 476 | ||
| Care plans for heart failure | 476 | ||
| Additional nursing diagnoses | 479 | ||
| Acute coronary syndrome | 479 | ||
| Pathophysiology | 479 | ||
| Cardiovascular assessment: Acute coronary syndrome | 480 | ||
| Goal of system assessment | 480 | ||
| History and risk factors | 480 | ||
| Chest pain: Angina | 480 | ||
| Chest pain: Acute myocardial infarction | 480 | ||
| 12-lead electrocardiogram: Angina and acute myocardial infarction | 480 | ||
| Vital signs | 480 | ||
| Observation | 481 | ||
| Palpation | 481 | ||
| Auscultation | 481 | ||
| Labwork | 481 | ||
| Electrocardiographic monitoring and interpretation | 484 | ||
| First ECG | 484 | ||
| Standard 12-lead ECG | 484 | ||
| 15- to 18-lead ECG | 484 | ||
| Serial ECGs | 484 | ||
| Significant electrocardiogram changes | 484 | ||
| ST-segment changes and new bundle branch block | 484 | ||
| Q waves | 485 | ||
| T-wave changes | 485 | ||
| Collaborative management | 486 | ||
| Care priorities for all acute coronary syndromes | 486 | ||
| 1. Relief of acute ischemic pain | 486 | ||
| 2. Prevention of coronary artery clot formation | 487 | ||
| 3. Reduction of myocardial workload and myocardial oxygen consumption | 487 | ||
| 4. Prevention, recognition, and treatment of dysrhythmias | 487 | ||
| 5. Prevention of contrast-induced nephropathy related to use of contrast during coronary angiography/PCI | 488 | ||
| Additional treatments | 488 | ||
| 1. Management of unstable AMI with st-segment elevation (STEMI) | 488 | ||
| 2. Acute STEMI: PCI procedures | 488 | ||
| 3. Surgical revascularization | 489 | ||
| 4. Acute STEMI: Thrombolytic therapy | 489 | ||
| Care plans for acute coronary syndromes | 491 | ||
| Care plans for patients undergoing percutaneous coronary intervention | 497 | ||
| Additional nursing diagnoses | 498 | ||
| Acute infective endocarditis | 498 | ||
| Pathophysiology | 498 | ||
| Assessment | 498 | ||
| Goal of assessment | 498 | ||
| History and risk factors | 499 | ||
| Vital signs | 499 | ||
| Hemodynamic measurements | 499 | ||
| Observation | 499 | ||
| Auscultation | 499 | ||
| Screening labwork | 499 | ||
| 12-lead electrocardiogram | 499 | ||
| Collaborative management | 502 | ||
| Care priorities | 502 | ||
| 1. Prevent infective endocarditis in patients undergoing invasive procedures | 502 | ||
| 2. Treat infection and prevent further complications, such as septic emboli, hf, or cardiogenic shock | 503 | ||
| 3. Pharmacotherapy | 503 | ||
| 4. Manage hf and/or cardiogenic shock | 504 | ||
| 5. Consider surgical valve replacement | 504 | ||
| Care plans for acute infective endocarditis | 504 | ||
| Additional nursing diagnoses | 507 | ||
| Acute pericarditis | 507 | ||
| Pathophysiology | 507 | ||
| Assessment | 507 | ||
| Goal of assessment | 507 | ||
| History and risk factors | 508 | ||
| Observation | 508 | ||
| Early indicators of pericarditis | 508 | ||
| Late indicators and evidence of effusions | 508 | ||
| Vital sign assessment | 508 | ||
| Hemodynamic measurements | 508 | ||
| Auscultation | 508 | ||
| Screening labwork | 508 | ||
| 12-lead electrocardiogram | 509 | ||
| Collaborative management | 510 | ||
| Care priorities | 510 | ||
| 1. Relieve acute pain | 510 | ||
| 2. Prevent cardiac damage and manage pericardial effusions to prevent cardiac tamponade | 511 | ||
| Care plans for acute pericarditis | 511 | ||
| Additional nursing diagnoses | 512 | ||
| Aortic aneurysm/dissection | 512 | ||
| Pathophysiology | 512 | ||
| Assessment | 513 | ||
| Goal of the assessment | 513 | ||
| History and risk factors | 513 | ||
| Vital signs | 513 | ||
| Observation | 513 | ||
| Pain | 513 | ||
| Impaired organ perfusion | 513 | ||
| Palpation | 513 | ||
| Auscultation | 514 | ||
| Diagnostic tests | 514 | ||
| Collaborative management | 515 | ||
| Care priorities | 516 | ||
| 1. Preserve the tissue integrity of the aorta with beta-blocker therapy (e.g., metoprolol, esmolol) | 516 | ||
| 2. Control pain | 516 | ||
| 3. Evaluate for and facilitate surgical or endovascular treatment | 516 | ||
| 4. Continue medical management | 517 | ||
| Care plans for aortic aneurysm/dissection | 517 | ||
| Additional nursing diagnoses | 518 | ||
| Cardiogenic shock | 518 | ||
| Pathophysiology | 518 | ||
| Assessment | 518 | ||
| Goals of assessment | 518 | ||
| Observation | 519 | ||
| Vital signs and diagnostic criteria for cs | 519 | ||
| Auscultation | 519 | ||
| Hemodynamic measurements | 519 | ||
| Hemodynamic monitoring | 519 | ||
| Measuring tissue perfusion | 519 | ||
| Improving cellular oxygen transport | 519 | ||
| Diagnostic tests | 520 | ||
| Collaborative management | 520 | ||
| Care priorities | 520 | ||
| Initial therapy | 520 | ||
| Pharmacologic support of the failing heart | 520 | ||
| Intravascular volume optimization | 521 | ||
| Loop diuretics | 521 | ||
| Mechanical support of the failing heart | 521 | ||
| Reduce left ventricular afterload and increase coronary arterial perfusion using balloon counterpulsation therapy/iabp | 521 | ||
| Advanced mechanical circulatory support | 522 | ||
| Provide other treatments for cardiogenic shock after the cause of pump failure has been identified | 522 | ||
