Menu Expand
AACN Advanced Critical Care Nursing - E-Book Version to be sold via e-commerce site

AACN Advanced Critical Care Nursing - E-Book Version to be sold via e-commerce site

Karen K. Carlson

(2008)

Additional Information

Book Details

Abstract

From AACN experts comes a resource dedicated to helping you oversee or care for critical care patients in any practice setting. This comprehensive critical care nursing textbook addresses serious and potentially life-threatening patient conditions with a foundation rooted in the critical thinking process: the comprehension, analysis, synthesis, and application of knowledge.

  • Endorsed by the American Association of Critical-Care Nurses (AACN), the largest specialty nursing organization in the United States, for the most authoritative coverage available.
  • Thorough discussions of each body system emphasize advanced concepts, presenting physiology in an application format that examines the clinical implications of physiological science.
  • Coverage of assessment focuses on interpreting abnormal findings and linking those findings to diagnosis and intervention.
  • Appropriate interventions are discussed from an interdisciplinary, evidence-based perspective.
  • Hundreds of new, full-color illustrations and design clarify important concepts and improve the book's usability.
  • Complex, unfolding case studies are presented in all disease chapters, accompanied by review questions with a comprehensive answer key.
  • Multidisciplinary Plans of Care provide at-a-glance information for common ICU conditions.
  • Nutrition boxes appear in each relevant chapter, offering guidelines for patient needs with specific illnesses.
  • Research-Based Practice Guidelines boxes and Promoting Evidence-Based Practice features appear throughout the text whenever applicable to present the latest research-supported nursing assessment and intervention practices.
  • Drug boxes include common classifications of critical care drugs for specific disorders, including drug, actions, dosage, and special considerations.
  • Applying the Technology features help you apply the latest technology to patient care.
  • NIC Interventions boxes list NIC intervention labels appropriate for the conditions discussed in a chapter.

Table of Contents

Section Title Page Action Price
Front Cover Cover
AACN Advanced Critical Care Nursing iii
Copyright Page iv
Dedication Page v
Section Editors ix
Contributors x
Reviewers xiii
Preface xvii
Introduction xvii
Organization xvii
Special Features xvii
Full-Color Illustrations xviii
Evolve xviii
Acknowledgments xx
Contents xxi
Unit 1: Practice in Today's Critical Care Environment 1
Chapter 1: The Critical Care Environment 3
Synergy Model Overview 4
Healthy Work Environment Standards 4
Skilled Communication 5
True Collaboration 11
Effective Decision Making 12
Appropriate Staffing 14
Meaningful Recognition 16
Authentic Leadership 17
Conclusions 19
References 19
Chapter 2: Alternative Settings for Critical Care 22
Moving Critical Care Beyond Traditional Critical Care 22
The Patient's Journey to Progressive Care 23
Progressive Care in the Hospital Setting 24
Out-of-Hospital Venues 29
Skilled Nursing Facilities/Long Term Care Facilities 29
Ambulatory Settings 30
Home Care 30
Conclusions 31
References 32
Chapter 3: Comorbid Conditions 33
Critical Care Predictive Scoring Systems 33
Scoring Systems Defined 33
Comorbidities Within the Scoring Systems 33
Additional Scoring Systems and Their Identified Comorbidities 34
Impact of Comorbidities on Length of Stay and Treatment 34
Comorbidities Used in Scoring Systems 35
Metastatic Cancer/Hematologic Malignancy 35
HIV, AIDS, and Immunosuppression 36
Hepatic Failure and Cirrhosis 36
Renal Insufficiency and End-Stage Renal Disease 37
Other Comorbidities as Predictors of Outcome 37
Respiratory Conditions 37
Cardiovascular Disease 38
Diabetes Mellitus 39
Age 39
Obesity 40
Social and Psychological Comorbidities 40
Care of Patients with Multiple Comorbidities 40
Conclusions 40
References 41
Chapter 4: Pain and Sedation 44
Patients at Risk 44
Acute Versus Chronic Pain 46
Peripheral Versus Central Pain 47
Pain Theory 47
Nociception and Inflammation 47
Response to Pain 48
Stress Response Theory 49
Guidelines Proposed by the Joint Commission on Accreditation of Healthcare Organizations 50
Measuring and Assessing Pain 52
Management of Pain and Discomfort 58
Nonpharmacologic Interventions 58
Pharmacologic Interventions 63
Recognizing and Managing Opioid Side Effects 68
Co-Analgesics 70
Assessment and Management of Sedation 70
Sedating Agents 77
Neuromuscular Blockade 79
Conclusions 83
References 84
Unit 2: Elements of Care 89
Chapter 5: Symptom Management 91
Patients at Risk 91
Nausea and Vomiting 91
Pathophysiology of Nausea and Vomiting 93
Causes Involving the Bowel 93
Causes Involving Toxins 93
Specific Causes 93
Assessment and Treatment 95
Diarrhea 100
Definition 100
Types of Diarrhea 100
Osmotic Diarrhea 100
Malabsorption Diarrhea 100
Secretory Diarrhea 102
Infectious Diarrhea 102
Exudative and Hypermotile Diarrhea 102
Diarrhea as a Side Effect of Medications 103
Diarrhea as the Result of Disease 103
Management 103
Dyspnea 104
Definition 104