| Care plans for cardiogenic shock | 522 | ||
| Cardiomyopathy | 526 | ||
| Pathophysiology | 526 | ||
| Functional classifications of cardiomyopathy | 528 | ||
| Dilated cardiomyopathy | 528 | ||
| Hypertrophic cardiomyopathy | 528 | ||
| Restrictive cardiomyopathy | 528 | ||
| Arrhythmogenic right ventricular cardiomyopathy/dysplasia | 528 | ||
| Left ventricular noncompaction | 528 | ||
| Assessment | 529 | ||
| Goal of assessment | 529 | ||
| Observation | 529 | ||
| Collaborative management | 533 | ||
| Care priorities | 533 | ||
| 1. Reduce activity level to decrease oxygen demand during periods of activity intolerance because of instability | 533 | ||
| 2. Initiate pharmacotherapy to maintain or reestablish hemodynamic stability, control symptoms, and prevent cardiac remo ... | 534 | ||
| 4. Initiate electrical/device-based therapy to maintain or reestablish hemodynamic stability, control symptoms, and prev ... | 535 | ||
| 5. Initiate hemodynamic monitoring to help evaluate intracardiac pressures during therapeutic interventions | 535 | ||
| 6. Initiate advanced therapies for symptom management and stabilization | 535 | ||
| 7. Provide surgical interventions to maintain or reestablish hemodynamic stability, control symptoms, and prevent cardia ... | 535 | ||
| Care plans for cardiomyopathy | 536 | ||
| Additional nursing diagnoses | 537 | ||
| Dysrhythmias and conduction disturbances | 537 | ||
| Pathophysiology | 537 | ||
| Abnormal electrocardiographic tracings | 539 | ||
| Causes of abnormal rhythms | 539 | ||
| Disturbances in automaticity | 539 | ||
| Disturbances in conduction | 539 | ||
| Combinations of disturbed automaticity and conduction | 544 | ||
| Assessment | 544 | ||
| Goal of assessment | 544 | ||
| History and risk factors | 544 | ||
| Observation | 544 | ||
| Vital signs | 544 | ||
| Electrocardiographic and hemodynamic measurements | 544 | ||
| Auscultation | 546 | ||
| Palpation | 546 | ||
| Collaborative management | 563 | ||
| Care priorities | 563 | ||
| 1. Identify the dysrhythmia and assess for symptoms | 563 | ||
| 2. Determine the urgency of correcting the dysrhythmia and whether drugs or electrical therapy is the most appropriate app ... | 563 | ||
| 3. Provide pharmacologic management to correct dysrhythmias if recommended as the first strategy by acls guidelines | 563 | ||
| 4. Provide therapy for rapid hrs using current acls guidelines to manage ventricular tachycardias (monomorphic and polymor ... | 565 | ||
| 5. Provide electrical therapy (cardiac pacing) to support unstable patients with slow hrs, and some rapid hrs if recommend ... | 568 | ||
| 6. Provide surgical procedures to help control dysrhythmias | 570 | ||
| 7. Initiate anticoagulation for patients at higher risk for development of blood clots within the heart secondary to dysrh ... | 571 | ||
| 8. Explain the content of dietary guidelines designed to help reduce stimulants normally consumed | 571 | ||
| Care plans for dysrhythmias and conduction disturbances | 572 | ||
| For patients with an ICD and/or permanent pacemaker | 573 | ||
| For patients with a pacemaker (temporary or permanent) or patients with third-generation ICDs with cardiac pacing | 575 | ||
| For patients with an ICD | 576 | ||
| Additional nursing diagnoses | 576 | ||
| Hypertensive emergencies | 576 | ||
| Pathophysiology | 576 | ||
| Pathophysiology | 578 | ||
| Assessment | 578 | ||
| Goal of assessment | 578 | ||
| History and risk factors | 578 | ||
| Observation | 579 | ||
| Early indicators | 579 | ||
| Late indicators (nearly always present during a hypertensive crisis) | 579 | ||
| Eye assessment | 579 | ||
| Neurologic assessment | 579 | ||
| Vital signs | 580 | ||
| Blood pressure measurements | 580 | ||
| Pheochromocytoma assessment | 580 | ||
| Renal insufficiency assessment | 580 | ||
| Palpation | 580 | ||
| Evaluate for LV hypertrophy | 580 | ||
| Peripheral pulses | 580 | ||
| Auscultation | 580 | ||
| Heart sounds | 580 | ||
| Vascular sounds | 581 | ||
| Diagnostic tests | 581 | ||
| Collaborative management | 582 | ||
| Care priorities | 582 | ||
| 1. Control the BP within minutes to 2 hours during hypertensive crisis | 582 | ||
| 2. Manage patients with acute ischemic stroke according to the american stroke association (asa)/aha guidelines | 582 | ||
| 3. Manage patients with acute subarachnoid hemorrhage | 583 | ||
| 4. Facilitate adjustment to a routine antihypertensive regimen | 584 | ||
| 5. Provide patient education regarding lifestyle alterations | 584 | ||
| 6. Educate patients regarding ongoing pharmacotherapy | 584 | ||
| 7. Discuss surgical treatment of appropriate conditions that prompt hypertension | 584 | ||
| Care plans for hypertensive emergencies | 584 | ||
| Additional nursing diagnoses | 589 | ||
| Peripheral vascular disease | 589 | ||
| Pathophysiology | 589 | ||
| Carotid artery occlusive disease | 590 | ||
| Lower extremity peripheral artery occlusive disease: Acute | 590 | ||
| Peripheral vascular assessment: Arterial occlusive disease | 592 | ||
| Goal of system assessment | 592 | ||