Types of Dyspnea 104
Assessment and Management 105
Delirium 106
Definition 106
Types of Delirium 106
Assessment and Management 107
Multidisciplinary Plan of Care 109
Conclusions 109
References 109
Chapter 6: Nutrition 111
Normal and Altered Metabolism 111
Carbohydrate Metabolism 111
Protein Metabolism 111
Lipid Metabolism 112
The Metabolic Response 112
Nutrition Support 114
Total Parenteral Nutrition 114
Enteral Nutrition 116
Nutrition Assessment 119
Indirect Calorimetry 120
Predictive Equations 120
Obesity 121
Overfeeding 122
Protein Needs 122
Serum Proteins 122
Micronutrients 124
Antioxidants and Critical Illness 124
Wound Healing 125
Immunonutrition 126
Multidisciplinary Care 127
Conclusions 127
References 127
Chapter 7: Thermoregulation 130
Physiology of Thermoregulation 130
Fever 131
Definition 131
Patients at Risk 132
Pathophysiology 132
Fever Management 134
Hypothermia 136
Patients at Risk 136
Definition 137
Pathophysiology 137
Multidisciplinary Plan of Care 137
Hyperthermia 140
Patients at Risk 140
Definition 141
Pathophysiology 141
Multidisciplinary Plan of Care 142
Conclusions 143
References 143
Chapter 8: Families in Critical Care 145
Theoretical Foundations for Family-Centered Critical Care 146
Chaos/Complexity Theory 146
Theory of Human Relatedness 146
Family Systems Theory 147
Role Theories 147
Crisis Theory 150
Maslow's Theory of the Hierarchy of Needs 150
Evidence-Based Care for Families of the Critically Ill 151
Family Needs 151
Family Presence 152
Family-Centered Interventions and Outcomes 152
Implementing Family-Centered Critical Care 153
Unit and Organizational Assessment 153
Strategies and Tools for Implementing Family-Centered Care 154
Evaluation of Outcomes 155
Conclusions 156
References 157
Chapter 9: Improving Outcomes Through Prophylaxis 158
Rapid Response Teams 158
Venous Thromboembolism 159
Stress-Related Erosive Syndrome 161
Bloodstream Infection Related to Central Lines 162
Ventilator-Associated Pneumonia 164
Definition 164
Patient Outcomes of VAP 165
Ventilator Bundle of Care 165
Conclusions 167
References 167
Unit 3: Cardiac 171
Chapter 10: Advanced Dysrhythmias 173
The Cardiac Action Potential 173
Normal Cardiac Cell Function 173
Action Potential of Ventricular Muscle Cells 173
Action Potential of Pacemaker Cells 174
Ionic Channels and Pumps 174
Implications for Patient Care 175
Dysrhythmogenic Mechanisms 176
Alterations in Impulse Formation 176
Alterations in Impulse Conduction 183
Supraventricular Tachycardias 184
Wolff-Parkinson-White Syndrome 184
Atrioventricular Nodal Reentry Tachycardia 185
AV Reciprocating Tachycardia 187
Clinical Presentation of AVNRT and AVRT 188
Management of AVNRT and AVRT 188
Ventricular Tachycardias 189
Monomorphic Ventricular Tachycardia 189
Polymorphic Ventricular Tachycardia 190
Disorders of Repolarization 192
The QT Interval 192
Long QT Syndrome 192
Brugada Syndrome 194
Aberrancy Versus Ectopy 195
Mechanisms of Aberrancy 195
General Principles of Diagnosis 195
Digitalis Toxicity 196
Digitalis Dysrhythmias 196
Management of Digitalis Dysrhythmias 199
Atrial Fibrillation 199
Electrophysiologic Features 199
Management of Atrial Fibrillation 200
Heart Rate Variability 202
Measurement 202
Clinical Significance 202
Monitoring in Critical Care 202
Accurate Lead Placement 202
Choosing a Monitoring Lead 202
Conclusions 203
References 203
Chapter 11: Acute Coronary Syndromes 207
Pathophysiology 207
Patients At Risk 209
Classic (Stable) Angina 210
Physical Assessment 210
Laboratory Tests 210
Other Diagnostic Tests 211
Unstable Angina and Non-St Segment Elevation Myocardial Infarction 212
Multidisciplinary Plan of Care 213
Anti-Ischemic Nursing Interventions and Bedside Monitoring 213
Anti-Ischemic Medication Therapy 216
Antiplatelet and Anticoagulation Therapy 219
Preventive Nursing Interventions 221
Revascularization Therapy 222
Nursing Interventions for Patients Treated With Percutaneous Coronary Interventions 223
St Segment Elevation Myocardial Infarction 226
Physical and Laboratory Assessment 226
Other Diagnostic Tests 226
Reperfusion Therapy 226
Pharmacologic Reperfusion Therapy 227
Interventional Reperfusion Therapy 229
Complications of STEMI 229
Emergency Interventions 231
Prevention of Coronary Artery Disease 233
Lipid Management 233
Smoking Cessation 233
Blood Pressure Control 234
General Preventive Interventions 234
Conclusions 234
References 234
Chapter 12: Heart Failure 237
Prevention of Acute Decompensated Heart Failure 237
Definition 237
Pathophysiology of Heart Failure 238
Pathophysiology of Acute Decompensation in the Setting of Chronic Heart Failure 245
Stages and Types of Heart Failure 245
Patients at Risk 247
Assessment 249
Multidisciplinary Plan of Care 252
Pharmacologic Therapy: Acute Management 254
Diuretics 257
Vasodilators 257
Inotropic Agents 258
Other Vasoactive Agents 259
Device Therapy 259
Managing Comorbidities 261
Assessing Stability for Hospital Discharge 262
Pharmacologic Therapy: Chronic Management 262
Nonpharmacologic Therapy 263
Heart Failure Disease Management 266
Conclusions 270
References 270
Chapter 13: Heart Disease in Women 276
Primary Prevention 276
Assess Risk 277
Lower Risk With Lifestyle Changes 279
Other Risk-Reducing Interventions 280
Highest Risk Priority Interventions 281
Avoid Unhelpful Interventions 281
Depression 282
Applied Pathophysiology 285
Vessel Size 285
Plaque 285
Endothelial Integrity 285
Lipids, Apolipoproteins, and Lipoproteins 286
Hormones 286
Presentation 286
Angina With \"Normal\" Coronary Arteries 287
Assessment 287
Interventions 289
Medications 290
Hormone Replacement Therapy 291
Percutaneous Coronary Interventions 291
Coronary Artery Bypass Surgery 292
Conclusions 292
References 292
Chapter 14: Cardiac Surgery 297
Coronary Artery Bypass Grafting 297
Indications 297
Selection of Conduits 297
Surgical Procedure 299
Cardiopulmonary Bypass 300
Off-Pump\" Surgery 301
Transmyocardial Revascularization 302
Indications 303
Unit 4: Pulmonary 445
Chapter 19: Acute Respiratory Failure and Acute Lung Injury 447
Definition 447
Mechanism of Hypoxemic Acute Respiratory Failure 447
Ventilation/Perfusion Mismatching 447
Intrapulmonary Shunt 447
Alveolar Hypoventilation 448
Impaired Diffusion 448
Low Partial Pressure of Inspired Oxygen 449
Mechanisms of Hypercapnic Acute Respiratory Failure 449
Acute Lung Injury/Acute Respiratory Distress Syndrome 453
Epidemiology and Risk of Acuteā€¢Lung Injury/Acute Respiratory Distress Syndrome 453
Pathophysiology of Acute Lung Injury/Acute Respiratory Distress Syndrome 454
Physical Assessment Findings 456
Diagnostic Evaluations 457
Laboratory and Microbiology Studies 458
Multidisciplinary Plan of Care 458
Mechanical Ventilation 458
Positive End-Expiratory Pressure 461
Permissive Hypercapnia 461
Inverse Ratio Ventilation 461
Recruitment Maneuvers 461
High-Frequency Oscillatory Ventilation 461
Inhaled Nitric Oxide 461
Liquid Ventilation 462
Other Interventions 462
Noninvasive Positive Pressure Ventilation 462
Prone Positioning 462
Medication/Fluid Use in ALI/ARDS 463
Resolution of Acute Lung Injury and Acute Respiratory Distress Syndrome 465
Conclusions 466
References 466
Chapter 20: Mechanical Ventilation and \nWeaning 469
Volume Versus Pressure Modes 469
Characteristics of Volume Ventilation 469
Characteristics of Pressure Ventilation 470
Volume Versus Pressure Modes: the Science 471
Ventilating the Noncompliant Lung 471
Ventilating Patients With Severe Airflow Limitation 472
Permissive Hypercarbia 473
Ventilator Parameters 473
Invasive Modes of Ventilation 473
Volume Modes 473
Pressure Modes 475
Volume-Guaranteed Pressure Modes 475
High-Frequency Oscillation 477
Noninvasive Ventilator Modes 477
CPAP 477
BiPAP 477
Respiratory Waveform Monitoring 478
Pressure-Time and Flow-Time Waveforms 478
Pressure-Volume Loops 480
Flow-Volume Loops 481
Additional Uses of Respiratory Waveforms 481
Weaning from Mechanical Ventilation 481
Assessment 483
Respiratory Muscle Fatigue, Rest, Work, and Conditioning 484
Modes and Methods 486
Components of Weaning Protocols 486
Criteria for Entry (\"Wean Screen\") 486
Timing of Tracheostomy and Weaning Trials 488
Multidisciplinary Plan of Care 488
Conclusions 489
References 489
Chapter 21: Thoracic Surgery 493
Thoracic Surgeries 493
Pulmonary Resection 493
Indications 493
Diagnostic Evaluation 494
Preoperative Evaluation 495
Approaches and Procedures 496
Wedge Resection 496
Segmentectomy 500
Lobectomy 500
Pneumonectomy 501
Pleural Surgery 503
Problems of the Pleural Space 504
Pleural Space Procedures 505
Mediastinal Disease 506
Diaphragmatic Surgery 506
Diaphragmatic Abnormalities 507
Chest Wall Disorders 507
Complications of Thoracic Surgery 507
Intraoperative 507
Postoperative 508
Pulmonary Complications 508
Cardiac Complications 511
Neurologic Complications 511
Other Complications 511
Multidisciplinary Care 512
Principles of Care 512
Preoperative Preparation 512
Intraoperative Management 513
Chest Drainage Management 513
Pain Management 514
Nutrition 514
Mechanical Ventilation 517
Respiratory Care 517
Mobilization 517
Critical Pathway 517
Esophageal Surgeries 519
Esophageal Disease 519
Esophageal Cancer 519
Diagnosis 520
Esophageal Resection Procedures 520
Preoperative Evaluation 520
Preoperative Preparation 522
Postoperative Care 522
Complications Related to Esophageal Surgery 523
Other Esophageal Surgery 524
Conclusions 524
References 524
Unit 5: Nervous System 527
Chapter 22: Head Injury and Dysfunction 529
Applied Physiology 529
Cerebral Hemodynamics 530
Mechanism of Injury 531
Types of Traumatic Brain Injury 533
Focal Injuries 533
Skull Fractures 533
Contusions 535
Hematomas 536
Diffuse Injuries 538
Pathophysiology 539
Ischemia 539
Impaired Metabolism 540
Inflammatory Factors 541
Types of Cerebral Edema 542
Intracranial Pressure and Cerebral Perfusion 544
Herniation 545
Multidisciplinary Plan of Care for the Traumatic Brain Injury Patient 546
Prehospital Phase 546
Early Hospital Management 546
Continued Critical Care Management 547
Rehabilitation 548
Monitoring 548
Intracranial Pressure Monitoring 548
Neuroimaging 549
Cerebral Oxygen Monitoring 552
Microdialysis 553
Continuous Electroencephalography 553
Treatment of Traumatic Brain Injury 555
Management of Hypoxia and Hypotension 555
Management of Intracranial Pressure 555
First-Level Approaches for Intracranial Pressure Management 556
Second-Level Approaches for Intracranial Pressure Management 559