| History and risk factors | 592 | ||
| Carotid artery occlusive disease | 592 | ||
| Peripheral artery occlusive disease with or without distal limb involvement, chronic | 593 | ||
| Peripheral artery occlusive disease with or without distal limb involvement, acute | 593 | ||
| Observation | 593 | ||
| Carotid artery occlusive disease | 593 | ||
| Peripheral artery occlusive disease | 594 | ||
| Vital signs | 594 | ||
| Palpation | 594 | ||
| Auscultation | 595 | ||
| Screening labwork | 595 | ||
| Postprocedural screening labwork | 595 | ||
| Carotid duplex and arteriogram | 598 | ||
| Ankle-brachial index | 598 | ||
| Collaborative management | 598 | ||
| Care priorities: Peripheral artery occlusive disease | 598 | ||
| Lower extremity peripheral artery occlusive disease: Critical limb ischemia | 602 | ||
| 1. relief of ischemic pain | 602 | ||
| 2. prevention of injury to the ischemic limb | 602 | ||
| 3. promoting perfusion of the extremity | 602 | ||
| 4. prevention of peripheral artery clot formation | 602 | ||
| 5. prevent contrast-induced nephropathy (cin) secondary to contrast during angiography | 603 | ||
| 6. endovascular or surgical treatment of cli/ali | 603 | ||
| Lower extremity peripheral artery occlusive disease: Acute limb ischemia | 603 | ||
| 1. thrombolysis | 604 | ||
| 2. thromboembolectomy | 604 | ||
| Collaborative management | 604 | ||
| Care priorities: Carotid artery occlusive disease | 604 | ||
| 1. facilitate recovery from cea | 607 | ||
| 2. facilitate recovery from an endovascular stenting | 607 | ||
| 3. in a patients undergoing cea or carotid artery stent with 100% occlusion of the contralateral carotid artery, prevent ... | 607 | ||
| 4. initiate medical management, including antiplatelet medications | 607 | ||
| Care plans for generalized peripheral vascular disease | 607 | ||
| Care plans for carotid artery occlusive disease | 609 | ||
| Care plans for peripheral artery occlusive disease | 610 | ||
| Care plans for patients undergoing endovascular repair of stenosis or occlusion | 611 | ||
| Additional nursing diagnoses | 612 | ||
| Valvular heart disease | 612 | ||
| Pathophysiology | 612 | ||
| Atrioventricular valves | 612 | ||
| Semilunar valves | 612 | ||
| Mitral valve disease | 612 | ||
| Tricuspid valve disease | 613 | ||
| Aortic valve disease | 613 | ||
| Pulmonic valve disease | 614 | ||
| Assessment: Valvular heart disease | 614 | ||
| Goal of system assessment | 614 | ||
| History and risk factors | 614 | ||
| Physical assessment | 614 | ||
| Collaborative management | 618 | ||
| Care priorities | 618 | ||
| 1. Consider antibiotic prophylaxis for infective endocarditis and rheumatic fever | 618 | ||
| 2. Manage aortic stenosis | 619 | ||
| 3. Manage aortic insufficiency/regurgitation | 620 | ||
| 4. Manage mitral stenosis | 620 | ||
| 5. Manage mitral regurgitation | 620 | ||
| 6. Manage tricuspid valve disease | 621 | ||
| 7. Manage pulmonic valve disease | 621 | ||
| 8. Provide lifelong anticoagulation for patients with prosthetic heart valves | 621 | ||
| 9. Provide short-term anticoagulation for patients with biological heart valves | 621 | ||
| 10. Reverse excessive anticoagulation | 621 | ||
| 11. Manage thrombosis of prosthetic valves | 621 | ||
| Surgical interventions | 621 | ||
| Care plans for valvular heart disease | 622 | ||
| For patients undergoing valve replacement | 622 | ||
| Ineffective protection | 622 | ||
| Circulatory precautions | 622 | ||
| Decreased cardiac output (or risk for same) | 623 | ||
| Shock prevention | 623 | ||
| Ineffective tissue perfusion (or risk for same): Cerebral | 624 | ||
| Neurologic monitoring | 624 | ||
| 6 Kidney injury | 636 | ||
| Genitourinary assessment: General | 636 | ||
| Acute kidney injury | 637 | ||
| Pathophysiology | 637 | ||
| Assessment | 643 | ||
| Goal of assessment | 643 | ||
| History and risk factors | 644 | ||
| Special populations at risk | 644 | ||
| Prerenal presentation | 644 | ||
| Intrarenal presentation | 644 | ||
| Postrenal presentation | 645 | ||
| Vital signs | 645 | ||
| Observation | 645 | ||
| Palpation | 645 | ||
| Auscultation | 645 | ||
| Uremic manifestations | 646 | ||
| Screening laboratory tests | 646 | ||
| Kidney attack: Early recognition of aki with urinary and serum biomarkers | 647 | ||
| Collaborative management | 648 | ||
| Care priorities for aki | 648 | ||
| 1. Maintain renal perfusion | 649 | ||
| 2. Minimize exposure to nephrotoxic agents | 649 | ||
| 3. Provide nutrition support | 651 | ||
| 4. Avoid hyperglycemia | 651 | ||
| 5. Continue assessment and monitoring of hemodynamic and oxygenation measurements | 651 | ||
| 6. Initiate renal replacement therapy | 651 | ||
| Care plans for acute kidney injury | 651 | ||
| Additional nursing diagnoses | 656 | ||
| Continuous renal replacement therapies | 656 | ||
| Pathophysiology | 657 | ||
| Assessment: Pre-crrt | 658 | ||
| Goal of assessment | 658 | ||
| History and risk factors | 658 | ||
| Vital signs | 658 | ||
| Observation | 658 | ||
| Palpation | 659 | ||
| Auscultation | 659 | ||
| Uremic manifestations | 659 | ||
| Screening labwork | 659 | ||