Strategies for Neuroprotection 562
Complications After Traumatic Brain Injury 562
Immunosuppression 562
Coagulopathy 562
Electrolyte Disturbances 562
Volume Depletion 564
Metabolic Response 565
Infectious Complications 565
Pulmonary Complications 567
Complications Related to Immobility 567
Seizures 567
Other Medications Used for Traumatic Brain Injury 568
Lidocaine 568
Furosemide 568
Steroids 568
Outcomes 569
Conclusions 569
References 570
Chapter 23: Cerebrovascular Disorders 576
Patients At Risk 576
Stroke Across the Life Continuum 577
Prevention 578
Definition 578
Pathophysiology 580
Ischemic Stroke 580
Subarachnoid Hemorrhage 582
Intracerebral Hemorrhage 586
Assessment 589
Laboratory Findings 590
Radiographic Findings 593
Management 599
Initial Management 599
Critical Care Management 599
Ischemic Stroke 615
Subarachnoid Hemorrhage 619
Intracerebral Hemorrhage 626
Evidence-Based Care 627
Ethical Considerations 628
Conclusions 628
References 628
Chapter 24: Spinal Cord Injury 637
Patients at Risk 637
Prevention 637
Definition 637
Applied Pathophysiology 641
Assessment 650
Management 656
Critical Care Management 660
Neurologic 661
Pulmonary 666
Cardiac 668
Gastrointestinal 668
Genitourinary 670
Endocrine 671
Musculoskeletal 671
Integumentary 673
Pain 673
Psychosocial 673
Evidence-Based Care 675
Research 675
Outcomes 675
Ethical Considerations 677
Conclusions 677
References 678
Chapter 25: Special Neurologic Patient Populations 681
Neurodiagnostic Testing 681
Computed Tomography Scan 681
Computed Tomography Angiography 687
Magnetic Resonance Scan 688
Cerebral Angiogram 688
Positron Emission Tomography Scan 688
Single Photon Emission Computed Tomography Scan 688
Electroencephalogram 688
Electromyography, Nerve Conduction Studies, and Neuromuscular Junction Studies 689
Evoked Potentials 689
Seizure Disorders 689
Status Epilepticus 689
Other Seizure-Related Admissions to Critical Care 695
Brain Tumors 696
Incidence and Classification 697
Clinical Presentation and Diagnosis 697
Management and Treatment 700
Infections of the Central Nervous System 705
Meningitis 705
Encephalitis 708
Brain Abscess 708
Neurocysticercosis 710
Creutzfeldt-Jakob Disease 712
Ventriculostomy-Related Infections 714
Neuromuscular Disorders 715
Myasthenia Gravis 715
Guillain-Barreacute Syndrome 717
Critical Illness Polyneuropathy/Myopathy 720
Therapeutic Hypothermia After Cardiac Arrest 721
Determination of Death by Neurologic Criteria 722
Multidisciplinary Plan of Care 727
Conclusions 727
References 727
Unit 6: Gastrointestinal 735
Chapter 26: Gastrointestinal Bleeding 737
Applied Physiology and Pathophysiology 737
Prevention 741
Assessment 743
Physical Assessment Findings 743
Laboratory Findings 745
Radiology Findings 746
Diagnostic Evaluations 746
Multidisciplinary Plan of Care 747
Conclusions 751
References 751
Chapter 27: Liver Dysfunction and Failure 754
Acute Liver Failure 754
Acute-On-Chronic Liver Dysfunction and Failure 754
Applied Physiology 755
Cirrhosis 756
Hepatic Encephalopathy 759
Multidisciplinary Plan of Care 768
Referral/Listing for Liver Transplantation 769
Liver Support Devices 770
Conclusions 771
References 771
Chapter 28: Pancreatitis 774
Definition 774
Patients at Risk 774
Applied Physiology 776
Assessment of Severity and Early Risk Stratification 778
Laboratory Findings 779
Radiology Findings 780
Complications of Acute Pancreatitis 781
Cardiopulmonary Complications 781
Pulmonary Complications 782
Renal Complications 782
Gastrointestinal Complications 782
Hematologic and Coagulation Derangements 782
Multiple Organ Dysfunction Syndrome 782
Local and Systemic Infectious Complications 783
Multidisciplinary Plan of Care 783
Conclusions 790
References 790
Chapter 29: The Gut in Critical Illness 792
Normal Gastrointestinal Physiology 792
Alterations to Normal Gastrointestinal Physiology in Critical Illness 792
Gastrointestinal Mucosal Hypoperfusion 792
Gastric Tonometry 796
Historical Development 796
Principles of Gastric Tonometry 796
Physiologic Underpinnings of Gastric Tonometry 796
Physiologic Influences on the Measurement of Carbon Dioxide Within the Tonometer Balloon 797
Clinical Evaluation of Tonometrically Derived Measurements 797
Technical Limitations of Gastric Tonometry 800
Procedural Errors 800
Semi-Continuous Measurement of Ptco2 800
Stress-Related Mucosal Disease in Critically Ill Patients 802
Prevalence 802
Pathophysiology 802
Risk Factors 803
Stress-Related Mucosal Disease: Prophylaxis 803
Antacids 805
Histamine-2 Receptor Antagonists 805
Proton Pump Inhibitors 805
Sucralfate 806
Enteral Nutrition 806
Abdominal Compartment Syndrome 806
Etiology 806
Pathophysiology 806
Measurement of Intra-Abdominal Pressure 807
Management of Abdominal Compartment Syndrome 810
Multidisciplinary Plan of Care 812
References 814
Chapter 30: Liver, Kidney, and Pancreas Transplantation 818
Liver Recipient Before Transplant 818
Liver Transplantation 819
Types of Liver Donors 819
Preoperative Care 820
Postoperative Care 820
Primary Graft Nonfunction 820
Assessment of the Liver Transplant Patient 827
Liver and Kidney Transplantation 828
Multidisciplinary Plan of Care 828
Conclusions 832
Renal Transplantation 832
Patients at Risk 832
Postoperative Care 832