| Determining type and modality of crrt used | 660 | ||
| Principles applied to specific therapies | 662 | ||
| Procedure | 662 | ||
| Anticoagulation | 663 | ||
| Factors related to coagulation | 664 | ||
| Patient factors | 664 | ||
| Vascular access factors | 664 | ||
| Treatment variations | 664 | ||
| Heparin | 664 | ||
| Direct thrombin inhibitors | 664 | ||
| Citrate | 664 | ||
| Isotonic sodium chloride solution | 665 | ||
| Replacement fluid | 665 | ||
| Assessment: During continuous renal replacement therapy | 665 | ||
| Goal of system assessment | 665 | ||
| History and risk factors | 665 | ||
| Vital signs | 665 | ||
| Observation | 666 | ||
| Hourly monitoring of the crrt circuit | 666 | ||
| Hourly monitoring of the vascular access | 666 | ||
| Palpation | 666 | ||
| Auscultation | 666 | ||
| Screening labwork | 666 | ||
| Collaborative management | 666 | ||
| Care priorities | 667 | ||
| 1. Maintain hemodynamic stability | 667 | ||
| 2. Provide adequate nutrition to promote healing | 667 | ||
| 3. Replacement fluids | 667 | ||
| 4. Vascular access adequacy | 667 | ||
| 5. Maintain patency of the crrt machine circuit | 667 | ||
| Care plans for continuous renal replacement therapy | 667 | ||
| Additional nursing diagnoses | 670 | ||
| Selected references | 670 | ||
| 7 Neurologic disorders | 673 | ||
| General neurologic assessment | 673 | ||
| Brain death | 677 | ||
| Pathophysiology | 677 | ||
| Neurologic assessment: Brain death | 678 | ||
| Goal of system assessment | 678 | ||
| History and risk factors | 678 | ||
| Apnea test (CO₂ challenge) | 679 | ||
| Vital signs | 679 | ||
| Observation/inspection/palpation | 679 | ||
| Screening labwork | 679 | ||
| Collaborative management | 681 | ||
| Care priorities | 682 | ||
| 1. Confirm a clinical diagnosis of brain death | 682 | ||
| 2. Allay doubts about the diagnosis | 682 | ||
| 3. Discuss organ donation only after the clinical diagnosis of brain death has been made and the family understands the ... | 682 | ||
| 4. Maintain organs for donation if the family/significant others agree | 683 | ||
| 5. Discontinue life support after the family has had time to visit the patient, if the family declines the opportunity t ... | 683 | ||
| Care plans for brain death | 683 | ||
| Additional nursing diagnoses | 684 | ||
| Cerebral aneurysm and subarachnoid hemorrhage | 684 | ||
| Pathophysiology | 684 | ||
| Neurologic assessment: Cerebral aneurysm(s) and subarachnoid hemorrhage | 686 | ||
| Goal of system assessment | 686 | ||
| History and risk factors | 686 | ||
| Hunt and hess classification system | 687 | ||
| Vital signs | 687 | ||
| Intracranial pressure | 687 | ||
| Indicators of hydrocephalus | 688 | ||
| Observation and functional assessment | 688 | ||
| Diminished level of consciousness | 688 | ||
| Pupillary changes | 688 | ||
| Motor/sensory assessment | 688 | ||
| Fundoscopic assessment | 689 | ||
| Screening labwork | 689 | ||
| Diagnostic testing | 689 | ||
| Collaborative management | 689 | ||
| Care priorities | 689 | ||
| 1. Pharmacotherapy | 689 | ||
| 2. Surgical/endovascular intervention | 691 | ||
| 3. Management of hydrocephalus | 692 | ||
| Care plans for cerebral aneurysm and subarachnoid hemorrhage | 692 | ||
| Additional nursing diagnoses | 694 | ||
| Care of the patient after intracranial surgery | 694 | ||
| Neurologic assessment: Postoperative care | 694 | ||
| Goal of system assessment | 694 | ||
| History and risk factors | 695 | ||
| Vital signs | 695 | ||
| Observation | 695 | ||
| Observation and functional assessment | 696 | ||
| 1. Assess motor function and sensory responses | 696 | ||
| 2. Assess for cranial nerve impairment | 696 | ||
| Screening labwork | 696 | ||
| Diagnostic testing | 696 | ||
| Collaborative management after intracranial surgery | 696 | ||
| Care priorities | 696 | ||
| 1. Respiratory support | 696 | ||
| 2. Positioning | 697 | ||
| 3. Manage pain | 697 | ||
| 4. Reduce cerebral edema: | 697 | ||
| 5. Perioperative and postoperative deep venous thrombosis (dvt) prevention | 697 | ||
| 6. Control seizures | 698 | ||
| 7. Prevent infection | 698 | ||
| 8. Nutrition support | 698 | ||
| 9. Reduce fever | 698 | ||
| 10. Prevent gastric ulcers | 698 | ||
| 11. Facilitate mobility and return of functions needed for activities of daily living | 698 | ||
| 12. Implement therapeutic hypothermia | 698 | ||
| Care plans: Complications after intracranial surgery | 698 | ||
| Additional nursing diagnoses | 701 | ||
| Meningitis | 701 | ||
| Pathophysiology | 701 | ||
| Bacterial meningitis | 701 | ||
| Other microbes | 702 | ||
| Tuberculous meningitis | 702 | ||
| Fungal meningitis | 702 | ||
| Viral meningitis | 702 | ||
| Eosinophilic meningitis | 702 | ||
| Aseptic meningitis syndrome | 702 | ||
| Noninfectious causes | 702 | ||
| Neurologic assessment: Meningitis | 703 | ||
| Goal of system assessment | 703 | ||
| History and risk factors | 703 | ||
| Vital signs | 704 | ||
| Observation | 704 | ||
| Level of consciousness | 704 | ||
| Pupillary changes | 704 | ||
| Clinical presentation | 704 | ||
| Functional assessment | 705 | ||
| 1. Assess motor function and sensory responses | 705 | ||