Kidney-Pancreas or Pancreas-Only Transplantation 834
Patients at Risk 834
Postoperative Complications 835
Assessment 836
Multidisciplinary Plan of Care 836
Hospitalizations for Nontransplant Concerns 836
Conclusions 836
References 836
Unit 7: Renal 839
Chapter 31: Electrolyte Emergencies 841
Applied Physiology 841
Multidisciplinary Plan of Care 842
Potassium 842
Applied Physiology 842
Hyperkalemia 843
Hypokalemia 846
Sodium 849
Applied Physiology and Pathophysiology 849
Hypernatremia 850
Hyponatremia 851
Calcium 854
Applied Physiology and Pathophysiology 854
Hypercalcemia 856
Hypocalcemia 857
Magnesium 859
Applied Physiology and Pathophysiology 859
Hypermagnesemia 859
Hypomagnesemia 860
Phosphorus 861
Applied Physiology and Pathophysiology 861
Hyperphosphatemia 861
Hypophosphatemia 862
Conclusions 863
References 863
Chapter 32: Complex Acid-Base Disorders and Associated Electrolyte Imbalances 865
Patients At Risk 865
Acid-Base Physiology 865
Definitions and Normal Values 865
Understanding Compensation 866
Application of Acid-Base Principles 866
The Anion Gap 867
Primary Acid-Base Disorders 869
Metabolic Acidosis 869
Causes of Metabolic Acidosis 870
Manifestations of Metabolic Acidosis 871
Electrolyte Imbalances Associated With Metabolic Acidosis 872
Treatment of Metabolic Acidosis 872
Metabolic Alkalosis 876
Causes of Metabolic Alkalosis 876
Manifestations of Metabolic Alkalosis 877
Electrolyte Imbalances Associated With Metabolic Alkalosis 877
Treatment of Metabolic Alkalosis 879
Respiratory Acidosis 880
Causes of Respiratory Acidosis 880
Manifestations of Respiratory Acidosis 880
Treatment of Respiratory Acidosis 880
Respiratory Alkalosis 881
Causes of Respiratory Alkalosis 881
Manifestations of Respiratory Alkalosis 882
Treatment of Respiratory Alkalosis 882
Mixed Acid-Base Disorders 882
Conclusions 884
References 884
Chapter 33: Acute Renal Failure 886
Prevention of Renal Failure 886
Definition 887
Applied Pathophysiology 888
Types of Renal Failure 888
Prerenal Renal Failure 889
Intrarenal Renal Failure 891
Postrenal Renal Failure 892
Assessment 892
Uremic Complications 893
Cardiovascular Manifestations 893
Respiratory Manifestations 894
Hematologic Manifestations 894
Gastrointestinal Manifestations 894
Neurologic Manifestations 895
Interventions 895
Fluid Balance 895
Alterations in Electrolyte Balance 901
Metabolic Acidosis 901
Renal Replacement 901
Peritoneal Dialysis 901
Hemodialysis 902
Continuous Renal Replacement Therapies 903
Nutrition in Acute Renal Failure with Renal Replacement Therapy 909
Multidisciplinary Plan of Care 910
Conclusions 911
References 911
Unit 8: Endocrine 913
Chapter 34: Glycemic Control 915
Patients At Risk 916
Definition 916
Classification of Diabetes Mellitus 917
Physiology of Glucose Metabolism 917
Functions of the Pancreatic Hormones 919
Pathophysiology of Diabetes Mellitus and Hyperglycemia 920
Acute Complications of Diabetes Mellitus 921
Diabetic Ketoacidosis 921
Causes or Precipitating Factors of Diabetic Ketoacidosis 921
Hyperosmolar Hyperglycemic Nonketotic Syndrome 926
Hypoglycemia 932
Hyperglycemia 933
References 937
Chapter 35: Pituitary, Thyroid, and Adrenal Disorders 939
Applied Pathophysiology 939
Disorders of Antidiuretic Hormone 942
Diabetes Insipidus 942
Syndrome of Inappropriate Antidiuretic Hormone 946
Thyroid Gland Disorders 950
Hyperthyroidism (Thyrotoxicosis/Thyroid Storm) 950
Hypothyroidism and Myxedema Coma 956
Adrenal Insuffiency in Critical Illness 957
Definition of Adrenal Insufficiency 957
References 964
Unit 9: Hematologic 967
Chapter 36: Blood Conservation and Blood Component Replacement 969
Controversies in Transfusion 969
Blood Conservation 970
Increasing Erythropoiesis 971
Minimizing Perioperative and Iatrogenic Blood Loss 971
Optimizing Hemostasis and Blood Transfusion Practices 971
Alternatives To Transfusion 971
Recombinant Human Erythropoietin 971
Vitamin K 971
Recombinant Activated Factor VIIa 971
Blood Component Review 975
Whole Blood 976
Red Blood Cells 977
Fresh Frozen Plasma 977
Thawed Plasma 978
Cryoprecipitate 978
Platelets 978
Apheresis Platelets 979
Pooled Platelets 979
Granulocytes 979
Blood Component Modification 980
Leukocyte Reduction 980
Plasma Volume Reduction 981
Cytomegalovirus-Negative Components 981
Gamma Irradiation 981
Artificial Red Blood Cell Substitutes (Modified Hgb Blood Substitutes, Perfluorochemicals) 981
Hemoglobin-Based Oxygen Carriers 981
Perfluorochemicals 981
Considerations in Blood Transfusion 981
ABO/Rh Compatibility 981
Rhesus (Rh) System 982
Autologous Transfusion 982
Preoperative Autologous Donation 982
Perioperative Blood Salvage 982
Acute Normovolemic Hemodilution 982
Postoperative Blood Collection 983
Directed Donor Transfusion 983
Massive Transfusions 983
Use of Blood Warmers 983
Adverse Effects Related To Transfusion of Blood Components 984
Transfusion-Related Acute Bacteremia/Bacterial Contamination 985
Transfusion-Associated Graft-Versus-Host Disease 985
Delayed Hemolytic Transfusion Reaction 985
Febrile Nonhemolytic Transfusion Reaction 985
Allergic Transfusion Reactions 988
Nonimmune-Related Hemolysis Transfusion Reaction 988
Acute Hemolytic Transfusion Reaction 989
Other Blood-Related Issues 991