| 2. Assess for cranial nerve impairment | 706 | ||
| Screening labwork | 706 | ||
| Diagnostic tests | 706 | ||
| Collaborative management | 708 | ||
| Care priorities | 708 | ||
| 1. Control infection | 708 | ||
| 2. Reduce inflammation with adjunctive pharmacologic therapies | 708 | ||
| 3. Monitor | 708 | ||
| 4. Maintain fluid and electrolyte balance | 708 | ||
| 5. Provide adequate nutrition | 708 | ||
| 6. Control seizures with antiepileptic therapy | 708 | ||
| 7. Maintain normothermia/control fever | 708 | ||
| 8. Prevent infection | 708 | ||
| 9. Facilitate mobility | 709 | ||
| 10. Evaluate the need for support services | 710 | ||
| Care plans: Meningitis | 710 | ||
| Additional nursing diagnoses | 711 | ||
| Neurodegenerative and neuromuscular disorders | 711 | ||
| Pathophysiology | 711 | ||
| Myasthenia gravis | 712 | ||
| Pathophysiology | 712 | ||
| Assessment | 712 | ||
| Goal of assessment | 712 | ||
| History and risk factors | 712 | ||
| Vital signs | 713 | ||
| Observation | 713 | ||
| Symptom progression | 713 | ||
| Ocular muscle group | 713 | ||
| Muscles of face, neck, and oropharynx with bulbar signs | 713 | ||
| Muscles of limbs and trunk | 713 | ||
| Myasthenic and cholinergic crises | 713 | ||
| Auscultation | 713 | ||
| Collaborative management | 714 | ||
| Care priorities for patients with myasthenia gravis | 714 | ||
| 1. Manage respiratory failure | 714 | ||
| 2. Provide emergency interventions for myasthenic or cholinergic crisis | 714 | ||
| 3. Initiate nutrition support | 714 | ||
| 4. Manage pharmacotherapy during noncrisis periods | 714 | ||
| 5. Consider plasmapheresis | 715 | ||
| 6. Carefully consider thymectomy | 715 | ||
| Care plans for myasthenia gravis | 715 | ||
| Additional nursing diagnoses | 720 | ||
| Guillain-barré syndrome | 720 | ||
| Pathophysiology | 720 | ||
| Assessment: Guillain-barré syndrome | 720 | ||
| Goal of assessment | 720 | ||
| History and risk factors | 720 | ||
| Vital signs | 721 | ||
| Observation | 721 | ||
| Collaborative management | 722 | ||
| Care priorities | 722 | ||
| 1. Provide respiratory support | 722 | ||
| 2. Perform plasmapheresis | 722 | ||
| 3. Administer ivig (IV immunoglobulin g or ivig) | 722 | ||
| 4. Support cardiovascular function and carefully monitor for dysrhythmias | 722 | ||
| 5. Manage bowel and bladder dysfunction | 722 | ||
| 6. Provide nutrition support | 722 | ||
| 7. Rehabilitation | 722 | ||
| Care plans for guillain-barré syndrome | 722 | ||
| Additional nursing diagnoses | 727 | ||
| Status epilepticus | 727 | ||
| Pathophysiology | 727 | ||
| Assessment | 727 | ||
| Goal of system assessment | 727 | ||
| History and risk factors | 727 | ||
| Vital signs | 727 | ||
| Observation and seizure assessment | 728 | ||
| Screening labwork | 728 | ||
| Electroencephalography | 728 | ||
| Collaborative management | 729 | ||
| Care priorities | 729 | ||
| 1. Support of ventilation and perfusion | 729 | ||
| 2. Establish IV access | 729 | ||
| 3. Pharmacotherapy | 729 | ||
| 4. Treatment of refractory status | 730 | ||
| 5. Nutrition support | 731 | ||
| Care plans for status epilepticus | 731 | ||
| Additional nursing diagnoses | 733 | ||
| Stroke: Acute ischemic and hemorrhagic | 734 | ||
| Pathophysiology | 734 | ||
| Assessment of stroke: Acute ischemic stroke and intracranial hemorrhage | 737 | ||
| Goal of system assessment | 737 | ||
| History and risk factors | 737 | ||
| Vital sign assessment | 737 | ||
| Neurologic evaluation: Observation | 737 | ||
| General presentation: Acute ischemic stroke and intracranial hemorrhage | 737 | ||
| Clinical presentation: Acute ischemic stroke (table 7-5) | 738 | ||
| Clinical presentation: Intracranial hemorrhage (table 7-6) | 738 | ||
| Screening neurologic imaging | 738 | ||
| Screening labwork | 738 | ||
| Collaborative management | 741 | ||
| Care priorities | 741 | ||
| 1. Rapidly evaluate patients for type of stroke and minimize brain damage | 741 | ||
| Interventional approaches for acute ischemic stroke | 742 | ||
| Endovascular surgery: Interventional approaches for intracranial hemorrhage | 742 | ||
| 2. Manage hypertension and stabilize vital signs | 742 | ||
| 3. Monitor icp and manage cpp | 744 | ||
| 4. Prevent stroke extension | 744 | ||
| 5. Prevention of recurrent stroke | 744 | ||
| 6. Manage agitation | 744 | ||
| 7. Optimize regulatory functions | 748 | ||
| 8. Provide rehabilitation | 748 | ||
| 9. Manage seizures | 750 | ||
| 10. Surgical management | 750 | ||
| Nursing care plans: Acute ischemic stroke and intracranial hemorrhage | 750 | ||
| Additional nursing diagnoses | 752 | ||
| Selected references | 752 | ||
| 8 Endocrinologic disorders | 756 | ||
| Endocrine assessment | 756 | ||
| Acute adrenal insufficiency (adrenal crisis) | 757 | ||
| Pathophysiology | 757 | ||
| Critical illness induced adrenal insufficiency | 758 | ||
| Endocrine assessment adrenal glands | 759 | ||
| Goal of system assessment | 759 | ||
| History and risk factors | 759 | ||
| Observation and vital signs: Primary (first-degree) and secondary (second-degree) insufficiency | 759 | ||
| Observation and vital signs: Primary (first-degree) insufficiency only | 759 | ||
| Screening lab work | 760 | ||
| For suspected acute adrenal crisis | 760 | ||
| For noncritical adrenocortical insufficiency | 760 | ||
| 9 Gastrointestinal disorders | 814 | ||
| Gastrointestinal assessment: General | 814 | ||
| Acute gastrointestinal bleeding | 816 | ||
| Pathophysiology | 816 | ||
| Upper gastrointestinal bleeding | 816 | ||
| Esophagus | 816 | ||
| Stomach and duodenum | 816 | ||
| Lower gastrointestinal bleeding | 817 | ||
| Small intestine | 817 | ||
| Large intestine | 817 | ||
| Rectum | 817 | ||
| Neighboring organs | 817 | ||
| Pancreas and vascular grafts | 817 | ||
| Systemic organ diseases | 817 | ||
| Medications | 817 | ||
| Other | 817 | ||
| Gastrointestinal assessment: Acute gastrointestinal bleeding | 818 | ||
| Goal of assessment | 818 | ||
| History and risk factors | 818 | ||
| Vital sign assessment | 818 | ||
| Blood loss | 818 | ||
| Abdominal pain | 819 | ||
| Observation | 819 | ||
| Auscultation | 819 | ||
| Palpation | 819 | ||
| Nutrition assessment | 819 | ||
| Screening labwork | 819 | ||
| Hemodynamic measurements | 819 | ||
| Blood urea nitrogen–to–creatinine ratio | 821 | ||
| Esophagogastroduodenoscopy | 821 | ||
| Colonoscopy | 822 | ||
| Collaborative management | 822 | ||
| Care priorities | 823 | ||
| 1. Fluid and electrolyte management | 823 | ||
| 2. Respiratory support | 823 | ||
| 3. Nutrition support | 823 | ||
| 4. Gastric intubation | 824 | ||
| 5. Endoscopic therapies | 824 | ||
| 6. Pharmacotherapy | 824 | ||
| 7. Surgical management | 825 | ||
| Care plans for acute gastrointestinal bleeding | 825 | ||
| Additional nursing diagnoses | 828 | ||
| Acute pancreatitis | 828 | ||
| Pathophysiology | 828 | ||
| Risk stratification | 829 | ||
| Complications | 829 | ||
| Assessment | 830 | ||
| Goal of system assessment: Acute pancreatitis | 830 | ||
| History and risk factors | 830 | ||
| Vital sign assessment | 833 | ||
| Abdominal pain | 833 | ||
| Observation | 833 | ||
| Auscultation | 833 | ||
| Palpation | 834 | ||
| Nutrition assessment | 834 | ||
| Screening labwork | 834 | ||
| Hemodynamic measurements for complications of sap | 834 | ||
| Serum lipase and amylase | 837 | ||
| Collaborative management | 837 | ||
| Care priorities for severe acute pancreatitis | 837 | ||
| 1. Aggressive fluid resuscitation | 837 | ||
| 2. Support ventilation and oxygenation | 837 | ||
| 3. Correct electrolyte and metabolic abnormalities | 838 | ||
| 4. Provide effective pain control | 839 | ||
| 5. Initiate nutrition support | 839 | ||
| 6. Suppress pancreatic secretions | 839 | ||
| 7. Manage medically versus surgically | 840 | ||
| 8. Prevent infection; the role of antibiotics | 840 | ||
| 9. Intraabdominal pressure monitoring | 840 | ||
| 10. Prevent recurrence | 840 | ||
| Care plans for acute pancreatitis | 840 | ||
| Additional nursing diagnoses | 845 | ||
| Enterocutaneous fistula | 845 | ||
| Pathophysiology | 845 | ||
| Gastrointestinal assessment: Enterocutaneous fistula | 846 | ||
| Goal of assessment: Enterocutaneous fistula | 846 | ||
| History and risk factors | 846 | ||
| Vital sign assessment | 846 | ||
| Abdominal pain | 846 | ||
| Abdominal drainage | 846 | ||
| Observation | 847 | ||
| Auscultation | 847 | ||
| Palpation | 847 | ||
| Nutrition assessment | 847 | ||
| Screening labwork | 847 | ||
| Hemodynamic measurements | 847 | ||
| Nonradiographic evaluation | 848 | ||
| Collaborative management | 848 | ||
| Care priorities | 849 | ||
| 1. Fluid and electrolyte replacement | 849 | ||
| 2. Control of sepsis | 849 | ||
| 3. Nutrition support | 849 | ||
| 4. Fistula management | 849 | ||
| Care plans for enterocutaneous fistula | 850 | ||
| Additional nursing diagnoses | 854 | ||
| Hepatic failure | 854 | ||
| Pathophysiology | 854 | ||
| Acute liver failure | 854 | ||
| Chronic liver failure | 855 | ||
| Benefits of care in a transplant center | 856 | ||
| Hepatic assessment | 856 | ||
| Goal of system assessment | 856 | ||
| History and risk factors | 856 | ||
| Vital sign assessment | 856 | ||
| Observation | 857 | ||
| Palpation | 857 | ||
| Auscultation | 857 | ||
| Screening labwork | 858 | ||
| Liver biopsy | 858 | ||
| Other studies | 858 | ||
| Liver function tests | 862 | ||
| Alanine aminotransferase (ALT) and aspartate aminotransferas (AST) | 862 | ||
| Serum bilirubin (bili) | 862 | ||
| Alkaline phosphatase | 863 | ||
| Serum albumin | 863 | ||
| Prothrombin time (PT) | 863 | ||
| Liver biopsy | 863 | ||
| Before biopsy | 864 | ||
| During biopsy | 864 | ||
| After biopsy | 864 | ||
| Collaborative management | 864 | ||
| Care priorities | 866 | ||
| 1. Manage fluid and electrolyte imbalance | 866 | ||
| 2. Provide nutrition therapy | 866 | ||
| 3. Provide pharmacotherapy that will minimize or avoid further liver dysfunction because all drugs have hepatotoxic pote ... | 866 | ||
| 4. Prevent spontaneous bacterial peritonitis | 867 | ||
| 5. Manage accumulation of ascites | 868 | ||
| 6. Eliminate or correct the precipitating factors of encephalopathy | 868 | ||
| 7. Infection control | 870 | ||