Red Blood Cell Storage Lesion 991
2,3-Diphosphoglyceric Acid and Adenosine Triphosphate 991
Red Blood Cell Deformability 991
Red Blood Cell Adhesion 991
Transfusion-Related Immune Modulation 991
Transfusion-Related Acute Lung Injury 991
Post-Transfusion Purpura 992
Disease Transmission 993
Conclusions 993
References 993
Chapter 37: Coagulopathies 995
Normal Hemostasis and the Pathways to a Clot 995
Disseminated Intravascular Coagulation 998
Pathophysiology of DIC 998
Clinical Manifestations of DIC 1001
Laboratory Features of DIC 1001
Management of DIC 1002
Postoperative Coagulopathy 1004
Bleeding Resulting from Anticoagulation 1005
Platelet Inhibitors 1007
Warfarin 1008
Heparin 1008
Direct Thrombin Inhibitors 1009
Inhibitors of Factor Xa 1010
Thrombolytic Agents 1010
Thrombocytopenia 1010
Heparin-Induced Thrombocytopenia 1010
Pathologic Fibrinolysis 1011
Vitamin K Deficiency 1011
Bleeding Associated With Liver Disease 1011
Bleeding Associated with Uremia 1012
Bleeding Associated with Head Injury 1012
Circulating Inhibitors of Coagulation 1012
Thrombotic Disorders 1012
Deep Venous Thrombosis 1013
Pulmonary Emboli 1013
Multidisciplinary Plan of Care 1013
Conclusions 1017
References 1017
Unit 10: Critical Care Immunology 1019
Chapter 38: Caring for the Immunocompromised Patient 1021
Definitions 1021
Patients at Risk 1022
Assessment 1027
Physical Findings 1027
Diagnostic Test Results 1027
Multidisciplinary Plan of Care 1030
Prevention of Infection 1030
Enhancement of Immune Function 1036
Treatment of Infection 1038
Conclusions 1040
References 1040
Chapter 39: Bone Marrow Transplantation 1042
Autologous Stem Cell Transplantation 1042
Allogeneic Stem Cell Transplantation 1042
Pretransplant Considerations 1043
Recipient Evaluation and Preparation 1043
Conditioning Regimen 1045
Donor Evaluation 1046
Stem Cell Harvesting, Mobilization, and Collection 1047
Transplantation and Engraftment 1048
Psychosocial Implications 1049
Complications of Transplant 1053
Graft-Versus-Host Disease 1053
Infection 1056
Anemia 1058
Thrombocytopenia 1058
Mucositis 1058
Nutritional Issues 1059
Veno-Occlusive Disease of the Liver 1060
Pulmonary Complications 1060
Relapse of Primary Disease 1061
Conclusions 1061
References 1061
Unit 11: Multisystem Disorders 1065
Chapter 40: Shock and End Points of Resuscitation 1067
Applied Physiology of Cellular Metabolism 1067
Oxygen Delivery, Consumption, and Extraction 1067
Oxygen Consumption 1068
Oxygen Delivery Dependence and Oxygen DEBT 1068
Classifications of Shock 1070
Hypovolemic Shock 1070
Obstructive Shock 1070
Cardiogenic Shock 1071
Vasogenic Shock 1071
Neurogenic Shock 1071
Septic Shock 1071
Anaphylactic Shock 1072
General Phases of Shock 1072
Compensatory Phase 1073
Decompensated Phase 1073
Irreversible Shock Phase 1074
Resuscitation Measures in Shock 1074
Initial Evaluation 1074
Fluid Resuscitation 1075
Colloid Solutions 1076
Nutritional Support in Shock 1077
End Points of Resuscitation 1078
Blood Pressure 1079
Urine Output 1080
Serum Lactate Levels 1080
Arterial Base Deficit 1080
Monitoring Technology 1081
Oxygen Monitoring 1081
Mixed Venous Oxygen Saturation 1082
Hemodynamic Indices 1082
Preload 1083
Right Ventricular End-Diastolic Volume Index 1083
Afterload 1084
Contractility 1084
End-Tidal Carbon Dioxide 1085
Regional Resuscitation End Points 1086
Intramucosal pH 1086
Sublingual Capnometry 1087
Near-Infrared Spectroscopy 1088
Multidisciplinary Plan of Care 1088
Complications of Shock 1094
Conclusions 1095
References 1096
Chapter 41: Optimizing Hemodynamics: Strategies for Fluid and Medication Titration in Shock 1099
Hypoperfusion States and Systemic Responses 1099
The Truth about Blood Pressure 1100
Identifying and Interpreting Hemodynamic Measures 1103
Arterial Blood Pressure 1104
Preload Measures 1104
Afterload Measures 1105
Contractility Measures 1105
Overall Cardiovascular Performance and Perfusion Indicators 1107
Putting It Together: Differentiating Shock States 1109
Shock-Specific Therapy 1109
Hypovolemic Shock 1109
Cardiogenic Shock 1112
Vasogenic Shock 1113
Titratable Medications Used in Managing Shock 1115
Inotropic Agents 1122
Vasopressor Agents 1125
Vasodilator Agents 1126
Nursing Care of the Shock Patient 1128
Conclusions 1131
References 1131
Chapter 42: Trauma 1134
Epidemiology 1134
Development of the Trauma System 1134
Mechanisms of Injury 1134
Laws of Motion and Energy (Kinematics) 1135
Blunt Trauma 1137
Motor Vehicle Crash 1137
Other Types of Collisions 1137
Falls 1140
Blast Injuries 1140
Penetrating Trauma 1140
Gunshot Wounds 1140
Stab Wounds and Impalements 1142
Applied Pathophysiology 1142
Physiologic Responses to Shock 1142
Shock 1142
Systemic Inflammatory Response During Traumatic Shock 1143
Hypermetabolic Response to Trauma 1143
Physiologic Sequelae During Trauma Resuscitation 1144
Abdominal Compartment Syndrome 1148
Rhabdomyolysis 1148
Pathophysiology of Specific Injuries 1149
Brain and Spinal Cord Injury 1149
Facial Trauma 1149
Chest Trauma 1149
Abdominal Trauma 1151
Musculoskeletal Injuries 1152
Assessment and Intervention 1154
Primary Survey 1155
Airway 1155
Breathing 1155
Circulation 1155
Disability 1157
Secondary Survey 1157
Assessment and Intervention of Specific Injuries 1159