| 8. prevent skin breakdown | 870 | ||
| 9. Pain management | 871 | ||
| 10. Hepatic transplantation | 871 | ||
| Care plans for hepatic failure | 871 | ||
| Additional nursing diagnoses | 879 | ||
| Peritonitis | 879 | ||
| Pathophysiology | 879 | ||
| Gastrointestinal assessment: Peritonitis | 880 | ||
| Goal of system assessment | 880 | ||
| History and risk factors | 880 | ||
| Vital sign assessment | 880 | ||
| Abdominal pain | 880 | ||
| Observation | 880 | ||
| Auscultation | 880 | ||
| Palpation | 880 | ||
| Nutrition assessment | 880 | ||
| Screening labwork | 881 | ||
| Hemodynamic measurements | 881 | ||
| Hematologic tests | 882 | ||
| Blood chemistry tests | 882 | ||
| Radiologic procedures | 882 | ||
| Nuclear medicine scans | 882 | ||
| Diagnostic paracentesis | 882 | ||
| Collaborative management | 883 | ||
| Care priorities | 883 | ||
| 1. Correct fluid and electrolyte imbalances | 883 | ||
| 2. Control peritoneal infection with antimicrobial therapy | 883 | ||
| 3. Control peritoneal infection with surgical procedure(s) | 883 | ||
| 4. Control pain resulting from peritoneal inflammation | 884 | ||
| 5. Provide nutrition support | 884 | ||
| 6. Intraabdominal pressure monitoring | 884 | ||
| Care plans for peritonitis | 884 | ||
| Additional nursing diagnoses | 888 | ||
| Selected references | 888 | ||
| 10 Hematologic/immunologic disorders | 891 | ||
| General hematology assessment | 891 | ||
| Anaphylactic shock | 892 | ||
| Pathophysiology | 892 | ||
| Assessment: Anaphylactic shock | 893 | ||
| Goal of system assessment | 893 | ||
| History and risk factors | 895 | ||
| Vital signs | 895 | ||
| Observation (see table 10-1) | 895 | ||
| Auscultation | 896 | ||
| Palpation | 896 | ||
| Percussion | 896 | ||
| Collaborative management (see figure 10-2) | 897 | ||
| Care priorities | 897 | ||
| Prevention | 897 | ||
| 1. Position the patient and maintain a patent airway | 898 | ||
| 2. Provide supplemental oxygen | 898 | ||
| 3. Manage vasodilation and increased capillary permeability | 898 | ||
| 4. Electrocardiogram (ECG) monitoring | 899 | ||
| Care plans for anaphylaxis and anaphylactic shock | 899 | ||
| Additional nursing diagnoses | 902 | ||
| Profound anemia and hemolytic crisis | 902 | ||
| Pathophysiology | 902 | ||
| Anemia | 902 | ||
| Hemolytic crisis | 902 | ||
| Assessment | 902 | ||
| Goal of system assessment | 902 | ||
| Anemia | 903 | ||
| Risk factors | 903 | ||
| Clinical presentation (chronic indicators) | 903 | ||
| Clinical presentation (acute indicators) | 903 | ||
| Vital signs | 903 | ||
| Observation | 903 | ||
| Palpation | 903 | ||
| Auscultation | 903 | ||
| Hemolytic crisis | 904 | ||
| Risk factors | 904 | ||
| Clinical presentation (acute) | 904 | ||
| Clinical presentation (chronic) | 904 | ||
| Vital signs | 904 | ||
| Observation | 904 | ||
| Palpation | 904 | ||
| Auscultation | 904 | ||
| Collaborative management: Anemias | 906 | ||
| Care priorities | 906 | ||
| 1. Oxygen therapy: Administered to relieve sob or dyspnea | 906 | ||
| 2. Transfusions/blood component replacement | 906 | ||
| 3. Volume replacement | 907 | ||
| 4. Elimination of causative factor | 907 | ||
| 5. Folic acid supplement | 907 | ||
| 6. Iron supplements | 907 | ||
| 7. Epoetin alfa/erythropoietin, recombinant (epogen/procrit) | 907 | ||
| 8. Vitamin b12 | 907 | ||
| 9. Bone marrow transplantation | 907 | ||
| Care plans for anemias | 908 | ||
| Collaborative management: Hemolytic crisis | 910 | ||
| Care priorities | 910 | ||
| 1. Oxygen therapy | 910 | ||
| 2. Pain management | 910 | ||
| 3. Volume replacement | 910 | ||
| 4. Transfusions/blood component replacement | 910 | ||
| 5. Red cell exchange therapy for sickle cell crisis | 910 | ||
| 6. Thrombocytapheresis | 910 | ||
| 7. Therapeutic phlebotomy | 911 | ||
| 8. Corticosteroids | 911 | ||
| 9. Splenectomy | 911 | ||
| Care plans for hemolytic crisis | 911 | ||
| Additional nursing diagnoses | 913 | ||
| Bleeding and thrombotic disorders | 913 | ||
| Pathophysiology | 913 | ||
| Heparin-induced thrombocytopenia | 915 | ||
| Pathophysiology | 915 | ||
| Assessment | 915 | ||
| Goal of system assessment | 915 | ||
| Risk factors | 915 | ||
| Vital signs | 915 | ||
| Observation | 916 | ||
| Palpation | 916 | ||
| Collaborative management | 917 | ||
| Care priorities | 917 | ||
| 1. Screen preheparin platelet count, and monitor platelets and amount of heparin needed | 917 | ||
| 2. Administer defibrinogenating agents if high morbidity symptoms are present | 918 | ||
| 3. Prevent pulmonary emboli with a vena cava filter | 918 | ||
| 4. Maintain anticoagulation, if needed, with a direct thrombin inhibitor | 918 | ||
| 5. Consider use of newer anticoagulation agents in those who are difficult to manage | 918 | ||
| 6. Provide platelet transfusions for high morbidity patients who continue to bleed | 918 | ||
| 7. Provide plasma exchange for high morbidity patients who fail to respond to other therapies | 918 | ||
| Care plans: Heparin-induced thrombocytopenia | 918 | ||
| Additional nursing diagnoses | 920 | ||
| Immune thrombocytopenia purpura | 920 | ||
| Pathophysiology | 920 | ||
| Assessment | 920 | ||
| Goal of system assessment | 920 | ||
| Risk factors | 920 | ||
| Vital signs | 920 | ||
| Observation | 920 | ||
| Palpation | 920 | ||
| Collaborative management: Immune thrombocytopenic purpura | 921 | ||
| Care priorities | 921 | ||
| 1. Suppress immune response to reduce platelet destruction | 921 | ||
| 2. Increase platelet count | 922 | ||
| Care plans for immune thrombocytopenic purpura | 922 | ||
| Additional nursing diagnoses | 924 | ||
| Disseminated intravascular coagulation | 924 | ||
| Pathophysiology | 924 | ||
| Assessment | 925 | ||
| Goal of system assessment | 925 | ||
| risk factors | 927 | ||
| Vital signs | 927 | ||
| observation | 927 | ||
| Palpation | 927 | ||
| Auscultation | 927 | ||
| Collaborative management: Disseminated intravascular coagulation | 929 | ||
| Care priorities | 929 | ||
| 1. Treat the primary cause of the disease | 929 | ||
| 2. Manage abnormal clotting with continuous IV heparin therapy | 929 | ||
| 3. Manage abnormal bleeding resulting from fibrinolysis with antifibrinolytics | 929 | ||
| 4. Consider use of thrombolytic agents for abnormal clotting | 929 | ||
| 5. Provide replacement of necessary blood components | 929 | ||
| 6. Supplement vitamin k1 (phytonadione) and folate | 930 | ||
| 7. Prevent viral infections resulting from immunosuppression with protease inhibitors | 930 | ||
| 8. Manage hypotension related to heart failure, as appropriate | 930 | ||
| Care plans: Disseminated intravascular coagulation | 930 | ||
| Ineffective tissue perfusion (or risk for same) | 933 | ||
| Additional nursing diagnoses | 935 | ||
| Selected references | 935 | ||
| 11 Complex special situations | 937 | ||
| Abdominal hypertension and abdominal compartment syndrome | 937 | ||
| Pathophysiology | 937 | ||
| Risk factors | 937 | ||
| Definitions | 937 | ||
| Assessment | 939 | ||
| Goal of system assessment | 939 | ||
| History and risk factors | 939 | ||
| Vital signs and other values | 940 | ||
| The following values may be increased | 940 | ||
| The following may be decreased | 940 | ||
| Observation | 940 | ||
| Diagnostic tests | 941 | ||
| Methods of intraabdominal pressure measurement | 941 | ||
| Direct intraperitoneal measurement | 941 | ||
| Indirect methods | 941 | ||
| Collaborative management | 942 | ||
| Care priorities | 942 | ||
| 1. Prevent abdominal compartment syndrome | 942 | ||
| 2. Perform a decompressive laparotomy to relieve abdominal compartment syndrome | 943 | ||
| Care plans for abdominal compartment syndrome and intraabdominal hypertension | 943 | ||
| Additional nursing diagnoses | 945 | ||
| Drug overdose | 945 | ||
| Overview/epidemiology | 945 | ||
| Ingestion of unknown substances | 945 | ||
| Assessment | 946 | ||
| General treatment options: Gastric decontamination | 946 | ||
| Activated charcoal | 946 | ||
| Gastric lavage | 946 | ||
| Whole bowel irrigation | 946 | ||
| General treatment options: Extracorporeal removal of toxins | 947 | ||
| Illicit and prescription drugs commonly seen in overdose situations | 947 | ||
| Acetaminophen | 947 | ||
| Routes of administration | 947 | ||
| Effects on body systems | 947 | ||
| Collaborative management | 947 | ||
| Care priorities | 947 | ||
| Alcohols | 948 | ||
| Ethanol | 948 | ||
| Route of administration | 948 | ||
| Effects on body systems | 948 | ||
| Collaborative management | 948 | ||
| Care priorities | 948 | ||
| Methanol and ethylene glycol | 949 | ||
| Route of administration | 949 | ||
| Effects on body systems | 949 | ||
| Collaborative management | 949 | ||
| Aspirin and other salicylates | 949 | ||
| Routes of administration | 950 | ||
| Effects on body systems | 950 | ||
| Collaborative management | 950 | ||
| Care priorities | 950 | ||
| Barbiturates | 951 | ||
| Common agents: See table 11-2. | 951 | ||
| Street names | 951 | ||
| Routes of administration | 951 | ||
| Effects on body systems | 951 | ||
| Collaborative management | 951 | ||
| Care priorities | 951 | ||
| Benzodiazepines | 952 | ||
| Common agents | 952 | ||
| Street names | 952 | ||
| Routes of administration | 952 | ||
| Effects on body systems | 952 | ||
| Collaborative management | 952 | ||
| Care priorities | 952 | ||
| Beta blockers | 953 | ||
| APPENDIX 1 Heart and breath sounds | 1029 | ||
| APPENDIX 2 Glasgow coma scale | 1034 | ||
| APPENDIX 3 Cranial nerves: Assessment and dysfunctions | 1035 | ||
| APPENDIX 4 Major deep tendon (muscle-stretch) reflexes | 1037 | ||
| APPENDIX 5 Major superficial (cutaneous) reflexes | 1038 | ||
| APPENDIX 6 Inotropic and vasoactive medication infusions | 1039 | ||
| APPENDIX 7 Sample relaxation technique | 1041 | ||
| APPENDIX 8 Abbreviations used in this manual | 1042 | ||
| Index | 1046 | ||
| A | 1046 | ||
| B | 1050 | ||
| C | 1051 | ||
| D | 1056 | ||
| E | 1058 | ||
| F | 1060 | ||
| G | 1061 | ||
| H | 1062 | ||
| I | 1067 | ||
| J | 1068 | ||
| K | 1069 | ||
| L | 1069 | ||
| M | 1069 | ||
| N | 1072 | ||
| O | 1073 | ||
| P | 1074 | ||
| Q | 1079 | ||
| R | 1079 | ||
| S | 1081 | ||
| T | 1084 | ||
| U | 1086 | ||
| V | 1086 | ||
| W | 1088 | ||
| Z | 1089 | ||
| Ibc | ibc |