Early Critical Care Resuscitation 1159
Continued Resuscitation 1171
Reversing the Lethal Triad of Hypothermia, Acidosis, and Coagulopathy 1173
Managing Abdominal Compartment Syndrome 1176
Identifying, Preventing, and Managing Rhabdomyolysis 1176
Providing Analgesia and Sedation 1177
Critical Care Management of Complications Following Trauma 1177
Acute Respiratory Distress Syndrome 1177
Providing Nutritional Support 1179
Assessing and Treating Infection 1180
Preventing Deep Venous Thrombosis 1181
Providing Psychosocial Support 1183
Conclusions 1184
References 1184
Chapter 43: Systemic Inflammatory Response Syndrome and Multiple Organ Dysfunction Syndrome 1189
Definitions and Patient Identification 1189
Epidemiology 1190
Pathophysiology of Multiple Organ Dysfunction Syndrome 1190
Inflammation 1190
Activation of Coagulation 1191
Impairment of Fibrinolysis 1191
Role of the Endothelium 1193
Mechanisms of Organ Dysfunction in MODS 1193
Cardiovascular System 1193
Respiratory System 1194
Gastrointestinal System 1194
Hepatic System 1195
Renal System 1195
Neurologic System 1195
Hematologic System 1195
Assessment of Multiple Organ Dysfunction Syndrome 1196
Interventions 1198
Initial Resuscitation 1199
Management of Infection 1205
Additional Hemodynamic Support 1205
Conclusions 1210
References 1210
Chapter 44: Burns 1212
Applied Physiology 1214
Initial Assessment 1214
Burn Stress Response 1216
Sympathetic Nervous System 1216
Use of Medications to Reduce Metabolic Demands 1217
Causative Agents 1217
Thermal Burns 1217
Electrical Burns 1218
Chemical Burns 1218
Inhalation Injury 1219
Zones of Burn Wounds 1221
Depth of Burns 1222
First-Degree Burns (Superficial) 1223
Second-Degree Burns (Partial Thickness) 1224
Third-Degree Burns (Full Thickness) 1226
Fourth-Degree Burns 1226
Severity of Burns 1226
Rule of Nines 1227
Rule of Palms 1228
Lund and Browder Chart 1229
Resuscitation 1229
Fluid Resuscitation in the First 24 Hours 1229
Pediatric Resuscitation 1233
Difficult Resuscitation 1234
Fluid Resuscitation in the Second 24 Hours (Hours 24 to 48) 1234
Fluid Resuscitation in the Third 24 Hours (Hours 48 to 72) 1234
Specific Burn Injury Interventions 1235
Electrical Injury 1235
Chemical Burns 1236
Circumferential Burns 1238
Compartment Syndrome 1240
Abdominal Compartment Syndrome 1240
Specific Anatomic Burns 1242
Extremity Burns 1242
Facial Burns 1242
Burns of the Eyes 1242
Burns of the Ears 1242
Burns of the Hands and Feet 1243
Burns of the Genitalia and Perineum 1243
Other Burn Center Patients 1243
Appropriate Diagnostic Evaluations 1243
Laboratory Testing 1243
Radiologic Testing 1243
Fiberoptic Bronchoscopy 1243
Other Diagnostic Interventions 1243
Patient Transport 1244
Monitoring 1244
Hemodynamic Monitoring 1244
Indwelling Urinary Catheter 1245
Mechanical Ventilation 1245
Carboxyhemoglobin 1245
Interventions for Inhalation Injury 1245
Intravenous Fluid 1245
Analgesia 1246
Nutritional Support 1246
Wound Care 1247
Topical Antimicrobial Therapy 1249
Primary Approaches to Wound Care 1250
Surgical Excision and Grafting 1251
Vacuum-Assisted Closure 1252
Identification of Targeted/Expected Outcomes 1257
Conclusions 1258
References 1258
Chapter 45: Mass-Casualty Competencies 1261
Mass-Casualty Preparation 1265
Triage and Decontamination 1265
Personal Protective Equipment 1266
Command and Control 1266
Critical Care Unit Planning and Management 1267
Chemical-Biological-Radiologic-Nuclear Review 1269
Chemical Attack 1270
Biological Attack 1270
Nuclear and Radiologic Attacks 1279
Educational Competencies for Registered Nurses Related to Mass-Casualty Incidents 1280
Conclusions 1280
References 1284
Unit 12: Special Patient Populations 1287
Chapter 46: Caring for the Patient in the Immediate Postoperative Period 1289
Patients at Risk for Postoperative Complications 1289
Overview of Anesthesia and the Anesthetic Agents 1290
General Anesthesia 1290
Intravenous Agents 1291
Neuromuscular Blocking Agents 1293
Regional Anesthesia 1293
Local Anesthetics 1293
Patient Transfer to Postanesthesia Care from the Operating Room 1298
Respiratory Complications 1300
Cardiovascular Complications 1301
Central Nervous System Complications 1302
Electrolytes 1302
Nutrition 1303
Thermoregulation 1303
Postanesthesia Shivering 1304
Acute Postoperative Pain and Comfort Management 1305
Postoperative Nausea and Vomiting 1305
Other Complications: Risks Associated With the Use of Herbal or Vitamin Supplements 1305
The Surgical Care Improvement Project 1306
Multidisciplinary Plan of Care 1307
Conclusions 1310
References 1311
Chapter 47: Caring for the Critically Ill Pregnant Patient 1313
Pregnancy and Critical Illness 1313
Normal Physiologic Changes in Pregnancy 1315
Reproductive System 1315
Cardiovascular System 1315
Pulmonary System 1316
Gastrointestinal System 1317
Renal System 1317
Monitoring of the Critically Ill Obstetric Patient 1317
Maternal Monitoring 1317
Fetal Monitoring 1318
Multidisciplinary Plan of Care 1318
Environment of Safety 1319
Psychosocial Care 1322
Maintenance of Cardiac Output 1322
Airway and Oxygenation Support 1322
Infection Control 1323
Pharmacologic Concerns 1323
Nutritional Considerations/Glycemic Control 1326
Prevention of Deep Venous Thrombosis 1327
Labor and Delivery Considerations 1327
Pain Management 1329
Postdelivery Care 1329
Prevention of Hemorrhage 1329
Support of Breast-Feeding 1330
Support of Maternal-Infant Bonding 1330
Cardiac Disease in Pregnancy 1330
General Considerations 1330
Pregnancy in Women With Preexisting Valvular Heart Disease 1331
Pregnancy in Women With Congenital Heart Disease 1331
Cardiac Disease Arising During Pregnancy 1332
Hypertensive Disease 1333
Pulmonary Dysfunction in Pregnancy 1334
Mechanical Ventilation 1335
Asthma 1335
Acute Respiratory Distress Syndrome 1335
Pulmonary Embolism 1335
Amniotic Fluid Embolism/Anaphylactoid Syndrome of Pregnancy 1335
Acute Fatty Liver of Pregnancy 1336
Trauma in Pregnancy 1336
General Pregnancy Considerations 1336
Cardiovascular Considerations 1336
Abdominal and Pelvic Considerations 1337
Reproductive System Considerations 1337
Neurologic System Considerations 1337
Multisystem Considerations 1337
Conclusions 1338
References 1338
Chapter 48: Caring for the Pediatric Patient in an Adult Critical Care Unit 1340
Levels of PICU Care 1340
Models of Co-Residence 1340
Service Line Model 1340
Geographic Model 1340
Regionalization of Care 1340
Pediatric Intensivist Coverage 1341
Tiered Care 1341
Localized Community Care 1341
Standardizing Care for Children 1341
Standardized Equipment 1347
Standardizing Emergency Equipment 1349
Standardizing Documentation Across the Institution 1350
Child and Family-Centered Care 1350
Decreasing Family Stressors 1351
Family Presence 1353
Siblings and Childhood Friends 1353
Quality Monitoring 1353
The Child's Response to Critical Care 1354
Considerations in Pediatric Care 1355
Pediatric Assessment 1355
Fluid Balance in Children 1356
Medication Administration in Children 1357
Pain in Children 1358
Neuromuscular Blockade 1360
Intentional Injuries in the Pediatric Patient 1361
Role of the Nurse 1361
Parental Permission and Child Assent 1361
Transitions for the Child and Family in Critical Care 1364
Out of the PICU 1364
Palliative Care 1364
Pediatric Resuscitation Priorities 1364
Competent Pediatric Intensive Care Nursing 1364
Initial Pediatric Orientation 1367
Ongoing Competencies 1367
Conclusions 1369
References 1369
Chapter 49: Caring for the Critically Ill Elderly Patient 1372
The Aging Population 1372
Demographics 1372
Factors that Influence Aging 1372
Age-Related Changes 1372
Social and Environmental Factors 1373
Cumulative Health History 1373
Comorbidities 1373
The Geriatric Critical Care Patient 1373
Demographics 1373
Traumatic Injury 1374
Minimizing Potential Critical Care Problems 1375
Cardiovascular System 1375
Age-Related Changes 1375
Common Problems and Management Strategies 1377
Respiratory System 1378
Age-Related Changes 1378
Common Problems and Management Strategies 1379
Neurologic System 1381
Age-Related Changes 1381
Common Problems and Management Strategies 1382
Musculoskeletal System 1384
Age-Related Changes 1384
Answers to Decision Point Questions 1527
Chapter 4, Pain and Sedation 1527
Chapter 5, Symptom Management 1528
Chapter 7, Thermoregulation 1529
Chapter 8, Families in Critical Care 1529
Chapter 11, Acute Coronary Syndromes 1530
Chapter 12, Heart Failure 1530
Chapter 14, Cardiac Surgery 1531
Chapter 15, Valvular Disease and Surgery 1531
Chapter 16, Vascular Emergencies 1532
Chapter 17, Cardiomyopathy 1532
Chapter 18, Heart and Lung Transplantation 1532
Chapter 19, Acute Respiratory Failure and Acute Lung Injury 1533
Chapter 20, Mechanical Ventilation and Weaning 1534
Chapter 21, Thoracic Surgery 1534
Chapter 22, Head Injury and Dysfunction 1535
Chapter 23, Cerebrovascular Disorders 1536
Chapter 24, Spinal Cord Injury 1536
Chapter 25, Special Neurologic Patient Populations 1537
Chapter 27, Liver Dysfunction and Failure 1538
Chapter 28, Pancreatitis 1539
Chapter 32, Complex Acid-Base Disorders and Associated Electrolyte Imbalances 1539
Chapter 33, Acute Renal Failure 1542
Chapter 34, Glycemic Control 1543
Chapter 35, Pituitary, Thyroid, and Adrenal Disorders 1544
Chapter 36, Blood Conservation and Blood Component Replacement 1546
Chapter 37, Coagulopathies 1547
Chapter 38, Caring for the Immunocompromised Patient 1548
Chapter 39: Bone Marrow Transplantation 1550
Chapter 40, Shock and End points of Resuscitation 1551
Chapter 41, Optimizing Hemodynamics: Strategies for Fluid and Medication Titration in Shock 1553
Chapter 42, Trauma 1554
Chapter 43, Systemic Inflammatory Response Syndrome and Multiple Organ Dysfunction Syndrome 1555
Chapter 44, Burns 1556
Chapter 45, Mass-Casualty Competencies 1557
Chapter 46, Caring for the Patient in the Immediate Postoperative Period 1559
Chapter 47, Caring for the Critically Ill Pregnant Patient 1560
Chapter 49, Caring for the Critically Ill Elderly Patient 1561
Chapter 50, Caring for the Critically Ill Patient with A Neuropsychiatric Disorder 1561
Chapter 51, Caring for the Bariatric Patient 1562
Chapter 53, Chemical Dependency 1564
Illustration Credits 1567
Chapter 4 1567
Chapter 16 1567
Chapter 17 1567
Chapter 18 1567
Chapter 19 1567
Chapter 23 1567
Chapter 24 1567
Chapter 25 1567
Chapter 26 1568
Chapter 27 1568
Chapter 28 1568
Chapter 35 1568
Chapter 41 1568
Chapter 43 1568
Chapter 44 1568
Chapter 48 1568
Index 1569